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January 7, 2020
Even More Concerns About MRI Safety
Seems like we’ve been writing a lot about MRI safety in the last several months. But there’s even more. You’ll recall our November 5, 2019 Patient Safety Tip of the Week “A Near-Fatal MRI Incident” about a serious MRI accident in Sweden. It turns out that a Swedish national survey on MR safety compared with CT has suggested a false sense of security (Hansson 2019).
Sweden has no formal system for reporting MRI-related incidents, so the authors surveyed all sites performing MRI or CT and had a 60% response rate for MR workers and 90% for all hospitals/facilities with MR units, likely providing a good representation of nationwide experience. Overall, 200 MR safety incidents and 156 CT safety incidents over a 12-month period were reported by the 529 participants.
More MR workers (73%) than CT workers (50%) were confident in being aware of any incident occurring at their workplace. However, it turns out that 69% of MR workers (83% for CT) were not aware of reported incidents at their hospitals. Those results indicated that a high proportion of MR personnel were sure that they would have been aware of any incident occurring in their own department yet, in reality, incidents did occur without their knowledge. The authors conclude that a false sense of security exists for MR.
Incidents related to MRI most often involved the static magnetic field, the radiofrequency field, and the gradient magnetic field (projectiles, implants, and burns), whereas incidents related to CT most often involved radiation or contrast.
Actual human injury was more common in CT incidents, but in all MR cases, potential (worst-case scenario) severity scores were higher than actual severity scores for human injuries, but unchanged for CT. 16% of reported MR safety incidents were given the highest potential (worst-case scenario) severity score.
Five incidents involving human injury were related to burns, and three to projectiles. However, 19 incidents involving material injuries were related to projectiles.
The data they collected on incidents involving projectiles is particularly striking. The following items were reported in 6 or more incidents in a 12-month period: scissors or knife, walker, wheelchair, bed, infusion pump, oxygen tank, and metal object in pocket. Projectiles reported in fewer incidents included ventilator or monitor, cart or cleaning cart, crutches, keys, phone, forceps, laryngoscope, sharp object, magnetic object, equipment part, glasses, hair clip, hair pin, basket lid, rescue stretcher, screw, vacuum cleaner.
The authors point out the importance of involving in MR safety endeavors all who may come in contact with the MRI suite or unit, including radiographers, radiologists, personnel from other departments accompanying patients to MR units, administrative staff, janitors, and firemen. (Note that we have emphasized in several columns the importance of training firemen, police, and other first responders.) They note that leaving out any one piece might jeopardize security and possibly lead to a catastrophe.
Hansson et al. note that MR safety screening checklists are not enough to prevent all adverse events. Because severe adverse events still exist, are poorly shared within the team, and are preventable, they recommend the following action steps:
In a video on MRI safety from the recent RSNA 2019 conference (RSNA 2019), Dr. Emanuel Kanal discussed the importance of having structure and standardization for all MRI programs. The key components of such programs were outlined in a guideline put together by a coalition of societies and organizations dealing with MRI that included a delineation of responsibilities for the management of MRI facilities (Calamante 2016). That document outlined a suggested organizational oversight structure, including a magnetic resonance medical director, magnetic resonance safety officer, and magnetic resonance safety expert. Each has their own assigned roles and tasks. Dr. Kanal noted that an American Board of MR Safety was established in 2015 and certifies individuals for the above positions by means of exams. He noted that over 2500 individuals have already been certified.
Dr. Kamal did comment on the near fatal event that we discussed in our November 5, 2019 Patient Safety Tip of the Week “A Near-Fatal MRI Incident”, noting that the investigation is still incomplete but that ferromagnetic materials in the weighted vest likely played a role. He also alluded to a second incident in an MR unit in which weights attached to someone’s ankles were involved. But he also noted that, while we often focus on projectile incidents in MRI safety, there are many other issues, such as burns, neural excitation, etc.
A Swedish expert on MRI safety recently discussed issues related to projectiles and other events (Owman 2019). Screening for metal is important, but you shouldn’t rely on just one method for screening. For example, most MRI practices fill out a special screening form, but some also require the patient change from street clothes into known MRI-safe clothing. The MR radiographer needs to interview the patient right before entering the examination room to check that the patient has fully understood the information, and there must never be any unknown circumstances. If there are, further investigations must be done. These procedures are very important and must never be excluded. She also discusses use a ferromagnetic detector as a support to the screening procedure. Such a detector is a good asset if you want to reduce the risk of something being accidentally taken into the room. At the same time, it is important to know that while a ferromagnetic detector may increase MRI safety, it should never replace any of the ordinary screening procedures used.
She also discussed the importance of identifying every implant. That is essential to find out if the MRI examination can be performed on a patient with a certain implant and, if so, how it can be done safely. Implants may become heated during MRI scanning and heating injuries have increased due to the use of more efficient and powerful methods and scanners. Occasionally, they are also caused by a lack of MRI safety competence regarding how to position the patient, etc.
She also notes the importance of teamwork in the MRI suite. Working alone with MRI examinations and equipment should never be an option, and all members of the scanning team must have a high level of MRI safety skills. (The danger of working alone in an MRI suite was apparent in our November 5, 2019 Patient Safety Tip of the Week “A Near-Fatal MRI Incident”.)
One thing that we are always struck by in reports about safety issues in the MRI suite is that most of the reported adverse events are related to the MRI itself and related processes. Contrast that to all the issues we’ve discussed in our multiple columns on patient safety issues in the radiology suite. The vast majority of those are not related to the imaging process itself, but rather to the fact that sick patients with complex medical conditions are being brought to the radiology suite and problems tend to involve issues like medications, IV lines mix ups, falls, oxygen issues, sedation, monitoring, patient or test misidentification, unexpected clinical deterioration, and many others. See our October 22, 2013 Patient Safety Tip of the Week “How Safe Is Your Radiology Suite?” for details. Surely, many of the same incidents occur in MRI suites.
An example of a patient safety issue only indirectly related to MRI was a study that showed most children who undergo MRI while under anesthesia experience hypothermia at some point during the procedure (Cronin 2019). Using MRI-compatible temperature monitoring, the researchers found that 63% of patients less than 8 years of age exhibited hypothermia (median temperature less than 36°C) at some point during MRI. Most instances of hypothermia occurred early, particularly during anesthesia induction and prior to the initiation of the MRI scan, and then improved during the scan. That was ascribed to the fact that the scanning environment is typically kept cool, with a low humidity, and heat loss to the surrounding environment typically occurs after induction of anesthesia. Later, body temperature tends to increase during the MRI scan secondary to MR radiofrequency heating.
The researchers did not find any increase in perianesthetic complications or an impact on PACU length of stay. However, the study was limited to children undergoing outpatient procedures. It is quite conceivable that sicker, more vulnerable inpatients might be impacted by such hypothermia. The authors, therefore, recommend interventions for these patients should be focused on maintaining normothermia during the anesthesia induction and prior to initiation of the MRI scan. MRI-compatible continuous temperature monitoring is important for managing temperature for these anesthetized patients.
For a modality that has now been around since the late 1970’s, we still continue to learn about new patient safety risks associated with its use.
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:
Hansson, B., Olsrud, J., Wilén, J. et al. Swedish national survey on MR safety compared with CT: a false sense of security? Eur Radiol 2019; Online first December 13, 2019
https://link.springer.com/content/pdf/10.1007%2Fs00330-019-06465-5.pdf
Video from RSNA 2019: What's happening with MRI safety. AuntMinnie.com 2019; December 3, 2019
https://www.auntminnie.com/index.aspx?sec=rca&sub=rsna_2019&pag=dis&ItemID=127478
Calamante F, Ittermann B, Kanal E, The Inter-Society Working Group on MR Safety and Norris D. Recommended responsibilities for management of MR safety. J Magn Reson Imaging 2016; 44: 1067-1069
http://onlinelibrary.wiley.com/doi/10.1002/jmri.25282/epdf
Owman T. MRI safety: An urgent issue for an increasing crowd. AuntMinnieEurope.com 2019; December 3, 2019
https://www.auntminnieeurope.com/index.aspx?sec=sup&sub=mri&pag=dis&ItemID=618062
Cronin JA, Shen ., Rana S, et al. Association Between Magnetic Resonance Imaging in Anesthetized Children and Hypothermia. Pediatric Quality & Safety 2019, 4(4): e181
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6708655/
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January 14, 2020
More on Newborn Falls
In our July 28, 2015 Patient Safety Tip of the Week “Not All Falls Are the Same” we discussed newborn falls as being distinct from most other falls. Such falls or “drops” have characteristics and risk factors different from most other “falls” and, hence, merit discussion on their own.
Newborn falls are, fortunately, fairly rare. But they may have devastating consequences. We discussed newborn falls and the factors contributing to them in our March 2019 What's New in the Patient Safety World column “Newborn Falls”. But five recent events have brought newborn falls to our attention again. Two were reports of newborns being dropped during a delivery, one of which resulted in a video that went viral. Two others were safety alerts (one from The Joint Commission and one from the UK NHS). Last was a review article in the Pennsylvania Patient Safety Authority’s new journal “Patient Safety”.
In our July 28, 2015 Patient Safety Tip of the Week “Not All Falls Are the Same” and our March 2019 What's New in the Patient Safety World column “Newborn Falls” we highlighted a Pennsylvania Patient Safety Authority review that found a surprising number of newborn injuries related to falls (Wallace 2014). However, an increase in the number and rate of serious newborn fall events reported to PA-PSRS (Pennsylvania Patient Safety Reporting System) compared with that previous analysis has led to a new column by the PPSA in their new journal “Patient Safety” (Kukielka 2019). An analysis of reports submitted to the PA-PSRS from January 2014 through December 2018 identified 318 events specifically related to newborn falls plus 14 near-misses in the hospital following birth.
The authors estimated annual rates of newborn falls as ranging from 3.7 to 5.9 falls per 10,000 live births from 2014 to 2018, with an average annual rate of newborn falls of 4.8 falls per 10,000 live births over the five-year study period. Almost 70% occurred within the first 72 hours following birth and 90% within the first 7 days.
56.6% of newborn falls occurred between midnight and 7 a.m. 52.8% of events took place after the caregiver fell asleep. A couple happened when a caregiver lost consciousness following a seizure. Other circumstances included caregiver dropping the newborn while in motion (19.8%), caregiver dropping the newborn while stationary (12.6%), and the newborn falling from another surface, such as a bed or couch (5.7%).
There were 5 cases (1.6%) in which the newborn fall occurred following a precipitous delivery.
The following contributing factors were identified:
84.6% of events involved the mother, 10.3% the father, 2.9% another family member (most often a grandparent), and 1.9% a member of the hospital staff (most often a nurse).
Regarding harm to the newborn, 10.4% were classified as Serious Events though, fortunately, none of the events resulted in permanent harm or death. In 63% of those classified as Serious Events, the newborn experienced temporary harm that required treatment or intervention. In the remaining 36.4%, the newborn experienced temporary harm (eg. bumps, bruises, swelling, hematomas, hemorrhages, and fractures) that required initial or prolonged hospitalization.
Just as in the earlier PPSA study (Wallace 2014), the authors of the current PPSA study focused heavily on feeding and, in particular, breastfeeding as important contributing factors. Since many hospitals allow the infants to sleep in-room (in bassinettes) with the mothers, the importance of putting the infant back in the bassinette becomes apparent.
The report focuses heavily on the sleepiness of the parents, particularly the mothers, noting studies demonstrating maternal sleep deprivation in the peripartum and postpartum periods. One of the most important points made by the authors is “The cluster of events during hours when parents or caregivers would otherwise be sleeping suggests that maternal sleep in the immediate postpartum period should be a focal point in newborn fall prevention strategies.”
Focusing on education for new parents may be an important intervention to prevent newborn falls. The authors give examples from some hospital interventions, such as giving new parents a welcome letter that includes information on newborn safety and safe sleep and discourages co-sleeping.
Parents should be encouraged to give their baby to nursing staff to take to the nursery if they are feeling tired or just need a break. Some also encourage parents to have a break in visiting hours from 2 p.m. to 4 p.m. each day to give them the opportunity to rest.
The earlier PPSA study mentioned hourly rounding as a potential preventive intervention, with nurses intervening when finding a sleepy mother with a newborn in her arms. One of the hospitals in the more recent PPSA study noted nurses were already rounding every hour on the maternity ward, so they increased this to every 15 minutes as an added precaution when mothers are breastfeeding. Some even use handheld timers to support the nurses in this practice.
Staff training should include education on the American Academy of Pediatrics recommendations for safe sleep practices to prevent sleep-related deaths among infants, and learning how to lock hospital beds in the lowest position to reduce the likelihood of injury if a newborn were to fall from the bed.
The recent PPSA review (Kukielka 2019) does not comment on the role that maternal medications might have played. But the prior PPSA review (Wallace 2014) did note their literature review of risk factors noted cesarean birth, pain medication in the last two to four hours, and history of narcotic substance use and/or methadone treatment program as potential risk factors.
The Joint Commission, in a Quick Safety alert “Preventing Newborn Falls and Drops” (TJC 2018), advocated doing a risk assessment to identify newborns most at risk for falls, then educating the parents based on that assessment. The Joint Commission Quick Safety alert also recommends:
Note that we have stressed in several prior columns on falls the importance of doing post-fall assessments promptly. We’re not just talking about examining the newborn for evidence of physical harm. We are talking about determining factors that likely contributed to the event so that recurrences can be prevented. In prior columns we gave links to some examples of post-fall evaluation tools, such as an excellent form for post-fall huddles after newborn falls on the PPSA website.
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The National Health Service (UK) also in 2019 released a safety alert on assessment and management of babies who are accidentally dropped in hospitals (NHS 2019a). A search of their National Reporting and Learning System (NRLS) for a recent 12-month period identified 182 babies who had been accidentally dropped in obstetric/midwifery inpatient settings, 66 babies accidentally dropped on pediatric wards, and two in mother and baby units in mental health trusts. Almost all of these 250 incidents occurred when the baby was in the care of parents or visiting family members. Eight of those dropped in the obstetrical settings had significant reported injuries, including fractured skulls and/or intracranial bleeds,
The NHS found that responses to such incidents were quite variable, so the alert provided a resource to support providers to develop or update a tailored local guide on the initial actions to take when a baby has been accidentally dropped. Guidelines for the latter (NHS 2019b) include recommendations on:
The 2 PPSA reviews, and other studies in our March 2019 What's New in the Patient Safety World column “Newborn Falls” such as the one from Driscoll et al. (Driscoll 2019), have emphasized breastfeeding and rooming-in as significant risk factors. Of course, we encourage breastfeeding. So, we need to take extra precautions to ensure that breastfeeding is done safely. In addition to the “educational” interventions, we like the ideas for signage and for upping the hourly rounding to every 15-minute rounding when the mother is breastfeeding. But that can be difficult on labor and delivery units, especially when there are several ongoing labors that may require staff be elsewhere during those nocturnal hours when newborns are at greatest risk. Is this a scenario where technology might help? Companies are working on smart cameras to detect when a car driver’s eyelids are getting heavy. Perhaps that sort of technology could be used to identify mothers (or fathers) at risk of falling asleep while holding their newborns.
We like the idea of a technology intervention since most of the other interventions mentioned above rely heavily on education (of parents and staff). In one of our other January 2020 What's New in the Patient Safety World columns “ISMP Canada: Change Management to Prevent Recurrences” we again remind everyone that education/training rank lowest on our list of strengths of interventions. However, we also caution against overreliance on technology, since we may become complacent and assume the technology will prevent untoward events at the expense of our other interventions (see our Patient Safety Tips of the Week for August 23, 2016 “ISMP Canada: Automation Bias and Automation Complacency” and June 11, 2019 “ISMP’s Grissinger on Overreliance on Technology”).
And, yes, don’t forget dads, too. Fathers are the caregiver with the newborn in about 10% of the newborn falls. While moms have done all the work and are entitled to be fatigued, dads may get fatigued trying to balance visits to the maternity wing with caring for the other kids at home.
And what about those falls/drops that occur during deliveries? The viral video and the other report of newborns falling or being dropped during deliveries are particularly distressing. In one incident, a newborn was dropped on her head while being handled by staff immediately following delivery (Westfall 2019). Video of the incident shows three staff members transferring the baby from one set of blankets to another. The newborn is lifted up by one of them, who is still gripping a medical instrument. Then the worker loses control of her. The baby flips, lands on her head on the table and almost falls over the edge. The workers snatch her up, turn her over and wrap her in a blanket. The baby apparently had some sort of cerebral hemorrhage, though the article did not clarify whether that was the result of the drop or due to prematurity.
In the other incident, a newborn died during delivery (Penza 2019). His mother had reportedly been told to push, but he came out too fast and fell onto the ground. According to the father “My wife was in labor and was just about to have the baby and they asked her to push and she pushed so he would come out. He came out really fast and no-one grabbed him and he fell to the floor. The midwife didn’t have time to catch him and the obstetrician didn’t react.”
Seems to be a rarity. However, the UK NHS alert (NHS 2019a) also notes that 4% of their incidents occurred during “precipitate” birth and the recent PPSA study (Kukielka 2019) found 5 events over the 5 year period (1.6% of the total newborn falls) in which the newborn fall occurred following a precipitous delivery. Few details were provided though they note high-risk situations have been identified including delivery, especially when the mother has lost a significant amount of blood. The infant in the case described above (Westfall 2019) was a twin, though the article does not mention whether she was the first or second delivered (though one of many articles with the viral video said the father was watching delivery of the other twin while he was filming the video). Either way, it suggests some sort of urgency during the delivery. So, we’d probably add distractions (such as maternal hemorrhage or multiple births) as risk factors for newborn falls during delivery.
The increase in occurrence of newborn falls as noted by the PPSA and the Joint Commission and UK NHS should raise our awareness of the risks and contributing factors. Particularly if your organization takes care of newborns in any setting, you might consider doing a FMEA (Failure Mode and Effects Analysis) to identify your potential vulnerabilities. And learn from the many valuable lessons in this and our other columns on newborn falls.
Update: Regarding a technology solution, the very day we posted the original column we received notice of an iPhone app called “Keep Alert”. It appears to do exactly what we are looking for! You focus the iPhone camera on your face and, if your eyelids droop or close, it sets off an alarm. We tried it on ourselves and it clearly delivered as advertised. Maybe one of you with a maternity ward can try this out on your moms who are breastfeeding.
Some of our prior columns related to newborn falls:
Some of our prior columns related to falls:
References:
Wallace SC. (Pennsylvania Patient Safety Authority). Balancing Family and Newborn Bonding with Patient Safety. Pa Patient Saf Advis 2014; 11(3): 102-108
http://patientsafety.pa.gov/ADVISORIES/Pages/201409_102.aspx
Kukielka E, Wallace SC. Newborn Falls in Pennsylvania: An Analysis of Recent Events and a Review of Prevention Strategies. Patient Safety 2019; 1(2): 45-53 December 2019
https://patientsafetyj.com/index.php/patientsaf/article/view/newborn-falls/55
The Joint Commission. Quick Safety 40: Preventing Newborn Falls and Drops. The Joint Commission 2018; March 27, 2018
PPSA (Pennsylvania Patient Safety Authority). Newborn Fall UOR Debrief Form. PPSA 2014
http://patientsafety.pa.gov/pst/Pages/Newborn%20Injuries/form.aspx
NHS (National Health Service UK). Patient Safety Alert. Assessment and management of babies who are accidentally dropped in hospital. NHS 2019; 9 May 2019
NHS (National Health Service UK). Creating a local guide for the assessment and management of babies who are accidentally dropped in hospital. NHS 2019
Driscoll CAH, Pereira N, Lichenstein R. In-hospital Neonatal Falls: An Unintended Consequence of Efforts to Improve Breastfeeding. Pediatrics 2019; 143(1): e20182488
Westfall A, Sanders RL. Graphic video shows baby dropped on head by staff at Chandler hospital. Arizona Republic 2019; May 3, 2019
Penza N. Freak Accident. Newborn baby died seconds after birth when medics failed to catch him and he fell headfirst on to the floor. The Sun 2019; 19 Dec 2019
https://www.thesun.co.uk/news/10566959/newborn-baby-died-birth-medics-fell-headfirst-floor/
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January 21, 2020
Disruptive Behavior and Patient Safety: Cause or Effect?
We’ve done many columns, listed below, on the association between disruptive behavior and adverse outcomes from a patient safety perspective. Multiple studies have shown that healthcare professionals who exhibit disruptive behavior are more likely to be associated with poor patient outcomes or adverse patient safety events.
But what about the other potential interpretation of the association, i.e. that the disruptive behavior might be the result rather than the cause? Some new research actually raises that possibility.
Heslin and colleagues (Heslin 2019) analyzed 314 reports of disruptive behavior, involving 227 healthcare professionals, at a single institution over a 2-year period. They compared both reporter accounts and involved party responses to determine if disruptive behavior was inherent to the surgeon or the hospital environment and its relationship to patient safety. 76% of involved parties had only a single event. All involved parties were physicians, 2/3 being attending physicians and 1/3 residents.
Surgical, medical, and other specialties were the involved parties in 48%, 25% and 27% of reports, respectively. High intensity environments (OR, ICU, etc.) made up 56% of the total.
Perceived unprofessional behavior or lack of communication was present in 70% and 44% of events, respectively. They found a significant direct relationship between the stress of the clinical situation and the egregiousness of the behavior. The following factors were associated with potential patient harm: unclear hospital policies, the involved party being a surgeon, and urgent competing responsibilities. The authors concluded that unclear policies and urgent competing responsibilities in the surgical environment create stress, leading to conflict. That most involved parties had a singular event suggests the environment as the primary contributor.
