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Janary 6, 2009
Preventing Inpatient Suicides
It has been almost 20 years since New York State issued a report on preventing inpatient suicides and over 10 years since Joint Commission first published a Sentinel Event Alert on prevention of inpatient suicides. Though many excellent recommendations have been made, the problem continues to occur. Inpatient suicide still accounts for 12.4% of all sentinel events collected by Joint Commission over the years. The hospital incident reporting system in New York (NYPORTS) had 278 reported attempted suicides in the 3-year period from 2002-2004.
The original New York report focused on hangings because that was the most common mode of suicide in inpatients. Most of these hangings occurred in relatively secluded areas, especially bathrooms, closets and private or semiprivate bedrooms. Many of these occurred despite patients being on 15-minute observation status. They identified many environmental factors and procedural factors that might be modified to help prevent inpatient suicides.
Environmental factors included exposed pipes, showerheads, bars in showers and toilet stalls. The commission recommended recommended environmental safeguards such as use of breakaway physical structures. Joint Commission also recommends that breakaway hardware actually be tested regularly (weight testing to ensure that hardware will, in fact, break away when sufficient weight is applied). Other environmental safeguards include keeping doors closed, and keeping sharps or other hazardous materials away from patients. The Joint Commission Sentinel Event Alert noted 75% of inpatient suicides were by hanging but also noted that 20% involved jumping from roofs or windows. So careful attention to access to such sites is important.
Procedural factors were also important. They noted that physician-ordered suicide observation status was in effect in about a third of all the patients at the time of suicide but that in half the cases those observations were not being carried out appropriately. The manner in which the physician wrote the order was important. Explicit orders were more likely to be carried out than were vaguely-worded orders.
Obviously, patient-related factors are important and patients with depression and affective disorders are at greatest risk. Patients with multiple diagnoses (eg. depression and substance abuse) are at higher risk for suicide but there may also be different risk profiles for different demographics as well.
Though the original New York report focused on psychiatric facilities, many inpatient suicides occur on med-surg units and units other than inpatient psychiatric units. The Joint Commission Sentinel Event Alert noted that of 27 suicides occurring in general hospitals, 12 occurred in med-surg units and one in the emergency room. An AHRQ WebM&M Case & Commentary several years ago highlighted many of the issues involved in cases where patients are admitted to non-psychiatric services. There are a variety of reasons why suicides may occur on non-psychiatric services. While most psychiatric units now have rigorous policies and procedures about assessing the environment for hazards that could be used for suicide, the same rigor is seldom applied on med-surg units. In the AHRQ case noted above, the suicide attempt occurred in a bathroom in the radiology suite. We wonder how many hospitals would have inspected that bathroom for potential suicide risk. None are likely to have done such inspection as part of their routine environmental safety process. So it would have to be done ad hoc at a time a potentially suicidal patient is brought to the area. Weve talked about the Ticket to Ride communication tool for hospital transports. Perhaps even that useful tool needs to be modified to account for potentially suicidal patients.
Suicide risk assessments are often incomplete or not done and the Joint Commission especially noted a dearth of suicide reassessments. Sound familiar? How often have we noted that other key assessments in healthcare, such as fall risk or DVT risk assessment, are done on admission but are not repeated even though clinical circumstances have changed during the hospital course? Another issue is that even though the reason for admission may have been related to a suicide attempt, the patient on admission may be unable to cooperate with a suicide risk assessment (eg. the patient may be comatose or obtunded because of a drug overdose). Sometimes many days pass where the patient physically would have been incapable of another suicide attempt but, ironically, as they begin to improve medically the suicide risk reappears.
As in most sentinel events, communication issues are often root causes. The Joint Commission emphasized issues such as training/education, not only of staff but also of family and friends. An Austrailian study on inpatient suicides specifically mentions the risk of suicide in patients on leave or pass and several other studies have also noted that association.
An excellent review, based on root cause analyses (RCAs) of inpatient suicides and suicide attempts in the VA Hospital system, appears in the August 2008 Joint Commission Journal on Quality and Patient Safety (Mills et al 2008). About half their events occurred on non-psychiatric units and the methods differed by site. Whereas hanging/asphyxiation, cutting, and fires occurred most often on the psychiatric units, overdoses, jumpings, stabbings, and ingestion of chemicals was more common on non-psychiatric units. They provide tables describing the types of anchor points in hangings, the materials used as nooses, the implements used in cuttings, and the loctions for jumpings. They point out that, for a variety of reasons, it may be impossible to eliminate the materials used for nooses so they suggest a focus on eliminating anchor points. For example, they note that interior doors and cabinets can be removed or replaced with accordion doors that cannot be used as anchor points. And they recommend that things like door knobs, railings, faucets and hooks be eliminated or constructed so as to break away when weight is applied. They also note that most of the attempted overdoses took place on units other than psychiatric inpatient units (though many of these units were detox units, etc.) so careful assessment of security of medications is important on all units. They also note that the VA has developed a mental health environment-of-care checklist that is available by e-mail request.
Bathrooms on non-psychiatric floors may be especially problem prone. Not only are they seldom assessed for tools and implements that could be used for suicide, but some also allow the door to be locked from the inside. So observation protocols for potentially suicidal patients on such units should ensure that doors are not locked (or, if they can be locked, that the observer has keys to access the bathroom). Having observers of the same gender as the patient also is recommended.
Several articles have noted that the sitters commonly utilized to monitor the potentially suicidal patient on the non-psychiatric unit are often not specifically trained in assessment of the environment or management of the suicidal patient. The AHRQ article noted above has a good discussion on this.
Most healthcare organizations that have developed standardized order sets, whether they are paper-based or CPOE-based, tend to focus on the more commonly seen diagnoses and conditions. Weve previously made the case that standardized order sets may be even more important for conditions or circumstances that are high risk but less likely to be encountered. For example, we have noted that some drugs (eg. argotroban or desmopressin) may need to be used under rare circumstances and that few practitioners have extensive experience with those drug. Therefore, some organizations have made special attempts to make appropriate information on the less familiar drugs available to practitioners and have developed standardized order sets for dealing with such drugs. Using similar logic, it would be appropriate to develop standardized order sets for dealing with the potentially suicidal patient admitted to non-psychiatric services.
Since it is very difficult to predict suicides, careful attention to environmental factors that could facilitate suicide is critical. Appropriate assessment and reassessment for suicide risk are important. Similarly, for those patients identified as at-risk for suicide, it is essential that appropriate monitoring with appropriately trained staff be used. Transitions of care are especially vulnerable and suicide risk should be considered in all handoffs and other communications.
References:
New York State Commission on Quality of Care. Preventing Inpatient Suicides: An Analysis of 84 Suicides by Hanging in New York State Psychiatric Facilities (1980-1985).
http://www.cqc.state.ny.us/publications/pubinsui.htm
Joint Commission. Sentinel Event Alert Issue #7. Inpatient Suicides: Recommendations for Prevention. November 6, 1998
http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_7.htm
Joint Commission. Sentinel Event Statistics as of September 2008.
http://www.jointcommission.org/NR/rdonlyres/241CD6F3-6EF0-4E9C-90AD-7FEAE5EDCEA5/0/SE_Stats9_08.pdf
NYSDOH. NYPORTS Annual Report 2002-2004.
Gibson J, Taylor DH. AHRQ Web M&M Case & Commentary The Dangerous Detour. June 2003
http://www.webmm.ahrq.gov/case.aspx?caseID=20
Victorian Government Health Information (Australia). Sentinel Event Program. Annual Report 2007-2008.
http://www.health.vic.gov.au/clinrisk/downloads/annrep0708.pdf
Mills PD, DeRosier JM, Ballot BA, Sheperd M, Bagian JP. Inpatient Suicide and Suicide Attempts in Veterans Affairs Hospitals. The Joint Commission Journal on Quality and Patient Safety 2008; 34: 482-488 (August 2008)
http://www.ncbi.nlm.nih.gov/pubmed/18714751
Print Preventing Inpatient Suicides
January 13, 2009
Lab Errors in the News
Its been over a year since we last talked about errors in the laboratory. Last week there was considerable attention in the media about one of the largest ever lab test recalls. USA Today reported that Quest labs had begun notifying physicians last summer about possible errant vitamin D test results (Marcus 2009). The New York Times (Pollack 2009) also reported on the issue and noted the story was first reported by The Dark Report, an industry newsletter for pathologists. The Dark Report, in fact, dedicated an entire issue to the incident.
The Times article and the Dark Report issue discuss many of the technical details about the events, which involved a proprietary test done by Quest labs using mass spectroscopy. They discuss also how some diagnostic tests fall outside the FDAs oversight responsibilities. Importantly, they also discuss the Quest response to the errors and the Quest intentions to repeat testing at no cost.
Could a similar problem occur at your own lab? How long would it take for your hospital to recognize that its lab test results were showing an abnormal pattern? Hospital labs must undergo very rigorous certification reviews. They all have in place quality assurance programs that include frequent (usually daily) calibration of testing equipment, close monitoring of environmental conditions like ambient temperature, and cross checking results with reference laboratories. Nevertheless, problems may arise even despite such rigorous standards. Thats why it is extremely important that hospitals have methods in place to identify unusual lab result patterns.
Sometimes the abnormal patterns point to problems outside the lab. We recall a circumstance long ago where serum phenytoin levels were running higher than normal on hospital inpatients. The higher than normal levels were validated with a reference laboratory and the investigation uncovered that the pharmacy had received a formulation of generic phenytoin that differed from the previous generic formulation.
But other times the abnormal pattern means a problem with the lab itself. We recall another circumstance where abnormally high protimes were traced to faulty lab equipment.
In both cases above, the problem was noted only when multiple physician inquiries came into the lab about the abnormal results. Both incidents might have been detected sooner if automated surveillance had been operational (both incidents preceded the current sophisticated high tech environment).
With todays sophisticated computer programs it is fairly easy to write simple applets, programs or rules to track lab value results and trigger an alert if there is a new trend in the results (eg. the values tend to be running higher or lower than normal). The logic might go something like this: Check every 10th serum ZZZZZ level. If more than x out of y such values exceed the average value for 2008, send alert to lab director.
You could just compare the average values for the test results this year compared to last year, but if the test is a high volume test it may take a while before there is significant change in the average value. You could also choose to sample consecutive specimens but such a trend might just reflect serial testing on a patient with a known abnormality (eg. a patient with hypokalemia may have his potassium level checked frequently during replacement therapy so the lab may see a trend with frequent low potassiums). The more random sampling method (eg. every 10th test) may help get around the latter problem. But that doesnt help if the test is one that is infrequently performed.
Whatever methods your lab uses to detect unusual trends, you need to make sure you have a plan in place for what to do if you do detect such a trend. Now is a good time for your lab to review its contingency plan for communication with physicians and patients should such unusual trends be identified.
There is one last consideration worth discussion. In the hundreds of incident investigations and root cause analyses we have see over the years, there is one question that consistently fails to be asked: Was the procedure or surgery or admission or test indicated in the first place?. That is especially important with diagnostic tests. We try to teach our medical students and residents to ask themselves a series of key questions when they are considering ordering a diagnostic test:
In most cases, if the answer to the first 2 questions is Ill still do the same thing, you have to think hard about whether the test really adds value. (There are, of course, circumstances where the test result could give important information about prognosis even if it did not alter management). And weve all been in the uncomfortable position of finding something unexpected (and often unrelated or incidental) when we do order a test and then having to do further tests or interventions because of that finding. Given the substantial increase in vitamin D testing in recent years, it is probably also a good time to be asking questions about the proper indications for that testing.
