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January 1, 2013
Don't Throw Away Those View Boxes Yet
This month we learned from researchers at Johns Hopkins (Mehtsun 2012) that over 4000 surgical never events occur annually in the US (see our What’s New in the Patient Safety World column for January 2013 “How Frequent are Surgical Never Events?”). And we can again benefit from many lessons learned in the most recent California Department of Public Health release of root cause analyses and plans of correction for 12 serious events (CDPH 2012). Of the most recent group of 12 events, 4 involved retained surgical items, 2 involved wrong-site surgery, 2 medication-related events, one surgical fire, and 3 other types of event.
One theme seen in several of the RCA’s reported by CDPH had to do with imaging studies, or lack thereof, in the operating room. The plan of correction for one of the hospitals (in a case where the wrong kidney was removed) has now mandated that images must be reviewed in all cases where an image had been obtained and that the OR circulator nurse and the surgeon ensure that all imaging studies are available, displayed and verified. In addition, all OR circulator nurses were given access to and trained on the PACS system.
In the old days we always brought relevant radiologic imaging studies to the OR and put them up on view boxes in the OR where they could easily be referenced. But what we have seen now on multiple occasions is that films and view boxes have been replaced by PACS systems in most hospitals and there are a number of factors that make images on PACS less accessible within the OR:
Remember, your surgical timeout procedure must include verification of correct patient (using multiple identifiers), the surgical procedure(s) to be done, the side or site of surgery and must use multiple primary documentation sources in this process. Primary source materials include things like the H&P, the booking form, the consent form, and imaging studies. Yet we commonly see that failure to review imaging studies (or even the reports) occurs frequently.
There were problems in the old days with radiographic films brought into the OR that sometimes led to adverse events. The classic problem was putting the films up backwards and mixing up left and right. The other classic, of course, was putting up the films on the wrong patient. Often the surgeon would bring in a whole radiology folder for that patient which contained multiple films. And occasionally that folder would mistakenly contain a couple films from a different patient. And a third scenario had to do with surgeons bringing into the OR films for all the patients they had scheduled that day. Allowing films on multiple patients to be in the OR at one time is simply an accident waiting to happen.
But do these potential contributory factors go away with PACS? Well, you are not likely to put a film up backwards (though if a technician puts the wrong side marker at the time the image is taken you are left with reversed images regardless of whether you are using PACS or the old fashioned images). But the wrong patient scenario does not go away. In fact, in some respects it may be easier to get the wrong patient when using PACS (see our Patient Safety Tips of the Week for May 20, 2008 “CPOE Unintended Consequences: Are Wrong Patient Errors More Common?”, June 26, 2012 “Using Patient Photos to Reduce CPOE Errors” and July 17, 2012 “More on Wrong-Patient CPOE”). When you search for images in a PACS system you may get multiple search results depending upon how you input your search query. If you get a list of several possible results you might easily choose the wrong one and assume you are looking at images on your patient. The chance of making such a mistake gets amplified when you throw in some of the pressures commonly seen in the OR setting.
The other important factor is the timing out process employed by the PACS system (or other IT systems). This, of course, is implemented in all facilities to maintain confidentiality and meet HIPAA standards. If your PACS system times out at 10 or 15 minute intervals but your OR case lasts several hours there could be multiple times during that case that someone has to reaccess the PACS system, log on again with username and password, and load the correct patient and correct images. Every time that is done is another opportunity for error, particularly when done during some of the rapidly changing dynamics in the OR. Some systems do allow customization of the IT time out interval for individual locations but most do not.
If you are able to customize your PACS/IT time out interval for the OR, keep in mind that you also have to be careful to exit that PACS system at the end of each OR case (so you don’t erroneously start the next case with images from the current patient on the screen).
Having all necessary images available in the OR is important for the surgeon but, frankly, may not help much in the verification process during the surgical timeout. That’s because all the other personnel in the room (nurses, surgical techs, CRNA’s and anesthesiologists) may not be able to interpret the images and thus might not appreciate which is the correct side to be operated on. In some images the most salient feature may, in fact, be an incidental finding and not relevant to the reason for which the surgery is being done. So from the standpoint of the verification during the surgical timeout you are probably better off having a copy of the radiology report.
Also, don’t forget that the process of correct site verification begins well before your surgical timeout is done in the OR. We strongly recommend that you do not book cases for surgery until all necessary documents are received (see our October 30, 2012 Patient Safety Tip of the Week “Surgical Scheduling Errors”). Once those documents are received your preoperative nurse can check for discrepancies between site/side on all documents. Your anesthesiologist also has the opportunity to check for discrepancies when he/she is doing the anesthesia pre-case review. And one of the items on the checklist you use for your pre-op huddle should be “Do we have all the imaging studies that we will need for this case?”. Years ago, long before Joint Commission began working on Universal Protocol, we instituted at one hospital a policy that the patient could not be taken into the OR until the surgeon was physically on site and ready to go and attested in the medical record that he/she had all the materials he/she would need for the surgery, including necessary images.
As an aside, the “wrong kidney” case also illustrates another problem often encountered in wrong-site surgery events. While we encourage active participation of the patient (or family) in the verification process, sometimes it can be misleading. In the case above the patient indicated to the nurse practitioner and an OR nurse that he had right-sided pain and even pointed to the right side when asked which kidney was to be operated on. However, the procedure was to have been a left nephrectomy for a mass lesion that had been identified on four previous CT scans. Note that the operative booking form also had listed that the surgery was to have been on the right kidney. Review of the imaging studies hence would have been crucial in identifying a disparity in those primary source documents so that a reconciliation could take place before surgery.
We encourage all facilities to review their current practices regarding availability of imaging studies in the OR and take steps to ensure adequate access to them, removing some of the barriers noted above.
References:
Mehtsun WT, Ibrahim AM, Diener-West M, Pronovost PJ, Makary MA. Surgical never events in the United States. Surgery 2012; published online ahead of print 18 December 2012
http://www.surgjournal.com/article/S0039-6060%2812%2900623-X/abstract
California Department of Public Health (CDPH). CDPH Issues 12 Penalties to California Hospitals. December 20, 2012
http://www.cdph.ca.gov/Pages/CDPHIssues12PenaltiestoCaliforniaHospitals.aspx
Print “Don’t Throw Away Those View Boxes Yet”
January 8, 2013
More Lessons Learned on Retained Surgical Items
In our June 12, 2012 Patient Safety Tip of the Week “Lessons Learned from the CDPH: Retained Foreign Bodies” and our November 2012 What’s New in the Patient Safety World column “More on Retained Surgical Items” we identified many of the risk factors for retained surgical items (RSI’s) and interventions implemented to reduce risks for RSI’s.
This month we learned from researchers at Johns Hopkins (Mehtsun 2012) that over 4000 surgical never events occur annually in the US (see our What’s New in the Patient Safety World column for January 2013 “How Frequent are Surgical Never Events?”). The authors estimate that, on average, retained surgical items occur 39 times a week in the US.
We’ve learned many lessons on RSI’s from the California Department of Public Health releases of root cause analyses and plans of correction for serious events (see our June 12, 2012 Patient Safety Tip of the Week “Lessons Learned from the CDPH: Retained Foreign Bodies”). Now in their most recent release on a group of 12 events, 4 involved retained surgical items (CDPH 2012). In these there were some recurrent themes and some new ones. Among the recurrent themes were emergent procedures, change of shift or change of personnel, excessive bleeding, surgeon’s taking items off the instrument table without declaring them for the count, time pressures (eg. next case waiting), and counts done prematurely before a body cavity was closed.
One of the newer lessons learned had to do with gauze as an RSI. We did mention a case of retained gauze in our June 12, 2012 column but this time there was a new nuance. Remember that gauze is not radiopaque so it typically eludes detection by radiographic imaging. In the case described a 17 x 2 cm. piece of gauze was removed from an infected (?superficial) skin wound several weeks after a laparoscopic surgical procedure. None of the 3 surgical setup trays used in the original procedure had gauze listed and none of the surgeons doing post-op followups could recall using gauze. However, an apparently common practice at this facility had been to use Xeroform gauze (petroleum based gauze dressing) around one of the trocar sites to prevent air leaks during laparoscopy. Such gauze was not part of the surgical count process prior to this incident. It may be important to add items such as gauze or surgical mesh to your white boards or other vehicles you are utilizing for your surgical counts as a reminder that such items need to be declared when put into the surgical field and properly counted.
Other lessons include the importance of being careful to separate sponges (by identifying the “tail” of the sponge) to avoid miscounts and the importance of continuity of staff. Changes in personnel during cases significantly increase the chance of discrepant counts. We’ve previously noted that the chance of discrepant counts is three times more likely when OR staff change during a procedure (Greenberg 2008). Some policies adopted at various facilities require all cases of specified duration (eg. those expected to last less than 2 or 3 hours) not change personnel during the case.
Another excellent recent study confirmed the continued occurrence of retained surgical items (RSI’s) and identified barriers to solving this issue (Stawicki 2013). This retrospective review identified cases of RSI’s at multiple institutions and matched cases with controls who did not have RSI’s to determine factors that may be contributing to RSI’s. The study confirmed many of the previously known risk factors for RSI’s (high body mass index, unexpected intraoperative events, prolonged surgical duration) but also found that the occurrence of any safety variance (especially incorrect counts) at any time during the procedure was an additional risk factor. Interestingly, the presence of trainees actually reduced the likelihood of an RSI by 70%.
In 4 of the 59 cases of RSI identified there was no surgical count. Moreover, in 18% of those cases that did have surgical counts the operation proceeded to completion despite at least one team member being aware of the incorrect count.
They also determined that some of the hi tech things we do to exclude RSI’s are not always successful in doing so. In 48% of cases in which an X-ray was done prior to the patient leaving the OR the RSI was missed on initial X-ray interpretation. Also, in 6.3% of the cases in which RFID tagging was used the RSI’s were missed.
The authors call attention to the failure to heed incorrect surgical counts as a form of “alarm fatigue”. By that they mean that incorrect counts that later get reconciled are so common that they begin to assume that all incorrect counts will be reconciled and they discredit the importance of the incorrect count. The authors recommend that an incorrect count always be treated as a “hard stop” requiring re-inspection of the surgical site and radiographic imaging if the RSI is not found. This, ideally, should occur before wound closure, before patient emergence from anesthesia and before the patient has left the OR.
Another interesting point they noted was that the surgeon’s failure to document whether counts were done and were correct or not may also be important. They suggest that such failure to attest to the surgical counts may reflect an inattentiveness to the counts.
But they point out that in 45 of the 59 cases there was no count discrepancy reported. That is similar to the 88% figure most often cited from the RSI literature. It clearly shows that additional methods of identifying RSI’s are needed. Such alternative methods include barcoding, RFID technology and radiographic imaging. But even those, as pointed out in this study, may miss RSI’s. Our November 2012 What’s New in the Patient Safety World column “More on Retained Surgical Items” had a discussion of the current status of the technological approaches to minimizing RSI’s and the fact that none of these systems are yet 100% accurate for detection of RSI’s.
Most of the plans of corrections in the CDPH releases added audits of the surgical counting process. Isn’t it ironic that, just as we see with surgical timeouts, we wait until we have a never event before we audit to determine how well we are doing with measures we institute to improve patient safety?
Our prior columns on retained surgical items (RSI’s):
References:
Mehtsun WT, Ibrahim AM, Diener-West M, Pronovost PJ, Makary MA. Surgical never events in the United States. Surgery 2012; published online ahead of print 18 December 2012
http://www.surgjournal.com/article/S0039-6060%2812%2900623-X/abstract
California Department of Public Health (CDPH). CDPH Issues 12 Penalties to California Hospitals. December 20, 2012
http://www.cdph.ca.gov/Pages/CDPHIssues12PenaltiestoCaliforniaHospitals.aspx
Greenberg C, Regenbogen SE, Lipsitz SR, Diaz-Flores R, Gawande AA. The Frequency and Significance of Discrepancies in the Surgical Count. Annals of Surgery 2008: 248(2): 337-341
Stawicki SPA, Moffatt-Bruce SD, Ahmed HM, Anderson HL, et al. Retained Surgical Items: A Problem Yet to Be Solved. Journal of the American College of Surgeons 2013; 216(1): 15-22
http://www.journalacs.org/article/S1072-7515%2812%2901124-6/abstract
Print “More Lessons Learned on Retained Surgical Items”
January 15, 2013
Falls on Inpatient Psychiatry
In our May 29, 2012 Patient Safety Tip of the Week “Falls, Fractures, and Fatalities” we briefly mentioned that the inpatient psychiatric/behavioral health unit is one area in which attention to fall risk tends to be less than optimal. Yet the risks on such units may be as great or greater than on even med/surg units or rehab units.
The Pennsylvania Patient Safety Authority published a “snapshot” of falls in behavioral health hospitals compared to other hospitals for the year 2009 (PPSA 2010). Falls accounted for 21.7% of submitted reports in behavioral health hospitals compared to 15.4% in non-behavioral hospitals. A greater percentage of medications related to falls were reported by behavioral health hospitals than other hospitals (70.3% versus 57.6%). Moreover, patient harm was more likely in falls in behavioral health hospitals (9.6% compared to 3.7% in non-behavioral health hospitals).
So why do patients on psychiatric inpatient units fall? Clearly many of the same risk factors for falls in any inpatient setting contribute. But there are also some risk factors and contributing factors that are unique to the inpatient psychiatry unit.
One obvious factor is simply the level of activity on the psychiatric unit. Compared to med/surg units where patients are largely confined to bed or chairs (even though we encourage early ambulation) patients on behavioral health units are usually much more active. Hence the increased risk for falls may simply be related to this increased opportunity to fall. Scanlan et al. (Scanlan 2012) looked at activity during falls and found that the majority occurred on walking or transferring. Location of falls was most often bedrooms, outdoor areas, corridors and bathrooms.
The VA National Patient Safety Center, which does a great job of aggregating lessons learned from RCA’s across the VA system, put together such lessons learned as they pertain to falls on behavioral health units (Lee 2012). They noted that falls most often occurred as patients were getting up from bed or a chair or wheelchair, walking/running, bathroom-related, or behavior-related. The most common root causes they identified were environmental hazards, poor communication of fall risk, lack of suitable equipment, and a need to improve the system of falls assessment.
Lee et al. point out that patients on behavioral health units are at risk for falls for a number of reasons. Most importantly, they are on a variety of medications that may increase the fall risk (antipsychotics, antidepressants, sedative/hypnotics, and others). Some may be confused or agitated. Others may have impaired gait or balance, sometimes as a result of extrapyramidal side effects of their medications. Many of the medications cause orthostatic hypotension. The elderly patient on the behavioral health unit is especially at risk for falls with injury. They also note that sometimes behavioral health units restrict use of canes or other devices that could assist ambulation because such might also be used as weapons.
The authors have numerous recommendations for ways to improve fall prevention on such units. One is assessing the environmental risks, using a checklist. Quite frankly we’d like to see a checklist-like audit tool for assessing all the risks they have pointed out, not just the environmental ones.