In an interview with Anesthesiology News (Frangou 2020) the investigators said “To us, this is an indication that further resources are needed to address the systemic stressors that can lead to frustration that is perceived as disruptive behavior, resulting in event reports for individuals who are most often focused on delivering high-quality patient care.”. They note that efforts to improve the culture of communication in hospitals might not be addressing the root causes of many cases of disruptive behavior.
They also noted that reported cases involving a physician who had been reported for more than one incident of disruptive behavior were less likely to be related to a patient safety event.
Reported causes or contributing factors included:
Some incidents involved more than one factor.
We’ve had plenty of experience dealing with disruptive physician behavior over the years. And, yes, there are always 2 sides to every story. While you cannot dismiss the disruptive behavior, you do need to listen to and look for events or circumstances that may have served as triggers for such behavior. Our own experience would identify inadequate resources (personnel or equipment/supplies), overwork, and fatigue as the most frequent contributing factors.
Contrary to what Heslin et al. found, we often saw such triggers in system issues even for those “repeat offenders”. So, a good rule is to always look at the entire picture, even in cases where that physician has exhibited more than one episode of such behavior. But beware: be very sure that your investigation and actions do not serve to deter anyone from coming forward with such complaints against healthcare professionals. We’ve certainly seen examples where actions taken by Medical Executive Committees have appeared to show retribution to those who came forward. That leads to a culture that is detrimental to both patient safety and workforce morale in general. In fact, we might argue that the biggest factor contributing to disruptive behavior is a culture that tolerates such behavior.
So, is there a lesson here? Yes. When we see something that violates a patient safety concept, we need to look for a root cause or contributing factors. You have heard us before state that when you come across a workaround, you always need to look for reasons that workaround was used (i.e. a root cause). The same probably applies in cases of disruptive behavior, perhaps more so when the “offending party” has no history of previous disruptive behavior. If you identify an instance of disruptive behavior, you must deal not only with the individual and the behavior, but also look to see what system factors may have contributed to that behavior.
Some of our prior columns on the impact of “bad behavior” of healthcare workers:
January 2011 “No Improvement in Patient Safety: Why Not?”
March 29, 2011 “The Silent Treatment: A Dose of Reality”
July 2012 “A Culture of Disrespect”
July 2013 “"Bad Apples" Back In?”
July 7, 2015 “Medical Staff Risk Issues”
September 22, 2015 “The Cost of Being Rude”
April 2017 “Relation of Complaints about Physicians to Outcomes”
October 2, 2018 “Speaking Up About Disruptive Behavior”
August 2019 “More on the Cost of Rudeness”
References:
Heslin MJ, Singletary B, Benos K, et al. Is Disruptive Behavior Inherent to the Surgeon or the Environment? Analysis of 314 Events at a Single Academic Medical Center. (Abstract #8) American Surgical Association Annual Meeting 2019
https://meeting.americansurgical.org/abstracts/2019/8.cgi
Frangou C. Disruptive Behavior Mostly Arises from Systemic Causes, Study Finds
Most Cases Involve Physicians With No History of Abusive Behavior. Anesthesiology News 2020; January 3, 2020
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January 28, 2020
Dang Those Cell Phones!
Cell phones are great. They have made great improvements, not only in our private lives, but also in healthcare. They allow us to get medical information to our fingertips almost instantaneously. They allow us to get appropriate access to necessary medical records easily. They give us access to medical algorithms and calculators at the point of care. They have largely made the pager an anachronism. The ability to do asynchronous communication (for example, by texting or email) has made communication more efficient. We now even use them to alert appropriate caregivers to alarms and alerts, helping to reduce alarm fatigue (keeping in mind the potential downside that we discussed in our February 9, 2016 Patient Safety Tip of the Week “It was just a matter of time…”).
But not everything about cell phones in healthcare is rosy. They can serve as a significant and growing source of distractions and interruptions in multiple healthcare venues, such as the OR (see our multiple columns listed below).
But it’s not just in the OR that they may be a source of distraction. A new study in a Pediatric Intensive Care Unit (PICU) setting (Bonafide 2019) demonstrated that incoming telephone call interruptions may be temporally associated with medication administration errors among PICU nurses.
This was a retrospective study looking at incoming telephone calls and text messages received on the institutional mobile telephone assigned to the nurse in the 10 minutes leading up to a medication administration attempt. Medication errors included both reported medication administration errors and bar code medication administration error alerts generated when nurses attempted to give medications without active orders for the patient whose bar code they scanned.
The overall rate of errors during 238,540 medication administration attempts was 3.1% when nurses were uninterrupted by incoming telephone calls and 3.7% when they were interrupted by such calls.
Risk of error did vary by shift, nurse level of experience, nurse to patient ratio, and level of patient care required. Phone call related errors were more frequent on the night shift and for nurses with less than 6 months of experience. Nurses administering medications to 1 or more patients receiving mechanical ventilation and arterial catheterization while caring for at least 1 other patient also had an increased risk of error related to phone calls.
Interestingly, incoming text messages were not associated with error.
There is one consideration we always raise with a study like this. The study did not measure the impact on overall errors in the PICU. It focused solely on those related to medication errors. It is quite likely that many of the phone calls may have been important in averting adverse events for other patients in the PICU.
Answers are not readily available to address this issue. Obviously, if we truly make medication administration a “no interruption zone”, the answer is for the nurse to turn off the cell phone all together. That might be a solution on a floor where one nurse is charged with medication administration. However, in a unit like the PICU the nurse is likely administering medications to just the one or two patients he/she is responsible for. It may not be practical to turn off cell phones in that scenario (particularly if their cell phones are tied to an alarm/alert system). Even on the floor, it might be impractical on some shifts for a nurse administering medications to be totally freed from other responsibilities that might necessitate use of a cell phone.
The issue of personal phones in other venues, particularly the OR, has long been debated. A case described in our August 20, 2019 Patient Safety Tip of the Week “Yet Another (Not So) Unusual RSI” was a great example of a reason we counsel against allowing phones in the OR. In that case, a surgeon’s phone ringing several times during a surgical count was one of several factors likely contributing to a retained surgical item. Our Patient Safety Tips of the Week May 21, 2013 “Perioperative Distractions”, March 17, 2015 “Distractions in the OR”, and July 21, 2015 “Avoiding Distractions in the OR” had detailed discussion about use of cell phones and other wireless devices in and around the OR with multiple examples of distractions related to such in the OR. There are a multitude of issues related to cell phones in the OR including not only interruptions and distractions but also infection control issues, security and confidentiality issues, and detrimental effects on communication in the OR. Our own recommendation is for all the OR team to leave their cellphones at the main OR desk where someone can triage incoming phone calls and messages.
AORN (Association of periOperative Registered Nurses) recently proposed several recommendations to reduce distractions and interruptions in the OR (AORN 2019). Some focused on reducing overall sources of noise pollution in the OR. But others focused specifically on cell phones.
One recommendation is to “Emphasize the importance of limiting non-essential conversations, muting cell phones or limiting their use, and limiting the number of people in the OR.”
Another is to reiterate safe cell phone use, recognizing that some facilities allow surgical team members to carry their personal cell phone with them, Regular reminders about safe cell phone use can be helpful, such as “Personal devices may add to the overall noise pollution in the OR, which can distract personnel from clear communication and safe patient care.” It goes on to emphasize minimization of distractions during critical phases of the procedure, such as the time out, anesthesia induction and emergence, surgical counts, and specimen management. Especially during those critical times, “personal devices should be left outside the OR, turned off, placed on vibrate or silent mode, and handled only when needed.”
A number of questions about cell phones in the OR were addressed in a recent AORN Journal (Ogg 2019). The AORN "Guideline for a safe environment of care" recommends that personal electronic devices should be limited to use directly required for job performance. It states that health care organizations should have policies and procedures in place that specify when a cell phone may be brought into the OR. Furthermore, it states that perioperative personnel also should consider interventions to mitigate the known risks associated with bringing personal electronic devices into the OR.
They note the risks involved with bringing a personal electronic device into the OR include:
They cite statistics on microbial contamination of cell phones and note interventions that may reduce the risk of a surgical site infection (SSI) originating from contaminated personal electronic devices include cleaning the device regularly, handling the device sparingly, and performing hand hygiene after each use.
Overall, they recommend that, whenever possible, personal devices should be:
And the other issue related to cell phones is the issue of texting. Orders should never be texted (see our multiple columns on the subject below). But even for messages used for communication other than orders, care must be taken so that commonly used text abbreviations and shortcuts are not mistaken by these receiving the texts.
Prior Patient Safety Tips of the Week dealing with cell phones:
See our other Patient Safety Tip of the Week columns dealing with texting:
References:
Bonafide CP, Miller JM, Localio AR, et al. Association Between Mobile Telephone Interruptions and Medication Administration Errors in a Pediatric Intensive Care Unit. JAMA Pediatr 2019; Published online December 20, 2019
https://jamanetwork.com/journals/jamapediatrics/article-abstract/2757364
AORN (Association of periOperative Registered Nurses). Can You Hear Me? 3 Reminders to Reduce OR Distractions. Periop Today 2019; December 11, 2019
Ogg MJ, Anderson MA. Clinical Issues—August 2019. AORN Journal 2019; 110(2): 199-202 First published: 29 July 2019
https://aornjournal.onlinelibrary.wiley.com/doi/full/10.1002/aorn.12767
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February 4, 2020
Drugs and Chronic Kidney Disease
Medication use is an important aspect of management of CKD (chronic kidney disease). There are at least 5 important issues:
In the last couple months there have been several studies pertinent to these issues. First, there was an excellent recent review of the management of CKD by Chen et al. in JAMA (Chen 2019). Then there was a study (Tuttle 2019) showing, in patients at risk for CKD, low rates of prescribing potentially beneficial medications (eg. ACE inhibitors or ARB’s) but common use of potentially nephrotoxic agents (eg, NSAID’s and PPI’s). Yet another study (Lefebvre 2020) found that potentially nephrotoxic medications are prescribed at high rates to children with CKD. And, then, an expert panel published in the Annals of Pharmacotherapy (Taji 2020) a consensus-based pragmatic list of medications used in primary care that require dosage adjustment or avoidance in people with CKD.
The Tuttle study (Tuttle 2019) mined detailed patient-level EHR data from more than 600,000 adults and over 12,000 children with CKD in the CURE-CKD registry. 33.7% of adults with CKD received potentially nephrotoxic agents nonsteroidal anti-inflammatory drugs (NSAID’s) or proton pump inhibitors (PPI’s), compared to renoprotective drugs like renin-angiotensin system inhibitors, which were prescribed to only 20.6%. Although nearly two-thirds of the adults with CKD had diabetes, hypertension, or prediabetes, rates of laboratory testing for albuminuria or proteinuria and of prescribing ACE inhibitors or ARBs were low. Given the most common cause of death in CKD is cardiovascular disease, the low use of cardiovascular preventive agents, such as statins and aspirin, is also concerning. The Tuttle study did not report prescription rates for other potentially nephrotoxic drugs.
Though the CURE-CKD data registry included children, the Tuttle study reported primarily on adults with CKD. On the other hand, Lefebvre and colleagues (Lefebvre 2020) looked at use of potentially nephrotoxic medications in patients aged <18 years in a large research database of patients in primary care practices in the UK, matching patients with CKD to those without CKD. The overall rate of nephrotoxic medication prescriptions was 71 prescriptions per 100 person-years in patients with CKD and eight prescriptions per 100 person-years in patients without CKD (adjusted rate ratio, 4.1). One would actually have expected the CKD group would have lower rates of nephrotoxic medication prescriptions, so the findings were particularly bothersome.
One of the most important things in management of CKD is to avoid potential nephrotoxins. NSAID’s (non-steroidal anti-inflammatory drugs) are probably the biggest offender that are commonly used. The Chen review (Chen 2019) notes “Routine administration of NSAID’s in CKD is not recommended, especially among individuals who are taking ACE-I or ARB therapy.”
The Chen review also discussed common medications that require dose reductions in the presence of CKD, including most antibiotics, direct oral anticoagulants, gabapentin and pregabalin, oral hypoglycemic agents, insulin, chemotherapeutic agents, and opiates, among others. Most of these categories also made the Taji (Taji 2020) consensus-based final list of 24 medications routinely used in the primary care setting that should be avoided or dose adjusted based on a patient’s eGFR:
The Taji study also produced a list of 12 medications that could be considered for dose adjustment or avoidance, including:
The Taji lists do not include over-the-counter medications or commonly used herbal or alternative medication remedies. The Chen review notes, in particular, those herbal remedies containing aristolochic acid or anthraquinones have been associated with a variety of adverse renal effects.
Not included in the list compiled by Taji et al. (Taji 2020) are drugs that should be avoided because they may aggravate some complications of CKD. For example, the Chen review notes that phosphate-based bowel preparations (both oral and enema formulations), which are readily available over-the-counter, can lead to acute phosphate nephropathy.
The Chen review also clarified some issues about the use of PPI’s (proton pump inhibitors) in patients with CKD. Though it concludes that uniform discontinuation of proton pump inhibitors in CKD is not necessary, it does suggest that indications for use of PPI’s should be addressed at each primary care visit. (Of course, in our many columns on polypharmacy and deprescribing, we’ve frequently discussed that PPI’s are often inadvertently continued without clear-cut indications in all patients, not just those with CKD.)
The Chen review notes that gadolinium-based contrast agents are contraindicated in individuals with acute kidney injury, eGFR less than 30 mL/min/1.73 m2, or end-stage kidney disease, given the risk of nephrogenic systemic fibrosis (NSF). It goes on to note that newer macrocyclic chelate formulations (eg, gadoteridol, gadobutrol, or gadoterate) are much less likely to cause nephrogenic systemic fibrosis, but that the best prevention may still be to avoid gadolinium altogether. They recommend that, if administration of gadolinium is deemed essential, the patient must be counseled on the potential risk of nephrogenic systemic fibrosis and a nephrologist may be consulted for consideration of postexposure hemodialysis.
Other contrast dyes, such as those used in CT scanning and angiography, may rarely be associated with Contrast Induced Nephropathy (CIN). About 2 percent of people receiving dyes can develop CIN (NKF 2019). However, the risk for CIN can increase for people with diabetes, a history of heart and blood diseases, and chronic kidney disease (CKD). The risk of CIN in people with advanced CKD (GFR below 30 mL/min/1.73m2) increases to 30 to 40 percent. And the risk of CIN in people with both CKD and diabetes is 20 to 50 percent.
Clearly, caution must be used when using such contrast agents in patients with CKD. The most important consideration is whether contrast is absolutely necessary for the study. If it is necessary, steps should be taken to minimize the risk of CIN, such as ensuring adequate hydration, using the least amount of contrast necessary, and avoiding repeat contrast administration too soon.
It’s also important to monitor the patient for CIN or NSF after studies utilizing each type of contrast agent, respectively.
CPOE (computerized physician order entry) and e-Prescribing systems offer clinical decision support (CDSS) tools that should help avoid both inappropriate medications and inappropriate medication dosages in patients with CKD. The eGFR is readily available in the electronic medical record of almost every patient so the CDSS should be able to check the eGFR and alert the clinician of the need to adjust the dose of one of these medications or avoid their use altogether. Now is a good time for you to utilize the information in these recent studies to investigate whether your CPOE system (if you are a hospital) or your e-Prescribing system (in your practice or clinic setting) have up-to-date clinical decision support tools that can aid your prescribing medications to patients with CKD.
Similarly, your CPOE and e-Prescribing systems and radiology information systems (RIS) should have decision support tools that automatically check the eGFR when any study is ordered using contrast or gadolinium contrast and issue alerts as appropriate.
Update: After we posted this column, Wooden and colleagues (Woolen 2020) published a systematic review and meta-analysis on the incidence of the risk of nephrogenic systemic fibrosis in patients with stage 4 or 5 chronic kidney disease receiving a group II gadolinium-based contrast agent. Agents in the American College of Radiology classification group II GBCA are: gadobenate dimeglumine, gadobutrol, gadoterate meglumine, and gadoteridol. They found that the risk of NSF from group II GBCA administration in stage 4 or 5 CKD is likely less than 0.07%. They suggest that the potential diagnostic harms of withholding group II GBCA for indicated examinations may outweigh the risk of NSF in this population.
The accompanying editorial (Maripuri 2020) concurs that the strength of the evidence favors a more permissive approach to using group II GBCAs in patients with CKD, especially when contrast-enhanced MRI is the superior imaging modality. It points out a disconnect between the more conservative approach still maintained by the FDA and the more permissive guidelines from the ACR. It notes a probable similar disconnect between nephrologists and radiologists, with the former concerned that the lack of cases may be driven by avoidance of GBCAs in high-risk patients and the latter more convinced by the biochemical case for safety of newer GBCAs.
Some of our prior columns on dialysis, CKD, and ESRD:
March 26, 2007 “Alarms Should Point to the Problem”
February 2009 “Unintended Consequences of eGFR Reporting”
May 2009 “Erythropoiesis-Stimulating Agents and Mortality”
September 20, 2011 “When Practice Changes the Evidence: The CKD Story”
September 2013 “Is Nephrologist Caseload Related to Dialysis Mortality?”
September 2014 “New Tubing Connections”
June 23, 2015 “Again! Mistaking Antiseptic Solution for Radiographic Contrast”
November 1, 2016 “CMS Emergency Preparedness Rule”
April 25, 2017 “Dialysis and Alarm Fatigue”
July 16, 2019 “Avoiding PICC’s in CKD”
December 10, 2019 “Dialysis Line Dislodgements”
References:
Chen TK, Knicely DH, Grams ME. Chronic Kidney Disease Diagnosis and Management: A Review. JAMA 2019; 322(13): 1294-1304
https://jamanetwork.com/journals/jama/article-abstract/2752067
Tuttle KR, Alicic RZ, Duru OK, et al. Clinical Characteristics of and Risk Factors for Chronic Kidney Disease Among Adults and Children: An Analysis of the CURE-CKD Registry. JAMA Netw Open 2019; 2(12): e1918169
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2757881
Lefebvre CE, Filion KB, Reynier P, et al. Primary Care Prescriptions of Potentially -Nephrotoxic Medications in Children with CKD. CJASN 2020; 15(1): 61-68
https://cjasn.asnjournals.org/content/15/1/61
Taji L, Battistella M, Grill AK, et al. Medications Used Routinely in Primary Care to be Dose-Adjusted or Avoided in People With Chronic Kidney Disease: Results of a Modified Delphi Study. Annals of Pharmacotherapy 2020; First Published January 2, 2020
https://journals.sagepub.com/doi/abs/10.1177/1060028019897371?journalCode=aopd
NKF (National Kidney Foundation). Contrast Dye and the Kidneys. NKF 2019; Accessed January 28, 2020
https://www.kidney.org/atoz/content/Contrast-Dye-and-Kidneys
Woolen SA, Shankar PR, Gagnier JJ, MacEachern MP, Singer L, Davenport MS. Risk of Nephrogenic Systemic Fibrosis in Patients With Stage 4 or 5 Chronic Kidney Disease Receiving a Group II Gadolinium-Based Contrast Agent: A Systematic Review and Meta-analysis. JAMA Intern Med. 2020;180(2):223–230
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2757311
Maripuri S, Johansen KL. Risk of Gadolinium-Based Contrast Agents in Chronic Kidney Disease—Is Zero Good Enough? JAMA Intern Med. 2020;180(2):230–232
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2757307
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February 11, 2020
ERAS Rocks!
We did our first presentation on ERAS (Enhanced Recovery After Surgery) 10 years ago. It has also been known by multiple different names (Enhanced Recovery After Surgery or ERAS, Enhanced Recovery or ERP, Fast Track, Accelerated Recovery, etc.). ERAS made its name in colorectal surgery but now has been adopted for a wide variety of surgical procedures. ERAS has been a success in both financial and human terms. It reduces complications or surgery, shortens hospital length of stay considerably, and is very cost-effective.
But widespread adoption of ERAS has been relatively slow, perhaps because many of its components were foreign to many “old time” surgeons. Perhaps we were early champions of ERAS because one of its major elements dates back to seminal research done by one of our former colleagues at the Erie County Medical Center and University of Buffalo, Dr. John Borders. Dr. Borders’ research showed the detrimental effects of letting the gut go to sleep in trauma patients. One of the key elements of ERAS is “don’t put the gut to sleep”.
The basic philosophical elements of ERAS are:
Components of ERAS:
A review of ERAS (Ljungqvist 2017) described work of the international ERAS® Society. The review described the evidence-based care changes in ERAS programs: change from overnight fasting to carbohydrate drinks 2 hours before surgery, minimally invasive approaches instead of large incisions, management of fluids to seek balance rather than large volumes of intravenous fluids, avoidance of or early removal of drains and tubes, early mobilization, and serving of drinks and food the day of the operation. It touts that ERAS protocols have resulted in shorter length of hospital stay by 30% to 50% and similar reductions in complications, while readmissions and costs are reduced. Altman et al. (Altman 2019) note that implementation of an ERAS protocol can lead to savings of $2200-$2500 per patient treated.
In 2017 the American College of Surgeons (ACS), in collaboration with the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality launched the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Surgical Care and Recovery (ISCR), funded and guided by AHRQ (ACS 2017, ACS 2020).
The AHRQ Safety Program for ISCR will support hospitals in implementing perioperative evidence-based pathways to meaningfully improve clinical outcomes, reduce hospital length-of-stay, and improve the patient experience. This program aims to enroll at least 750 hospitals throughout the five-year contract. Participating hospitals will have access to US leaders in enhanced recovery, including representatives of surgery, anesthesiology, and nursing, prototype enhanced recovery pathways developed for procedures in colorectal, orthopedic, gynecology, and emergency general surgery, based on up-to-date evidence review, literature to support pathways, tools and educational materials to facilitate implementation, quality improvement support from a nurse consultant, and coaching calls to support hospital work.