References:
Marucs MB. Lab sent out number of flawed Vitamin D test results. USA Today Janary 8, 2009 http://www.usatoday.com/news/health/2009-01-08-vitaminD-testrecall_N.htm
Pollack A. Quest Acknowledges Errors in Vitamin D Tests. New York Times January 7, 2009
http://www.nytimes.com/2009/01/08/business/08labtest.html?partner=rss&emc=rss
The Dark Report. December 22, 2008. Special Issue on Quest Diagnostics Inc.
http://www.darkreport.com/dark/current.htm
Print Lab Errors in the News
January 20, 2009
The WHO Surgical Safety Checklist Delivers the Outcomes
This has been quite a week for long-awaited studies! The report on the investigation of the Minnesota nursery fire has been released. The NTSB has released its preliminary report on several of the medical helicopter crashes. But youll have to wait for future columns for our comments on those because this weeks most significant study was the report in the New England Journal of Medicine on the outcomes from implementation of the WHO Surgical Safety Checklist (Hayes 2009).
Our July 1, 2008 Patient Safety Tip of the Week WHOs New Surgical Safety Checklist described the tool and provided the link to download the checklist tool and instructions how to use it. We also discussed checklist design and use in our September 23, 2008 Patient Safety Tip of the Week Checklists and Wrong Site Surgery.
The New England Journal study was a prospective preintervention/postintervention study that looked at mortality rates and major complication rates after non-cardiac surgery. It involved hospitals in eight different countries, allowing the investigators to assess the utility of the checklist in both wealthy and poor countries. The intervention, of course, was introduction and use of the WHO Surgical Safety Checklist. Mortality at 30-days post-op decreased from 1.5% before introduction of the checklist to 0.8% after. Rate of any complication decreased from 11% to 7%. Both these outcomes were highly statistically significant. Thats a relative risk reduction of approximately 36% for mortality and major morbidity! Of important specific surgery complications, both surgical site infections and unplanned reoperations decreased significantly. Improvements were seen at all participating sites.
Looking at 6 sample processes on the checklist, all 6 were completed in 34% of cases prior to implementation of the checklist and improved to 57% after. So the striking improvement in outcomes occurred even without complete adherence to all items on the checklist.
The biggest debate seems to be whether the striking improvement is attributable to use of the checklist per se or to the change in culture that accompanied use of the checklist. To that debate we say who cares?. If merely using a checklist results in such powerful improvement in the culture of safety and promotion of better communication and teamwork, use it!!!
The most important issue will be the sustainability of the improvements. We have all seen numerous quality improvement projects that have lost their luster several months after initially encouraging results. The authors do acknowledge the possibility of a Hawthorne effect being partially responsible for the striking results. Time will tell if the results are sustainable.
Other issues pertain to the study design. It was not a randomized controlled trial. Rather, it was your typical before/after type of prospective study. Significant practical issues make a randomized controlled trial unfeasible.
In our previous tip of the week Checklists and Wrong Site Surgery we described even more comprehensive checklists that have been developed for specific surgical settings and demonstrated comparable striking outcome improvements. Use of a 28-item structured checklist (Verdaasdonk 2008) addressing problems with laparoscopic equipment resulted in a 53% reduction of incidents related to such equipment. The Verdaasdonk article also discusses human factors considerations in the design of checklists and references an excellent guidance from the UK Civil Aviation Authority on the proper design, presentation and use of checklists.
One important point to remember is that developing checklists is not enough. You need to educate all staff in their importance and implementation and must audit the use of and adherence to the checklists you develop. The audit should be done for anything you develop a checklist for, not just a safe surgery checklist.
Checklists are some of the most valuable tools we have available in quality improvement and patient safety. They are simple and save time in the long run. Even the 28-item laparoscopic checklist in the Verdaasdonk article took only an average of 3.3 minutes to complete. They are also the least expensive of all tools. All the items in the WHO Surgical Safety Checklist have negligible financial costs. The WHO study did not publish the likely financial savings resulting from the improvements but they would obviously be substantial. The ROI on checklists is incredibly high, both in human terms and financial terms.
And, speaking of checklists, dont forget that Joint Commissions 2009 National Patient Safety Goals (see our July 2008 Whats New in the Patient Safety World column Joint Commission 2009 National Patient Safety Goals) have a requirement for use of a checklist during the pre-procedure verification process. The checklist can be paper or electronic or even on a wall-mounted white board and needs to include elements such as the H&P, anesthesia assessment, completed informed consent, appropriate diagnostic and imaging reports or images, and any required implants, devices, special equipment or blood products that will be needed.
So checklists are here to stay. But one word of caution: dont let your checklists become so complicated that they become cumbersome. Then they wont be used. Youll recall that the WHO Surgical Safety Checklist actually consists of 3 separate checklists, each having 7 or fewer items on them. Keep it simple!
Update: Institute for Healthcare Improvement (IHI) is also sponsoring a new campaign the WHO Surgical Safety Checklist Sprint to get as many hospitals as possible using the checklist. Their website offers most of the downloads available on the WHO website plus some additional useful resources. They include a video of the presentation that Atul Gawande, M.D. did at the IHI 20th Annual National Forum on Quality Improvement in Health Care in Nashville this past December.
References:
Haynes AB, Weiser TG, Berry WR, et al. for the Safe Surgery Saves Lives Study Group. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. N Engl J Med. Online First January 14, 2009 (DOI: 10.1056/NEJMsa0810119), in Print January 29, 2009
http://content.nejm.org/cgi/content/full/NEJMsa0810119
WHO Surgical Safety Checklist
http://www.who.int/entity/patientsafety/safesurgery/tools_resources/SSSL_Checklist_finalJun08.pdf
WHO Safe Surgery Saves Lives website (includes also an implementation manual and videos on how to use the checklist and how not to use it)
http://www.who.int/patientsafety/safesurgery/en/index.html
Verdaasdonk EG, Stassen LP, Hoffman WF, van der Elst M, Dankelman J. Can a structured checklist prevent problems with laparoscopic equipment. Surgical Edoscopy 2008; 22: 2238-2243 (accessed online 9/22/2008) http://www.springerlink.com/content/1845j684574501v2/
Civil Aviation Authority (UK). CAP 676: Guidance on the Design, Presentation and Use
of Emergency and Abnormal Checklists. January 2006.
http://www.avhf.com/html/Publications/Outside_Pubs/CAA CAP676.pdf
Joint Commission. 2009 National Patient Safety Goals.
http://www.jointcommission.org/NR/rdonlyres/31666E86-E7F4-423E-9BE8-F05BD1CB0AA8/0/09_NPSG_HAP.pdf
Institute for Healthcare Improvement (IHI.org). WHO Surgical Safety Checklist Sprint
http://www.ihi.org/IHI/Programs/ImprovementMap/WHOSurgicalSafetyChecklist.htm
Print The WHO Surgical Safety Checklist Delivers the Outcomes
January 27, 2009
Oxygen Therapy: Everything You Wanted to Know and More!
In our April 8, 2008 Patient Safety Tip of the Week Oxygen as a Medication we discussed both the benefits and risks of oxygen therapy. We followed this up in June 2008 with Monitoring the Postoperative COPD Patient. In the latter we alluded to the upcoming publication by the British Thoracic Society of a new comprehensive guideline on oxygen therapy. That has been published in the journal Thorax in October 2008 and the British Thoracic Society website includes not only the guideline but a whole host of incredibly useful downloadable tools for managing oxygen therapy.
The guideline was developed by a multidisciplinary group representing multiple different specialty groups in the UK after audits showed multiple problems with oxygen use and significant lack of agreement on issues related to oxygen use.
The full guideline is 81 pages but there is a 10-page executive summary and a separate summary for hospital use. They provide a sample audit tool and samples of what the oxygen prescription should look like. A sample hospital oxygen therapy policy is also available for download. There are even PowerPoint presentations for use in education of your physician and nursing staffs and an educational handout for patients.
The philosophy of the guideline is straightforward. Oxygen is a drug, in fact one of the most widely used drugs in healthcare. It should be used for the treatment of hypoxemia, not breathlessness. It should be prescribed toward a target saturation range. That target saturation range will be lower in those patients at risk for hypercapnic respiratory failure (eg. COPD, certain neuromuscular disorders, chest wall deformities, massive obesity). Patients should be assessed and monitored appropriately, with complete documentation in the chart. And oxygen should be discontinued when it is no longer necessary.
The guideline contains tables identifying which medical conditions commonly require oxygen therapy. Just as importantly, it contains a table of common medical conditions where oxygen is not necessary unless the patient is hypoxemic. The latter include conditions such as acute MI and stroke. For years we routinely put such patients on oxygen and well bet you can find some such patients in your hospital today!
The guideline has a comprehensive discussion on the various methods of oxygen delivery and good sections on related issues (humidification, nebulizers, etc.). The full guideline also has an excellent section on physiology and discusses the benefits of oxygen therapy but also discusses the potential harms of hyperoxia and hypercapnia.
Perhaps most useful are the recommendations for safeguarding patients at risk of hypercapnic respiratory failure during oxygen therapy (eg. COPD, certain neuromuscular disorders, chest wall deformities, massive obesity). This includes the lower target saturation range (88-92%), use of controlled oxygen via Venturi masks, appropriate education of patients and healthcare workers, use of alert cards, and issue of personal Venturi masks to high risk patients. Because of limitations of noninvasive methods for monitoring for hypercapnia (such as use of end-tidal carbon dioxide measurement), they stress observation for the clinical signs of hypercapnia (vasodilation, bounding pulse, flapping tremor, drowsiness, confusion and coma). While the target oxygen saturation for most acutely ill patients is 94-98%, in those patients at risk for hypercapnic respiratory failure the target range is recommended to be 88-92% pending availability of arterial blood gas results. It is recommended that those patients with a history of previous hypercapnic respiratory failure carry an alert card that contains recommendations about the ideal oxygen dose and target saturation range for that individual patient. A sample oxygen alert card is included in the March 2008 AHRQ Web M&M case that we discussed previously. This facilitates a patient at risk of CO2 retention in getting the most appropriate oxygen concentration/flow with the correct target saturation range.
The guideline recommends usage of a preprinted section for oxygen prescription in the order section of patient charts (in the medication section). They provide good examples of such preprinted orders. Such could also be easily adapted for computerized order entry. And, just as for drugs, appropriate documentation of the administration of oxygen and it monitoring is required.
The oxygen prescription should include the desired target saturation range and the method of delivery (appropriate device and flow rates to maintain that saturation in the target range). Rather than using a fixed dose of oxygen, as has been the typical practice in most hospitals, the guideline stresses adjustment of the dosage to achieve the target oxygen saturation. Oxygen saturation is the 5th vital sign and the guideline discusses the value and nuances of using pulse oximetry to measure oxygen saturation, as well as its limitations. It provides advice on the appropriate use of arterial blood gas (ABG) analysis as well. They note the limitations of noninvasive methods for monitoring for hypercapnia (such as use of end-tidal carbon dioxide measurement).
The guideline contains useful algorithms that step one through the important questions to ask when beginning a patient on oxygen therapy, starting with the question Is the patient at risk for hypercapnic respiratory failure?. The answer to that question not only helps establish the saturation target range but also helps determine initial oxygen concentration and delivery method and monitoring methods.
The guideline discusses in detail use of oxygen in emergency and prehospital settings and in other special circumstances (such as obstetrics, near-drowning, carbon monoxide poisoning, etc.). It also has an extensive discussion about oxygen delivery devices and practical advice about topics such as oxygen storage. It has a section on oxygen use and issues during patient transport that complements our previous discussions on transport issues (see Patient Safety Tips of the Week Oxygen as a Medication and Ticket to Ride: Checklist, Form, or Decision Scorecard?).
The importance of staff education and development of local oxygen champions are emphasized. The PowerPoint slides they provide are excellent educational materials. They have sets for physicians and sets for nursing and other healthcare professionals.