Because more traditionally used fall risk assessment tools have not been particularly applicable to psychiatric inpatients, Edmonson and colleagues (Edmonson 2011) have developed their own fall risk assessment tool for psychiatric inpatients. They identified 9 categories of fall risk factors from the literature, then determined how frequent those occurred in records of psychiatric inpatients who fell, resulting in a weighted tool for predicting falls in this population. They then administered this tool, the Edmonson Psychiatric Fall Risk Assessment Tool (EPFRAT), and a more traditional fall risk assessment tool (the Morse Fall Scale) simultaneously to an inpatient psychiatric population and found the EPFRAT had a higher sensitivity in predicting falls and comparable specificity. This tool is very promising and is awaiting validation of its utility in other settings. We did find one site that has used it and successfully reduced falls in a psychiatric hospital after implementing the tool and model (Vermont State Hospital 2011). The nine domains in the EPFRAT are age, mental status, elimination (bowel/bladder), medications, diagnosis, ambulation/balance, nutrition, sleep disturbance, and history of falls.
Age, by itself, may not be a good fall risk predictor. In the series reported by the Pennsylvania Patient Safety Authority (PPSA 2010) the average age of patients with falls in behavioral health hospitals was 45 years old, compared to 65 years old for those with falls in other hospitals. We suspect this may to some degree reflect the demographics of behavioral health hospitals but it may also reflect the other risk factors unique to this population and setting. In general, we see fall risk increase with increasing age. Other studies (Scanlan 2012) have shown higher fall rates in psychogeriatric units. However, many studies have found that age, per se, is not an independent risk factor for falls but rather older people are more likely to have multiple comorbidities and conditions that predispose to falls and are more likely to be on multiple medications. Also, the elderly are more likely to have the multiple sensory deficit syndrome. That is where deficits of such senses as vision, hearing, proprioception, etc. are individually not sufficient to causes falls but collectively do pose a significant fall risk.
Sleep disturbances are common on inpatient psychiatric units and may increase the fall risk. Keep in mind that sedative/hypnotic medications are at the top of the list of medications commonly increasing the risk for falls.
Primary psychiatric diagnosis may play a role related both to both the diagnosis and the treatment for that diagnosis. Depression is a risk factor for falls, at least in the elderly. One metanalysis showed an odds ratio of 1.63 for the association between depression and falls (Deandrea 2010). But the relationship is very complex and bidirectional (Iaboni 2012). The psychomotor slowing and fear of falling in depression may lead to falls but treatment with antidepressants may also lead to falls. In a metanalysis of relation of medication classes to falls in the elderly antidepressants had an odds ratio of 1.68 (Woolcott 2009). Antidepressants may lead to falls via either causing orthostatic hypotension or by their effects on cognitive function.
Similarly, patients with acute psychosis or the manic phase of bipolar disorder may be predisposed to falls either because of the increased physicial activity and clouded mental status or because of the medications used to treat these conditions. In the study by Lee et al (Lee 2012) the authors noted that as root causes both undertreatment and overtreatment. The “undertreated” patients had falls related to agitation, etc. But patients with acute psychosis are often treated with multiple drugs that increase the risk of falls. Some are sedating drugs used to treat agitation or anxiety. Others are antipsychotic drugs that may have extrapyramidal side effects which affect gait, balance, and reaction times.
Estrin and colleagues (Estrin 2009) did a retrospective analysis of fallers vs. matched nonfallers at a psychiatric inpatient facility and looked at a variety of potential variables that might predict falls. Fallers were more likely to have an acute medical condition at the time of the fall, to have more physical symptoms on the day of the fall, and to be on more medications. They were also more likely to have urinary frequency or incontinence, generalized weakness, dizziness, mental status impairment, history of falls within 90 days, history of syncope and history of impaired mobility. However, after multivariate logistic regression analysis only summed physical complaints on the day of the fall and current clonazepam use held up as independent predictors of falls.
An important point made by Estrin and colleagues (Estrin 2009) is that tools with low specificity for predicting falls (i.e. a high percentage of false positives) may have a “desensitizing” effect on staff. Given that just about every patient on an inpatient psychiatric unit is on one or more drugs that increase their fall risk, almost all inpatients could be classified as being at high risk for falls. That, of course, could justify some of the general fall prevention interventions you might consider on a psychiatric inpatient unit (eg. non-slip footware, beds low to the ground, bedside mats, etc.) but it doesn’t really pick out those who need more specific individualized interventions to prevent falls. We discussed the issue of general vs. individualized fall risk assessment in our August 4, 2009 Patient Safety Tip of the Week “Faulty Fall Risk Assessments?”.
We could find no good reviews on the role of time of day of falls on psychiatric inpatient units. Logically, one might expect more to occur at night because of factors such as poor lighting, need to get out of bed for toileting, sleep disturbances, etc. An increased frequency of falls has been reported at night in a psychogeriatric hospital ward (Tangman 2010). Another inpatient psychiatric unit discovered that falls were occurring during shift report and this improved when they divided up report into two separate groups so that one group of nurses was always with the patients (Lusky 2008).
In our December 22, 2009 Patient Safety Tip of the Week “Falls on Toileting Activities” we noted that almost half of falls in the nonpsychiatric hospital occur during activities related in some way to toileting. Falls on inpatient psychiatric units also often occur during toileting activities. Many of the fall risk assessment tools include urinary frequency and bladder/bowel incontinence as risk factors for falls. Of falls that took place on medical, surgical or mixed medical/surgical units in a community hospital only 6% of the falls actually occurred while getting on or off the toilet but most of the falls occurred when attempting to go from bed or chair to the bathroom or returning from the bathroom (Tzeng 2010). Such falls are especially likely to occur at night. While lighting issues may play a role, another root cause is not having enough staff to help such patients do their toileting activities before they go to bed. On a busy psychiatry inpatient service, where 20-30 patients may be on every 15 minute safety checks, staff often do not have adequate time to help those patients with their toileting activities. Note also that polydipsia, a common occurrence on psychiatric floors whether psychogenic or because of medication-induced dryness of the mouth, might lead to the need to urinate multiple times at night, further increasing the opportunity for falls.
Unfortunately, one of the dilemmas on inpatient psychiatric units is that there is sometimes a tradeoff between the fall risk and the suicide risk. Some of the bathroom assist devices we might use to help prevent falls (eg. grab bars) may be “loopable” items that represent a suicide risk. We don’t have good advice on resolving that dilemma.
Medications, of course, are a major risk factor for falls regardless of whether a patient is on an inpatient psychiatric unit or a med/surg floor. The total number of medications, regardless of type, is a risk factor for falls. But certain categories, most of which are commonly used on inpatient psychiatric units, are especially likely to be associated with falls. These include benzodiazepines, sedative/hypnotic drugs, antidepressants, antipsychotic drugs, and anticonvulsants.
Many of the drugs used on psychiatric inpatient units may have orthostatic hypotension as a side effect. And some patients may have underlying conditions or other medications that are associated with orthostatic hypotension. Yet virtually every inpatient psychiatric unit we’ve ever reviewed does inadequate monitoring for orthostatic hypotension. Moreover, most also fail to perform assessment for orthostatic hypotension appropriately. Our seemingly annual tirade on the appropriate way to look for orthostatic hypotension goes back to our April 16, 2007 Patient Safety Tip of the Week “Falls With Injury”. The proper technique for checking orthostatic signs is as follows:
On most inpatient psychiatric units that look for orthostatic hypotension they simply measure blood pressure going from the sitting position to the standing position. That will underestimate the magnitude of any orthostatic hypotension. Remember, the patient with orthostatic hypotension is most likely to fall when they get out of bed from the supine to standing position to use the bathroom.
The other major category typically used on inpatient psychiatric units are antipsychotic drugs that may have extrapyramidal side effects. These may affect gait, balance, and reaction times to increase the risk of falls. When these drugs are started the patient should be examined daily to identify the occurrence of extrapyramidal side effects and the fall prevention strategies modified appropriately as they occur.
One of the frequent root causes identified by Lee et al. (Lee 2012) was failure to adequately communicate the fall risk from caregiver to caregiver. It should be a part of the daily discussion during the multidisciplinary case conference on each patient. Fall risk must be addressed during all handoffs and should be a formal item on your standardized handoff tool.
The Lee study also notes that the culture on many inpatient psychiatry units is such that staff may not see psychiatric patients as medically ill and thus may overlook their need for assistance in avoiding falls. Yet we know that the underlying medical conditions may be contributory factors to falls in many cases.
We’ve also stressed the risks of falls that occur when patients are sent to the radiology suite (see our January 2010 What’s New in the Patient Safety World column “Falls in the Radiology Suite”). One of the items on your “Ticket to Ride” (or other structured tool you use to communicate various risks and concerns when you send a patient off to another part of the hospital) needs to be a flag for fall risk. Note also that some of the other items you’ll put on your “Ticket to Ride” (such as altered mental status, certain medications, etc.) may also infer an increased risk of falling (see our November 18, 2008 Patient Safety Tip of the Week “Ticket to Ride: Checklist, Form, or Decision Scorecard?”).
Not only does fall risk status need to be communicated between nursing staff and ancillary staff but it must also be adequately communicated between physicians. In most psychiatric inpatient units the psychiatrist often attends to just the psychiatric needs of the patient and another physician or midlevel practitioner attends to the “medical” issues. The latter is often attuned to the fall risk but the psychiatrist, if not aware of fall risk at all times, may make alterations in the treatment plan that increase the fall risk. Hopefully, all such parties are represented at the daily multidisciplinary rounds to make sure they are all on the same page.
To summarize key action points:
Some of our prior columns related to falls:
April 16, 2007 “Falls With Injury”
January 1, 2008 “Fall Prevention”
October 7, 2008 “Lessons from Falls....from Rehab Medicine”
November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
August 4, 2009 “Faulty Fall Risk Assessments?”
September 22, 2009 “Psychotropic Drugs and Falls in the SNF”
December 22, 2009 “Falls on Toileting Activities”
January 2010 “Falls in the Radiology Suite”
May 29, 2012 “Falls, Fractures, and Fatalities”
References:
PPSA. Data Snapshot: Falls Reported by Behavioral Health Hospitals. Pa Patient Saf Advis 2010; 7(4): 149-150
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2010/dec7%284%29/Pages/149.aspx
Scanlan J, Wheatley J, McIntosh S.. Characteristics of falls in inpatient psychiatric units. Australas Psychiatry 2012; 20(4): 305-308
http://apy.sagepub.com/content/20/4/305.abstract
Lee A, Mills PD, Watts BV. Using root cause analysis to reduce falls with injury in the psychiatric unit. Gen Hosp Psych 2012; 34(3): 304-311
http://www.sciencedirect.com/science/article/pii/S0163834311004117
Edmonson D, Robinson S, Hughes L. Development of the Edmonson Psychiatric Fall Risk Assessment Tool. J Psychosoc Nurs Ment Health Serv. 2011; 49(2): 29-36
Edmonson D/Memorial Medical Center (Springfield, IL). Edmonson Psychiatric Fall Risk Assessment Tool ©. (Download page – requires copyright agreement).
Vermont State Hospital. Report Card 2011. Patient Falls. Edmonson Psychiatric Fall Risk Assessment Model. 2011
Deandrea S, Lucenteforte E, Bravi F, et al: Risk factors for falls in community-dwelling older people: a systematic review and metaanalysis. Epidemiology 2010; 21(5): 658–668
Iaboni A, Flint AJ. The Complex Interplay of Depression and Falls in Older Adults: A Clinical Review. American Journal of Geriatric Psychiatry 2012; [Epub ahead of print] 27 April 2012
http://journals.lww.com/ajgponline/pages/results.aspx?k=iaboni&Scope=AllIssues&txtKeywords=iaboni
Woolcott JC, Richardson KJ, Wiens MO, et al: Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med 2009; 169: 1952–1960
http://archinte.jamanetwork.com/data/Journals/INTEMED/22602/ira90005_1952_1960.pdf
Estrin I, Goetz R, Hellerstein DJ, et al. Predicting Falls Among Psychiatric Inpatients: A Case-Control Study at a State Psychiatric Facility. Psychiatric Services 2009; 60(9): 1245-1250
http://ps.psychiatryonline.org/article.aspx?articleID=100772
Tangman S. Eriksson S. Gustafson Y. Lundin-Olsson L. Precipitating factors for falls among patients with dementia on a psychogeriatric ward. International Psychogeriatrics 2010; 22(4): 641-649
http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=7667260
Lusky K. Wiping out falls. Systemic interventions help reduce patient risk. ACP Hospitalist 2008; August 2008
http://www.acphospitalist.org/archives/2008/08/falls.htm
Tzeng H-M. Understanding the Prevalence of Inpatient Falls Associated With Toileting in Adult Acute Care Settings. Journal of Nursing Care Quality 2010; 25(1):22-30
Print “Falls on Inpatient Psychiatry”
January 22, 2013
You Don't Know What You Don't Know
Everyone dreads the error where lab specimens get mixed up and a patient (or likely 2 patients) gets the wrong diagnosis and wrong treatment. We’ve done multiple columns on such errors and they are listed at the end of today’s column.
But here’s one type of lab error that is kind of scary: occult specimen provenance complications (SPC’s). It’s scary because it is occult, i.e. the error is not recognized because it is not identified by standard laboratory procedures. There are actually 2 types of such errors:
So I could have a prostate biopsy that either gets mixed up with someone else’s biopsy or that gets contaminated by tissue from another patient and my specimen gets reported as showing cancer. I might end up getting a treatment for prostate cancer and all the side effects even though I don’t have cancer. Or I actually could have cancer and my specimen gets interpreted as normal and I don’t get any treatment.
Such errors usually only come to attention when a patient undergoes, for example, a mastectomy or prostatectomy after a biopsy was interpreted as showing cancer and the full surgical specimen removed shows no cancer.
In one of our earliest columns on lab errors (see our October 9, 2007 Patient Safety Tip of the Week “Errors in the Laboratory“) we noted a paper (Suba 2007) that suggested we consider the “DNA timeout” akin to the surgical timeout where we ask the question “Is this the correct diagnosis for the correct patient?” before doing an invasive procedure.
Now one of the co-authors of that 2007 paper has done a study providing an estimate of how often such SPC’s occur (Pfeifer 2013). They examined about 13,000 prostate biopsy specimens from a wide variety of urology practices and pathology laboratories using a DNA identification technology. They found the frequency of occult type 1 errors (a complete transposition between patients) was 0.26% and type 2 errors (contamination of the patient’s tissue with 1 or more unrelated patients) was 0.67%. Overall, the mean frequency of SPCs across practice settings was 0.22% for type 1 errors and 1.69% for type 2 errors.
Basically, it means that just under 1% of patients might be given an incorrect diagnosis that no one even suspects is incorrect!
Perhaps just as striking is the fact that virtually every lab or clinical setting they studied had at least one SPC identified.
The authors also point out that in many or most of these occult SPC’s there may be 2 “victims”, the one whose specimen this was thought to be and the one whose tissue it actually is because both patients may end up getting the wrong diagnosis and wrong treatment. So the clinical impact might be twice as high as the SPC rates they identified.
Keep in mind that SPC’s, like most “lab errors” may actually have nothing to with the lab itself. From our many previous columns you’ll recognize that most “lab errors” actually occur in the pre-analytical phase, i.e. before the specimen ever even arrives at the lab. In our March 6, 2012 Patient Safety Tip of the Week ““Lab” Error” we noted that the vast majority of “lab”errors really occur in the pre-analytical and post-analytical phases of laboratory evaluation. Such mixups can occur at the time the specimen is obtained and labeled. They can also occur when it first gets accessioned at the lab. But even during processing in the lab there can be carryover artifacts or cross-contamination of tissues.
