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January 3, 2017
What's Happening to
"I'm Sorry"?
We thought we were done doing columns about disclosure and apology following medical errors. Most hospitals seem to have come on board and recognize that transparency and honesty, when accompanied by sincere apology, are the right things to do following medical errors.
But what about physicians? Are they also on board?
A recent survey with two hypothetical vignettes was presented to primary care physicians (Mazor 2016). The first involved a delayed diagnosis of breast cancer. The second involved a care coordination breakdown causing a delayed response to patient symptoms. In both cases, multiple physicians shared responsibility for the error, and both involved oncology diagnoses. A majority of respondents would not fully disclose the errors in either situation. Things that predicted intent to disclose were perceived personal responsibility, perceived seriousness of the event and perceived value of patient-centered communication.
A 2016 survey done by Medscape also shows a disturbing trend (Lowes 2016). 78% of respondents to the Medscape survey said that it is never okay to cover up or avoid revealing such an error. Sounds pretty good. However, the percentage who answered that way was down from 91% in 2014 and almost 95% in 2010. To be fair, only 7% actually answered “yes” (yes, it is okay to cover up or avoid revealing an error) and the other 14% said “it depends”. But the direction of the trend is bothersome. Here’s the link to the full Medscape Ethics Report 2016 (Reese 2016).
In our August 9, 2016 Patient Safety Tip of the Week “More on the Second Victim” we discussed a study of how surgeons address adverse clinical events with their patients and/or patient families (Elwy 2016). Elwy and colleagues surveyed surgeons in the Veterans Affairs medical system about their experiences in disclosing adverse events. Most of the respondents to the survey used 5 of 8 recommended disclosure items:
But use of the other 3 recommended disclosure items was less frequent:
They found that surgeons who reported they were less likely to discuss preventability of the adverse event, those who stated the event was very or extremely serious, or who reported difficult communication experiences were more negatively affected by disclosure than others. Those surgeons with more negative attitudes about disclosure at baseline reported more anxiety about patients’ surgical outcomes or events following disclosure. The study clearly highlights the need for training for disclosure and apology and development of skillsets to use for such. Logically, it might be anticipated that development of those skills might reduce the negative experiences with disclosure and apology on the part of surgeons and perhaps be a first step in aiding the “second victims”, too.
The American Academy of Pediatrics just released a policy statement “Disclosure of Adverse Events in Pediatrics” (AAP 2016). It notes that physicians and residents are in agreement that it is an ethical obligation to their patients to disclose preventable adverse events but that, in practice, this is not often done. It notes that in an anonymous survey among pediatric residents and attending pediatricians (Garbutt 2007), pediatricians in private practice were less likely to report errors than other attending pediatricians (72% vs 92%) and that most attendings and residents agreed that disclosing a serious error would be difficult. It also showed that residents were more likely than attending pediatricians to have received education about how to disclose errors (57% vs 29%). The new AAP policy statement discusses the barriers to disclosure and legal issues and ways to facilitate better disclosure. It emphasizes the need for education and training in disclosure skills, including use of simulation in such training.
Very timely is a Health Services Research theme issue (Ridgely 2016) that deals with communication-and-resolution programs. While you’ll find multiple articles of interest in that issue, you’ll probably most appreciate the one by Lambert et al. (Lambert 2016). They implemented their own version of a communication and optimal resolution (CANDOR) program, which they named the “Seven Pillars” program, at the University of Illinois Hospital and Health Sciences System. We discussed CANDOR in our June 2016 What's New in the Patient Safety World column “Disclosure and Apology: The CANDOR Toolkit”. The 7 pillars are:
(1) incident reporting
(2) investigation while holding hospital bills and professional fees
(3) early communication with patient/family
(4) full disclosure, apology, and rapid remedy if appropriate
(5) system improvement
(6) data tracking and evaluation
(7) education and training
Using an interrupted time series analysis, they were able to show the program was associated with increases in the frequency of incident reports, event analyses, and post-event communication consults, and reductions in claims, legal fees, legal expenses, costs per claim, settlement costs, and self-insurance costs. Their results were both clinically and financially significant and persisted for more than 7 years after the initial intervention. Annual contributions to their self-insurance fund declined dramatically, and the self-insurance fund moved from a $30 million deficit to a $40 million surplus. Those results are reassuring and in keeping with the promise seen after the original University of Michigan success that we described in our September 2010 What's New in the Patient Safety World column “Followup to Our Disclosure and Apology Tip of the Week”.
Meanwhile, results from a demonstration project in New York City were less impressive (Mello 2016a). The communication-and-resolution program implemented in surgical departments of 5 NYC acute care hospitals was quite successful in handling events not caused by substandard care, but less consistent in offering compensation in cases involving substandard care. But one striking finding in that study was that clinician awareness of the communication-and-resolution program was quite low and many felt the program did not likely help avoid a lawsuit. The authors felt that, in those cases where there were violations of standard of care, there was difficulty adhering to the principle that compensation should be proactively offered.
Some of the other papers in the theme issue describe some of the challenges and barriers in establishing disclosure and apology or CANDOR programs. A study of a communication-and-resolution program (CRP) involving six hospitals and clinics and a liability insurer in Washington State (Mello 2016b) found that sites experienced small victories in resolving particular cases and streamlining some working relationships, but they were unable to successfully implement a collaborative CRP. Barriers included the insurer's distance from the point of care, passive rather than active support from top leaders, coordinating across departments and organizations, workload, nonparticipation by some physicians, and overcoming distrust.
Two very important parts of any CANDOR program are (1) understanding the perspective of patients/families following adverse events that impact them and (2) training healthcare professionals on how to do disclosure and apology with those patients and families. Gallagher and colleagues used a patient-created simulation exercise to help accomplish both (Gallagher 2016). Their experience showed that many stakeholders felt that the current responses to adverse events were complex, siloed, and uncoordinated and thus failed to meet the needs of patients and families. Participants suggested creating a patient navigator-like role to help support the patient/family throughout the process. They also found that the interest of the patient/family might not be the top priority for many stakeholders. They note that risk managers and defense attorneys care about patients and families but their primary role is to protect the institution or providers and that plaintiff attorneys and Boards of Medicine may serve as structural barriers that hamper CANDOR programs. Experiencing how a patient felt in reading a hospital’s response to her complaint about a delayed cancer diagnosis elicited both intellectual and visceral responses in many stakeholders. And patient advocates were impressed by the desire of stakeholders to better understand the patient/family perspective and improve the response to adverse events. The article has good recommendations on using this type of simulation exercise in other organizations.
Another study provided very interesting insights regarding the involvement of patients and families in investigating adverse events (Etchegaray 2016). We’ve always said that the patient perspective should be important and have sought ways to involve patients/families in such investigations. However, we’ve had a hard time figuring out how to do so and have met resistance from both clinicians and administrators. But the Etchegaray study is a real eye opener. They recruited patients and families (roughly 50% for each group) who had been involved in an adverse patient event and did semi-structured interviews with them.
All the participants identified at least one factor contributing to the adverse event that they or their family member had suffered. In fact, the average number of contributing factors identified was 3.67 factors. The most common categories of contributing factors noted were staff qualifications/knowledge (such as unfamiliarity with a drug) identified in 79%, safety policy/procedures (such as failure to adhere to hand hygiene) identified in 74%, and communication identified in 64%. While there were a variety of ways such factors were identified, a full third were identified by direct observation and, in some cases, would not likely have been identified by others during a root cause analysis (RCA). And some of the “human” factors they identified as contributing will surprise you! Those included things like greed, anger, and one-upsmanship, factors that almost certainly would not have been revealed during our traditional RCA’s.
Yes, there was likely some degree of selection bias in the results in that the participants voluntarily agreed to participate and many were involved in patient safety advocacy groups. They also clearly wanted to foster learning from their events to help others. But the findings have merit regardless of any selection bias.
We understand the reluctance of many healthcare professionals and administrators to have patients or families sit in on a formal RCA meeting. However, we think that when disclosure and apology are offered to a patient or family, that is an appropriate time to also seek their input and perspective. You need to let them know that an investigation will be done to identify issues that can be corrected to prevent future similar events and that any observations they may have had will be helpful in that regard. We usually recommend that the physician do the disclosure/apology and let them know that a member of the RCA team will meet with them to get their input. That both gives them time to think about their direct observations and reinforces that we are committed to improve care and we truly respect their input into the process.
Levinson et al. recently presented a good practical discussion of what to do after a medical incident and how to handle disclosure and apology (Levinson 2016).
Not to be lost in the successes reported at the University of Illinois in the Lambert study is that they also included peer support in a “care-for-the-caregiver” program for professionals involved in serious incidents (see our Patient Safety Tips of the Week for December 17, 2013 “The Second Victim” and August 9, 2016 “More on the Second Victim”). In the latter column we noted Carolyn Clancy’s editorial (Clancy 2012) which suggested the evolving practice of disclosure and apology might be a means of alleviating the emotional trauma of both the first and second victims of patient safety events.
The case for disclosure-and-apology and communication-and-resolution programs is growing. Not only is such transparency the right thing to do but in the long run is likely mutually beneficial and leads to future improvements in patient care.
Some of our prior columns on Disclosure & Apology:
July 24, 2007 “Serious Incident Response Checklist”
June 16, 2009 “Disclosing Errors That Affect Multiple Patients”
June 22, 2010 “Disclosure and Apology: How to Do It”
September 2010 “Followup to Our Disclosure and Apology Tip of the Week”
November 2010 “IHI: Respectful Management of Serious Clinical Adverse Events”
April 2012 “Error Disclosure by Surgeons”
June 2012 “Oregon Adverse Event Disclosure Guide”
December 17, 2013 “The Second Victim”
July 14, 2015 “NPSF’s RCA2 Guidelines”
June 2016 “Disclosure and Apology: The CANDOR Toolkit”
August 9, 2016 “More on the Second Victim”
Other very valuable resources on disclosure and apology:
References:
Mazor K, Roblin DW, Greene SM, et al. Primary care physicians’ willingness to disclose oncology errors involving multiple providers to patients. BMJ Qual Saf 2016; 25: 787-795
http://qualitysafety.bmj.com/content/25/10/787.abstract?sid=bf40c687-a54c-4669-9b9c-f68ae6dc99e6
Lowes R. More Physicians Willing to Hide Mistakes, Survey Reveals. Medscape Medical News 2016; December 01, 2016
http://www.medscape.com/viewarticle/872660
Reese S. Medscape Ethics Report 2016: Money, Romance, and Patients. Medscape 2016; December 1, 2016
http://www.medscape.com/features/slideshow/ethics2016-part1
Elwy AR, Itani KMF, Bokhour BG, et al. Surgeons’ Disclosures of Clinical Adverse Events. JAMA Surg 2016; 151(11): 1015-1021
http://jamanetwork.com/journals/jamasurgery/article-abstract/2534133
AAP (American Academy of Pediatrics). Policy Statement. Disclosure of Adverse Events in Pediatrics. Committee on Medical Liability and Risk Management, Council on Quality Improvement and Patient Safety. Pediatrics 2016; 138(6): e20163215
http://pediatrics.aappublications.org/content/138/6/e20163215
Garbutt J, Brownstein DR, Klein EJ, et al. Reporting and disclosing medical errors: pediatricians’ attitudes and behaviors. Arch Pediatr Adolesc Med 2007; 161(2): 179-185
http://jamanetwork.com/journals/jamapediatrics/fullarticle/569612
Ridgely MS, Greenberg MD, Clancy CM (eds.). Special Issue: Progress at the Intersection of Patient Safety and Medical Liability. Health Services Research 2016; 51(Suppl S3): 2395-2648 December 2016
http://onlinelibrary.wiley.com/doi/10.1111/hesr.2016.51.issue-S3/issuetoc
Lambert BL, Centomani NM, Smith KM, et al. The “Seven Pillars” Response to Patient Safety Incidents: Effects on Medical Liability Processes and Outcomes. Health Services Research 2016; 51(Suppl S3): 2491-2515 December 2016
http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12548/full
Mello MM, Armstrong SJ, Greenberg Y, McCotter PI, Gallagher TH. Challenges of Implementing a Communication-and-Resolution Program Where Multiple Organizations Must Cooperate. Health Services Research 2016; 51(Suppl S3): 2550-2568 December 2016
https://www.ncbi.nlm.nih.gov/pubmed/27807858
Mello MM, Greenberg Y, Senecal SK, Cohn JS. Case Outcomes in a Communication-and-Resolution Program in New York Hospitals. Health Services Research 2016; 51(Suppl S3): 2583-2599 December 2016
https://www.ncbi.nlm.nih.gov/pubmed/27781266
Gallagher TH, Etchegaray JM, Bergstedt B, et al. Improving Communication and Resolution Following Adverse Events Using a Patient-Created Simulation Exercise. Health Services Research 2016; 51(Suppl S3): 2537-2549 December 2016
https://www.ncbi.nlm.nih.gov/pubmed/27790708
Etchegaray JM, Ottosen MJ, Aigbe A, et al. Patients as Partners in Learning from Unexpected Events. Health Services Research 2016; 51(Suppl S3): 2600-2614 December 2016
http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12593/full
Levinson W, Yeung J, Ginsburg S. Disclosure of Medical Error. JAMA 2016; 316(7): 764-765
http://jamanetwork.com/journals/jama/article-abstract/2544645
Clancy CM. Alleviating “Second Victim” Syndrome: How We Should Handle Patient Harm. Journal of Nursing Care Quality 2012; 27(1): 1-5, January/March 2012
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January 10, 2017
The 26-ml Applicator Strikes Again!
In several of our columns on surgical fires we have issued a warning about use of the 26-ml Chloraprep applicator in head and neck surgery (see, for example, our December 16, 2014 Patient Safety Tip of the Week “More on Each Element of the Surgical Fire Triad”).
We noted a surgical fire in which a hospital had switched from the 10.5 ml Chloraprep applicator, which did not have the warning to avoid use in head and neck surgery, to the 26 ml applicator which did have the warning. It is actually quite predictable that staff would assume the new supplies were the same as the old (because the active ingredients and percent of alcohol are the same) and not “read the fine print”.
So we are not at all surprised to find another incident in which the 26-ml Chloraprep applicator was a factor in a surgical fire. The California Department of Public Health publishes statements of deficiencies/plans of correction several times a year. We find the lessons learned from those to be incredibly useful. The most recent release included two cases of surgical fires and one included the 26-ml applicator issue (CDPH 2016).
The patient was scheduled to have a temporal artery biopsy. The skin was prepped with a 26-ml Chloraprep applicator and dry towels and sterile tenting drape were placed after a period for drying of the area prepped. The patient was receiving oxygen via face mask at 4L/min, subsequently increased to 8L/min. When a Bovie (eclectrosurgical unit) was used for a second time a sudden spark occurred and surgical fire ignited. The patient sustained burns on the earlobe, lower neck and chest wall, and contralateral upper extremity. Both second degree and full-thickness burns resulted.
The investigation found that, though there was no formal documentation of drying time after the Chloraprep application, the nurse estimated it was about 10 minutes. The nurse did retrospectively note that the site was close to the patient’s hair and that “just the edge of her hair got wet with Chloraprep”. The nurse was unaware of the warning on the 26-ml Chloraprep applicator that indicated “do not use the 26-ml applicator for head and neck surgery”.
There obviously were multiple factors contributing to this surgical fire. The “open” delivery of oxygen was obviously a major factor and is a significant cause in almost all surgical fires we see now. The lack of communication and coordination between surgeon and anesthesiologist regarding stopping oxygen flow when initiating electrocautery was also a key contributing factor. But we’re just discussing the skin prep issue today. The 26-ml Chloraprep applicator has a specific warning indicating it should not be used in cases of head/neck surgery. In addition, when alchohol-based skin preps touch a patient’s hair, the drying time may be as long as an hour or more. In the CDPH case both the amount of alcohol-based skin prep used and getting some on the patient’s hair were likely important factors predisposing to surgical fire when the other two elements of the “fire triad” appeared.
The facility’s plan of correction focused heavily on policy revision and inservicing regarding alcohol-based skin preps. Plans of care for OR patients were revised to include visualization that flammable prepping solutions are completely dry and fumes have dissipated before applying surgical drapes, and documentation of dry time. It also made available smaller Chloraprep applicators (previously it apparently only had the 26-ml applicators). It also focused on drills for surgical fires. Interestingly, while it did include wording that the surgeon should notify the anesthesiologist prior to Bovie use, it made no mention about the “open” use of oxygen.
We would, of course, encourage the FDA to work with the manufacturer of Chloraprep to make the warning not to use in head/neck surgery even more salient. Do we think that will decrease the likelihood of a surgical fire related to this agent? Probably not. Certain errors are predictable. And it is very predictable that nurses, physicians, or surgical techs who have long used Chloraprep are not likely to look at the label when grabbing a 26-ml applicator or a smaller one. Therefore, we need to look at other solutions.
To our thinking, the most logical way is to deliver a real-time message to prevent use of the bigger applicator. How would we do this? We’d add it to the checklists used for the pre-op huddle or the surgical timeout or both. We have long advocated that the surgical fire risk be discussed as part of the pre-op huddle (or pre-op briefing) and, if the case is considered high-risk, respective roles of all OR participants are called out during the surgical timeout. In our January 2011 What's New in the Patient Safety World column “Surgical Fires Not Just in High-Risk Cases” we noted the San Francisco VA checklist “The Surgical Fire Assessment Protocol” (Murphy 2010), This checklist/protocol is actually printed on the reverse side of their larger preoperative checklist. This is really a very good tool! The fire risk is assessed by a simple numerical scale. If the score is 3 (high risk) the rest of the form is filled out, which basically delineates the respective roles of all those participants. That’s a really good way to remind all about their responsibilities in preventing a fire and what to do if a fire occurred. One of the checkbox items for the circulating nurse on that checklist is “Assess that enough time has been allowed for fumes of alcohol-based skin preps to dissipate (minimum of 3 minutes)”. It is there that we would propose adding the warning in bold, colored print that the 26-ml applicator of Chloraprep should not be used in head/neck surgery.
Mark Bruley, ECRI Institute’s authoritative expert on surgical fires, notes in an AORN article (AORN 2015) he has seen some surgical fire risk assessments take far too long and recommends teams tailor their fire risk assessment during Time Out to a model created in an algorithm and video from the Anesthesia Patient Safety Foundation (APSF 2010).
Adding the specific item not to use a 26-ml Chloraprep applicator in head/neck cases to either model could create that “real-time” reminder that can have a much more significant impact than any “education” or “training” or “inservice” interventions that are likely to be forgotten when most needed.
Of course, another solution is simply to use skin preps that are not alcohol-based and not flammable for cases like the one above. See our October 1, 2013 Patient Safety Tip of the Week “Fuels and Oxygen in OR Fires” and our January 2011 What's New in the Patient Safety World column “Surgical Fires Not Just in High-Risk Cases” for comments about aqueous-based skin preps.
And just another reminder: the nature of the cases in which surgical fires occur has changed. Now the vast majority of cases occur in patients undergoing what are considered to be relatively minor surgeries. These include cases like temporal artery biopsies, removal of skin lesions on the head or face, plastic procedures, etc. That trend is important for several reasons. First, many of these cases are done under sedation or monitored anesthesia care where there is open delivery of oxygen, which is probably the most important contributing factor to surgical fires. Second, there may be a degree of relative complacency in that our safety “antennas” are lowered when we think we are doing a “minor” case. Third, these cases are often “add-ons” to the surgical schedule (added on when time permits following more major cases in an OR). As such, the OR staff may not be as familiar with the details of the more minor cases. For example, you might have nurses and surgical techs in a room that usually does major abdominal cases (where the 26-ml Chloraprep applicator is commonly used) now prepping for a temporal artery biopsy that they may seldom participate in. Fourth, and it may impact our proposed solution, many facilities lacking a strong safety culture tend to skip the pre-op huddle for these “minor” add-on cases. Maybe that’s a good reason to add it as an item to the surgical “time out” checklist.
We recommend you read about all the other important aspects of surgical fires in our numerous columns listed below, which also have useful links to many valuable resources on the topic.
Our prior columns on surgical fires:
References:
CDPH (California Department of Public Health). Complaint Intake Number CA00262114; 2016
http://www.cdph.ca.gov/certlic/facilities/Documents/2567_ValleyPresbyterianHospital_IJAP_LA.pdf
Murphy J. A New Effort to Promote Fire Safety in the OR.
Topics In Patient Safety (TIPS) 2010; 10(6): 3
http://www.patientsafety.va.gov/docs/TIPS/TIPS_NovDec10.pdf#page=3
SF VAMC Surgical Fire Risk Assessment Protocol
http://www.patientsafety.va.gov/docs/TIPS/TIPS_NovDec10.pdf#page=3
AORN. 4 actions to improve fire safety. Periop Insider 2015
http://www.informz.net/InformzDataService/OnlineVersion/Pub/bWFpbGluZ0luc3RhbmNlSWQ9MTk3NTM4NA==
APSF (Anesthesia Patient Safety Foundation). Fire Safety Video. 2010
http://www.apsf.org/resources/fire-safety/
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January 17, 2017
Pediatric MRI Safety
In our January 2017 What's New in the Patient Safety World column “Still Too Many CT Scans for Pediatric Appendicitis” we cited a recent presentation at the 2016 RSNA meeting that showed the use of MRI scanning in pediatric patients has been increasing in the emergency department at a major New York City hospital (Hulkower 2016). We suspect that is a trend we’d see at many hospitals across the country. The reasons for more MRI scans are mostly due to the increased availability of MRI, the campaigns to reduce the use of ionizing radiation, particularly in children, such as the Imaging Gently® campaign, and the fact that some diagnoses are more readily found on MRI than on CT scan. In the Hulkower study the increase in MRI was primarily driven by neurological imaging and there was a corresponding decrease in the use of CT scanning.
Along with that trend we’d be concerned we may see more patient safety issues arising. We’ve actually done numerous columns on patient safety related to MRI scanning (see the full list at the end of today’s column) and pediatric patients have special concerns that render them more vulnerable to safety incidents during MRI.
In our February 19, 2008 Patient Safety Tip of the Week “MRI Safety” we noted that not even a month after the first published paper on projectile cylinder accidents in MRI units (Chaljub 2001) there was a fatality related to an MR-related projectile accident. A 6 y.o. boy developed respiratory distress while undergoing an MRI. There was a problem with the oxygen source in the MRI suite. Both MR technologists briefly left the MR suite to try to resolve the issue but in the interim a nurse responding to anesthesiologist’s calls for help found an oxygen cylinder in the control room and brought it into the MR room. Unfortunately, it was steel cylinder and the MR pulled the cylinder free, thrusting it into the bore of the MR machine and causing a fatal head injury to the boy. Root cause analysis of the latter event by Tobias Gilk and Robert Latino (Gilk 2011, video ) showed the typical cascade of events and errors that collectively led to the unfortunate outcome. Many of the same conditions and events occurred in the cases assembled by Chaljub et al. had reported on 5 projectile cylinder accidents at 2 academic medical centers. Cases involved ferromagnetic cylinders of oxygen or nitrous oxide inadvertently being introduced into the MR rooms and turned into projectiles by the magnetic forces of the MR machine, resulting in patient injury or damage to the MR unit or both. They also sent out questionnaires to multiple academic MR units and found slightly more than 50% of those who responded had experienced similar projectile incidents. Objects involved included vacuum cleaners, mop buckets, tools boxes, ventilators, defibrillators, wheelchairs, IV poles, etc. Failure to adhere to MR safety policies and human error were cited as the most common reasons for the accidents.