A good understanding about oxygen therapy is critical for the safety and wellbeing of your patients. A good oxygen management program will also likely be beneficial to the economic wellbeing of your hospital. Reading and understanding the BTS Guideline should be a good first step in your organizations efforts to improve the safety and efficacy of oxygen management.
References:
ODriscoll BR, Howard LS, Davison AG and the British Thoracic Society. Emergency Oxygen Guideline Group. BTS Guideline Emergency Oxygen Use in Adult Patients. Thorax 2008; 63 (suppl. VI): 1-68
Full guideline (81 pages)
O'Driscoll BR, Howard LS, Davison AG on behalf of the British Thoracic Society BTS guideline for emergency oxygen use in adult patients. Thorax 2008; 63 (suppl. VI): 1-68
Summary guideline
Print Oxygen Therapy: Everything You Wanted to Know and More!
February 3, 2009
NTSB Medical Helicopter Crash Reports: Missing the Big Picture
A couple columns back we mentioned that the NTSB has released its preliminary report on several of the medical helicopter crashes. We have been waiting for that since we did a couple columns previously regarding the epidemic of EMS helicopter crashes in the recent past (see our July 8, 2008 Patient Safety Tip of the Week Medical Helicopter Crashes and our October 2008 Whats New in the Patient Safety World column More Medical Helicopter Crashes). In all there were 7 EMS helicopter crashes, in which 28 people died in 2008.
On January 15, 2009 the NTSB released its public dockets regarding investigations into nine helicopter EMS accidents. The NTSB reports cite the litany of proximate causes we see in many aircraft accidents flying in the dark or poor visibility, poor weather conditions, flying without night vision or terrain awareness and warning systems, lack of GPS guidance, pilot error, air traffic controller error, etc. But they dont delve deeply into the root causes and we can find almost no reference to the question that should be asked first in any such accident Was the helicopter transport necessary in the first place?.
Ironically, on the very day we started preparing this column, I chanced upon a medical helicopter evacuation scene. I couldnt help but wonder if helicopter was the most appropriate vehicle. Judging by the state of the cars involved in the crash, it was pretty clear that the injuries suffered by someone were likely severe enough to merit transport to a Level I Trauma Center. By car from that spot is exactly 29 minutes in morning traffic (I know because I did that exact drive daily for over 12 years, where I was medical director of the hospital). It was a sunny day and the roads were dry, though it was a bit windy. It was not rush hour. Rather it was just shortly before 1PM. It would probably take the helicopter about 10 minutes to fly to the Trauma Center. I wondered how long it had taken the helicopter to arrive. The helicopter base site is about 30 miles from the accident site. The accident site was actually less than half a mile from another hospital so an ambulance was probably available within minutes of the accident. I dont know if the victim had required extrication that might have added to any time elapsed. And I dont know whether any specific medical expertise was required during that transport to the Trauma Center. The helicopter team is staffed by very well-trained EMTs and I personally know each of the very well-qualified medical directors who are available round-the-clock to provide medical guidance for the helicopter team. Yet I couldnt help but wonder whether the total time elapsed to get the patient to the trauma center was faster by helicopter than he would have if he had been taken there by ambulance (keeping in mind that considerations other than speed may have also been important).
So you can see some of the thinking that should go on in planning and implementing a medical rescue and transport to a trauma center. The first responders on the scene need to rapidly determine a number of factors and contact the emergency medical hub. Questions like the following need to be addressed:
The above questions are really subquestions to the main question Whats the fastest way to get the patient/victim the medical interventions he needs?.
After the Maryland helicopter crash in September 2008, the Baltimore Sun did its own investigation of 26 fatal medevac crashes since 2003. They found a substantial number of the patients being transported probably could have been transported by other means. They did point out that Maryland implemented changes after the 2008 crash to limit the number of flights not medically necessary.
This, of course, is not the first time that the lack of medical necessity for helicopter transport has been raised. In our July 8, 2008 Patient Safety Tip of the Week Medical Helicopter Crashes we noted the studies done by Bledsoe and others that raised the issue of potential overutilization of air medevac services. Our prior column also discussed some of the time pressures and financial pressures that may play roles as contributory factors in medical helicopter crashes.
A position paper on medical helicopter crashes prepared for the NTSB meeting by a consortium of air medical services providers does address numerous safety issues and makes recommendations. However, it is written primarily from the same perspective that the NTSB had and does not address the medical need issue. At times, it seems to be more of a self-promotional document than one addressing overall safety. Nevertheless, it is worth reading and contains a good description of the evolution of medical helicopter services in the US and the various models in different communities.
Hopefully, several of you reading this column are saying to yourselves Why wait for a crash to do a root cause analysis?. You are correct. There should be an independent review of every medical helicopter transport to assess whether it was medically necessary and whether alternative transport might have been more appropriate. We suspect that solutions to reduce the numbers of fatal medical helicopter crashes are more likely to come from community-wide reviews that encompass the bigger picture rather than from the more narrow focus taken by the NTSB to date.
References:
Safety board probes EMS helicopter crashes.
By JOAN LOWY ASSOCIATED PRESS
Houston Chronicle (chron.com) Jan. 15, 2009, 3:45AM
http://www.chron.com/disp/story.mpl/side/6212321.html
NTSB Advisory. January 13, 2009
NTSB TO RELEASE PUBLIC DOCKETS ON NINE FATAL HELICOPTER EMERGENCY MEDICAL SERVICES (HEMS) ACCIDENTS; FOUR OF THEM CONTAIN A PROBABLE CAUSE
http://www.ntsb.gov/pressrel/2009/090113b.html
Sassser SM, Hunt, RC, Sullivent EE, et al. Guidelines for Field Triage of Injured Patients Recommendations of the National Expert Panel on Field Triage. MMWR 2009; 58(RR01): 1-35 January 23, 2009
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5801a1.htm
Unnecessary flight risks? Review of 26 fatal medevac crashes shows many didn't involve life-or-death missions. By Robert Little. Baltimore Sun. October 23, 2008
http://www.baltimoresun.com/news/nation/bal-te.medevac23oct23,0,5946638.story
Air Medical Service Safety Position Paper. AAMS, HAI and AMOA. National Transportation Safety Board. January 13, 2009.
Print NTSB Medical Helicopter Crash Reports: Missing the Big Picture
February 10, 2009
Sedation in the ICU: The Dexmedetomidine Study
Those of you who have read our prior columns pertaining to preventing delirium and managing delirium know that use of sedating agents is one of the biggest contributors to the development of delirium in the hospitalized patient. Their use is often a necessary evil in the intubated, mechanically ventilated patient in the ICU, a major reason why the prevalence of delirium is so high in ICU patients.
The most significant sedating agents used in the ICU have historically been midazolam, lorazepam, and propofol. All agree that finding an agent that is less likely to precipitate delirium would be desirable. The drug dexmedetomidine, an 2-adrenoreceptor agonist, has often been mentioned as a potentially useful drug to fulfill that role (Pun 2007, Pandharipande 2007).
Now a new study published in JAMA (Riker 2009) touts the use of dexmedetomidine for sedation in the ICU. That study concluded that dexmedetomidine was as effective as midazolam at keeping patients in the desired sedation range and was associated with a reduced prevalence of delirium and reduced time to extubation. The dexmedetomidine was associated with more episodes of bradycardia, whereas the midazolam was associated with more tachycardia and hypertension. However, the side effects were relatively mild and the overall safety profile of dexmedetomidine was reasonable.
But lets look more closely at the study (this will also give you insight into how research studies need to be interpreted). First, the study was sponsored by the pharmaceutical company that makes the study drug and most of the authors have received some sort of financial support from that company. Note that when we read a paper we do not look at the conflict of interest or financial disclosures section until weve finished the paper so that we will not be biased in our assessment. However, this paper had the usual tell-tale warning of an industry-sponsored paper in its abstract and discussion: the study failed to meet the primary outcome yet is presented as a very positive study.
The primary outcome was the time a patient spent in the desired sedation range, as measured by RASS (Richmond Agitation and Sedation Scale) scores. The study showed no difference in this primary outcome measure between the group receiving dexmedetomidine and the group receiving the comparator drug, midazolam. (Note that if we were designing this study that would not have been the primary outcome wed have been interested in anyway. The much more important outcomes to assess are mortality, duration of ventilation, ICU and total hospital length of stay, and overall costs).
Secondary outcomes included prevalence and duration of delirium, use of fentanyl and open-label midazolam, a bedside nursing assessment, duration of mechanical ventilation, and ICU length of stay.
Delirium was assessed daily using the CAM-ICU tool that we previously described in our October 14, 2008 Patient Safety Tip of the Week Managing Delirium, though a rather complex statistical analysis incorporating a generalized estimating equation was used to model the prevalence of delirium. Using that method the prevalence of delirium was 24.9% reduced in the dexmedetomidine group (statistically significant).
There was no difference in the ICU length of stay but the median time to extubation was 1.9 days shorter in the dexmedetomidine group (statistically significant). Our antennas are always raised when we see a study that reports median and does not also include mean since that often means the data were presented in the most favorable light.
The composite nursing assessment score showed statistically significant better scores for the dexmedetomidine group for 2 of the components (communication effectiveness and cooperation) but this appears to be a tool developed for this study and the authors include no references to the validation of that tool.
There are several other methodological problems with the study. The results were not reported by intention to treat analysis, which is the customary format for studies of this nature. Also, there is no report on the efficacy of the blinding in the study. The latter is significant in this case because the side effect profile of the two agents is so different (one causing bradycardia, the other tachycardia) that one might anticipate the blinding was less than ideal. The characteristics of the populations at the time of randomization appear to be similar. They did look at incidence of delirium at time of randomization and it was similar in the two groups but they did not report the incidence of pre-existing dementia in the two groups, which is perhaps the best predictor of delirium. An unequal number of dementia patients could sway the results toward one group. And patients could be entered into the study up to 96 hours of mechanical ventilation before randomization. Probably a more appropriate protocol would have required randomization at the time of intubation and onset of mechanical ventilation.
Also, there was no significant impact on clinically important outcomes like mortality, ICU length of stay, or incidence of VAP (ventilator-associated pneumonia) though the study may not have been powered to assess all of these. And the paper did not report any data on costs of care.
Are there good aspects to this study? Yes. The sedation protocols with daily arousal assessments and use of a standardized tool (the RASS) were excellent. The use of the CAM-ICU tool for delirium assessment is also something that all ICUs should be doing.
So what do we learn from this study? Wed put it in the category of a pilot study that suggests dexmedetomidine may be administered safely and may eventually prove to be a better alternative than benzodiazepines or other sedating agents currently used in ICUs. But it really just posits that hypothesis. The next step should be a randomized controlled trial looking at use of this drug vs. one or more comparator sedating agents used early in mechanically ventilated patients. However, it must focus on clinical relevant outcomes and correct all the methodological problems weve noted above.
Will such a study get done? The FDA has not approved use of dexmedetomidine in the manner in which it was used in this study. However, the FDA has also indicated its intent to allow pharmaceutical representatives to use published papers about off label uses of drugs in their presentations to physicians. Our bet is that the latter will significantly increase the use of dexmedetomidine in ICUs, removing the sole incentive that the pharmaceutical company would have to do the study correctly.