Importantly, the authors of the Pfeifer study had no financial interest in the DNA testing kit or the company (nor do we!) and the company did not sponsor the study. So it truly appears to be an unbiased study in that regard. However, there may well be some selection bias in that the urology practices submitting specimens for DNA testing may not be representative of all urology practices. They may be more patient safety conscious or they may have experienced a prior patient identification error. And the cost-effectiveness is not yet known. The Pfeifer study had no data on patient outcomes so it is not known how many patients received an incorrect diagnosis or incorrect treatment.
So this is a new application of technology that shows great promise in reducing the chances a patient may get an incorrect diagnosis and treatment with serious implications. But there are lots of important unanswered questions. It needs to be tested in a randomized fashion in a variety of settings with collection of patient-specific outcome data and good analysis of cost (both costs of testing and potential cost savings from reduction of errors).
Other technologies do play a role in minimizing specimen labeling errors. In our April 2012 What’s New in the Patient Safety World column “Specimen Labeling Errors” we noted such labeling errors may occur either before the specimen ever arrives at the lab or may occur in the lab itself. One report on laboratory errors (Snydman 2012) found that the top 2 errors were specimen not labeled (18.7%) and specimen mislabeled (16.3%) and concluded that many “lab” errors occur before the specimen ever reaches the lab and could be prevented by better labeling. Technological solutions such as barcoding and RFID (radiofrequency identification) techniques may be helpful in reducing such errors. A paper from the Mayo Clinic (Francis 2009) discusses changes made after their gastrointestinal and colorectal surgery endoscopy units had experienced mislabeling or no labeling of specimens. They initiated a new specimen-labeling system that uses RFID technology, a paperless requisition process, and confirmation of the correct site and correct patient by 2 healthcare providers. They were able to document a substantial decrease in errors as a result of the new processes.
Labeling errors can also be reduced by good performance improvement projects or doing a FMEA (failure mode and effects analysis). A study on specimen labeling errors within a surgical pathology laboratory (Layfield 2010) found labeling errors occurred at a rate of 0.25% of cases and could involve either patient name or site of the specimen. The majority of the mislabelings occurred in the gross room. One theme they noted was that more errors occurred with small specimens that were similar in appearance and were batch processed. They also noted that batch processing had been previously identified in the literature as a root cause of labeling errors in the laboratory.
See our Patient Safety Tips of the Week for October 9, 2007 “Errors in the Laboratory“ and November 16, 2010 “Lost Lab Specimens” for discussions on specimen identification, labeling, etc. And our October 11, 2011 Patient Safety Tip of the Week “LEAN in the Lab” describes use of LEAN principles to improve lab safety and efficiency.
Some of our other columns on errors related to laboratory studies:
References:
Suba EJ, Pfeifer JD, Raab SS. Patient Identification Error Among Prostate Needle Core Biopsy Specimens—Are We Ready for a DNA Time-Out? J Urol 2007; 178(4): 1245-1248
http://www.jurology.com/article/S0022-5347%2807%2901423-1/abstract
Pfeifer JD, Liu J. Rate of Occult Specimen Provenance Complications in Routine Clinical Practice. Am J Clin Path 2013; 139: 93-100
http://ajcp.ascpjournals.org/content/139/1/93.abstract
Snydman LK, Harubin B, Kumar S, et al. Voluntary Electronic Reporting of Laboratory Errors: An Analysis of 37 532 Laboratory Event Reports From 30 Health Care Organizations. American Journal of Medical Quality March/April 2012 27: 147-153, first published on September 14, 2011
http://ajm.sagepub.com/content/27/2/147.abstract
Francis DL, Prabhakar S, Sanderson SO. A Quality Initiative to Decrease Pathology Specimen–Labeling Errors Using Radiofrequency Identification in a High-Volume Endoscopy Center. Am J Gastroenterol 2009; 104: 972–975
http://www.nature.com/ajg/journal/v104/n4/abs/ajg2008170a.html
Layfield LJ. Anderson GM. Specimen labeling errors in surgical pathology: an 18-month experience. American Journal of Clinical Pathology 2010. 134(3): 466-70, 2010 Sep.
http://ajcp.ascpjournals.org/content/134/3/466.full.pdf+html
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January 29, 2013
A Flurry of Activity
on Handoffs
Recently we’ve seen a flurry of scholarly and practical activity on handoffs. BMJ Quality & Safety did a whole supplement on handoffs (or handovers as they are called in most countries outside the US) based on the European Handover Research Collaborative (BMJ Quality & Safety 2012). We’ll get to some of those articles shortly.
But first we want to come back to an important concept in handoffs: while structured handoffs are valuable in almost all settings, one structure does not fit all handoffs. In our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics” we emphasized the need to tailor the structure and content of the handoff to the particular setting and the context. Organizations collaborating in the I-PASS project found the commonly used SBAR format did not meet their needs for resident-to-resident handoffs so they developed their own tool (Starmer 2012).
A new study (Hilligoss and Cohen 2013) addresses the between-unit handoff and highlights the many ways that such handoffs differ from within-unit handoffs and the challenges and barriers raised by such handoffs. In within-unit handoffs (eg. change of shift, change of coverage, etc.) the timing of the handoff and the participants are usually well-defined. On the other hand, between-unit handoffs (as exemplified by the ED-to-inpatient handoff) take place all times of the day in an unscheduled manner and often involve parties who may have never even met before. The between-unit handoff is triggered by issues related to the patient whereas the within-unit handoff is triggered by changes in the personnel.
But the between-unit handoff also is subject to some contextual issues not typically seen in within-unit handoffs. Two key areas identified by Hilligoss and Cohen are negotiation and coordination. There are often differences in the orientations of the professionals on each side of the between-unit handoff. They note that the emergency physician is often focused on triaging and stabilizing patients and is more comfortable with dealing with uncertainties and ambiguities. Inpatient physicians tend to be more focused on honing in on a definitive diagnosis and developing a treatment plan.
On the “negotiation” front there are several factors that come into play. The degree of familiarity of the involved parties is important. A negotiation between two parties who have not previously met is much more difficult that one in which the parties have long-standing relationships. Liken that to the recent political crisis where Vice President Biden was able to call upon his long-standing relationships with members of both parties of Congress to broker a deal that otherwise would have been very difficult to achieve. Parties in the within-unit handoffs are much more likely to have established relationships with each other than those in between-unit handoffs.
A lack of familiarity with the services themselves also becomes an issue. An emergency physician typically does not know much about the census on the inpatient service, any urgent or emergent crises on that service, pending transfers, etc. Similarly, the inpatient service often has no idea about the patient backlog in the emergency department.
Sometimes the handoff in the between-unit circumstance is not even face-to-face. We have long stressed the importance of the face-to-face meeting where adequate time is allotted for the handoff and the receiving party has ample opportunity to ask questions and get clarification of issues. Hearback is an important part of a handoff that helps ensure that the receiving party has a good understanding of the patient’s condition and needs (see below). But sometimes between-unit handoffs do not even occur face-to-face. The inpatient service representative may be on rounds and talks to the emergency physician (who may be at end of his/her shift) by phone. That is almost always suboptimal but has become a fact-of-life in many institutions.
In the last few years differences of opinion about level of care needed have become magnified. After CMS began doing its RAC audits we’ve seen a 10-20% increase in the number of patients going on observation status rather than inpatient status. We now find emergency physicians and hospitalists (or other inpatient physicians) at odds over where the patient should go and whose service he/she should be on. Also negotiation often has to take place with multiple physicians. For example, does that patient with abdominal pain and possible partial bowel obstruction go the medical or surgical service? Hilligoss and Cohen note that the culture of the hospital and the informal hierarchy come into play as well. They note at one hospital the general medical service had earned the nickname “dumping ground” because the hospital culture was such that surgery and specialty services could refuse admissions but the general medical service could not. So emergency physicians often find themselves having to “sell” admissions to various services. Not mentioned in their article but a problem we often see in academic hospitals is that of disparities in “rank” between the parties who are negotiating. Many ED’s are staffed by full-time attending physicians and the party representing the inpatient service may be a senior resident or even a more junior resident.
The handoff involves 2 key components: (1) transfer of information and (2) transfer of responsibility. Hilligoss and Cohen note that the latter is often incomplete in between-unit transfers. For instance, sometimes the decision to admit a patient to the inpatient service is made and the transfer of information takes place at a handoff and the inpatient service may write orders on the patient but there may be a delay in physically moving the patient to the inpatient unit. That may create issues and ambiguities as to responsibility for the patient until that physical transfer takes place. Sometimes the inpatient service might want more diagnostic studies (eg. imaging studies) to be done before the patient gets physically moved to the inpatient floor. In other cases it needs to be made clear who will deliver certain critical interventions while such transfers are pending. Back in the 90’s we realized that patients with community-acquired pneumonia at some renowned organizations were not getting their first dose of antibiotics for up to 18 hours. That, of course, was related to bottlenecks in moving patients from the ED to the floor. Fortunately, we had performance improvement projects that focused on ensuring timely administration of the antibiotics regardless of physical location of the patient. But undoubtedly we still see ambiguities of coordination and responsibility that occur in between-unit transfers that need to be resolved in the handoff.
Coordination is also often problematic in just setting up and handoff. Whereas the within-unit handoff usually occurs at a specified time and between specified parties, the between-unit handoff is often more difficult to set up. For example, the emergency physician may have to make multiple phone calls or pages just to find out who the responsible party on the inpatient service will be.
Hilligoss and Cohen point out that there has been very little research to date on the between-unit handoff. They note that structured formats like the SBAR format, used extensively for many within-unit handoffs, are not well-suited for between-unit transfers. Their paper is a good start on identifying the unique aspects of this type of handoff and hopefully will stimulate interest in developing tools and interventions that will improve handoffs between units.
We have previously discussed one type of between-unit handoff, the perioperative handoff, in several columns (see our What’s New in the Patient Safety World columns for December 2011 “AORN Perioperative Handoff Toolkit”, March 2012 “More on Perioperative Handoffs” and August 2012 “Review of Postoperative Handoffs”).
We mentioned above the importance of “hearback’ or “readback” and other techniques to ensure the recipient understands the information being conveyed during a handoff. Another new study (Greenstein 2012) using the Handoff Evaluation Assessing Receivers (HEAR) checklist assessed listening behaviors during handoffs between hospitalists. The authors found that “active” listening occurs infrequently in such handoffs. Active listening behaviors include things like note taking, reading back, and repeating. Though the handoffs typically did include the recipient asking clarifying questions, the active listening techniques only were seen in about 20% of handoffs. Nevertheless, they did note evidence of “passive” listening (head nodding, eye contact, affirmatory statements) in the majority of handoffs. (The latter emphasizes a point we often make: one of the advantages of face-to-face handoffs is that so much of what we convey is in body language.) In addition, interruptions were extremely common, occurring in 98% of handoffs. These included side conversations, pagers going off, and other clinicians arriving.
The European Handover Research Collaborative (BMJ Quality & Safety 2012) had numerous interesting findings. That collaborative looked at handoff (handover) practices in 9 health systems in Spain, Poland, Italy, Sweden, and the Netherlands and involved a population of patients with chronic diseases who were discharged to home following hospitalizations or ED visits. One of the primary foci was on the role of the patient in the handoff (Flink 2012a, Flink 2012b). As you’d expect, some patients wanted to be the “key actor” in such handoffs, others wanted the healthcare providers to be the key actors, and yet others wanted shared roles. When patients served as the key actor, they were responsible for collecting and conveying to the next caregiver discharge notes, medication lists, etc. Typically, such patients realized from prior experiences that transfer of information was poor or perceived their providers expected them to be the key actor. Health literacy, personal resources, family and other factors were important in determining who might be capable of being a key actor. One interesting feature is that many patients assumed that electronic medical records would ensure proper transfer of information, often an erroneous assumption. That supplement of the BMJ Quality and Safety has several other articles on handoffs/handovers that are worth reading and all are open-access.
Yet another interesting handoff study (Cohen 2012) showed that in intensive care unit attending-to-attending handoffs at the end of the week, patients discussed earlier had a disproportionate amount of time allocated. This finding was irrespective of the severity or complexity of the patient’s case. Cases earliest in the handoff sessions had about 50% more time in discussion that those discussed toward the end of the handoff. These findings have implications both for prioritizing patients to be discussed and for ensuring adequate discussion for all patients.
Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:
May 15, 2007 “Communication, Hearback and Other Lessons from Aviation”
May 22, 2007 “More on TeamSTEPPS™”
August 28, 2007 “Lessons Learned from Transportation Accidents”
December 11, 2007 “Communication…Communication…Communication”
February 26, 2008 “Nightmares….The Hospital at Night”
September 30, 2008 “Hot Topic: Handoffs”
November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
December 2008 “Another Good Paper on Handoffs”.
June 30, 2009 “iSoBAR: Australian Clinical Handoffs/Handovers”
April 25, 2009 “Interruptions, Distractions, Inattention…Oops!”
April 13, 2010 “Update on Handoffs”
July 12, 2011 “Psst! Pass it on…How a kid’s game can mold good handoffs”
July 19, 2011 “Communication Across Professions”
November 2011 “Restricted Housestaff Work Hours and Patient Handoffs”
December 2011 “AORN Perioperative Handoff Toolkit”
February 14, 2012 “Handoffs – More Than Battle of the Mnemonics”
March 2012 “More on Perioperative Handoffs”
June 2012 “I-PASS Results and Resources Now Available”
August 2012 “New Joint Commission Tools for Improving Handoffs”
August 2012 “Review of Postoperative Handoffs”
References:
BMJ Qual Saf December 2012, Volume 21, Suppl 1
Proceedings from the European Handover Research Collaborative
http://qualitysafety.bmj.com/content/21/Suppl_1.toc
Starmer AJ, Spector ND, Srivastava R, et al. and the I-PASS Study Group. I-PASS, a Mnemonic to Standardize Verbal Handoffs.
Pediatrics 2012; 129(2): 201 -204
http://pediatrics.aappublications.org/content/129/2/201.extract
Hilligoss B, Cohen MD. The Unappreciated Challenges of Between-Unit Handoffs: Negotiating and Coordinating Across Boundaries. Ann Emerg Med 2013; 61(2): 155-160
http://www.annemergmed.com/article/S0196-0644%2812%2900376-9/abstract
Greenstein EA, Arora VM, Staisiunas PG, et al. Characterising physician listening behaviour during hospitalist handoffs using the HEAR checklist. BMJ Qual Saf 2012; Published Online First: 20 December 2012
http://qualitysafety.bmj.com/content/early/2012/12/19/bmjqs-2012-001138.abstract
Flink M, Hesselink G, Pijnenborg L, et al. The key actor: a qualitative study of patient participation in the handover process in Europe. BMJ Qual Saf 2012; 21: i89-i96 Published Online First: 30 October 2012
http://qualitysafety.bmj.com/content/21/Suppl_1/i89.full.pdf+html
Flink M, Öhlén G, Hansagi H, et al. Beliefs and experiences can influence patient participation in handover between primary and secondary care—a qualitative study of patient perspectives. BMJ Qual Saf 2012; 21: i76-i83 Published Online First: 30 October 2012
http://qualitysafety.bmj.com/content/21/Suppl_1/i76.full.pdf+html
Cohen MD, Ilan R, Garrett L, et al. The Earlier the Longer: Disproportionate Time Allocated to Patients Discussed Early in Attending Physician Handoff Sessions. Arch Intern Med 2012; 172(22): 1762-1764
http://archinte.jamanetwork.com/article.aspx?articleid=1391009#qundefined
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February 5, 2013
Antidepressants and QT Interval Prolongation
In our June 29, 2010 Patient Safety Tip of the Week “Torsade de Pointes: Are Your Patients At Risk?” we discussed the risks of this potentially fatal syndrome in hospitalized patients. Torsade de Pointes is a form of ventricular tachycardia, often fatal, in which the QRS complexes become “twisted” (changing in amplitude and morphology) but is best known for its occurrence in patients with long QT intervals. Though cases of the long QT interval syndrome (LQTS) may be congenital, many are acquired and due to a variety of drugs that we prescribe. The syndrome is more common in females and many have a genetic predisposition. And there are a number of reasons why this syndrome is more likely to both occur and result in death in hospitalized patients. Hospitalized patients have a whole host of other factors that may help precipitate malignant arrhythmias in vulnerable patients. They tend to have underlying heart disease, electrolyte abnormalities (eg. hypokalemia, hypomagnesemia, hypocalcemia), renal or hepatic impairment, and bradycardia, all of which may be precipitating factors. More importantly they may have the sorts of conditions for which we prescribe the drugs that are primarily responsible for prolonging the QT interval (eg. haloperidol, antiarrhythmic agents, etc.). And many of those drugs are given intravenously and in high doses in the hospital as compared to the outpatient arena. Rapid intravenous infusion of such drugs may be more likely to precipitate Torsade de Pointes than slow infusion.