Another recent presentation at the 2016 RSNA meeting showed that the prevalence of safety reports in MRI performed in children is increased relative to previously published data on adults (Jaimes Cobos 2016). They found the rate of such reports was 0.53%, compared to a 0.35% rate of incident reporting for adults at the same hospital (Mansouri 2016). Jaimes Cobos and colleagues found that younger children had higher rates of safety reports: newborns (1.1%), infants (1.1%), and young children (0.9%). Those rates were significantly higher than those in older children. The odds ratio of younger children (<6 yrs) having a safety report relative to older children (>6yr) was 2.2. As in adults, the rates were highest for inpatients, followed by ER patients, then outpatients. The majority of events caused no harm or only minor harm. There were no deaths and only 3% of the incidents reported involved major harm. Children below the age of 6 years, inpatients, and use of sedation or general anesthesia were all factors associated with higher safety report rates. The most common causes of safety reports were service coordination and adverse drug reactions. You’ll recall from our numerous columns on patient safety in the radiology suite (full list below) that the majority of patient safety issues seen in the radiology suite have little to do with the imaging study or radiology itself. Rather it is the confluence of vulnerable patients being temporarily in an environment where communication and coordination issues can be problematic.
In our Patient Safety Tips of the Week for March 17, 2009 “More on MRI Safety” and October 25, 2011 “Renewed Focus on MRI Safety” we discussed some of the care coordination issues that arise for any patient undergoing MRI. We discussed the American Society of Anesthesiologists Practice Advisory on Anesthetic Care for Magnetic Resonance Imaging, which has now been updated in 2015 (ASA 2015). It states that the anesthesiologist needs to develop a plan for implementing anesthesia care before each individual case. Such a plan should be done in collaboration with other personnel who will be involved in the care of the patient, including the MRI technician, radiologist, radiology nurse, other clinical personnel accompanying the patient and even the facility biomedical engineer. In addition to the anesthetic plan, preparation includes a plan for optimal positioning of equipment and personnel in the MRI suite during the procedure. We refer you to that guideline for details. The anesthesiologist should also prepare a plan for rapidly summoning additional personnel in the event of an emergency.
We suggested a few additions to this otherwise excellent ASA practice advisory. First is the importance of determining up front whether the MRI is truly indicated, whether the potential benefits of performing the MRI outweigh the potential risks, and whether alternative safer imaging modalities might suffice. In many of the incidents we’ve seen occurring in ICU patients transported to the MRI suite or radiology suite, we’ve been surprised at how often the scan being done was really of marginal value.
Second is the need for a huddle/timeout before the procedure is performed. We should approach doing MRI on these critically ill patients in the same manner in which we approach patients going to the OR. A “huddle” or whatever else you’d like to call a pre-procedure briefing is very important in such cases. Not only do you need to know you have all the equipment needed, but you also need to know everyone’s role and have contingency plans for emergencies. This is where you ensure all parties know what to do if there is a fire or if there is a cardiopulmonary arrest or a “quench”. You discuss what location you will need to move the patient to in such events. You discuss the availability and location of equipment and medications you may need. You discuss the line of sight required and where the monitoring equipment will be deployed. You may need to discuss also how you will communicate (with both staff and patient) given the high noise levels associated with MRI scanning. You should probably even discuss the potential impact of the lighting levels in the various zones (and fact that you may not be able to wear your ferromagnetic glasses in Zones III and IV).
Third, really related to the above, is use of a checklist. To remember all the needs for the procedure (which vary be individual patient) and the contingencies you have to plan for is really too much to expect for any individual or group of individuals. That’s where the simple checklist comes in: it helps you to remember details you might otherwise overlook.
Fourth, you need to practice. We wonder how many MRI facilities, particularly hospital-based ones, actually simulate an emergency during MRI scanning.
Use of sedation is probably the most serious issue in pediatric MRI safety. Our August 2016 What's New in the Patient Safety World column “Guideline Update for Pediatric Sedation” discussed the recently updated American Academy of Pediatrics (AAP)/American Academy of Pediatric Dentistry (AAPD) “Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures” (Coté 2016). We refer you to our prior column and the updated guideline itself for all the details needed in performing safe sedation in pediatric patients for any procedure. But the guideline has an excellent section on sedation in the MRI suite, which is a very restricted environment and has needs for special equipment and monitoring techniques as we have discussed in our numerous columns on patient safety issues in the radiology and MRI suites. It notes that MRI-compatible pulse oximeters and capnographs capable of continuous function during scanning should be used in any sedated or restrained pediatric patient. Appropriate precautions must be taken to avoid thermal injuries. For example, the practitioner is cautioned to avoid coiling of all wires (oximeter, ECG) and to place the oximeter probe as far from the magnetic coil as possible to diminish the possibility of injury. It notes that ECG monitoring during MRI has been associated with thermal injury and that special MRI-compatible ECG pads are essential to allow safe monitoring. If sedation is achieved by using an infusion pump, then either an MRI-compatible pump is required or the pump must be situated outside of the room with long infusion tubing so as to maintain infusion accuracy. All equipment must be MRI compatible, including items such as laryngoscope blades and handles, oxygen tanks, and any ancillary equipment. In addition, all individuals, including parents, must be screened for ferromagnetic materials, phones, pagers, pens, credit cards, watches, surgical implants, pacemakers, etc, before entry into the MRI suite.
In our August 2010 What's New in the Patient Safety World column “Sedation Costs for Pediatric MRI” we discussed a study (Vanderby 2010) that addressed the financial impact of sedation for MRI scanning in pediatrics. They analyzed the workflow, personnel, and costs involved in MRI scanning of children at Hospital for Sick Children in Toronto, Ontario. They found that the average time spent in the MRI suite was 2 hours and 21 minutes for children scanned awake, 3 hours 38 minutes for those sedated, and 4 hours 7 minutes for those anesthetized. Corresponding average costs (in Canadian dollars) were $54.68, $177.27, and $522.73 respectively. The Toronto group used their analysis to significantly redesign workflow and scheduling. This article has a good discussion about those workflow and personnel issues and has some good lessons learned that you may apply in your organization. To their recommendations we would again add that strong consideration needs to be given to the appropriateness of the MRI scan, in light of the patient safety and cost issues involved.
Note that the Hulkower study noted above (Hulkower 2016) also had some workflow implications. They found the highest pediatric MRI volume was during the evening and early nighttime hours with peak volume occurring during the 10 PM hour when 8.2% of MRI exams were performed. That suggested the need for deployment of additional resources at certain times and need for availability of radiologists, particularly those with expertise in neurological MRI, to read the MRI scans.
We discussed another issue primarily related to pediatric patients in our August 2012 What's New in the Patient Safety World column “Newest MRI Hazard: Ingested Magnets”: harm due to MRI in patients who have ingested magnets. Small children frequently ingest non-food items and may not be able to verbally tell you they did so. A cited paper (Bailey 2012) described a case of a 5 y.o. boy who had ingested magnets and had an MRI that led to bowel perforation. The authors reviewed the literature and came up with a recommended tool to screen for magnets before MRI is performed. The authors note that most cases of ingested magnets occur in young children and most often boys and are often, in fact typically, not witnessed. Most are passed in the stool without incident and less than 10% require intervention (only 1% requiring surgery). However, swallowing multiple magnets may be more troublesome since the magnets adhere to each other, increasing the likelihood they might obstruct the bowel. In their index case, the authors note the patient actually presented to an ED with complaints of neck pain. Initial workup focused on the cervical spine and included a normal CT scan of the neck and normal lumbar puncture. A decision to do an MRI of the brain and cervical spine was then done under moderate sedation and was also negative. The following day his neck pain was better but he now had severe abdominal pain and would not eat. Abdominal X-rays showed air in the peritoneal cavity and 11 small round metallic objects in the left upper quadrant. At surgery, four full-thickness small intestinal perforations were found and 11 small spherical magnets were removed from the peritoneal cavity. The magnets were most likely from a magnetic game the child had been playing near. He had an uneventful recovery.
The hospital changed their MRI screening protocol. While they still do a written and verbal questionnaire of the children and parents for presence of metallic objects, they now also have all children change into a hospital gown and undergo screening using a hand-held ferromagnetic detection scanner.
An FDA safety warning just released (FDA 2017a) about MRI and implantable infusion pumps could apply to children as well as adults. FDA has received reports, including some with serious patient harm or death, of problems with such pumps following MRI. They have noted issues such as medication dosing inaccuracies (e.g., over-infusion or under-infusion, unintended bolus) and other mechanical problems with the pump (e.g., motor stall, pump not restarting after an MRI exam). FDA recommends that the “implant card” (which is usually issued at the time of pump implantation) for the specific implantable infusion pump accompany the patient to the MRI site so that the MRI technologist and team can identify the specific pump model to locate the specific MRI safety information for that pump. It even recommends patients consider obtaining a medical alert bracelet or necklace to notify medical professionals that they have an implantable pump. Even when the specified conditions of MR Conditional use have been followed, the implantable pump may need to be checked and/or reprogrammed by the healthcare team responsible for the pump. And don’t forget that only implantable infusion pumps labeled as “MR Conditional” may be safely scanned, and only under the specific conditions of safe use. A companion document (FDA 2017b) provides recommendations for patients, MRI technologists, radiologists, healthcare professionals who implant and those who manage the infusion pumps, and those who prescribe/order MRI exams.
Lastly, a coalition of societies and organizations dealing with MRI has proposed a delineation of responsibilities for the management of MRI facilities (Calamante 2016). Though it does not specifically note issues related to pediatric patients, this document does a nice job of identifying the roles of various people in ensuring overall safety in an organization’s MRI activities and the types of safety activities that should be undertaken.
You’ll also find many valuable tips on MRI safety for both children and adults in our previous columns listed below.
Some of our prior columns on patient safety issues related to MRI:
Some of our prior columns on patient safety issues in the radiology suite:
References:
Hulkower M, Taragin B, Davoudzadeh R, et al. Pediatric MRI in the Emergency Department Over Five Years: An Analysis of Usage and Trends. Program SSQ17-06. Radiological Society of North America 2016 Scientific Assembly and Annual Meeting, November 27 - December 2, 2016, Chicago IL
http://archive.rsna.org/2016/16005757.html
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Chaljub G, Kramer LA, Johnson RF, Johnson RF, Singh H, Crow WN. Projectile Cylinder Accidents Resulting from the Presence of Ferromagnetic Nitrous Oxide or Oxygen Tanks in the MR Suite. Am. J. Roentgenol 2001; 177: 27-30
http://www.ajronline.org/doi/full/10.2214/ajr.177.1.1770027
Gilk T, Latino RJ. MRI Safety 10 Years Later. What can we learn from the accident that killed Michael Colombini? Patient Safety and Quality Healthcare 2011; online first Nov-Dec 2011
http://www.psqh.com/analysis/mri-safety-10-years-later/
Latino RJ, Gilk T. Healthcare RCA - Michael Colombini MRI. Root Cause Analysis Movie: Colombini MRI Case: - 10 Years Later. Reliability Center, Inc. 2011
http://www.reliability.com/mri/
Jaimes Cobos C, Murcia D, Miguel K, et al. Identification of Quality Improvement Areas in Pediatric MRI from Analysis of Patient Safety Reports. Radiological Society of North America 2016 Scientific Assembly and Annual Meeting, November 27 - December 2, 2016, Chicago IL
http://archive.rsna.org/2016/16006085.html
Mansouri M, Aran S, Harvey HB, et al. Rates of safety incident reporting in MRI in a large academic medical center. Journal of Magnetic Resonance Imaging 2016. 43(4): 998-1007
http://onlinelibrary.wiley.com/doi/10.1002/jmri.25055/full
ASA (American Society of Anesthesiologists). Practice Advisory on Anesthetic Care for Magnetic Resonance Imaging: An Updated Report by the American Society of Anesthesiologists Task Force on Anesthetic Care for Magnetic Resonance Imaging. Anesthesiology 2015; 122(3): 495-520
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2091587&resultClick=3
Coté CJ, Wilson S, American Academy of Pediatrics, American Academy of Pediatric Dentistry. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics 2016; 138(1): e2016121
http://pediatrics.aappublications.org/content/138/1/e20161212
Vanderby SA, Babyn PS, Carter MW, et al. Effect of Anesthesia and Sedation on Pediatric MR Imaging Patient Flow. Radiology 2010; 256(1): 229-237
http://pubs.rsna.org/doi/full/10.1148/radiol.10091124
Bailey JR, Eisner EA, Edmonds EW. Unwitnessed magnet ingestion in a 5 year-old boy leading to bowel perforation after magnetic resonance imaging: case report of a rare but potentially detrimental complication. Patient Safety in Surgery 2012; 6: 16 (19 July 2012)
http://pssjournal.biomedcentral.com/articles/10.1186/1754-9493-6-16
FDA (US Food & Drug Administration). Implantable Infusion Pumps in the Magnetic Resonance (MR) Environment: FDA Safety Communication - Important Safety Precautions. FDA 2017; January 11, 2017
FDA (US Food & Drug Administration). Safety Concerns with Implantable Infusion Pumps in the Magnetic Resonance (MR) Environment: FDA Safety Communication. FDA 2017; January 11, 2017
http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm536518.htm
Calamante F, Ittermann B, Kanal E, The Inter-Society Working Group on MR Safety and Norris D. Recommended responsibilities for management of MR safety. JMRI 2016; Early View 3 Jun 2016
http://onlinelibrary.wiley.com/doi/10.1002/jmri.25282/epdf
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January 24, 2017
Dexmedetomidine to Prevent Postoperative Delirium
Post-operative delirium is a significant problem in the elderly associated with excessive morbidity and mortality, prolonged hospital lengths of stay, poor long-term functional and cognitive outcomes, discharge to places other than home, and excessive costs. Estimates of its occurrence range up to 65%, even higher when patients require ICU care. So the search for interventions to prevent postoperative delirium has been important. Many of our prior columns on delirium (see the list below) have focused on multi-component non-pharmacological approaches to prevention (and treatment) of delirium. However, the improvements have been modest.
Pharmacologic interventions to prevent or treat delirium have been elusive. A recent literature review (Tremblay 2016) found fourteen articles that reported a reduced incidence of post-operative delirium using pharmacological agents: eight with antipsychotics, two with statins, one with melatonin, one with dexamethasone, one with gabapentin, and one with diazepam. However, Tremblay concludes that study designs, methodological issues, or authors' interpretations raise questions on these conclusions and that further double-blinded randomized clinical trials should be conducted before administering pharmacological agents to reduce postoperative delirium in a non-research setting.
One drug that has generated significant interest over the past several years is dexmedetomidine, an α2-adrenoreceptor agonist, often used as a sedation agent in the ICU because it might be associated with less delirium. In our February 10, 2009 Patient Safety Tip of the Week “Sedation in the ICU: The Dexmedetomidine Study” we discussed the SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study, which concluded that dexmedetomidine was as effective as midazolam at keeping patients in the desired sedation range and was associated with a reduced prevalence of delirium and reduced time to extubation (Riker 2009). However, we urged caution in interpreting the conclusions of that study because of several methodological and other concerns outlined in our column. We again discussed dexmedetomidine in our June 16, 2015 Patient Safety Tip of the Week “Updates on Delirium”. And in our April 2016 What's New in the Patient Safety World column “Dexmedetomidine and Delirium” we discussed the Dexmedetomidine to Lessen ICU Agitation (DahLIA) study was a double-blind, placebo-controlled, parallel-group randomized clinical trial in 15 ICU’s in Australia and New Zealand (Reade 2016).. Subjects were ICU patients who were deemed to be ready for extubation except that they had delirium. Dexmedetomidine increased ventilator-free hours at 7 days compared with placebo and reduced time to extubation and accelerated resolution of delirium.
See those previous columns for our cautions and concerns about dexmedetomidine despite several promising studies.
More recently, Su and colleagues did a randomized, double-blind, placebo-controlled trial in two tertiary-care hospitals in Beijing, China on patients aged 65 years or older who were admitted to intensive care units after non-cardiac surgery (Su 2016). They randomly assign patients to receive either low-dose (sub-sedative) intravenous dexmedetomidine or placebo from intensive care unit admission on the day of surgery until 0800 h on the first day after surgery. The CAM-ICU was the tool used to assess for delirium. Their reported results are remarkable. The incidence of delirium in the dexmedetomidine group was just 9%, compared to 23% in controls. That translates to a number needed to treat (NNT) of 7.4! The results applied equally whether patients were intubated or not and applied to all 3 subtypes of delirium. And there were significant benefits in the dexmedetomidine group compared to the control group for ICU length of stay, time to extubation (in those who were intubated), sleep quality, and early hospital discharge. There was no difference in the incidence of overall adverse events or 30-day mortality. Moreover, the safety profile of dexmedetomidine was excellent. Patients receiving dexmedetomidine did not have higher rates of bradycardia or hypotension (as is often seen with higher doses) and actually had lower rates of hypertension, tachycardia, and hypoxemia than the placebo group. There was also a suggestion that the delirium-reducing effect was dose-dependent in that the dexmedetomidine dose (the rate of the infusion x the duration of the infusion) was negatively correlated with the occurrence of delirium.
These results sound too good to be true! Such pronouncements always raise our “hype radar” or “spin radar” (see our February 16, 2010 Patient Safety Tip of the Week “Spin/Hype…Knowing It When You See It”).
In the editorial accompanying the Su study, Kronzer and Avidan (Kronzer 2016) provide a very thoughtful assessment of the methodology in the Su study that should temper our enthusiasm about the reported results. They note that the consent for participation took place after surgery and that patients’ families provided consent in 58% of the cases. That raises the possibility (or should we say likelihood) that some of the patients may have already had delirium before they were even entered into the study. They also note that the CAM-ICU was the tool used to ascertain the presence of delirium. The CAM-ICU is an excellent tool for assessing intubated ICU patients who are unable to speak but it is a non-verbal assessment tool that is not as good as those in which verbal communication can help better identify the presence of delirium. And there was no baseline assessment for delirium or cognitive function. Lastly, they challenge the biological plausibility (i.e. that a sub-sedative very low dose of a sedative agent could be given to awake, non-delirious patients to prevent delirium). They felt such was counterintuitive. Kronzer and Avidan point out the numerous instances in which initially promising interventions turn out not to work when large well-conducted studies are done. They therefore consider the work by Su et al to be hypothesis-generating and look for replication of the findings in other studies.
While Kronzer and Avidan may have a good point about the biological plausibility, we actually think Su and colleagues had some good rationale for doing this study. They had noted several previous studies touting dexmedetomidine for prevention of delirium but all had used higher doses and the control groups were receiving active sedative drugs like benzodiazepines. Because dexmedetomidine provides anxiolysis, sedation, and modest analgesia and is touted not to be associated with significant respiratory depression, many have felt it has the potential to be an ideal candidate for prophylaxis against development of delirium. And they chose the low (sub-sedative) dose of dexmedetomidine because they felt it would likely not have the bradycardia or hypotension seen with higher doses. And a previous study had shown nighttime infusions of dexmedetomidine were associated with sleep improvements.
Nevertheless, we think the criticisms raised by Kronzer and Avidan are legitimate and we agree that prophylactic use of dexmedetomidine to prevent delirium should not be adopted as a usual practice until further validation studies are done.
Perhaps the biggest factor pushing everyone to look at dexmedetomidine is its purported minimal respiratory depression. Now, even that has been called into question by a new study that compared ventilatory responses to hypoxia and hypercapnia during sedation with dexmedetomidine and propofol in healthy male volunteers (Lodenius 2016). Those researchers found that dexmedetomidine-induced sedation reduces ventilatory responses to hypoxia and hypercapnia to a similar extent as sedation with propofol. This finding implies that sedation with dexmedetomidine interacts with both peripheral and central control of breathing.
So, given that there is currently no clearcut pharmacological agent to prevent post-op delirium, what are we to do? A very interesting pragmatic clinical trial recently addressed delirium prevention in patients age 65 and older who underwent surgery for hip fracture (Freter 2016). Rather than intervene with all the elements of multifactorial interventions that have been used for delirium prevention, the researchers used only those that lent themselves to easy incorporation into postoperative preprinted orders. Those that fit included interventions for nausea, nighttime sedation, pain control, and bowel and bladder care. The postoperative preprinted orders had the same elements as the standardized postoperative orders for hip surgery patients with several differences:
Delirium occurred significantly less frequently (27% vs. 42% in controls on POD#1 and 7% vs. 30% in controls on POD#5) despite the fact that more patients in the intervention group had pre-existing dementia, a known risk factor for delirium. More patients in the intervention group had early postoperative bowel movements and more urinary catheter removals on POD#2. Significantly, intervention patients received less opioid analgesia (24 mg morphine equivalents vs. 44 mg morphine equivalents in controls). But, although the intervention group had less postoperative delirium, there were no differences in length of stay, mortality, or nursing home placement rates.
While we anxiously await studies that might validate use of pharmacological agents, such as dexmedetomidine, to prevent postoperative delirium we need to stick with multi-component non-pharmacological interventions such as HELP, the Hospital Elder Life Program (see our October 21, 2008 Patient Safety Tip of the Week “Preventing Delirium” and our September 2011 What's New in the Patient Safety World column “Modified HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery”) or tools like the ABCDEF Bundle (see our September 20, 2016 Patient Safety Tip of the Week “Downloadable ABCDEF Bundle Toolkits for Delirium”).