References:
Pun BT. Ely EW. The importance of diagnosing and managing ICU delirium. [Review] [90 refs] Chest 2007; 132(2):624-636
http://www.chestjournal.org/content/132/2/624.full
Pandharipande PP, Pun B, Herr DL et al. Effect of Sedation With Dexmedetomidine vs Lorazepam on Acute Brain Dysfunction in Mechanically Ventilated Patients: The MENDS Randomized Controlled Trial. JAMA 2007; 298(22):2644-2653
http://jama.ama-assn.org/cgi/reprint/298/22/2644
Riker RR, Shehabi Y, Bokesch PM, et al for the SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group. Dexmedetomidine vs Midazolam for Sedation of Critically Ill Patients. A Randomized Trial. JAMA.2009; 301(5):489-499. Published online February 2, 2009
http://jama.ama-assn.org/cgi/reprint/301/5/489
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February 17, 2009
Reducing Risk of Overdose with Midazolam Injection
The UK NHS National Patient Safety Agency has issued a Rapid Response Report on Reducing Risk of Overdose with Midazolam Injection in Adults. This was done after they identified 498 reported adverse events related to midazolam over a 4 year period, three of which resulted in death. Most of these events were related to adult patients receiving IV midazolam for moderate sedation (also known as conscious sedation). The report describes the nature of the incidents, some of the contributing factors and root causes, and makes recommendations to improve patient safety related to use of midazolam.
One of the key findings was that many patients were inadvertently overdosed with midazolam because of confusion over the strength of the midazolam preparation. Specifically, the midazolam was available in 5mg/ml ampules and 2mg/ml ampules. One of their key recommendations is to ensure that the storage and use of the higher concentration is limited to general anesthesia, intensive care, palliative care, or clinical areas in which there has been a formal risk assessment (eg. areas where syringe drivers are used).
In the US, midazolam is available for injection in pre-filled syringes in 2 concentrations: 1mg/ml (with 2 ml per syringe) and 5 mg/ml (in 1 ml per syringe). So the risk of inadvertent overdosing may be slightly less than in the UK where a syringe could be filled with a higher total dose of midazolam. Nevertheless, it probably makes sense for you to review your needs and consider only stocking one strength in those areas outside the OR and ICU. Also, especially if your providers may work in multiple areas of the hospital, standardization becomes an important safety issue and you should question why you have the need to ever stock more than one concentration of this drug.
The second key finding in the UK NPSA Rapid Response Report is the reminder that flumazenil, the agent typically used to reverse the effects of benzodiazepine overdose, has a half-life shorter than that of the midazolam. Hence, the risk of re-sedation exists when the flumazenil wears off but some midazolam is still on board. This is particularly a risk in patients being discharged home after short diagnostic or procedural events. (Also keep in mind that flumazenil only reverses the sedating effects of benzodiazepines. It will not reverse the sedating effects of any other sedating medications or opiates given concomitantly during the procedure.)
Failure to titrate the dose to the needs of the patient was noted to be a common problem. They did note that a high reliance on using flumazenil to reverse the effects of midazolam may have contributed to use of excessive doses of midazolam as well and conclude that the routine use of flumazenil reversal is not a good practice.
Their analysis also notes many other contributory risk factors. Many or most patients were receiving concomitant other sedating agents, analgesics or opioids. Often the midazolam was being used in patients whose underlying conditions predisposed them to adverse reactions. Many of the patients suffering adverse events were also elderly or frail.
While all these issues appear in the detailed prescribing information on midazolam available through the FDA and other reputable drug information resources, practitioners seldom read through those details at the time a procedure is being performed. The NPSA rapid response report would suggest that a false comfort level with the safety of IV midazolam has developed and that understanding of the substantial risks involved has not been routinely appreciated.
It should be noted that a similar problem with inadvertent overdosing due to confusion about concentration has been noted for lorazepam (Sheth et al. 2008). That paper looked at adverse events in patients admitted to medical floors who received lorazepam. Over 7% of patients admitted to medical floors during the 2 years of their study had been given lorazepam and they identified 14 cases of oversedation, 5 of which also suffered respiratory depression. Four of the five suffering respiratory depression had underlying respiratory problems. Those suffering adverse events all were receiving other concomitant sedating medications (commonly haloperidol, which potentiates the sedating effect of lorazepam) and in general received higher doses of lorazepam, had higher total doses of lorazepam, and 11 of the 14 had received the lorazepam parenterally. They also noted that those suffering adverse events were more likely to have a low serum albumin or pre-existing liver disease. And the ADE rate per 10,000 doses was twice as high in the elderly. They attributed some of the overdosing to the fact that the lorazepam was packaged in 2 mg. packages rather than in smaller dosage sizes that might have prevented overdosing. Importantly, inadequate monitoring of vital signs, pulse oximetry, and sedation level was often seen when high dose lorazepam was used on non-ICU medical floors.
As a class, benzodiazepines are the drugs most commonly precipitating delirium (see our prior columns pertaining to preventing delirium and managing delirium) and they are on Beers List of drugs that should be avoided in the elderly (see our January 15, 2008 Patient Safety Tip of the Week Managing Dangerous Medications in the Elderly and June 2008 Whats New in the Patient Safety World Potentially Inappropriate Medication Use in Elderly Hospitalized Patients). Yet their use continues to be widespread, both in inpatients and outpatients. When we are asked about topics a hospital should choose for conducting a FMEA (Failure Mode and Effects Analysis), we often suggest looking at benzodiazepine use (either in toto or just the parenteral use). When you do such a FMEA, youll be amazed at what you find in your organization. We truly, in most organizations, have developed a comfort level with the use of these drugs that is clearly not warranted.
Clearly, there are risk reduction strategies you need to undertake. Restricting the higher concentrations of injectable agents to those areas where use is acceptable (OR, ICU, etc.) is a step every organization needs to consider. And standardizing on a single concentration of these agents may make even more sense. Ensuring that reversal agents are available everywhere these agents are used is also mandatory, but keep in mind that the mere presence of a reversal agent often produces a false sense of security that makes us push the envelope and perhaps take more risks with these agents. Ensuring that all personnel involved in moderate sedation (aka conscious sedation) are fully trained is required. However, in this day and age you need to also look at your information technology capabilities to help. Identifying patients who may be at risk when certain drugs are prescribed (eg. the elderly, those with low albumin or liver diseases, those with underlying respiratory conditions, those receiving other sedating agents or analgesics, etc.) may allow you to trigger alerts or reminders at the time of order entry.
Also included below are links to some guidelines and useful resources on moderate sedation from the American Gastroenterological Association, the American Society for Gastrointestinal Endoscopy, the American Dental Association, and a statement from the American Society of Anesthesiologists on training, credentialing and privileging for non-anesthesiologists performing moderate sedation.
References:
National Patient Safety Agency (UK). Rapid Response Report. Reducing risk of overdose with midazolam injection in adults. December 2008
FDA information on midazolam from Drugs.com
http://www.drugs.com/pro/midazolam-injection.html
Sheth HS, Galhotra S, Verrico MM, Towers AL, DeVita MA. Adverse Events Related to Lorazepam Use on Medical Floors. Journal of Patient Safety 2008; 4(2):61-65
Cohen LB, Delegge MH, Aisenberg J, Brill JV, Inadomi JM, Kochman ML, Piorkowski JD. AGA Institute Review of Endoscopic Sedation. Gastroenterology 2007; 133: 675701 (American Gastroenterological Association) http://www.gastro.org/user-assets/Documents/02_Clinical_Practice/medical_position_statments/endoscopic_sedation_mps.pdf
Waring JP, Baron TH, Hirota WK, Goldstein JL, Jacobson BC, Leighton JA, Mallery JS, Faigel DO. Guidelines for conscious sedation and monitoring during gastrointestinal endoscopy. Gastrointest Endosc2003; 58(3):317-22 (American Society for Gastrointestinal Endoscopy Guideline)
http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=4141&nbr=3177
American Dental Association (ADA.org). Guidelines For The Use Of Sedation And General Anesthesia By Dentists 2007; ADA.org 2007
http://www.ada.org/prof/resources/positions/statements/anesthesia_guidelines.pdf
American Society of Anesthesiologists. Statement On Granting Privileges For Administration Of Moderate Sedation To Practitioners Who Are Not Anesthesia Professionals. 2006
http://www.asahq.org/publicationsAndServices/standards/40.pdf
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February 24, 2009
Discharge Planning: Finally Something That Works!
We spend a lot of time discussing the many dangerous things that can happen during a hospitalization. But the period following discharge is just as or even more dangerous. The most widely cited study on post-discharge adverse events (Forster et al 2003) found 19% of patients discharged from an academic tertiary care center suffered an adverse event within 3 weeks of discharge. And almost two-thirds of these events were considered either potentially preventable or ameliorable. Adverse drug events were the most common type seen.
A big problem in the past has involved transitioning patients cared for in tertiary hospitals back to their primary care providers. And now that many community hospitals have begun using the hospitalist model for inpatient care, the physicians providing the inpatient care may never see the patient again after discharge. Hence, the communication and coordination of care that occur at discharge have become even more important.
Weve discussed on several occasions the problem of test results pending at the time of discharge that fail to be followed up on (see our May 1, 2007 Tip of the Week The Missed Cancerand our February 12, 2008 Tip of the Week More on Tracking Test Results). A study by Roy et al in two tertiery care hospitals (Roy et al 2005) found that 41% of patients had test results that returned after patients had been discharged. Almost 10% of those were potentially actionable and over 60% of physicians surveyed were unaware of those test results.
And, of course, one of the biggest reasons for the push to perform medication reconciliation has been the frequent occurrence of medication errors at the time of discharge. A recent study (Zhang et al 2009) found that comorbidities, but not advancing age, were associated with repeat admission for adverse drug events in older adults.
Nationally, almost 18% of Medicare patients get readmitted to the hospital within 30 days after discharge. We all spend a considerable amount of time on the discharge planning process but there is a surprising dearth of literature showing what specific interventions are successful in avoiding readmissions or avoiding other post-discharge adverse events. A recent review of the discharge planning process (Katikireddi and Cloud 2008) provided practical advice on performing discharge planning and outlined many of the key elements to incorporate in that process but pointed out that almost none of the recommendations are evidence-based.
However, this month a new randomized study (Jack et al. 2009) documented considerable improvement in rehospitalization rates using a structured hospital discharge program. In that program, a nurse discharge advocate interacted with a multidisciplinary team to develop a post-discharge plan, schedule and coordinate followup medical appointments and tests, provide a list of pending test results, a description of the discharge diagnosis and medications, and information about what to do if a problem occurred. A clinical pharmacist then called the patient by phone 2-4 days after discharge. The primary outcome measure was a composite of repeat hospitalizations or ER visits within 30 days. The intervention group had 21.6% of such events, compared to 26.9% in the usual care group. The average time spent by the discharge advocate (in contact with the patient or the medical team and preparing the discharge documents) was 87.5 minutes per patient and the pharmacist spent a median of 14 minutes talking to the patient plus 10 minutes preparation time. And the average net savings was $412 per person who received the intervention.
A prior demonstration project by the Colorado Foundation for Medical Care (a Medicare QIO) had demonstrated that a coaching model was successful in reducing readmission rates by almost 50%. In that model, an RN coach visits the patient once in the hospital and once within 48 hours after discharge and also calls the patient by phone three additional times. They discuss medication management, followup visits with physicians, a patient-centered record, and knowledge of red flags the patient should be aware of.
So these two studies demonstrate that use of a nurse-managed model with well-designed plans for discharge successfully reduce the likelihood of readmission and more than pay for themselves.
More than that, weve found that post-discharge phone calls to patients can do wonders for the public relations of your organization. The patients perception that you care about them after discharge can significantly improve their satisfaction with the entire hospital experience.