And, this month, Williams and colleagues published a study on the Canadian experience with ERAS in a special issue of the Canadian journal Healthcare Quarterly (Williams 2020). The Canadian Patient Safety Institute (CPSI) launched the Enhanced Recovery Canada™ (ERC) program in early 2017.
The ERC began as “a volunteer group of passionate physicians, nurses, patients and allied healthcare providers who agreed to work together to spread ERAS across the country” after recognizing its slow adoption in Canada. It convened stakeholders from multiple disciplines and multiple organizations.
A core group developed the resources and knowledge tools to support teams with ERAS implementation and identified metrics for evaluation of the program. They developed clinical pathways, first focusing on ERAS in colorectal surgery but with the intent to spread to other surgeries in the future. The ERC clinical pathways focus on nutrition, mobilization, hydration, pain and symptom control and other surgical best practices (such as prevention of surgical site infections).
What are the features of ERAS programs and protocols?
Two excellent articles describe the development and implementation of ERAS protocols. Wu et al. (Wu 2017) described the development and implementation of a colorectal ERAS pathway at Johns Hopkins Hospital. Altman and colleagues (Altman 2019) also describe both the elements of ERAS and how to go about implementing ERAS in Canadian hospitals.
There are slight differences between the Hopkins and the Canadian individual elements in the ERAS protocols, but they are mostly in agreement. Both, of course, also incorporate those evidence-based elements that apply to all surgery, regardless of whether ERAS is being used or not.
Pre-hospital Optimization
Both the patient’s primary care physician and the multidisciplinary team are important in educating the patient about the surgery and the recovery period and preparing him/her for the surgery. Patients are encouraged to quit smoking at least 4 weeks prior to surgery for elective cases. PCP’s can be very valuable in both counseling the patients and prescribing smoking cessation aids. Patients are also counseled about alcohol cessation, where appropriate. They are also instructed about when and which medications should be discontinued prior to surgery. Nutritional counseling is also important.
Pre-operative Phase
Most important in the pre-operative period relates to diet/oral intake. The time-honored adage “NPO after midnight” no longer applies. Many ERAS protocols do recommend stopping solid foods 6 hours before surgery and clear fluids 2 hours before surgery. But a carbohydrate load 2 hours prior to surgery is a mainstay of ERAS protocols.
The issue of a bowel prep depends upon what type of surgery is being performed. Pre-op, patients are usually given a combination of non-opioid analgesics (usually acetaminophen and/or NSAID’s, if appropriate) and antiemetics. (Some have also used gabapentin but we’d be cautious about that given our discussion in our January 2020 What's New in the Patient Safety World column “FDA Warning on Gabapentinoids”.) Also, for those surgeries where maintenance of normothermia is important, a warming blanket or equivalent is provided.
Intraoperative Phase
Just prior to surgery, prophylactic antibiotics are given (as recommended for the particular type of surgery) and DVT prophylaxis may be indicated in some cases (beware when epidural catheters used).
The original ERAS protocols, which were developed for colorectal surgery, emphasized use of epidural anesthesia/analgesia in order to minimize the use of opioids. Whether an epidural is used depends today upon the type of surgery being performed. During surgery, in addition to the anesthesia used, non-opioid analgesics and antiemetics are usually also given.
One of the basic theories leading to ERAS has been avoidance of fluid overload. Hence, most ERAS protocols have focused on maintenance of euvolemia. We recall seeing many colorectal surgery patients with significant edema and symptoms of fluid overload, including pulmonary congestion, several days following surgery. That is one of the reasons ERAS protocols have focused on fluid management. Restricting fluids to achieve zero balance is a key component of enhanced recovery after surgery (ERAS) pathways. But that concept has been challenged by researchers who noted the evidence for fluid restriction is scant and theoretically might predispose patients to complications of hypotension and reduced organ perfusion, leading to organ dysfunction. So those researchers undertook the Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) trial (Myles 2018). They found that, in patients at increased risk for complications during major abdominal surgery, a restrictive fluid regimen was not associated with a higher rate of disability-free survival than a liberal fluid regimen and was associated with a higher rate of acute kidney injury.
So, issues surrounding fluid status remain somewhat controversial. It is probably wise to avoid fluid restriction that might promote hypotension or inadequate tissue perfusion, yet also avoid providing so much fluid that the post-op sequelae described above don’t occur.
One core concept of ERAS has been to avoid tubes (NG tubes, Foley catheters, etc.) and drains. Nasogastric intubation is not routinely recommended for bowel surgery as it is known to be associated with increased risk of postoperative pneumonia and has not been associated with a reduction in wound dehiscence or anastomotic leak. And the historic use of peritoneal drains (e.g., Jackson–Pratt drain) has also become less common.
Post-op Phase
Early feeding and early mobilization are the hallmarks of ERAS protocols. We emphasized above avoiding putting the gut to sleep. So early feeding is a key component of all ERAS protocols. Many begin clear liquids right after surgery and advance diet as tolerated. Use of antiemetics and avoidance of opioids are important in promoting early feeding.
Pain management depends upon whether the oral route is available. If a patient is not yet taking things orally, epidural analgesia is important. The Hopkins protocol used patient-controlled epidural bupivacaine. Once the patient is able to take things orally, multimodal analgesia, minimizing use of opioids, is the heart of the ERAS protocol. The Hopkins protocol uses acetaminophen, ibuprofen and gabapentin (again, see our caution on gabapentin in our January 2020 What's New in the Patient Safety World column “FDA Warning on Gabapentinoids”). Use of a Lidoderm patch may also be helpful. For breakthrough pain, they first use tramadol and only go to more potent opioids if that fails.
Get that Foley out! We have done so many columns on CAUTI’s that we hate to elaborate on this again. But there may be challenges in this population. Continued use of epidural analgesia may prevent early urinary catheter removal. And, in those cases where fluid overload remains problematic, some advocate continued use of a urinary catheter for accurate I&O measurement. But if the patient is alert the catheter can usually be removed. If there are questions about urinary retention, use of bladder ultrasound has been very useful.
Note that early catheter removal also facilitates promotion of early mobilization, the other key component of post-op ERAS. The Altman article notes that many protocols include actively mobilizing the patient within 24 hours of surgery, and that most suggest mobilizing for a minimum of 2 hours on the day of surgery, followed by 6 hours on all subsequent hospital days. And it is important to note that early mobilization can take place in an ICU setting as well as on a med/surg floor,
So how do you go about implementing ERAS?
Altman and colleagues (Altman 2019) offered the following key points in starting an ERASA program:
They emphasize that your multidisciplinary team should include family physicians and will interact with patients before admission and after discharge.
These are the same steps we went through 10 years ago as we promoted ERAS. We began with meetings with surgeons, anesthesiologists, OR nurses, OR manager, floor and ICU nurses, and administrators. Our first task was to show the theory of ERAS, elaborate on the evidence base for ERAS, and point out the advantages to patients, healthcare professionals, and the hospital.
Barriers/Challenges
The Altman article also notes some of the challenges in implementing ERAS protocols. One is having adequate staffing to promote that early mobilization, noting that may require increased support from nursing, health care aids and physiotherapy. It also notes that sometimes resistance to early removal of urinary catheters may come from night staff, though we have always found nursing staff to actually be forceful advocates for catheter removal. It also points out the issue of DVT prophylaxis in patients with epidural catheters.
In our experience, the biggest barrier to ERAS implementation is resistance to change in general. “We’ve always done it this way” is the bane of any change management program. Another barrier is the lack of availability of anesthesia support for epidural analgesia, a problem more often seen in small and rural hospitals. And, of course, there is the dichotomy between complete elimination of pain vs. the adverse effects on bowl function of opioids.
You may have to convince your CFO to fund the extra help needed for early mobilization. But once he/she sees the likely fiscal benefits of an ERAS program, he/she should have no qualms about complying with that request.
Facilitators
Having clinical champions is the key. That includes not only surgical champions but also anesthesiologist and nursing staff that are strong advocates. Having a representative multidisciplinary team involved in all aspects of planning and implementation is important. Above all, communication is essential at all levels. Getting the support of frontline staff is key in any change management project.
Grant et al. (Grant 2019) emphasized the role anesthesiologists play in ERAS programs. They looked at compliance with 9 specific process measures directly influenced by the anesthesiologist or acute pain service. They found that process measure compliance was associated with a stepwise reduction in LOS (length of stay). Patients who received >4 process measures (high compliance) had a significantly shorter LOS (incident rate ratio IRR 0.77) compared to low compliance (0–2 process measures) counterparts. Parameters independently associated with reduced LOS were: utilization of multimodal nausea and vomiting prophylaxis (IRR 0.78), scheduled postoperative nonsteroidal pain medication use (IRR 0.76), and strict adherence to a postoperative opioid administration protocol for breakthrough pain (IRR 0.58).
We also recommend you start ERAS for one type of surgery first. Once you have demonstrated the benefits of ERAS, you’ll probably find others beginning to clamor for ERAS in their respective areas. Historically, ERAS made its name in colorectal surgery, so most hospitals try it there first. But you need to determine which procedures are done in your facility and consider which types of surgery are ready for the switch to ERAS.
Stone and colleagues in a systematic review (Stone 2018) found that, despite many studies looking at safety or efficacy or cost-effectiveness of ERAS, there was a paucity of studies on success factors or barriers in implementation of ERAS programs. They basically found that the facilitators were those you need for any quality improvement program:
Also, not unexpectedly, the biggest barrier identified was resistance from frontline clinicians.
So, what are the benefits of ERAS?
ERAS has resulted in significant reduction in hospital costs, largely due to reductions in hospital length of stay (LOS). But the improvements in patient outcomes have also been substantial, with reductions in complications and reduced mortality rates.
The Enhanced Recovery in National Surgical Quality Improvement Program (ERIN) pilot was designed to support enhanced recovery protocol (ERP) implementation (Berian 2018). 15 hospitals of varied size and academic status from the National Surgical Quality Improvement Program (NSQIP) achieved shorter LOS and decreased complications after elective colectomy, without increasing readmissions, compared to control hospitals. Mean LOS decreased by 1.7 days in the pilot hospitals, compared with 0.4 days in controls. Serious morbidity or mortality decreased for pilot participants (14.1% before implementation vs. 10.5% after implementation), with no difference in controls.
Jung and colleagues at the University of Cincinnati College of Medicine published results that followed implementation of enhanced recovery pathways (Jung 2018). Implementation of an ERP for patients undergoing elective colorectal resection substantially reduced length of stay, total hospital cost, and direct pharmacy cost without increasing complications or readmission rates. Enhanced recovery pathway after colorectal resection has both clinical and financial benefits. After implementation, median length of stay decreased from 5.0 to 3.0 days. ERP patients required significantly less narcotics during their index hospitalization and tolerated a regular diet 1 day sooner. Despite a higher daily pharmacy cost, the total direct pharmacy cost for the hospitalization was reduced in ERP patients ($1,534 vs $1,859) and total direct cost was also lower in ERP patients ($9,791 vs $11,508). There were no differences in 30-day complications (8.1% vs 8.9%) or hospital readmission (11.9% vs 11.0%).
Liu and colleagues (Liu 2017) evaluated an ERAS program at 20 medical centers within the Kaiser Permanente Northern California integrated health care delivery system. There were 2 target populations: patients undergoing elective colorectal resection and patients undergoing emergency hip fracture repair. Most process metrics had significantly greater changes in the ERAS target populations after implementation compared with comparator surgical populations, including those for ambulation, nutrition, and opioid use. Hospital length of stay and postoperative complication rates were also significantly lower among ERAS target populations after implementation. Postoperative complications were reduced for both patients undergoing colorectal resection and for patients with hip fracture (odds ratios 0.68 and 0.67, respectively). Among patients undergoing colorectal resection, ERAS implementation was associated with decreased rates of hospital mortality. Among patients with hip fracture, implementation was associated with increased rates of discharge to home.
POWER, a multi-center study of over 2000 colorectal surgeries in Spain (Ripollés-Melchor 2019) achieved some striking results. The rate of moderate or severe complications was lower in patients in the ERAS group (25.2% vs 30.3%; odds ratio 0.77). Moreover, patients with the highest rates of adherence to the ERAS protocols had fewer moderate to severe complications (OR, 0.34), overall complications (OR 0.33), and mortality (OR 0.27) compared with those who had the lowest adherence rates.
Another major benefit is that almost all ERAS programs have also reported significant reductions in opioid usage. Penn Medicine found that ERAS in patients undergoing spine or peripheral nerve surgery saw substantial reductions in opioid use (Penn Medicine 2019). In fact, use of intravenous opioid medications via patient-controlled analgesia (PCA) was nearly eliminated in the ERAS group (0.5 percent) compared to over half of spinal surgical patients in the control group. And, after one month, 38% of patients in the ERAS group were using opioids compared to 53% of patients in the historical control group. ERAS, of course, includes multi-modal pain management protocols, with judicious use of opioids only as needed.
How do you evaluate whether your ERAS program is successful?
Every quality improvement project needs objective measures to be able to demonstrate that improvement resulted from the project. Here are some parameters of measurement to consider:
Calculating the financial benefits is more complex. Most calculate those using formulas pertinent to the LOS savings. But we always caution that reducing LOS translates to cost savings only if you can reduce staffing (either by using flex staffing or by being able to close a unit). So be wary of simply multiplying your reduced hospital days by some magic number. Today’s sophisticated hospital cost-accounting systems provide a better picture.
What types of surgery have used ERAS?
While ERAS had its origin in colorectal surgery, enhanced recovery components are being implemented in an increasing number of surgeries. A recent systematic review of enhanced recovery after surgery (ERAS) protocols across noncolorectal abdominal surgical procedures (Visioni 2018) concluded that ERAS protocols decreased length of stay and cost without increasing complications or readmission rates. Liu et al. (Liu 2017) demonstrated their ERAS program resulted in significant absolute and relative decreases in hospital length of stay and postoperative complication rates patients undergoing emergency hip fracture repair. The Wu article (Wu 2017) discussed expansion of the Johns Hopkins ERAS pathways to liver resection, radical cystectomy, gynecologic oncology and pediatric surgery, with plans to develop ERAS pathways for thoracic surgery, hyperthermic intraperitoneal chemotherapy (HIPEC), pancreatoduodenectomy, and breast surgery.
ERAS protocols have also now been used in spine surgery (Helwick 2018, Penn Medicine 2019), peripheral nerve surgery (Penn Medicine 2019), pancreaticoduodenectomy (Mander 2018a), elective C-sections (Mander 2018b), complex hip and pectus excavatum surgeries in children (Vlessides 2018b), craniotomy (Porter 2018), esophagectomy (Mander 2019), breast flap reconstruction (Vlessides 2017), and even in the interventional radiology suite (Vlessides 2018a). Guidelines for perioperative care in cardiac surgery have now also incorporated ERAS concepts and protocols (Engelman 2019).
Hospitals that have implemented ERAS across service lines have also seen quality improvements and reductions in LOS and costs for most surgeries (Smith 2019). New Hanover Regional Medical Center in North Carolina implemented ERAS across six service lines—colorectal, gynecology, hepatopancreatobiliary (HPB), urology, cardiac and spinal fusion. Hospital LOS decreased for all service lines except urology. LOS for colorectal surgery fell from 5.5 to 3.6 days, gynecology from 3.9 to 1.4 days, and spinal fusion from 2.38 to 1.6 days. LOS in cardiac surgery also decreased from 4.67 to 3.05 days but this did not reach statistical significance. Overall, this resulted in 1,846 hospital days saved in 2018 and hospital cost savings of more than $4.7 million in 2018 alone. The cost savings was due to both decreased LOS and less time spent in ICU and step-down care units, At the same time, the 30-day readmission rate either fell (for colorectal, gynecology, urology and HPB) or remained about the same compared with pre-ERAS procedures, and complications were either fewer (for colorectal, gynecology, urology and spinal fusion) or about the same as they had been for the pre-ERAS procedures.
A Geisinger Health System program highlighted the importance of the switch from traditional pre-op fasting to use of a carbohydrate drink given 2 hours prior to surgery as part of its ProvenRecovery program, a typical ERAS program that also focuses on early mobilization and appropriate pain management (Porter 2018). Benefits due at least in part to the program include a length of stay reduction for the average neurosurgery patient of 39% (from 4.3 to 2.62 days) and for the average colon surgery patient 44% (from 4.5 days to 2.5 days). Those earlier discharges saved more than $4,500 per case for colorectal surgery patients. Geisinger has announced that it will make the pilot permanent and roll out the ProvenRecovery program systemwide across 42 surgical procedures affecting about 15,000 cases annually.
If you are not yet using ERAS, you probably should be! For those of you who have not yet implemented ERAS for any surgeries, we suggest you read the CMAJ article (Altman 2019) and the article about the Johns Hopkins ERAS program (Wu 2017). Other excellent resources may be found at the ERAS® Society, Enhanced Recovery Canada™, and the ACS AHRQ Safety Program for Improving Surgical Care and Recovery (ISCR) (ACS 2020).
Update: Since our original column the result of the POWER2 study have been published (Ripollés-Melchor 2020). This study looked at the impact of ERAS on elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) in Spain. Fewer patients in the ERAS group had moderate to severe complications (4.6% vs 6.1%, OR, 0.74). Patients with the highest adherence to ERAS protocols had fewer overall postoperative complications (10.6% vs 13.0%; OR, 0.80), and moderate to severe postoperative complications (4.4% vs 6.9%, OR, 0.62), and shorter median length of hospital stay (4 vs 5 days, OR, 0.97). The study confirms that adherence to ERAS protocols is important in reducing postop complications in total joint arthroplasty.
References:
Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery. A Review. JAMA Surg 2017; 152(3): 292-298
ERAS® Society
Altman AD, Helpman L, McGee J, et al. on behalf of the Society of Gynecologic Oncology of Canada’s Communities of Practice in ERAS and Venous Thromboembolism. Enhanced recovery after surgery: implementing a new standard of surgical care. CMAJ 2019; 191(17): E469-E475 April 29, 2019
https://www.cmaj.ca/content/191/17/E469
ACS (American College of Surgeons). National Effort to Advance Best Practices in Surgical Patient Care Begins with Recommendations for Colorectal Operations. Press release August 8, 2017
https://www.facs.org/media/press-releases/2017/colorectal080817
ACS (American College of Surgeons) AHRQ Safety Program for Improving Surgical Care and Recovery (ISCR). Accessed February 5, 2020
https://www.facs.org/quality-programs/iscr
Williams C, Laflamme C, Penner B. Accelerating Post-Surgical Best Practices Using Enhanced Recovery After Surgery. Healthcare Quarterly 2020; 22(SP): 72-81
Enhanced Recovery Canada™
Wu CL, Benson AP, Hobson DB, Wick EC. Development and Implementation of a Colorectal ERAS Pathway. Anesthesiology News 2017; October 16, 2017
Myles PS, Bellomo R, Corcoran T, et al. Restrictive versus Liberal Fluid Therapy for Major Abdominal Surgery. N Engl J Med 2018; Published online May 10, 2018
https://www.nejm.org/doi/full/10.1056/NEJMoa1801601?query=featured_home
Grant MC, Pio Roda CM, Canner JK, et al. The Impact of Anesthesia-Influenced Process Measure Compliance on Length of Stay: Results From an Enhanced Recovery After Surgery for Colorectal Surgery Cohort. Anesthesia & Analgesia 2019; 128(1): 68-74, January 2019
Stone AB, Yuan CT, Rosen MA, et al. Barriers to and Facilitators of Implementing Enhanced Recovery Pathways Using an Implementation Framework. JAMA Surg 2018; 153(3): 270-279
https://jamanetwork.com/journals/jamasurgery/article-abstract/2669915?resultClick=1&redirect=true
Berian JR, Ban KA, Liu JB, et al. Association of an Enhanced Recovery Pilot With Length of Stay in the National Surgical Quality Improvement Program. JAMA Surg 2018; 153(4): 358-365
Jung AD, Dhar VK, Hoehn RS, et al. Enhanced Recovery after Colorectal Surgery: Can We Afford Not to Use It? J Am Coll Surg 2018; 226(4): 586-593
http://www.journalacs.org/article/S1072-7515(17)32194-4/fulltext
Liu VX, Rosas E, Hwang J, et al. Enhanced Recovery After Surgery Program Implementation in 2 Surgical Populations in an Integrated Health Care Delivery System. JAMA Surg 2017; 152(7): e171032. Epub 2017 Jul 19
https://jamanetwork.com/journals/jamasurgery/article-abstract/2625131?redirect=true
Ripollés-Melchor J, Ramírez-Rodríguez JM, Casans-Francés R, et al. Association Between Use of Enhanced Recovery After Surgery Protocol and Postoperative Complications in Colorectal Surgery: The Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol (POWER) Study. JAMA Surg 2019; 154(8): 725-736
https://jamanetwork.com/journals/jamasurgery/article-abstract/2732442?resultClick=1
Penn Medicine. Penn’s ‘Enhanced Recovery’ Protocol Reduces Opioid Use in Spinal Surgery Patients. First study to show benefit of a comprehensive ERAS pathway in spine and peripheral nerve surgery patients. Penn Medicine Press Release 2019; January 25, 2019
Visioni A, Shah R, Gabriel E, et al. Enhanced Recovery After Surgery for Noncolorectal Surgery? A Systematic Review and Meta-analysis of Major Abdominal Surgery. Annals of Surgery 2018; 267(1): 57-65
Helwick C. Reduced Opioids After Spinal Surgery With ERAS Protocol. Medscape Medical News 2018; May 08, 2018
https://www.medscape.com/viewarticle/896332
Mander K. Pancreaticoduodenectomy Enhanced Recovery Program Reduces Opioid Use. Anesthesiology News 2018; May 10, 2018
Mander K. Implementing an Enhanced Recovery Program For Elective Cesareans Improves Care and Saves Money. Anesthesiology News 2018; May 21, 2018
Vlessides M. ERAS Protocol Succeeds in Breast Flap Reconstruction. Anesthesiology News 2017; August 30, 2017
Vlessides M. Pediatric Enhanced Recovery Pathways Reduced Pain, PONV, Length of Stay and Costs. Anesthesiology News 2018; July 16, 2018
Porter S. Beyond Pre-Surgery Fasting: Geisinger Boosts Nutrition to Speed Up Recovery. HealthLeaders 2018; November 26, 2018
Vlessides M. Enhanced Recovery Protocol Successful In Interventional Radiology Suite. Anesthesiology News 2018; November 19, 2018
Mander K. Multidisciplinary Enhanced Recovery Pathway Reduces LOS Post-Esophagectomy. Anesthesiology News 2019; January 22, 2019
Engelman DT, Ben Ali W, Williams JB, et al. Guidelines for Perioperative Care in Cardiac Surgery: Enhanced Recovery After Surgery Society Recommendations. JAMA Surg 2019; 154(8): 755-766
https://jamanetwork.com/journals/jamasurgery/fullarticle/2732511
Smith MJ. Group Shares ERAS Experience Across 8 Surgical Services. Length of Stay, Complications Decrease for Most Surgical Lines. Anesthesiology News 2019; June 26, 2019
Ripollés-Melchor J, Abad-Motos A, Díez-Remesal Y, et al. Association Between Use of Enhanced Recovery After Surgery Protocol and Postoperative Complications in Total Hip and Knee Arthroplasty in the Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol in Elective Total Hip and Knee Arthroplasty Study (POWER2). JAMA Surg 2020; Published online February 12, 2020
https://jamanetwork.com/journals/jamasurgery/fullarticle/2760956
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February 18, 2020
More Nudges
We learned a lesson from commercial laboratories many years ago. Those commercial labs made their money, of course, by doing more tests. So, they packed their order forms for tests in a manner that made it most easy for clinicians to check as many boxes as possible.