Some of our prior columns on delirium assessment and management:
References:
Tremblay P, Gold S. Prevention of Post-Operative Delirium in the Elderly Using Pharmacological Agents. Can Geriatr J 2016; 19(3): 113-126
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5038927/
Riker RR, Shehabi Y, Bokesch PM, et al for the SEDCOM (Safety and Efficacy of Dexmedetomidine Compared With Midazolam) Study Group. Dexmedetomidine vs Midazolam for Sedation of Critically Ill Patients. A Randomized Trial. JAMA. 2009; 301(5):489-499. Published online February 2, 2009
http://jama.jamanetwork.com/article.aspx?articleid=183300
Reade MC, Eastwood GM, Bellomo R, et al. Effect of Dexmedetomidine Added to Standard Care on Ventilator-Free Time in Patients With Agitated Delirium: A Randomized Clinical Trial. JAMA 2016; Published online March 15, 2016
http://jama.jamanetwork.com/article.aspx?articleid=2503421
Su X, Meng Z-T, Wu X-H, et al. Dexmedetomidine for prevention of delirium in elderly patients after non-cardiac surgery: a randomised, double-blind, placebo-controlled trial. The Lancet 2016; 388(10054): 1893-1902 Published: 15 October 2016
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30580-3/fulltext
Kronzer VL, Avidan MS. Preventing postoperative delirium: all that glisters is not gold
Vanessa L Kronzer. The Lancet 2016; 388(10054): 1854-1856 Published: 15 October 2016
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31353-8/fulltext
Lodenius A, Ebberyd A, Hårdemark A, et al. Sedation with Dexmedetomidine or Propofol Impairs Hypoxic Control of Breathing in Healthy Male Volunteers: A Nonblinded, Randomized Crossover Study. Anesthesiology 2016; 125(4): 700-715
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2540550&resultClick=3
Freter S, Koller K, Dunbar M, MacKnight C, Rockwood K. Translating Delirium Prevention Strategies for Elderly Adults with Hip Fracture into Routine Clinical Care: A Pragmatic Clinical Trial. J Am Geriatr Soc 2016; Early View 22 NOV 2016
http://onlinelibrary.wiley.com/doi/10.1111/jgs.14568/epdf
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January 31, 2017
More Issues in Pediatric Safety
In our January 17, 2017 Patient Safety Tip of the Week “Pediatric MRI Safety” we noted that many safety issues for children undergoing MRI result from the confluence of vulnerable patients being temporarily in an environment where communication and coordination issues can be problematic. But communication issues can affect the safety of pediatric patients in almost any venue. Young children obviously must rely on parents, other adults, and other caregivers for overseeing their safety. Moreover, they may be unable to convey their own feelings or symptoms, at least in a verbal fashion. Children are also vulnerable to errors because doses of their medications and IV fluids may require calculations based upon weight and such calculations may be subject to errors.
But the behavior of parents can also affect the care their children receive. In our September 22, 2015 Patient Safety Tip of the Week “The Cost of Being Rude” we discussed a study (Riskin 2015) showing shown how rudeness among the healthcare team can negatively impact performance. Now the same researchers have demonstrated in simulation exercises that rudeness by parents may also negatively impact performance by healthcare workers (Riskin 2017).
They randomly assigned NICU teams to either an exposure to rudeness (in which the comments of the patient’s mother included rude statements completely unrelated to the teams’ performance) or control (neutral comments) condition. Rudeness had adverse consequences not only on diagnostic and intervention parameters but also on team processes, such as information and workload sharing, helping and communication, central to patient care.
There’s little question that even such subtle behaviors can introduce biases that may foster diagnostic errors. There has recently also been attention in the adult patient safety literature to the occurrence of diagnostic errors in patients who exhibit disruptive behaviors (Mamede 2017, Redelmeier 2017).
Communication issues were also a key finding in a recent analysis of primary care patient safety incidents involving sick children from England and Wales’ National Reporting and Learning System between 2005 and 2013 (Rees 2017). Of the 2,191 safety incidents, 30% were harmful, including 12 deaths and 41 cases of severe harm. The researchers identified several priority areas for improvement:
We don’t know enough about the UK telephone triage system(s) to know whether such systems in the US may be vulnerable to the same issues. In such systems, the person receiving the phone call from a parent concerned about their child lets the parent describe the problem, then selects a computerized protocol that prompts them to ask further questions, after which they provide advice. In the Rees study two common issues were: (1) choosing the wrong protocol (for example, choosing the “head wound” rather than the “head trauma” protocol) and (2) failure to use “critical thinking”. We wonder if some of the latter was really a matter of the telephone advisors simply not having adequate training in some areas. For example, one incident described a feverish 4-month old who had asymmetric pupils and a hard fontanelle. The health advisor commented that he did not know the implications of a hard fontanelle and followed a simple “generally unwell” protocol and incorrectly answered that the infant was able to respond normally despite the mother’s comment that the infant was “dazed” and “drowsy, not with it”.
As you might expect, medication-related incidents were most common and over half were related to dispensing errors in community pharmacies. Anticonvulsants, antibiotics, and asthma medications were implicated most often. Wrong dosage, wrong medication, and incorrect labeling were specifically mentioned. Communication errors with the parent contributed frequently to medication errors, especially when the parents were administering the medication at home.
We’ve previously described how parental health literacy, numeracy in particular, can render children vulnerable to medication errors (see our What’s New in the Patient Safety World columns for June 2012 “Parents' Math Ability Matters” and November 2014 “Out-of-Hospital Pediatric Medication Errors” and our January 13, 2015 Patient Safety Tip of the Week “More on Numeracy”).
Dosing errors related to the vehicles used for administration of medications to children have also been problematic. In our What's New in the Patient Safety World columns for April 2015 “Pediatric Dosing Unit Recommendations” and September 2015 “Alert: Use Only Medication Dosing Cups with mL Measurements” we discussed use of metric units for liquid medications administered to pediatric patients (AAP 2015). Use of measures such as “teaspoon” and “tablespoon” should no longer be used. Moreover, the correct abbreviation for milliliters is “mL” (rather than “ml”, “ML”, or “cc”). Dispensing devices are also critical. Pharmacies, hospitals, and healthcare centers should distribute appropriate-volume milliliter-based dosing devices such as syringes. And the syringe (or other dosing device) should not be significantly larger than the dose prescribed. And a national alert recommended hospitals replace medication dosage cups that use units other than mL (NAN 2015).
The 2015 AAP statement also recommends that manufacturers avoid labeling, instructions or dosing devices that contain units other than metric units. But poorly designed labels and packaging continue to contribute to errors. A recent study in 3 urban pediatric clinics (Yin 2016) randomly assigned parents to 1 of 5 study arms and given labels and dosing tools that varied in unit pairings. 84.4% of parents made 1 or more dosing errors and 21.0% made 1 or more large error. More errors were seen with cups than syringes, especially for smaller doses. Use of a teaspoon-only label (with a milliliter and teaspoon tool) was associated with more errors than when milliliter-only labels and tools were used. The authors recommend that use of oral syringes over cups, particularly for smaller doses, should be part of a comprehensive pediatric labeling and dosing strategy to reduce medication errors.
Children are also more vulnerable to 10-fold dosing errors, primarily because dose calculations often result in results with decimal points. The decimal points can be overlooked, resulting in administration of a dose that is 10 times (or 100 times if there are two digits following the decimal point) higher than intended. In our September 2011 “Dose Rounding in Pediatrics” we discussed under which circumstances it might be appropriate to keep a decimal point and when the dose should simply be rounded to eliminate the need for a decimal point.
More information on pediatric medication errors outside the hospital can be found in our November 2014 What's New in the Patient Safety World column “Out-of-Hospital Pediatric Medication Errors” and May 7, 2013 Patient Safety Tip of the Week “Drug Errors in the Home”.
We’ve also discussed the problems often seen with opioids in children, particularly those related to use of codeine (see columns listed below). These columns described the original cases of death and serious adverse effects in children treated with codeine following adenotonsillectomy for obstructive sleep apnea. The problem originally noted for codeine was that there are genetic variations that cause some people to be “ultra-rapid metabolizers” of codeine, which leads to higher concentrations of morphine in the blood earlier. But recommendations have now gone further than just avoiding codeine after adenotonsillectomy and it is now recommended that codeine not be used for pain or cough in children. And children are often the victims of accidental ingestion of discarded transdermal patches of fentanyl or other dangerous medications.
Our March 15, 2016 Patient Safety Tip of the Week “Dental Patient Safety” had an extensive section on the adverse outcomes of pediatric patients receiving sedation. Young children are particularly vulnerable because they are often sedated since they may be uncooperative for dental procedures. Moreover, many such incidents have occurred when a child is restrained by a device called a “papoose”. Proper procedures and guidelines for pediatric sedation were discussed in our August 2016 What's New in the Patient Safety World column “Guideline Update for Pediatric Sedation”.
Overdiagnosis, overutilization of testing, and overtreatment may result in harm to children, just as it can in adults. We’ve often discussed the Imaging Gently® and Imaging Wisely® campaigns, which are attempts to reduce the inappropriate use of imaging with ionizing radiation when safer alternatives are available (see, for example, our January 2017 What's New in the Patient Safety World column “Still Too Many CT Scans for Pediatric Appendicitis”). A recent review of articles published in just one year (2015) provides insight into the magnitude of these problems in children (Coon 2017). Their findings included evidence for overdiagnosis of hypoxemia in children with bronchiolitis and skull fractures in children suffering minor head injuries. Findings of overtreatment included evidence that up to 85% of hospitalized children with radiographic pneumonia may not have a bacterial etiology; many children are receiving prolonged intravenous antibiotic therapy for osteomyelitis although oral therapy is equally effective; antidepressant medication for adolescents and nebulized hypertonic saline for bronchiolitis appear to be ineffective; and thresholds for treatment of hyperbilirubinemia may be too low. Regarding overutilization, they suggested that the frequency of head circumference screening could be relaxed; large reductions in abdominal computed tomography testing for appendicitis appear to have been safe and effective; and overreliance on C-reactive protein levels in neonatal early onset sepsis appears to extend hospital length-of-stay.
Pediatric safety issues such as car and bicycle safety, accidental poison ingestions, falls, firearm accidents, and others are beyond the scope of today’s column.
These are but a few of the many possible patient safety issues potentially affecting one of our most vulnerable patient populations. Some are due to the unique biological and physiological characteristics of children but even more may be related to the fact that communication, which is always an error-prone process, usually happens through third parties rather than directly with children.
Some of our other columns on pediatric medication errors:
November 2007 “1000-fold Overdoses by Transposing mg for micrograms”
December 2007 “1000-fold Heparin Overdoses Back in the News Again”
September 9, 2008 “Less is More and Do You Really Need that Decimal?”
July 2009 “NPSA Review of Patient Safety for Children and Young People”
June 28, 2011 “Long-Acting and Extended-Release Opioid Dangers”
September 13, 2011 “Do You Use Fentanyl Transdermal Patches Safely?”
September 2011 “Dose Rounding in Pediatrics”
April 17, 2012 “10x Dose Errors in Pediatrics”
May 2012 “Another Fentanyl Patch Warning from FDA”
June 2012 “Parents’ Math Ability Matters”
September 2012 “FDA Warning on Codeine Use in Children Following Tonsillectomy”
May 7, 2013 “Drug Errors in the Home”
May 2014 “Pediatric Codeine Prescriptions in the ER”
November 2014 “Out-of-Hospital Pediatric Medication Errors”
January 13, 2015 “More on Numeracy”
April 2015 “Pediatric Dosing Unit Recommendations”
September 2015 “Alert: Use Only Medication Dosing Cups with mL Measurements”
November 2015 “FDA Safety Communication on Tramadol in Children”
Some of our previous columns on opioid safety issues in children:
References:
Riskin A, Erez A, Foulk TA, et al. The Impact of Rudeness on Medical Team Performance: A Randomized Trial. Pediatrics 2015; 136: 487-495
http://pediatrics.aappublications.org/content/136/3/487.abstract
Riskin A, Erez A, Foulk TA, et al. Rudeness and medical team performance. Pediatrics 2017; doi:10.1542/peds.2016-2305
Mamede S, Van Gog T, Schui SCE, et al. Why patients’ disruptive behaviours impair diagnostic reasoning: a randomised experiment. BMJ Qual Saf 2017; 26: 13-18
http://qualitysafety.bmj.com/content/26/1/13.full
Redelmeier DA, Etchells EE. Unwanted patients and unwanted diagnostic errors. BMJ Qual Saf 2017; 26: 1-3
http://qualitysafety.bmj.com/content/26/1/1.full.pdf+html
Rees P, Edwards A, Powell C, et al. Patient Safety Incidents Involving Sick Children in Primary Care in England and Wales: A Mixed Methods Analysis. PLOS One Medicine 2017; published January 17, 2017
http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002217
AAP (American Academy of Pediatrics). Committee on Drugs. Policy Statement. Metric Units and the Preferred Dosing of Orally Administered Liquid Medications. Pediatrics 2015; 135(4): 784-787; originally published online March 30, 2015
http://pediatrics.aappublications.org/content/early/2015/03/25/peds.2015-0072.full.pdf
NAN (National Alert Network). Move toward full use of metric dosing: Eliminate dosage cups that measure liquids in fluid drams. Use cups that measure mL. NAN 2015; June 30, 2015
http://www.ismp.org/NAN/files/NAN-20150630.pdf
Yin HS, Parker RM, Sanders LM, et al. Liquid Medication Errors and Dosing Tools: A Randomized Controlled Experiment. Pediatrics 2016; published online early September 12, 2016
http://pediatrics.aappublications.org/content/early/2016/09/08/peds.2016-0357
Imaging Gently®
Imaging Wisely®
Coon ER, Young PC, Quinonez RA, et al. Update on Pediatric Overuse. Pediatrics 2017; Published Ahead of Print January 3, 2017
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February 7, 2017
Maternal Safety Bundles
It has been almost 7 years since the (now retired) Joint Commission Sentinel Event Alert on Maternal Deaths” (see our February 2010 What's New in the Patient Safety World column “Joint Commission Sentinel Event Alert on Maternal Deaths”). It cited studies putting the percentage of preventable maternal deaths at between 28 and 50%. Prior studies of preventable maternal deaths have identified issues such as inadequate attention to blood pressure management, inadequate management of pre-eclampsia, inadequate attention to vital signs after C-section, hemorrhage after C-section, and pulmonary embolism.
There has been attention recently to maternal safety issues on several fronts. In October last year the APSF (Anesthesia Patient Safety Foundation) had an article on maternal safety bundles (Banayan 2016). Then in December the Pennsylvania Patient Safety Authority (PPSA) had a review of serious maternal events reported to the Pennsylvania Patient Safety Reporting System (Wallace 2016).
The Banayan article notes a study showing that the US is the only developed nation where maternal mortality has increased since 1990 (Kassebaum 2014). And while the most common causes of maternal mortality historically have been hemorrhage, hypertensive disorders, thromboembolic events and infection, there has been a trend in recent years for more deaths attributable to cardiovascular diseases and other co-existing medical conditions (Creanga 2015, Berg 2010). The average age of parturients is also increasing but that is also happening in other countries where rates of maternal death are decreasing.
The Banayan article goes on to describe quality improvement initiatives in California and New York that have addressed maternal safety. The California initiative was a collaborative that created multiple toolkits and resulted in a significant reduction in maternal mortality. In New York the ACOG District II Safe Motherhood Initiative (SMI) similarly developed “bundles” of safety tools to address maternal safety. The National Partnership for Maternal Safety (NPMS) has similarly developed bundles for hemorrhage, hypertension in pregnancy, and VTE and others and published their materials on the Council on Patient Safety in Women’s Healthcare Safe Healthcare for Every Woman website.
The bundles on the ACOG District II Safe Motherhood Initiative (SMI) website are arranged into sections: Readiness, Recognition and Prevention, Response, and Reporting/System Learning. For example, the bundle for VTE discusses risk assessment scoring tools and recommendations regarding mechanical and pharmacological prophylaxis, including dosing protocols and recommendations about the timing of neuroaxial anesthesia events in relation to pharmacological prophylaxis. The hemorrhage bundle includes risk assessment, checklists, massive transfusion protocols, and other tools. The hypertension bundle includes risk assessment, multiple checklists, recommendations for when to treat and which agents to use (first line and subsequent agents), monitoring, escalation process, etc. Each bundle includes a slide set, checklists, other educational tools, and links to other valuable resources.
The December Pennsylvania Patient Safety Authority (PPSA) review of serious maternal events reported to the Pennsylvania Patient Safety Reporting System from 2011 to 2015 (Wallace 2016) updated a prior PPSA review (PPSA 2009). The update included 537 events and the top 5 categories were:
This review was simply a snapshot and did not go into lessons learned or recommendations. The 2009 PPSA review had a similar short “snapshot” but also had a companion articles on preventing maternal and fetal injuries during vacuum assisted vaginal deliveries (PPSA 2009b) and on medication errors in labor and delivery (PPSA 2009c). The most common medication error event types associated with this area were dose omission (22.5%) and wrong drug (10.7%). Almost half (46.4%) of wrong-dose/overdosage errors and 55.2% of wrong-rate errors involved high-alert medications (eg. oxytocin, magnesium sulfate, opioids). Some of the strategies to prevent medication errors and patient harm were:
That article also had good recommendations about labeling all lines, storage of medications, look-alike/sound-alike (LASA) medication pairs, double checks, verbal orders, and monitoring.
Speaking of high-alert medications, a period of both fetal and maternal vulnerability occurs when a decision is made to perform an emergency cesarean delivery. Such patients often have IV and epidural infusion pumps and other IV lines. In our November 3, 2015 Patient Safety Tip of the Week “Medication Errors in the OR - Part 2” we discussed an excellent article on medication safety issues when obstetric patients to the OR are transferred to the OR for emergency cesarean deliveries (Kacmar 2015). It notes that during such emergency transfers there may be inadvertent administration of some of the high-risk medications (eg. oxytocin, magnesium, insulin) a patient may have had infusing prior to the transfer. See the Kacmar article for details and excellent recommendations about which ones to discontinue prior to transport and other issues.
Note that ACOG (American College of Obstetricians and Gynecologists) and SMFM (Society for Maternal-Fetal Medicine) have not yet created or endorsed a single, comprehensive definition of severe maternal morbiditiy. But they did publish a consensus statement with some recommendations (ACOG 2016). While that document does provide an example list of diagnoses and complications that could be considered severe maternal morbidity, it suggests that at a minimum organizations screen for severe maternal morbidity by identifying cases either of the following:
Cases meeting either of those criteria should be reviewed in detail to determine potential preventability and opportunities for system change and improved future performance.
We mentioned that an increasing burden of chronic diseases in parturients has been suggested as a reason for higher maternal morbidity and mortality rates in the US compared to other countries. Parellel with the obesity epidemic we have seen increasing rates of obstructive sleep apnea. In our May 13, 2014 Patient Safety Tip of the Week “Perioperative Sleep Apnea: Human and Financial Impact” we noted a study that demonstrated an association between OSA and maternal mortality in pregnancy (Louis 2014). The rate of OSA increased from 0.7 in 1998 to 7.3 in 2009, an average annual increase of 24%. After controlling for obesity and other potential confounders, OSA was associated with increased odds of preeclampsia, eclampsia, cardiomyopathy, and pulmonary embolism. Women with OSA experienced a more than fivefold increased odds of in-hospital mortality. The adverse effects of OSA on selected outcomes were exacerbated by obesity. Just as we have recommended screening pre-op patients for OSA, it would probably be wise to screen obstetrical patients for OSA with a simple tool like the STOP-Bang questionnaire. Particularly since many women may receive drugs that may cause respiratory depression or aggravate OSA before, during, or after labor and delivery, it is important to recognize those at risk so that appropriate monitoring is done.
One of the likely reasons for higher rates of maternal morbidity and mortality in the US is our high rate of cesarean deliveries. About a third of births in the United States occur with cesarean delivery. So efforts to reduce the rate of cesarean deliveries that lack a medical indication should be a way to improve our maternal morbidity and mortality rates. A multi-strategy approach at Boston’s Beth Israel Deconess Medical Center successfully reduced its NTSV (nulliparous term singleton vertex) cesarean delivery rate from 35% to 21% over eight years (Vadnais 2017). Their total cesarean delivery rate declined as well from 40.0% to 29.1%. These rates of improvement exceeded any state or national trends for the same period.
Their multi-strategy approach included provider education, provider feedback, and implementation of new policies to target the five key factors that may influence the NTSV cesarean delivery rate: interpretation and management of fetal heart rate tracings, provider tolerance for labor, induction of labor, provider awareness of NTSV cesarean delivery rate, and environmental stress.
And the reduced rates were largely without unintended consequences. There was an increase in meconium aspiration but the mean 5-minute Apgar score and the rate of NICU admission for more than 24 hours were stable throughout the study period and they could not detect a difference in the rate of neonatal demise. There was also a slight increase in the maternal transfusion rate. The amount of time patients occupied beds in the Labor and Delivery Unit increased, largely because of longer labors compared to those where cesarean deliveries were done.
In several of our columns we’ve mentioned the MOREOB Program (Managing Obstetrical Risk Efficiently). The MOREOB Program focuses on communication and teamwork building, skill building, culture of safety, emergency skill drills, education, and use of patient safety tools like RCA, FMEA, near miss reviews, audits, etc. The program has reduced NICU admissions and resulted in fewer neonates with respiratory distress, sepsis, CNS hemorrhage, and a variety of other neonatal and maternal outcomes. In our September 7, 2010 Patient Safety Tip of the Week “Patient Safety in Ob/Gyn Settings” we noted multiple hospitals in Alberta participating in the 3-year long MOREOB Program saw that severe newborn morbidity was significantly reduced and maternal outcomes (reduced third- and fourth-degree tears and reduced lengths of stay) were also improved (Thanh 2010).
And, of course, we are always big fans of drills and exercises that help prepare teams for emergencies. Fortunately, ob/gyn has been a pioneer in simulation programs that use team-based interdisciplinary training for events like post-partum hemorrhage and other obstetrical emergencies. Many academic medical centers put on such simulation programs for interested parties to attend. We are familiar with the one put on by the University of Rochester Medical Center. These simulations can be quite comprehensive. There’s even one module in which there is simulation of the expectant father fainting in the delivery room!
A couple other observations also keep popping up: the “weekend effect” and disparities in outcomes between rural and urban hospitals.
We’ve discussed the “weekend effect” (and “after hours effect”) in multiple columns and discussed many of the factors likely contributing to the phenomenon (see the list at the end of today’s column). Several studies have found increased maternal and/or neonatal mortalitiy on weekends compared to weekdays. A UK study found that performance across four of seven measures of maternal and neonatal outcomes was significantly worse for women admitted, and babies born, at weekends (Palmer 2015). No consistent association between outcomes and staffing was identified other than a slightly lower rate of perineal tears in sites that complied with recommended levels of consultant presence. But two studies recently presented at the 37th Annual Meeting of the Society for Maternal Fetal Medicine: The Pregnancy Meeting had contradictory findings. Moaddab and colleagues, using data on over 45 million deliveries from 2 large CDC databases, found tht maternal mortality rates were highest on Saturday and Sunday (Moaddab 2017). They also found that stillbirths and fetal mortality reates were higher on weekends. The authors note these findings occur despite a likely systematic bias toward admission and delivery of more complex patients on weekdays. On the other hand, Einerson and colleagues (Einerson 2017) analyzed 208,695 deliveries and found that composite maternal adverse events and death did not differ between the daytime and night/weekend groups. Composite neonatal adverse events and perinatal mortality were less common in the daytime group. But in the subgroup of spontaneously laboring patients, there was no difference in composite maternal or neonatal adverse events and no difference in maternal death or perinatal mortality. The authors felt that scheduling of “low-risk” inductions and cesareans may account for lower risk of adverse obstetric outcomes observed during weekdays. An editorial accompanying the Palmer study (Snowden 2015) discusses potential factors that might contribute to a “weekend effect” in obstetrics. We’ve also discussed the multiple factors that contribute to the “weekend effect” in our several columns on the phenomenon (see full list below).