References:
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital.Ann Intern Med. 2003; 138:161-167
http://www.annals.org/cgi/reprint/138/3/161.pdf
Roy CL,Poon EG,Karson AS,et al.Patient safety concerns arising from test results that return after hospital discharge.Ann Intern Med 2005; 143:121-128
http://www.annals.org/cgi/reprint/143/2/121.pdf
Zhang M, Holman CDJ, Price SD, et al. Comorbidity and repeat admission to hospital for adverse drug reactions in older adults: retrospective cohort study. BMJ2009; 338: a2752 (Published)
http://www.bmj.com/cgi/reprint/338/jan07_3/a2752
Katikireddi SV, Cloud GC. Planning a patients discharge from hospital. BMJ 2008; 337: a2694 (Published 12 December 2008, doi:10.1136/bmj.a2694)
http://www.bmj.com/cgi/content/extract/337/dec12_1/a2694
Jack BW, Chetty VK, Anthony D et al. A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial. Annals of Internal Medicine. 150(3):178-187, February 3, 2009
http://www.annals.org/cgi/content/abstract/150/3/178
Atlantic Information Services. CMS Targets Readmission Through Payment, Audits; Coaching Model Reduces Rates. Report on Medicare Compliance 2008; 17(24): 1-2 (June 30, 2008)
http://www.cfmc.org/files/rmc063008.pdf
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March 3, 2009
Overriding Alerts...
Like Surfin' the Web
Was there an ad present when you came to this web page? The answer is no (because we dont do any ads!) but the point is: you dont remember whether there was one or not! The web has opened up vast resources to us but at the same time has shaped some of our behaviors. When we surf the web we are actually usually looking for a specific piece of information or performing a specific task. We have learned to ignore all the things that are extraneous to that task. If there is an ad or a request to fill out a survey, we click it off or simply ignore it or we just leave the site.
So should alert fatigue on computerized physician order entry (CPOE) come as a surprise to anyone? Just as you have developed web ad fatigue or staff in ICUs have developed alarm fatigue where they tend to ignore some alarms because alarms are always going off, clinicians readily develop alert fatigue where they ignore all alerts and reminders that pop up on the computer screen.
While alert fatigue is not a new phenomenon, two recent papers highlight its widespread nature and the many issues related to it. Lo et al. (Lo et al. 2009) found that non-interruptive alerts recommending baseline lab testing during medication order entry in an ambulatory setting were not effective in improving test ordering. Isaac et al. (Isaac et al. 2009) found that clinicians using an outpatient e-prescribing system accepted only 9.2% of drug interaction alerts and only 23% of allergy alerts.
That certainly questions the likelihood of quick success for the CMS e-prescribing initiative or the approximately $20 billion in President Obamas stimulus package that is targeted for healthcare information technology. That $20 billion investment was estimated to generate a downstream savings of many billion of dollars due to reduction of medical errors and better efficiencies. We remain strong advocates of using IT to improve quality and patient safety and save money in doing so. However, the dismal results of the above two studies show we have a lot of work to do to reap those benefits.
So what can we learn from these studies? In the Isaac study there was no significant difference in alert acceptance rates across different specialties. Clinicians who wrote more prescriptions were less likely to accept the drug interaction alerts, though those who used the e-prescribing system longer were somewhat more likely to accept alerts. Importantly, clinicians were only slightly more likely to accept high-severity alerts than moderate- or low-severity ones. Especially if a patient had previously received an alerted medication the physician was likely to override the alert (youll recall from many of our previous columns that alerts often lead to a reduction in new prescriptions for a medication but that physicians seldom stop a medication the patient is already taking).
Contrast that to a study done on inpatients (Paterno et al. 2009) which showed that tiering of drug-drug interaction (DDI) alerts by severity level was successful at improving compliance rates. In that study, acceptance rates for DDIs were compared at two comparable academic hospitals within a large system. Both used the same DDI database. At one hospital, the alerts were tiered by severity. Level I alerts (the most serious) accounted for only 0.2% of alerts but required a hard stop (i.e. the ordering physician could not continue with the order). At the control (non-tiered) hospital, where the clinician was not interrupted in any way, only 34% of those same alerts were accepted. For the next most serious level II alerts (which required at least some action by the clinician at the tiered hospital), the acceptance rates were also more likely to be accepted at the tiered hospital (29% vs. 10%). So at least on the inpatient side, it is clear that hard stop alerts or interruptive alerts are more likely to have an impact.
So if you have a patient safety issue you are trying to address through CPOE, your chance of influencing it with non-interruptive (informational) alerts is not very good no matter how colorful or animated you make that alert (remember, you also easily ignore those animated dancing figures in the webpage ads!). For example, if you are attempting to reduce the inappropriate use of Foley catheters, simply listing the legitimate indications for a Foley is not likely to reduce their use. But if you require the ordering physician to input a reason for the Foley by checking a checkbox with those legitimate reasons or inputting free text before they can proceed, you are much more likely to have an impact.
Another consideration is use of reflex orders. For example, if you dont want patients on full anticoagulation going unmonitored consider automatically ordering the lab monitoring tests when the anticoagulant is initially ordered. Obviously, such reflex ordering needs to be done under a protocol approved by your medical staff.
And, whenever possible, use standardized order sets to accomplish your goals rather than alerts and reminders. Standardized order sets work well but keep in mind that only a fraction of orders during a hospitalization are entered at a time when such order sets are likely to be used (eg. on admission or postoperatively).
A study from the same health system as the Paterno study (Shah et al. 2006) also demonstrated a beneficial effect of tiered alerts on the outpatient side. 67% of interruptive Level 1 or 2 alerts were accepted in this study. The knowledge base used in this study to generate alerts probably resulted in more clinically focused alerts than those generated in the commercial knowledge base used in the Isaac study. The Shah study also details many of the reasons clinicians chose to override alerts, providing keen insight into future development of alerts.
Your job does not stop when you deploy new rules, alerts and reminders. You need to have in place a system that tracks the number of times an alert is triggered, how often it is accepted or overridden, what the reasons are for overrides, what sort of responses clinicians made to alerts, and whether the alert achieved the clinical outcomes you were attempting to achieve (or avoid), getting both objective and subjective measures of the success or failure of that rule/alert. That review must take place early and often (we recommend at one and three months). Rules/alerts with high override rates either need to be removed or reconsidered. In addition, capturing the reasons for overrides may help design of future alerts so that such reasons can be included in dropdown boxes or checklists for overrides.
Providing the clinician with alternative actions when an alert is presented may be helpful, though there is not a lot of evidence to validate that. For example, in the study by Lo et al. the physician sometimes had to use a different modality to order the monitoring lab test. It is conceivable that such disruption in workflow may have played a significant role in failure to follow the alerts. While you want to minimize interruptions in the usual workflow for your clinicians, you also want to make it easy for them to do the right thing. If they cannot easily accept the alert and do the correct thing with one click (or a few at most), they are probably going to ignore the alert. Its like designing a website too many clicks and you lose the surfer.
Everyone agrees that the fewer interruptions you cause for physicians, the more they are likely to adopt CPOE. So you need to put your stake in the ground pick a relatively small number of serious things you are trying to prevent and use more interruptive techniques to discourage those things. The key question is whether the non-interruptive alerts and reminders are ever of value. We spend a great deal of time developing many of those despite lack of good evidence that they actually change outcomes. They are the ones that are like the internet ads well bet you never pay attention to them either!
References:
Lo HG, Matheny ME, Seger DL, Bates DW, Gandhi TK. Impact of non-interruptive medication laboratory monitoring alerts in ambulatory care. J Am Med Inform Assoc. 2009; 16:66-71
http://www.jamia.org/cgi/content/abstract/16/1/66
Isaac, Thomas MD, MBA, MPH; Weissman, Joel S. PhD; Davis, Roger B. ScD; Massagli, Michael PhD; Cyrulik, Adrienne MPH; Sands, Daniel Z. MD, MPH; Weingart, Saul N. MD, PhD Overrides of Medication Alerts in Ambulatory Care. Archives of Internal Medicine. 169(3):305-311, February 9, 2009.
http://archinte.ama-assn.org/cgi/content/abstract/169/3/305
Paterno MD, Maviglia SM, Gorman PN, et al. Tiering DrugDrug Interaction Alerts by Severity Increases Compliance Rates. J. Am. Med. Inform. Assoc. 2009; 16(1):40-46. PrePrint published January 1, 2009; doi:10.1197/jamia.M2808
Shah NR, Seger AC, Seger DL, et al. Improving Acceptance of Computerized Prescribing Alerts in Ambulatory Care. J. Am. Med. Inform. Assoc. 2006; 13(1):5-11. PrePrint published January 1, 2006; doi:10.1197/jamia.M1868
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March 10, 2009
Prolonged Surgical Duration and Time Awareness
Our interest was piqued by a recent article demonstrating a new IT technique for updating of times remaining in surgical cases (Dexter et al. 2009). The authors note that predicting the duration of an ongoing surgical procedure is not always straightforward. For example, most would think that a case booked for 2 hours and currently at 1.5 hours would have 0.5 hours remaining. Not so, according to the authors, and the actual amount differs by type of procedure and other variables.
It is a very interesting technique where complex mathematical formulas are applied to historical data about prior similar cases (by surgeon and procedure) if available, then updated in a running time fashion during the surgical case and incorporating physiologic monitored data to provide an estimate of the time remaining in the current case. Sometimes text messages to and from the anesthesiologists participating in the case may also supplement the estimates. The updated estimates are then available on the whiteboards in the OR suite or on the operating room IT system. The updated estimates are very valuable to a variety of perioperative stakeholders such as anesthesiologists, surgerons, the PACU, the holding area, the scheduling desk, etc.
The system is touted as a way to significantly improve OR efficiency. And certainly it could. It would provide more accurate estimates to help transition to subsequent OR cases or to facilitate scheduling of add-on cases and improve flow in post-surgical care areas.
But we are intrigued that such a system could have a significant patient safety impact as well. It should certainly help minimze the time a patient would spend in a holding area, where staff monitoring the patient may be less familiar with the intricacies of his/her medical problems than would the staff back on the floor the patient came from.
But we wonder whether there might be additional advantages. Prolonged surgery has many potential patient safety complications. Cases that last longer than anticipated are likely more complicated and, as such, expected to have more complications. However, some complications are likely a result of the excessive length of the procedure itself. The longer a surgical procedure is, the higher the risk of surgical site infection and DVT/pulmonary embolism. Other potential complications of prolonged surgery are hypothermia, fluid shifts, nerve compression injuries, compartment syndromes, and rhabdomyolysis. One would expect that some other potential complications of prolonged surgery might include retained foreign bodies and traction-related tissue injuries.
Youve heard us say before that the OR team, during the surgical timeout or during the presurgical huddle, should discuss issues related to prolonged cases. For example, they should discuss whether intraoperative DVT prophylaxis should begin if the procedure lasts beyond a certain duration. Or discuss at what duration a repositioning of the patient (to avoid nerve compression, compartment syndrome, or rhabdomyolysis) might be wise.
So it could be very useful to use the updated estimate of time remaining to again trigger some discussion on the above issues. In addition to the DVT prophylaxis and repositioning issues, it might raise questions about the need to temporarily ease up on traction. It might direct attention to maintenance of the patients body temperature. In a very prolonged case it might raise questions about the need for further doses of prophylactic antibiotics.
Our experience is that most OR teams are not very time aware. As cases go on longer, foot traffic in and out of the OR increases, both as staff go on breaks or change shifts and as interruptions for questions, etc. begin to affect the surgeons and anesthesiologists. That increased foot traffic may be one factor that increases the likelihood of surgical site infections (Lynch et al. 2009). Long duration of surgery has long been known to be a factor associated with increased risk of surgical site infection. Particularly in academic/teaching facilities, better time awareness might suggest the need for a more senior surgeon to take over a case that is not progressing as smoothly as it should.
Unfortunately, these are mostly just ideas that make sense. We dont like to provide you with a lot of patient safety ideas that make good sense but have not been based in evidence. Weve seen too many unintended consequences when we implement good ideas. But this paper so wet our appetite that we decided to throw out these ideas in hopes that some of you may pick up on them and perhaps try to develop that evidence base.