But, of course, the syndrome is not limited to hospitalized patients and we must remain vigilant for prolongation of the QT interval in outpatients as well. That is especially the case when dose escalations occur.
In our prior column we discussed the many drugs potentially implicated in prolonging the QT interval and potentially leading to Torsade de Pointes. But one class of drugs that had been relatively unrepresented was the antidepressant class. Then, in 2011 the FDA issued a warning about QT interval prolongation for citalopram (Celexa), later updated to restrict the dosage of citalopram to 20 mg. in patients older than 60 years and patients taking other drugs inhibiting cytochrome P450 2C19 (FDA 2012). The FDA also recommends discontinuation of citalopram in patients found to have persistent QTc measurements greater than 500 msec.
Antidepressants, of course, are used not only in the treatment of depression but are also sometimes used for a wide variety of other clinical problems (eg. chronic pain, migraine, etc.).
Now a new study from the Partners HealthCare System has used innovative electronic health record technologies to assess the risk in patients taking both newer and older antidepressants (Castro 2013). The approach (see below) also has tremendous potential for other studies and for development of clinical decision support systems.
The authors were able to examine medical records for over 4 million unique patients within their system of hospitals and outpatient practices. They identified over 240,000 adult patients given at least one antidepressant.prescription and were then able to assess corrected QT intervals (QTc) from the electronic medical records in those patients who had electrocardiograms done. In many cases they had the opportunity to see the impact of dose escalations on the QTc. Plus they were able to assess a whole host of comorbidities and potentially confounding variables from the clinical records on these patients. They were able to identify a dose-response association of QTc prolongation for citalopram, escitalopram, and amitriptyline. This was not seen for other antidepressants. On the other hand, they found an association with QTc shortening for buproprion, a drug sometimes used in patients in whom first line antidepressants fail to produce anticipated result.
The authors, in discussing the implications of their findings, are quick to point out that QTc prolongation is only a surrogate measure for potential Torsade de Pointes and that the reported incidence of torsade in patients taking antidepressants is low. Nevertheless, they found that almost one in every five patients taking antidepressants had prolongation of the QTc interval and might be potentially at risk. Their findings might help in selection of individual drugs in certain patients. Importantly, it emphasizes the need for periodic monitoring in such patients, particularly when dose escalation is considered.
In our June 29, 2010 Patient Safety Tip of the Week “Torsade de Pointes: Are Your Patients At Risk?” we referenced the AHA/ACCF statement on Torsade de Pointes (Drew et al 2010). The drugs most commonly associated with Torsade de Pointes are haloperidol, methadone, thioridazine, amiodarone, quinidine, sotalol, procainamide, erythromycin, azithromycin, the antihistamine terfenadine and certain antifungals. For a full list of drugs that commonly cause prolongation of the QT interval and may lead to Torsade de Pointes, go to the CredibleMeds™ website. That site also has a list of drugs that prolong the QT interval and might possibly cause Torsade de Pointes and another list of drugs that have conditional risk (eg. only when combined with other drugs). Some drugs (eg. cisapride/Propulsid, a drug formerly used to promote GI motility) have actually been withdrawn from the market because of serious cardiac side effects, including prolongation of the QT interval and torsade de pointes.
Our June 29, 2010 Patient Safety Tip of the Week “Torsade de Pointes: Are Your Patients At Risk?” also discussed not only inpatient issues but also issues related to QTc prolongation and the emergency department, psychiatry, anesthesia, and surgery and the nuances of measuring the QT interval and the QTc (corrected QT). In all settings it is important to consider not only the potential effect of various drugs but also underlying conditions and other contributing factors such as electrolyte disturbances. We had recommendations on what your hospital facilities should be doing:
To those we obviously now would add appropriate attention to those patients in outpatient settings who are begun on any of the drugs noted or have dose escalations of such drugs.
One must keep in mind that the incidence of Torsade de Pointes and fatal arrhythmias is still quite low overall. Prolongation of the QTc interval is only a surrogate measure of the potential for such serious events. The potential benefits of many of these psychotropic agents may outweigh the risks of Torsade. But identifying the risk factors should at least flag such patients for closer monitoring during treatment with psychotropic drugs.
As we mentioned, the approach used by Castro and colleagues (Castro 2013) also has tremendous potential for other studies and for development of clinical decision support systems. They examined electronic health records using natural language processing (NLP) and machine-learning algorithms. Their article discusses the difficulties in identifying serious, but rare, adverse medication effects in the randomized controlled trials done prior to FDA approval or in the post-marketing surveillance studies done after approval. While results of studies using the techniques they used can really only demonstrate associations rather than determining definite cause-effect they really have unlimited potential to raise red flags that otherwise would take many years to appear.
They also have great potential for clinical decision support systems. Though we always need to keep in mind the risks of “alert fatigue”, such systems could be used to prompt ordering of electrocardiograms in those patients on one of the higher risk drugs when a dose escalation occurs or when additional drugs are ordered. Or they could provide reminders when serum potassium or magnesium levels should be considered in patients on such drugs. We described potential rules logic for some of those alerts in our June 29, 2010 Patient Safety Tip of the Week “Torsade de Pointes: Are Your Patients At Risk?”
This is really great work. Kudos to Castro and colleagues at Partners HealthCare not just for the messages in the specific study conducted but also for highlighting the potential use of such pharmacovigilance techniques for many other potential purposes.
References:
Castro VM, Clements CC, Murphy SN, et al. QT interval and antidepressant use: a cross sectional study of electronic health records. BMJ 2013; 346: f288 (Published 29 January 2013)
http://www.bmj.com/content/346/bmj.f288.pdf%2Bhtml
FDA. FDA Drug Safety Communication: Revised recommendations for Celexa (citalopram hydrobromide) related to a potential risk of abnormal heart rhythms with high doses. 3/28/12
http://www.fda.gov/Drugs/DrugSafety/ucm297391.htm
Drew BJ, Ackerman MJ, Funk M on behalf of the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology, the Council on Cardiovascular Nursing, and the American College of Cardiology Foundation
Prevention of Torsade de Pointes in Hospital Settings: A Scientific Statement From the American Heart Association and the American College of Cardiology Foundation
Circulation 2010;121;1047-1060; originally published online Feb 8, 2010
http://circ.ahajournals.org/cgi/reprint/121/8/1047
CredibleMeds™ website.
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February 12, 2013
CDPH: Lessons Learned from PCA Incident
PCA (Patient Controlled Analgesia) safety has been one of our most frequent topics. Serious incidents related to PCA continue to occur frequently. Another case with some valuable lessons learned comes from the California Department of Public Health (CDPH 2012).
In that case an opioid-naïve patient received an estimated total dose of 67.8 mg of morphine over an 8-hour period via PCA following a surgical procedure on his heel. He was found unconscious and not breathing at 3AM and could not be resuscitated.
There were multiple lessons learned in this case. The most obvious one is the total opioid dose in a patient who was apparently opioid-naïve. The patient had a surgical procedure on his heel from 2:15 PM to 6:50 PM. The PCA order, written by a CRNA in the PACU, was for 3 mg morphine per injection with a lockout interval of 10 minutes and a basal rate of 1 mg morphine per hour. The PCA computerized log showed that a total of 20 injections were given plus the basal infusion between 7:10 PM and 3 AM when the patient was found unresponsive and not breathing. The last self-administered dose had been given at 1:27 AM.
Generally in opioid-naïve patients we would begin with a much lower starting dose of morphine and titrate upward as needed for pain control. Also we avoid basal infusions in opioid-naïve patients.
The other obvious problem in this case had to do with lack of appropriate monitoring. The patient was apparently monitored via the medical-surgical post-operative protocol and not monitored via a PCA protocol or policy. It appears the patient was evaluated by nursing every 30 minutes for the first hour on the med/surg floor, then hourly until midnight. There was another nursing evaluation at 2:00 AM. The last evaluation (when the patient was found unresponsive and not breathing) was about 3:00 AM and apparently the nurse entered the patient’s room to check on him because the patient could no longer be heard snoring. The monitoring apparently included blood pressure, pulse, respirations, pain level, and level of arousal. The patient’s oxygen saturation was not monitored (pulse oximetry equipment apparently was available in the room but not utilized). It also does not appear that electrocardiographic monitoring or capnography were used. Note also that it is not clear in the report what specific monitoring parameters had been ordered.
But those are only the more proximate causes in this case. The root causes are much more revealing.
It appears that numerous providers were unfamiliar that the hospital even had a PCA policy. The CRNA who wrote the PCA orders was not familiar with the hospital PCA protocol. The surgeon stated he does not write PCA orders and that all he wrote was “pain control per PCA” and that anesthesia took responsibility for initiating it. An RN and a CNA taking care of the patient on the med/surg unit were both unfamiliar with the PCA policy. Despite everything that has been written about PCA safety issues we still find that hospitals underappreciate the potential dangers and don’t put the appropriate policies, procedures, monitoring and education in place to prevent adverse events related to PCA.
The relatively high dose of morphine being administered by PCA in this case also was not questioned by the pharmacists at the hospital. We certainly recommend that all hospitals have dosage range limits for their high alert drugs that trigger alerts when an ordered dose falls outside those set limits. Sometimes, however, such limits are set wide to accommodate doses sometimes given. For PCA those dose limits might be set high for opioid-tolerant patients, who might need a dose as high as used in this case. They key is having a trigger that forces the pharmacist to verify whether the patient is opioid-tolerant or opioid-naïve. The easiest way to do that is to have a required field on a standardized order set for PCA (computer-based or paper-based) that makes the ordering provider state whether the patient is opioid-tolerant or not. However, because a provider might bypass such order set you still need a flag for the pharmacist to verify that status. (Note also that this really should apply to opioids administered via any route, not just PCA.)
PCA pump setup is one procedure that should require an independent double check by nursing. Though we’ve written a lot about both the pros and cons of the independent double check, when dealing with high alert medications it probably does not hurt to have another set of eyes that might say “hey, I think the dose of this drug might be too high”. It’s not clear if an independent double check was done when the PCA was set up in this case.
The CDPH investigation and hospital RCA/POC also mention several other items that bear comment and there are other potential contributory factors we’ll speculate about.
The policy at the hospital in this incident did apparently require nursing to verify that the patient’s cognitive function was adequate to understand and participate in the PCA process. Confusion or impaired cognition are clearly contraindications to PCA. However, we also feel there are several other relative contraindications. These include sleep apnea, COPD, severe neuromuscular weakness, skeletal conditions that may restrict respiration, and others. Perhaps the most important consideration in this case would be sleep apnea. We know from the report that the patient was obese and loud snoring was heard on several occasions. So it is a distinct possibility this patient may have had sleep apnea and we’ll comment on that further below. That is one of the reasons we advocate use of a screening tool for sleep apnea, such as the STOP-Bang questionnaire, in all patients undergoing surgery. If such a tool suggests that sleep apnea is likely, we recommend special precautions if opioids are administered via any route (eg. continuous monitoring in an ICU or stepdown setting).
Who should be able to order PCA? In this case the order was written by a CRNA. It is not clear in the report whether or not that CRNA was part of a pain management team that would be following the patient throughout the hospitalization. If not, wouldn’t it make more sense if the order were written by a physician who would be following that patient on an ongoing basis? Who would nursing call if a question arose at night related to the PCA (the surgeon or the CRNA?)? Quite frankly, we actually recommend that providers should require specific hospital privileges to order PCA. Just as we privilege providers to do moderate sedation, those desiring to use PCA should undergo appropriate educational sessions and be certified to order PCA. We’ve simply seen too many errors related to PCA to allow all providers to order PCA without knowing they are proficient in doing so.
The orders for PCA depend on whether the patient is opioid-naïve or opioid-tolerant. That is an issue often neglected in writing the order for PCA, as it apparently was in this case. Using a standard order set (paper or computer) is a good way to force attention to opioid tolerance level. But that still is only good if the provider uses that form. In the current case a standard order form is alluded to in the hospital policy but it was obviously not used in this case.
Monitoring patients on PCA remains problematic. Any form of monitoring that is intermittent is obviously very risky. Pulse oximetry is recommended for all and it should be continuous pulse oximetry. But we’ve warned many times in the past that pulse oximetry may also provide false reassurances. Opioid-induced respiratory depression leads to hypercarbia before significant hypoxemia occurs. That is especially true in patients who are receiving supplemental oxygen (so supplemental oxygen should be used with caution in patients on PCA).
Patients on PCA (or receiving opioids via other route) may have normal ventilation and oxygenation when you arouse them (as opposed to what happens when they are sleeping). So if you only check their pulse oximetry when you arouse them you will almost never document hypoxemia.
Capnography has really now become the standard of care for avoiding post-operative opioid-induced respiratory depression and has been endorsed by numerous specialty organizations. However, a recent article does point out that the capnorgraphy used in unintubated patients is sidestream capnography and this is not particularly good for detecting hypercarbia (ASGE Technology Committee 2013). However, it can be used to monitor the respiratory rate and detect apnea and both of those are critical to monitor in the post-op patient on opioids.
Back to the issue of possible sleep apnea. Apparently no one was bothered by the loud snoring in the case at hand. Particularly in an obese patient it should have been a red flag that this patient might have had sleep apnea. Opioids in patients with sleep apnea may not cause the typical picture we associate with CO2 narcosis, i.e. a progressive hypoventilation resulting in CO2 retention. Rather, patients with sleep apnea undergo periodic hypoventilation broken up by “arousals”. Eventually the opioids blunt the ability to have physiological arousals and that is when deaths result.
This patient was described as being “arousable” at 2AM and was apparently alert enough to self-dose with the PCA pump at 1:27AM. That suggests to us this was not simply a case of opioid-induced CO2 narcosis. Rather, it suggests the third pattern of unexpected in-hospital death described in the excellent article by Lynn and Curry (Lynn 2011) on alarms and their failure to identify deteriorating patients early. Our February 22, 2011 Patient Safety Tip of the Week “Rethinking Alarms” highlighted that article in which they describe 3 patterns of unexpected in-hospital deaths and demonstrate the problems with threshold-based alarms (almost all currently used alarm systems use threshold-based principles) in detecting early deterioration. Indeed, they posit that threshold-based alarms themselves often cause us to miss signs of early deterioration.