A recent Canadian study looked at differences in maternal morbidity between rural and urban settings, noting that most prior similar studies focused on infant outcomes (Lisonkova 2016). The found that rates for eclampsia, obstetric embolism, and uterine rupture or dehiscence were twice as common in rural settings. Though there was no difference in neonatal mortality, there was higher neonatal morbiditiy in rural settings as well. The authors suggest that maternity care providers in rural regions need to be aware of potentially life-threatening maternal and perinatal complications requiring advanced obstetric and neonatal care. Though this was a Canadian study we suspect we’d find similar patterns in the US. We often see referral for “high risk” pregnancies based upon fetal factors and fetal risk and less often for maternal risk. It’s probably not just the driving distance to the hospital or even the density of obstetricians that is the critical factor. One study found that the density of maternal-fetal medicine specialists is significantly and inversely associated with maternal mortality ratios, even after controlling for state-level measures of maternal poverty, education, race, age, and their significant interactions (Sullivan 2005). An abstract presented last year (Guglielminotti 2016) found in 605,534 discharges in 139 hospitals in New York state severe maternal morbidity increased from 1.1% in 2009 to 1.4% in 201. The 3 most frequent severe maternal morbidity were severe postpartum hemorrhage (35%), disseminated intravascular coagulation (27%), and heart failure (16%). Interestingly, neighborhood characteristics were not associated with severe maternal morbidity but four hospital characteristics were associated with decreased rate of severe maternal morbidity: urban location, low proportions of minority patients and high-risk pregnancies, and higher cesarean delivery rate. So any rural/urban disparity may more a problem in matching maternal risk with hospitals best prepared to handle patients with those risks.
And then there are some rarer threats to maternal health. We described one very interesting phenomenon in our December 4, 2012 Patient Safety Tip of the Week “Unintentional Perioperative Hypothermia: A New Twist” that needs to be recognized to avoid maternal morbidity. There appears to be a syndrome related to cases (most often obstetrical) in which spinal anesthesia with morphine is used and patients develop hypothermia with paradoxical sweating. Most cases in the literature have followed cesarean deliveries. Prompt recognition of this syndrome is important because the syndrome often responds to benzodiazepines. You need to amend your hypothermia management protocols to take this phenomenon into account. Specifically there should be a prompt to consider the phenomenon if the expected improvement in hypothermia is not occurring within a reasonable amount of time after conventional warming procedures have been instituted. Perhaps even a prompt at the beginning of your protocol to look for signs you would not expect with hypothermia (i.e. sweating, hot feeling, vasodilation) might suggest this unusual etiology for the hypothermia. See that December 4, 2012 Patient Safety Tip of the Week “Unintentional Perioperative Hypothermia: A New Twist” for details.
Some “never events” may also threaten maternal safety.One rare preventable cause of maternal morbidity is a surgical fire. While we usually think about high risk for surgical fires with chest or head/neck surgery, we’ve described surgical fires during cesarean deliveries in Israel (see our January 2011 What's New in the Patient Safety World column “Surgical Fires Not Just in High Risk Cases”) and New Zealand (see our April 24, 2012 Patient Safety Tip of the Week “Fire Hazard of Skin Preps Oxygen”). As a result, in New Zealand some hospitals abandoned the use of alcohol-based skin preps for ob/gyn procedures, moving instead to aqueous-based skin preps, especially in view of lack of a clearcut difference in surgical site infections by skin prep type for such ob/gyn procedures.
And don’t forget about the possibility of retained surgical items (RSI’s) in obstetrics (see our August 19, 2014 Patient Safety Tip of the Week “Some More Lessons Learned on Retained Surgical Items”). A substantial proportion of retained surgical items have been reported in Ob/Gyn procedures, including cesarean and vaginal deliveries (Stiller 2010). The Minnesota Hospital Association and ICSI also have focused on Ob/Gyn procedures in their efforts to prevent retained foreign objects. Like most cases of RSI’s, surgical sponges are the items most commonly left behind but there have been increasing reports of retained instruments and other objects including - you guessed it – a cellphone (Moran 2015)!
And since many women during labor have both intravenous and epidural infusions, don’t forget the potential for mistaken infusion into the wrong line. In our April 2010 What's New in the Patient Safety World column “RCA: Epidural Solution Infused Intravenously” we discussed a case of such a tragic mistake that led to a maternal death.
Though they are technically not related to maternal safety, we’ve also listed below our columns related to events that can transpire after delivery, such as infant abductions, switched babies, breastfeeding and breastmilk mixups.
Some of our previous columns on maternal and ob/gyn issues:
February 5, 2008 “Reducing Errors in Obstetrical Care”
February 2010 “Joint Commission Sentinel Event Alert on Maternal Deaths”
April 2010 “RCA: Epidural Solution Infused Intravenously”
July 20, 2010 “More on the Weekend Effect/After-Hours Effect”
August 2010 “Surgical Case Listing Accuracy”
September 7, 2010 “Patient Safety in Ob/Gyn Settings”
January 2011 “Surgical Fires Not Just in High Risk Cases”
February 8, 2011 “Inducing Too Early”
April 2011 “Ob/Gyn Patient Safety Programs”
April 24, 2012 “Fire Hazard of Skin Preps Oxygen”
July 2012 “WHO Safe Childbirth Checklist”
December 4, 2012 “Unintentional Perioperative Hypothermia: A New Twist”
September 2013 “Full-Time Laborists Reduce C-Section Rates”
October 2013 “Challenging the 39-Week Campaign”
November 2013 “The Weekend Effect: Not One Simple Answer”
January 2014 “It MEOWS But Doesn’t Purr”
May 13, 2014 “Perioperative Sleep Apnea: Human and Financial Impact”
August 19, 2014 “Some More Lessons Learned on Retained Surgical Items”
November 3, 2015 “Medication Errors in the OR - Part 2”
Some of our prior columns related to identification issues in newborns:
November 17, 2009 “Switched Babies”,
December 20, 2011 “Infant Abduction”
September 4, 2012 “More Infant Abductions”.
December 11, 2012 “Breastfeeding Mixup Again”.
April 8, 2014 “FMEA to Avoid Breastmilk Mixups”
August 2015 “Newborn Name Confusion”
January 19, 2016 “Patient Identification in the Spotlight”
July 19, 2016 “Infants and Wrong Site Surgery”
Some of our previous columns on the “weekend effect”:
References:
The Joint Commission. Sentinel Event Alert. Issue 44, January 26, 2010
Preventing Maternal Death (now retired)
https://www.jointcommission.org/sentinel_event_alert_issue_44_preventing_maternal_death/
Banayan JM, Scavone BM. National Partnership for Maternal Safety—Maternal Safety Bundles. NPSF Newsletter 2016; 31(2): 29, 32-35 October 2016
http://www.apsf.org/newsletters/pdf/Oct2016.pdf
Wallace SC. Data Snapshot: Maternal Serious Events. Pa Pat Saf Advis 2016; 13(4): 163-165
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2016/dec;13(4)/Pages/163.aspx
Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, et al. Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 980-1004
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60696-6/fulltext
Creanga AA, Berg CJ, Syverson C, et al. Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol 2015; 125: 5-12
Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancy-related mortality in the United States, 1998 to 2005. Obstet Gynecol 2010; 116: 1302-1309
ACOG District II Safe Motherhood Initiative (SMI) website
http://www.acog.org/About-ACOG/ACOG-Districts/District-II/Safe-Motherhood-Initiative
Safe Healthcare for Every Woman website
http://safehealthcareforeverywoman.org/
PPSA (Pennsylvania Patient Safety Authority). Data Snapshot: Maternal Complications. Pa Patient Saf Advis 2009; 6(Suppl 1): 26-27
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/dec16_6(suppl1)/Pages/26.aspx
PPSA (Pennsylvania Patient Safety Authority). Preventing Maternal and Neonatal Harm during Vacuum-Assisted Vaginal Delivery. Pa Patient Saf Advis 2009; 6(Suppl 1): 7-17
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/dec16_6(suppl1)/documents/07.pdf
PPSA (Pennsylvania Patient Safety Authority). Medication Errors in Labor and Delivery: Reducing Maternal and Fetal Harm. Pa Patient Saf Advis 2009; 6(Suppl 1): 1-6
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/dec16_6(suppl1)/documents/01.pdf
Kacmar RM, Mhyre JM. Obstetric Anesthesia Patient Safety: Practices to Ensure Adequate Venous Access and Safe Drug Administration During Transfer to the Operating Room for Emergency Cesarean Delivery. APSF Newsletter 2015; 30(2): 24-25, 42-43 October 2015
http://apsf.org/newsletters/pdf/Oct2015.pdf
ACOG (American College of Obstetricians and Gynecologists) and SMFM (Society for Maternal-Fetal Medicine). Severe maternal morbidity: screening and review. Obstetric Care Consensus No. 5. American College of Obstetricians and Gynecologists. Obstetrics & Gynecology 2016; 128(3): 670-671
Louis JM, Mogos MF, Salemi JL, et al. Obstructive sleep apnea and severe maternal-infant morbidity/mortality in the United States, 1998-2009. Sleep 2014; 37(5): 843-849
Vadnais MA, Hacker MR, Shah NT, et al. Quality Improvement Initiatives Lead to Reduction in Nulliparous Term Singleton Vertex Cesarean Delivery Rate, The Joint Commission Journal of Quality and Safety 2017; published online January 2017
http://www.jointcommissionjournal.com/article/S1553-7250%2816%2930057-5/fulltext
MOREOB Program
Thanh NX, Jacobs P, Wanke MI, et al. Outcomes of the Introduction of the MOREOB Continuing Education Program in Alberta. J Obstet Gynaecol Can 2010; 32(8): 749–755
http://www.jogc.com/article/S1701-2163(16)34615-1/pdf
Palmer WL, Bottle A, Aylin P. Association between day of delivery and obstetric outcomes: observational study. BMJ 2015; 351: h5774 (Published 24 November 2015)
http://www.bmj.com/content/351/bmj.h5774
Moaddab A, Davidson CM, Sangi-Haghpeykar H, et al. Association between day and month of delivery and maternal-fetal mortality: weekend effect and July phenomenon in current obstetric practice. American Journal of Obstetrics and Gynecology 2017; 216(1 Suppl): S42
http://www.ajog.org/article/S0002-9378(16)31923-8/pdf
Einerson BD, Gibbins KJ, Zhang JW, et al. The “night & weekend effect” in obstetrics: truth, or artifact? American Journal of Obstetrics and Gynecology 2017; 216(1 Suppl): S295-S296
http://www.ajog.org/article/S0002-9378(16)31214-5/fulltext
Snowden JM, Caughey AB. Is there a weekend effect in obstetrics? BMJ 2015; 351: h6192. doi: 10.1136/bmj.h6192.
http://www.bmj.com/content/351/bmj.h6192.long
URMC (University of Rochester Medical Center). Center for Obstetrics and Gynecology Simulation (COGS).
https://www.urmc.rochester.edu/ob-gyn/education/simulation.aspx
Lisonkova S, Haslam MD, Dahlgren L, et al. Maternal morbidity and perinatal outcomes among women in rural versus urban areas. CMAJ 2016; 188: E456-E465; published ahead of print September 26, 2016
http://www.cmaj.ca/content/188/17-18/E456.full
Sullivan SA, Hill EG, Newman RB, Menard M.K. Maternal-fetal medicine specialist density is inversely associated with maternal mortality ratios. Am J Obstet Gynecol 2005; 193: 1083-1088
http://www.ajog.org/article/S0002-9378(05)00782-9/abstract
Guglielminotti J, Landau R, Wong CA, et al. Neighborhood- and Hospital-Level Factors Associated with Severe Peripartum Maternal Morbidity in New York State, 2009-2011. Abstract Number: BP-02. 2016 annual meeting of the Society for Obstetric Anesthesia and Perinatology.
https://soap.org/display_2016_abstract.php?id=BP-02
Stiller RJ, Ivy MJ, Thompson T. Preventing retained foreign objects in ob/gyn surgery. Contemporary OB/GYN 2010; June 1, 2010
Minnesota Hospital Association. Eliminating Retained Foreign Objects (Safe Count and Safe Account Programs).
ICSI (Institute for Clinical Systems Improvement). Prevention of Unintentionally Retained Foreign Objects During Vaginal Deliveries. Revision date: January 2012
Moran L. Jordanian doctor left cell phone in women's abdomen after C-section: report.
New York Daily News 2015; May 15, 2015
Print “Maternal Safety Bundles”
February 14, 2017
Yet More Jumps from Hospital Windows
A patient jumps to his or her death from a hospital window. Think that could never happen at your non-psychiatric hospital? Think again. Last year we described 2 such cases (see our April 12, 2016 Patient Safety Tip of the Week “Falls from Hospital Windows”) and we’ve come across several additional cases since then. We wouldn’t be surprised if there are other cases that we simply have not heard about. There are also many news headlines about patients who have jumped from hospital windows that provide no details.
Suicide on non-behavioral health units has been a topic of several of our columns and also one of Joint Commission’s sentinel event alerts (see our December 2010 What’s New in the Patient Safety World column “Joint Commission Sentinel Event Alert on Suicide Risk Outside Psych Units”). But not all jumps from windows are suicide attempts. In many cases it is a confused patient trying to escape from the hospital. The two cases we described in our April 12, 2016 Patient Safety Tip of the Week “Falls from Hospital Windows” had traumatic brain injuries.
In one of the cases we’ve subsequently come across (Pearson 2016) a 25 y.o. man who had attempted an overdose with aspirin and multivits was on a “crisis stabilization” unit on the third floor (that hospital’s main behavioral health unit is on first floor). The patient “launched” himself off the bed and through the window, even while he was under direct observation. When found, he had “medical wires still connected”.
In another case (Bay Bulletin 2016) a man‚ age 29‚ had been admitted to hospital for alcohol-related issues on a Saturday before the incident the next morning‚ Christmas Day. He ran away from a doctor‚ broke the window and fell from the fifth floor to the ground.” Both his legs were fractured in the fall and he suffered a serious head injury and subsequently died.
In another (Hutton 2014) a 39 y.o. man suffering from alcohol withdrawal threw himself out of a fourth-floor window after he became disorientated and confused while waiting for a psychiatric review. His condition had stabilized over three days but his state of mind went from “jovial and chirpy” to “confused” until the night of his death when he began wandering around the ward incoherently before running away from the two nurses monitoring him, locking himself in a room, breaking the security locks on windows and throwing himself out.
Even the elderly may be at risk. An 80 y.o. man admitted for elderly care was left unattended in day room and broke window with a chair, crawled onto a ledge and fell to his death from second floor (Jolly 2016).
And not all victims are males. A female patient in her 40’s on acute medical unit jumped to death from window (Yorkshire Evening Post 2014). No other details were provided. An older case (Associated Press 2002) again involved a head-injured patient but the patient was female. She was located in the hospital’s head trauma unit on the 11th floor. She apparently was in some sort of restraints. A hospital worker heard a scuffling sound as he tended to the other patient in the room but events transpired so quickly that "by the time he heard the noise and went over, the person had already broken from the restraints" and squeezed through the 18-inch high opening of the large window in her room and fell fatally seven stories before hitting the roof of another building.
And the most recent case, which led to today’s column, comes from another statement of deficiencies/plan of correction from the California Department of Public Health (CDPH 2016). A patient with auditory hallucinations attempted suicide by stabbing himself in the chest and neck, resulting in hospital admission as a trauma patient. He had a hemothorax and needed chest tube insertion. He was under 1:1 observation in a trauma/medical/surgical unit on the hospital’s 10th floor. He suddenly “launched himself” up off his bed and out the window, breaking the window pane and falling 60 feet to his death on a 4th floor roof top. As we usually find with the reports from the CDPH, this case had numerous lessons learned. While several communication issues contributed, there were important lessons about the dangers in the environment that contributed or were otherwise hazardous (discussed below).
Even though we lack details on many of these cases, there clearly is a pattern. Moreover, there are some surprisingly simple issues that are actually very good lessons learned. The typical patient is a young or middle-aged male, but occasionally elderly patients or females have also jumped through or out of windows. The patient is often admitted for an attempted suicide but, again, not always. Typically he/she is confused or hallucinating. It’s not just patients with known psychiatric disorders or a history of suicide attempt that are at risk. Patients with brain injuries or delirium are at risk, particularly those who have demonstrated a tendency to wander or have verbalized their intent to “get out of here” or “go home”. And the incidents have commonly occurred while patients are already on 1:1 continuous observation and the observer is actually in the room.
In patients committing suicide, we often see that a period of greater vulnerability when their depression is improving. The same probably applies to the patient with traumatic brain injury (TBI) and staff need to be aware that the impulsivity often seen after TBI accompanied by the desire to go home can lead to the sort of disastrous consequences unfortunately seen in many of these cases.
Most general acute care hospitals have not installed the type of window used on behavioral health units that is not breakable or subject to manipulation. But perhaps it might be reasonable to designate one or two rooms on acute care floors for housing such patients deemed at risk and install such windows in those rooms. And, given that many such victims have been head trauma patients, perhaps it would be wise to install such windows on any acute head trauma units or other units dealing with TBI patients. But be wary that even windows you may consider “safe” may not be. At one hospital a male patient (no further details) removed a metal grill from a third floor window and fell out (Malloy 2016). The hospital subsequently checked the “safety restrictors” on all their windows.
But at a minimum, every room that is to be used for such patients needs a thorough environemental assessment such as the VA’s Mental Health Environment of Care Checklist. Particularly in a room where medical equipment is being used there will be special dangers. For example, in the CDPH case discussed above the patient’s oxygen had been discontinued but the mask, tubing, etc. were still in the room. These are objects that can be used by a patient to hang himself or otherwise injure himself. So make sure that medical equipment and supplies that are no longer needed are promptly removed from the room. The environmental assessment should also evaluate the immediate surroundings. For example, in that CDPH case there was a stairway exit 15 feet from the patient’s room with a door that was unlocked. (Note that we’ve discussed the VA’s Mental Health Environment of Care Checklist in several columns and will probably do another soon. Recent studies (Watts 2016, Mills 2016) have shown that it has been very successful in reducing suicides, perhaps more important than any other interventions.)
So what are the more subtle lessons learned? First is that several patients were able to stand up on the bed and “launch themselves” through the window from the bed. That implies a proximity of the bed to the window. So one key lesson is to position the patient’s bed in the room at a reasonable distance away from the window so such “launches” are not possible.
Second, positioning of the observer may be important. The observer is usually positioned in the room on the side away from the window and near the door. We suspect that is intentional and may be a consideration for the safety of the observer plus it would allow the observer to easily yell for help if necessary. But that obviously needs to be rethought.
And some other less obvious equipment needs to be removed: the second bed in a 2-bed room should probably be temporarily moved. That can only hinder someone from attempting to rescue a patient who is trying to jump out of a window.
And since the patient often uses an object in the room to break the window, such as a chair or piece of medical equipment, care must be taken to make sure such objects are not in reach for a patient even for a very brief time. For example, if the observer needs to briefly leave the room perhaps the chair should be removed.
We’ve also discussed before the importance of adequate training for the personnel designated as observers. Most people assigned as observers on med/surg floors have never worked in behavioral health units or even worked with behavioral health patients. Often they are not even healthcare personnel (some hospitals have utilized security personnel as observers) and may not have been adequately trained to recognize red flags or trained in de-escalation techniques.
And don’t forget that intrahospital patient transports may also be vulnerable events. You’ve heard us talk on several occasions about the “Ticket to Ride” concept in which a formal checklist is completed for all transports (eg. to radiology). Such checklists typically contain information related to adequacy of any oxygen supplies and medications needed but should also include information about things like suicide risk and wandering/elopement risk. These all need to be conveyed to the caregiver who may be accepting the patient in the new area. Just as we’ve talked about cases where a patient may attempt suicide in a bathroom in the radiology suite that is not suicide-proofed, a patient at risk for wandering or elopement may wander off easily while waiting in the radiology suite if not appropriately supervised. We also hope that you’ve checked those bathrooms in radiology for loopables and other implements that might be used in a suicide attempt (see our March 16, 2010 Patient Safety Tip of the Week “A Patient Safety Scavenger Hunt”).
Staff on med/surg units, ICU’s and rehab units need to be aware of risk factors for wandering, elopement, suicide or other impulsive behavior just as much as staff on behavioral health units do. Doing risk assessments and ensuring that staff caring for at-risk patients are adequately trained in dealing with such patients is important. When high-risk patients are identified it is also important to ensure they are not left alone in rooms with windows that can be opened (or broken) by patients and appropriate environmental assessments done to minimize the chance a patient may harm him/herself.
Some of our prior columns on preventing hospital suicides:
See our previous columns on wandering, eloping, and missing patients:
References:
Pearson K. Investigation continues into man's death by jumping from Winter Haven hospital window. Girlfriend talked to him hours before, said he showed no signs of self-harm. The Ledger 2016; Published: Monday, April 25, 2016
http://www.theledger.com/article/20160425/news/160429648
Bay Bulletin. Port Elizabeth - Patient Dies After Jumping From Livingstone Hospital Window. Bay Bulletin 2016; December 28, 2016
https://thebaybulletin.blogspot.com/2016/12/port-elizabeth-patient-dies-after.html
Hutton A. Patient died after jumping from hospital window, inquest hears. Camden New Journal (UK) 2014; 14 February 2014
Jolly L. Vulnerable man, aged 80, dies after jumping through third-floor window at Paisley's Royal Alexandra Hospital. Daily Record (UK) 2016; 20 June 2016
http://www.dailyrecord.co.uk/news/local-news/vulnerable-man-aged-80-dies-8235725
Yorkshire Evening Post. Changes ordered following patient’s jump from Leeds hospital window. Yorkshire Evening Post (UK) 2016; 2 June 2014
http://www.yorkshireeveningpost.co.uk/news/health/changes-ordered-following-patient-s-jump-from-leeds-hospital-window-1-6646904
Associated Press. Patient jumps to her death from 11th story of Miami hospital.
StAugustine.com. April 8, 2002
http://staugustine.com/stories/040802/sta_627753.shtml#.WI4L1X_g884
CDPH (California Department of Public Health). Complaint Intake Number CA00397967; 2016
http://www.cdph.ca.gov/certlic/facilities/Documents/2567_ScrippsMercyHospital_IJAP_SanDiego.pdf
(suicidal patient in acute care setting)
Malloy T. Patient falls from window at Weston General Hospital after removing safety grill. SomersetLive 2016; August 12, 2016
VA Mental Health Environment of Care Checklist (MHEOCC).
http://www.patientsafety.va.gov/professionals/onthejob/mentalhealth.asp
Watts BV, Shiner B, Young-Xu Y, Mills PD. Sustained Effectiveness of the Mental Health Environment of Care Checklist to Decrease Inpatient Suicide. Psychiatric Services 2016; Published Online Ahead of Print: November 15, 2016
http://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201600080
Mills PD. Use of the Mental Health Environment of Care Checklist to Reduce the Rate of Inpatient Suicide in VHA. TIPS (Topics in Patient Safety) 2016; 16(3): 3-4 July/August/September 2016
http://www.patientsafety.va.gov/professionals/publications/newsletter.asp
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February 21, 2017
Alarm Fatigue in the ED
Ten years ago in one of our first columns we presented a case resulting in the death of a young patient in the emergency department (ED) because of alarm fatigue (see our April 2, 2007 Patient Safety Tip of the Week “More Alarm Issues”). In the investigation of that case we found that the volume of certain alarms were turned down, not just once but many times. In the root cause analysis of that case two major contributors were faulty ED design and an ED culture that had accepted turning down alarm volumes to avoid distraction. In both the literature and our own subsequent experiences we’ve encountered numerous instances where well intentioned healthcare workers have similarly turned off or volumed down alarms, putting patient safety at risk. While alarm fatigue is a complicated issue, site and equipment design and the culture of safety are only parts of the puzzle. The sheer volume of alarms is a major contributing factor and multiple studies have demonstrated that very large percentages of alarms are triggered for reasons that do not lead to any clinical intervention. So reducing unnecessary use of alarms is one of the key strategies to managing alarms and reducing alarm fatigue.
