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Those of you who are participating in IHIs 5 Million Lives Campaign likely are focusing on preventing harm from high-alert medications. If you are not, you should be even if you are not officially participating in the campaign. One of the suggested changes to improve management of narcotics is to make available protocols and reversal agents that can be administered without additional physician orders. Given the frequency with which unintended respiratory depression (or other side effects) occurs secondary to narcotics, such protocols undoubtedly will prevent harm in almost every hospital or ambulatory surgery/procedure center.
However, we have now seen several cases where Narcan, administered by a nurse under such a protocol, actually precipitated an acute narcotic withdrawal syndrome. In each case, the patient had been on long-standing narcotic treatment (eg. for cancer-related pain) and had received an intravenous narcotic as part of conscious sedation for a procedure, resulting in respiratory depression. The Narcan administration was successful at reversal of the respiratory depression. However, the patients developed a very painful, uncomfortable state that was not immediately recognized as a withdrawal state.
The take-home lesson here is to build into your narcotic reversal protocol a provision for monitoring for an acute narcotic withdrawal syndrome in those patients who had previously been narcotic-dependent. The chance of this occurring is very small compared to the large number of patients who will benefit from a narcotic reversal protocol. But you need to keep this unintended consequence in mind as you develop those protocols at your facilities.
Print Unintended Consequences
Ignoring alarms or intentionally disabling alarms is a topic well revisit over and over (this is one of the Big 3 root causes that can be found in many root cause analyses of cases with adverse outcomes).
However, we encountered an interesting case in which good intentions almost caused a disastrous outcome. The case was a near-miss in which a patients oxygen line had become disconnected from the wall source of oxygen. Mechanical ventilators often have an oxygen blender alarm. This is an alarm that is triggered by oxygen concentration falling below the prescribed level. In this particular case, the alarm failed to alert nursing staff that the oxygen content had dropped. At least one other monitoring system also failed to detect a drop in the patients O2 saturation. But fortunately the patients clinical condition was evaluated by staff and the problem remediated before any harm came to the patient.
In the course of the investigation, a piece of tape was found covering the blender alarm. The alarm, in fact, was functional. It was just not audible because of the tape. It was ultimately determined that during maintenance of the ventilators between use by patients, staff would test the ventilators with compressed air rather than oxygen (as a cost-saving measure). They would tape the blender alarm because it would go off when the compressed air was used instead of oxygen. The protocol used to assess alarms at set-up time for patient use did not include a specific assessment of the blender alarm. No other ventilators in use at this hospital were found to have tape over the blender alarm. However, when the potential issue was mentioned in an alert to other hospitals in this multi-hospital system, six other ventilators in use were found to have tape over the blender alarm!
The lesson learned in this case is that one should have a checklist-type routine for checking alarms immediately before a ventilator is used on a patient. And the checklist should be specific for the ventilator being used. It is not at all uncommon for a hospital to have multiple different models of ventilators and some may have alarms that others do not. Therefore, your protocol should include not only checking those alarms that are on all ventilators but also those that may be specific to the unit being used.
Frankly, this ultimately comes back to a design issue as a root cause. Good design principles would have led to an automated alarm testing protocol that would have to be carried out before a unit could be used in patient care.
The second lesson is also obvious when you find a disabled alarm, dont jump and take punitive action on the individual who disabled the alarm. Continue your root cause analysis and youll always find some other root cause that led them to disable the alarm and that other staff are likely also disabling such alarms.
Print Disabled Alarms
A number of erroneous processes have been involved in causing inadvertent administration of 10 times the intended dosage of medications. Probably the most common and dangerous error is the use of the abbreviation U for unit. Fatal overdoses of insulin have been given when a U written by provider is misinterpreted as a 0. That is a primary reason that U is one of the items on theNever Use These Abbreviations list from ISMP. Your hospital should not only have a policy of which abbreviations can and cannot be used but also an audit process to ensure that the policy is being complied with. Keep in mind that such abbreviations should not only be excluded from orders, but they should not appear anywhere not in progress notes, H&Ps, consultations, discharge summaries, etc.
The second common scenario leading to tenfold medication overdoses is use of a trailing zero in order writing. When writing, for example 2.0 mg, the transcriber may miss the decimal point and see 20 mg. This especially tends to be problematic if your facility accepts faxed orders (your facility should have a policy specifying how faxed orders will be accepted and under what circumstances they will be rejected). As above, make sure you audit charts to make sure trailing zeroes are not being used in your facility.
A third cause of tenfold overdoses is when the last letter of the drug ordered ends in a letter that can look like a 1. Typically this is an L, as in Tegretol. This occurs when there is little space between the last letter and the subsequent dosage.
Yet another cause is another unintended consequence, this time the result of technology. As weve move to computerized order entry weve improved upon many of the handwriting errors that led to incorrect medication administration in the past. However, the technology has introduced new types of errors. The data entry person may double press a key (or the key may become stuck) resulting in, for example, 88 instead of 8. Also, during data entry it is possible to think one hit a decimal point but it fails to print out. Such data entry errors may occur with any type of keyboard but we find them especially likely to occur when using handheld devices with small keyboards or styli for input. These types of data entry error have recently been noted in programmable intravenous infusion pumps and there have been several occurrences of 10x overdoses with those pumps. Therefore, a policy of having a second independent observer verify the dosage or rate on such pumps makes sense (however, keep in mind that error rates from other industries tell us that one who oversees someone elses work typically does so in error up to 10% of the time!).
It is almost inevitable that at some time in your facility such an order for 10x the intended dose will be written or entered. It is therefore especially important that you have appropriate second line defenses to capture such errors before they reach the patient. Examples are computerized pharmacy systems that flag doses falling outside usual ranges.
Print 10x Overdoses
Most often a cascade of errors, rather than a single error, is necessary before patients actually suffer harm. When we do a root cause analysis, it is usually painfully apparent that avoiding any one of the errors in that cascade would likely have prevented the adverse patient outcome.
A dialysis patient was admitted via the emergency room to an acute psychiatric service because of abnormal behavior. He later suffered a cardiac arrest, precipitated by hyperkalemia. The RCA revealed multiple issues (delay in lab specimens being processed, poor panic value communication, poor communication between the psychiatry service and medical consultants, etc.). The EKG which had been obtained in the ER did show peaked T-waves highly characteristic of hyperkalemia. However, these were not readily recognized because that EKG had been run at voltage/sensitivity unintentionally. The EKG machine had been used on other patients and during its previous use the voltage/sensitivity was used. The technician running the EKG on the new patient did not recognize that the EKG was at voltage/sensitivity and, though the scale was clearly marked at the beginning of the EKG, one would not realize that on rapid perusal of the strip. Several other patients had EKGs with the reduced voltage/sensitivity but none were impacted by the EKG findings. This is an example of a latent error coming together with several more acute errors to result in adverse patient outcome.