References:
Dexter F, Epstein RH, Lee JD, Ledolter J. Automatic Updating of Times Remaining in Surgical Cases Using Bayesian Analysis of Historical Case Duration Data and "Instant Messaging" Updates from Anesthesia Providers. Anesth Analg 2009; 108:929-940
http://www.anesthesia-analgesia.org/cgi/content/abstract/108/3/929
Alterman I, Sidi A, Azamfirei L, Copotoiu S, Ezri T. Rhabdomyolysis: another complication after prolonged surgery. J Clin Anesth. 2007 Feb;19(1):64-6.
http://www.ncbi.nlm.nih.gov/pubmed/17321931
Lynch RJ, Englesbe MJ, Sturm L, et al. Measurement of Foot Traffic in the Operating Room: Implications for Infection Control. American Journal of Medical Quality 2009; 24: 45-52
http://ajm.sagepub.com/cgi/content/abstract/24/1/45
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March 17, 2009
More on MRI Safety
Many of our columns have highlighted the radiology suite as a site where many patient safety issues occur. In our October 16, 2007 Patient Safety Tip of the Week Radiology as a Site at High-Risk for Medication Errors we noted at least 14 factors that make adverse events more likely in the radiology suite. Undoubtedly there are many more contributing factors and conditions. Our September 16, 2008 Patient Safety Tip of the Week More on Radiology as a High Risk Area highlighted patient safety issues related to transportation to the radiology suite as well as numerous other safety issues related to radiology.
The MRI suite has virtually all the same potential risks that we see in the radiology suite plus a whole host of additional risks that are associated with the unique features of the MRI scanner and the special construction and design of the MRI suite to accommodate the scanner. In our Patient Safety Tip of the Week for February 19, 2008 MRI Safety we discussed Joint Commissions Sentinel Event Alert Preventing accidents and injuries in the MRI suite and The American College of Radiologys updated guidance document for safe MR practices published in the June 2007 issue of the American Journal of Radiology (Kanal et al 2007). These two document outline multiple safety issues related to MR imaging and provide numerous excellent recommendations about MRI safety. This months Whats New in the Patient Safety World column Risk of Burns during MRI Scans from Transdermal Drug Patches discusses the burns during MRI from drug patches, something we had previously discussed in our Patient Safety Tips of the Week for February 19, 2008 MRI Safety and May 13, 2008 Medication Reconciliation: Topical and Compounded Medications.
Now the American Society of Anestheiologists (ASA) has released its Practice Advisory on Anesthetic Care for Magnetic Resonance Imaging. Dont let the title fool you you can learn a lot about MRI safety from this paper regardless of whether you are an anesthesiologist or other healthcare professional.
This ASA practice advisory is based as much on consensus and expert opinion as it is on hard evidence. Therefore the ASA notes that this advisory does not carry the same weight that would a standard, guideline, or absolute requirement. Nevertheless, the recommendations are practical and the advisory raises patient safety and environmental safety issues that all healthcare workers need to be aware of.
All staff should receive education about the general risks of the MRI suite, including the segmentation of the suite into 4 zones (see our Patient Safety Tip of the Week for February 19, 2008 MRI Safety), the health risks associated with this environment (eg. high decibel levels and the high-intensity magnetic fields), and information about the risks of ferromagnetic items and implantable devices that should not be brought into zones III or IV, and education about the protocols for responding to code blue situations in the MRI suite.
All anesthesia team members, like all other patients and personnel, must be screened for ferromagnetic materials, foreign bodies, or implantable devices before entering Zones III and IV. Think of all the ferromagnetic materials a typical physician might have on his or her body: stethoscopes, pens, watches, wallets, hairclips, nametags, pagers, cell phones, credit cards, batteries, eye glasses, PDAs, and maybe even an iPod! These cannot be taken into zones III or IV.
The anesthesia team participates in screening the patient for patient-related risks. These include age-related risks and health-related risks, plus specific risks or contraindications related to the presence of ferromagnetic materials or implanted devices.
The anesthesia team needs to work with radiologists and all other relevant parties to ensure that equipment to be used in the MRI suite is safe for use in that suite. Caution must be taken with all monitoring equipment, particularly paying attention to leads and wires and especially loops that may become excessively heated when exposed to the magnetic fields.
The anesthesiologist needs to develop a plan for implementing anesthesia care before each individual case. Such a plan should be done in collaboration with other personnel who will be involved in the care of the patient, including the MRI technician, radiologist, radiology nurse, other clinical personnel accompanying the patient and even the facility biomedical engineer. They need to find the appropriate location of moveable equipment in relation to the gauss lines within the MRI suite. The plan should include where the optimal line of sight will be for both observing the patient and any monitors. The plan needs to have a contingency for emergencies. The latter would include how to summon assistance during an emergency, where emergency medications and equipment will be located, where the patient will be evacuated to (note that rescuscitation is begun as the patient is transported to the previously designated safe area outside Zone IV), and how emergency response personnel need to be prevented from entering Zone IV. The plan also needs to address the level of sedation or anesthesia anticipated and what to do if a higher level is needed or inadvertently achieved. The plan needs to specify how the intravenous drugs, oxygen, anesthetic gases, suction and waste management will be handled. In some cases where MRI-safe or MRI-conditional equipment is not available, special conduits called wave guides may have to be used for some of these management activities. When deep sedation is used or when direct observation of respiration cannot be performed during moderate sedation, monitoring of exhaled carbon dioxide should be considered (simply monitoring oxygen saturation by pulse oximetry is insufficient in such circumstances). It should also be remembered that the magnetic fields may interfere with interpretation of some monitoring tools, such as EKG, so some data must be interpreted with caution.
Weve discussed surgical and neonatal fires in several columns on this website (see our Patient Safety Tips of the Week for December 7, 2007 Surgical Fires, January 29, 2008Thoughts on the Recent Neonatal Nursery Fire, and April 29, 2008 ASA Practice Advisory on Operating Room Fires). The fire triangle consists of a fuel, a heat source, and an oxidyzer. So a patient who is receiving supplemental oxygen certainly could be at risk for a fire under certain circumstances during MRI scanning. We have already pointed out that burns may occur in association with ferromagnetic substances, implanted devices, or certain monitoring equipment. The magnetic current passing over leads or wires, particularly in certain looped configurations, may generate a tremendous amount of heat. Patient fires have been reported during MRI scanning, albeit rarely, so the same precautions and planning should be undertaken as would be done in the OR. Everyone needs to know their role in the event of a patient fire.
The entire staff must also be aware of the remote possibility of a quench. That is what happens when the magnet shuts down, catastrophically releasing gases (often under high pressure) and dissipating oxygen. The emergency protocol for a quench must be followed. If it is possible to rescue the patient and remove him/her from Zone IV, oxygen should be administered immediately.
Postanesthetic care should be consistent with all standards that would apply to postanesthetic care elsewhere in the institution.
There are a few issues wed add to this otherwise excellent ASA practice advisory. First is the importance of determining up front whether the MRI is truly indicated, whether the potential benefits of performing the MRI outweigh the potential risks, and whether alternative safer imaging modalities might suffice. In many of the incidents weve seen occurring in ICU patients transported to the MRI suite or radiology suite, weve been surprised at how often the scan being done was really of marginal value.
Second is the need for a huddle/timeout before the procedure is performed. We should approach doing MRI on these critically ill patients in the same manner in which we approach patients going to the OR. A huddle or whatever else youd like to call a pre-procedure briefing is very important in such cases. Not only do you need to know you have all the equipment needed, but you also need to know everyones role and have contingency plans for emergencies. This is where you ensure all parties know what to do if there is a fire or if there is a cardiopulmonary arrest or a quench. You discuss what location you will need to move the patient to in such events. You discuss the availability and location of equipment and medications you may need. You discuss the line of sight required and where the monitoring equipment will be deployed. You may need to discuss also how you will communicate (with both staff and patient) given the high noise levels associated with MRI scanning. You should probably even discuss the potential impact of the lighting levels in the various zones (and fact that you may not be able to wear your ferromagnetic glasses in Zones III and IV).
Third, really related to the above, is use of a checklist. To remember all the needs for the procedure (which vary be individual patient) and the contingencies you have to plan for is really too much to expect for any individual or group of individuals. Thats where the simple checklist comes in: it helps you to remember details you might otherwise overlook.
Fourth, you need to practice. We wonder how many MRI facilities, particularly hospital-based ones, actually simulate an emergency during MRI scanning. Looking for a topic for a FMEA (failure mode and effects analysis)? What better one than an emergency in your MRI suite?
References:
Joint Commission. Sentinel Event Alert. Preventing accidents and injuries in the MRI suite. Issue 38. February 14, 2008
http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_38.htm
Kanal E et al. ACR Guidance Document for Safe MR Practices: 2007. AJR 2007; 188: 1-27 http://www.acr.org/SecondaryMainMenuCategories/quality_safety/MRSafety/safe_mr07.aspx
Practice Advisory on Anesthetic Care for Magnetic Resonance Imaging.
A Report by the American Society of Anesthesiologists Task Force on Anesthetic
Care for Magnetic Resonance Imaging. Anesthesiology. 110(3):459-479, March 2009
http://pdfs.journals.lww.com/anesthesiology/2009/03000/9.pdf
Print More on MRI Safety
March 24, 2009
Medication Errors in the OR
We have previously talked about the Radiology suite as a site at high risk for medication errors (see our Patient Safety Tips of the Week October 16, 2007 Radiology as a Site at High-Risk for Medication Errors and September 16, 2008 More on Radiology as a High Risk Area). The OR is another site at high risk for serious medication errors. Our interest in this topic was triggered by two recent articles from our Canadian colleagues. Medication Safety in the Operating Room: Teaming Up to Improve Patient Safety (Merali et al 2008) summarized findings from an ongoing project on medication safety for operating rooms. The second was an ISMP Canada safety bulletin just issued ALERT: Fatal Outcome after Inadvertent Injection of Epinephrine Intended for Topical Use after a fatal case in an OR.
Though the OR is not one of the top 10 sites for medication errors in the USP MEDMARX database, the serious nature of the outcomes of such errors in the OR makes it imperative organizations be aware of the risks in the OR and take steps to minimize them (Beyea et al 2003).
There are a number of factors that make medication errors in the OR both more likely and more serious when they do occur:
So it should not be surprising that serious outcomes may arise from medication errors occurring in the OR.
Most of you are familiar with the Beyond Blame video (now available through ISMP online store in the US). One of the cases highlighted in that video was that of a child who died after an inadvertent injection of high concentration epinephrine instead of a solution of lidocaine with low-dose epinephrine intended for tissue infiltration.
ISMP Canada has just published a safety bulletin about a similar case ALERT: Fatal Outcome after Inadvertent Injection of Epinephrine Intended for Topical Use. The new case was also an ENT case (the original case in the Beyond Blame video was also an ENT case). The surgeon requested local anesthetic for injection (lidocaine 1% with epinephrine 1:100,000) but was handed a pre-drawn syringe that contained epinephrine 1 mg/ml (1:1000) that was intended for topical use. Unfortunately, the patient immediately suffered a cardiac arrhythmia and cardiac arrest and died.
The ISMP Canada bulletin highlights several contributing factors that came out of the root cause analysis. Some typical enabling factors were present: preparation for the surgery was behind schedule, the OR nurse was interrupted after drawing the epinephrine into a syringe, the unlabelled syringe was placed on the metal stand beside the OR table. But some other root causes were found. Both medications were often prepared prior to the start of the procedure by one nurse, typically in one area of the OR. The concentrated epinephrine for topical use was actually on back order so the OR was using epinephrine 1 mg/ml for injection as a substitute. So the nurse had to draw the contents into a syringe rather than pouring the epinephrine from the manufacturers container directly into a sterile open container with pledgets as is usually done. Also, packaging issues may have been a contributing factor. Even though the topical product was intended to produce a pour-bottle format, the top looked similar to a multidose vial, suggesting to some to use a needle and syringe to withdraw medication. ISMP Canada has made recommendations to the manufacturer regarding changes in packaging.