In our many discussions on alarm fatigue we have noted that a reduction in the number of patients unnecessarily on telemetry or cardiac monitoring is one of the best ways to reduce alarms and thereby reduce alarm fatigue (see our Patient Safety Tips of the Week for July 2, 2013 “Issues in Alarm Management” and August 16, 2016 “How Is Your Alarm Management Initiative Going?” for good summaries). We’ve noted the ACC/AHA Practice Standards for Electrocardiographic Monitoring in Hospital Settings (Drew 2004) and how adherence to those standards has helped many hospitals significantly reduce unnecessary use of telemetry.
Typically it is much harder to get physician buy-in into discontinuing telemetry or cardiac monitoring. We physicians often think “this will be an added measure of safety just in case…” We tend to think there is no downside to our own patient being continued on monitoring, without realizing the impact that unnecessary monitoring has in contributing to alarm fatigue which may adversely affect multiple other patients.
While much of our discussion on alarm fatigue has focused on inpatients and ICU patients, the ED (emergency department) is another area prone to alarm fatigue. Patients being evaluated for chest pain are commonly placed on cardiac monitors while they are being evaluated. In addition to contributing to alarm fatigue, unnecessary cardiac monitoring utilizes valuable resources that could be better used for other patients. Given that the incidence of arrhythmias is actually low in such patients, one group of clinical researchers developed a tool to help physicians determine which patients could have their cardiac monitoring discontinued in the ED (Gatien 2007). The Ottawa Chest Pain Cardiac Monitoring Rule is a very simple rule, based on only two parameters. It states that a patient (in the ED) with chest pain can be removed from cardiac monitoring on initial physician assessment if:
That clinical decision rule was developed from analysis of 992 consecutive chest pain patients were monitored in the ED, of whom 14% and 12% had myocardial infarction and unstable angina, respectively. There were only 17 patients (1.7%) with serious arrhythmias detected in the ED. The rule developed had 100% sensitivity for serious arrhythmias. The authors estimated that applying this rule would have allowed physicians to immediately remove 29% of patients from cardiac monitoring.
We have not seen widespread adoption of the decision rule in practice in ED’s. But now the same group of Canadian researchers has prospectively validated the tool (Syed 2017). A total of 1125 patients with chest pain seen in 2 busy ED’s in Ottawa, Ontario were enrolled in the study, 71% of whom were monitored during their ED stay. Only 15 (1.9%) had an arrhythmia within 8 hours that required intervention. The clinical decision rule detected all 15 for a sensitivity of 100% without missing any patients. Specificity was 36.4% but the negative predictive value was 100%. So their results were almost identical to those found in the original derivation study. The authors note that application of the decision rule would have allowed 36% of all such ED patients to have been removed from cardiac monitoring.
Remember, this rule applies to chest pain patients seen in the ED. It does not apply to patients in other settings, such as inpatient or ICU settings, or to ED patients with other problems. Note also that the rule does not determine which patients should initially be placed on cardiac monitoring. Rather, the rule applies to discontinuation of such monitoring. Also, it does not mean that such patients are ready for discharge from the ED. It simply means they can be moved to a non-monitored part of the ED, freeing up resources for other patients to use.
The authors cannot explain the inordinately long period between the derivation study and this validation study. Also, this current study was performed in the same hospital system that was used for the original study. So validation in other patient populations in other hospitals would be very helpful. So US hospitals – get with it! Do a multi-hospital validation study. Who could argue against a decision rule so simple to administer which has the opportunity to reduce unnecessary utilization of resources and reduce the risk of alarm fatigue?
The ED is relatively neglected in the literature on alarm fatigue. One particularly good article was in Patient Safety and Quality Healthcare by Kathryn Pelczarski of the ECRI Institute (Pelczarski 2013). While that article describes many of the elements we use in alarm management initiatives in general, it does a good job of pointing out some of the issues that are unique to the ED environment. One example is failure to put the bedside monitor in stand-by mode when the monitor is only being used for vital sign spot checks rather than continuous monitoring. Similarly, failure to put the bedside monitor in stand-by mode when ED patients go off to radiology or elsewhere for testing, as they commonly do. And many ED’s have to make use of stand-alone monitors rather than monitors connected to a central monitoring site. Many of these may be in more remote areas in which it is difficult to hear alarms or in isolation rooms where it is also difficult to hear the alarms. The article has good recommendations regarding alarm notification processes, designation of responsibility, and escalating response procedures.
We do have caveats on a couple of the recommendations in the Pelczarski article. One is the recommendation of moving non-networked monitors closer to the nurse’s station or centers of activity so the alarms can be better heard. That was actually a root cause in our 2007 column and several other cases we’ve seen (proximity to the nurse’s station or areas where physicians and nurses are busy writing notes or using computers led to workers turning down the volume of the alarms). Second, though we fully endorse use of technology (eg. pagers, messaging apps, etc.) to send alarm alerts to the people who need to respond, don’t assume nothing can go wrong (see our February 9, 2016 Patient Safety Tip of the Week “It was just a matter of time…”).
Our Patient Safety Tips of the Week for July 2, 2013 “Issues in Alarm Management” and August 16, 2016 “How Is Your Alarm Management Initiative Going?” are good places to start to get recommendations on alarm management.
Prior Patient Safety Tips of the Week pertaining to alarm-related issues:
References:
Drew BJ, Califf RM, Funk M, et al. Practice Standards for Electrocardiographic Monitoring in Hospital Settings. An American Heart Association Scientific Statement from the Councils on Cardiovascular Nursing, Clinical Cardiology, and Cardiovascular Disease in the Young: Endorsed by the International Society of Computerized Electrocardiology and the American Association of Critical-Care Nurses. Circulation 2004; 110: 2721-2746
http://circ.ahajournals.org/content/110/17/2721.short
correction January 25, 2005; Circulation 2005; 111: 378
http://circ.ahajournals.org/content/111/3/378.5
Gatien M, Perry JJ, Stiell IG, et al. A clinical decision rule to identify which chest pain patients can safely be removed from cardiac monitoring in the emergency department. Ann Emerg Med 2007; 50: 136-143
http://www.annemergmed.com/article/S0196-0644(07)00160-6/pdf
Syed S, Gatien M, Perry JJ, et al. Prospective validation of a clinical decision rule to identify patients presenting to the emergency department with chest pain who can safely be removed from cardiac monitoring. CMAJ 2017; doi: 10.1503/cmaj.160742, published 30 January 2017
http://www.cmaj.ca/content/189/4/E139
Pelczarski KM. Addressing Alarm Problems in the Emergency Department. Patient Safety & Quality Healthcare 2013; May/June 2013
http://www.psqh.com/analysis/addressing-alarm-problems-in-the-emergency-department/
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February 28, 2017
The Copy and Paste ETTO
Our September 15, 2009 Patient Safety Tip of the Week “ETTO’s: Efficiency-Thoroughness Trade-Offs” discussed efficiency-thoroughness trade-offs or ETTO’s. That concept, best associated with Erik Hollnagel (Hollnagel 2009), is well known to everyone in the human factors and safety fields. Basically, the ETTO concept means there are certain procedures and practices that we do which make our work more efficient but at the risk we may compromise thoroughness or safety. Hollnagel, in his book, notes that such things usually go right but occasionally go wrong. A classic example of an ETTO is the “copy and paste” function that we all know well from our word processors and spread sheets. Copy and paste functionality is also widely used in electronic medical records. It allows us to easily input a large amount of text, images, etc. into one part of an EHR without having to type in all the details. This can be a huge timesaver.
But there are times when “copy and paste” can go wrong. For example, we might only copy part of a patient’s medication list, inadvertently leaving off some important medications. (That’s particularly a problem when the medication list is long and may span more than one computer screen or is otherwise truncated). Or we may copy information that is no longer accurate, such as copying an old medication list and not amending it to account for medications since discontinued or those added or those whose dose has been adjusted.
There are also instances where an inaccurate piece of information may get deleted (or more properly amended with appropriate attribution) from the medical record but someone copies and pastes that item from a prior part of the medical record, thus perpetuating the erroneous information. A good example is when the record says a patient is allergic to a certain antibiotic but that later gets amended when a physician realizes there was no true allergy. If the original note noting the “allergy” gets copied and pasted, the patient may be deprived of a most appropriate antibiotic in the future.
And in our many articles on wrong patient/patient identification errors we’ve noted that information sometimes gets copied from the chart of one patient inadvertently into the chart of a different patient.
In 2015 two significant studies highlighted the problems associated with “cut and paste”. A National Institute of Standards and Technology (NIST) study (Lowry 2015) showed that the integrity of information in EHR’s is frequently compromised by how data is used and reused, with “copy and paste” being a major contributor. The second was a comprehensive review of the practice by the ECRI Institute (ECRI 2015). A follow up report from NIST is now available (Lowry 2017).
The ECRI study (ECRI 2015) did a nice job of trying to determine the frequency of copy and paste in the EHR. They note that reported rates vary depending upon the definitions used, the venue, and the method used to detect copy and paste (eg. self-report, chart review, direct observation, etc.). You can get all the details in the ECRI study but a good example is the self-reported frequency found in a study by O’Donnell and colleagues (O'Donnell 2009). They found that 90% of physicians surveyed using an EHR for inpatient documentation used copy/paste to write daily progress notes, and 78% identified themselves as high-frequency users. 81% of copy/paste users frequently copied notes authored by other physicians and 72% copied notes from prior admissions.
The ECRI study also found that nearly all aspects of the medical note have been subject to copy/paste, including chief complaint, history of present illness, past medical history, review of systems, physical exam, medications, lab and radiology results, assessment, plan, etc.
The ECRI study noted there is a paucity of studies documenting the adverse consequences of copy/paste. Most of the examples of adverse outcomes are in individual case studies. They do note that the large study of electronic medical records at the VA (Singh 2013) noted substantial errors related to copy/paste but did not provide details (as discussed in our March 2013 What's New in the Patient Safety World column “Diagnostic Error in Primary Care”).
The ECRI study also noted prior attempts to categorize the risk level of the various copy/paste events. One study (Thielke 2007) gave as an example of “high risk” copying notes from another physician or copying notes greater than 6 months old. A “moderate risk” example was copying from oneself 1 to 6 months prior and a “lesser risk” example was copying from oneself from <1 month prior. In the Thielke study 55% of copy/paste events were in the highest risk category, and 18% and 27% in the moderate and lesser risk categories, respectively. Other studies categorized by whether a full note was copied, whether minor changes were made, or substantial changes made.
The ECRI study also noted that many, if not most, physicians recognize that errors might be made through copy/pasted. The O’Donnell study had found that 25% agreed that copy/paste makes progress notes more likely to lead to a mistake in patient care but only 3% reported committing an error related to confusion caused by a note with copy/pasted text. Physicians also agreed that frequent copy/pasting can result in notes that are less accurate, lengthier, and less organized and felt copy/paste facilitated generation of progress notes that were more likely to contain outdated or inconsistent information. However, in keeping with the concept of ETTO’s, O’Donnell’s study also noted that copy/paste had important benefits like a “more trustworthy” medical note, improved documentation of the patient’s hospital course, documentation for legal purposes, and documentation for billing.
Much as we have seen, the ECRI study noted four problems for the medical chart:
The ECRI study also noted the following factors that contribute to problems related to copy/paste:
The ECRI study has numerous recommendations. Responsibilities for the authors of medical record notes should:
Some items that should not be copied include medical student notes or the history of present illness. Also not to be copied from another provider’s notes are history of present illness, review of systems, physical examination, assessment, and plan. But some sections such as past medical history, family history, and social history might be amenable to a “copy-forward” approach with modifications after the author confirmed the accuracy with the patient.
The ECRI study also has numerous recommendations for those who design EHR’s.
With the ECRI study (ECRI 2015) and the first NIST study (Lowry 2015) as background, a follow up report from NIST was just published (Lowry 2017). The researchers in the current study collected data while observing clinicians (nurses and physicians) interacting with the EHR during their routine tasks and then follow-up interviews were conducted. Specifically, they looked at how practices met with four ECRI recommendations:
The current NIST report focused on improving EHR systems with the intent of:
The NIST report recommends that a mechanism for copy/paste should be available in the EHR but that there should be a mechanism where the material to be copied should be visually enhanced so that the copier does not inadvertently copy only part of the information, leaving key information uncopied. There should be a mechanism facilitating verification that “the copied information was read consciously and edited by the clinical provider which would promote the attribution of the source of the information.” Moreover, there should be a display of the “chain of custody” of the information, providing appropriate attribution.
They recommend certain elements be prevented from being copied: demographic information, dates, and any information should be blocked from entry into a blood bank information system. Demographic data should be autopopulated by the EHR and copying demographic information from one chart to another should never be allowed.
The report also has some recommendations about vital sign documentation, including date and time stamping of not only when the vital signs were taken and recorded but also when it was signed, revised and retrieved. (They also recommend including how the vital signs were taken.) Allergies can be copied and pasted but should have a clear “chain of custody” for attribution. They recommend that ensuring that surgical notes be copied in toto since context might be lost if only part of a note is copied.
The report notes that copying a medication list may actually be preferable to using drop down menus (because of the known vulnerabilities to inaccurate selection from drop down lists). But it specifies that copy/paste should never be allowed for ordering new medications (so that the provider is forced to consciously think about the order). And any copied medications should have a clear “chain of custody” for attribution.
They note that the discharge summary is one place where copy/paste can improve efficiency but stress the need for a “chain of custody” for attribution.
And then a point we have stressed over and over: there must be a mechanism to ensure a provider using copy/paste between two systems (eg. copying information from a radiology system into an EHR) the “EHR system must keep the clinician oriented as to which patient’s record they are accessing at any given point in the process”, again with a clear “chain of custody”.
Regarding the recommendation to “Ensure adequate staff training and education regarding the appropriate and safe use of ‘copy and paste’” the current NIST study confirmed the importance of training for copy and paste functionality, noting that training raised awareness of the error-prone nature of copy/paste. Moreover, they found during task performance that participants learned instructions better by watching an instructional video than reading printed material.
And don’t forget that the electronic medical record is not the only healthcare IT system vulnerable to copy and paste errors. In our June 17, 2008 Patient Safety Tip of the Week “Technology Workarounds Defeat Safety Intent” we noted that in our very first barcoding implementation we saw an instance where the label on the medication could not scanned so the nurse simply cut and pasted the bar code information from the computer, totally bypassing the safety feature of a barcoding system!
And in our April 15, 2014 Patient Safety Tip of the Week “Specimen Identification Mixups” we also noted the caveat in laboratory information systems to never allow two patient records to be open at the same time so that copy/paste can never get a report into the wrong chart.
Copy and paste is a great computer tool. We couldn’t do Patient Safety Tip of the Week without it, since we often copy information from previous columns. But if we are not careful, mistakes will occur. Whenever we copy information we have to consciously verify the accuracy of all the copied information. For example, links to other columns or to our references may have expired or changed so we have to verify the current links.
So “copy and paste” and healthcare IT in general are classical ETTO’s. Technology has greatly changed the way we practice medicine and in most respects these changes have been very positive. Nevertheless, technology introduces its own set of unanticipated consequences and errors so we need to remain vigilant at all times and try to design our information systems to anticipate, mitigate, and minimize errors.
See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:
References:
Hollnagel E. The ETTO Principle: Efficiency-Thoroughness Trade-Off. Why Things That Go Right Sometimes Go Wrong. Burlington, VT: Ashgate Publishing Company, 2009
Lowry SZ, Ramaiah M, Patterson ES, et al. NISTIR 7804-1. Technical Evaluation, Testing, and Validation of the Usability of Electronic Health Records: Empirically Based Use Cases for Validating Safety-Enhanced Usability and Guidelines for Standardization. National Institute of Standards and Technology 2015; October 2015
http://nvlpubs.nist.gov/nistpubs/ir/2015/NIST.IR.7804-1.pdf
ECRI Institute. Copy/Paste: Prevalence, Problems, and Best Practices. Health Technology Assessment Information Service Special Report. ECRI Institute 2015; October 2015
https://www.ecri.org/Resources/HIT/HTAIS_Copy_Paste_Report.pdf
Lowry SZ, Ramaiah M, Prettyman SS, et al. NISTIR 8166. Examining the ‘Copy and Paste’ Function in the Use of Electronic Health Records. National Institute of Standards and Technology. January 2017
http://nvlpubs.nist.gov/nistpubs/ir/2017/NIST.IR.8166.pdf
O'Donnell HC, Kaushal R, Barron Y, et al. Physicians' attitudes towards copy and
pasting in electronic note writing. J Gen Intern Med 2009; 24(1): 63-68
http://link.springer.com/article/10.1007%2Fs11606-008-0843-2
Singh H, Giardina TD, Meyer AND, et al. Types and Origins of Diagnostic Errors in Primary Care Settings. JAMA Intern Med 2013; 173(6): 418-425 published online February 25, 2013
http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1656540
Thielke S, Hammond K, Helbig S. Copying and pasting of examinations within the electronic medical record. Int J Med Inform 2007; 76(Suppl 1): S122-128.
http://www.ijmijournal.com/article/S1386-5056(06)00166-3/abstract
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March 7, 2017
Nested Interruptions
Interruptions and distractions are significant factors contributing to errors in any industry and in patient safety events in healthcare (as well as unintended events in your everyday life!). Our multiple columns on the scope and impact of interruptions and distractions in healthcare are listed at the end of today’s column.
Recovery from interruptions requires keeping in your short-term memory several things:
Previous research also shows that study participants were always slower to resume the primary task when they were interrupted during the middle of a subtask than when interrupted between subtasks (Monk 2004).
But one concept we’ve never discussed is that of “nested” interruptions. Workers in multiple industries are often interrupted during a task, move on to another task, and then get interrupted again. They thus have to remember where they left off in not just one task but in several tasks. This obviously leads to vulnerability to errors. While we often tout our ability to multitask as a positive talent that improves our efficiency, that multitasking also makes us more prone to make errors. Unintended consequences of interruptions include not only making errors but also performing redundant work.
Human factors researchers have delved into how interruptions impact various task performances. A recent study showed that the scope of interruptions and distractions is even more complicated (Sasangohar 2017). These researchers noted that ICU nurses are often interrupted from one task to perform another task and that interruptions in the second task are also frequent. That results in nurses having to resume not just one task where they left off but having to resume multiple tasks at varying stages of completion, a classic example of “nested” interruptions.
They hypothesized “that nested interruptions tax the working memory even more than just performing multiple secondary tasks sequentially because the nurse would have to encode in working memory the resumption goals for both the primary and the interrupted secondary tasks”. So they performed a laboratory study with 30 ICU nurses performing an electronic order-entry task under three interruption conditions:
Their results confirmed that the nested interruptions resulted in significantly longer primary-task resumption lag and less accurate task resumption compared with both the serial interruption and baseline conditions.
While a primary goal should be to minimize interruptions and distractions, we need to recognize that some interruptions may be unavoidable (and some even positive) and take steps to mitigate the impact of such interruptions on tasks. And we clearly need ways to recognize all the tasks needing completion, not just the one most recently interrupted.
One such mechanism for mitigation is use of technology to help us return to our previous task(s). As we write this column we are often interrupted by numerous external sources (phone calls, comments from others, etc.) and internal sources (other topics popping up, coffee or bathroom breaks, etc.). For example, we may suddenly think about something we want to include in a separate column on a related or even different topic. We jump to that other draft column but then have to return to the original column. Thank goodness we usually have a blinking cursor that helps reorient us to where we had left off! And some word processors allow you to re-open a saved document to the location you had most recently left off when saving that document. And if we are really meticulous, we’ll leave a bookmark of some sort to redirect us to where we left off. But even using these technological tools to help mitigate the impact of interruptions there is often a cascade of events (just as we see in virtually all serious patient safety events) that can lead to unwanted consequences. For example, a power failure can in seconds overcome all those safety barriers you just put in place.
So why not use technology to mitigate the impact of interruptions in healthcare? For example, virtually all EHR’s (electronic health records) and CPOE (computerized physician order entry) or e-prescribing or related IT systems have automatic time out protocols built in. That means that after x minutes of inactivity the user is automatically logged out. The technology exists that would allow for a text message to be sent to the user at the time of automatic time out indicating that some activity may have gone unfinished and then put that user on the appropriate screen once they log back in.
Such use of technology might well be beneficial in reducing interruption-related errors related to computerized functions. But what about other tasks? Nurses already utilize a number of behavioral mechanisms to mitigate the impact of interruptions. An excellent 2010 observational study of ICU nurses (Grundgeiger 2010), using a mobile eye tracker to measure the task resumption lag and other parameters, found that in 37.6% of all interruptions, nurses used a behavioral strategy to reduce or avoid individual prospective memory demands. For example, nurses sometimes decided to finish primary tasks before attending to the interrupting task. In other instances, nurses used artifacts such as syringes, cables, equipment for blood samples, or blood gas analysis result sheets in their hands while attending to the interrupting task (the artifacts being part of the primary task that needed to be resumed). And sometimes nurses placed reminders in an obvious position to help them resume the interrupted primary task later, such as putting utensils to take a blood sample on the medication desk. They also observed some general strategies nurses used to remind themselves about forgotten interrupted tasks. Examples include scanning the top of the bed area while washing hands, looking at places where artifacts are generally placed, accessing the clinical information system, or writing paper notes.
Their data suggests that nurses remembered documentation tasks more frequently than expected without applying a behavioral strategy and less frequently by holding an artifact but if medication tasks or cleaning up tasks were interrupted, a task artifact was held in the hand while serving the interruption more frequently than expected.
Some other factors were related to lags in resumption of tasks. Length of the interruption had a significant positive correlation with resumption lags (longer interruptions result in longer resumption times). And context cues were important. It was anticipated that if an interrupting task required the nurse to change location and leave the context in which the goal was encoded, resumption lags would increase because the contextual cues are missing. Indeed, they found that such change of context had a significant effect on resumption times, likely because “the context change may have changed environmental cues, which in turn may have triggered retrieval of task demands other than the to-be resumed task, causing longer resumption times”.