At your facility, how is the EKG voltage/sensitivity recorded on the EKG? If the scale is indicated, is it indicated on each segment or is it just at the beginning of what might be a long EKG strip? Do the EKG machines revert to full voltage/sensitivity after each use? Do they require manual reversion or is the process automatic? If you are like most hospitals, you probably have EKG machines of varied ages. Some may automatically reset to standard voltage recording but others may not. Do you have a policy (and appropriate training and audit) to ensure that those requiring manual reset get reset immediately after each use?
Obviously, this comes back to a design issue. The optimal design would clearly delineate the voltage/sensitivity on all segments but would also automatically revert the voltage/sensitivity back to standard after each use.
Print Put that machine back the way you found it!
An ESRD patient was having his regularly scheduled dialysis session. Since he would be in the dialysis center for several hours, he was in a comfortable lounge chair that tipped back. Also, since it was somewhat cool, he was offered a blanket to keep warm.
Midway through the dialysis session, the low-pressure alarm rang. The nurse turned off the alarm and eyeballed the patient and saw no blood. Nothing further was done. Soon thereafter the low pressure alarm triggered again. This time it was recognized that the dialysis catheter had become dislodged and the patient had, in fact, had considerable blood loss. It had not been appreciated immediately because the blanket had been covering up the catheter site and the blood, rather than being visible on the floor, had been pooling in the webbing of the lounge chair.
Anyone who has ever spent time in an ICU or other hi tech medical environment knows that the usual response to an alarm is to turn the alarm off. Proper design of medical equipment therefore should force the responder to focus on the source of the problem. In the case at hand, the equipment and alarm were on the side of the patient opposite from the involved limb so that the visual attention of the responder was not directed immediately to the site the alarm was drawing attention to.
My copy machine tells me exactly where to look when there is a paper jam. Why cant critical medical monitoring devices do the same thing?!!! Proper design of medical equipment necessitates seeing how humans will respond to it in the typical medical setting. When Microsoft develops new software, it puts real people in a real-life setting and sees exactly how people are likely to respond to various scenarios. Why cant all medical device manufacturers learn from this?
Unfortunately, you all have lots of equipment that have alarms that dont make the responder focus directly at the problem. Faulty response to alarms is one of the big 3 problems encountered in many root cause analyses of sentinel events. Performing FMEA (Failure Mode and Effect Analysis) is a good way to help anticipate events that might arise in your critical settings.
Print Alarms Should Point to the Problem
A patient with asthma arrived mid-morning at an emergency room with status asthmaticus. Treatment was begun but the patient required intubation and mechanical ventilation. He was stabilized and the ICU was called to admit the patient. The ICU had no empty beds but told the ER that they expected a bed to open up shortly. The ER said the patient could stay on a ventilator in an ER room until that bed was ready. Respiratory Therapy evaluated the patient and hooked the patient up to a dual power-source portable ventilator. That was felt to be ideal for this patient because it could be used either with typical AC current in the ER or use its built in battery during transport.
A call to the ICU after an hour still found no available ICU bed. The ER now started getting busier but the patient remained stable on the portable ventilator. Unbeknownst to all, the circuit breaker on the AC wall source had tripped, so the portable ventilator was running on battery power. After 5 hours in the ER, the portable ventilator exhausted its battery power and ceased functioning. The patient had a respiratory and then cardiac arrest.
Investigation revealed that no staff had heard any alarms on the EKG monitor even though it was likely the patient would have developed tachycardia and/or bradycardia after the ventilator had ceased functioning. The alarm volume, in fact, had been turned down to a level barely audible even by those in the immediate room. The room was immediately adjacent to the nursing and secretarial work area and staff had turned down the alarm volume because it distracted them from work.
When the hospital team conducting the RCA investigation came to the ER to re-enact the events, they found that the volume on the same alarms had been turned down again. A similar visit done with the health department a week later again found the alarm volume turned down.
Avoiding the snap reaction to take punitive action against the staff member who had initially turned down the alarm volume, it became very clear that the root cause was a flawed design to the ER. That design obviously led to the practice of turning down the alarm volume. One wonders how many ERs, ICUs, etc. suffer from this same type of design flaw that promotes such an unsafe practice. Im always amazed when a hospital administrator proudly states we designed this unit to have full visual contact of all patients, only to find that the very proximity led to this practice of lowering alarm volumes.
A second root cause was the development of a culture in the ER that tolerated manipulation of the alarms as an unsafe workaround.
Another root cause was in the design of the portable ventilator. How was one to know that it was functioning on battery power rather than AC power from the wall outlet? In fact, it did have an indicator light to flag which power source was being utilized. However, that indicator light was located on the back of the unit and not readily visible to staff in the room.
The case is also a good example of how technological safety advances may not actually reduce accidents, much like maritime radar simply encouraged ships to go faster. In this case, the ideal dual power-source ventilator fostered a false sense of security.
Lastly, the bottleneck caused by bed unavailability in the ICU was yet another root cause that led to implementation of a better system for triage of ICU beds.
A very unfortunate case but it illustrates multiple points that one often sees in cases with adverse outcomes (cascade of errors, latent errors, violations, unsafe workarounds, communication breakdowns, misuse of alarm systems, multiple design flaws, safety culture issues, bottlenecks and patient flow issues, and technological advances with unintended consequences).
Print More Alarm Issues
Weve often heard surgeons complain that they waste a lot of time doing surgical timeouts to prevent events that are very rare to start with. In fact, you can use surgical timeouts (either the pre-surgical timeout and/or the final verification timeout) to also focus on what are more common complications you wish to avoid. For example, use the timeout to ask questions such as following:
Print Make Your Surgical Timeouts More Useful
Important update: See November 20, 2007 Patient Safety Tip of the Week "New Evidence Questions Perioperative Beta Blocker Use"
Falls with injury occur in virtually all health care settings. Some excellent resources are available to help institutions reduce the risk of harm to their patients from falls: IHI (The Institute for Healthcare Improvement), the VA National Center for Patient Safety, the Health Care Association of New Jersey, to mention just a few.
The Institute for Healthcare Improvement also has an upcoming web-based initiative to help organizations reduce harm from falls .
Having reviewed numerous reports and RCAs involving falls with injury, we have a couple observations that merit discussion. First is that, though most hospitals/facilities use some sort of fall risk assessment tool, these are often only used on admission to the facility. It is not uncommon for a patients to have a low risk for falls on admission, only to have multiple factors change during the hospitalization that now make them fall-prone. It is therefore imperative that any fall prevention program have built-in flags that trigger reassessment for fall risk.