Some very good recommendations are made by ISMP Canada as a result of this case. They note that the practice of withdrawing medication intended for topical use into a parenteral syringe is very risky. They suggest that all hospitals that use epinephrine 1 mg/ml (1:1000) for topical application review their processes and procedures and consider the following considerations:
Medication intended for topical application should not be placed into a parenteral syringe. Epinephrine for topical use should be provided in a pour-bottle format. (And, in a back order situation such as the current case, pharmacy should prepare the epinephrine in a distinct, ready-to-pour format.)
Preparations for topical use should be stored and prepared in areas distinct from those where injectable medications are stored and prepared.
Medications intended for injection should not be placed into open containers.
All syringes and containers should be labeled. There are available preprinted sterile labels for operating rooms or other areas where sterility must be maintained. Unlabelled syringes or containers should be discarded.
Any containers that will hold solutions intended for topical application should have a label containing the word TOPICAL.
Local anesthetics intended for injection should be kept in their original vials. They can be drawn into a syringe immediately before use, allowing the surgeon to participate in the verification process. The ISMP Canada bulletin notes that at a hospital where a similar event had previously occurred, current practice is to have the surgeons infiltrate the surgical site with local anesthetic before scrubbing and gowning for the ENT procedures. They state that subsequent infiltration is seldom needed.
Dont stock multidose vials of injectable epinephrine 1 mg/ml in any OR. This is a high alert drug and there is no reason for the multidose vials to be present in the OR.
Pharmacy should communicate to the point-of-care any product changes (such as a product back order situation). This applies not only to the OR but all areas of the hospital using medications.
Interestingly, the article in AORN Journal back in 2003 (Beyea et al 2003) also highlighted the significant risk related to epinephrine preparations in the OR and a prior ISMP Canada Safety Bulletin in 2004 had described a similar case. ISMP (US) has also published frequently on the risks of unlabelled syringes or open containers.
ISMP Canada has been collaborating with the Canadian Anesthesiologists Society, the Operating Room Nurses Association of Canada, and ISMP (US) and other parties to develop an Operating Room Medication Safety Checklist. The work done in the Beyea paper played a major role in developing that collaborative project. This is currently a web-based program. It allows facilities to compare themselves to other facilities, both nationally and regionally.
The Association of periOperative Registered Nurses (AORN) also produces the AORN Safe Medication Administration Tool Kit, another valuable tool in developing your OR medication safety program.
Most hospitals have at some time, as part of their perioperative patient safety programs, reviewed their medication safety. Nevertheless, the fact that the recent case is a recurrence of a serious issue makes this a good time for your organization to review its OR medication safety issues.
References:
Merali R, Orser BA, Leeksma A, Lingard S, Belo S, Hyland S. Healthcare Quarterly 2008;11(Sp):54-57
http://www.longwoods.com/view.php?aid=19650&cat=538
ISMP Canada Safety Bulletin. ALERT: Fatal Outcome after Inadvertent Injection of Epinephrine Intended for Topical Use. March 5, 2009
Beyea SC, Hicks RW, Becker SC. Medication Errors in the ORA Secondary Analysis of Medmarx. AORN Journal 2003; 77: 122-134
http://www.aornjournal.org/article/S0001-2092(06)61382-3/abstract
ISMP Canada Safety Bulletin. Risk of Tragic Error Continues in Operating Rooms. December 2004
http://www.ismp-canada.org/download/ISMPCSB2004-12.pdf
ISMP. ISMP Medication Safety Alert. Errors with Injectable Medications: Unlabeled Syringes Are Surprisingly Common! November 15, 2007
http://www.ismp.org/newsletters/acutecare/articles/20071115.asp?ptr=y
ISMP Canada. Operating Room Medication Safety Checklist
https://www.ismp-canada.org/operatingroomchecklist/
AORN Safe Medication Administration Tool Kit
http://www.aorn.org/PracticeResources/ToolKits/SafeMedicationAdministrationToolKit/
Print Medication Errors in the OR
March 31, 2009
Screening Patients for
Delirium Risk
In October 2008 we did back-to-back columns Managing Delirium and Preventing Delirium. We talked about high cost of delirium in both human terms and financial terms. The first column dealt with ways to identify delirium and manage it once it has occurred. The second dealt with what is probably the more important issue: identifying patients who are at risk for delirium in hopes of intervening to minimize the likelihood of actually developing delirium. We strongly advocated that any patient over the age of 65 have a delirium risk assessment prior to admission by a primary care physician or geriatrician who routinely does such screening or as part of a preoperative program staffed by a nurse or physician extender. We recommended doing the MMSE (or shorter versions) as the minimum assessment until future studies validate more complex instruments as well as looking for the other delirium risk factors noted in our October 21 column.
In the second of those two columns we mentioned some new work coming out of Duke on screening patients to predict the risk of postoperative delirium. That work has now been published (Greene et al 2009) along with a companion article (Smith et al 2009) and it provides some very encouraging insight into screening for delirium risk.
Greene et al screened 100 elderly patients prior to major noncardiac surgery, using a battery of tests of cognition and depression. A total of 16% of those patients subsequently developed postoperative delirium. They found 2 key predictors of postoperative delirium: impaired executive function (as measured by the Trail Making B Test) and depression (as measured by the Geriatric Depression Scale Short Form or GDS-SF). Several other measures that had been noted to be predictive of delirium in other studies did not independently predict delirium in the Duke studies. Those included age, Charlson comorbidity index, history of depression, education level, ASA score, level of preoperative pain, alcohol use, BMI, or a measure of global cognitive function). However, the relatively small sample size may have been of insufficient power to demonstrate predictive power for several of these factors.
Specifically, of patients who scored above the cutoff on the Trails B test 44% developed postoperative delirium and of those who scored above the cutoff on the GDS-SF 35% developed postoperative delirium. Of the patients who scored above the cutoff on both tests, 83% developed postoperative delirium.
The two tests are easy to administer and are not very time-consuming. The GDS-SF is a 15-item yes/no test that has been validated in surgical populations. It takes about 5 minutes to administer. The Trail Making B test consists of 25 circles distributed over a sheet of paper, with numbers (1 13) and letters (A L). The patient draws lines to connect the circles in an ascending pattern, alternating between the numbers and letters (i.e., 1-A-2-B-3-C, etc.). The patient is timed as he/she connects the circles as quickly as possible, without lifting the pen or pencil from the paper. It also takes less than 5 minutes to administer.
Interestingly, unlike several prior studies, the MMSE (mini-mental status exam) in their studies did not independently predict the occurrence of postoperative delirium. That may reflect that their population overall was functioning at a relatively higher cognitive level than the populations in the prior studies.
However, they also raise the interesting concept of cognitive reserve. By that they mean that many of their patients were functioning without obvious gross impairment, but their cognitive capacity was not sufficient in the presence of a new CNS insult. They speculate that the tests of executive function reflect higher order complex cognition and thus may be better markers than tests of more global cognitive function.
The companion article (Smith et al 2009) also performed a battery of tests prior to surgery on almost 1000 patients, though the population was quite different and the incidence of postoperative delirium was only 3.5%. They also found that impairment of executive function and presence of depressive symptoms were predictors of postoperative delirium. The greatest value of this paper is that it showed that tests of more complexity of executive function were more predictive of delirium. Specifically, the modified Stroop Color Word Interference Test was most predictive.
The science and our knowledge of the underlying pathophysiology of delirium are obviously still evolving. Though much more research is needed to improve our ability to prevent delirium, it would currently make sense for organizations to incorporate delirium screening into your preoperative protocols at least for the elderly. Based on the Greene study, use of the GDS-SF and the Trails B test rather than the MMSE or tests of more global cognitive function may make practical sense. These tests are short, easy to administer, and have good predictive value.
References:
Greene, Nathaniel H. B.S. *; Attix, Deborah K. Ph.D. +; Weldon, B Craig M.D. ++; Smith, Patrick J. M.A. [S]; McDonagh, David L. M.D. [//]; Monk, Terri G. M.D., M.S. # Measures of Executive Function and Depression Identify Patients at Risk for Postoperative Delirium. Anesthesiology. 110(4):788-795, April 2009
Smith, Patrick J. M.A. *; Attix, Deborah K. Ph.D. +; Weldon, B Craig M.D. ++; Greene, Nathaniel H. B.S. [S]; Monk, Terri G. M.D., M.S. [//] Executive Function and Depression as Independent Risk Factors for Postoperative Delirium. Anesthesiology. 110(4):781-787, April 2009
Positive Aging Resource Center. Geriatric Depression Scale Short Form.
http://www.positiveaging.org/provider/pdfs/depression_geriatric-short.pdf
University of Iowa. Trail Making Test Parts A and B.
http://www.healthcare.uiowa.edu/igec/tools/cognitive/trailMaking.pdf
Print Screening Patients for Risk of Delirium
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Unexpected Events During MRI
March 26, 2019
March 19, 2019
March 12, 2019
Update on Overlapping Surgery
March 5, 2019
Infusion Pump Problems
February 26, 2019
Vascular Access Device Dislodgements
February 19, 2019
Focus on Pediatric Patient Safety
February 12, 2019
From Tragedy to Travesty of Justice
February 12, 2019
2 ER Drug Studies: Reassurances and Reservations
February 5, 2019
Flaws in Our Medication Safety Technologies
January 29, 2018
National Patient Safety Goal for Suicide Prevention
January 22, 2019
Wandering Patients
January 15, 2019
Another Plus for Prehabilitation
January 8, 2019
Maternal Mortality in the Spotlight
January 1, 2019
More on Automated Dispensing Cabinet (ADC) Safety
December 25, 2018
Happy Holidays!
December 18, 2018
Great Recommendations for e-Prescribing
December 11, 2018
December 4, 2018
Don’t Use Syringes for Topical Products
November 27, 2018
November 20, 2018
November 13, 2018
Antipsychotics Fail in ICU Delirium
November 6, 2018
More on Promoting Sleep in Inpatients
October 30, 2018
October 23, 2018
Lessons From Yet Another Aviation Incident
October 16, 2018
October 9, 2018
October 2, 2018
Speaking Up About Disruptive Behavior
September 25, 2018
Foley Follies
September 18, 2018
September 11, 2018
September 4, 2018
The 12-Hour Nursing Shift: Another Nail in the Coffin
August 28, 2018
Thought You Discontinued That Medication? Think Again
August 21, 2018
Delayed CT Scan in the Anticoagulated Patient
August 14, 2018
ISMP Canada’s Updated “Do Not Use” Abbreviation List
August 7, 2018
Tip of the Week on Vacation
July 31, 2018
Surgery and the Opioid-Tolerant Patient
July 24, 2018
More on Speech Recognition Software Errors
July 17, 2018
OSA Screening in Stroke Patients
July 10, 2018
Another Jump from a Hospital Window
July 3, 2018
Tip of the Week on Vacation
June 26, 2018
Infection Related to Colonoscopy
June 19, 2018
June 12, 2018
Adverse Events in Cancer Patients
June 5, 2018
Pennsylvania Patient Safety Authority on Iatrogenic Burns
May 29, 2018
More on Nursing Workload and Patient Safety
May 22, 2018
Hazardous Intrahospital Transport
May 15, 2018
May 8, 2018
May 1, 2018
April 24, 2018
April 17, 2018
More on Tests Pending at Discharge
April 10, 2018
Prepping the Geriatric Patient for Surgery
April 3, 2018
March 27, 2018
March 20, 2018
Minnesota Highlights Lost Tissue Samples
March 13, 2018
March 6, 2018
February 27, 2018
Update on Patient Safety Walk Rounds
February 20, 2018
February 13, 2018
February 6, 2018
Adverse Events in Inpatient Psychiatry
January 30, 2018
January 23, 2018
Unintentional Hypothermia Back in Focus
January 16, 2018
January 9, 2018
More on Fire Risk from Surgical Preps
January 2, 2018
Preventing Perioperative Nerve Injuries
December 26, 2017
Tip of the Week on Vacation
December 19, 2017
December 12, 2017
Joint Commission on Suicide Prevention
December 5, 2017
Massachusetts Initiative on Cataract Surgery
November 28, 2017
More on Dental Sedation/Anesthesia Safety
November 21, 2017
OSA, Oxygen, and Alarm Fatigue
November 14, 2017
Tracking C. diff to a CT Scanner
November 7, 2017
Perioperative Neuropathies
October 31, 2017
Target Drugs for Deprescribing
October 24, 2017
Neurosurgery and Time of Day
October 17, 2017
Progress on Alarm Management
October 10, 2017
More on Torsade de Pointes
October 3, 2017
Respiratory Compromise: One Size Does Not Fit All
September 26, 2017
Tip of the Week on Vacation
September 19, 2017
Tip of the Week on Vacation
September 12, 2017
Can You Hear Me Now?