So, when we recognized at our hospital that many tests were either unnecessarily repetitive or of low value, we changed our own lab and radiology requisition forms (paper at the time) to remove from the front of the form those tests that were of low value. We also looked at all our standardized order sets and saw the same pattern. Those order sets that offered checkboxes for “prn” medications almost always invited checking boxes.
And, when we did our first electronic medical record implementation, we were extremely concerned that design of various screens and menus could make it too easy to order things that might not be absolutely necessary. We discussed that in our March 23, 2010 Patient Safety Tip of the Week “ISMP Guidelines for Standard Order Sets”. We noted that order sets often included prn orders for sleep meds, laxatives, antacids, etc. Often, these were included so a clinician did not have to be awakened at night to order such medications. ISMP’s guideline on order sets also cautioned against including blanket-type orders (eg. laxatives, sleep meds, antiemetics, antidiarrheals, antacids, etc).
Conversely, you can use form design to “nudge” clinicians to remember to do certain things, like assessing DVT risk and considering DVT prophylaxis.
We’ve done several columns on how use of “nudges” can increase the likelihood of the most desirable action occurring. But sometimes nudges can be in the wrong direction. That is, they push you to do something that may actually be detrimental or at least not the best course of action. We discussed these issues in our July 23, 2019 Patient Safety Tip of the Week “Order Sets Can Nudge the Right Way or the Wrong Way”.
A recent study looked at the impact of default settings for opioid prescribing in the emergency department (Montoy 2020). The researchers randomly altered the default settings for quantities of opioid tablets. These changes were made without announcement, and prescribers were not informed of the study itself. They found that an increase of 0.19 tablets prescribed was found for each tablet increase in default quantity. They conclude that this low-cost, easily implementable, EMR-based intervention could have far-reaching implications for opioid prescribing and could be used as a tool to help combat the opioid epidemic.
Chin and colleagues (Chin 2018) demonstrated similar findings for postprocedural prescribing of opioids. The electronic medical record (EMR) can autopopulate a default number of pills prescribed, and 1 potential method to alter prescriber behavior is to change the default number presented via the EMR system. In a multi-hospital system, they reduced the default number of opioid pills autopopulated in the EMR when prescribing discharge analgesia from 30 to 12. Clinicians could still alter the number of pills prescribed to any amount they deemed necessary. After the default change, the median number of opioid pills prescribed decreased from 30 to 20. The percentage of prescriptions written for 30 pills decreased from 39.7% before the default change to 12.9% after the default change, and the percentage of prescriptions written for 12 pills increased from 2.1% before the default change to 24.6% after the default change. This occurred without significant change in opioid refill rates. This translated to a decrease of 5.22 opioid pills per prescription and a total decrease of 34.41 morphine milligram equivalents (MME’s) per prescription. The authors concluded this is a simple, effective, cheap, and potentially scalable intervention to change prescriber behavior and decrease the amount of opioid medication prescribed after procedures.
Another recent study used an EMR “nudge” to reduce inappropriate orders for C. diff testing (Howard-Anderson 2020). Orders for hospital-onset C. difficile infection testing in patients administered a laxative or stool softener in <24 hours triggered an EMR alert defaulting to cancellation of the order (“nudge”). Orders considered inappropriate for C. diff testing decreased from 8% to 6% after implementation of the “nudge”. Total monthly orders decreased by 21% postintervention.
In our April 30, 2019 Patient Safety Tip of the Week “Reducing Unnecessary Urine Cultures” we noted how clinicians and researchers at Barnes-Jewish Hospital implemented a program to reduce unnecessary cultures (Munigala 2019). Their intervention consisted of notifications to providers, changes to order sets, and inclusion of urine culture reflex tests in commonly used order sets. The CPOE intervention they implemented was setting the default option to urine dipstick testing followed by a bacterial culture if positive (i.e. reflex testing), rather than a culture alone, This resulted in a 45% reduction in the urine cultures ordered. That intervention saved approximately $104,000 in laboratory costs alone over the 15-month period plus likely savings from reduced antibiotic use and less contribution to the emergence of resistant organisms.
Note that the “nudge” need not necessarily go to the physician. Another innovative intervention from the PennMedicine Nudge Center imcreased screening rates for breast cancer and colorectal cancer 22 percent and 14 percent, respectively (Hsiang 2019). The intervention was an active choice intervention in the electronic health record that prompted medical assistants to inform patients about cancer screening during check-in and template orders for clinicians to review during the visit. Unfortunately, there were minimal changes in the rates of patients who followed through within one year and completed their screenings. Perhaps a “nudge” at the patient level is necessary as well. But the study demonstrated that we can reduce the risk of alert fatigue for physicians by sending the alerts to other members of the healthcare team. We’ve previously noted that some alerts might be sent to pharmacists rather than directly to physicians.
Most of the examples above are aimed at overcoming one of the most powerful cognitive biases, the “default bias”. That bias demonstrates our natural tendency to select default options when several options are possible. Two related cognitive biases are the “inertia bias” and the “status quo bias”, both of which encourage us to keep doing something. (Remember that monthly fee for software you seldom use anymore that you keep forgetting to cancel?). We discussed these in our July 7, 2009 Patient Safety Tip of the Week “Nudge: Small Changes, Big Impacts”. The study by Chin et al. (Chin 2018) also raised the role of yet another cognitive bias, “anchoring”, to the result produced by the new default. “Anchoring reflects the idea that human adjustments of estimates are based on a given starting value. In this case, estimates of the number of opioid pills needed for analgesia were anchored around the default number of pills presented, and a new, lower anchor helped decrease overall prescribing.”
Nudges can also be valuable in steering medication ordering in a desirable way. A study by Patel et al. (Patel 2016) found that a change in the EMR default to generics instead of brand names resulted in prescribing rates for generics increasing from 75% to 98%.
In another study, Patel and colleagues (Patel 2018) found that nudges which asked clinicians to make an active choice on statin prescriptions and delivered feedback on how each clinician’s performance compared to their peers led to a significant increase in statin prescription rates. Physicians received an email with a link to an online information “dashboard” listing their patients who were eligible for statin therapy but not already receiving it. One group of physicians also received a note comparing their rate of prescribing statins for eligible patients to other doctors in relevant specialties. Physicians in both intervention groups were asked to review the list of patients and use a multi-choice menu to prescribe a statin for each one or indicate a reason for non-prescribing. Results were compared to a third group that received no “dashboard” list and no comparison feedback.
The “dashboard” listed each of their patients along with their age, sex, and the following data as available from the EHR: 10-year ASCVD risk score, most recent LDL-C level, other lipid levels, body mass index, history of smoking and any form of clinical ASCVD (eg, myocardial infarction or stroke), liver function tests, and medical record number. The PCPs were asked to review the list of patients within 1 week and use the dashboard to select whether or not to prescribe each patient a statin. The dashboard provided an overview of the study, a link to the American College of Cardiology/American Heart Association guidelines, and options for selecting statin dosage.
Compared with usual care, there was a significant increase in statin prescribing in the active choice with peer comparison arm (adjusted difference in percentage points, 5.8), but not in the active choice arm.
The authors felt that a key element of their intervention design was active choice framing. Physicians could review patients using the automated patient dashboard and make decisions on statin prescriptions. By offering multiple options to prescribe a guideline-indicated statin and requiring a reason to say no, clinicians may be nudged toward prescribing a statin. Peer comparison feedback delivered just once by email was effective at increasing physician engagement with the automated patient dashboard. One advantage of this approach is that it does not require waiting for a patient to come to the clinic to make a decision. It also might optimize future clinic visits by removing the identification of eligible patients and process of prescribing so that the physician and patient can focus more on other aspects of care. A potential downside is that physicians with larger patient panels may face difficulties managing these types of decisions outside of their traditional clinic model when they receive a long list of eligible patients.
Mitesh S. Patel, M.D., head of Penn Medicine’s “Nudge Unit”, and colleagues wrote an informative review on nudges in the New England Journal of Medicine (Patel 2018b). They describe nudges as ways of presenting choices in ways that strongly influence consumer behavior. They give some great practical examples from everyday life. Airlines require consumers to actively choose whether to purchase trip insurance before they can buy a plane ticket. Amazon displays additional, complementary items alongside the purchase you are about to make. Video streaming sites often use default settings to automatically play the next episode in a TV series to encourage binge watching.
They go on to describe how nudges can be designed to remind, guide, or motivate behavior in healthcare. They suggest targeting areas in which suboptimal care can be addressed by targeting a specific decision that drives a less-than-optimal behavior. For example, when prescribing medications, physicians must decide between brand-name and generic formulations. They cite the study we noted above (Patel 2016) that found a change in the EMR default to generics instead of brand names resulted in prescribing rates for generics increasing from 75% to 98%.
They note suboptimal referral of eligible patients for cardiac rehabilitation after myocardial infarction may have resulted from an opt-in system. So, they redesigned he process as an opt-out system in which referral for rehab was the default. The referral rate increased to more than 80%.
Thoughtful design of order entry screens and standardized order sets is important in helping physicians make correct choices and avoid less optimal ones. An editorial by Vaughn and Linder (Vaughn 2018) discussed how “nudges” may be helpful. They note some designs provide a stimulus to do the wrong thing. For example, simply providing a checkbox may nudge a physician to check that checkbox. Providing the brandname of a drug may nudge the physician to order the more expensive formulation rather than a generic equivalent. And allowing a test to be ordered repetitively (eg. “daily CBC”) may lead to inappropriate testing.
They suggest the following questions be asked during design of order sets or order entry screens:
They stress the strong effect of using appropriate default settings, citing the study mentioned above (Munigala 2018) that successfully reduced inappropriate urine cultures in an emergency room by changing the default option from “urinalysis with reflex to urine culture” to “urinalysis with reflex to microscopy”.
Of course, there are other interventions that can be used to reduce the amount of unnecessary tests. Education and audit and feedback may modestly reduce the ordering of “routine” tests. A recent study (Ambasta 2020) found an 11% reduction in “routine” lab tests ordered in an academic setting when residents were given education and feedback with comparison to peers and attending internists were given feedback with comparison to peers.
But education and training always rank low in our hierarchy of effective interventions. In our January 2020 What's New in the Patient Safety World column “ISMP Canada: Change Management to Prevent Recurrences” we noted the excellent editorial by Soong and Shojania “Education as a low-value improvement intervention: often necessary but rarely sufficient” (Soong 2019). It describes several scenarios and how education fits in with each. In our brief illustrative Power Point “RCA Strong vs. Weak Responses” we show education and training as the weakest actions. We don’t include “nudges” in that hierarchy because that list actually applies to RCA actions. But nudges would probably fit somewhere near the middle of a list of action effectiveness.
The strongest actions are forcing functions and constraints. How about this for an effective constraint: Don’t Pay for It! In a study on low-value tests, Henderson et al. (Henderson 2020) looked at the impact of Choosing Wisely recommendations for vitamin D testing in Canada and the US. These resulted in 4.5% and 14.5% reductions in testing in Ontario and the US, respectively. But Ontario implemented a payment policy change that eliminated reimbursement of vitamin D screening. That was associated with a 92.7% relative reduction in such screening!
To be effective, any “nudge” needs to be inexpensive to implement, nonobtrusive to the clinician, and provide useful information that helps lead to active choices. You need to be very wary you don’t simply create “noise” that leads to alert fatigue. Equally important is to establish a method by which you will evaluate whether the nudge actually produced desired results and, just as importantly, did not produce any unintended consequences.
In sum, we think nudges are a great way to help change clinician behavior. They can usually be implemented inexpensively and in a minimally obtrusive manner. They have a definite role in our armamentarium of interventions. But we should always continue to look for stronger interventions that might have a greater impact when feasible.
See some of our other columns dealing with “nudges”:
References:
Montoy JCC, Coralic Z, Herring AA, Clattenburg EJ, Raven MC. Association of Default Electronic Medical Record Settings With Health Care Professional Patterns of Opioid Prescribing in Emergency Departments: A Randomized Quality Improvement Study. JAMA Intern Med 2020; Published online January 21, 2020
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2759133
Chin AS, Jean RA, Hoag JR, et al. Association of Lowering Default Pill Counts in Electronic Medical Record Systems With Postoperative Opioid Prescribing. JAMA Surg 2018; Published online July 18, 2018
Howard-Anderson JR, Sexton ME, Robichaux C, et al. The impact of an electronic medical record nudge on reducing testing for hospital-onset Clostridioides difficile infection. Infection Control and Hospital Epidemiology 2020; Published online February 10, 2020
Munigala S, Rojek R, Wood H, et al. Effect of changing urine testing orderables and clinician order sets on inpatient urine culture testing: Analysis from a large academic medical center. Infection Control and Hospital Epidemiology 2019; Published online: 21 February 2019: 1-6
Hsiang EY, Mehta SJ, Small DS, et al. Association of an Active Choice Intervention in the Electronic Health Record Directed to Medical Assistants With Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening Tests. JAMA Netw Open 2019; 2(11) :e1915619
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2755489?resultClick=1
Patel MS, Day SC, Halpern SD, et al. Generic Medication Prescription Rates After Health System–Wide Redesign of Default Options Within the Electronic Health Record. JAMA Intern Med 2016; 176(6): 847-848
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2520677
Patel MS, Kurtzman GW, Kannan S, et al. Effect of an Automated Patient Dashboard Using Active Choice and Peer Comparison Performance Feedback to Physicians on Statin Prescribing: The PRESCRIBE Cluster Randomized Clinical Trial. JAMA Netw Open 2018; 1(3): e180818
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2688535?resultClick=3
Patel MS, Volpp KG, Asch DA. Nudge Units to Improve the Delivery of Health Care
N Engl J Med 2018; 378: 214-216
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6143141/
Vaughn VM, Linder JA Thoughtless design of the electronic health record drives overuse, but purposeful design can nudge improved patient care. BMJ Qual Saf 2018; Published Online First: 24 March 2018
http://qualitysafety.bmj.com/content/early/2018/03/24/bmjqs-2017-007578
Ambasta A, Ma IWY, Woo S, et al. Impact of an education and multilevel social comparison–based intervention bundle on use of routine blood tests in hospitalised patients at an academic tertiary care hospital: a controlled pre-intervention post-intervention study. BMJ Quality & Safety 2020; Published Online First: 10 February 2020
https://qualitysafety.bmj.com/content/early/2020/02/10/bmjqs-2019-010118
Soong C, Shojania KG. Education as a low-value improvement intervention: often necessary but rarely sufficient. BMJ Quality & Safety 2019; Published Online First: 16 December 2019
https://qualitysafety.bmj.com/content/early/2019/12/16/bmjqs-2019-010411
Our Power Point: RCA - Strong vs. Weak Responses
docs/RCA_strong_vs_weak_responses.ppt
Henderson J, Bouck Z, Holleman R, et al. Comparison of Payment Changes and Choosing Wisely Recommendations for Use of Low-Value Laboratory Tests in the United States and Canada. JAMA Intern Med. Published online February 10, 2020
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2760344
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February 25, 2020
More on Perioperative Gabapentinoids
Gabapentinoids have increasingly been used as an adjunct for analegesia in a variety of surgical procedures. They have been promoted as part of multimodal analgesia regimens intended to reduce the use of opioids. In our February 11, 2020 Patient Safety Tip of the Week “ERAS Rocks!” we noted that many ERAS (Enhanced Recovery After Surgery) protocols use them but we inserted our own warning about their use. Over the past 3 years we have done several columns on patient safety issues related to gabapentinoids (see list below).
In fact, a recent systematic review and meta-analysis on perioperative use of gabapentinoids (Verret 2019) found no clinically significant analgesic effect for the perioperative use of gabapentinoids, with low level of evidence, and an increased risk of adverse events with moderate level of evidence. The authors concluded that their results do not support the use of gabapentinoids for the management postoperative acute pain in adult patients.
Duke University researchers have also taken a look at the impact of gabapentinoids used in the perioperative period. Ohnuma et al. (Ohnuma 2019) analyzed data from a large administrative claims database, including 862,524 patients from 592 hospitals, who underwent elective primary THA or TKA between 2009 and 2014. They looked at the following drugs, alone or in combination, on the day of surgery for patients undergoing TKA or THA: acetaminophen, nonsteroidal anti-inflammatory drugs (NSAID’s), gabapentinoids (gabapentin or pregabalin), or none of the three drugs.
Compared to none of the three drugs as the reference category, exposure to gabapentinoids was associated with increased odds of naloxone use after surgery (OR 2.11), noninvasive ventilation (OR, 1.45), invasive mechanical ventilation (OR 1.25), and ICU admission (OR 1.28). A similar increase was seen in analgesic combinations including gabapentinoids. The group receiving NSAID’s plus acetaminophen showed the most protective associations with naloxone use after surgery (OR 0.59), invasive mechanical ventilation (OR, 0.72), and ICU admission (OR 0.69), and was associated with the lowest opioid consumption on the day before discharge.
The authors conclude that preoperative gabapentinoids were associated with significant increased risk of postoperative opioid-related respiratory depression. It also failed to find benefits for gabapentinoids in terms of postoperative opioid consumption and LOS. They recommend reconsideration of routine use of preoperative gabapentinoids in the adult TKA and THA population.
The researchers also looked at 108,616 patients who underwent elective colorectal surgery across the 605 hospitals, 2% of whom received gabapentinoids on the day of surgery (Yan 2019). They found that use of gabapentinoids was associated with higher odds of noninvasive ventilation (OR 1.39) and receipt of naloxone after surgery (OR 1.70). There was no difference in invasive mechanical ventilation, opioid consumption, or LOS. They cite other small studies showing increased risk of postoperative respiratory depression and naloxone use in patients receiving gabapentinoids, which may be explained by an interaction between gabapentinoids and opioids.
Our January 2020 What's New in the Patient Safety World column “FDA Warning on Gabapentinoids” summarized some of our previous concerns about gabapentinoids and discussed a new warning on gabapentinoids from the FDA (FDA 2019). The FDA warns that “serious breathing difficulties may occur in patients using gabapentin (Neurontin, Gralise, Horizant) or pregabalin (Lyrica, Lyrica CR) who have respiratory risk factors. These include the use of opioid pain medicines and other drugs that depress the central nervous system, and conditions such as chronic obstructive pulmonary disease (COPD) that reduce lung function. The elderly are also at higher risk.”
The FDA notes that gabapentinoids are often being combined with CNS depressants (including opioids, anti-anxiety medicines, antidepressants, and antihistamines), which increases the risk of respiratory depression. It acknowledges that there is less evidence supporting the risk of serious breathing difficulties in healthy individuals taking gabapentinoids alone.
The FDA decision was based upon both reports it received and studies in the medical literature. Of fatal cases involving gabapentinioids reported to the FDA, all had at least one additional risk factor.
Keep in mind that the above data are not from randomized controlled trials (the FDA did review two RCT’s in healthy people), It’s doubtful that RCT’s will be conducted on the use of gabapentinoids in this setting. But, in the absence of hard evidence for their efficacy in analgesia for perioperative pain, it’s probably wise to exclude them from your protocols.
Gabapentinoids have been very valuable in the management of chronic neuropathic pain. But it appears they add little or no benefit to management of perioperative pain and they add additional risks.