Our second observation is that the initial medical responder to a patient who has fallen often has a focus much different from that of a quality improvement professional. That responder typically is most concerned with whether any injury has resulted from the fall. Ascertaining the reason for the fall is often only an afterthought and often neglected all together. And, sometimes, the only clue to the cause of the fall can be found only around the time of the fall (for example, orthostatic hypotension may no longer be present a day or so later when someone finally gets around to looking for it). The initial responder is often a housestaff member who has little knowledge about the patient prior to the fall. And we have not done a particularly good job of educating housestaff on how to perform a good post-fall assessment. Therefore, facilities should build protocols and checklists for housestaff (or other first medical responders) to utilize in their post-fall assessment. Several good tools for post-fall assessment are available (see references above).
Now that weve mentioned orthostatic hypotension, it is most notable that orthostatic signs are very seldom actually checked by the medical responder to a fall. Even when they are checked, they are often inadequately assessed. The proper technique for checking orthostatic signs is as follows:
First, have the patient lie supine for at least 5 minutes prior to beginning measurements (this is because many of the neurological causes of orthostatic hypotension are associated with supine hypertension, so one is most interested in the magnitude of the orthostatic change rather than just in the absolute standing blood pressure). One should then measure both the blood pressure and pulse of the patient in the supine position. Then, after telling the patient what you will be doing and asking him to tell you about symptoms such as dizziness or graying out of vision that might occur when upright, one stands the patient upright (being sure you can safely lie him down if they do become symptomatic!). The pulse should be measured first on standing, since what the heart rate does in response to orthostatic hypotension may provide clues to the etiology of orthostatic hypotension. The blood pressure is then recorded. If there is a drop in blood pressure, one should keep the patient upright (unless symptomatic) and record the blood pressure and pulse again at 1-2 minutes intervals until it has stabilized.
Sorry for the digression! But we find this one of the simplest, yet most neglected, parts of the physical examination in the post-fall patient.
Lastly, food for thought: How many of you have had osteoporosis screening? If you did, how many had a fall-risk assessment? Not many, well bet! Isnt the goal of osteoporosis screening to prevent fractures? Wouldnt it be wise to incorporate a fall-risk assessment (and education) any time someone is sent for osteoporosis screening? Sounds like an opportunity for providers, quality improvement professionals, and third-party payors to all climb on board.
Print Falls with Injury
Some errors are predictable. The classic example given is people writing checks in January dated for the previous year. Banks had to alter their usual time limitation for cashing checks to take into account this predictable error. Some errors in medicine are also predictable.
One type of predictable error in medicine we call the two in a box phenomenon. Assume there are 2 items (A and B) in a box or some other sort of container. You are looking for item A. You reach into the box and pull out B. Many people put B back in the box and pull out the other item, assuming it is A without checking its identity. Thats human nature. But what happens if your assumption was wrong (i.e. that the items in the box were different items and that an A was even in the box)? Suppose the box was a refrigerator with 2 units of blood in it. Youve now pulled out a unit of blood that may be inappropriate for your patient. You say thats why you have a double check built into your blood products policy? That may help you in that particular circumstance but keep in mind that we know from industry in general that the error rate for someone who checks someone elses work may be as high as 10%!
Think of what circumstances you might find this two in a box problem in your facility. We have seen the following examples of this phenomenon in medicine events with adverse outcomes:
So next time you are making safety walk rounds in your facility, take a look to see how often you come across this potential two in a box scenario. Youll be surprised how often you find it.
When there is an untoward incident, the person who failed to check the item often gets reprimanded or punished in some other way. But it should be clear that this is a system design problem that set up that individual (and potentially many others) to do exactly what they did. So make sure your systems are designed to avoid putting anyone in the two in a box scenario.
Print Predictable Errors
Everyones worst nightmare is identifying a possible cancer yet the patient not being made aware and getting prompt attention when the cancer might be at a treatable stage. Lots of examples are available:
How can we prevent these sorts of disasters? Communication at multiple levels is critical (lab/hospital, physician/practice/outpatient clinic, patient/family). And you need systems to help you.
At the hospital level, several things can be done. First is putting in place a system to ensure notification of practitioners of any unexpected findings (eg. a suspicious lesion seen on a radiograph ordered for other purposes). It is not uncommon these days for patients to be discharged from the hospital before the final radiology report hits the chart. So one must assume that such a finding could be overlooked, even if the hospital sends copies of all reports to the physician office as well. Such a system requires setting up a log (paper or electronic) to confirm that the practitioner was contacted by the radiologist to notify him/her of the suspicious finding. The case is not closed until that conversation has taken place. There are examples in the literature of successful implementation of such systems.
Also, the hospital discharge summary should always include a section for tests done but official reports pending so that the practitioner following up the patient is alerted to the fact not all reports were final at discharge.
At the physician/practice level, you need a system to track results of all tests ordered. A paper-based tracking system is theoretically possible but not practical for most practices. Technology provides the best solutions. However, you dont need an expensive electronic medical record. A simple Excel spreadsheet or Access database will do. Simply set it up with the patient name (and a second identifier so you dont mistakenly mix up 2 patients!) and a column/field for tests pending and one for date ordered. You could also have a column for the date you contacted the patient with the results. You simply then sort your list each day by the tests pending field so you can follow up on reports that should have been received but have not yet been received. You then remove the test from the test result pending field as the result comes in. You can have a similar system on your handheld PDA but make sure you take appropriate measures to safeguard patient health information.
Also, when the paper reports come in to the office, they should not be filed until the practitioner has indicated (usually by initialing the report) that he/she has read the report.
At both the hospital and practice levels, make sure you perform periodic audits to ensure that the process you set up is indeed effective.
Lastly, as a patient, never assume that no news is good news. Any time you have a test done, ask your physician when and how the results will be communicated to you. And if you have not heard the results within a reasonable period of time, contact your physician to find out the result.
Print The Missed Cancer
One of my most embarrassing moments as a young neurologist was when, as I was providing inpatient discharge instructions to a young multiple sclerosis patient, she asked the above question. It caught me totally by surprise that she had a Foley catheter in place. Later, when I first became involved in quality improvement, unnecessary Foley catheters became one of my pet peeves. You would be amazed at how often the Foley catheter appears unbeknownst to the primary physician responsible for the patients care and how often they are placed without legitimate medical indication. They often get put in for measuring I&O, for incontinence, or for convenience. Very often they are put in either in the emergency room or perioperatively or ordered by a covering physician who will never see that patient again. So years ago, we established catheter rounds and began putting a brightly-colored sticker on the order sheets of all patients with a Foley catheter, requiring the physician to indicate the reason for the Foley catheter and the expected duration of its use. Catheter use dropped about 50%!