Another study by Sasangohar and colleagues (Sasangohar 2015) found that ICU nurses spent about 50% of their time conducting medium-severity tasks (e.g., documentation), 35% conducting high-severity tasks (e.g., procedure), and 14% conducting low-severity tasks (e.g., general care). They found that the rate of interruptions with personal content observed during low-severity tasks was higher than the rate during high- and medium-severity tasks, suggesting that interrupters might have evaluated task severity before interrupting. The authors propose that increasing the transparency of the nature and severity of the task being performed may help others further modulate when and how they interrupt a nurse and that, rather than try to eliminate all interruptions, mitigation strategies should consider the relevance of interruptions to a task or patient as well as their urgency.
There is one such high-severity task for which such transparency is often already used: medication administration. The nursing activity perhaps most studied with regard to interruptions is medication administration and there have been multiple studies aimed at reducing such interruptions during medication administration. A recent study in a large teaching hospital in Australia looked at the impact of a ‘Do not interrupt’ bundled intervention to reduce non-medication-related interruptions to nurses during medication administration (Westbrook 2017).
The Westbrook study confirmed a very high rate of interruptions during medication administration. At baseline, they found a rate of 57 interruptions for every 100 medication administrations and 87.9% of the interruptions were not related to medication administration. The majority of the interruptions were from other nurses and pertained to other patients. Interestingly, requests from patients and social interruptions each accounted for only about 10% of interruptions.
The bundled intervention in the Westrbrook study consisted of:
Results of the intervention showed modest reductions in interruption rates. The average rate of interruptions was reduced from 56/100 to 38/100 administrations on the intervention units compared with little change on the control units. Most of the reduction was from reducing interruptions from other nurses. There was no change in interruptions from patients.
The study did not report medication error rates. However, it used data from other studies to extrapolate the potential reduction in medication administration errors and estimated that rate as 1.8%. They noted that compared unfavorably to the literature reduction in medication errors of 14% by implementation of an electronic medication administration record.
The post-intervention survey of nurses was particularly telling. While most nurses recognized the importance of interruptions on medication errors, a surprising number expressed their opinion they did not think the intervention should continue. Many noted that donning and wearing the vest was cumbersome and led to longer durations for medication administration.
As we’ve noted before, it is not enough to simply use a reduction in interruptions as the primary outcome measure in such studies. And it’s not even enough to measure reductions in medication errors as the only outcome. We must measure other patient safety outcomes as well. That is because not all interruptions have negative impacts. Clearly some interruptions are important and have a positive impact on patient safety. In the Westbrook study the majority of interruptions were by other nurses and pertained to questions about other patients. Presumably, some of those interruptions would be expected to have had a positive impact on those other patients.
In our November 8, 2016 Patient Safety Tip of the Week “Managing Distractions and Interruptions” we noted a study which sought to help differentiate the “good” interruptions from the “bad” ones (Myers 2016). They found that, on average, nurses were interrupted every 11 min, with 20.3% of their workload triggered by interruptions. Those figures are comparable to most other studies on nursing interruptions. They then developed a statistical model which showed that alarms and call lights returning nurses’ attention to the patient outside the patient room are beneficial, while interruptions in the patient room are generally detrimental. Beneficial interruptions are those that return the nurse’s focus to the patient and those supporting patient-clinician and clinician-clinician communications. A previous study by Sasangohar and colleagues also identified the inconsistencies in the way interruptions are defined and categorized potential sources of negative and positive interruptions (Sasangohar 2012).
Our November 8, 2016 Patient Safety Tip of the Week “Managing Distractions and Interruptions” summarized many of the interventions that have been implemented to minimize or mitigate impact of interruptions and distractions. And we again refer you back to the article by Flynn et al (Flynn 2016) that did an excellent job of summarizing the literature on interruptions and their impact on medication administration and chronicling those interventions which are evidence-based.
Prior Patient Safety Tips of the Week dealing with interruptions and distractions:
References:
Monk CA, Boehm-Davis DA, Trafton, JG. Recovering from interruptions: Implications for driver distraction research. Human Factors 2004; 46: 650-663
https://www.interruptions.net/literature/Monk-HF04.pdf
Sasangohar F, Donmez B, Easty AC, Trbovich PL. Effects of Nested Interruptions on Task Resumption. A Laboratory Study with Intensive Care Nurses. Human Factors: The Journal of the Human Factors and Ergonomics Society 2017; First Published January 27, 2017
http://journals.sagepub.com/doi/abs/10.1177/0018720816689513?journalCode=hfsa
Grundgeiger T, Sanderson P, MacDougall HG, Venkatesh B. Interruption Management in the Intensive Care Unit: Predicting Resumption Times and Assessing Distributed Support. Journal of Experimental Psychology: Applied 2010; 16(4): 317-334
https://interruptions.net/literature/Grundgeiger-JEPA10.pdf
Sasangohar F, Donmez B, Easty AC, Trbovich PL. The relationship between interruption content and interrupted task severity in intensive care nursing: An observational study. International Journal of Nursing Studies 2015; 52: 1573-1581
http://www.journalofnursingstudies.com/article/S0020-7489(15)00196-0/abstract
Westbrook JI, Li L, Hooper TD, et al. Effectiveness of a ‘Do not interrupt’ bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study. BMJ Qual Saf 2017; 0: 1-9 published online first 23 February 2017
http://qualitysafety.bmj.com/content/early/2017/02/23/bmjqs-2016-006123
Myers RA, McCarthy MC, Whitlatch A, Parikh PJ. Differentiating between detrimental and beneficial interruptions: a mixed-methods study. BMJ Qual Saf 2016; 25: 881-888 Published Online First: 16 November 2015
http://qualitysafety.bmj.com/content/25/11/881
Sasangohar F, Donmez B, Trbovich P, Easty AC, Not all interruptions are created equal: Positive interruptions in healthcare. In Proceedings of the Human Factors and Ergonomics Society 56th Annual Meeting (pp. 824-828). Santa Monica, CA: Human Factors and Ergonomics Society 2012
http://journals.sagepub.com/doi/10.1177/1071181312561172
Flynn F, Evanish JQ, Fernald JM, et al. Progressive Care Nurses Improving Patient Safety by Limiting Interruptions During Medication Administration. Crit Care Nurse 2016; 36: 19-35
http://ccn.aacnjournals.org/content/36/4/19.full.pdf+html
Print “Nested Interruptions”
March 14, 2017
More on Falls on Inpatient Psychiatry
It’s been somewhat surprising to us that one of our most frequently accessed columns was our January 15, 2013 Patient Safety Tip of the Week “Falls on Inpatient Psychiatry”. Then again, maybe it should not be so surprising since there has been so little written in the literature about this topic.
Some studies have reported higher fall rates on behavioral health units compared to med/surg units and others have reported lower rates, but several studies have shown that falls on behavioral health units may be more likely to lead to injury. The VHA National Falls Data Collection Project demonstrated that overall fall rates were lower on behavioral health units but percentages of falls with injury were higher on those units (Stalhandske 2008). The Pennsylvania Patient Safety Authority “snapshot” that we highlighted in our prior column compared falls in behavioral health hospitals to those in 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).
Most of the work on prevention of falls has focused on healthcare venues other than inpatient psychiatry. And most of the tools developed to assess fall risk were also developed for patient populations other than inpatient psychiatric populations. In our January 15, 2013 Patient Safety Tip of the Week “Falls on Inpatient Psychiatry” we described the work of Edmonson and colleagues (Edmonson 2011) who 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.
In 2016, Abraham looked at the applicability of several fall risk assessment tools to psychiatry inpatient services (Abraham 2016). Tools included were:
Abraham concluded that no perfect instrument exists but that the best fall risk assessment tools for psychiatric adult and geriatric patients based on his research are the Wilson Sims and the Edmonson scales. He further pointed out that the major difference between these two is inclusion of nurse’s judgment in the Wilson Sims scale. We concur with his opinion that the clinical judgment of an experienced professional is often as good as the results from a fall prediction tool.
A more recent study (Bugajski 2017) compared its homegrown tool, the Baptist Health High-Risk Falls Assessement (BHHRFA), to published results of the EPFRAT and the Wilson Sims Fall Risk Assessment Tool (WSFRAT). The BHHRFA was developed as a tool to assess fall risk across clinical settings in the Bapstist Health system (Kentucky) because of perceived deficiencies in some of the existing fall risk prediction or assessment tools (Corley 2014). It was found to have good sensitivity, reasonable specificity, and good diagnostic odds ratios across hospitals but primarily in med/surg patients. So Bugajski and colleagues applied it to psychiatric inpatients and found that had a higher sensitivity (0.68) than the other psychiatric specific assessments, an acceptable specificity (0.70), and a strong diagnostic odds ratio (4.964). The authors felt that the medication profiles considered in the BHHRFA might be more relevant to behavioral health compared to those in the other 2 tools. Importantly, the BHHRFA takes nurses only 38 seconds, on average, to administer.
But there is a problem with all fall risk assessments that use a “score” to identify patients at high risk. 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?”. While labeling a patient as “high risk” could justify some of the general fall prevention interventions you might consider on a psychiatric inpatient unit (eg. non-slip footwear, beds low to the ground, bedside mats, etc.) it doesn’t really pick out those who need more specific individualized interventions to prevent falls.
So what are some of the more individual risk factors for falls encountered in behavioral health or psychiatric inpatients?
Physical Activity
One obvious factor is simply the level of physical activity and movement 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. Another study (Al-Khatib 2013) attributed falls to behavioral issues more often (around 40%) than medical (around 30%) or environmental (around 12%) or other issues. About a third of their falls occurred while the patient was ambulating (observed), in 20% the patient was found on the floor, and about 15% on toileting activities.
Primary Psychiatric Diagnosis
Primary psychiatric diagnosis may play a role both with regard to the diagnosis and the treatment for that diagnosis. Depression is a risk factor for falls, at least in the elderly. One meta-analysis 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 meta-analysis 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 physical 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.
And the patient’s primary psychiatric problem may interfere with their ability to comprehend instructions about avoiding activities that may precipitate falls.
Sleep disturbances
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.
Medications
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. Medications in several of those categories may cause drowsiness, which is a significant risk factor for falls. Many also cause orthostatic hypotension. And several cause extrapyramidal (parkinsonian) side effects that impair mobility and impair balance or ability to recover from loss of balance. Anticholinergic side effects of several may also lead to visual impairment, another fall risk factor. And the anticholinergic side effects may also lead to dry mouth which, in turn, may lead to polydipsia and polyuria (you’ll recall falls are especially prevalent during toileting activities in many settings). Lastly, several of the medications may potentially have cardiac side effects which can lead to falls during syncope.
Medical Conditions
While patients on behavioral health, in general, are probably younger than those on med/surg units, they can still have multiple medical comorbidities that may predispose them to falls. 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.
Previous History of Falls
One of the strongest predictors of falls, regardless of setting, is a history of prior falls. Inpatient psychiatry patients are no different.
Toileting Activities
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. As above, 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.
Age
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.
But there are also non-patient factors that predispose to falls. These include environmental factors and inadequate communication.
Environmental Risk Factors
Environmental factors like poor lighting, slippery floors, uneven surfaces, loose floor tiles, etc. may predispose to falls. Behavioral health units must remove items that could be used for suicide so some items that can help prevent falls (eg. grab bars in bathrooms or showers, height-adjustable beds with electrical cords) may not be available.
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). One of their recommendations is assessing the environmental risks, using a checklist.
Time of Day
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).
Communication/Handoff Failures
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.
Equipment Issues
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. And even some of the walking assist devices may be banned from behavioral health units because they could be used as “weapons”. We don’t have good advice on resolving this dilemma.
Likewise, there is a paucity of literature on actual interventions implemented to prevent falls on behavioral health units or to mitigate their consequences. In our December 3, 2013 Patient Safety Tip of the Week “Reducing Harm from Falls on Inpatient Psychiatry” we highlighted a VA collaborative project (Quigley 2014) which addressed prevention of falls and fall-related injuries on psychiatry/behavioral health units. This VA collaborative project looked at evidence-based interventions for fall prevention and injury prevention and modified the interventions for inpatient psychiatry. Many of their interventions came from the VA NCPS Falls Toolkit, a compendium of useful references, resources, presentations, posters, and spreadsheets that were culled from existing research and the Falls Collaborative. Ultimately they recommended each of the following across all their participating sites:
Another study reported what one primarily behavioral health, urban teaching hospital did to reduce fall rates (Al-Khatib 2013). They used the Morse Fall Scale for fall risk assessment and developed treatment plan templates for those patients classified as low- or high-fall risk. For patients deemed at high-risk for falls they placed a yellow identification band on the patient, dispenses yellow non-skid slipper socks, and used yellow dots on patient charts, communication boards, outside patient rooms, and in the medication book. They also developed educational tools for patients and their families to be used on admission and discharge.
One important piece of the program (and one which we have often expounded upon in our numerous columns on fall prevention) was development of a post-fall documentation tool. They attributed the success of their program to use of this tool and discussion of fall events in treatment team meetings, leading to changes in the individualized care plans. Interestingly, they attributed falls to behavioral issues more often (around 40%) than medical (around 30%) or environmental (around 12%) or other issues. And, surprisingly, only about 8% were attributed primarily to medications. About a third of their falls occurred while the patient was ambulating (observed), in 20% the patient was found on the floor, and about 15% on toileting activities.
After the initial improvement in fall rate there was a second increase in fall rate. Using prn haloperidol and lorazepam injections as a proxy measure for patient acuity, they attributed this increase in the fall rate to the increased patient acuity.
Another point is worth mentioning. They often received requests to reduce a patient’s fall risk status from high risk to low risk. So they developed a “justification” form to provide a rationale that would support such a downgrade in fall risk status. In our January 15, 2013 Patient Safety Tip of the Week “Falls on Inpatient Psychiatry” that Estrin and colleagues (Estrin 2009) found 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?”.
One criticism we’ve had of most fall risk assessment tools is that they tend to trigger global interventions rather than focusing on interventions for the key risks for falling. For example, the interventions for drug-induced orthostatic hypotension are different than those for drug-induced extrapyramidal syndromes. Tools that just use a score to identify patients at high risk for falls are of limited utility.
The other critical point is that fall risk assessment needs to be updated frequently. On med/surg units fall risk should be reviewed and updated daily or any time there is any change (such as addition of a new medication, surgery, anesthesia, etc.). On inpatient psychiatry units it is important to regularly update the fall risk assessment even if no such changes have taken place. The primary reason for that is that the extrapyramidal (parkinsonian) side effects of many of the medications used are not immediate when such medications are started but develop more gradually. It is really essential, then, that the patient be assessed daily for such extrapyramidal side effects by someone qualified to recognize them. Similarly, monitoring for orthostatic hypotension needs to be done daily if a patient is on one of the drugs that may have orthostatic hypotension as a side effect (and please see our January 15, 2013 Patient Safety Tip of the Week “Falls on Inpatient Psychiatry” for the correct way to check for orthostatic hypotension).
To summarize key action points:
Some of our prior columns related to falls:
References:
Stalhandske E, Mills P, Quigley P, et al. VHA’s National Falls Collaborative and Prevention Programs. In Henriksen K, Battles JB, Keyes MA, Grady ML (eds.) Advances in Patient Safety: New Directions and Alternative Approaches. Volume 2. Culture and Redesign. AHRQ 2008
http://www.ncbi.nlm.nih.gov/books/NBK43724/pdf/advances-stalhandske2_70.pdf
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
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).
Abraham S. Looking for a Psychiatric Fall Risk Assessment Tool. Ann Psychiatry Ment Health 2016; 4(2): 1061
https://www.jscimedcentral.com/Psychiatry/psychiatry-4-1061.pdf
Bugajski A, Lengerich A, McCowan D, et al. The Baptist Health High-Risk Falls Assessment: One Assessment Fits All. J Nurs Care Qual 2017; 32(2): 114-119
Corley D, Brockopp D, McCowan D, et al. The Baptist Health High Risk Falls Assessment. A Methodological Study. J Nurs Admin 2014; 44(5): 263-269
Scanlan J, Wheatley J, McIntosh S. Characteristics of falls in inpatient psychiatric units. Australas Psychiatry 2012; 20(4): 305-308
http://journals.sagepub.com/doi/abs/10.1177/1039856212455250
Al-Khatib Y, Arnold P, Brautigam L, et al. Prevention Strategies to Reduce Falls in Psychiatric Settings. Journal of Psychosocial Nursing and Mental Health Services 2013; 51(5): 28-34
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; 21(5): 484-492
http://www.ajgponline.org/article/S1064-7481(13)00013-4/fulltext
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
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
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/doi/full/10.1176/ps.2009.60.9.1245
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
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
Quigley PA, Barnett SD, Bulat T, et al. Reducing Falls and Fall-Related Injuries in Mental Health: A 1-Year Multihospital Falls Collaborative. J Nurs Care Qual 2014; 29(1): 51-59
NCPS Falls Toolkit. VA National Center for Patient Safety. updated July 2014
http://www.patientsafety.va.gov/professionals/onthejob/falls.asp
Print “More on Falls on Inpatient Psychiatry”
March 21, 2017
Success at Preventing Delirium
Our many columns on delirium have stressed the importance of prevention, since treatment of delirium is difficult. Two of the most common settings in which we see delirium are the ICU and the postoperative setting.
We’ve frequently mentioned multi-component non-pharmacological interventions such as HELP, the Hospital Elder Life Program (see our October 21, 2008 Patient Safety Tip of the Week “Preventing Delirium” and our September 2011 What's New in the Patient Safety World column “Modified HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery”) or tools like the ABCDEF Bundle (see our September 20, 2016 Patient Safety Tip of the Week “Downloadable ABCDEF Bundle Toolkits for Delirium”).
Another recent study examined the impact of a delirium prevention bundle (DPB) on ICU patients (Smith and Grami 2017). Bundle components were similar to many from the above mentioned bundles and included sedation cessation, pain management, sensory stimulation, early mobilization, and sleep promotion. The bundle was implemented on one ICU and another ICU with comparable patients served as the control. Nurses assessed patients with the CAM-ICU and RASS tools that we’ve described in multiple columns.
For those patients on mechanical ventilation a spontaneous awakening trial, if successful, was followed by a spontaneous breathing trial. The sensory stimulation included not only placing familiar objects (clock, calendar) nearby but also opening/closing window blinds to create diurnal variation, and wearing any devices (hearing aids, glasses) that a patient would wear at home. Mobilization was tailored to the physical capabilities of the patient and ranged from range-of-motion exercises to actual ambulation. Sleep was promoted by clustering nursing interventions in a manner to avoid waking the patient as much as possible, dimming lights and closing blinds, and minimizing ambient noise.
The odds of delirium were reduced by 78% on the intervention unit compared to the control unit.
But perhaps the biggest contribution of the study is the description of the difficulties encountered in delivering the delirium prevention bundle. Implementing a bundle like this is not easy. Smith and Grami point out that barriers were encountered with almost every facet of the multicomponent intervention. For example, families were often reluctant to bring in the patients’ hearing aids or glasses for fear of these items getting lost. And not all physicians were using the sedation cessation protocol. And the sleep promotion was less than satisfactory because of lights and sound in the ICU. And the early mobilization program suffered from lack of staff and equipment plus the “incongruity” between physical therapy and more aggressive mobilization guidelines. And some details about the pain management were missing (their intended data collection included information about not just pain levels but also pain medication doses and times and pain scores one hour following administration).
So it’s pretty remarkable that they were still able to demonstrate a 78% reduction in delirium. But it really demonstrates that a predominantly nurse-led intervention bundle can have a significant impact on preventing this serious complication. Kudos to the dedication of that nursing staff for their persistence in doing the right thing!
Postoperative delirium is the other very problematic entity that needs prevention. Our December 2014 What's New in the Patient Safety World column “American Geriatrics Society Guideline on Postoperative Delirium in Older Adults” discussed the work done by the American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. They developed a clinical practice guideline (AGS 2015a) that was followed by a best practice statement published in the Journal of the American College of Surgeons (AGS 2015b). The guideline describes the nonpharmacologic prevention and treatment of postoperative delirium. It recommends that hospitals and healthcare systems have educational programs with frequent refresher sessions on delirium. It recommends that an interdisciplinary team implement a multicomponent nonpharmacologic intervention program.and follow that patient throughout the hospital course. It notes such interventions have reduced the incidence of delirium 30-40%. It also describes the medical evaluation that should be undertaken once a patient is diagnosed as having delirium. It notes again that multicomponent interventions have been successful in reducing delirium duration and severity, length of stay, etc. but that it is not possible to conclude which specific component(s) are responsible.
So the results of a recent survey of anesthesiologists who were attendees of the 16th World Congress of Anaesthesiologists in Hong Kong last year were somewhat bothersome (Agres 2017). Though the vast majority of respondents acknowledged they frequently or occasionally encountered postoperative delirium, 77% lacked a process to screen for at-risk patients. Moreover, 84% said their hospital or clinic did not have protocols to prevent postoperative delirium and 73% lacked protocols to manage delirium. The survey was commissioned by POND Awareness.
Our January 24, 2017 Patient Safety Tip of the Week “Dexmedetomidine to Prevent Postoperative Delirium” focused on the study by Su et al. (Su 2016) on using low dose dexmedetomidine to prevent postoperative delirium. However, in that column we also mentioned several of the other interventions, primarily non-pharmacological, used to prevent delirium.
We noted the recent pragmatic clinical trial that addressed delirium prevention in patients age 65 and older who underwent surgery for hip fracture (Freter 2016). Rather than intervene with all the elements of multifactorial interventions that have been used for delirium prevention, the researchers used only those that lent themselves to easy incorporation into postoperative preprinted orders. Those that fit included interventions for nausea, nighttime sedation, pain control, and bowel and bladder care. The postoperative preprinted orders had the same elements as the standardized postoperative orders for hip surgery patients with several differences:
Delirium occurred significantly less frequently (27% vs. 42% in controls on POD#1 and 7% vs. 30% in controls on POD#5) despite the fact that more patients in the intervention group had pre-existing dementia, a known risk factor for delirium. More patients in the intervention group had early postoperative bowel movements and more urinary catheter removals on POD#2. Significantly, intervention patients received less opioid analgesia (24 mg morphine equivalents vs. 44 mg morphine equivalents in controls). But, although the intervention group had less postoperative delirium, there were no differences in length of stay, mortality, or nursing home placement rates.
As an aside, in follow up to the article in our January 24, 2017 Patient Safety Tip of the Week “Dexmedetomidine to Prevent Postoperative Delirium” by Su et al. on use of dexmedetomidine to prevent postoperative delirium (Su 2016), there was a recent discussion in The Lancet about the potential neuroprotective effects of dexmedetomidine (Avramescu 2017, Su 2017). They note its effects could be due to reducing sedative drug consumption, enhancing sleep quality, and relieving surgical stress and inflammatory responses after surgery. However, they note that dexmedetomidine use is still only recommended in highly monitored settings because of its potential cardiorespiratory effects but express hope that safety and efficacy studies in other venues might be performed.
So while you are waiting for the dexmedetomidine study to be replicated and validated in other clinical settings, take the opportunity to implement one of the non-pharmacologic multicomponent interventions that have proven successful. The very practical protocols put in place by Smith and Grami and by Freter and colleagues show good results are possible. But be prepared to encounter some of the barriers that Smith and Grami described.