Some of our prior columns on safety issues with gabapentinoids:
References:
Verret M, Lauzier F, Zarychanski R, et al. Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain: A Systematic Review and Meta-analysis. 2019 annual meeting of the American Society of Anesthesiologists (ASA; abstract A2096).
http://www.asaabstracts.com/strands/asaabstracts/abstract.htm?year=2019&index=18&absnum=1927
OhnumaT, Raghunathan K, Ellis A, et al. Abstract S-344 Effects of Acetaminophen, NSAID’s, Gabapentinoids and Their Combinations on the Day of Surgery in Total Hip and Knee Arthroplasties. Anesthesia & Analgesia 2019; 128(5): 741
https://iars.app.box.com/v/AM19AbstractSupplement
Yan R, Ohnuma T, Krishnamoorthy V, et al. Abstract S-353 Gabapentinoids on the Day of Colorectal Surgery Are Associated with Adverse Postoperative Respiratory Outcomes. Anesthesia & Analgesia 2019; 128(5): 760
https://iars.app.box.com/v/AM19AbstractSupplement
FDA (US Food and Drug Administration). FDA warns about serious breathing problems with seizure and nerve pain medicines gabapentin (Neurontin, Gralise, Horizant) and pregabalin (Lyrica, Lyrica CR)When used with CNS depressants or in patients with lung problems. FDA 2019; 12-19-2019
https://www.fda.gov/media/133681/download
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March 3, 2020
Opportunities to Reduce Unnecessary Contact Precautions
We’ve done multiple columns on the unintended consequences of contact precautions (see full list below). Patients in contact isolation have less contact by healthcare workers (and visitors) and this may lead to errors and omissions in care and other unintended consequences like decubiti, delirium, falls, and fluid/electrolyte disorders among other preventable adverse events. Contact precautions for those with endemic MRSA are often associated with longer admission wait times, longer length of stay, and delays in transfers to long-term care facilities (Popescu 2019). Treating patients on contact precautions is cumbersome, time-consuming, and resource-intensive, both in human and financial terms.
So, contact precautions clearly have some downsides. But do they have an upside? That is, do they actually accomplish their intended goal of reducing the transmission of infectious agents like methicillin-resistant Staphylococcus aureus (MRSA) to other patients in the hospital?
The answer to the latter is not so clear cut. In our May 2016 What's New in the Patient Safety World column “More Debate on Contact Precautions” we noted that Morgan and colleagues at the University of Maryland, who have done much of the work we’ve previously cited on adverse consequences of contact isolation, have reconsidered contact precautions for endemic VRE and MRSA (Morgan 2015). They did a literature review, a survey of the SHEA Research Network members on use of contact precautions, and a detailed examination of the experience of a convenience sample of hospitals not using contact precautions for MRSA or VRE. They found that there is no high-quality data to support or reject use of contact precautions for endemic MRSA or VRE and that hospital practices are widely varied. They concluded that higher quality research on the benefits and harms of contact precautions in the control of endemic MRSA and VRE is needed and that until more definitive data are available, practices in acute care hospitals should be guided by local needs and resources.
There may well be some interventions that can reduce use of unnecessary contact precautions. One of the most common reasons for putting a patient on contact precautions is testing positive for MRSA. A survey of physicians in the Emerging Infections Network (Russell 2016) found that over 90% of respondents routinely use contact precautions for MRSA and VRE, with the most widely used trigger being a positive culture for these pathogens. They also found wide variation in other practices, like routine chlorhexidine gluconate bathing or decolonization with mupirocin. Practices for discontinuation of isolation also varied widely. And only 23% reported using either hydrogen peroxide vapor or ultraviolet-C room disinfection at discharge.
Moreover, adherence to all elements of contact isolation precautions has always been less than optimal and that, as the proportion of patients in contact isolation increases, compliance with contact isolation precautions decreases (Dhar 2014).
Most hospitals still use contact precautions for MRSA-infected patients. But what to do about MRSA-colonized patients has been less clear. A new study (Christie 2020) looked at the impact of replacing contract precautions with targeted nasal and body decolonization for high-risk MRSA-colonized patients in a 7-hospital network. They used an alcohol-based nasal antiseptic twice daily plus daily 2% chlorhexidine gluconate bathing for nasal and body decolonization, respectively.
They realized an 88% decrease in MRSA-isolation days, with each hospital seeing a reduction. And MRSA bacteremia rates did not change significantly during the study.
They then analyzed the impact on costs. Average daily cost per patient was $42.32 for contact precautions versus $6.25 for nasal and body decolonization. That totaled a savings of $430,604 for the hospital system over a 10-month period.
A study at Boston’s Beth Israel Deaconess Medical Center (Schrank 2019) looked at the impact of discontinuation of contact precautions for patients with endemic MRSA and VRE colonization. Prior to discontinuation of contact precautions, the mean monthly number of beds closed daily for MRSA and/or VRE isolation ranged from 2.7 to 5.3. The estimate of potential lost charges due to these bed closures before the policy change was $9383 per 100 bed days. After implementation, there was no change in ED wait times, patient satisfaction survey results, or rates or trends for patient falls or pressure ulcers. A slight increase in incidence rates of nosocomial MRSA did not meet statistical significance. There were significant reductions in monthly expenditures on gowns (−61.0%) and gloves (−16.3%). The authors concluded that discontinuation of contact precautions was associated with an increase in bed availability and revenue recovery, and a reduction in PPE expenditures, without significant change in other hospital operations metrics or patient outcomes.
Our October 18, 2016 Patient Safety Tip of the Week “Yet More Questions on Contact Precautions” also noted several other studies that showed financial benefits of discontinuing contact precautions on MRSA-colonized patients without increasing rates of MRSA transmission.
And our July 2018 What's New in the Patient Safety World column “Contact Precautions Conundrum” cited a study which found that, after discontinuing routine contact precautions for endemic MRSA/VRE, the rate of noninfectious adverse events declined, especially in patients who no longer required isolation (Martin 2018). Noninfectious adverse events (ie, postoperative respiratory failure, hemorrhage/hematoma, thrombosis, wound dehiscence, pressure ulcers, and falls or trauma) decreased by 19% (from 12.3 to 10.0 per 1,000 admissions) from the preintervention to the postintervention period. There was no significant difference in the rate of infectious adverse events after CP discontinuation. Patients with MRSA/VRE showed the largest reduction in noninfectious adverse events after CP discontinuation, with a 72% reduction (from 21.4 to 6.08 per 1,000 MRSA/VRE admissions).
A previous study by Martin and colleagues (Martin 2016) had shown that removal of contact precautions for endemic MRSA and vancomycin-resistant Enterococcus (VRE) did not increase the prevalence of either pathogen and resulted in hospital savings of an estimated $643,776 in one year.
So, more and more evidence is accumulating that shows contact precautions might be safely discontinued in MRSA-colonized patients, providing financial savings and perhaps reducing non-infectious adverse events, while not increasing rates of MRSA infections. The Christie study (Christie 2020) suggests that using targeted nasal and body decolonization for high-risk MRSA-colonized patients is an inexpensive alternative to contact precautions.
Even if you still use contact precautions for MRSA-colonized patients, you might see financial benefits by paying attention to when you can discontinue contact precautions for them or other patients on contact precautions. Our March 2018 What's New in the Patient Safety World column “Duration of Contact Precautions” noted the SHEA (Society for Healthcare Epidemiology of America) expert guidance on duration of contact precautions for acute care settings (Banach 2018).
Note that nasal decontamination may also be important in patients undergoing outpatient surgery. A recent issue of Outpatient Surgery had an article with some good tips about nasal decontamination (O”Connor 2020).
A second opportunity to reduce isolation and contact precautions has to do with C. difficile. Once C. diff is suspected, patients are often placed on contact precautions. When we began using clinical decision support tools 13 years ago, one of our first algorithms was designed for early identification of C. diff infections. An alert was triggered on any patient receiving antibiotics who then had an order for an antidiarrheal agent. That alert did identify many patients with C. diff infections, but it also led to some unnecessary testing for C. diff and also contributed alert fatigue (even when we sent the alert to nursing staff rather than physicians).
But several studies have taken the reverse approach: use of clinical decision support tools to reduce the number of inappropriate tests for C. diff infection (CDI). In addition to leading to unnecessary isolation and contact precautions, inappropriate testing for CDI may lead to misdiagnosis and unnecessary treatment of patients.
A recent systematic review looked at the impact of clinical decision support alerts on C. diff testing (Dunn 2020). They found use of electronic alerts for diagnostic stewardship for C. diff was associated with reductions in CDI testing, the proportion of inappropriate CDI testing, and rates of CDI in most studies. However, they did note that the occurrence of unintended adverse consequences and alert fatigue remain understudied.
An example of an alert that might reduce inappropriate orders for C. diff testing would be one that pops up if a patient has received a laxative within 24 hours of the order. Others have used markers of CDI such as clinically significant diarrhea, no laxative use within 24 hours, and confirmation of additional symptoms or risk factors, such as a temperature higher than 100.4°F, abdominal pain or tenderness within 48 hours, a white blood cell count of more than 15,000/mm3 or less than 4,000/mm3 within 48 hours, antibiotic use or a discharge from any health care facility within 30 days of testing (Fleming 2019). They found that implementation of such an embedded electronic medical record decision-support matrix resulted in a 27% reduction in total C. diff testing and a statistically significant improvement in test fidelity after the intervention.
Kwon et al. (Kwon 2019) took a different approach. They used an electronic hard-stop clinical decision support tool on repeat C. diff toxin enzyme immunoassay (T-EIA) testing. They placed a hard stop in the EMR system, which limited repeat testing within 96 hours of a negative test. They found a significant reduction in the number of admissions that included repeat tests conducted within 96 hours from an initial negative test, from 11% in the preintervention period to 2% after the intervention was implemented.
Any intervention that prevents unnecessary isolation and contact precautions (or shortens the duration of such precautions) is likely to save your organization money while avoiding the many patient safety hazards associated with contact precautions. The above examples provide some potential opportunities for interventions.
Some of our prior columns on the unintended consequences of contact isolation:
References:
Popescu SV. A New Approach to Discontinuing MRSA/VRE Isolation Precautions. ContagionLive/Infectious Disease Today 2019; Aug 27, 2019
Morgan DJ, Murthy R, Munoz-Price LS, et al. Reconsidering Contact Precautions for Endemic Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus. Infect Control Hosp Epidemiol 2015; 36(10): 1163-1172
Russell D, Beekmann SE, Polgreen PM, et al. Routine Use of Contact Precautions for Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus: Which Way Is the Pendulum Swinging? Infection Control & Hospital Epidemiology 2016; 37(1): 36-40, 2016 Jan
Dhar S, Marchaim D, Tansek R, et al. Contact Precautions More Is Not Necessarily Better. Infection Control & Hospital Epidemiology 2014; 35(3): 213-219. Published online: 10 May 2016
Christie J, Wright D, Liebowitz J, Stefanacci P. Can a nasal and skin decolonization protocol safely replace contact precautions for MRSA-colonized patients? American Journal of Infection Control 2020; Published online January 13, 2020
https://www.ajicjournal.org/article/S0196-6553(19)31058-2/fulltext
Schrank GM, Snyder GM, Davis RB, et al The discontinuation of contact precautions for methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus: Impact upon patient adverse events and hospital operations. BMJ Quality & Safety Published Online First: 18 July 2019
https://qualitysafety.bmj.com/content/early/2019/07/19/bmjqs-2018-008926
Martin EM, Bryant B, Grogan TR, et al. Noninfectious Hospital Adverse Events Decline After Elimination of Contact Precautions for MRSA and VRE. Infect Control Hosp Epidemiol. 2018; Published online: 10 May 2018, pp. 1-9
Martin EM, Russell D, Rubin Z, et al. Elimination of Routine Contact Precautions for Endemic Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus: A Retrospective Quasi-Experimental Study. Infect Control Hosp Epidemiol. 2016; 37(11): 1323-1330
Banach D, Bearman G, Barnden M, et al. Duration of Contact Precautions for Acute-Care Settings. Infection Control & Hospital Epidemiology 2018; 1-18. Published online: 11 January 2018
O”Connor D. Nasal Antisepsis Done Right. 4 tips to stop staph where it lurks. Outpatient Surgery 2020; XXI(1): January 2020
Dunn AN, Radakovich N, Ancker JS, et al. The Impact of Clinical Decision Support Alerts on Clostridioides difficile Testing: A Systematic Review. Clinical Infectious Diseases 2020; Published online February 15, 2020
Fleming M, Hess O, Albert H, et al. Test stewardship, frequency and fidelity: Impact on reported hospital-onset Clostridioides difficile. Infection Control & Hospital Epidemiology, 40(6): 710-712
Kwon J, Reske K, Hink T, et al. Impact of an electronic hard-stop clinical decision support tool to limit repeat Clostridioides difficile toxin enzyme immunoassay testing on test utilization. Infection Control & Hospital Epidemiology, 40(12), 1423-1426
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March 10, 2020
Medication Harm in the Elderly
We’ve, of course, done many columns on Beers’ List, the STOPP and START lists, and other topics related to potentially inappropriate medications in the elderly. But in the past couple months there have been several studies focusing on medication dangers in the elderly.
Stevenson et al. (Stevenson 2020) recently labeled medication-related harm as “a geriatric syndrome”, calling for a new approach. They developed a conceptual model, where well-recognized physiological changes are incorporated, as well as other rarely considered psychosocial issues that influence medication-related harm. They note that medication-related harm is increasing, driven by increased life expectancy coupled with multimorbidity that frequently leads to polypharmacy and an increased risk of medication-related harm, particularly in the elderly.
They note that, in frail older adults, even 'appropriate' medicines can be harmful due to multiple reserve deficits impairing mechanisms to deal with even a minor side-effect. Age-related physiological changes influence drug handling and age-related changes may impact drug action so that, for specific medicines, the risk of harm is likely to outweigh any potential benefit. But, in frail older adults, depletion of physiologic reserves may increase the risk of medication-related harm, with or without multimorbidity. Add to this the concept of “psychosocial reserve”. They note that a reduction in functional ability, social support, cognition, mood or financial circumstances may all contribute to the depletion of psychosocial reserve. They suggest that poor health due to disease resulting in impaired physiological function and the addition of a new medicine can reduce mood, and thus psychosocial reserve, and vice versa.
They posit that medication-related harm meets the following criteria that have been proposed for something to be a “geriatric syndrome”:
Importantly, they note that even the medicines review the component of the Comprehensive Geriatric Assessment (CGA) concentrates on inappropriate medicines. They stress that more work is required on mitigating harm from appropriate medicines which, despite the anticipated risk of adverse effects, are necessary to delay disease progression and alleviate symptoms.
They note that medication-related harm often masquerades as another syndrome (for example, falls), and so can be misclassified. Hence, medication-related harm should be considered a differential diagnosis in all older adults. We should also no longer consider older adults as having an “atypical” response to medication; but rather they are responding “typically”.
They conclude that a medication-related harm assessment and intervention need to move from a unidimensional medicines focus to a multidimensional assessment, with a toolkit of interventions available to generate an individual care plan.
Concepts in the Stevenson paper drew upon lessons from the Pharm2Pharm study (Pellegrin 2018), which reduced medication-related harm admissions in older adults by over a third, the majority of which were due to appropriate medicines. This study considered medication management issues in the context of health literacy, cultural practices and social service issues over a 12-month period after hospital discharge, and engaged with the patient and prescriber during follow-up to identify and resolve problems.
Pharm2Pharm assigned specially trained pharmacists the role of managing medications across prescribers and settings for high risk patients. This model assigned hospital consulting pharmacists the responsibility of identifying newly admitted inpatients at risk of medication problems, engaging them, beginning the medication management process and formally handing them off to a community consulting pharmacist at discharge. Their results demonstrated a decrease in community-acquired medication-related hospitalization rate per 1000 admissions of participants aged 65 and older over time in intervention hospitals was 4.28 per quarter greater than in non-intervention hospitals.
Among hospital-acquired medication adverse outcomes, the most frequent medication categories were antibiotics, analgesics (especially opiates), antipyretics and antirheumatics, and corticosteroids. Drugs most frequently the cause of harm originating in the community were anticoagulants, antineoplastic and immunosuppressive drugs and corticosteroids. The rate of community-acquired anticoagulant-related hospitalizations decreased most significantly with the medication management intervention relative to the comparison group.
Key lessons from the Pharm2Pharm study:
We’ve traditionally relied heavily on the “brown bag” medication review. That, of course, refers to our having patients (and their families in many cases) bring in all their medications (including any OTC medications, herbal supplements, etc.) in a brown bag so we can go over each one. We look for those that the total number of medications, those that fit in “inappropriate” categories, those that are duplicative, those that may no longer be necessary, and those that may be interacting with each other. We assess patient compliance or adherence to their medications. Importantly, as noted in our October 19, 2010 Patient Safety Tip of the Week “Optimizing Medications in the Elderly”, we also look to see whether there are medications the patient should be taking but is not taking.
AHRQ provides a nice Brown Bag Medication Review Tool. Murtha et al. (Murtha 2020) recently used that tool to identify medication nonadherence in a Midwestern clinic. Adult patients were instructed to bring all prescribed and over-the-counter medication to office visits. A reviewer transcribed administration directions and the patient's verbal instruction of how the medication is taken. 58% participants were nonadherent for at least 1 medication. 26% of all medications were nonadherent. Mental health drugs were the highest nonadherence category (38%). The majority of medication nonadherence was due to lack of access. That, or course, fits in with the concept proposed by Stevenson et al. that psychosocial factors need to be a required part of any medication reviews.
Recently, Romskaug et al. (Romskaug 2019) found that, among older patients exposed to polypharmacy, clinical geriatric assessments and collaborative medication reviews carried out by a geriatrician in cooperation with the patient’s family physician can result in positive effects on health-related quality of life. Compared to a “usual care” control population, the patients receiving the joint medication management intervention had a significant improvement in health-related quality of life, more drug withdrawals, reduced dosages, and new drug regimens started.
Two other recent studies have dealt specifically with medication harms following hospital discharge. Transitions of care, such as discharge from a hospital, are points where patient outcomes can be affected, especially patients at high risk for medication errors.
Crannage et al. (Crannage 2019) examined the impact of a discharge medication education program on successful telephone follow-up contact and pharmacist-led post-discharge telephone counseling. 50 patients were included in the initial evaluation of this service; 78% of patients were successfully contacted within 2 business days after discharge, an increase from a 20% success rate prior to service implementation. At follow-up telephone calls, patients reported taking an average of 16 medications. The 30-day readmission rate was 10% for patients receiving this service, compared with 19% prior to implementation.
Pareckh et al. (Parekh 2020) analyzed data on patients age 65 and older who were discharged from five UK teaching hospitals and developed a tool that might be used to predict the risk of an older adult experiencing medication-related harm requiring healthcare use following hospital discharge. Their tool derivation cohort consisted of 818 patients, 15% of whom experienced ‘definite’ medication-related harm requiring healthcare use. Modelling resulted in a prediction tool (the PRIME tool) with eight variables measured at hospital discharge: age, gender, antiplatelet drug, sodium level, antidiabetic drug, past adverse drug reaction, number of medicines, living alone. The authors acknowledge that the tool needs to be validated in multiple settings before it should be adopted widely.
Notably, in the Pharm2Pharm study mentioned above (Pellegrin 2018), the hospital-acquired medication harm rate did not change. Rather, the rate of admissions with community-acquired medication harm was reduced by 4.28 admissions per 1000 admissions per quarter in the Pharm2Pharm hospitals relative to the comparison hospitals. This suggests that deployment of pharmacists in the community to review medications in high-risk patients should have an increased role.
Of course, identifying medications that should be stopped or have the dose altered is just the first step. Knowing how to manage those situations is the next step. Our many columns on deprescribing listed below have many recommendations and links to useful resources on deprescribing.
Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:
Some of our past columns on deprescribing:
Some of our other columns on failed discontinuation of medications:
May 27, 2014 “A Gap in ePrescribing: Stopping Medications”
March 2017 “Yes! Another Voice for Medication e-Discontinuation!”
February 2018 “10 Years on the Wrong Medication”
August 28, 2018 “Thought You Discontinued That Medication? Think Again”
December 18, 2018 “Great Recommendations for e-Prescribing”
August 2019 “Including Indications for Medications: We Are Failing”
August 6, 2019 “Repeat Adverse Drug Events”
Some of our previous columns on medication reconciliation:
October 23, 2007 “Medication Reconciliation Tools”
December 30, 2008 “Unintended Consequences: Is Medication Reconciliation Next?”
May 13, 2008 “Medication Reconciliation: Topical and Compounded Medications”
September 8, 2009 “Barriers to Medication Reconciliation”
August 2011 “The Amazon.com Approach to Medication Reconciliation”
January 2012 “AHRQ’s New Medication Reconciliation Tool Kit”
September 2012 “Good News on Medication Reconciliation”
October 1, 2019 “Electronic Medication Reconciliation: Glass Half Full or Half Empty?”