September 5, 2017
Another Iatrogenic Burn
August 29, 2017
Suicide in the Bathroom
August 22, 2017
August 15, 2017
Delayed Emergency Surgery and Mortality Risk
August 8, 2017
Sedation for Pediatric MRI Rising
August 1, 2017
Progress on Wrong Patient Orders
July 25, 2017
Can We Influence the “Weekend Effect”?
July 18, 2017
Another Hazard from Alcohol-Based Hand Gels
July 11, 2017
The 12-Hour Shift Takes More Hits
July 4, 2017
Tip of the Week on Vacation
June 27, 2017
June 20, 2017
June 13, 2017
June 6, 2017
NYS Mandate for Sepsis Protocol Works
May 30, 2017
Errors in Pre-Populated Medication Lists
May 23, 2017
May 16, 2017
Are Surgeons Finally Ready to Screen for Frailty?
May 9, 2017
Missed Nursing Care and Mortality Risk
May 2, 2017
Anatomy of a Wrong Procedure
April 25, 2017
April 18, 2017
Alarm Response and Nurse Shift Duration
April 11, 2017
Interruptions: The Ones We Forget About
April 4, 2017
Deprescribing in Long-Term Care
March 28, 2017
More Issues with Dental Sedation/Anesthesia
March 21, 2017
Success at Preventing Delirium
March 14, 2017
More on Falls on Inpatient Psychiatry
March 7, 2017
February 28, 2017
February 21, 2017
Yet More Jumps from Hospital Windows
February 14, 2017
February 7, 2017
January 31, 2017
More Issues in Pediatric Safety
January 24, 2017
Dexmedetomidine to Prevent Postoperative Delirium
January 17, 2017
January 10, 2017
The 26-ml Applicator Strikes Again!
January 3, 2017
What’s Happening to “I’m Sorry”?
December 27, 2016
Tip of the Week on Vacation
December 20, 2016
End-of-Rotation Transitions and Mortality
December 13, 2016
More on Double-Booked Surgery
December 6, 2016
Postoperative Pulmonary Complications
November 29, 2016
Doubling Down on Double-Booked Surgery
November 22, 2016
Leapfrog, Picklists, and Healthcare IT Vulnerabilities
November 15, 2016
November 8, 2016
Managing Distractions and Interruptions
November 1, 2016
CMS Emergency Preparedness Rule
October 25, 2016
Desmopressin Back in the Spotlight
October 18, 2016
Yet More Questions on Contact Precautions
October 11, 2016
New Guideline on Preop Screening and Assessment for OSA
October 4, 2016
September 27, 2016
September 20, 2016
Downloadable ABCDEF Bundle Toolkits for Delirium
September 13, 2016
Vanderbilt’s Electronic Procedural Timeout
September 6, 2016
August 30, 2016
Can You Really Limit Interruptions?
August 23, 2016
ISMP Canada: Automation Bias and Automation Complacency
August 16, 2016
How Is Your Alarm Management Initiative Going?
August 9, 2016
August 2, 2016
Drugs in the Elderly: The Goldilocks Story
July 26, 2016
Confirmed: Keep Your OR Doors Closed
July 19, 2016
Infants and Wrong Site Surgery
July 12, 2016
Forget Brexit – Brits Bash the RCA!
July 5, 2016
Tip of the Week on Vacation
June 28, 2016
Culture of Safety and Catheter-Associated Infections
June 21, 2016
Methotrexate Errors in Australia
June 14, 2016
Nursing Monitoring of Patients on Opioids
June 7, 2016
CPAP for Hospitalized Patients at High Risk for OSA
May 31, 2016
More Frailty Measures That Predict Surgical Outcomes
May 24, 2016
Texting Orders – Is It Really Safe?
May 17, 2016
Patient Safety Issues in Cataract Surgery
May 10, 2016
Medical Problems in Behavioral Health
May 3, 2016
Clinical Decision Support Malfunction
April 26, 2016
Lots More on Preventing Readmissions But Where's the Beef?
April 19, 2016
Independent Double Checks and Oral Chemotherapy
April 12, 2016
April 5, 2016
Workarounds Overriding Safety
March 29, 2016
March 22, 2016
Radiology Communication Errors May Surprise You
March 15, 2016
March 8, 2016
Tip of the Week on Vacation
March 1, 2016
February 23, 2016
February 16, 2016
February 9, 2016
February 2, 2016
January 26, 2016
More on Frailty and Surgical Morbidity and Mortality
January 19, 2016
Patient Identification in the Spotlight
January 12, 2016
New Resources on Improving Safety of Healthcare IT
January 5, 2016
Lessons from AirAsia Flight QZ8501 Crash
December 29, 2015
More Medical Helicopter Hazards
December 22, 2015
The Alberta Abbreviation Safety Toolkit
December 15, 2015
Vital Sign Monitoring at Night
December 8, 2015
Danger of Inaccurate Weights in Stroke Care
December 1, 2015
TALLman Lettering: Does It Work?
November 24, 2015
Door Opening and Foot Traffic in the OR
November 17, 2015
Patient Perspectives on Communication of Test Results
November 10, 2015
Weighing in on Double-Booked Surgery
November 3, 2015
Medication Errors in the OR - Part 2
October 27, 2015
Sentinel Event Alert on Falls and View from Across the Pond
October 20, 2015
Updated Beers List
October 13, 2015
Dilaudid Dangers #3
October 6, 2015
Suicide and Other Violent Inpatient Deaths
September 29, 2015
More on the 12-Hour Nursing Shift
September 22, 2015
The Cost of Being Rude
September 15, 2015
Another Possible Good Use of a Checklist
September 8, 2015
TREWScore for Early Recognition of Sepsis
September 1, 2015
August 25, 2015
Checklist for Intrahospital Transport
August 18, 2015
Missing Obstructive Sleep Apnea
August 11, 2015
New Oxygen Guidelines: Thoracic Society of Australia and NZ
August 4, 2015
Tip of the Week on Vacation
July 28, 2015
July 21, 2015
Avoiding Distractions in the OR
July 14, 2015
July 7, 2015
June 30, 2015
What Are Appropriate Indications for Urinary Catheters?
June 23, 2015
Again! Mistaking Antiseptic Solution for Radiographic Contrast
June 16, 2015
June 9, 2015
Add This to Your Fall Risk Assessment
June 2, 2015
May 26, 2015
May 19, 2015
May 12, 2015
More on Delays for In-Hospital Stroke
May 5, 2015
Errors with Oral Oncology Drugs
April 28, 2015
April 21, 2015
April 14, 2015
Using Insulin Safely in the Hospital
April 7, 2015
March 31, 2015
Clinical Decision Support for Pneumonia
March 24, 2015
Specimen Issues in Prostate Cancer
March 17, 2015
March 10, 2015
FDA Warning Label on Insulin Pens: Is It Enough?
March 3, 2015
Factors Related to Postoperative Respiratory Depression
February 24, 2015
More Risks with Long-Acting Opioids
February 17, 2015
Functional Impairment and Hospital Readmission, Surgical Outcomes
February 10, 2015
The Anticholinergic Burden and Dementia
February 3, 2015
CMS Hopes to Reduce Antipsychotics in Dementia
January 27, 2015
The Golden Hour for Stroke Thrombolysis
January 20, 2015
He Didn’t Wash His Hands After What!
January 13, 2015
January 6, 2015
Yet Another Handoff: The Intraoperative Handoff
December 30, 2014
Data Accumulates on Impact of Long Surgical Duration
December 23, 2014
Iatrogenic Burns in the News Again
December 16, 2014
More on Each Element of the Surgical Fire Triad
December 9, 2014
December 2, 2014
ANA Position Statement on Nurse Fatigue
November 25, 2014
Misdiagnosis Due to Lab Error
November 18, 2014
Handwashing Fades at End of Shift, ?Smartwatch to the Rescue
November 11, 2014
Early Detection of Clinical Deterioration
November 4, 2014
Progress on Fall Prevention
October 28, 2014
RF Systems for Retained Surgical Items
October 21, 2014
The Fire Department and Your Hospital
October 14, 2014
October 7, 2014
Our Take on Patient Safety Walk Rounds
September 30, 2014
More on Deprescribing
September 23, 2014
Stroke Thrombolysis: Need to Focus on Imaging-to-Needle Time
September 16, 2014
Focus on Home Care
September 9, 2014
The Handback
September 2, 2014
Frailty and the Trauma Patient
August 26, 2014
Surgeons’ Perception of Intraoperative Time
August 19, 2014
Some More Lessons Learned on Retained Surgical Items
August 12, 2014
Surgical Fires Back in the News
August 5, 2014
Tip of the Week on Vacation
July 29, 2014
The 12-Hour Nursing Shift: Debate Continues
July 22, 2014
More on Operating Room Briefings and Debriefings
July 15, 2014
Barriers to Success of Early Warning Systems
July 8, 2014
Update: Minor Head Trauma in the Anticoagulated Patient
July 1, 2014
Interruptions and Radiologists
June 24, 2014
Lessons from the General Motors Recall Analysis
June 17, 2014
SO2S Confirms Routine Oxygen of No Benefit in Stroke
June 10, 2014
Another Clinical Decision Support Tool to Avoid Torsade de Pointes
June 3, 2014
More on the Risk of Sedative/Hypnotics
May 27, 2014
A Gap in ePrescribing: Stopping Medications
May 20, 2014
May 13, 2014
Perioperative Sleep Apnea: Human and Financial Impact
May 6, 2014
Monitoring for Opioid-induced Sedation and Respiratory Depression
April 29, 2014
More on the Unintended Consequences of Contact Isolation
April 22, 2014
Impact of Resident Workhour Restrictions
April 15, 2014
Specimen Identification Mixups
April 8, 2014
FMEA to Avoid Breastmilk Mixups
April 1, 2014
Expensive Aspects of Sepsis Protocol Debunked
March 25, 2014
March 18, 2014
Systems Approach Improving Stroke Care
March 11, 2014
We Miss the Graphic Flowchart!
March 4, 2014
Evidence-Based Prescribing and Deprescribing in the Elderly
February 25, 2014
Joint Commission Revised Diagnostic Imaging Requirements
February 18, 2014
February 11, 2014
Another Perioperative Handoff Tool: SWITCH
February 4, 2014
But What If the Battery Runs Low?
January 28, 2014
Is Polypharmacy Always Bad?
January 21, 2014
January 14, 2014
Diagnostic Error: Salient Distracting Features
January 7, 2014
Lessons From the Asiana Flight 214 Crash
December 24-31, 2013
Tip of the Week on Vacation
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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