The second pattern of deterioration they describe is the classic CO2 narcosis. As CO2 rises one sees further central depression of respiration and a vicious cycle. It is notoriously difficult at the bedside to predict who is hypoventilating. This is a pattern for which we have advocated using a combination of sedation scales and capnography. However, the authors point out that even such monitoring may be inadequate because many of these cases are complicated by the third pattern described below. The important point is that there may be a huge difference when the patient is awake and when he/she is asleep.
The third pattern they describe is one that is typically seen in sleep apnea. In this pattern one sees repetitive reductions in airflow and oxygen saturation during sleep followed by arousals. The arousals rescue the patient but eventually the capacity or reserve of the patient to recover with arousals becomes impaired (often in response to narcotics or sedatives) and the patient may experience sudden death during sleep. The authors discuss the inability of currently used oximeters to recognize this pattern. They even imply that this pattern may give rise to oximeters alarming and being interpreted as “false” alarms attributed to motion artifact, etc. because when staff respond to the alarm the patient is now awake, breathing normally and has a normal oxygen saturation.
See the list of our previous columns on sleep apnea in the perioperative period at the end of today’s column.
Education at several levels is imperative. At the medical staff level we’ve already mentioned our recommendation about requiring specific privileges to order PCA and having them have appropriate training prior to granting those privileges. At the nursing level all staff should receive inservices on PCA and be required to demonstrate competency on PCA annually.
At the patient level there are several considerations. When PCA was set up in the PACU nursing noted that PCA was explained to the patient and questions were answered. It is not clear what the patient’s capability of understanding was at that time since he may well have had residual effects from anesthesia and other medications given during and immediately after his surgery. Patient education should begin before the day of surgery, either in the surgeon’s office or at a pre-op visit, and should include both verbal and printed materials. Such education should also be given to any family members likely to be with the patient in the hospital.
And there is also the issue of education at the family level. It is also not clear whether any education was provided to family members in this case. The report does state that the patient’s wife left around 11PM or 12AM so she should have received education about the PCA process. Because of the well-known problem of “PCA by proxy” (where family or others push the PCA button to administer analgesic) it is imperative that family and visitors be educated not to manipulate the PCA pump in any way. We also recommend specific signage be affixed to the PCA pump to warn family and visitors not to manipulate the pump.
Communication and handoffs are critical in most incidents that result in patient harm and this case is no different. In this case there was an apparent handoff from one CRNA to another CRNA. Did the second CRNA have adequate knowledge of the patient’s history and current status? We don’t like to see any of the key players in surgery (physicians, residents, nurses, surgical techs, anesthesiologists, CRNA’s) change in the middle of a procedure. Scheduling and timing of cases should take into account the need to maintain a full complement of personnel through the entire procedure.
And there was a handoff from the PACU nursing staff to the nursing staff on the med/surg floor. Were any standardized handoff tools used? We recommend that PCA be a specific item that needs to appear on such nursing handoff tools.
And there are other potential contributing factors we cannot adequately assess from the CDPH report. For example, the surgical case was of fairly long duration and ended around 7PM. We don’t know if ending that late in the day put any time pressures on staff. For example, was there any pressure to move the patient from the PACU to the med/surg floor so the PACU staff could go home? Did the timing and/or duration of the case have anything to do with the change in CRNA’s noted above?
In our May 17, 2011 Patient Safety Tip of the Week “Opioid-Induced Respiratory Depression – Again!” we encouraged hospitals to perform their own FMEA (Failure Mode and Effects Analysis) on the PCA process and provided links to two tools we use when doing FMEA’s of the PCA pump process: the PCA Pump Audit Tool and the PCA Pump Criteria. And we hope that you’ll go back and look at the string of recommendations we made in our September 6, 2011 Patient Safety Tip of the Week “More Tips on PCA Safety”. We think you will find them extremely helpful. And don’t forget that most of the issues pertaining to patients on PCA pumps apply also to patients receiving postoperative opioids by other routes.
And in our October 2012 What’s New in the Patient Safety World column “Another PCA Pump Safety Checklist” we mentioned that the Physician-Patient Alliance for Health & Safety (PPAHS) had a workgroup addressing PCA safety. On their website are some heart-wrenching stories about patients who died during PCA, likely as a result of inadequate monitoring. We noted they had just released a checklist for PCA pump safety (PPAHS 2012). Their website not only has the link to the PCA Safety Checklist itself but also links to several columns and blogs regarding PCA safety, PCA hazards, monitoring, capnography, etc. These are excellent resources.
Another excellent resource on PCA safety is the San Diego Patient Safety Council and the San Diego Patient Safety Taskforce, which put together a tool kit for PCA safety. It is a comprehensive document that discusses assessment for PCA appropriateness, distinction between opioid naïve and opioid tolerant patients, PCA patient education, pain assessment, sedation assessment, respiratory assessment, monitoring, adjuvant therapies (eg. for treating side effects of opioid therapy such as constipation, nausea and vomiting, pruritis), multimodal pain management strategies, standardized order sets, and specific issues related to equipment and products.
Other Patient Safety Tips of the Week pertaining to opioid-induced respiratory depression and PCA safety:
January 4, 2011 “Safer Use of PCA”
July 13, 2010 “Postoperative Opioid-Induced Respiratory Depression”
May 12, 2009 “Errors With PCA Pumps”
September 21, 2010 “Dilaudid Dangers”
November 2010 “More on Preoperative Screening for Obstructive Sleep Apnea”
February 22, 2011 “Rethinking Alarms”
May 17, 2011 “Opioid-Induced Respiratory Depression – Again!”
September 6, 2011 “More Tips on PCA Safety”
December 6, 2011 “Why You Need to Beware of Oxygen Therapy”
February 21, 2012 “Improving PCA Safety with Capnography”
October 2012 “Another PCA Pump Safety Checklist”
Tools: PCA Pump Audit Tool and the PCA Pump Criteria
Our prior columns on obstructive sleep apnea in the perioperative period:
June 10, 2008 “Monitoring the Postoperative COPD Patient”
August 18, 2009 “Obstructive Sleep Apnea in the Perioperative Period”
August 17, 2010 “Preoperative Consultation – Time to Change”
July 13, 2010 “Postoperative Opioid-Induced Respiratory Depression”
July 2010 “Obstructive Sleep Apnea in the General Inpatient Population”
November 2010 “More on Preoperative Screening for Obstructive Sleep Apnea”
February 22, 2011 “Rethinking Alarms”
November 22, 2011 “Perioperative Management of Sleep Apnea Disappointing”
March 2012 “Postoperative Complications with Obstructive Sleep Apnea”
May 22, 2012 “Update on Preoperative Screening for Sleep Apnea”
References:
California Health and Human Services Agency Department of Public Health (CDPH).
State of Deficiencies and Plan of Correction. 2012
ASGE Technology Committee, Gottlieb KT, Banerjee S, Barth BA, et al. Monitoring equipment for endoscopy. Gastrointestinal Endoscopy 2013; 77(2): 175-180
http://www.giejournal.org/article/S0016-5107%2812%2902755-1/fulltext
Lynn LA, Curry JP. Patterns of unexpected in-hospital deaths: a root cause analysis. Patient Safety in Surgery 2011, 5:3 (11 February 2011)
http://www.pssjournal.com/content/pdf/1754-9493-5-3.pdf
PPAHS (Physician-Patient Alliance for Health & Safety)
PPAHS (Physician-Patient Alliance for Health & Safety). Physician-Patient Alliance for Health & Safety Announces New Expert Checklist for Facilitating Safety of Hospital-Based Intravenous Patient-Controlled Analgesia Pumps. July 17, 2012
PPAHS. PCA Safety Checklist.
http://ppahs.files.wordpress.com/2012/07/pca-safety-checklist3.pdf
San Diego Patient Safety Taskforce. Tool Kit: Patient Controlled Analgesia (PCA) Guidelines of Care for the Opioid Naïve Patient. Published: December 2008
http://www.patientsafetycouncil.org/uploads/Tool-Kit-PCA_Dec_2008.pdf
Print “CDPH: Lessons Learned from PCA Incident”
February 19, 2013
Practical Postoperative Pain Management
In last week’s Patient Safety Tip of the Week “CDPH: Lessons Learned from PCA Incident” we discussed an unfortunate fatal incident related to patient-controlled analgesia (PCA) in a post-operative setting. This week we came across an outstanding article outlining a whole host of steps and actions that should be utilized to minimize the risk of post-op opioid-induced respiratory depression (Pasero 2013).
Many of you will recognize the author’s name. We noted in our June 10, 2008 Patient Safety Tip of the Week “Monitoring the Postoperative COPD Patient” her very practical sedation scale for monitoring patients on opioid therapy.
The current article is written from the perspective of the perianesthesia nurse but obviously has implications for healthcare workers at all levels and for patients and families. She provides two and one-half pages of recommendations in tabular format and focuses on two extremely important themes: (1) we need to change the way we think about post-op pain management and (2) we need to change the way we monitor patients.
Her first theme revolves around the concept that the best way to prevent opioid-induced respiratory depression is to avoid opiates or minimize their dose. This is best accomplished by a multimodal analgesia approach. A key principle is that opioid-only analgesic regimens are simply unacceptable in this day and age and that we really need to change the culture. Combining two or more analgesics with different mechanisms of action can provide pain relief at lower doses than would be needed with a single drug, thus minimizing side effects. Local/regional anesthesia techniques (nerve blocks, epidural analgesia, etc.) can be part of multimodal analgesia but the mainstays are usually use of acetaminophen or non-steroidal anti-inflammatory drugs (NSAID’s) if there are no contraindications. She notes that because the non-opioids seldom interfere with coagulation they may be started immediately after surgery or even intraoperatively.
A second key principle is that we should not tie the dose of opioids to specific pain levels. Rather, because the relationship between opioid dose and pain level is not linear, the opioid dose should be titrated to achieve an analgesic goal while minimizing dangerous side effects.
Her second theme regards monitoring practices. She stresses the importance of monitoring level of sedation, since sedation almost always precedes opioid-induced respiratory failure. She also has a good discussion on how to assess respiration by observation, reiterating our frequent point that the respiratory assessment must be done before arousing the patient.
Pasero then has an excellent discussion about a key red flag in last week’s case: snoring. She emphasizes that snoring is a sign of airway obstruction and should be attended to promptly. Snoring patients should be aroused and repositioned. She notes that many patients and families (and to that we will add staff) think that snoring is “normal”. That’s because the patient snores at home but usually self-arouses (or gets poked by their unhappy spouse!) and has no untoward consequences. However, under the influence of opioids and/or sedating agents that ability to self-arouse may be lost. We discussed that in last week’s column and cited the excellent description by Lynn and Curry (Lynn 2011) of that as a specific pattern of unexpected death in inpatients. Pasero notes the importance of educating all staff, patients and families to recognize that snoring and sedation are not normal in patients receiving opioids and should be reported to nursing staff immediately.
She reiterates our previous comments about pulse oximetry, both in terms of its inability to pick up respiratory depression early, the false reassurance in patients on supplemental oxygen, and the need to monitor continuously rather than intermittently. And she touts the benefits of capnography, noting that technological advances are underway to further improve capnography as a monitoring tool. Nevertheless, she states that patients with any evidence of sedation or respiratory depression should be promptly moved to settings where more close observation can be undertaken. She also emphasizes the need to have protocols which allow nursing to administer naloxone when clinically significant opioid-induced respiratory depression is suspected (keeping in mind that the phenomenon of “renarcotization” may occur after naloxone administration depending on the specific opioid involved).
Last week we provided a list of PCA Pump Criteria that included some relative contraindications to use of PCA because they put patients at greater risk of opioid-induced respiratory depression. Pasero provides an even larger list of risk factors for opioid-induced respiratory depression in the article. She emphasizes the potential for coadministration of other sedating agents to increase the likelihood of respiratory depression.
Pasero also emphasizes the importance of providing adequate information during any handoffs to other units. Such information should include a comprehensive report of how pain was managed, what medications and doses were used, how they were tolerated, and the patient’s current pain level and sedation level, and the specific risk factors the patient may have for opioid-induced respiratory depression.
There are very few articles we call “must reads” but this is one of them. Pasero does an excellent job summarizing the things we all need to do to prevent incidents with post-op opioid-induced respiratory depression. She also challenges perianesthesia nurses to speak up and make it clear to surgeons and other physicians that old practices are no longer acceptable and that cultural change is needed when it comes to opioid analgesia. It is an extremely practical article that all your surgeons, anesthesiologists, nursing staff and others will learn from.
Other Patient Safety Tips of the Week pertaining to opioid-induced respiratory depression and/or PCA safety:
January 4, 2011 “Safer Use of PCA”
July 13, 2010 “Postoperative Opioid-Induced Respiratory Depression”
May 12, 2009 “Errors With PCA Pumps”
September 21, 2010 “Dilaudid Dangers”
November 2010 “More on Preoperative Screening for Obstructive Sleep Apnea”
February 22, 2011 “Rethinking Alarms”
May 17, 2011 “Opioid-Induced Respiratory Depression – Again!”
September 6, 2011 “More Tips on PCA Safety”
December 6, 2011 “Why You Need to Beware of Oxygen Therapy”
February 21, 2012 “Improving PCA Safety with Capnography”
July 3, 2012 “Recycling an Old Column: Dilaudid Dangers”
September 2012 “Joint Commission Sentinel Event Alert on Opioids”
September 2012 “FDA Warning on Codeine Use in Children Following Tonsillectomy”
October 2012 “Another PCA Pump Safety Checklist”
Tools: PCA Pump Audit Tool and the PCA Pump Criteria
References:
Pasero C. The Perianesthesia Nurse’s Role in the Prevention of Opioid-Related Sentinel Events. Journal of PeriAnesthesia Nursing 2013; 28(1): 31-37
http://download.journals.elsevierhealth.com/pdfs/journals/1089-9472/PIIS1089947212005217.pdf
Lynn LA, Curry JP. Patterns of unexpected in-hospital deaths: a root cause analysis. Patient Safety in Surgery 2011, 5:3 (11 February 2011)
http://www.pssjournal.com/content/pdf/1754-9493-5-3.pdf
Print “Practical Postoperative Pain Management”
February 26, 2013
Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?
Here in Western New York we have recently had 2 hospitals reveal they had reused insulin pens on multiple patients, potentially exposing patients to bloodborne pathogens. First, the local VA hospital revealed that over 700 patients may have been exposed to such pathogens when the improper practice of reusing insulin pens on multiple patients was identified (Zremski 2013a). Then another area hospital, after reviewing its own practices upon hearing about the VA incidents, discovered that it, too, had possibly reused insulin pens on over 1900 patients (Davis 2013).
ISMP has now called for removal of insulin pens from use in inpatient settings (ISMP 2013). They cite not only the incidents at the above 2 hospitals but also similar incidents occurring at multiple hospitals since 2009. Many of those instances have occurred despite warnings from both the FDA and CDC. And though there apparently have been no documented cases of actual transmission of bloodborne diseases from insulin pens, they do cite the evidence that blood and other materials have been found in such pens after use. They note that such pens were originally introduced for use in ambulatory care. They note that placing a label on the pen for a single patient has its difficulties and that other problems are seen, such as using the pens as multi-dose vials, risk of needlesticks, etc. They note that the VA National Center for Patient Safety has now prohibited use of multi-dose pen devices on patient care units in VA facilities with certain exceptions (VA 2013).