Its no laughing matter. Nosocomial UTIs, still the most common nosocomial infection, are not only a safety issue for patients but they are also very costly to hospitals. The average additional cost for patients who develop nosocomial UTIs is about $2000 due to increased length of stay and increased antibiotic and supply needs. So establishing systems to prevent unnecessary Foley use is not only good for your patient safety program, it is also very cost-effective.
The system you put in place can be low-tech or hi-tech. The simple colored sticker alert mentioned above was very effective. Adding lines for indication and duration to pre-printed order sheets can also be effective. For those facilities fortunate enough to have computerized physician order entry, add a new pop-up screen with these questions any time someone orders a Foley catheter.
Beware of unintended consequences, though. Your policy should not be so restrictive that patients who truly do need a Foley catheter are made uncomfortable. Alternatives to Foley catheters may include condom catheters or intermittent catheterization.
Also, be sure to include monitoring and measuring in your QI activities because the initial Hawthorne effect of implementing such a system often fades with time.
Print Doctor, when do I get this red rubber hose removed?
Analogies between the aviation industry and healthcare are well-known in patient safety circles. The types of problems encountered in aviation accident investigations are eerily similar to those encountered in root cause analyses of adverse events in healthcare. One exercise we recommend is reading some of the detailed investigation reports available through the NTSB (National Transportation Safety Board). As you read them, you can usually visualize a situation in healthcare in which almost identical issues occur.
A good case to start on is the investigation of the Avianca Airlines flight from Medellin, Columbia to JFK airport in New York in 1990. Multiple factors and events cascaded to result in this fatal crash, similar to the typical cascade seen in healthcare incidents. However, this investigation illustrates several of the key communication problems encountered in either an aviation or healthcare setting. It is an excellent example of both language and lingo problems and also shows how non-content verbal features can play a role in context.
Basically, the plane ran out of fuel after weather and air traffic led to a prolonged holding pattern and an unsuccessful approach to JFK. Though an issue with fuel was noted on several occasions in conversations between the cockpit crew and air traffic control, the urgency of that fuel shortage was never properly conveyed in the verbal interactions. Some of the issues had to do with the language barrier (the pilot spoke little English and communicated primarily via the first officer). Others had to do with different interpretations of the word priority, the air crew apparently thinking it meant emergency but the air traffic controllers not appreciating that specific term as meaning an emergency situation existed. One might even speculate from occasional small talk and occasional laughter in the cockpit whether priority being taken in the appropriate context by all involved.
The team approach to training known as Cockpit Resource Management (CRM) training is now used not only in the airline industry but is being used to improve teamwork in healthcare as well. Important communication techniques, such as hearback, are used to ensure that all members of the healthcare team clearly understand the intent and urgency of specific verbal communications. Simulation is another technique borrowed from aviation and used by healthcare teams to look at how teams communicate and respond in scenarios such as the operating room or emergency room. Loudness, intonation, and body language are also important determinants of effective communication. We highly recommend organizations serious about patient safety consider investing time and resources in training their various teams using CRM or simulation training. Also, a lot can be learned from simply recording or videotaping an operating room session and then having all relevant parties sit down and constructively critique their communication and team interactions.
Another good program for team training is TeamSTEPPS, developed by the Department of Defense (DoD) in collaboration with the Agency for Healthcare Research and Quality (AHRQ).
Print Communication, Hearback and Other Lessons from Aviation
Print More on TeamSTEPPS
May 29, 2007
Update: See Our May27, 2008 Patient Safety Tip of the Week "If You Do RCAs or Design Healthcare ProcessesRead Gary Kleins Work"
June 5, 2007
We frequently see hospital systems focus the bulk of their patient safety activity on the inpatient side. Historically, there have always been fewer serious adverse events in the ambulatory surgery suite, whether hospital-based or free-standing, than in acute care hospital operating rooms. This, of course, largely reflects the relatively good overall health of the patient population and the fact that procedures are generally less complex than those done in acute care settings. Nevertheless, serious incidents can occur in ambulatory surgery settings and there are certain factors unique to these settings that may predispose to certain kinds of error. In fact, more than half of the wrong-site surgeries reported to Joint Commission have occurred in ambulatory surgery sites.
One factor is that a surgeon will often be performing many cases of the same or similar procedures. Interestingly, very experienced surgeons may be more likely to be involved in wrong-site cases, perhaps because their experience allows them to schedule so many cases in one day.
The quality of the medical records is often not as good in ambulatory settings. The facility medical record is often scant and the physician often brings in his/her office notes that are unofficial as far as the facility is concerned. Often critical information is in the physician office record and never appears in the facility medical record. It is therefore incumbent upon the facility and entire team to ensure the adequacy of the medical record and all documentation prior to the procedure.
Another practice that should be frowned upon is allowing the medical records of multiple patients to be in the operating room. Weve seen instances where a surgeon might bring in a stack of office charts on all the patients on that days ambulatory schedule. The system should never allow one to mistakenly pick up the chart of the wrong patient during a procedure. The same applies to other things a physician might bring in for all the days patients (eg. X-rays, scans, implants, etc.). The rule should be that all the things in the OR apply to only the patient on the table.
And there are certain production pressures unique to the ambulatory setting. When a surgeon is booked for many cases in one day, there is a higher likelihood of last-minute changes in the schedule. Also, weve seen cases in the ambulatory setting where one patient may demand a procedure earlier in the day, leading to last-minute alterations in the order on the schedule. And lastly, the pressure to get cases done promptly and stay on schedule are everpresent.
Remember that all elements of the Joint Commission Universal Protocol apply equally to the ambulatory setting. And keep in mind that the verification process must take place at multiple points preoperatively, including at the time the procedure is scheduled.
Availability of all appropriate documents at the timeout is essential. They should be reviewed for actual content rather than simply acknowledging their presence and there should be agreement by all on what the documents say rather than simply having individual review of the documents. And, of course, good communication among all team members, utilization of hearback, requiring agreement of all team members before proceding, and involvement of the patient and/or family are all important in ensuring safe outcomes.
Organizations should utilize some of the resources available for patient safety in the ambulatory surgery setting. The American Academy of Ophthalmology has issued good guidance statements onavoiding wrong-site surgery and avoiding incorrect intraocular lens placement , with good examples of how checklists might be utilized. And the American Academy of Orthopedic Surgeons also has very good resources.
Overall compliance with the timeout requirements of Joint Commissions patient safety goals for ambulatory surgery is still only in the 80% range so organizations should take a hard look there.