References:
Stevenson JM, Davies JG, Martin FC. Medication-related Harm: A Geriatric Syndrome. Age Ageing 2020; 49(1): 7-11
https://academic.oup.com/ageing/article/49/1/7/5607678
Pellegrin K, Lozano A, Miyamura J, et al. Community-acquired and hospital-acquired medication harm among older inpatients and impact of a state-wide medication management intervention. BMJ Qual Saf 2018; 28: 103–110
https://qualitysafety.bmj.com/content/28/2/103
AHRQ (Agency for Healthcare Research and Quality). Brown Bag Medication Review Tool #8; AHRQ
https://health.gov/hcq/trainings/pathways/assets/pdfs/AHRQ-Tool8.pdf
Murtha E, Elder B, Faragher M. Brown Bag Medication Review. Using AHRQ's Brown Bag Medication Tool. Journal of Nursing Care Quality 2020; 35(1): 58-62
Romskaug R, Skovlund E, Straand J, et al. Effect of Clinical Geriatric Assessments and Collaborative Medication Reviews by Geriatrician and Family Physician for Improving Health-Related Quality of Life in Home-Dwelling Older Patients Receiving Polypharmacy: A Cluster Randomized Clinical Trial. JAMA Intern Med 2019; Published online October 16, 2019
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2753318
Crannage AJ, Hennessey EK, Challen LM, Stevens AM, Berry TM. Implementation of a discharge education program to improve transitions of care for patients at high risk of medication errors. Ann Pharmacother 2019; First Published December 21, 2019
https://journals.sagepub.com/doi/10.1177/1060028019896377
Parekh N, Ali K, Davies JG, et al. Medication-related harm in older adults following hospital discharge: development and validation of a prediction tool. BMJ Quality & Safety 2020; 29: 142-153
https://qualitysafety.bmj.com/content/29/2/142
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March 17, 2020
Video Recording in the OR
For over a decade we’ve argued for proactive use of video recording, particularly in the OR. Video recording can be used constructively to assess communication and teamwork in the OR. It can be used evaluate OR door opening and closing, which may be factor contributing to surgical site infections. It can help quantitate interruptions and distractions that occur during procedures and identify some of the reasons for those interruptions and distractions. It can be used to determine compliance with Universal Protocol, surgical timeouts, surgical checklists and whether parties were truly active participants in those important processes. It can help determine whether all parties are actively participating in sponge/instrument counts. In our March 2019 “Another Use for Video Recording” we showed how it has been used to demonstrate compliance with key steps in specific surgical procedures. And it can obviously be used to assess and improve performance in medical education and training.
So we were pleased to see a recent article in HealthLeaders on Northwell Health’s use of such technology (Cheney 2020). Northwell Health has employed OR black box technology since early 2019. They have used it in laparoscopic cases of urologic and colon surgery. Those were chosen for pilot projects because there is a digital feed from the camera used during the laparoscopic surgery and because there were physician champions for the project.
So, what’s recorded? There are video feeds from the laparoscopic camera and video of the OR staff, audio of the OR staff, and physiological data from various OR monitors.
Northwell’s primary purpose has been to use the integrated data to help improve OR teamwork and communication. They use it proactively to improve coordination in the OR. They have used it for one of our examples above – to identify distractions and interruptions and, especially, people entering and leaving the room. But it’s also used in their quality improvement and educational activities. Interestingly, Northwell has also used it to cover some of the aspects we discuss during post-procedure “debriefings”. For example, they might identify issues related to equipment availability or other problems with equipment or supplies.
Can they use this technology akin to the way the airline industry and NTSB use black boxes? Yes. Northwell does use the collected information when they do root cause analyses (RCA’s) or other investigations on adverse outcomes.
It also has a role in teaching programs. They can look to see if a resident’s performance improved over a 4-month rotation, to evaluate the success of the teaching program. Our March 2019 “Another Use for Video Recording” noted a study (van de Graaf 2019) that showed systematic video recording was better at capturing the essential steps of some laparoscopic procedures than was the narrative operative report.
Our first 3 columns listed below recommended use of video recording as one means of improving compliance with surgical timeouts or elements of a safe surgery checklist. In fact, Overdyk et al. (Overdyk 2016) demonstrated that real-time feedback from video recording conferred a 3.37-fold increased odds of time-out compliance versus no feedback, and 2.75-fold and 2.4-fold increased odds of compliance with the sign-in and sign-out components of the WHO surgical safety checklist, respectively. It also led to some improvements in efficiency (shorter OR turnaround times for scheduled cases).
In our March 17, 2015 Patient Safety Tip of the Week “Distractions in the OR” we recommended video/audio recording in the OR with subsequent playback for all parties in a constructive fashion so they can see how well (or not so well) they communicated and how distractions and interruptions interfered with their communications. Jung et al. reported their first-year analysis of the operating room black box study (Jung 2020). They conducted a prospective cohort study in 132 consecutive patients undergoing elective laparoscopic general surgery at an academic hospital during the first year after the definite implementation of a multiport data capture system called the OR Black Box to identify intraoperative errors, events, and distractions. They found that auditory distractions occurred a median of 138 times per case and that at least 1 cognitive distraction appeared in 64% of cases. Medians of 20 errors and 8 events were identified per case. Both errors and events occurred often in dissection and reconstruction phases of operation. Technical skills of residents were lower than those of the attending surgeon.
Some formal studies have demonstrated that such use of video/audio recording can in fact, reduce interruptions and distractions. Bergstrom et al. (Bergström 2018) found that audio-video recording during laparoscopic surgery in a Swedish study reduced irrelevant conversations in the OR. Irrelevant conversation time fell from 4.2% of surgical time to 1.4% when both audio and video recordings were made. No differences in perioperative adverse event or complication rates were seen but, again, sample size was too small to assess those outcomes.
People entering and exiting the operating room, with consequent door opening and closing, has been identified as a factor potentially exposing patients to surgical infections. In our November 24, 2015 Patient Safety Tip of the Week “Door Opening and Foot Traffic in the OR” we noted some low-cost methods that might assess such events, but we also noted that video/auditory recording might identify not only the frequency of such events, but also the reasons for such events.
We’ve often recommended doing video/audio recording in the OR and then play it back for all parties in a constructive fashion so they can see how well (or not so well) they communicated and how distractions or interruptions interfered with their communications. Teodor Grantcharov, MD, creator of surgery's 'black box' and senior author on the Jung study, noted in an interview that they’ve shown that coaching surgical teams with black box data reduces the rate of surgical errors by 50%. (Grantcharov 2019). He notes that the black box captures video and audio recordings of everything that happens in the OR, including what steps were completed, how well the team communicated, and includes physiological information from patient monitors and the physical environment of the room, including ambient temperature, decibel levels and how many times the door is opened. He notes that it's designed to identify near misses, understand the risks involved and proactively mitigate those risks. But he notes this isn't just about targeting errors and near-misses. They use the data to study successes in great detail, so they can identify and reinforce positive behaviors. They use the information to coach surgical teams on ways to improve their performances, using the analogy of how sports teams study videos and stats to enhance how they play.
Unfortunately, too many surgeons and hospital attorneys are loathe to use video recording even when it is clearly being done for quality improvement activities and even when the recordings would be destroyed immediately following their use in quality improvement activities. It might take very clear cut statutes in every state to protect such recordings from the legal discovery process for us to convince more organizations of the value of video recording.
So how did Northwell get around those fears of litigation? First, everything is de-identified. The cameras even blur the faces of the OR team! And second, the focus is to look at system issues, not individual human issues. They also note that de-identifying the data also protects patient privacy.
Several of the studies in today’s column note that design of the systems or studies had the purpose of looking at team performance and not individual performance, and that this was a critical step in recruiting the support of all OR stakeholders.
There are ethical considerations for video recording in the operating room. Prigoff et al. (Prigoff 2016) discussed these and recommended the following guidelines:
Northwell has not yet published any outcome data that can be attributed to their OR black box program. Likewise, several studies that have demonstrated improvement in process measures have not been of sufficient sample size to assess actual patient outcomes.
So, what does all this cost? It’s not for the faint of heart! Northwell’s OR Black Box equipment costs $100,000 per operating room according to the HealthLeaders article. They also analyze all their data centrally, so that lessons learned can be shared among multiple hospitals in their system. The total cost of implementing the less sophisticated remote video auditing in the Overdyk study (Overdyk 2016) had three cost components: one-time video equipment cost of approximately $4000 per camera; one-time remote video auditing set-up and onsite consulting training fee of $7500 per OR; and an remote video auditing service charge of $40/day per OR. So, there is probably a whole spectrum of implementation components and costs.
Nice job, Northwell! We wish we could convince more hospitals to adopt this approach. Hopefully, other hospitals will see the benefit of video recording and black box integration that you’ve experienced and implement it at their facilities.
Some of our previous columns discussing video recording:
September 23, 2008 “Checklists and Wrong Site Surgery”
December 6, 2010 “More Tips to Prevent Wrong-Site Surgery”
November 2011 “Restricted Housestaff Work Hours and Patient Handoffs”
March 2012 “Smile...You’re on Candid Camera!”
August 27, 2013 “Lessons on Wrong-Site Surgery”
March 17, 2015 “Distractions in the OR”
November 24, 2015 “Door Opening and Foot Traffic in the OR”
March 2019 “Another Use for Video Recording”
References:
Cheney C. Northwell Pioneers Black Boxes in Operating Rooms for Performance Improvement. HealthLeaders Media 2020; February 26, 2020
van de Graaf FW, Lange MM, Spakman JI, et al. Comparison of Systematic Video Documentation With Narrative Operative Report in Colorectal Cancer Surgery. JAMA Surg 2019; 154(5): 381-389
https://jamanetwork.com/journals/jamasurgery/fullarticle/2720695
Overdyk FJ, Dowling O, Newman S, et al. Remote video auditing with real-time feedback in an academic surgical suite improves safety and efficiency metrics: a cluster randomized study. BMJ Qual Saf 2016; 25: 947-953
https://qualitysafety.bmj.com/content/25/12/947
Jung JJ, Jüni P, Lebovic G, Grantcharov T. First-year Analysis of the Operating Room Black Box Study. Annals of Surgery 2020; 271(1): 122-127 Published Ahead of Print June 18, 2018
Bergström, H., Larsson, L. & Stenberg, E. Audio-video recording during laparoscopic surgery reduces irrelevant conversation between surgeons: a cohort study. BMC Surg 2018; 18: 92
https://bmcsurg.biomedcentral.com/articles/10.1186/s12893-018-0428-x#citeas
Grantcharov T. Real-time OR Monitoring Leads to Better, Safer Surgery. QA with Teodor Grantcharov, MD, PhD, FACS, creator of surgery's 'black box' and believer that data doesn't lie. Outpatient Surgery Magazine 2019; April 2019
Prigoff JG, Sherwin M, Divino CM. Ethical Recommendations for Video Recording in the Operating Room. Annals of Surgery 2016; 264(1): 34-35
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March 24, 2020
Mayo Clinic: How to Get Photos in Your EMR
Patient misidentification has been a topic of many of our columns. We’ve long been advocates of including patient photographs in the EMR as a means of reducing patient identification errors. And there are many other benefits of having patient photographs in the EMR.
Our December 17, 2019 Patient Safety Tip of the Week “Tale of Two Tylers” showed a glaring example of how patient photographs in the EMR might prevent a wrong patient error. It also described the mechanical steps one hospital uses to get patient photographs into the EMR. In a study by Blanchfield et al. (Blanchfield 2019) the patient photographs were taken when the patient presented to the ED. The ease with which we can today take a digital photograph today and upload it to the EHR enables the use of up-to-date patient photos. In the Blanchfield study, they created a new standard of care and implemented a new workflow for ED registration staff. Using iPod touch devices, ED registration staff took photos of consenting patients either at the front desk when patients check-in, or at the end of the registration process.
But having the equipment and a protocol is the easy part. Actually, achieving a goal of getting photos in all patient EMR’s is more complicated. A study from the Mayo Clinic (Aseem 2020) is informative in that regard. A survey of all physicians practicing in their executive medicine division showed overwhelming support of respondents (92.3%) for inclusion of a patient photograph in the upper left corner of the EMR to help them in responding to phone messages and other issues of patient care. But, before they began a quality improvement intervention, the mean weekly measurement of the rate of photograph inclusion in the EMR was only 49.5%. Their multidisciplinary quality improvement team set a goal of increasing the rate of photo inclusion in the EMR by 20%, with a target rate of 70% or greater within 6 months of intervention.
They describe 3 PDSA cycles, each lasting 6 to 9 weeks. In the first, they gave visual cue cards to patients. The cards reinforced the importance of having a picture in their medical record to aid in proper identification, while addressing potential privacy concerns. It also gave them options to get the photos into the EMR.
The second PDSA cycle involved face-to-face meetings between the clinical staff and front office staff. This resulted in changes to workflow that made it easier to capture a patient photograph at the time of check-in for their medical appointment.
The third PDSA cycle focused on feedback and encouragement. Weekly results were shared in clinical staff meetings, on a notice board, and in the form of a poster. Barriers
to implementation were discussed and all encouraged ideas to streamline workflow. Encouragement was passed back on to staff to continue with their improved process.
After the first cycle, the photograph inclusion rate increased from 49.5% to 59.4%. After the second cycle, the rate increased to a peak of 74.7%, but then began to regress toward previous levels, After the third cycle, the rate remained relatively static at 76.0%. Overall, after 3 PDSA cycles, the mean weekly rate of patient photographs included in the EMR was 71.4%, meeting their original goal.
The article includes a nice graphic representation of the results on a weekly basis. It demonstrates 2 important elements: first, you will see some week-to-week variation in rates and, second, quality improvement projects need to be monitored for sustainability of results.
Some barriers were noted. These were patients in an executive medicine clinic, many of whom “seek to maintain a low profile” or were otherwise concerned with privacy issues.
Importantly, the researchers did look for unintended consequences. Fortunately, they did not find any. One bonus noted was that clinical assistants found that having a patient photograph allowed them to more easily identify the patient in the waiting area, improving the patient experience.
They also concluded that the intervention can be implemented inexpensively and without significant impact on workflow.
Note that the study did not measure the ultimate goal: reduction in patient misidentification errors. If you were to implement such a project in your organization, you might use the RAR (Retract-and-Reorder) methodology (see our July 17, 2012 Patient Safety Tip of the Week “More on Wrong-Patient CPOE”) to identify instances where a user initially entered an order on the wrong patient. The RAR methodology is also nicely described in the supplement to the Adelman study (Adelman 2019) that we referenced in our May 21, 2019 Patient Safety Tip of the Week “Mixed Message on Number of Open EMR Records”. It is a tool we’ve recommended you use in tracking and monitoring patient misidentification issues as part of your quality improvement program (see our March 26, 2019 Patient Safety Tip of the Week “Patient Misidentification”). The RAR methodology, of course, measures near misses (by definition, it identifies instances where the user recognized the error and corrected it). But it is one of the only proxies we have for assessing the frequency of potential wrong-patient ordering errors.
Our June 26, 2012 Patient Safety Tip of the Week “Using Patient Photos to Reduce CPOE Errors” described how Children’s Hospital of Colorado successfully implemented use of patient photographs to reduce CPOE errors (Hyman 2012). Beginning with a nice review of the literature on patient-note mismatches, they implemented tools to help avoid such mismatches during CPOE. First, they modified their CPOE workflow to include a verification screen asking the provider to verify that this is the patient on whom he/she intends to enter orders. They then began taking photographs of patients at admission or registration and including these on the above noted verification screen. They found a dramatic reduction in the number of events of actual ordering on the wrong patient or near-misses. And when such events or near-misses did occur, it was usually in charts that did not have a photograph of the patient. While they could not separate out the impact of the verification screen from that of the photograph, they felt that the photographs played a large role in reducing the number of orders placed in the records of wrong patients. They noted that, unlike other CPOE alerts that have a high likelihood of being ignored, the presence of the large centrally placed photograph is effective in capturing the attention of the CPOE user. They did note that photographs have limitations, particularly for newborns and when pictures are poorly exposed. And they note that photographs need to be updated at appropriate times.
The Blanchfied study mentioned above (Blanchfield 2019) demonstrated that a passive display of patient photos in the EHR was associated with reduced rates of wrong patient orders and near misses in the Brigham and Women’s Emergency Department. While the study looked at how having patient photos in the EHR helped physicians identify the correct patient when entering orders in the EHR, one can readily see how having the photo at the top of every screen (in the EHR or the radiology PACS system), along with their name and DOB and medical record number, would help whomever is searching for an image identify the correct patient.
What could go wrong? The biggest risk would be that the photo could be inadvertently be put into the EMR of the wrong patient. Staff inputting the photos obviously need to comply with 2-factor patient identification. A double check would not be practical for those offices with only a single receptionist and would likely be fraught with error in busy reception areas. But, for those EMR systems that provide patient access, you might ask the patient to confirm their photo is the correct one.
Some have questioned whether photos in the EMR might enable fraud. Actually, using photos in the EMR probably is a deterrent to fraud. Someone fraudulently using the ID of another patient would now likely be recognized as not being the intended patient.
People’s appearances change as they age and their appearance may also change for other reasons. They change their hair color or hair length, they lose their hair, they get new glasses, they get facial surgery, etc. So that raises the issue of when and how patient photographs should be taken. Your organization should have a policy on how often or under what other circumstances you should require a new photo. Most DMV’s require a new photo every 2 years or so when you renew your driver’s license. Your front office staff might also play a role in spotting cases where a new photo should be taken. Many front office staff get popup screens when registering patients that ask useful questions like “Do you have a current advance directive?”. You could easily add a question about whether there is an up-to-date photo.
There is also something to be said about real-time photographs in certain settings. Our November 12, 2019 Patient Safety Tip of the Week “Patient Photographs Again Help Radiologists” showed how real-time photographs, taken at the same time a radiology study was being done, were of great value not only in identifying the correct patient but also improving the clinical information available to the radiologist. And, in the Blanchfield study (Blanchfield 2019) the patient photographs were taken when the patient presented to the ED. The ease with which we can today take a digital photograph today and upload it to the EHR enables the use of up-to-date patient photos. In the Blanchfield study, they created a new standard of care and implemented a new workflow for ED registration staff. Using iPod touch devices, ED registration staff took photos of consenting patients either at the front desk when patients check-in, or at the end of the registration process.
Could facial recognition software eventually play a role? One might anticipate someone calling in to an office might have their identity verified via facial recognition on a cell phone or computer, with matching occurring against the photo in the EMR. Just a thought… That might lead to more confusion given the current state of the art, but who knows in the future? And you’d have to figure out what would happen with identical twins.
The Mayo system was thought to be especially helpful when clinicians were talking to patients on the phone (the photo reminding them about the patient). We think the most important value of the photo is when you search on a patient name in the EMR and the EMR truncates to the first result meeting the search criteria. You then have the opportunity of seeing a photo that may tell you it’s the wrong patient.
There, of course, are other benefits to having patient photographs in the EMR. In our July 28, 2009 Patient Safety Tip of the Week “Wandering, Elopements, and Missing Patients” we briefly mentioned using photographs of patients when broadcasting an alert for a missing patient. We recommend that you include in your IT system a digital photograph of patients you identify as being at risk for wandering and elopement. Many communities, often in conjunction with their local chapter of the Alzheimer Association, have programs where families provide photos of their relatives with Alzheimer’s Disease or other dementia to the local police department to facilitate searches when such individuals go missing.
Inclusion of patient photographs would be a logical tool to use in avoiding wrong patient surgeries or mix ups in medication administration. In fact, there are programs that have used patient photographs to reduce the risk of patient misidentification during medication administration (AHRQ Health Care Innovations Exchange). The JPS Health Network in Fort Worth, Texas implemented such a system on its psychiatry units. They first implemented it on adolescent psychiatry in 2000 then, based on success of that program, extended it to their adult psychiatry service in 2006. They noted that this additional method of correct patient identification is especially needed on psychiatry because patients frequently remove their wristband identifications and may be unable or unwilling to respond to questions at the time of medication administration. In the year after implementation on the adult unit, there were no misidentification errors on either unit. Reappearance of misidentification errors a year later led to a reeducation effort and such errors again fell to almost zero.
Radiologists have also found patient photographs to be helpful. In our December 2008 What’s New in the Patient Safety World “Patient Photographs Improve Radiologists’ Performance” we noted a paper presented at the Radiological Society of North America’s annual meeting showing that inclusion of photographs of patients improved accuracy of radiologists’ reports. Putting a photograph of the patient aside their images on a PAC screen resulted not only in the radiologists feeling more empathy toward the patient but they also identified more incidental findings (the files were chosen because of incidental findings in this randomized study) without taking more time to review the images.
Another study (Ridley 2012) demonstrated that including patient photographs in PACS systems likely leads to fewer misidentification errors. Researchers at Emory University developed a low-cost system for obtaining patient photographs at the time an imaging procedure was being done and integrating them via wireless connection with the images going to their PACS system. They then gave radiologists imaging studies to read that purposefully including some instances of misidentification. Those reading without patient photographs picked up only 12.5% of the misidentified patients. Those reading with the patient photographs detected 64% of the errors.
Our November 12, 2019 Patient Safety Tip of the Week “Patient Photographs Again Help Radiologists” showed how real-time photographs, taken at the same time a radiology study was being done, were of great value not only in identifying the correct patient but also improving the clinical information available to the radiologist. Another article detailed how digital photographs can be integrated with medical imaging studies (Ramamurthy 2013).
So, it’s pretty clear that use of patient photographs has an important role in multiple aspects of patient safety. The current Mayo Clinic study provides some useful guidance on how your organization can promote the use of patient photos in the EMR.
Some of our prior columns on use of patient photographs in patient safety:
December 2008 “Patient Photographs Improve Radiologists’ Performance”
January 12, 2010 “Patient Photos in Patient Safety”
June 26, 2012 “Using Patient Photos to Reduce CPOE Errors”
April 30, 2013 “Photographic Identification to Prevent Errors”
January 19, 2016 “Patient Identification in the Spotlight”
March 26, 2019 “Patient Misidentification”
November 12, 2019 “Patient Photographs Again Help Radiologists”
December 17, 2019 “Tale of Two Tylers”
Some of our prior columns related to patient identification issues:
May 20, 2008 “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?”