ISMP goes on to note the ease with which such errors are likely to occur when providers not fully familiar with the safety issues around such pens are now confronted with such pens. They note that we cannot reasonably expect education and inservicing to reach all necessary parties and that punishment of those who never learned the correct use of such devices is not appropriate. Hence, they suggest the best solution is removal of such devices from the inpatient setting (with the exception of those circumstances identified by the VA NCPS and outlined in the ISMP article).
But these incidents also have another important root cause: how hospitals (and other provider organizations) identify alerts and recalls. A spokesperson for the Buffalo VA noted “we do not have a record of receiving the FDA alert or clinical reminder” (Zremski 2013b). That, of course, highlights a system problem that we suspect lurks at many hospitals: lack of a system for dealing with safety alerts and recalls that may come from a variety of sources. Every hospital (or other provider venue) should have in place a system to identify potential sources for alerts and recalls and specify who will be responsible for receiving and disseminating that information to the appropriate people. Alerts and recalls should be a formal part of every organization’s regularly scheduled quality improvement or patient safety meetings.
ISMP had first issued a safety alert about this problem in early 2009 (ISMP 2009), followed closely by an FDA alert (FDA 2009). Both followed reports that over 2000 patients at 2 US military medical facilities had been potentially exposed to bloodborne pathogens by reuse of insulin pens in multiple patients. ISMP had, in fact, in 2008 noted studies that showed biological contamination in half of all reused insulin pen cartridges (ISMP 2008a) and provided many useful safety recommendations about use of such pens (ISMP 2008b). CDC also has a clinical reminder on the issue (CDC 2012).
The FDA alert emphasized that such pens are meant for use by a single patient only and recommended that labeling the pen with the name of the patient and other patient identifiers might reduce the chance such pens would be used for multiple patients. They recommended that hospitals review their policies and procedures regarding insulin pens and educate their staff (and patients) on appropriate use. ISMP also advised education of all staff and monitoring of use of such pens. ISMP has always noted that mistakes like these that occur at one facility are likely to be encountered at many facilities. They specifically noted we should never assume that providers will know how to use the pens.
So alerts come from multiple authoritative sources (FDA, ISMP, CDC) and are often also noted in resources like Medscape, specialty journals, trade publications, manufacturers and others. But that may actually also be part of the problem. The alerts come from so many sources, are often duplicative, and may be included with many other alerts that are not relevant to all providers. Often when we get an email from the FDA it has alerts on medications, foods, and devices all interspersed. There are often so many that we miss the important ones as we rapidly scroll through the document(s). Having the alerts come through in a filtered manner would obviously be helpful. And when the alerts are going to multiple parties there is always the tendency to assume that someone else will pick up on the alert.
Note that the FDA has recently convened a committee to address “message fatigue” regarding its frequent alerts to consumers about food products (FDA 2013). They should probably extend that to alerts to hospitals and providers about medications and medical devices as well.
Your organization’s policy on alerts and recalls should specify what sources will be scanned for alerts and recalls, which newsletters you will subscribe to (whether they are free or require a fee), and who will be responsible to report on such alerts. Moreover, you need to specify what that responsible person is to do with the alerts. When you send them out to all staff or all senior management there is a tendency for them to be ignored by “all”. In setting up your procedures for handling alerts and reminders make sure you take into account vacations or other extended absences. You don’t want to miss an important alert because the responsible party was not available to pick it up in a timely fashion. And, as above, make sure that alerts and reminders are a specific agenda item on your monthly patient safety committee or performance improvement committee agenda.
Hospitals therefore should not only review and update their policies related to use of multi-dose pen devices (with consideration of eliminating the devices all together for inpatients) but also review their current procedures for handling alerts and recalls coming from external sources.
Specifically you should:
You should also read ISMP’s most recent newsletter (ISMP 2013b) that warns you might create some unintended consequences as you switch completely from insulin pens to use of insulin vials. It has some great safety recommendations that apply to insulin therapy in general.
References:
Zremski J. 716 patients at VA may have been exposed to HIV. The Buffalo News. January 11, 2013
http://www.buffalonews.com/apps/pbcs.dll/article?AID=/20130111/CITYANDREGION/130119728/1002
Davis H. Olean General checking for insulin pen reuse. The Buffalo News. January 24, 2013
http://www.buffalonews.com/apps/pbcs.dll/article?AID=/20130124/CITYANDREGION/130129583
ISMP (Institute for Safe Medication Practices). Ongoing concern about insulin pen reuse shows hospitals need to consider transitioning away from them. ISMP Medication Safety Alert. Acute Care Edition. February 7, 2013
http://www.ismp.org/Newsletters/acutecare/showarticle.asp?id=41
VA Patient Safety Alert. Multi-dose pen injectors. January 17, 2013
http://www.patientsafety.gov/alerts/AL13-04MultiDosePens.pdf
ISMP (Institute for Safe Medication Practices). Reuse of insulin pen for multiple patients risks transmission of bloodborne disease. ISMP Medication Safety Alert. Acute Care Edition. February 12, 2009
http://www.ismp.org/Newsletters/acutecare/articles/20090212-2.asp
FDA. FDA Safety Alert. Information for Healthcare Professionals: Risk of Transmission of Blood-borne Pathogens from Shared Use of Insulin Pens. March 19, 2009
ISMP (Institute for Safe Medication Practices). Cross contamination with insulin pens. ISMP Medication Safety Alert. Acute Care Edition. March 27, 2008
http://www.ismp.org/newsletters/acutecare/articles/20080327_1.asp
ISMP (Institute for Safe Medication Practices). Considering insulin pens for routine hospital use? Consider this... ISMP Medication Safety Alert. Acute Care Edition. May 8, 2008
http://www.ismp.org/newsletters/acutecare/articles/20080508.asp
CDC. CDC Clinical Reminder. Insulin Pens Must Never Be Used for More than One Person. Updated January 5, 2012
http://www.cdc.gov/injectionsafety/clinical-reminders/insulin-pens.html
Zremski J. VA officials don’t think they received insulin pen alert. Two federal agencies issued warnings on dangers of reusing pens on patients. The Buffalo News. January 18, 2013
http://www.buffalonews.com/apps/pbcs.dll/article?AID=/20130118/CITYANDREGION/130119106
FDA (Food and Drug Administration). Discussion Topics and Background for
FDA’s Risk Communication Advisory Committee. February 12, 2013
ISMP (Institute for Safe Medication Practices). A clinical reminder about the safe use of insulin vials. ISMP Medication Safety Alert. Acute Care Edition. February 21, 2013
http://www.ismp.org/Newsletters/acutecare/showarticle.asp?id=42
Print “Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?”
March 5, 2013
Underutilized Safety Tools: The Observational Audit
We’ve frequently recommended performing audits on a variety of processes in healthcare. To name just a few, we’ve discussed audits in MRI safety, PCA (patient-controlled analgesia) safety, hi-alert medication safety, and many others. But most of those are retrospective audits and involve reviewing information that has been recorded in the chart or electronic medical record. Often there are processes in healthcare that are very necessary, even crucial, yet never get recorded anywhere.
One of the most underutilized tools in patient safety is the observational audit. Other industries (eg. aviation, banking, pharmaceuticals, steel making, etc.) have used audit techniques successfully for many years. We’ve previously talked about the line operations safety audits (LOSA) audits in aviation where an independent observer sits in the cockpit and monitors and assesses multiple operations and procedures, then critiques the crew. An audit such as the LOSA is resource-intense, requires a well-trained auditor, and behavior may be quite different when a known audit is being undertaken. Nevertheless, the findings are often eye-opening. The power of real-time observational methodologies has largely been untapped in healthcare today.
We have previously discussed one form of observational audit, the real-time random safety audit (see our May 18, 2010 Patient Safety Tip of the Week “Real-Time Random Safety Audits”).
Perioperative processes are an area ripe for auditing and two recent studies in the surgical literature demonstrate how auditing using observational tools can be used to identify areas for improvement. They illustrate 2 slightly different methodologies that are helpful in identifying processes of care not well done.
First is a Metric for Evaluating Task Execution in the Operating Room, better known as the acronym METEOR (Russ 2013). Their underlying concept is that there are certain key tasks by the OR team that are critical for patient safety and OR efficiency, coordination and teamwork. Another key principle they considered is that safety and efficiency in the OR are not often compromised by single, large, catastrophic failures but rather more often by small failures that go unnoticed and accumulate to impact safety or efficiency.
They note that the list of such tasks goes well beyond what would typically be included in a working checklist. You’ll recall from our previous discussions about checklists that the number of items in a checklist should be small and should include things you might otherwise forget (see our July 6, 2010 Patient Safety Tip of the Week “Book Reviews: Pronovost and Gawande” and our September 23, 2008 Patient Safety Tip of the Week “Checklists and Wrong Site Surgery”). Your typical checklist used for patient safety purposes may have 10 or fewer items. An exception is the SURPASS (SURgical PAtient Safety System) checklist (see our November 30, 2010 Patient Safety Tip of the Week “SURPASS: The Mother of All Checklists”).
But Russ and colleagues note that there are far more processes and tasks involved in surgery than you would include in a checklist. So they developed an audit tool that contains items for the preoperative, intraoperative, and postoperative stages and breaks the tasks down roughly into categories of patient tasks, communication tasks and equipment tasks. They first developed a list of 106 discrete OR tasks felt to be important in “getting things done”. They then had 2 general surgeons trained in use of the list observe 50 general surgical procedures in real-time and compute task completion rates for each of the 106 tasks in the list. If tasks were completed less than 70% of the time they considered that as either a signal of poor OR team performance or that the task was not really relevant for safety or efficiency. Those tasks with <70% completion rates were then evaluated by a panel of OR experts to be rated for the tasks’ contribution to OR safety or efficiency. The ratings were then reviewed again by a smaller select group of OR experts and 2 practicing clinicians. This iterative process ultimately led to the final list, METEOR, consisting of 80 OR tasks (34 preoperative, 18 intraoperative, and 28 postoperative). METEOR theoretically can be used to identify patient safety vulnerabilities and to identify factors contributing to OR inefficiencies. It serves as a good data collection tool that obviously needs to be combined with constructive feedback to the OR team members. Because of its size and the fact that a real-time observer is needed it is not something that would be applied on a daily basis in your OR suite. However, it has considerable potential as a tool for periodic auditing of compliance with good OR practices and safety measures.
The second study used an observational methodology to assess failures in postoperative care (Symons 2013). Many of our columns have focused on problematic care of postoperative patients. A variety of system failures have contributed to adverse outcomes in such patients. These have included poor handoffs, failure to identify patients at risk for specific complications, failure to identify early clinical deterioration and failure to rescue, a variety of problems related to pain management, and medication-related problems.
Most of those have stemmed from specific case examples. But the Symons study used observational tools on a population of general surgical patients to identify and quantify such process failures. The population included 50 adults undergoing major upper or lower gastrointestinal surgery (most often for cancer) at a large urban teaching hospital. Two surgical residents, trained in patient safety research, observed the care of these patients from the first postoperative day through discharge. They attended rounds, reviewed patient charts and records, and did structured interviews with care providers and identified any event that was not considered routine in the postoperative period. They further broke those events down into those with or without process failures and assessed the likely preventability of these events. They also determined whether harm resulted from the events
A total of 352 nonroutine events were identified in the 50 patients observed for 659 days of inpatient care. Of these, 256 (73%) were deemed process failures or a median of 4.5 process failures per patient. 85% of process failures were felt to be preventable and 51% directly led to patient harm or prolonged length of stay. Process failures occurred in all aspects of care, the most frequent being medication prescribing and administration, management of lines, tubes, and drains, and pain control interventions. Process failures accounted for 57% of all preventable adverse events. Although no patient died or suffered permanent disability, the frequency of potentially preventable process failures here points out potential vulnerabilities for serious adverse outcomes.
They further analyzed their data for factors contributing to the failures and found that communication failures and delays were the main causes, together accounting for over half of all process failures and almost three quarters of adverse events.
The authors suggest that interventions found to be successful in other venues, such as daily goals and team training programs, might be applied to the postoperative setting.
This was a good study. The observational methodology allowed them to identify process failures and events that might not have been found using other methodologies.
It’s important that the feedback from the observational audits be constructive in nature. It should be used to identify gaps in the care processes that can significantly impact patient outcomes. However, the observational methodology also from time to time may uncover risky behaviors that would not otherwise come to attention. Of interest, the NTSB report in our October 2, 2007 Patient Safety Tip of the Week “Taking Off from the Wrong Runway” mentioned that a LOSA Collaborative showed that flight crewmembers who intentionally deviated from standard operating procedures were three times more likely to commit other types of errors, mismanage more errors, and find themselves in more undesired aircraft situations compared with those flight crewmembers who did not intentionally deviate from procedures. We suspect the numbers in healthcare would be similar. So auditing as above might also identify risk for other situations.
References:
Russ S, Arora S, Wharton R, et al. Measuring Safety and Efficiency in the Operating Room: Development and Validation of a Metric for Evaluating Task Execution in the Operating Room. Journal of the American College of Surgeons 2013; 216(3): 472-481
http://www.journalacs.org/article/S1072-7515%2812%2901403-2/abstract
Symons NRA, Almoudaris AM, Nagpal K, et al. An Observational Study of the Frequency, Severity, and Etiology of Failures in Postoperative Care After Major Elective General Surgery. Annals of Surgery 2012; published ahead of print 20 September 2012
Annals of Surgery. 257(1):1-5, January 2013
Print “Underutilized Safety Tools: The Observational Audit”
March 12, 2013
More on Communicating Test Results
We’ve emphasized on numerous occasions the importance of having systems in place to ensure that significant findings of test results get appropriately communicated and that appropriate follow up gets done in a timely fashion. We’ve all seen cases where the suspicious pulmonary nodule on a chest X-ray or CT scan is noted in the radiology report but no practitioner follows up on it until a diagnosis of metastatic cancer appears many months later. Just as important is having systems in place to ensure that appropriate investigation and follow up takes place when an ordered test is not resulted within the anticipated time frame. For example, a Pap smear can be lost in transit to the lab and thus never be examined. Yet the practitioner and patient often assume that the test was done and was normal when, in fact, the test was never done.
One recent study looked at suspected GI malignancies newly discovered on imaging studies (Browning 2012). They electronically routed critical results messaging to the ordering provider. But they also messaged the surgical oncology clinic. This resulted in more than doubling the number of patients who saw the surgical oncology specialist (from 45.9% to 98.0%) and reduced the median time for that consultation from 35 days to 7 days. It almost halved the median time to initiation of definitive management (from 62 days to 35 days).
The system you choose obviously depends upon many factors, most important of which is the nature of the healthcare organization you work in. What works in a relatively “closed” system where there is true integration between the outpatient and inpatient staff may not work nearly as well in a community hospital where there is less integration. We’ve also cautioned that you need to be careful about “dual” messaging. A previous study (Singh 2009) found that the well-intentioned process of sending test results to both the ordering physician and another physician (such a the primary care physician) actually almost doubled the lack of timely followup (see our Patient Safety Tip of the Week October 13, 2009 “Slipping Through the Cracks”).
Another study (Dimigen 2012) described a radiology notification system, dubbed “Tsunami” that improved communication of non-urgent but significant findings. When a radiologist would see potentially serious findings, such as lung nodules suspicious for malignancy or unexpected fractures, they would email an alert to a centralized clerk who, in turn, would directly notify the referring clinical team by phone or fax. The system was well received by clinicians. Two-thirds felt that an automated email alert system would be difficult to implement or unworkable so this system provided a good alternative. The system was low-cost and easily implemented.