Joint Commission is also finding less than full compliance in ambulatory surgery on several medication-related goals (eg. medication reconciliation, labeling medications and solutions, do not use abbreviations, and look-alike/sound-alike drugs). Well address some of those issues in future Tips of the Week.
Print Patient Safety in Ambulatory Surgery
June 12, 2007
Many have asked why all Joint Commissions patient safety goals should apply to ambulatory surgery sites. After all, the patient is only there for a matter of hours and then goes home. Right? Why should we have to jump through all sorts of hoops for something that really doesnt pertain to us? We are only here to do this one procedure and what do we know, anyway, about all those other medical problems the patient has.
Well, you have to remember that ambulatory surgery is a part of a larger healthcare continuum and events related to ambulatory surgery can be reflected in other parts of that continuum. Lets look at an example. Last week we mentioned that medical records are often a problem in ambulatory surgery sites. A patient came to an ambulatory surgery site for a procedure. Very little history had been provided prior to the patients arrival so on the day of the procedure staff asked the physicians office to fax over some relevant office notes and the medication sheet. While hospitals have clearly begun to comply with the do not use abbreviation lists, most physician office notes are still replete with such abbreviations. The faxed notes were included in the facility medical record. The surgical procedure went well and the patient went home without incident or complication. However, 2 weeks later she was seen in the ER of the same hospital system for an unrelated problem. The patients primary physician was not available. The ER physician found in the patient chart copies of those office records that had been faxed in to the ambulatory surgery site. One of the medications listed in those records had a qd abbreviation that, perhaps in part because of fax artifact, looked like qid. The patient was admitted from the ER to the hospital and her maintenance medication that had been intended to be given once daily was now actually give four times daily. The error was not discovered until the patient developed symptoms of drug toxicity 5 days later. Well-performed medication reconciliation and compliance with the do not use list goal could have prevented this adverse outcome. But the case nicely illustrates how events in one part of the system can effect events in another part.
Medication reconciliation is also critical before and after ambulatory surgery. It is critical that a full list of the patients medications, including OTC drugs and herbal remedies, be reviewed before the procedure. Several of these might predispose the patient to bleeding problems, for example. And one especially needs to know when the last dose of medication prior to arrival for the procedure was taken. This is especially relevant for medications such as insulin and ties together with orders for the patient to be nothing by mouth for a period prior to surgery. Similarly, it can be anticipated that on discharge from ambulatory surgery the patient is likely to receive some new drugs, for example analgesics and perhaps and antiemetic. One needs to be sure there is not likely to be a drug-drug interaction with the patients current medications.
Last week we noted that Joint Commission is finding less than full compliance in ambulatory surgery on several medication-related goals (eg. medication reconciliation, labeling medications and solutions, do not use abbreviations, and look-alike/sound-alike drugs). Todays tip illustrates why at least 2 of those goals are important in ambulatory surgery patient safety. Well talk about labeling medications and solutions and look-alike/sound-alike drugs in future tips.
Print Medication-Related Issues in Ambulatory Surgery
In our April 2, 2007 Tip of the Week we showed an example about how a technological advance (a dual-power source portable ventilator) gave rise to an unintended consequence. It is not at all uncommon for technological advances to create some new unintended consequences.
In the early days of telemetry, hospitals realized they could now utilize remote telemetry to free up valuable ICU beds. A hospital purchased such a remote telemetry system in which the transmitter could be placed on a patient on one floor of a hospital and the receiver/monitor was in the CCU as part of a bank of telemetry screens that were continuously viewed by a nurse assigned to that duty. One day, right around nursing change of shift, two patients were admitted to the remote floor and telemetry was ordered on both. The nurse took two transmitters with him and hooked the patients up, then called the CCU monitoring nurse to tell her about the two patients just hooked up. About an hour later the CCU monitoring nurse called the remote floor because one of the patients was in ventricular fibrillation. A code was called and the floor staff and code team ran to the patients room, only to find him sitting in bed, watching TV and eating a meal. Only after several minutes of fiddling with his EKG leads and talking to the nurse in the CCU did anyone realize that the patient several rooms down the hall was really the one in ventricular fibrillation. The transmitters obviously had been transposed! This is a variation of the two in a box phenomenon we talked about in the April 23, 2007 Tip of the Week. And, of course, the system was poorly designed in that it allowed the first nurse to take out two remote telemetry transmitters at the same time. However, we are presenting it here as an example of how a technological solution expected to enhance patient safety actually created a new unintended problem.
Another example was when a hospital purchased a new alarm system that would send an alarm when the patient got out of bed. It turned out that on some units there were not enough electrical outlets for both the new bed alarms and the nurse call buttons. So a decision was made in some cases to swap out these two devices. You can guess what happened: nursing staff responded to the out-of-bed alarm only to find the patient lying on the floor with an injury because he tried to get out of bed after no one responded when he pushed the nurse call button!
And there are lots of examples of unintended consequences associated with CPOE (computerized physician order entry). The classic example is correction of the illegible handwriting problem but introduction of the cursor error or stylus error in which the physician inadvertently chooses a medication above or below the one he/she actually intended to choose on the computer or PDA screen. The last issue of ISMPs newsletter had an example of a nonventilated patient inadvertently being given a paralytic agent, in part because the ordering physician was entering orders from a remote site and accidentally ordered this for the wrong patient.
We present these cases not to discourage use of technology, which is one of our most potent weapons in the patient safety arsenal, but rather to remind all that any solution (whether technological or instituting a new approach, etc.) may give rise to unintended consequences. Sometimes they can be anticipated, other times they cannot. Either way, careful vigilance for unintended consequences is necessary.
Print Unintended Consequences of Technological Solutions
Much of the morbidity and mortality in patients with acute stroke is related not just directly to the neurological deficit but rather to the complications that occur, many of which are potentially preventable. Those complications include decubiti, falls, DVT, UTI and pneumonia. Preventing these complications is good not only from a patient perspective but very important in avoiding unnecessary costs for the hospital. Most hospitals already incorporate risk assessments for decubiti, falls, and DVT into their nursing care plans and clinical pathways. In our May 8, 2007 Tip of the Week, we talked about how inappropriate use of Foley catheters causes many nosocomial UTIs.
A paper in the last issue of the journal Neurology highlighted the human and financial impact of pneumonia in the acute stroke patient1. The occurrence of pneumonia was associated with about $15,000 incremental cost per case. Previous work by the same group showed that pneumonia increased the risk of dying within 30 days threefold in patients with acute stroke, after correction for severity of the stroke2.
The incidence of pneumonia in the acute stroke population varies considerably in the literature, largely because of stroke populations of varying severity and differences in definitions used. However, studies that have looked at stroke patients having at least some degree of paralysis present have noted incidences of pneumonia typically in the 12-13% range3,7.