November 17, 2009 “Switched Babies”
July 17, 2012 “More on Wrong-Patient CPOE”
June 26, 2012 “Using Patient Photos to Reduce CPOE Errors”
April 30, 2013 “Photographic Identification to Prevent Errors”
August 2015 “Newborn Name Confusion”
January 12, 2016 “New Resources on Improving Safety of Healthcare IT”
January 19, 2016 “Patient Identification in the Spotlight”
August 1, 2017 “Progress on Wrong Patient Orders”
June 19, 2018 “More EHR-Related Problems”
November 2018 “More on Hearing Loss”
March 26, 2019 “Patient Misidentification”
May 21, 2019 “Mixed Message on Number of Open EMR Records”
September 10, 2019 “Joint Commission Naming Standard Leaves a Gap”
December 17, 2019 “Tale of Two Tylers”
References:
Blanchfield BB, Salmaisian H, Landman A. Abstract #56. Adding Patient Photos to the Electronic Health Record to Improve Patient Identification and Reduce Wrong Patient Order Errors. Ann Emerg Med 2019; 74(4s): S22-23 October 2019
https://www.annemergmed.com/article/S0196-0644(19)30733-4/fulltext
Aseem S, Ratrout BM, Litin SC, et al. A Process of Acceptance of Patient Photographs in Electronic Medical Records to Confirm Patient Identification. Mayo Clinic Proceedings: Innovations, Quality & Outcomes 2020; 4(1): 99-104
https://mcpiqojournal.org/article/S2542-4548(19)30152-3/fulltext
Adelman JS, Applebaum JR, Schechter CB, et al. Effect of Restriction of the Number of Concurrently Open Records in an Electronic Health Record on Wrong-Patient Order Errors. A Randomized Clinical Trial. JAMA 2019; 321(18): 1780-1787
https://jamanetwork.com/journals/jama/fullarticle/2733207
Hyman D, Laire M, Redmond D, Kaplan DW. The use of patient pictures and verification screens to reduce computerized provider order entry errors. Pediatrics 2012; 130(1): e211-e219
https://pediatrics.aappublications.org/content/130/1/e211?download=true
AHRQ Health Care. Innovations Exchange. Innovation Profile: Use of Photographs as Second Means of Identifying Patients on Psychiatry Units Virtually Eliminates Medication Errors Related to Misidentification. Last Updated: 10/09/2013
Ridley EL. Integrating digital photos within PACS may cut ID errors. AuntMinnie.com June 20, 2012
http://www.auntminnie.com/index.aspx?sec=sup&sub=pac&pag=dis&ItemID=99747
Ramamurthy S, Bhatti P, Arepalli CD, Salama M, Provenzale JM, Tridandapani S. Integrating patient digital photographs with medical imaging examinations. J Digit Imaging 2013; 26(5): 875-885
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3782605/pdf/10278_2013_Article_9579.pdf
Print “Mayo Clinic: How to Get Photos in Your EMR”
March 31, 2020
Intrahospital Transport Issues in Children
Lots of things can go wrong when hospital inpatients are transported to other areas of the hospital (for example, to radiology, a lab, the OR, physical therapy, etc.). We’ve done many columns (listed below) on the hazards of such intrahospital transports. Our May 22, 2018 Patient Safety Tip of the Week “Hazardous Intrahospital Transport” summarized the multiple issues encountered in such transports.
But we.ve focused primarily on adult inpatients in our prior columns. A new systematic review looked at adverse events during intrahospital transport of critically ill children (Haydar 2019). They identified 40 full-text articles with sufficient information about adverse events in children during intrahospital transport. Studies were heterogeneous and the incidence of adverse events varied widely between studies.
Respiratory and airway events were the most common type of adverse event. Hypothermia was common in infants. They also found instances of emergent tracheostomy, pneumothorax, and cardiac arrest. One transport-associated death was reported.
One hazard we have not commented upon often enough in intrahospital transports is hypothermia. We did discuss the risk of hypothermia in interhospital transfers (see our October 30, 2018 Patient Safety Tip of the Week “Interhospital Transfers”). But children, particularly infants, are especially prone to hypothermia.
In our January 7, 2020 Patient Safety Tip of the Week “Even More Concerns About MRI Safety” we discussed a study that showed most children who undergo MRI while under anesthesia experience hypothermia at some point during the procedure (Cronin 2019). Using MRI-compatible temperature monitoring, the researchers found that 63% of patients less than 8 years of age exhibited hypothermia (median temperature less than 36°C) at some point during MRI. Most instances of hypothermia occurred early, particularly during anesthesia induction and prior to the initiation of the MRI scan, and then improved during the scan. That was ascribed to the fact that the scanning environment is typically kept cool, with a low humidity, and heat loss to the surrounding environment typically occurs after induction of anesthesia. Later, body temperature tends to increase during the MRI scan secondary to MR radiofrequency heating. The researchers did not find any increase in perianesthetic complications or an impact on PACU length of stay. However, the study was limited to children undergoing outpatient procedures. It is quite conceivable that sicker, more vulnerable inpatients might be impacted by such hypothermia. The authors, therefore, recommend interventions for these patients should be focused on maintaining normothermia during the anesthesia induction and prior to initiation of the MRI scan. MRI-compatible continuous temperature monitoring is important for managing temperature for these anesthetized patients.
A recent study (Brozanski 2020); focused on keeping infants warm in the perioperative period. While their interventions included prewarming the OR and standardized practice to prevent intraoperative heat loss, they also included establishing euthermia before transport to the operating room (OR) and standardized practice for maintaining euthermia on transport to and from the OR. Postoperative hypothermia decreased by 48%, from a baseline of 20.3% to 10.5% after implementation of these interventions. And, if your focus is on preventing hypothermia, you obviously need to have a way of monitoring body temperature.
Haydar et al. found that many adverse events during intrahospital transport were deemed potentially preventable. Two strategies stood out to potentially mitigate adverse consequences: use of checklists and double checks.
Checklists are essential for patient safety during intrahospital transports. Our many columns on the “Ticket to Ride” checklist are listed at the end of today’s column. In our August 25, 2015 Patient Safety Tip of the Week “Checklist for Intrahospital Transport” we discussed many factors contributing to incidents related to intrahospital transports. These include equipment failures, oxygenation issues, battery/power issues, and things like attention to patient hydration. And don’t forget the problems that arise when sending diabetic patients off for substantial periods of time (what to do with their insulin, planning for meals, etc.). We refer you to a Netherlands study (Brunsveld-Reinders 2015) to actually see a good checklist they created for intrahospital transports. The article also addresses transport team composition (which may vary depending upon whether the patient is ventilated or on pressors or inotropes) and education/training needs for members of the transport team.
A good “Ticket to Ride” type checklist for intrahospital transport should cover all three phases of transport: pre-transport, during-transport, and post-transport (Jarden 2010, Brunsveld-Reinders 2015)
We probably would not put as much weight on double checks at do Haydar et al. Double checks in such situations are often done in a perfunctory manner and the original and second person often assume that any discrepancies will be picked up by the other person. If you rely on double checks, they must done in a truly independent manner. Probably the two most important items you would want to double check are the oxygen supply and the battery charge on any portable ventilator, ensuring that both are adequate for the anticipated duration of the transport (plus an allowance for unanticipated duration).
Of course, staff accompanying the patient need to be familiar with any equipment used during transport. We’d add that hospital personnel on the receiving end also be familiar with the transport equipment. That brings us to another thing we’d emphasize: the need for an appropriate handoff prior to the and following the transport. Let’s say you are transporting a critically ill child to the Radiology suite for a CT scan. You should discuss with the radiology nurse or radiology staff whether your patient is on oxygen, being ventilated, what sorts of medications are running in various lines, etc. and discuss what events might be anticipated.
The literature suggests that the risk of incidents and adverse events during transports is also related to the time duration of the transport. Hence, events such as CT scanning tend to be associated with more incidents because they require more time (PPSA 2005). For example, the risk of running out of oxygen would be greater on longer transports. You’ll recall that the original “Ticket to Ride” checklists were created because of such oxygen depletions during transports.
Two key factors related to the risk of adverse events during transport noted by Haydar et al. are the patient’s underlying illness and degree of respiratory support. They noted that mechanical ventilation was superior to manual ventilation in intubated patients. Don’t forget that, in addition to checking to make sure the oxygen supply will be adequate for the planned duration of the transport, to also check that the battery charge on any portable ventilator will be sufficient for the duration of the transport.
And Haydar et al. stress the importance of optimizing the patient’s physiological status prior to transport. They also recommend having experienced clinicians accompany the patient.
The destination of the transport may also be important. Probably the most common destination for intrahospital transports is the Radiology suite. We refer you back to our October 22, 2013 Patient Safety Tip of the Week “How Safe Is Your Radiology Suite?” for a comprehensive discussion of all the things that can go wrong when a patient is sent to the radiology suite. With children, you also need to consider they may require sedation or anesthesia for their imaging study or procedure and plan for appropriate monitoring. Keep in mind that some effect of sedation may still be present during the trip back to the ICU or floor so you must be prepared for an event such as respiratory depression.
Do you want a parent to accompany the child? That may be a good idea in some cases, since it may help allay any anxiety the child has. But even if a parent is not accompanying the child, it is a good idea to keep the parent(s) in the loop. A checklist for transport of pediatric surgery patients at the Medical Center of Central Georgia (Nakayama 2012) included an item for verification of family location and actually included their cell phone number and home telephone number on the checklist.
Lastly, there is one question that we see consistently overlooked: does the patient really need the test/procedure for which you are transporting him/her?. When we do a root cause analysis on any event related to a procedure, test, imaging, or transport, the first question we usually ask is “Was the procedure necessary?”. You’d be surprised how often we hear waffling on that question. In our August 25, 2015 Patient Safety Tip of the Week “Checklist for Intrahospital Transport” we noted a commentary by Shirley and Bion (Shirley 2004) which noted the importance of making the decision about whether to transport a patient. They note that such decision “should be made by a senior, experienced and appropriately skilled clinician who remains responsible for the conduct of the transfer”. The potential benefits of a transport must be critically weighed against the potential risks. Beckmann et al. (Beckmann 2004) cite studies suggesting that care plans were changed for patients after such transports in only 24-39% of cases. So one really needs to consider how likely the imaging study (or other procedure the patient may be going for) is really going to change patient management.
In our August 25, 2015 Patient Safety Tip of the Week “Checklist for Intrahospital Transport” we discussed “the 5 W’s” of intrahospital transport (Day 2010). The first “W” is “Why” or “Why does the patient need to leave the ICU for the procedure?”. Important questions to ask here are “Are there bedside alternatives for the procedure? And “Is the patient’s condition stable?”. If the patient is considered unstable, the next questions are “Is the transport for a lifesaving intervention?” and “Is the transport to a diagnostic test pivotal to decision for emergent plan?”. Day’s second “W” is “Who”. This included both who is the patient and who will be caring for the patient and, importantly, will a handoff be required? The third “W” is “What” and refers to equipment, airway, ventilator support, circulatory support, and special considerations (eg. spine stability, intracranial pressure monitors, etc.). Under the fourth “W” for “When” Day discusses considerations about coordinating with the timing of the test or procedure (eg. fasting or withholding anticoagulants for procedures), renal protective protocols for contrast-using procedures, and collaborating with other healthcare providers. The last “W” is for “Where” which includes details about the route to be taken, issues regarding MRI safety if going for MRI, etc.
Intrahospital transports, whether involving critical care patients or others, need to be undertaken with considerable planning. You need to ensure that you have systems in place to ensure the safety of the patients and tools like the “Ticket to Ride” checklists to facilitate safe transports.
Do you know the rate of adverse events during intrahospital transports is in your hospital? What sorts of issues have you found in your RCA’s (root cause analyses) of such events? Do you have formal policies and procedures for intrahospital transports? Do you utilize a “Ticket to Ride” type checklist before, during and after such transports? Do you have ones that specifically apply to pediatric patients? If not, that’s another great topic for FMEA (Failure Mode and Effects Analysis).
Some of our prior columns on the “Ticket to Ride” concept:
Some of our prior columns on patient safety issues in the radiology suite:
References:
Haydar B, Baetzel A, Elliott A, et al. Adverse Events During Intrahospital Transport of Critically Ill Children. A Systematic Review. Anesthesia & Analgesia 2019; Published ahead of print December 16, 2019
Cronin JA, Shen ., Rana S, et al. Association Between Magnetic Resonance Imaging in Anesthetized Children and Hypothermia. Pediatric Quality & Safety 2019, 4(4): e181
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6708655/
Brozanski BS, Piazza AJ, Chuo J, et al. STEPP IN: Working Together to Keep Infants Warm in the Perioperative Period. Pediatrics 2020; March 2020: e20191121
Brunsveld-Reinders AH, Arbous M, Kuiper SG, de Jonge E. A comprehensive method to develop a checklist to increase safety of intra-hospital transport of critically ill patients. Critical Care 2015; 19: 214 (7 May 2015)
http://www.ccforum.com/content/19/1/214
Jarden RJ, Quirke S. Improving safety and documentation in intrahospital transport: development of an intrahospital transport tool for critically ill patients. Intensive Crit Care Nurs 2010; 26: 101-107
Pennsylvania Patient Safety Authority. Patient Safety Advisory. Is CT a High-Risk Area for Patient Transport? PA PSRS Patient Saf Advis 2005; 2(3): 11-12
http://patientsafety.pa.gov/ADVISORIES/Pages/200509_11.aspx
Nakayama DK, Lester SS, Rich DR, et al. Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients. Journal of Pediatric Surgery 2012; 47(1): 112-118
https://www.jpedsurg.org/article/S0022-3468(11)00900-6/fulltext
Shirley PJ, Bion JF. Intra-hospital transport of critically ill patients: minimising risk. Intensive Care Medicine 2004; 30(8): 1508-1510
http://icmjournal.esicm.org/journals/abstract.html?v=30&j=134&i=8&a=2293_10.1007_s00134-004-2293-6&doi=
Beckmann U, Gillies DM, Berenholtz SM, Wu AW, Pronovost P. Incidents relating to the intra-hospital transfer of critically ill patients: An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care. Intensive Care Medicine 2004; 30(8): 1579-1585
http://icmjournal.esicm.org/journals/abstract.html?v=30&j=134&i=8&a=2177_10.1007_s00134-004-2177-9&doi=
Day D. Keeping Patients Safe During Intrahospital Transport. Crit Care Nurse 2010; 30: 18-32
http://ccn.aacnjournals.org/content/30/4/18.full
Print “Intrahospital Transport Issues in Children”
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NY State and Nurse Staffing Issues
August 25, 2020
The Off-Hours Effect in Radiology
August 18, 2020
August 11, 2020
Above-Door Alarms to Prevent Suicides
August 4, 2020
July 28, 2020
July 21, 2020
Is This Patient Allergic to Penicillin?
July 14, 2020
A Thesis on Intrahospital Transports
July 7, 2020
Another Patient Found Dead in a Stairwell
June 30, 2020
What Happens after Hospitalization?
June 23, 2020
June 16, 2020
June 9, 2020
Perioperative Medication Safety
June 2, 2020
May 26, 2020
May 19, 2020
Reminder on Telephone or Verbal Orders
May 12, 2020
May 5, 2020
COVID-19 and the Dental Office
April 28, 2020
April 21, 2020
Parenteral Nutrition Safety Issues
April 14, 2020
Patient Safety Tidbits for the COVID-19 Pandemic
April 7, 2020
From Preoperative Assessment to Preoperative Optimization
March 31, 2020
Intrahospital Transport Issues in Children
March 24, 2020
Mayo Clinic: How to Get Photos in Your EMR
March 17, 2020
March 10, 2020
Medication Harm in the Elderly
March 3, 2020
Opportunities to Reduce Unnecessary Contact Precautions
February 25, 2020
More on Perioperative Gabapentinoids
February 18, 2020
February 11, 2020
February 4, 2020
Drugs and Chronic Kidney Disease
January 28, 2020
January 21, 2020
Disruptive Behavior and Patient Safety: Cause or Effect?
January 14, 2020
January 7, 2020
Even More Concerns About MRI Safety
December 31, 2019
Tip of the Week on Vacation
December 14, 2019
Tip of the Week on Vacation
December 17, 2019
December 10, 2019
December 3, 2019
Overlapping Surgery Back in the News
November 26, 2019
Pennsylvania Law on Notifying Patients of Test Results
November 19, 2019
An Astonishing Gap in Medication Safety
November 12, 2019
Patient Photographs Again Help Radiologists
November 5, 2019
October 29, 2019
Tip of the Week on Vacation
October 22, 2019
Tip of the Week on Vacation
October 15, 2019
October 8, 2019
October 1, 2019
Electronic Medication Reconciliation: Glass Half Full or Half Empty?
September 24, 2019
EHR-related Malpractice Claims
September 17, 2019
American College of Surgeons Geriatric Surgery Verification Program
September 10, 2019
Joint Commission Naming Standard Leaves a Gap
September 3, 2019
Lessons from an Inpatient Suicide
August 27, 2019
August 20, 2019
Yet Another (Not So) Unusual RSI
August 13, 2019
Betsy Lehman Center Report on Medical Error
August 6, 2019
July 30, 2019
Lessons from Hospital Suicide Attempts
July 23, 2019
Order Sets Can Nudge the Right Way or the Wrong Way
July 16, 2019
July 9, 2019
Spinal Injection of Tranexamic Acid
July 2, 2019
Tip of the Week on Vacation
June 25, 2019
June 18, 2019
June 11, 2019
ISMP’s Grissinger on Overreliance on Technology
June 4, 2019
Medication Errors in the OR – Part 3
May 28, 2019
May 21, 2019
Mixed Message on Number of Open EMR Records
May 14, 2019
Wrong-Site Surgery and Difficult-to-Mark Sites
May 7, 2019
Simulation Training for OR Fires
April 30, 2019
Reducing Unnecessary Urine Cultures
April 23, 2019
In and Out the Door and Other OR Flow Disruptions
April 16, 2019
AACN Practice Alert on Alarm Management
April 9, 2019
Handoffs for Every Occasion
April 2, 2019
Unexpected Events During MRI
March 26, 2019
March 19, 2019
March 12, 2019
Update on Overlapping Surgery
March 5, 2019
Infusion Pump Problems
February 26, 2019
Vascular Access Device Dislodgements
February 19, 2019
Focus on Pediatric Patient Safety
February 12, 2019
From Tragedy to Travesty of Justice
February 12, 2019
2 ER Drug Studies: Reassurances and Reservations
February 5, 2019
Flaws in Our Medication Safety Technologies
January 29, 2018
National Patient Safety Goal for Suicide Prevention
January 22, 2019
Wandering Patients
January 15, 2019
Another Plus for Prehabilitation
January 8, 2019
Maternal Mortality in the Spotlight
January 1, 2019
More on Automated Dispensing Cabinet (ADC) Safety
December 25, 2018
Happy Holidays!
December 18, 2018
Great Recommendations for e-Prescribing
December 11, 2018
December 4, 2018
Don’t Use Syringes for Topical Products
November 27, 2018
November 20, 2018
November 13, 2018
Antipsychotics Fail in ICU Delirium
November 6, 2018
More on Promoting Sleep in Inpatients
October 30, 2018
October 23, 2018
Lessons From Yet Another Aviation Incident
October 16, 2018
October 9, 2018
October 2, 2018
Speaking Up About Disruptive Behavior
September 25, 2018
Foley Follies
September 18, 2018
September 11, 2018
September 4, 2018
The 12-Hour Nursing Shift: Another Nail in the Coffin
August 28, 2018
Thought You Discontinued That Medication? Think Again
August 21, 2018
Delayed CT Scan in the Anticoagulated Patient
August 14, 2018
ISMP Canada’s Updated “Do Not Use” Abbreviation List
August 7, 2018
Tip of the Week on Vacation
July 31, 2018
Surgery and the Opioid-Tolerant Patient
July 24, 2018
More on Speech Recognition Software Errors
July 17, 2018
OSA Screening in Stroke Patients
July 10, 2018
Another Jump from a Hospital Window
July 3, 2018
Tip of the Week on Vacation
June 26, 2018
Infection Related to Colonoscopy
June 19, 2018
June 12, 2018
Adverse Events in Cancer Patients
June 5, 2018
Pennsylvania Patient Safety Authority on Iatrogenic Burns
May 29, 2018
More on Nursing Workload and Patient Safety
May 22, 2018
Hazardous Intrahospital Transport
May 15, 2018
May 8, 2018
May 1, 2018
April 24, 2018
April 17, 2018
More on Tests Pending at Discharge
April 10, 2018
Prepping the Geriatric Patient for Surgery
April 3, 2018
March 27, 2018
March 20, 2018
Minnesota Highlights Lost Tissue Samples
March 13, 2018
March 6, 2018
February 27, 2018
Update on Patient Safety Walk Rounds
February 20, 2018
February 13, 2018
February 6, 2018
Adverse Events in Inpatient Psychiatry
January 30, 2018
January 23, 2018
Unintentional Hypothermia Back in Focus
January 16, 2018
January 9, 2018
More on Fire Risk from Surgical Preps
January 2, 2018
Preventing Perioperative Nerve Injuries
December 26, 2017
Tip of the Week on Vacation
December 19, 2017
December 12, 2017
Joint Commission on Suicide Prevention
December 5, 2017
Massachusetts Initiative on Cataract Surgery
November 28, 2017
More on Dental Sedation/Anesthesia Safety
November 21, 2017
OSA, Oxygen, and Alarm Fatigue
November 14, 2017
Tracking C. diff to a CT Scanner
November 7, 2017
Perioperative Neuropathies
October 31, 2017
Target Drugs for Deprescribing
October 24, 2017
Neurosurgery and Time of Day
October 17, 2017
Progress on Alarm Management
October 10, 2017
More on Torsade de Pointes
October 3, 2017
Respiratory Compromise: One Size Does Not Fit All
September 26, 2017
Tip of the Week on Vacation
September 19, 2017
Tip of the Week on Vacation
September 12, 2017
Can You Hear Me Now?
September 5, 2017
Another Iatrogenic Burn
August 29, 2017
Suicide in the Bathroom
August 22, 2017
August 15, 2017
Delayed Emergency Surgery and Mortality Risk
August 8, 2017
Sedation for Pediatric MRI Rising
August 1, 2017
Progress on Wrong Patient Orders
July 25, 2017
Can We Influence the “Weekend Effect”?