Importantly, they also used the system to notify clinicians of amended reports. Amended reports are especially prone to communication error because the clinician often perceives he or she has already seen the report and that it lacked significant abnormalities (see our October 2, 2012 Patient Safety Tip of the Week “Test Results: Everyone’s Worst Nightmare”). If an amended report goes out there must be a good way to alert the clinician that there has been a change to that original report. In the “Tsunami” system 9% of alerts were for amended reports.
How alerts are delivered is important. Another study by Singh and colleages (Singh 2013) looked at followup of tests in the electronic health record environment. They surveyed primary care clinicians at the DeBakey VA Medical Center in Houston and found that almost 30% of respondents reported they had missed test results that delayed patient care. Respondents noted they averaged receiving over 60 alerts daily and an overwhelming majority felt the number of alerts was excessive and not manageable. Information overload was felt to be a major contributing factor to missed test results, though not necessarily related to the actual number of alerts. The manner in which the alerts were presented was also perceived to contribute.
But they also found some factors that made it less likely clinicians would miss alerts. Those clinicians who said they consistently notified patients of abnormal results said they were less likely to miss alerts, as did those who found the EHR system easy to use. Interestingly, those whose native language was not Enlgish were also less likely to report missing test results.
One especially problematic situation encountered was the handoff situation. For example, when clinicians went on vacation there might be incomplete routing of alerts to the covering clinicians. Note that our own experience would suggest that is a two-way problem, in that covering physicians are notorious for deferring action on results back to the original physician. That often results in a situation where both clinicians assume, erroneously, that the other clinician has or will follow up on the result.
Note that the “handoff” situation is especially problematic for patients seen in the emergency department or those patients cared for as inpatients by hospitalists (or specialists) and then discharged to the care of their primary care physicians. We’ve discussed those issues in several previous Tips of the Week (March 1, 2011 “Tests Pending at Discharge”, August 21, 2012 “More on Missed Followup of Tests in Hospital”).
In a companion paper to the survey above Singh and colleagues (Singh 2012) discussed several of the other features of the VA system’s electronic health record as they pertain to patient notification of results. Over half believed that the EHRs did not have convenient features for notifying patients of test results. And only a little over a third (37.9%) reported having staff support needed for notifying patients of test results. Almost half relied on the patient's next visit to notify them of normal results and 20% relied on that next visit to notify patients of abnormal results. Many felt that there was inadequate technical assistance or training on use of the patient notification system. And many found they had to work extra hours or weekends to address the patient notifications. They discuss the need to improve the usability of the electronic systems with better methods to display and sort and visualize the test results. They note that sometimes a provider might accidentally delete an alert that they need to return to later. They again note the handoff problem, including assignment of responsibility. And they emphasize the importance of the EHR’s need to support “prospective” memory (eg. prompting to perform a future task, perhaps akin to “tickler” files). What they are really stressing is that issues revolving around EHR’s are not all technological but rather that social and organizational factors play key roles as well.
We have also found many of the barriers that Singh and colleagues have identified. We’ve put systems in place that produced alerts for every test ordered and found that clinicians readily became overwhelmed. So we had to prioritize the tests that might trigger alerts and assign time frames for checking to see you have received those results. For example, you might always want to know when a Pap smear report has not been received within 7-10 days. The time frame for MRI or CT scan reports might vary depending upon the reason for doing the study (and the accessibility of the study).
Who should communicate the test results to the patient has also been the subject of some debate. One study (Gunn 2013) surveyed primary care practices found ninety-five percent of respondents felt that ordering physicians should deliver the results of examinations. No respondents felt that radiologists should deliver results directly to patients. But another view presented by radiologists (Amber 2013) argues that radiologists not only have a right but also a duty to communicate test results directly to patients who are interested in knowing their diagnostic results. This is especially the case once the radiologist has established a doctor-patient relationship with the patient. They note that most patients want to know their results as soon as possible regardless of severity. They propose an interesting “sliding scale” for delivering results directly to patients, based not on the severity of the abnormalities found but rather on the diagnostic confidence of the imaging findings.
Common sense and courtesy are important in the above “controversy”. Probably what is most important is that if the radiologist communicates findings directly to the patient the radiologist also needs to convey to the ordering physician that such communication took place. There is nothing more uncomfortable than getting a phone call from a patient or family regarding a test result that you, yourself, are not yet aware of.
A point we’ve made before about managing test results is that there should be two systems in place: one in the radiology department (or other department doing the test) to ensure this message gets to the person who needs to know and one with the ordering physician that ensures the physician always identifies results of tests ordered. We’ve talked about 2 types of system: paper and electronic. And some findings would require both. Actually, there should be a 3rd system in place as well: one with the patients themselves. The educated patient should always ask the provider “when should I expect the result to be available?” and then contact the provider if they have not heard those results within a reasonable period of time. A patient should never assume that “no news is good news”. Some patients are timid when it comes to calling their physician. We recommend you actually use a script such as “We expect to get your test results in x days. The doctor or one of our staff will notify you of the results. However, if you have not heard from us within y days, please call us to double check whether we have received your test results.”
See also our other columns on communicating significant results:
References:
Browning T, Kasper J, Rofsky NM, et al. Quality improvement report. Quality improvement initiative: enhanced communication of newly identified, suspected GI malignancies with direct critical results messaging to surgical specialist. BMJ Qual Saf 2012; Published online first 4 October 2012
http://qualitysafety.bmj.com/content/early/2012/10/03/bmjqs-2012-001069.short?g=w_qs_ahead_tab
Singh H, Thomas EJ, Mani S, et al. Timely Follow-up of Abnormal Diagnostic Imaging Test Results in an Outpatient Setting. Arch Intern Med. 2009; 169(17): 1578-1586.
http://archinte.ama-assn.org/cgi/content/short/169/17/1578?home
Dimigen M, Zogovic B, Saks A, et al. 'Tsunami' Radiology Notification System: A Low Cost Method in Improving Communication between the Imaging Department and Clinicians. Poster Presentation RNSA 2012
http://rsna2012.rsna.org/search/event_display.cfm?em_id=12043395
Singh H, Spitzmueller C, Petersen NJ, et al. Information Overload and Missed Test Results in Electronic Health Record–Based Settings. JAMA Intern Med. 2013; ():1-3. doi:10.1001/2013.jamainternmed.61; Published online March 4, 2013
http://archinte.jamanetwork.com/article.aspx?articleid=1657753
Singh H, Spitzmueller C, Petersen NJ, et al. Primary care practitioners’ views on test result management in EHR-enabled health systems: a national survey. J Am Med Inform Assoc Published Online First: 25 December 2012 doi:10.1136/amiajnl-2012-001267
http://jamia.bmj.com/content/early/2012/12/24/amiajnl-2012-001267.full.pdf+html
Gunn AJ, Sahani DV, Bennett SE, Choy G. Recent Measures to Improve Radiology Reporting: Perspectives From Primary Care Physicians. Journal of the American College of Radiology 2013; 10(2): 122-127
http://www.jacr.org/article/S1546-1440%2812%2900498-X/abstract
Amber I, Fiester A. Communicating Findings: A Justification and Framework for Direct Radiologic Disclosure to Patients. American Journal of Roentgenology. 2013; 200: 586-591
http://www.ajronline.org/doi/abs/10.2214/AJR.12.9468
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March 19, 2013
Dealing with the Violent Patient in the Emergency Department
Over the last decade we have seen increasing numbers of violent incidents against healthcare workers. Hardly a week goes by now that we don’t hear about a healthcare worker somewhere being injured by a patient. Joint Commission in 2010 issued a Sentinel Event Alert “Preventing Violence in the Health Care Setting”, drawing attention to the various risk factors and making recommendations that organizations should implement to reduce the chance of harm to healthcare workers, patients or visitors. Workplace violence in healthcare settings obviously involves much more that patients directing violence toward healthcare workers. But today’s column deals just with the violent patient.
Among health care workers, 46% of all nonfatal assaults and violent acts requiring days away from work were committed against registered nurses (Bureau of Labor Statistics 2009). About 40% of psychiatrists are assaulted by patients at some time in their careers (Tishler 2013). But note that there is probably general underreporting of violence against healthcare workers.
Historically, the emergency department has usually been the area impacted by violence the most. 25% of ED nurses responding to a survey reported experiencing physical violence more than 20 times in the previous 3 years, and almost 20% reported experiencing verbal abuse more than 200 times during the same period (Boyett 2009). But we’ve also seen an increase in violent acts committed against staff in behavioral health units. The recent epidemic use of “bath salts” seems to have played a role in the increased violence in both areas. More and more we are seeing agitated, disoriented patients being brought to emergency departments by ambulance or by police. Long waits in the ED often lead to escalation of agitation and anger and violent behavior.
An article in the March issue of General Hospital Psychiatry (Tishler 2013) has an excellent and timely update on the assessment and management of the violent patient in critical hospital settings. Though it focuses on mental health care professionals working in the emergency department, it really applies to all health care workers in the emergency department or other hospital settings. This builds upon previous work by one of the authors (Tishler 2000). In addition to long ED waits, Tishler and colleagues note that overcrowding, small spaces, alcohol and drug reactions, the loud and chaotic ED environment and lack of an established therapeutic relationship are contributory factors. They also note that sometimes partners who accompany the patients may be unhelpful and actually serve to escalate situations. Lack of access to history and patient inability to provide accurate information are also problems.
The key to avoiding injuries due to violence in the ED is recognizing patient risk factors for violence, identifying circumstances or context that make violence more likely, and then recognizing signs of escalation.
Newton and colleagues (Newton 2012) had found 9 risk factors predicted 80% of violence in psychiatric inpatients. These were:
Notably absent from the Newton study were risk factors related to alcohol or substance abuse. However, the authors suspect that may reflect unavailability of information about those risk factors at the time of admission.
Tishler et al (Tishler 2013) discuss potential antecedents to violence and note that acute substance abuse or use of alcohol are very common. Stimulant drugs (cocaine, crack, amphetamines, and phencylclidine) are particularly likely to antecede violent behavior (as above, we’d add “bath salts” to that list). They note common clues of methamphetamine use are infections at injection sites, tooth decay, a gaunt appearance, and odor of ammonia.
They also note other common antecedent events are divorce, death of a loved one, financial problems, recent trouble with the law, child custody battles, or recent elopement from a psychiatric facility.
But they also describe occurrences in the ED that may trigger violent reactions. These include staff-patient interactions perceived as threatening to the patient, excessive sensory overload (lights, noise, people, etc.), and discussing treatment plans or security worries outside the patient’s room where they might be overheard by the patient.
Warning signs noted by Tishler et al. include:
The Tishler paper really emphasizes that clinicians need to have a “repertoire” of potential interventions to deal with such patients once they recognize the risk factors and warning signs. That way, if one strategy fails to de-escalate the situation they can try others. The patient should be separated from others to prevent unnecessary stimulation. Obviously access to potential weapons should be minimized. The presence of another ED staff member (or other responsible adult) may help while the assessment is ongoing but they caution that the presence of security personnel in the treatment room may serve to escalate the situation. They go on to discuss verbal de-escalation techniques and environmental ones. For example, if the patient is perceived to be claustrophobic, moving to a larger room may be beneficial.
Physical restraint of patients once violence is imminent is beyond the scope of our column. Most hospitals that have behavioral health units train staff in de-escalating techniques and in the proper manner to apply physical restraints. That training includes not only behavioral health personnel but also ED personnel and anyone who might be called upon to respond to violent patient situations. However, we’re not sure how well trained the ED staff (and other staff) are at non-psychiatric hospitals. We suggest that if you are not a psychiatric hospital you consult with your state or regional mental health agency to find out how to get such training for your staff. The last thing you want is one of your staff members getting disciplined by a regulatory agency for responding to a violent situation but using the wrong techniques.
The Tishler paper has an excellent discussion about the pharmacological management of the acutely violent patient. This includes not only choice of the various types of medications but also routes of administration, side effects, and other adverse effects. Keep in mind that some of the antipsychotics potentially used may prolong the QT interval and predispose the patient to ventricular arrhythmias like torsade de pointes (see our Patient Safety Tips of the Week for June 29, 2010 “Torsade de Pointes: Are Your Patients at Risk?” and February 5, 2013 “Antidepressants and QT Interval Prolongation”). We will also echo their warning about the potential for respiratory depression when benzodiazepines are used.
The Tishler paper is a very timely and practical update on managing the violent patient in the emergency department or other settings.
There are a number of excellent resources available regarding violence in the hospital. The 2010 Joint Commission Sentinel Event Alert had many useful recommendations. Around the same time ECRI Institute (ECRI 2011) put together a tool for screening your facility for factors important in patient violence and other workplace violence. OSHA has extensive guidelines for preventing workplace violence for health care and social service workers (OSHA 2015). The American College of Emergency Physicians has a position statement on preventing emergency department violence (ACEP 2011). Lastly, the Emergency Nurses Association (ENA) has an outstanding toolkit and resources for dealing with workplace violence. These include ED risk assessment tools, templates for actions plans, and a variety of other great resources.
References:
The Joint Commission. Sentinel Event Alert. Preventing violence in the health care setting. Sentinel Event Alert. Issue 45, June 3, 2010
http://www.jointcommission.org/assets/1/18/sea_45.pdf
US Department of Labor, Bureau of Labor Statistics. (2010). Case and demographic characteristics for work-related injuries and illnesses involving days away from work: 2009
http://www.bls.gov/iif/oshcdnew.htm
Boyett L, Gacki-Smith J, Homeyer C, et al. Violence Against Nurses Working in US Emergency Departments. Journal of Nursing Adminsitration 2009; 39(7/8): 340-349
http://www.nursingcenter.com/lnc/journalarticle?Article_ID=927697
Tishler CL, Reiss MS, Dundas J. The assessment and management of the violent patient in critical hospital settings. Gen Hosp Psych 2013; 35(2): 181-185
http://www.sciencedirect.com/science/article/pii/S0163834312003301
Tishler CL, Gordon LB, Landry-Meyer L. Managing the violent patient: a guide for psychologists and other mental health professionals. Prof Psychol Res Pr. 2000; 31(1): 34-41
http://psycnet.apa.org/journals/pro/31/1/34/
Newton VM, Elbogen EB, Brown CL, et al. Clinical Decision-making About Inpatient Violence Risk at Admission to a Public-Sector Acute Psychiatric Hospital. J Am Acad Psychiatry Law 2012; 40(2): 206-214
http://www.jaapl.org/content/40/2/206.full.pdf+html
ECRI Institute. Violence in Healthcare Facilities. Health Care Risk Control 2011; 2: 1-17
https://www.ecri.org/Documents/RM/HRC_TOC/SafSec3.pdf
OSHA (Occupational Safety & Health Administration). Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers. 2004
https://www.osha.gov/Publications/osha3148.pdf
ACEP (American College of Emergency Physicians). Protection from Physical Violence in the Emergency Department Environment. 2011
http://www.acep.org/content.aspx?id=29654
Emergency Nurses Association (ENA). Workplace Violence Resources. 2013
http://www.ena.org/IENR/Pages/WorkplaceViolence.aspx
Emergency Nurses Association (ENA). ENA Workplace Violence Toolkit.
http://www.ena.org/IENR/ViolenceToolKit/Documents/toolkitpg1.htm
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March 26, 2013
Failure to Recognize Sleep Apnea Before Surgery
In two of our recent Patient Safety Tips of the Week (February 12, 2013 “CDPH: Lessons Learned from PCA Incident” and February 19, 2013 “Practical Postoperative Pain Management”) we discussed problems related to postoperative opioid therapy in patients with sleep apnea. Obstructive sleep apnea (OSA) is one of the conditions we recommend be considered a relative contraindication to initiation of PCA (patient-controlled analgesia) or other opioid therapy. Also, because sleep apnea is associated with many other complications in patients undergoing surgery we have long recommended that screening for sleep apnea be part of the pre-operative evaluation of patients (see our August 17, 2010 Patient Safety Tip of the Week “Preoperative Consultation – Time to Change” August 18, 2009 “Obstructive Sleep Apnea in the Perioperative Period” and our July 2010 Whats New in the Patient Safety World column “Obstructive Sleep Apnea in the General Inpatient Population”).