Two of the most important factors in the stroke patient predisposing them to pneumonia are impaired swallowing ability and impaired cough reflex. There is currently no single gold standard for swallowing assessment and different hospitals may use different methods4. Some have suggested formal assessment of the cough reflex may be even more important5, though this has not been done at most facilities. The current standard of care is that all patients with acute stroke should have an assessment of their ability to swallow prior to being fed food or fluids orally. That assessment is one of the measures used in Joint Commissions accreditation program for stroke centers6. Quite frankly, it should be a measure routinely followed in the quality improvement program of any hospital that cares for acute stroke patients, regardless of whether the hospital has stroke center designation.
Use of a formal dysphagia screening tool has been shown to reduce the risk of pneumonia in stroke patients by as much as half7. Some hospitals have the swallowing assessment done by nursing staff, others by speech therapy. Others may have nursing do a screening assessment, with speech therapy doing a more formal assessment only in abnormal cases. There are preliminary reports showing that hospitals can increase their compliance with swallowing assessment by using preprinted order sets and by using written care protocols8,9.
Given the relatively low cost of implementing a dysphagia screening program for all stroke patients, a savings of $15,000 for each pneumonia prevented is an excellent return on investment. Again, this is another good example of how good patient safety programs can be very cost-effective for most hospitals.
Print Pneumonia in the Stroke Patient
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A Gap in ePrescribing: Stopping Medications
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Monitoring for Opioid-induced Sedation and Respiratory Depression
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Specimen Identification Mixups
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FMEA to Avoid Breastmilk Mixups
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Expensive Aspects of Sepsis Protocol Debunked
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Systems Approach Improving Stroke Care
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We Miss the Graphic Flowchart!
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Evidence-Based Prescribing and Deprescribing in the Elderly
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Joint Commission Revised Diagnostic Imaging Requirements
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Another Perioperative Handoff Tool: SWITCH
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Lessons From the Asiana Flight 214 Crash
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December 17, 2013
December 10, 2013
Better Handoffs, Better Results
December 3, 2013
Reducing Harm from Falls on Inpatient Psychiatry
November 26, 2013
Missed Care: New Opportunities?
November 19, 2013
Can We Improve Dilaudid/HYDROmorphone Safety?
November 12, 2013
More on Inappropriate Meds in the Elderly
November 5, 2013
Joint Commission Sentinel Event Alert: Unintended Retained Foreign Objects
October 29, 2013
PAD: The Pain, Agitation, and Delirium Care Bundle
October 22, 2013
How Safe Is Your Radiology Suite?
October 15, 2013
October 8, 2013
October 1, 2013
Fuels and Oxygen in OR Fires
September 24, 2013
Perioperative Use of CPAP in OSA
September 17, 2013
September 10, 2013
Informed Consent and Wrong-Site Surgery
September 3, 2013
Predicting Perioperative Complications: Slow and Simple
August 27 2013
Lessons on Wrong-Site Surgery
August 20 2013
Lessons from Canadian Analysis of Medical Air Transport Cases
August 13 2013
August 6, 2013
July 9-30, 2013
Tip of the Week on Vacation
July 2, 2013
June 25, 2013
June 18, 2013
DVT Prevention in Stoke – CLOTS 3
June 11, 2013
June 4, 2013
May 28, 2013
The Neglected Medications: IV Fluids
May 21, 2013
May 14, 2013
Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)
May 7, 2013
April 30, 2013
Photographic Identification to Prevent Errors
April 23, 2013
Plethora of Medication Safety Studies
April 16, 2013
April 9, 2013
Mayo Clinic System Alerts for QT Interval Prolongation
April 2, 2013
Absconding from Behavioral Health Services
March 26, 2013
Failure to Recognize Sleep Apnea Before Surgery
March 19, 2013
Dealing with the Violent Patient in the Emergency Department
March 12, 2013
More on Communicating Test Results
March 5, 2013
Underutilized Safety Tools: The Observational Audit
February 26, 2013
Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?
February 19, 2013
Practical Postoperative Pain Management
February 12, 2013
CDPH: Lessons Learned from PCA Incident
February 5, 2013
Antidepressants and QT Interval Prolongation
January 29, 2013
A Flurry of Activity on Handoffs
January 22, 2013
You Don’t Know What You Don’t Know
January 15, 2013
January 8, 2013
More Lessons Learned on Retained Surgical Items
January 1, 2013
Don’t Throw Away Those View Boxes Yet
December 25, 2012
Tip of the Week on Vacation
December 18, 2012
Unintended Consequences of the CAUTI Measure?
December 11, 2012
December 4, 2012
Unintentional Perioperative Hypothermia: A New Twist
November 27, 2012
November 20, 2012
Update on Perioperative Management of Obstructive Sleep Apnea
November 13, 2012
The 12-Hour Nursing Shift: More Downsides
November 6, 2012
Using LEAN to Improve Stroke Care
October 30, 2012
October 23, 2012
Latent Factors Lurking in the OR
October 16, 2012
What is the Evidence on Double Checks?
October 9, 2012
Call for Focus on Diagnostic Errors
October 2, 2012
Test Results: Everyone’s Worst Nightmare
September 25, 2012
Preoperative Assessment for Geriatric Patients
September 18, 2012
September 11, 2012
In Search of the Ideal Early Warning Score
September 4, 2012
August 28, 2012
New Care Model Copes with Interruptions Better
August 21, 2012
More on Missed Followup of Tests in Hospital
August 14, 2012
August 7, 2012
Cognition, Post-Op Delirium, and Post-Op Outcomes
July 31, 2012
Surgical Case Duration and Miscommunications
July 24, 2012
FDA and Extended-Release/Long-Acting Opioids
July 17, 2012
July 10, 2012
Tip of the Week on Vacation
July 3, 2012
Recycling an Old Column: Dilaudid Dangers
June 26, 2012
Using Patient Photos to Reduce CPOE Errors
June 19, 2012
More Problems with Faxed Orders
June 12, 2012
Lessons Learned from the CDPH: Retained Foreign Bodies
June 5, 2012
Minor Head Trauma in the Anticoagulated Patient
May 29, 2012
Falls, Fractures, and Fatalities
May 22, 2012
Update on Preoperative Screening for Sleep Apnea
May 15, 2012
May 8, 2012
Importance of Nontechnical Skills in Healthcare
May 1, 2012
April 24, 2012
Fire Hazard of Skin Preps Oxygen
April 17, 2012
April 10, 2012
April 3, 2012
New Risk for Postoperative Delirium: Obstructive Sleep Apnea
March 27, 2012
March 20, 2012
Adverse Events Related to Psychotropic Medications
March 13, 2012
Medical Emergency Team Calls to Radiology
March 6, 2012
February 28, 2012
AACN Practice Alert on Delirium in Critical Care
February 21, 2012
Improving PCA Safety with Capnography
February 14, 2012
Handoffs More Than Battle of the Mnemonics
February 7, 2012
Another Neuromuscular Blocking Agent Incident
January 31, 2012
January 24, 2012
Patient Safety in Ambulatory Care
January 17, 2012
Delirium and Contact Isolation
January 10, 2012
January 3, 2012
Unintended Consequences of Restricted Housestaff Hours
December 20, 2011
December 13, 2011
December 6, 2011
Why You Need to Beware of Oxygen Therapy
November 29, 2011
November 22, 2011
Perioperative Management of Sleep Apnea Disappointing
November 15, 2011
November 8, 2011
WHOs Multi-professional Patient Safety Curriculum Guide
November 1, 2011
So Whats the Big Deal About Inserting an NG Tube?