Some of our prior columns on delirium assessment and management:
References:
Smith CD, Grami P. Feasibility and Effectiveness of a Delirium Prevention Bundle in Critically Ill Patients. Am J Crit Care 2017; 26(1): 19-27
http://ajcc.aacnjournals.org/content/26/1/19.full?sid=bbc68db0-bd05-4271-bfc6-1346268290de
The American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. American Geriatrics Society Abstracted Clinical Practice Guideline for Postoperative Delirium in Older Adults. J Am Geriatr Soc 2015; 63(1): 142-150
The American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. Postoperative delirium in older adults: best practice statement from the American Geriatrics Society. J Am Coll Surg 2015; 220: 136-148.e1
http://www.journalacs.org/article/S1072-7515%2814%2901793-1/fulltext
Agres T. Protocol Lacking for Post-op Delirium. Anesthesiology News 2017; February 6, 2017
POND Awareness website.
Su X, Meng Z-T, Wu X-H, et al. Dexmedetomidine for prevention of delirium in elderly patients after non-cardiac surgery: a randomised, double-blind, placebo-controlled trial. The Lancet 2016; 388(10054): 1893-1902 Published: 15 October 2016
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30580-3/fulltext
Freter S, Koller K, Dunbar M, MacKnight C, Rockwood K. Translating Delirium Prevention Strategies for Elderly Adults with Hip Fracture into Routine Clinical Care: A Pragmatic Clinical Trial. J Am Geriatr Soc 2016; Early View 22 NOV 2016
http://onlinelibrary.wiley.com/doi/10.1111/jgs.14568/epdf
Avramescu S, Wang D-S, Choi S, Orser BA. Preventing delirium: beyond dexmedetomidine. The Lancet 2017; 389: 1009
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30661-X/fulltext
Su X, Wang D-X, Ma D. Preventing delirium: beyond dexmedetomidine – Authors' reply. The Lancet 2017; 389: 1009-1010
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30658-X/fulltext
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March 28, 2017
More Issues with Dental Sedation/Anesthesia
Our March 15, 2016 Patient Safety Tip of the Week “Dental Patient Safety” had an extensive section on the adverse outcomes of pediatric patients receiving sedation. Young children are particularly vulnerable because they are often sedated since they may be uncooperative for dental procedures. Moreover, many such incidents have occurred when a child is restrained by a device called a “papoose”. Proper procedures and guidelines for pediatric sedation were discussed in our August 2016 What's New in the Patient Safety World column “Guideline Update for Pediatric Sedation”.
Two events have brought the issue back to our attention. One was the death of another child occurring during sedation for a dental procedure. The other was a proposal from a Texas blue ribbon panel for new recommendations following a series of sedation-related deaths in Texas.
The new case was that of a 4 y.o. boy in Vancouver, WA who died during a routine dental procedure, apparently performed under ketamine sedation/anesthesia (Mehlhaf 2017, Balick 2017). The boy apparently was on the autism spectrum and had difficulty keeping his mouth open. But no other details are available.
The Texas blue ribbon panel (Texas SBDE 2017) made its recommendations after analyzing the Texas cases with adverse events and reviewing the scientific literature, the above mentioned guidelines, and regulations in place in other states. The recommendations include the following:
The panel also had a number of administrative recommendations and suggestions:
Other suggestions included encouraging or mandating a preoperative sedation checklist, clarifying what should be included in the preoperative evaluation, and what constitutes an acceptable sedation/anesthesia record.
The panel also encouraged sharing of de-identified data on sedation/anesthesia with other state legislatures.
The panel’s review of incidents that had occurred in Texas included some of the following root causes and contributing factors:
The latter factor (long delays in calling 911 or otherwise activating the EMS) was the most common contributing factor identified, though it was not universal. The panel identified several root causes for such delays, including fear that such might lead to a regulatory investigation, considering the need for EMS as a personal failure, and lack of practice in crisis management.
One other factor suspected, but which was difficult to prove, was that in some cases the sedation provider may have left the dental operatory for a period of time, leaving the patient unobserved. Current rules in Texas require continuous presence of the sedation provider until the patient has reached a defined level of recovery.
The panel found that at least 2 major failures had occurred in all 6 major events and that no sedation related event would likely have occurred if all rules currently in place had been closely followed and failures avoided.
Note that the panel’s recommendations and suggestions are only additions or changes to existing rules and regulations in Texas. For example, there already is a rule that at least one member of the assistant staff be present during nitrous oxide/oxygen inhalation sedation. The dental provider may delegate monitoring of nitrous oxide/oxygen inhalation sedation (once pharmacologic and vital sign stability has been established) to an assistant who is certified by the SBDE to do so. Assisting staff must also be certified in BLS (Basic Life Support).
However, one important item we could not find in either their current regulations or the recommendations made by the panel is a statement about patient restraints or immobilization devices. You’ll recall that several of the events we described in our March 15, 2016 Patient Safety Tip of the Week “Dental Patient Safety” involved use of a pediatric restraint called a “papoose” that may have contributed to the adverse outcomes. Our August 2016 What's New in the Patient Safety World column “Guideline Update for Pediatric Sedation” discussed the recently updated American Academy of Pediatrics (AAP)/American Academy of Pediatric Dentistry (AAPD) “Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures” (Coté 2016). That guideline has a good discussion about the use of immobilization devices, such as the “papoose” boards. Such must be applied in such a way as to avoid airway obstruction or chest restriction and the child’s head position and respiratory excursions should be checked frequently to ensure airway patency. If an immobilization device is used, a hand or foot should be kept exposed, and the child should never be left unattended.
It’s worth reiterating here some of the cases discussed in our March 15, 2016 Patient Safety Tip of the Week “Dental Patient Safety”:
Deaths in patients who received sedation for dental procedures make the news every year (Otto 2014, AP 2015). Columns highlighting 8 (ABC News 2016) and 31 (Bradford 2012) respective deaths related to dental sedation provide some estimate of how frequently such complications of sedation occur. The most recent incident was just reported last week (George 2016). In this case a 4-year old girl suffered brain damage after receiving sedation for a dental procedure while being restrained by a device called a “papoose”. A CBS News report on this case (CBS News 2016) notes she was given multiple sedatives in the office for over seven hours for what was described as a routine dental procedure. Her heart rate was noted to be as high as 195 and her blood pressure to 168/77 and her oxygen saturation dropped as low as 49 percent. The “papoose” is a device confines the child's arms and legs so they can't interfere with the dental procedure. The CBS report notes that use of such devices for dental procedures in children is fairly widespread in the US and families and professionals need to be made aware of the dangers.
Another study, using primarily media reports, found 44 children who died subsequent to receiving anesthesia for a dental procedure in US dental offices, ambulatory surgery centers, and hospitals between 1980 and 2011 (Lee 2013). Most deaths occurred among 2–5 year-olds, in an office setting, and with a general/pediatric dentist as the anesthesia provider. In this latter group, 17 of 25 deaths were linked with a sedation anesthetic. That study likely significantly underestimates the number of serious complications from sedation and also did not include children who suffered neurologic injuries, suffered cardiac arrest, and were successfully resuscitated, or those who experienced respiratory arrest, but not cardiac arrest. The authors called for development of a national database for reporting both serious incidents related to dental sedation and near misses.
In a study of closed malpractice claims in pediatric dental patients 13 of 17 claims related to anesthesia involved sedation (Chicka 2012). The average patient age was 3.6 years and 6 involved the dentist as the anesthesia provider and the location was the dental office in 71% of cases. Only 1 claim related to sedation in which physiologic monitoring was used.
A prospective study of 51 patients needing dental treatment under oral conscious sedation found that postdischarge excessive somnolence, nausea, and emesis were frequent complications (Huang 2015). 60.1% of patients slept in the car on the way home and 21.4% of that group were difficult to awaken upon reaching home. At home, 76.1% of patients slept and 85.7% of patients who napped following the dental visit slept longer than usual.
Our August 2016 What's New in the Patient Safety World column “Guideline Update for Pediatric Sedation” also noted an article in Anesthesiology News (Kronemyer 2016) that referred to a KVUE TV “Defenders” investigation (Pierrotti 2016) which said at least 85 patients in Texas who died shortly following dental procedures from 2010 to 2015. We are not sure of the accuracy of that number since the current Texas blue ribbon panel only found 78 cases of mortality or patient harm related to dental sedation/anesthesia between 2012 and 2016. Only 19 of those 78 cases were deemed to be related to mishandling of sedation/anesthesia and only 6 were deemed to be serious events. The reason for the disparity between the KVUE TV investigation and the blue ribbon panel report is unclear. But I think we’d all agree that even one death or instance of patient harm from dental sedation/anesthesia is one too many. The KVUE TV investigation, however, clearly led to the intensive review and recommendations made by the blue ribbon panel.
In that August 2016 What's New in the Patient Safety World column “Guideline Update for Pediatric Sedation” we discussed the newly revised American Academy of Pediatrics (AAP)/American Academy of Pediatric Dentistry (AAPD) “Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures” (Coté 2016). The updated guideline, which applies to not just dental procedures but to sedation for all procedures, notes that children under the age of 6 years (and especially those under the age of 6 months) are particularly likely to suffer adverse events during sedation. It emphasizes that there is a very narrow margin in children between the intended level of sedation and much deeper sedation or anesthesia. Therefore, the practitioner must be trained not only in moderate sedation but must have the skills to rescue patients from such deeper levels. That would include the need for maintenance of the skills needed to rescue a child with apnea, laryngospasm, and/or airway obstruction, include the ability to open the airway, suction secretions, provide continuous positive airway pressure (CPAP), perform successful bag-valve-mask ventilation, insert an oral airway, a nasopharyngeal airway, or a laryngeal mask airway (LMA), and, rarely, perform tracheal intubation. The guidelines note these skills are likely best maintained with frequent simulation and team training for the management of rare events. The guideline has specific recommendations for when the intended level of sedation is minimal, moderate, deep or general sedation.
The updated guideline emphasizes the role of capnography in appropriate physiologic monitoring and continuous observation by personnel not directly involved with the procedure to facilitate accurate and rapid diagnosis of complications and initiation of appropriate rescue interventions. We are glad to see the Texas blue ribbon panel recommendation for use of capnography.
Patient safety considerations for procedural sedation begin in advance of the procedure. There should be a careful preprocedure review of the patient’s underlying medical conditions and consideration of how the sedation process might affect or be affected by such conditions. The guideline specifically mentions that children with developmental
disabilities have been shown to have a threefold increased incidence of desaturation compared with children without developmental disabilities.
The guideline also describes the “SOAPME” mnemonic to help teams remember all the equipment and supplies needed for conduct of safe sedation:
S Suction
O Oxygen; an adequate reserve supply
A Airway; size-appropriate equipment to manage a nonbreathing child
P Pharmacy; drugs needed to support life and appropriate reversal agents
M Monitors; size-appropriate oximeter probes/monitors appropriate for procedure
E Equipment; a defibrillator with appropriately sized pads
Without going into details about specific drugs, the guideline notes the importance of selecting the lowest dose of drug with the highest therapeutic index for the procedure. That choice should also depend on whether the procedure is expected to be a painful or non-painful procedure. Knowledge about the duration of action of the drugs is important in informing how long a patient needs to be monitored after the procedure. That is especially important when combinations of drugs are being used (eg. a sedating agent and an analgesic or anxiolytic agent).
The guideline has specific recommendations for when the intended level of sedation is minimal, moderate, deep or general sedation. One critical point that should be of particular concern for dental practices, is that use of moderate or deeper sedation shall include the provision of a person, in addition to the practitioner, whose responsibility is to monitor appropriate physiologic parameters and to assist in any supportive or resuscitation measures. While that individual might also be responsible for assisting with interruptible patient-related tasks of short duration, such as holding an instrument or troubleshooting equipment, the primary role of that individual is monitoring the patient. For deep sedation the sole role of the support individual is to monitor the patient. In either case that individual should be trained in and capable of providing advanced airway skills (eg, PALS) and shall have specific assignments in the event of an emergency and current knowledge of the emergency cart/kit inventory.
Monitoring is critical and should include the level of patient’s ability to communicate (where assessable), heart rate, respiratory rate, blood pressure, oxygen saturation, and expired carbon dioxide values (via capnography) should be recorded, at minimum, every 10 minutes in a time-based record. The guideline stresses use of capnography but acknowledges that it may not be able to be used in some procedures around the face, including many dental procedures.
The guideline discusses the needs for the emergency cart/kit and backup emergency services access and availability.
The guideline has a good discussion about the use of immobilization devices, such as the “papoose” boards, as we discussed earlier in today’s column.
The guideline discusses what should be documented before, during, and after a procedure in which sedation is used and notes the importance of careful attention to calculating doses of drugs or infusions based on patient weight.
The guideline has a good discussion about discharge of the pediatric patient following a procedure in which sedation is used. It specifically highlights the dangers when a child is transported in a car seat where there is a need to carefully observe the child’s head position to avoid airway obstruction. Transportation in a car safety seat poses a particular risk for infants who have received medications known to have a long half-life. When there is only one adult to both drive and observe the child, there should be a longer period of observation in the facility where the procedure occurred. Discharge instructions should include details about what to look for, activity levels, dietary restrictions, and include a 24-hour phone number to call if necessary.
And while we have been emphasizing the application of the guideline to dental procedures, remember it applies to all diagnostic and therapeutic procedures. It has an excellent section on sedation in the MRI suite, which is a very restricted environment and has needs for special equipment and monitoring techniques as we have discussed in our numerous columns on patient safety issues in the radiology and MRI suites.
Proper patient selection, adherence to proper sedation technique, appropriate monitoring, and prompt intervention are obviously important when using sedation in any setting. But we are glad to see that the Texas blue ribbon panel has also emphasized the emergency planning aspect, including the need to perform drills which involve all members of a dental practice.
Sedation/anesthesia probably allows dental and oral surgery procedures needed by many young children. But it is not something that dental practices or parents of young children approach cavalierly. Guidelines like those outlined today need to be adhered to closely and a high level of vigilance incorporated into such dental practices.
References:
Mehlhaf N. Vancouver boy, 4, dies after anesthesia used in dental procedure. KGW TV (Portland) March 14, 2017
Balick L and KOIN 6 News Staff. What parents should know about pediatric dentistry. The American Academy of Pediatric Dentistry is looking into what happened. WKBN News 2017; March 15, 2017
http://wkbn.com/2017/03/15/what-parents-should-know-about-pediatric-dentistry/
Coté CJ, Wilson S, American Academy of Pediatrics, American Academy of Pediatric Dentistry. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics 2016; 138(1): e2016121
http://pediatrics.aappublications.org/content/138/1/e20161212
State Board of Dental Examiners (Texas). Report to the Texas Sunset Advisory Commission by the Blue Ribbon Panel on Dental Anesthesia/Sedation Safety. January 4, 2017
https://lintvkxan.files.wordpress.com/2017/01/anesthesia-recommendations-final-report.pdf
Otto M. Dentist under investigation after sedated child dies. Association of Health Care Journalists. January 13, 2014
http://healthjournalism.org/blog/2014/01/dentist-under-investigation-after-sedated-child-dies/
AP (Associated Press). Dentist charged in death of patient getting 20 teeth pulled. FoxNews.com Published February 18, 2015
ABC News. Children in Danger at the Dentist. ABC News. Accessed March 7, 2016
http://abcnews.go.com/Blotter/photos/children-danger-dentist-16763974/image-16764081
Bradford H. Dental Sedation Responsible For At Least 31 Child Deaths Over 15 Years. Huffington Post 2012; July 13, 2012
http://www.huffingtonpost.com/2012/07/13/dental-sedation-child-deaths_n_1671604.html
George C. Mom says dental restraint device led to child's brain damage. Preschooler remains hospitalized, conscious, but unable to talk, get up. Houston Chronicle 2016; March 10, 2016 Updated: March 11, 2016
CBS News. 4-year-old girl suffers brain damage after dentist visit, family says.
CBS News March 14, 2016
http://www.cbsnews.com/news/4-year-old-girl-suffers-brain-damage-after-dentist-visit/
Lee HH, Milgrom P, Starks H, Burke W. Trends in death associated with pediatric dental sedation and general anesthesia. Pediatric Anesthesia 2013; 23(8): 741-746
Chicka MC, Dembo JB, Mathu-Muju KR, et al. Adverse events during pediatric dental anesthesia and sedation: a review of closed malpractice insurance claims. Pediatr Dent 2012; 34(3): 231-238
Huang A, Tanbonliong T. Oral Sedation Postdischarge Adverse Events in Pediatric Dental Patients. Anesth Prog 2015; 62(3): 91-99
Kronemyer B. Deaths of Children During Dental Procedures Raise Safety Concerns. Anesthesiology News 2016; June 30, 2016
Pierrotti A. Defenders: Investigating Dental Deaths. KVUE 2016; April 28, 2016
http://www.kvue.com/news/investigations/defenders/defenders-investigating-dental-deaths/158354392
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January 23, 2018
Unintentional Hypothermia Back in Focus
January 16, 2018
January 9, 2018
More on Fire Risk from Surgical Preps
January 2, 2018
Preventing Perioperative Nerve Injuries
December 26, 2017
Tip of the Week on Vacation
December 19, 2017
December 12, 2017
Joint Commission on Suicide Prevention
December 5, 2017
Massachusetts Initiative on Cataract Surgery
November 28, 2017
More on Dental Sedation/Anesthesia Safety
November 21, 2017
OSA, Oxygen, and Alarm Fatigue
November 14, 2017
Tracking C. diff to a CT Scanner
November 7, 2017
Perioperative Neuropathies
October 31, 2017
Target Drugs for Deprescribing
October 24, 2017
Neurosurgery and Time of Day
October 17, 2017
Progress on Alarm Management
October 10, 2017
More on Torsade de Pointes
October 3, 2017
Respiratory Compromise: One Size Does Not Fit All
September 26, 2017
Tip of the Week on Vacation
September 19, 2017
Tip of the Week on Vacation
September 12, 2017
Can You Hear Me Now?
September 5, 2017
Another Iatrogenic Burn
August 29, 2017
Suicide in the Bathroom
August 22, 2017
August 15, 2017
Delayed Emergency Surgery and Mortality Risk
August 8, 2017
Sedation for Pediatric MRI Rising
August 1, 2017
Progress on Wrong Patient Orders
July 25, 2017
Can We Influence the “Weekend Effect”?
July 18, 2017
Another Hazard from Alcohol-Based Hand Gels
July 11, 2017
The 12-Hour Shift Takes More Hits
July 4, 2017
Tip of the Week on Vacation
June 27, 2017
June 20, 2017
June 13, 2017
June 6, 2017
NYS Mandate for Sepsis Protocol Works
May 30, 2017
Errors in Pre-Populated Medication Lists
May 23, 2017
May 16, 2017
Are Surgeons Finally Ready to Screen for Frailty?
May 9, 2017
Missed Nursing Care and Mortality Risk
May 2, 2017
Anatomy of a Wrong Procedure
April 25, 2017
April 18, 2017
Alarm Response and Nurse Shift Duration
April 11, 2017
Interruptions: The Ones We Forget About
April 4, 2017
Deprescribing in Long-Term Care
March 28, 2017
More Issues with Dental Sedation/Anesthesia
March 21, 2017
Success at Preventing Delirium
March 14, 2017
More on Falls on Inpatient Psychiatry
March 7, 2017
February 28, 2017
February 21, 2017
Yet More Jumps from Hospital Windows
February 14, 2017
February 7, 2017
January 31, 2017
More Issues in Pediatric Safety
January 24, 2017
Dexmedetomidine to Prevent Postoperative Delirium
January 17, 2017
January 10, 2017
The 26-ml Applicator Strikes Again!
January 3, 2017
What’s Happening to “I’m Sorry”?
December 27, 2016
Tip of the Week on Vacation
December 20, 2016
End-of-Rotation Transitions and Mortality
December 13, 2016
More on Double-Booked Surgery
December 6, 2016
Postoperative Pulmonary Complications
November 29, 2016
Doubling Down on Double-Booked Surgery
November 22, 2016
Leapfrog, Picklists, and Healthcare IT Vulnerabilities
November 15, 2016
November 8, 2016
Managing Distractions and Interruptions
November 1, 2016
CMS Emergency Preparedness Rule
October 25, 2016
Desmopressin Back in the Spotlight
October 18, 2016
Yet More Questions on Contact Precautions
October 11, 2016
New Guideline on Preop Screening and Assessment for OSA
October 4, 2016
September 27, 2016
September 20, 2016
Downloadable ABCDEF Bundle Toolkits for Delirium
September 13, 2016
Vanderbilt’s Electronic Procedural Timeout
September 6, 2016
August 30, 2016
Can You Really Limit Interruptions?
August 23, 2016
ISMP Canada: Automation Bias and Automation Complacency
August 16, 2016
How Is Your Alarm Management Initiative Going?
August 9, 2016
August 2, 2016
Drugs in the Elderly: The Goldilocks Story
July 26, 2016
Confirmed: Keep Your OR Doors Closed
July 19, 2016
Infants and Wrong Site Surgery
July 12, 2016
Forget Brexit – Brits Bash the RCA!
July 5, 2016
Tip of the Week on Vacation
June 28, 2016
Culture of Safety and Catheter-Associated Infections
June 21, 2016
Methotrexate Errors in Australia
June 14, 2016
Nursing Monitoring of Patients on Opioids
June 7, 2016
CPAP for Hospitalized Patients at High Risk for OSA
May 31, 2016
More Frailty Measures That Predict Surgical Outcomes
May 24, 2016
Texting Orders – Is It Really Safe?
May 17, 2016
Patient Safety Issues in Cataract Surgery
May 10, 2016
Medical Problems in Behavioral Health
May 3, 2016
Clinical Decision Support Malfunction
April 26, 2016
Lots More on Preventing Readmissions But Where's the Beef?
April 19, 2016
Independent Double Checks and Oral Chemotherapy
April 12, 2016
April 5, 2016
Workarounds Overriding Safety
March 29, 2016
March 22, 2016
Radiology Communication Errors May Surprise You
March 15, 2016
March 8, 2016
Tip of the Week on Vacation
March 1, 2016
February 23, 2016
February 16, 2016
February 9, 2016
February 2, 2016
January 26, 2016
More on Frailty and Surgical Morbidity and Mortality
January 19, 2016
Patient Identification in the Spotlight
January 12, 2016
New Resources on Improving Safety of Healthcare IT
January 5, 2016
Lessons from AirAsia Flight QZ8501 Crash
December 29, 2015
More Medical Helicopter Hazards
December 22, 2015
The Alberta Abbreviation Safety Toolkit
December 15, 2015
Vital Sign Monitoring at Night
December 8, 2015
Danger of Inaccurate Weights in Stroke Care
December 1, 2015
TALLman Lettering: Does It Work?