A very timely study (Singh 2013) was just published by Frances Chung and her colleagues at the University of Toronto, who have been pioneers in addressing sleep apnea in surgical patients. They looked at patients in preoperative clinics and screened them for possible OSA using the STOP-BANG questionnaire and performed polysomnography (PSG) on almost 1000 patients scheduled to have surgery. They found 111 patients with a pre-existing diagnosis of OSA. Of the remaining patients PSG showed mild OSA in 31%, moderate OSA in 21%, and severe OSA in 17%.
They then reviewed the medical charts of those patients who underwent surgery to see whether surgeons and anesthetists (who were blinded to PSG results) had recognized the patient had OSA. Of patients with a pre-existing known diagnosis of OSA 58% were not diagnosed by surgeons and 15% were not diagnosed by anesthetists before surgery. Of the 267 patients with moderate or severe OSA by PSG, 92% were not recognized by surgeons and 60% were not recognized by anesthetists. And this is coming from facilities at which we suspect the general level of recognition of OSA is probably higher than in most!
It’s long been known that the percentage of patients with OSA undergoing surgery is higher than that of the general population (Finkel 2009). That shouldn’t be surprising since obesity and other comorbidities that are risk factors for OSA are also risk factors for conditions requiring surgery, such as a variety of orthopedic procedures.
A previous study (Vasu 2010) found that 41.5% of 135 patients who scored high risk on the STOP-Bang questionnaire had higher rates of postoperative complications than those who scored low risk (19.6% vs. 1.3%). They did not confirm OSA with polysomnograms so the association here is with the STOP-Bang score rather than confirmed OSA. Nevertheless, the association was strong and applied across a wide range of types of surgery. On the other hand, a new study (Lockhart 2013) showed no difference in 30-day or 1-year mortality for surgical patients with a prior history of OSA or positive screen for OSA compared to controls.
When we’ve talked to primary care physicians about screening for OSA with tools like the STOP-BANG questionnaire during their preop medical evaluations they usually ask “What will be done differently if we suspect or know they have OSA?”. (They are usually a bit annoyed that we’d add an additional burden onto their already hectic days.) But the STOP-BANG takes less than a minute to administer and there are, in fact, numerous things that should be done differently if OSA is suspected in a patient undergoing surgery.
In the ideal world if you suspected a patient had OSA you’d have time to schedule a polysomnogram and the preoperative evaluation by anesthesiology would take place far enough in advance of the planned surgery so that there is adequate time for any further evaluation and time for the surgeon and anesthesiologist to jointly develop a management plan. The importance of involving family members in the evaluation is emphasized since much of the history suggestive of OSA may come from, for example, a spouse who notes the patient snores and has apneic spells. Assessments of common comorbidities in patients with OSA (hypertension, diabetes, CHF, etc.) should be done. The physical examination should take into account BMI, neck circumference, craniofacial abnormalities, tonsil size, tongue size, etc. Patients with OSA also may have airways that are difficult to manage so a good assessment of potential difficulties managing the airway is indicated. But in the real world practicalities often preclude studies such as polysomnography and often you must assume the patient might have OSA based on screening tools.
The American Society of Anesthesiologists published Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea in 2006 (ASA 2006). However, considerable research has been done since that time and more up-to-date best practices have since been developed. Those have recently been summarized in a consensus statement by the Society for Ambulatory Anesthesia (Joshi 2012). But, as we have said in the past, while there are many practical, rational and consensus-based recommendations for perioperative management of OSA, few are actually evidence-based. Even this new consensus statement is based upon a limited number of studies in the literature that met fairly strict criteria for inclusion.
The new consensus statement focuses on determining whether patients at high risk for OSA might still be candidates for outpatient surgery or whether they should be admitted as inpatients for surgery. The first big difference from the 2006 ASA guidelines regards the screening tool used. The ASA guideline recommended a 12-point checklist that has not been validated. A number of screening tools for OSA are available including the STOP-Bang tool noted above and its predecessor the STOP questionnaire, but also the Berlin questionnaire, the Flemons questionnaire, the ASA checklist, and others. The new consensus statement recommends use of the STOP-Bang questionnaire because of its ease of administration and high sensitivity. It also notes that its relatively low specificity can be improved by using a greater number of positive indicators (eg. >6) and there is some evidence that the higher the score the greater the probability of severe OSA.
The consensus statement suggests that if a high likelihood of OSA is predicted by the STOP-Bang questionnaire the patient should be approached as if they have OSA.
The decision about outpatient vs. inpatient surgery in patients with suspected or known OSA depends upon the nature of the surgical procedure, the status of comorbidities, and the likelihood of the need for opioid analagesics after surgery. Opioids, of course, are prime contributors to postop complications in patients with OSA. As we noted in our February 19, 2013 Patient Safety Tip of the Week “Practical Postoperative Pain Management” the use of multimodal approaches to postop pain management can significantly reduce the need for opioids. If it is determined that a patient’s postop pain can likely be managed without opioids, they may be a candidate for outpatient surgery. On the other hand, if it is highly likely the patient will need postop opioid analgesia the patient should probably have surgery as an inpatient.
For patients known to have OSA and receiving CPAP at home continued compliance with CPAP after discharge home is important. Such patients should generally bring their CPAP device with them to the ambulatory surgery facility and be advised about the importance of complying with their CPAP after discharge because the increased risk postoperatively lasts for several days. That use of CPAP should extend to any time they are sleeping, including daytime naps. The patients should also be advised against sleeping in the supine position, which increases the likelihood of airway obstruction.
Patients with OSA only suspected by the screening tool should be told to contact their primary care physician after discharge for possible sleep studies.
They do note that data is still lacking to determine whether a preoperative sleep study and initiation of CPAP or BiPAP preoperatively improves perioperative outcomes in patients with suspected OSA. (Our November 22, 2011 Patient Safety Tip of the Week “Perioperative Management of Sleep Apnea Disappointing” highlighted a study (O’Gorman 2013) that showed that autotitrating positive airway pressure (APAP) failed to prevent obstructive apnea in surgical patients deemed high risk for the disorder.) They call for larger, adequately powered, and well-controlled studies to evaluate whether preop or postop CPAP/BiPAP reduce complications or not.
The consensus statement also differs from the 2006 ASA guideline in the types of surgical procedures that might be considered for ambulatory surgery, stating that laparoscopic upper abdominal procedures may be safely performed on an ambulatory basis if all perioperative precautions are followed.
Several good reviews of the perioperative management of patients with OSA have been done in 2008 (Chung 2008) and 2010 (Adesanya 2010) and 2011 (Minokadeh 2011, Chung 2011).
Airway management may be more difficult in the patient with OSA. Such patients may be more difficult to intubate. They may also be at greater risk of gastroesophageal reflux and, hence, at greater risk for aspiration pneumonitis. Because airway obstruction in OSA is more common in the supine position, many advocate use of the sitting position for preoxygenation and anesthetic induction.
Minokadeh et al have a good discussion about sedatives, induction agents, and volatile anesthetics in the OSA patient (Minokadeh 2011), favoring short-acting agents but noting that redistribution of agents in tissues can lead to prolonged action of many drugs. They note that if intraoperative opioids are necessary, remifentanil may be preferred because of its rapid metabolism. All stress the importance of complete reversal of any neuromuscular blockade at the end of the procedure.
The stay in the PACU is especially critical in the OSA patient. Extubation is a time of very high risk. In addition to verifying complete reversal of neuromuscular blockade, one needs to ensure return of airway reflexes, adequate tidal volume and respiratory rate, adequate oxygenation without CO2 retention, and full consciousness prior to considering extubation. Putting the patient in a semi-upright recovery position is advisable, avoiding the supine position. Obviously, the patient must be closely monitored after extubation. The ASA guidelines recommend PACU observation for 3 hours for patients without respiratory events and 7 hours for patients with observed respiratory events in the PACU.
Aside from the time of extubation, the most critical vulnerability is when the patient requires opioids for pain management. As before, it is always preferable to utilize multimodal analgesia, with non-opioid analgesics and local/regional blocks where possible.
If the patient does require opioids, they need close monitoring. That includes frequent monitoring of vital signs and continuous monitoring of oxygenation status. Capnography has also now become the standard of care for monitoring patients with OSA who are on opioids. As in our February 12, 2013 Patient Safety Tip of the Week “CDPH: Lessons Learned from PCA Incident” sidestream capnography used in unintubated patients may not be particularly good at detecting hypercarbia but is useful in monitoring respiratory rate and detecting apnea. And don’t forget that sedative/hypnotic drugs may also be dangerous in patients with OSA, particularly when used in conjunction with opioids.
Night time is obviously a high risk time for patients with OSA. However, several reviews have noted that, while the first 12-hours post-operatively is a vulnerable period, REM rebound may be seen and REM-associated hypoxemic events may increase 3-fold on the second and third postoperative nights, with associated risk of complications. Patient positioning may be important, as patients with OSA are more likely to develop hypoxemic episodes when they are supine so patients should be encouraged to sleep on their side.
The issue of oxygenation is much debated. If a patient has known OSA and has been on CPAP at home, they should get CPAP post-operatively (preferably with their own CPAP equipment brought in from home). As above, the use of CPAP, NIPPV, BiPAP, or APAP are not currently evidence-based in those not previously on CPAP at home.
Monitoring is probably the most important aspect of care of the patient with suspected OSA and there remain problems with the threshold-based alarm systems most often used today. Lynn and Curry (Lynn 2011) described 3 patterns of unexpected in-hospital deaths (see our February 22, 2011 Patient Safety Tip of the Week “Rethinking Alarms”). The third pattern they describe is one that is typically seen in sleep apnea. In this pattern one sees repetitive reductions in airflow and oxygen saturation during sleep followed by arousals. The arousals rescue the patient but eventually the capacity or reserve of the patient to recover with arousals becomes impaired (often in response to narcotics or sedatives) and the patient may experience sudden death during sleep. The authors discuss the inability of currently used oximeters to recognize this pattern. They even imply that this pattern may give rise to oximeters alarming and being interpreted as “false” alarms attributed to motion artifact, etc. because when staff respond to the alarm the patient is now awake, breathing normally and has a normal oxygen saturation.
As mentioned above, continuous capnography has become the standard of care for monitoring patients on opioids, particularly those with suspected or known OSA. The ability for capnography to detect apneic events may be even more important than the ability to detect hypercarbia.
So back to the questions “Why should I screen for OSA preoperatively? What will they do differently?” The response should be “There’s plenty that will be done and your patients will be much safer”.
Our prior columns on obstructive sleep apnea in the perioperative period:
Patient Safety Tips of the Week:
June 10, 2008 “Monitoring the Postoperative COPD Patient”
August 18, 2009 “Obstructive Sleep Apnea in the Perioperative Period”
August 17, 2010 “Preoperative Consultation – Time to Change”
July 13, 2010 “Postoperative Opioid-Induced Respiratory Depression”
February 22, 2011 “Rethinking Alarms”
November 22, 2011 “Perioperative Management of Sleep Apnea Disappointing”
May 22, 2012 “Update on Preoperative Screening for Sleep Apnea”
February 12, 2013 “CDPH: Lessons Learned from PCA Incident”
February 19, 2013 “Practical Postoperative Pain Management”
What’s New in the Patient Safety World columns:
July 2010 “Obstructive Sleep Apnea in the General Inpatient Population”
November 2010 “More on Preoperative Screening for Obstructive Sleep Apnea”
March 2012 “Postoperative Complications with Obstructive Sleep Apnea”
References:
Singh M, Liao P, Kobah S, Wijeysundera DN, Shapiro C, Chung F. Proportion of surgical patients with undiagnosed obstructive sleep apnoea. Br J Anaesth 2013; 110(4): 629-636
http://bja.oxfordjournals.org/content/110/4/629.abstract
Finkel KJ, Searleman AC, Tymkew H. Prevalence of undiagnosed obstructive sleep apnea among adult surgical patients in an academic medical center. Sleep Med 2009; 10(7): 753–758
Vasu TS, Doghramji K, Cavallazzi R, et al. Obstructive Sleep Apnea Syndrome and Postoperative Complications: Clinical Use of the STOP-BANG Questionnaire. Arch Otolaryngol Head Neck Surg. 2010; 136(10): 1020-1024
http://archotol.ama-assn.org/cgi/content/abstract/136/10/1020
Lockhart EM, Willingham MD, Abdallah AB, et al. Obstructive sleep apnea screening and postoperative mortality in a large surgical cohort. Sleep Medicne 2013; Published online March 15, 2013
http://www.sleep-journal.com/article/S1389-9457%2812%2900396-6/abstract
American Society of Anesthesiologists (ASA). Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea. A Report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea. Anesthesiology 2006; 104: 1081–93
Joshi GP, Ankichetty SP, Gan TJ, Chung F. Society for Ambulatory Anesthesia Consensus Statement on Preoperative Selection of Adult Patients with Obstructive Sleep Apnea Scheduled for Ambulatory Surgery. Anesthesia & Analgesia 2012; 115(5): 1060-1068
O’Gorman SM, Gay PC, Morgenthaler TI. Does Auto-Titrating Positive Airway Pressure Therapy Improve Postoperative Outcome in Patients at Risk for Obstructive Sleep Apnea Syndrome? A Randomized Controlled Clinical Trial. Chest 2013; online first January 3, 2013
http://journal.publications.chestnet.org/article.aspx?articleid=1555392
Minokadeh A, Biship ML, Benumof JL. Obstructive Sleep Apnea, Anesthesia, and Ambulatory Surgery. Anesthesiology News 2011;
http://www.anesthesiologynews.com/download/OSA_ANGAM11.pdf
Chung F, Davidson T, Hillman D, et al. Perioperative Management of OSA Patients. Practical Solutions and Care Strategies. 2011 (an assimilation of material presented at the Challenges in the Perioperative Management of OSA Patients symposium, held in October 2010)
http://anesthesiaandsleep.org/wp-content/uploads/2011/05/OSA-Web-Final.pdf
Lynn LA, Curry JP. Patterns of unexpected in-hospital deaths: a root cause analysis. Patient Safety in Surgery 2011, 5:3 (11 February 2011)
http://www.pssjournal.com/content/pdf/1754-9493-5-3.pdf
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Vanderbilt’s Electronic Procedural Timeout
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Lots More on Preventing Readmissions But Where's the Beef?
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Independent Double Checks and Oral Chemotherapy
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Another Possible Good Use of a Checklist
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FMEA to Avoid Breastmilk Mixups
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Systems Approach Improving Stroke Care
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Joint Commission Revised Diagnostic Imaging Requirements
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Joint Commission Sentinel Event Alert: Unintended Retained Foreign Objects
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Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)
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Photographic Identification to Prevent Errors
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Plethora of Medication Safety Studies
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Mayo Clinic System Alerts for QT Interval Prolongation
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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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