October 25, 2011
October 18, 2011
October 11, 2011
October 4, 2011
Radiology Report Errors and Speech Recognition Software
September 27, 2011
The Canadian Suicide Risk Assessment Guide
September 20, 2011
When Practice Changes the Evidence: The CKD Story
September 13, 2011
Do You Use Fentanyl Transdermal Patches Safely?
September 6, 2011
August 30, 2011
Unintentional Discontinuation of Medications After Hospitalization
August 23, 2011
Catheter Misconnections Back in the News
August 16, 2011
August 9, 2011
Frailty and the Surgical Patient
August 2, 2011
July 26, 2011
July 19, 2011
Communication Across Professions
July 12, 2011
Psst! Pass it onHow a kids game can mold good handoffs
July 5, 2011
Sidney Dekker: Patient Safety. A Human Factors Approach
June 28, 2011
Long-Acting and Extended-Release Opioid Dangers
June 21, 2011
June 14, 2011
June 6, 2011
May 31, 2011
Book Review Human Factors and Team Psychology in a High Stakes Environment
May 24, 2011
May 17, 2011
Opioid-Induced Respiratory Depression Again!
May 10, 2011
Preventing Preventable Readmissions: Not As Easy As It Sounds
May 3, 2011
April 26, 2011
Sleeping Air Traffic Controllers: What About Healthcare?
April 19, 2011
DVT Prophylaxis in Acute Stroke: Controversy Reappears
April 12, 2011
Medication Issues in the Ambulatory Setting
April 5, 2011
March 29, 2011
The Silent Treatment:A Dose of Reality
March 22, 2011
An EMR Feature Detrimental to Teamwork and Patient Safety
March 15, 2011
March 8, 2011
Yes, Physicians Get Interrupted Too!
March 1, 2011
February 22, 2011
February 15, 2011
Controversies in VTE Prophylaxis
February 8, 2011
February 1, 2011
January 25, 2011
Procedural Sedation in Children
January 18, 2011
More on Medication Errors in Long-Term Care
January 11, 2011
NPSA (UK) How to Guide: Five Steps to Safer Surgery
January 4, 2011
December 28, 2010
HAIs: Looking In All The Wrong Places
December 21, 2010
More Bad News About Off-Hours Care
December 14, 2010
NPSA (UK): Preventing Fatalities from Medication Loading Doses
December 6, 2010
More Tips to Prevent Wrong-Site Surgery
November 30, 2010
SURPASS: The Mother of All Checklists
November 23, 2010
Focus on Cumulative Radiation Exposure
November 16, 2010
November 9, 2010
12-Hour Nursing Shifts and Patient Safety
November 2, 2010
Insulin: Truly a High-Risk Medication
October 26, 2010
Confirming Medications During Anesthesia
October 19, 2010
Optimizing Medications in the Elderly
October 12, 2010
October 5, 2010
September 28, 2010
September 21, 2010
September 14, 2010
Wrong-Site Craniotomy: Lessons Learned
September 7, 2010
Patient Safety in Ob/Gyn Settings
August 31, 2010
August 24, 2010
The BP Oil Spill Analogies in Healthcare
August 17, 2010
Preoperative Consultation Time to Change
August 10, 2010
Its Not Always About The Evidence
August 3, 2010
Tip of the Week on Vacation
July 27, 2010
EMRs Still Have A Long Way To Go
July 20, 2010
More on the Weekend Effect/After-Hours Effect
July 13, 2010
Postoperative Opioid-Induced Respiratory Depression
July 6, 2010
Book Reviews: Pronovost and Gawande
June 29, 2010
Torsade de Pointes: Are Your Patients At Risk?
June 22, 2010
Disclosure and Apology: How to Do It
June 15, 2010
Dysphagia in the Stroke Patient: the Scottish Guideline
June 8, 2010
Surgical Safety Checklist for Cataract Surgery
June 1, 2010
May 25, 2010
May 18, 2010
Real-Time Random Safety Audits
May 11, 2010
May 4, 2010
More on the Impact of Interruptions
April 27, 2010
April 20, 2010
HITs Limited Impact on Quality To Date
April 13, 2010
April 6, 2010
March 30, 2010
Publicly Released RCAs: Everyone Learns from Them
March 23, 2010
ISMPs Guidelines for Standard Order Sets
March 16, 2010
A Patient Safety Scavenger Hunt
March 9, 2010
Communication of Urgent or Unexpected Radiology Findings
March 2, 2010
Alarm Sensitivity: Early Detection vs. Alarm Fatigue
February 23, 2010
Alarm Issues in the News Again
February 16, 2010
Spin/HypeKnowing It When You See It
February 9, 2010
More on Preventing Inpatient Suicides
February 2, 2010
January 26, 2010
Preventing Postoperative Delirium
January 19, 2010
January 12, 2010
Patient Photos in Patient Safety
January 5, 2010
December 29, 2009
Recognizing Deteriorating Patients
December 22, 2009
December 15, 2009
December 8, 2009
December 1, 2009
Patient Safety Doesnt End at Discharge
November 24, 2009
Another Rough Month for Healthcare IT
November 17, 2009
November 10, 2009
Conserving ResourcesBut Maintaining Patient Safety
November 3, 2009
Medication Safety: Frontline to the Rescue Again!
October 27, 2009
Co-Managing Patients: The Good, The Bad, and The Ugly
October 20, 2009
Radiology AgainBut This Time Its Really Radiology!
October 13, 2009
October 6, 2009
Oxygen Safety: More Lessons from the UK
September 29, 2009
Perioperative Peripheral Nerve Injuries
September 22, 2009
Psychotropic Drugs and Falls in the SNF
September 15, 2009
ETTOs: Efficiency-Thoroughness Trade-Offs
September 8, 2009
Barriers to Medication Reconciliation
September 1, 2009
The Real Root Causes of Medical Helicopter Crashes
August 25, 2009
Interruptions, Distractions, InattentionOops!