November 24, 2015
Door Opening and Foot Traffic in the OR
November 17, 2015
Patient Perspectives on Communication of Test Results
November 10, 2015
Weighing in on Double-Booked Surgery
November 3, 2015
Medication Errors in the OR - Part 2
October 27, 2015
Sentinel Event Alert on Falls and View from Across the Pond
October 20, 2015
Updated Beers List
October 13, 2015
Dilaudid Dangers #3
October 6, 2015
Suicide and Other Violent Inpatient Deaths
September 29, 2015
More on the 12-Hour Nursing Shift
September 22, 2015
The Cost of Being Rude
September 15, 2015
Another Possible Good Use of a Checklist
September 8, 2015
TREWScore for Early Recognition of Sepsis
September 1, 2015
August 25, 2015
Checklist for Intrahospital Transport
August 18, 2015
Missing Obstructive Sleep Apnea
August 11, 2015
New Oxygen Guidelines: Thoracic Society of Australia and NZ
August 4, 2015
Tip of the Week on Vacation
July 28, 2015
July 21, 2015
Avoiding Distractions in the OR
July 14, 2015
July 7, 2015
June 30, 2015
What Are Appropriate Indications for Urinary Catheters?
June 23, 2015
Again! Mistaking Antiseptic Solution for Radiographic Contrast
June 16, 2015
June 9, 2015
Add This to Your Fall Risk Assessment
June 2, 2015
May 26, 2015
May 19, 2015
May 12, 2015
More on Delays for In-Hospital Stroke
May 5, 2015
Errors with Oral Oncology Drugs
April 28, 2015
April 21, 2015
April 14, 2015
Using Insulin Safely in the Hospital
April 7, 2015
March 31, 2015
Clinical Decision Support for Pneumonia
March 24, 2015
Specimen Issues in Prostate Cancer
March 17, 2015
March 10, 2015
FDA Warning Label on Insulin Pens: Is It Enough?
March 3, 2015
Factors Related to Postoperative Respiratory Depression
February 24, 2015
More Risks with Long-Acting Opioids
February 17, 2015
Functional Impairment and Hospital Readmission, Surgical Outcomes
February 10, 2015
The Anticholinergic Burden and Dementia
February 3, 2015
CMS Hopes to Reduce Antipsychotics in Dementia
January 27, 2015
The Golden Hour for Stroke Thrombolysis
January 20, 2015
He Didn’t Wash His Hands After What!
January 13, 2015
January 6, 2015
Yet Another Handoff: The Intraoperative Handoff
December 30, 2014
Data Accumulates on Impact of Long Surgical Duration
December 23, 2014
Iatrogenic Burns in the News Again
December 16, 2014
More on Each Element of the Surgical Fire Triad
December 9, 2014
December 2, 2014
ANA Position Statement on Nurse Fatigue
November 25, 2014
Misdiagnosis Due to Lab Error
November 18, 2014
Handwashing Fades at End of Shift, ?Smartwatch to the Rescue
November 11, 2014
Early Detection of Clinical Deterioration
November 4, 2014
Progress on Fall Prevention
October 28, 2014
RF Systems for Retained Surgical Items
October 21, 2014
The Fire Department and Your Hospital
October 14, 2014
October 7, 2014
Our Take on Patient Safety Walk Rounds
September 30, 2014
More on Deprescribing
September 23, 2014
Stroke Thrombolysis: Need to Focus on Imaging-to-Needle Time
September 16, 2014
Focus on Home Care
September 9, 2014
The Handback
September 2, 2014
Frailty and the Trauma Patient
August 26, 2014
Surgeons’ Perception of Intraoperative Time
August 19, 2014
Some More Lessons Learned on Retained Surgical Items
August 12, 2014
Surgical Fires Back in the News
August 5, 2014
Tip of the Week on Vacation
July 29, 2014
The 12-Hour Nursing Shift: Debate Continues
July 22, 2014
More on Operating Room Briefings and Debriefings
July 15, 2014
Barriers to Success of Early Warning Systems
July 8, 2014
Update: Minor Head Trauma in the Anticoagulated Patient
July 1, 2014
Interruptions and Radiologists
June 24, 2014
Lessons from the General Motors Recall Analysis
June 17, 2014
SO2S Confirms Routine Oxygen of No Benefit in Stroke
June 10, 2014
Another Clinical Decision Support Tool to Avoid Torsade de Pointes
June 3, 2014
More on the Risk of Sedative/Hypnotics
May 27, 2014
A Gap in ePrescribing: Stopping Medications
May 20, 2014
May 13, 2014
Perioperative Sleep Apnea: Human and Financial Impact
May 6, 2014
Monitoring for Opioid-induced Sedation and Respiratory Depression
April 29, 2014
More on the Unintended Consequences of Contact Isolation
April 22, 2014
Impact of Resident Workhour Restrictions
April 15, 2014
Specimen Identification Mixups
April 8, 2014
FMEA to Avoid Breastmilk Mixups
April 1, 2014
Expensive Aspects of Sepsis Protocol Debunked
March 25, 2014
March 18, 2014
Systems Approach Improving Stroke Care
March 11, 2014
We Miss the Graphic Flowchart!
March 4, 2014
Evidence-Based Prescribing and Deprescribing in the Elderly
February 25, 2014
Joint Commission Revised Diagnostic Imaging Requirements
February 18, 2014
February 11, 2014
Another Perioperative Handoff Tool: SWITCH
February 4, 2014
But What If the Battery Runs Low?
January 28, 2014
Is Polypharmacy Always Bad?
January 21, 2014
January 14, 2014
Diagnostic Error: Salient Distracting Features
January 7, 2014
Lessons From the Asiana Flight 214 Crash
December 24-31, 2013
Tip of the Week on Vacation
December 17, 2013
December 10, 2013
Better Handoffs, Better Results
December 3, 2013
Reducing Harm from Falls on Inpatient Psychiatry
November 26, 2013
Missed Care: New Opportunities?
November 19, 2013
Can We Improve Dilaudid/HYDROmorphone Safety?
November 12, 2013
More on Inappropriate Meds in the Elderly
November 5, 2013
Joint Commission Sentinel Event Alert: Unintended Retained Foreign Objects
October 29, 2013
PAD: The Pain, Agitation, and Delirium Care Bundle
October 22, 2013
How Safe Is Your Radiology Suite?
October 15, 2013
October 8, 2013
October 1, 2013
Fuels and Oxygen in OR Fires
September 24, 2013
Perioperative Use of CPAP in OSA
September 17, 2013
September 10, 2013
Informed Consent and Wrong-Site Surgery
September 3, 2013
Predicting Perioperative Complications: Slow and Simple
August 27 2013
Lessons on Wrong-Site Surgery
August 20 2013
Lessons from Canadian Analysis of Medical Air Transport Cases
August 13 2013
August 6, 2013
July 9-30, 2013
Tip of the Week on Vacation
July 2, 2013
June 25, 2013
June 18, 2013
DVT Prevention in Stoke – CLOTS 3
June 11, 2013
June 4, 2013
May 28, 2013
The Neglected Medications: IV Fluids
May 21, 2013
May 14, 2013
Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)
May 7, 2013
April 30, 2013
Photographic Identification to Prevent Errors
April 23, 2013
Plethora of Medication Safety Studies
April 16, 2013
April 9, 2013
Mayo Clinic System Alerts for QT Interval Prolongation
April 2, 2013
Absconding from Behavioral Health Services
March 26, 2013
Failure to Recognize Sleep Apnea Before Surgery
March 19, 2013
Dealing with the Violent Patient in the Emergency Department
March 12, 2013
More on Communicating Test Results
March 5, 2013
Underutilized Safety Tools: The Observational Audit
February 26, 2013
Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?
February 19, 2013
Practical Postoperative Pain Management
February 12, 2013
CDPH: Lessons Learned from PCA Incident
February 5, 2013
Antidepressants and QT Interval Prolongation
January 29, 2013
A Flurry of Activity on Handoffs
January 22, 2013
You Don’t Know What You Don’t Know
January 15, 2013
January 8, 2013
More Lessons Learned on Retained Surgical Items
January 1, 2013
Don’t Throw Away Those View Boxes Yet
December 25, 2012
Tip of the Week on Vacation
December 18, 2012
Unintended Consequences of the CAUTI Measure?
December 11, 2012
December 4, 2012
Unintentional Perioperative Hypothermia: A New Twist
November 27, 2012
November 20, 2012
Update on Perioperative Management of Obstructive Sleep Apnea
November 13, 2012
The 12-Hour Nursing Shift: More Downsides
November 6, 2012
Using LEAN to Improve Stroke Care
October 30, 2012
October 23, 2012
Latent Factors Lurking in the OR
October 16, 2012
What is the Evidence on Double Checks?
October 9, 2012
Call for Focus on Diagnostic Errors
October 2, 2012
Test Results: Everyone’s Worst Nightmare
September 25, 2012
Preoperative Assessment for Geriatric Patients
September 18, 2012
September 11, 2012
In Search of the Ideal Early Warning Score
September 4, 2012
August 28, 2012
New Care Model Copes with Interruptions Better
August 21, 2012
More on Missed Followup of Tests in Hospital
August 14, 2012
August 7, 2012
Cognition, Post-Op Delirium, and Post-Op Outcomes
July 31, 2012
Surgical Case Duration and Miscommunications
July 24, 2012
FDA and Extended-Release/Long-Acting Opioids
July 17, 2012
July 10, 2012
Tip of the Week on Vacation
July 3, 2012
Recycling an Old Column: Dilaudid Dangers
June 26, 2012
Using Patient Photos to Reduce CPOE Errors
June 19, 2012
More Problems with Faxed Orders
June 12, 2012
Lessons Learned from the CDPH: Retained Foreign Bodies
June 5, 2012
Minor Head Trauma in the Anticoagulated Patient
May 29, 2012
Falls, Fractures, and Fatalities
May 22, 2012
Update on Preoperative Screening for Sleep Apnea
May 15, 2012
May 8, 2012
Importance of Nontechnical Skills in Healthcare
May 1, 2012
April 24, 2012
Fire Hazard of Skin Preps Oxygen
April 17, 2012
April 10, 2012
April 3, 2012
New Risk for Postoperative Delirium: Obstructive Sleep Apnea
March 27, 2012
March 20, 2012
Adverse Events Related to Psychotropic Medications
March 13, 2012
Medical Emergency Team Calls to Radiology
March 6, 2012
February 28, 2012
AACN Practice Alert on Delirium in Critical Care
February 21, 2012
Improving PCA Safety with Capnography
February 14, 2012
Handoffs More Than Battle of the Mnemonics
February 7, 2012
Another Neuromuscular Blocking Agent Incident
January 31, 2012
January 24, 2012
Patient Safety in Ambulatory Care
January 17, 2012
Delirium and Contact Isolation
January 10, 2012
January 3, 2012
Unintended Consequences of Restricted Housestaff Hours
December 20, 2011
December 13, 2011
December 6, 2011
Why You Need to Beware of Oxygen Therapy
November 29, 2011
November 22, 2011
Perioperative Management of Sleep Apnea Disappointing
November 15, 2011
November 8, 2011
WHOs Multi-professional Patient Safety Curriculum Guide
November 1, 2011
So Whats the Big Deal About Inserting an NG Tube?
October 25, 2011
October 18, 2011
October 11, 2011
October 4, 2011
Radiology Report Errors and Speech Recognition Software
September 27, 2011
The Canadian Suicide Risk Assessment Guide
September 20, 2011
When Practice Changes the Evidence: The CKD Story
September 13, 2011
Do You Use Fentanyl Transdermal Patches Safely?
September 6, 2011
August 30, 2011
Unintentional Discontinuation of Medications After Hospitalization
August 23, 2011
Catheter Misconnections Back in the News
August 16, 2011
August 9, 2011
Frailty and the Surgical Patient
August 2, 2011
July 26, 2011
July 19, 2011
Communication Across Professions
July 12, 2011
Psst! Pass it onHow a kids game can mold good handoffs
July 5, 2011
Sidney Dekker: Patient Safety. A Human Factors Approach
June 28, 2011
Long-Acting and Extended-Release Opioid Dangers
June 21, 2011
June 14, 2011
June 6, 2011
May 31, 2011
Book Review Human Factors and Team Psychology in a High Stakes Environment
May 24, 2011
May 17, 2011
Opioid-Induced Respiratory Depression Again!
May 10, 2011
Preventing Preventable Readmissions: Not As Easy As It Sounds
May 3, 2011
April 26, 2011
Sleeping Air Traffic Controllers: What About Healthcare?
April 19, 2011
DVT Prophylaxis in Acute Stroke: Controversy Reappears
April 12, 2011
Medication Issues in the Ambulatory Setting
April 5, 2011
March 29, 2011
The Silent Treatment:A Dose of Reality
March 22, 2011
An EMR Feature Detrimental to Teamwork and Patient Safety
March 15, 2011
March 8, 2011
Yes, Physicians Get Interrupted Too!
March 1, 2011
February 22, 2011
February 15, 2011
Controversies in VTE Prophylaxis
February 8, 2011
February 1, 2011
January 25, 2011
Procedural Sedation in Children
January 18, 2011
More on Medication Errors in Long-Term Care
January 11, 2011
NPSA (UK) How to Guide: Five Steps to Safer Surgery
January 4, 2011
December 28, 2010
HAIs: Looking In All The Wrong Places
December 21, 2010
More Bad News About Off-Hours Care
December 14, 2010
NPSA (UK): Preventing Fatalities from Medication Loading Doses
December 6, 2010
More Tips to Prevent Wrong-Site Surgery
November 30, 2010
SURPASS: The Mother of All Checklists
November 23, 2010
Focus on Cumulative Radiation Exposure
November 16, 2010
November 9, 2010
12-Hour Nursing Shifts and Patient Safety
November 2, 2010
Insulin: Truly a High-Risk Medication
October 26, 2010
Confirming Medications During Anesthesia
October 19, 2010
Optimizing Medications in the Elderly
October 12, 2010
October 5, 2010
September 28, 2010
September 21, 2010
September 14, 2010
Wrong-Site Craniotomy: Lessons Learned
September 7, 2010
Patient Safety in Ob/Gyn Settings
August 31, 2010
August 24, 2010
The BP Oil Spill Analogies in Healthcare
August 17, 2010
Preoperative Consultation Time to Change
August 10, 2010
Its Not Always About The Evidence
August 3, 2010
Tip of the Week on Vacation
July 27, 2010
EMRs Still Have A Long Way To Go
July 20, 2010
More on the Weekend Effect/After-Hours Effect
July 13, 2010
Postoperative Opioid-Induced Respiratory Depression
July 6, 2010
Book Reviews: Pronovost and Gawande
June 29, 2010
Torsade de Pointes: Are Your Patients At Risk?
June 22, 2010
Disclosure and Apology: How to Do It
June 15, 2010
Dysphagia in the Stroke Patient: the Scottish Guideline
June 8, 2010
Surgical Safety Checklist for Cataract Surgery
June 1, 2010
May 25, 2010
May 18, 2010
Real-Time Random Safety Audits
May 11, 2010
May 4, 2010
More on the Impact of Interruptions
April 27, 2010
April 20, 2010
HITs Limited Impact on Quality To Date
April 13, 2010
April 6, 2010
March 30, 2010
Publicly Released RCAs: Everyone Learns from Them
March 23, 2010
ISMPs Guidelines for Standard Order Sets
March 16, 2010
A Patient Safety Scavenger Hunt
March 9, 2010
Communication of Urgent or Unexpected Radiology Findings
March 2, 2010
Alarm Sensitivity: Early Detection vs. Alarm Fatigue
February 23, 2010
Alarm Issues in the News Again
February 16, 2010
Spin/HypeKnowing It When You See It
February 9, 2010
More on Preventing Inpatient Suicides
February 2, 2010
January 26, 2010
Preventing Postoperative Delirium
January 19, 2010
January 12, 2010
Patient Photos in Patient Safety
January 5, 2010
December 29, 2009
Recognizing Deteriorating Patients
December 22, 2009
December 15, 2009
December 8, 2009
December 1, 2009
Patient Safety Doesnt End at Discharge
November 24, 2009
Another Rough Month for Healthcare IT
November 17, 2009
November 10, 2009
Conserving ResourcesBut Maintaining Patient Safety
November 3, 2009
Medication Safety: Frontline to the Rescue Again!
October 27, 2009
Co-Managing Patients: The Good, The Bad, and The Ugly
October 20, 2009
Radiology AgainBut This Time Its Really Radiology!
October 13, 2009
October 6, 2009
Oxygen Safety: More Lessons from the UK
September 29, 2009
Perioperative Peripheral Nerve Injuries
September 22, 2009
Psychotropic Drugs and Falls in the SNF
September 15, 2009
ETTOs: Efficiency-Thoroughness Trade-Offs
September 8, 2009
Barriers to Medication Reconciliation
September 1, 2009
The Real Root Causes of Medical Helicopter Crashes
August 25, 2009
Interruptions, Distractions, InattentionOops!
August 18, 2009
Obstructive Sleep Apnea in the Perioperative Period
August 11, 2009
August 4, 2009
July 28, 2009
Wandering, Elopements, and Missing Patients
July 21, 2009
Medication Errors in Long Term-Care
July 14, 2009
Is Your Do Not Use Abbreviations List Adequate?
July 7, 2009
Nudge: Small Changes, Big Impacts
June 30, 2009
iSoBAR: Australian Clinical Handoffs/Handovers
June 23, 2009
June 16, 2009
Disclosing Errors That Affect Multiple Patients
June 9, 2009
CDC Update to the Guideline for Prevention of CAUTI
June 2, 2009
Why Hospitals Should FlyJohn Nance Nails It!
May 26, 2009
Learning from Tragedies. Part II
May 19, 2009
May 12, 2009
May 5, 2009
Adverse Drug Events in the ICU
April 28, 2009
Ticket Home and Other Tools to Facilitate Discharge
April 21, 2009
April 14, 2009
More on Rehospitalization After Discharge
April 7, 2009
March 31, 2009
Screening Patients for Risk of Delirium
March 24, 2009
March 17, 2009
March 10, 2009
Prolonged Surgical Duration and Time Awareness
March 3, 2009
Overriding AlertsLike Surfin the Web
February 24, 2009
Discharge Planning: Finally Something That Works!
February 17, 2009
Reducing Risk of Overdose with Midazolam Injection
February 10, 2009
Sedation in the ICU: The Dexmedetomidine Study
February 3, 2009
NTSB Medical Helicopter Crash Reports: Missing the Big Picture
January 27, 2009
Oxygen Therapy: Everything You Wanted to Know and More!
January 20, 2009
The WHO Surgical Safety Checklist Delivers the Outcomes
January 13, 2009
January 6, 2009
December 30, 2008
Unintended Consequences: Is Medication Reconciliation Next?
December 23, 2008
December 16, 2008
Joint Commission Sentinel Event Alert on Hazards of Healthcare IT
December 9, 2008
December 2, 2008
Playing without the ballthe art of communication in healthcare
November 25, 2008
November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
November 11, 2008
November 4, 2008
October 28, 2008
More on Computerized Trigger Tools
October 21, 2008
October 14, 2008
October 7, 2008
Lessons from Falls....from Rehab Medicine
September 30, 2008
September 23, 2008
Checklists and Wrong Site Surgery
September 16, 2008
More on Radiology as a High Risk Area
September 9, 2008
Less is More.and Do You Really Need that Decimal?
September 2, 2008
August 26, 2008
August 19, 2008
August 12, 2008
Jerome Groopmans How Doctors Think
August 5, 2008
July 29, 2008
Heparin-Induced Thrombocytopenia
July 22, 2008
Lots New in the Anticoagulation Literature
July 15, 2008
July 8, 2008
July 1, 2008
WHOs New Surgical Safety Checklist
June 24, 2008
Urinary Catheter-Related UTIs: Bladder Bundles
June 17, 2008
Technology Workarounds Defeat Safety Intent
June 10, 2008
Monitoring the Postoperative COPD Patient
June 3, 2008
UK Advisory on Chest Tube Insertion
May27, 2008
If You Do RCAs or Design Healthcare ProcessesRead Gary Kleins Work
May20, 2008
CPOE Unintended Consequences Are Wrong Patient Errors More Common?
May13, 2008
Medication Reconciliation: Topical and Compounded Medications
May 6, 2008
Preoperative Screening for Obstructive Sleep Apnea
April 29, 2008
ASA Practice Advisory on Operating Room Fires
April 22, 2008
CMS Expanding List of No-Pay Hospital-Acquired Conditions
April 15, 2008
April 8, 2008
April 1, 2008
Pennsylvania PSAs FMEA on Telemetry Alarm Interventions
March 25, 2008
March 18, 2008
Is Desmopressin on Your List of Hi-Alert Medications?
March 11, 2008
March 4, 2008
Housestaff Awareness of Risks for Hazards of Hospitalization
February 26, 2008
Nightmares.The Hospital at Night
February 19, 2008
February 12, 2008
February 5, 2008
Reducing Errors in Obstetrical Care
January 29, 2008
Thoughts on the Recent Neonatal Nursery Fire
January 22, 2008
More on the Cost of Complications
January 15, 2008
Managing Dangerous Medications in the Elderly
January 8, 2008
Urinary Catheter-Associated Infections
January 1, 2008
December 25, 2007
December 18, 2007
December 11, 2007
CommunicationCommunicationCommunication
December 4, 2007
November 27,2007
November 20, 2007
New Evidence Questions Perioperative Beta Blocker Use
November 13, 2007
AHRQ's Free Patient Safety Tools DVD
November 6, 2007
October 30, 2007
Using IHIs Global Trigger Tool
October 23, 2007
Medication Reconciliation Tools
October 16, 2007
Radiology as a Site at High-Risk for Medication Errors
October 9, 2007
October 2, 2007
Taking Off From the Wrong Runway
September 25, 2007
Lessons from the National Football League
September 18, 2007
Wristbands: The Color-Coded Conundrum
September 11, 2007
Root Cause Analysis of Chemotherapy Overdose
September 4, 2007
August 28, 2007
Lessons Learned from Transportation Accidents
August 21, 2007
Costly Complications About To Become Costlier
August 14, 2007
More Medication-Related Issues in Ambulatory Surgery
August 7, 2007
Role of Maintenance in Incidents
July 31, 2007
Dangers of Neuromuscular Blocking Agents
July 24, 2007
Serious Incident Response Checklist
July 17, 2007
Falls in Patients on Coumadin or Other Anticoagulants
July 10, 2007
Catheter Connection Errors/Wrong Route Errors
July 3, 2007
June 26, 2007
Pneumonia in the Stroke Patient
June 19, 2007
Unintended Consequences of Technological Solutions
June 12, 2007
Medication-Related Issues in Ambulatory Surgery
June 5, 2007
Patient Safety in Ambulatory Surgery
May 29, 2007
Read Anything & Everything Written by Malcolm Gladwell!
May 22, 2007
May 15, 2007
Communication, Hearback and Other Lessons from Aviation
May 8, 2007
Doctor, when do I get this red rubber hose removed?
May 1, 2007
April 23, 2007
April 16, 2007
April 9, 2007
Make Your Surgical Timeouts More Useful
April 2, 2007
March 26, 2007
Alarms Should Point to the Problem
March 19, 2007
Put that machine back the way you found it!
March 12, 2007
March 5, 2007
February 26, 2007
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