August 18, 2009
Obstructive Sleep Apnea in the Perioperative Period
August 11, 2009
August 4, 2009
July 28, 2009
Wandering, Elopements, and Missing Patients
July 21, 2009
Medication Errors in Long Term-Care
July 14, 2009
Is Your Do Not Use Abbreviations List Adequate?
July 7, 2009
Nudge: Small Changes, Big Impacts
June 30, 2009
iSoBAR: Australian Clinical Handoffs/Handovers
June 23, 2009
June 16, 2009
Disclosing Errors That Affect Multiple Patients
June 9, 2009
CDC Update to the Guideline for Prevention of CAUTI
June 2, 2009
Why Hospitals Should FlyJohn Nance Nails It!
May 26, 2009
Learning from Tragedies. Part II
May 19, 2009
May 12, 2009
May 5, 2009
Adverse Drug Events in the ICU
April 28, 2009
Ticket Home and Other Tools to Facilitate Discharge
April 21, 2009
April 14, 2009
More on Rehospitalization After Discharge
April 7, 2009
March 31, 2009
Screening Patients for Risk of Delirium
March 24, 2009
March 17, 2009
March 10, 2009
Prolonged Surgical Duration and Time Awareness
March 3, 2009
Overriding AlertsLike Surfin the Web
February 24, 2009
Discharge Planning: Finally Something That Works!
February 17, 2009
Reducing Risk of Overdose with Midazolam Injection
February 10, 2009
Sedation in the ICU: The Dexmedetomidine Study
February 3, 2009
NTSB Medical Helicopter Crash Reports: Missing the Big Picture
January 27, 2009
Oxygen Therapy: Everything You Wanted to Know and More!
January 20, 2009
The WHO Surgical Safety Checklist Delivers the Outcomes
January 13, 2009
January 6, 2009
December 30, 2008
Unintended Consequences: Is Medication Reconciliation Next?
December 23, 2008
December 16, 2008
Joint Commission Sentinel Event Alert on Hazards of Healthcare IT
December 9, 2008
December 2, 2008
Playing without the ballthe art of communication in healthcare
November 25, 2008
November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
November 11, 2008
November 4, 2008
October 28, 2008
More on Computerized Trigger Tools
October 21, 2008
October 14, 2008
October 7, 2008
Lessons from Falls....from Rehab Medicine
September 30, 2008
September 23, 2008
Checklists and Wrong Site Surgery
September 16, 2008
More on Radiology as a High Risk Area
September 9, 2008
Less is More.and Do You Really Need that Decimal?
September 2, 2008
August 26, 2008
August 19, 2008
August 12, 2008
Jerome Groopmans How Doctors Think
August 5, 2008
July 29, 2008
Heparin-Induced Thrombocytopenia
July 22, 2008
Lots New in the Anticoagulation Literature
July 15, 2008
July 8, 2008
July 1, 2008
WHOs New Surgical Safety Checklist
June 24, 2008
Urinary Catheter-Related UTIs: Bladder Bundles
June 17, 2008
Technology Workarounds Defeat Safety Intent
June 10, 2008
Monitoring the Postoperative COPD Patient
June 3, 2008
UK Advisory on Chest Tube Insertion
May27, 2008
If You Do RCAs or Design Healthcare ProcessesRead Gary Kleins Work
May20, 2008
CPOE Unintended Consequences Are Wrong Patient Errors More Common?
May13, 2008
Medication Reconciliation: Topical and Compounded Medications
May 6, 2008
Preoperative Screening for Obstructive Sleep Apnea
April 29, 2008
ASA Practice Advisory on Operating Room Fires
April 22, 2008
CMS Expanding List of No-Pay Hospital-Acquired Conditions
April 15, 2008
April 8, 2008
April 1, 2008
Pennsylvania PSAs FMEA on Telemetry Alarm Interventions
March 25, 2008
March 18, 2008
Is Desmopressin on Your List of Hi-Alert Medications?
March 11, 2008
March 4, 2008
Housestaff Awareness of Risks for Hazards of Hospitalization
February 26, 2008
Nightmares.The Hospital at Night
February 19, 2008
February 12, 2008
February 5, 2008
Reducing Errors in Obstetrical Care
January 29, 2008
Thoughts on the Recent Neonatal Nursery Fire
January 22, 2008
More on the Cost of Complications
January 15, 2008
Managing Dangerous Medications in the Elderly
January 8, 2008
Urinary Catheter-Associated Infections
January 1, 2008
December 25, 2007
December 18, 2007
December 11, 2007
CommunicationCommunicationCommunication
December 4, 2007
November 27,2007
November 20, 2007
New Evidence Questions Perioperative Beta Blocker Use
November 13, 2007
AHRQ's Free Patient Safety Tools DVD
November 6, 2007
October 30, 2007
Using IHIs Global Trigger Tool
October 23, 2007
Medication Reconciliation Tools
October 16, 2007
Radiology as a Site at High-Risk for Medication Errors
October 9, 2007
October 2, 2007
Taking Off From the Wrong Runway
September 25, 2007
Lessons from the National Football League
September 18, 2007
Wristbands: The Color-Coded Conundrum
September 11, 2007
Root Cause Analysis of Chemotherapy Overdose
September 4, 2007
August 28, 2007
Lessons Learned from Transportation Accidents
August 21, 2007
Costly Complications About To Become Costlier
August 14, 2007
More Medication-Related Issues in Ambulatory Surgery
August 7, 2007
Role of Maintenance in Incidents
July 31, 2007
Dangers of Neuromuscular Blocking Agents
July 24, 2007
Serious Incident Response Checklist
July 17, 2007
Falls in Patients on Coumadin or Other Anticoagulants
July 10, 2007
Catheter Connection Errors/Wrong Route Errors
July 3, 2007
June 26, 2007
Pneumonia in the Stroke Patient
June 19, 2007
Unintended Consequences of Technological Solutions
June 12, 2007
Medication-Related Issues in Ambulatory Surgery
June 5, 2007
Patient Safety in Ambulatory Surgery
May 29, 2007
Read Anything & Everything Written by Malcolm Gladwell!
May 22, 2007
May 15, 2007
Communication, Hearback and Other Lessons from Aviation
May 8, 2007
Doctor, when do I get this red rubber hose removed?
May 1, 2007
April 23, 2007
April 16, 2007
April 9, 2007
Make Your Surgical Timeouts More Useful
April 2, 2007
March 26, 2007
Alarms Should Point to the Problem
March 19, 2007
Put that machine back the way you found it!
March 12, 2007
March 5, 2007
February 26, 2007
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