July 18, 2017
Another Hazard from Alcohol-Based Hand Gels
July 11, 2017
The 12-Hour Shift Takes More Hits
July 4, 2017
Tip of the Week on Vacation
June 27, 2017
June 20, 2017
June 13, 2017
June 6, 2017
NYS Mandate for Sepsis Protocol Works
May 30, 2017
Errors in Pre-Populated Medication Lists
May 23, 2017
May 16, 2017
Are Surgeons Finally Ready to Screen for Frailty?
May 9, 2017
Missed Nursing Care and Mortality Risk
May 2, 2017
Anatomy of a Wrong Procedure
April 25, 2017
April 18, 2017
Alarm Response and Nurse Shift Duration
April 11, 2017
Interruptions: The Ones We Forget About
April 4, 2017
Deprescribing in Long-Term Care
March 28, 2017
More Issues with Dental Sedation/Anesthesia
March 21, 2017
Success at Preventing Delirium
March 14, 2017
More on Falls on Inpatient Psychiatry
March 7, 2017
February 28, 2017
February 21, 2017
Yet More Jumps from Hospital Windows
February 14, 2017
February 7, 2017
January 31, 2017
More Issues in Pediatric Safety
January 24, 2017
Dexmedetomidine to Prevent Postoperative Delirium
January 17, 2017
January 10, 2017
The 26-ml Applicator Strikes Again!
January 3, 2017
What’s Happening to “I’m Sorry”?
December 27, 2016
Tip of the Week on Vacation
December 20, 2016
End-of-Rotation Transitions and Mortality
December 13, 2016
More on Double-Booked Surgery
December 6, 2016
Postoperative Pulmonary Complications
November 29, 2016
Doubling Down on Double-Booked Surgery
November 22, 2016
Leapfrog, Picklists, and Healthcare IT Vulnerabilities
November 15, 2016
November 8, 2016
Managing Distractions and Interruptions
November 1, 2016
CMS Emergency Preparedness Rule
October 25, 2016
Desmopressin Back in the Spotlight
October 18, 2016
Yet More Questions on Contact Precautions
October 11, 2016
New Guideline on Preop Screening and Assessment for OSA
October 4, 2016
September 27, 2016
September 20, 2016
Downloadable ABCDEF Bundle Toolkits for Delirium
September 13, 2016
Vanderbilt’s Electronic Procedural Timeout
September 6, 2016
August 30, 2016
Can You Really Limit Interruptions?
August 23, 2016
ISMP Canada: Automation Bias and Automation Complacency
August 16, 2016
How Is Your Alarm Management Initiative Going?
August 9, 2016
August 2, 2016
Drugs in the Elderly: The Goldilocks Story
July 26, 2016
Confirmed: Keep Your OR Doors Closed
July 19, 2016
Infants and Wrong Site Surgery
July 12, 2016
Forget Brexit – Brits Bash the RCA!
July 5, 2016
Tip of the Week on Vacation
June 28, 2016
Culture of Safety and Catheter-Associated Infections
June 21, 2016
Methotrexate Errors in Australia
June 14, 2016
Nursing Monitoring of Patients on Opioids
June 7, 2016
CPAP for Hospitalized Patients at High Risk for OSA
May 31, 2016
More Frailty Measures That Predict Surgical Outcomes
May 24, 2016
Texting Orders – Is It Really Safe?
May 17, 2016
Patient Safety Issues in Cataract Surgery
May 10, 2016
Medical Problems in Behavioral Health
May 3, 2016
Clinical Decision Support Malfunction
April 26, 2016
Lots More on Preventing Readmissions But Where's the Beef?
April 19, 2016
Independent Double Checks and Oral Chemotherapy
April 12, 2016
April 5, 2016
Workarounds Overriding Safety
March 29, 2016
March 22, 2016
Radiology Communication Errors May Surprise You
March 15, 2016
March 8, 2016
Tip of the Week on Vacation
March 1, 2016
February 23, 2016
February 16, 2016
February 9, 2016
February 2, 2016
January 26, 2016
More on Frailty and Surgical Morbidity and Mortality
January 19, 2016
Patient Identification in the Spotlight
January 12, 2016
New Resources on Improving Safety of Healthcare IT
January 5, 2016
Lessons from AirAsia Flight QZ8501 Crash
December 29, 2015
More Medical Helicopter Hazards
December 22, 2015
The Alberta Abbreviation Safety Toolkit
December 15, 2015
Vital Sign Monitoring at Night
December 8, 2015
Danger of Inaccurate Weights in Stroke Care
December 1, 2015
TALLman Lettering: Does It Work?
November 24, 2015
Door Opening and Foot Traffic in the OR
November 17, 2015
Patient Perspectives on Communication of Test Results
November 10, 2015
Weighing in on Double-Booked Surgery
November 3, 2015
Medication Errors in the OR - Part 2
October 27, 2015
Sentinel Event Alert on Falls and View from Across the Pond
October 20, 2015
Updated Beers List
October 13, 2015
Dilaudid Dangers #3
October 6, 2015
Suicide and Other Violent Inpatient Deaths
September 29, 2015
More on the 12-Hour Nursing Shift
September 22, 2015
The Cost of Being Rude
September 15, 2015
Another Possible Good Use of a Checklist
September 8, 2015
TREWScore for Early Recognition of Sepsis
September 1, 2015
August 25, 2015
Checklist for Intrahospital Transport
August 18, 2015
Missing Obstructive Sleep Apnea
August 11, 2015
New Oxygen Guidelines: Thoracic Society of Australia and NZ
August 4, 2015
Tip of the Week on Vacation
July 28, 2015
July 21, 2015
Avoiding Distractions in the OR
July 14, 2015
July 7, 2015
June 30, 2015
What Are Appropriate Indications for Urinary Catheters?
June 23, 2015
Again! Mistaking Antiseptic Solution for Radiographic Contrast
June 16, 2015
June 9, 2015
Add This to Your Fall Risk Assessment
June 2, 2015
May 26, 2015
May 19, 2015
May 12, 2015
More on Delays for In-Hospital Stroke
May 5, 2015
Errors with Oral Oncology Drugs
April 28, 2015
April 21, 2015
April 14, 2015
Using Insulin Safely in the Hospital
April 7, 2015
March 31, 2015
Clinical Decision Support for Pneumonia
March 24, 2015
Specimen Issues in Prostate Cancer
March 17, 2015
March 10, 2015
FDA Warning Label on Insulin Pens: Is It Enough?
March 3, 2015
Factors Related to Postoperative Respiratory Depression
February 24, 2015
More Risks with Long-Acting Opioids
February 17, 2015
Functional Impairment and Hospital Readmission, Surgical Outcomes
February 10, 2015
The Anticholinergic Burden and Dementia
February 3, 2015
CMS Hopes to Reduce Antipsychotics in Dementia
January 27, 2015
The Golden Hour for Stroke Thrombolysis
January 20, 2015
He Didn’t Wash His Hands After What!
January 13, 2015
January 6, 2015
Yet Another Handoff: The Intraoperative Handoff
December 30, 2014
Data Accumulates on Impact of Long Surgical Duration
December 23, 2014
Iatrogenic Burns in the News Again
December 16, 2014
More on Each Element of the Surgical Fire Triad
December 9, 2014
December 2, 2014
ANA Position Statement on Nurse Fatigue
November 25, 2014
Misdiagnosis Due to Lab Error
November 18, 2014
Handwashing Fades at End of Shift, ?Smartwatch to the Rescue
November 11, 2014
Early Detection of Clinical Deterioration
November 4, 2014
Progress on Fall Prevention
October 28, 2014
RF Systems for Retained Surgical Items
October 21, 2014
The Fire Department and Your Hospital
October 14, 2014
October 7, 2014
Our Take on Patient Safety Walk Rounds
September 30, 2014
More on Deprescribing
September 23, 2014
Stroke Thrombolysis: Need to Focus on Imaging-to-Needle Time
September 16, 2014
Focus on Home Care
September 9, 2014
The Handback
September 2, 2014
Frailty and the Trauma Patient
August 26, 2014
Surgeons’ Perception of Intraoperative Time
August 19, 2014
Some More Lessons Learned on Retained Surgical Items
August 12, 2014
Surgical Fires Back in the News
August 5, 2014
Tip of the Week on Vacation
July 29, 2014
The 12-Hour Nursing Shift: Debate Continues
July 22, 2014
More on Operating Room Briefings and Debriefings
July 15, 2014
Barriers to Success of Early Warning Systems
July 8, 2014
Update: Minor Head Trauma in the Anticoagulated Patient
July 1, 2014
Interruptions and Radiologists
June 24, 2014
Lessons from the General Motors Recall Analysis
June 17, 2014
SO2S Confirms Routine Oxygen of No Benefit in Stroke
June 10, 2014
Another Clinical Decision Support Tool to Avoid Torsade de Pointes
June 3, 2014
More on the Risk of Sedative/Hypnotics
May 27, 2014
A Gap in ePrescribing: Stopping Medications
May 20, 2014
May 13, 2014
Perioperative Sleep Apnea: Human and Financial Impact
May 6, 2014
Monitoring for Opioid-induced Sedation and Respiratory Depression
April 29, 2014
More on the Unintended Consequences of Contact Isolation
April 22, 2014
Impact of Resident Workhour Restrictions
April 15, 2014
Specimen Identification Mixups
April 8, 2014
FMEA to Avoid Breastmilk Mixups
April 1, 2014
Expensive Aspects of Sepsis Protocol Debunked
March 25, 2014
March 18, 2014
Systems Approach Improving Stroke Care
March 11, 2014
We Miss the Graphic Flowchart!
March 4, 2014
Evidence-Based Prescribing and Deprescribing in the Elderly
February 25, 2014
Joint Commission Revised Diagnostic Imaging Requirements
February 18, 2014
February 11, 2014
Another Perioperative Handoff Tool: SWITCH
February 4, 2014
But What If the Battery Runs Low?
January 28, 2014
Is Polypharmacy Always Bad?
January 21, 2014
January 14, 2014
Diagnostic Error: Salient Distracting Features
January 7, 2014
Lessons From the Asiana Flight 214 Crash
December 24-31, 2013
Tip of the Week on Vacation
December 17, 2013
December 10, 2013
Better Handoffs, Better Results
December 3, 2013
Reducing Harm from Falls on Inpatient Psychiatry
November 26, 2013
Missed Care: New Opportunities?
November 19, 2013
Can We Improve Dilaudid/HYDROmorphone Safety?
November 12, 2013
More on Inappropriate Meds in the Elderly
November 5, 2013
Joint Commission Sentinel Event Alert: Unintended Retained Foreign Objects
October 29, 2013
PAD: The Pain, Agitation, and Delirium Care Bundle
October 22, 2013
How Safe Is Your Radiology Suite?
October 15, 2013
October 8, 2013
October 1, 2013
Fuels and Oxygen in OR Fires
September 24, 2013
Perioperative Use of CPAP in OSA
September 17, 2013
September 10, 2013
Informed Consent and Wrong-Site Surgery
September 3, 2013
Predicting Perioperative Complications: Slow and Simple
August 27 2013
Lessons on Wrong-Site Surgery
August 20 2013
Lessons from Canadian Analysis of Medical Air Transport Cases
August 13 2013
August 6, 2013
July 9-30, 2013
Tip of the Week on Vacation
July 2, 2013
June 25, 2013
June 18, 2013
DVT Prevention in Stoke – CLOTS 3
June 11, 2013
June 4, 2013
May 28, 2013
The Neglected Medications: IV Fluids
May 21, 2013
May 14, 2013
Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)
May 7, 2013
April 30, 2013
Photographic Identification to Prevent Errors
April 23, 2013
Plethora of Medication Safety Studies
April 16, 2013
April 9, 2013
Mayo Clinic System Alerts for QT Interval Prolongation
April 2, 2013
Absconding from Behavioral Health Services
March 26, 2013
Failure to Recognize Sleep Apnea Before Surgery
March 19, 2013
Dealing with the Violent Patient in the Emergency Department
March 12, 2013
More on Communicating Test Results
March 5, 2013
Underutilized Safety Tools: The Observational Audit
February 26, 2013
Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?
February 19, 2013
Practical Postoperative Pain Management
February 12, 2013
CDPH: Lessons Learned from PCA Incident
February 5, 2013
Antidepressants and QT Interval Prolongation
January 29, 2013
A Flurry of Activity on Handoffs
January 22, 2013
You Don’t Know What You Don’t Know
January 15, 2013
January 8, 2013
More Lessons Learned on Retained Surgical Items
January 1, 2013
Don’t Throw Away Those View Boxes Yet
December 25, 2012
Tip of the Week on Vacation
December 18, 2012
Unintended Consequences of the CAUTI Measure?
December 11, 2012
December 4, 2012
Unintentional Perioperative Hypothermia: A New Twist
November 27, 2012
November 20, 2012
Update on Perioperative Management of Obstructive Sleep Apnea
November 13, 2012
The 12-Hour Nursing Shift: More Downsides
November 6, 2012
Using LEAN to Improve Stroke Care
October 30, 2012
October 23, 2012
Latent Factors Lurking in the OR
October 16, 2012
What is the Evidence on Double Checks?
October 9, 2012
Call for Focus on Diagnostic Errors
October 2, 2012
Test Results: Everyone’s Worst Nightmare
September 25, 2012
Preoperative Assessment for Geriatric Patients
September 18, 2012
September 11, 2012
In Search of the Ideal Early Warning Score
September 4, 2012
August 28, 2012
New Care Model Copes with Interruptions Better
August 21, 2012
More on Missed Followup of Tests in Hospital
August 14, 2012
August 7, 2012
Cognition, Post-Op Delirium, and Post-Op Outcomes
July 31, 2012
Surgical Case Duration and Miscommunications
July 24, 2012
FDA and Extended-Release/Long-Acting Opioids
July 17, 2012
July 10, 2012
Tip of the Week on Vacation
July 3, 2012
Recycling an Old Column: Dilaudid Dangers
June 26, 2012
Using Patient Photos to Reduce CPOE Errors
June 19, 2012
More Problems with Faxed Orders
June 12, 2012
Lessons Learned from the CDPH: Retained Foreign Bodies
June 5, 2012
Minor Head Trauma in the Anticoagulated Patient
May 29, 2012
Falls, Fractures, and Fatalities
May 22, 2012
Update on Preoperative Screening for Sleep Apnea
May 15, 2012
May 8, 2012
Importance of Nontechnical Skills in Healthcare
May 1, 2012
April 24, 2012
Fire Hazard of Skin Preps Oxygen
April 17, 2012
April 10, 2012
April 3, 2012
New Risk for Postoperative Delirium: Obstructive Sleep Apnea
March 27, 2012
March 20, 2012
Adverse Events Related to Psychotropic Medications
March 13, 2012
Medical Emergency Team Calls to Radiology
March 6, 2012
February 28, 2012
AACN Practice Alert on Delirium in Critical Care
February 21, 2012
Improving PCA Safety with Capnography
February 14, 2012
Handoffs More Than Battle of the Mnemonics
February 7, 2012
Another Neuromuscular Blocking Agent Incident
January 31, 2012
January 24, 2012
Patient Safety in Ambulatory Care
January 17, 2012
Delirium and Contact Isolation
January 10, 2012
January 3, 2012
Unintended Consequences of Restricted Housestaff Hours
December 20, 2011
December 13, 2011
December 6, 2011
Why You Need to Beware of Oxygen Therapy
November 29, 2011
November 22, 2011
Perioperative Management of Sleep Apnea Disappointing
November 15, 2011
November 8, 2011
WHOs Multi-professional Patient Safety Curriculum Guide
November 1, 2011
So Whats the Big Deal About Inserting an NG Tube?
October 25, 2011
October 18, 2011
October 11, 2011
October 4, 2011
Radiology Report Errors and Speech Recognition Software
September 27, 2011
The Canadian Suicide Risk Assessment Guide
September 20, 2011
When Practice Changes the Evidence: The CKD Story
September 13, 2011
Do You Use Fentanyl Transdermal Patches Safely?
September 6, 2011
August 30, 2011
Unintentional Discontinuation of Medications After Hospitalization
August 23, 2011
Catheter Misconnections Back in the News
August 16, 2011
August 9, 2011
Frailty and the Surgical Patient
August 2, 2011
July 26, 2011
July 19, 2011
Communication Across Professions
July 12, 2011
Psst! Pass it onHow a kids game can mold good handoffs
July 5, 2011
Sidney Dekker: Patient Safety. A Human Factors Approach
June 28, 2011
Long-Acting and Extended-Release Opioid Dangers
June 21, 2011
June 14, 2011
June 6, 2011
May 31, 2011
Book Review Human Factors and Team Psychology in a High Stakes Environment
May 24, 2011
May 17, 2011
Opioid-Induced Respiratory Depression Again!
May 10, 2011
Preventing Preventable Readmissions: Not As Easy As It Sounds
May 3, 2011
April 26, 2011
Sleeping Air Traffic Controllers: What About Healthcare?
April 19, 2011
DVT Prophylaxis in Acute Stroke: Controversy Reappears
April 12, 2011
Medication Issues in the Ambulatory Setting
April 5, 2011
March 29, 2011
The Silent Treatment:A Dose of Reality
March 22, 2011
An EMR Feature Detrimental to Teamwork and Patient Safety
March 15, 2011
March 8, 2011
Yes, Physicians Get Interrupted Too!
March 1, 2011
February 22, 2011
February 15, 2011
Controversies in VTE Prophylaxis
February 8, 2011
February 1, 2011
January 25, 2011
Procedural Sedation in Children
January 18, 2011
More on Medication Errors in Long-Term Care
January 11, 2011
NPSA (UK) How to Guide: Five Steps to Safer Surgery
January 4, 2011
December 28, 2010
HAIs: Looking In All The Wrong Places
December 21, 2010
More Bad News About Off-Hours Care
December 14, 2010
NPSA (UK): Preventing Fatalities from Medication Loading Doses
December 6, 2010
More Tips to Prevent Wrong-Site Surgery
November 30, 2010
SURPASS: The Mother of All Checklists
November 23, 2010
Focus on Cumulative Radiation Exposure
November 16, 2010
November 9, 2010
12-Hour Nursing Shifts and Patient Safety
November 2, 2010
Insulin: Truly a High-Risk Medication
October 26, 2010
Confirming Medications During Anesthesia
October 19, 2010
Optimizing Medications in the Elderly
October 12, 2010
October 5, 2010
September 28, 2010
September 21, 2010
September 14, 2010
Wrong-Site Craniotomy: Lessons Learned
September 7, 2010
Patient Safety in Ob/Gyn Settings
August 31, 2010
August 24, 2010
The BP Oil Spill Analogies in Healthcare
August 17, 2010
Preoperative Consultation Time to Change
August 10, 2010
Its Not Always About The Evidence
August 3, 2010
Tip of the Week on Vacation
July 27, 2010
EMRs Still Have A Long Way To Go
July 20, 2010
More on the Weekend Effect/After-Hours Effect
July 13, 2010
Postoperative Opioid-Induced Respiratory Depression
July 6, 2010
Book Reviews: Pronovost and Gawande
June 29, 2010
Torsade de Pointes: Are Your Patients At Risk?
June 22, 2010
Disclosure and Apology: How to Do It
June 15, 2010
Dysphagia in the Stroke Patient: the Scottish Guideline
June 8, 2010
Surgical Safety Checklist for Cataract Surgery
June 1, 2010
May 25, 2010
May 18, 2010
Real-Time Random Safety Audits
May 11, 2010
May 4, 2010
More on the Impact of Interruptions
April 27, 2010
April 20, 2010
HITs Limited Impact on Quality To Date
April 13, 2010
April 6, 2010
March 30, 2010
Publicly Released RCAs: Everyone Learns from Them
March 23, 2010
ISMPs Guidelines for Standard Order Sets
March 16, 2010
A Patient Safety Scavenger Hunt
March 9, 2010
Communication of Urgent or Unexpected Radiology Findings
March 2, 2010
Alarm Sensitivity: Early Detection vs. Alarm Fatigue
February 23, 2010
Alarm Issues in the News Again
February 16, 2010
Spin/HypeKnowing It When You See It
February 9, 2010
More on Preventing Inpatient Suicides
February 2, 2010
January 26, 2010
Preventing Postoperative Delirium
January 19, 2010
January 12, 2010
Patient Photos in Patient Safety
January 5, 2010
December 29, 2009
Recognizing Deteriorating Patients
December 22, 2009
December 15, 2009
December 8, 2009
December 1, 2009
Patient Safety Doesnt End at Discharge
November 24, 2009
Another Rough Month for Healthcare IT
November 17, 2009
November 10, 2009
Conserving ResourcesBut Maintaining Patient Safety
November 3, 2009
Medication Safety: Frontline to the Rescue Again!
October 27, 2009
Co-Managing Patients: The Good, The Bad, and The Ugly
October 20, 2009
Radiology AgainBut This Time Its Really Radiology!
October 13, 2009
October 6, 2009
Oxygen Safety: More Lessons from the UK
September 29, 2009
Perioperative Peripheral Nerve Injuries
September 22, 2009
Psychotropic Drugs and Falls in the SNF
September 15, 2009
ETTOs: Efficiency-Thoroughness Trade-Offs
September 8, 2009
Barriers to Medication Reconciliation
September 1, 2009
The Real Root Causes of Medical Helicopter Crashes
August 25, 2009
Interruptions, Distractions, InattentionOops!
August 18, 2009
Obstructive Sleep Apnea in the Perioperative Period
August 11, 2009
August 4, 2009
July 28, 2009
Wandering, Elopements, and Missing Patients
July 21, 2009
Medication Errors in Long Term-Care
July 14, 2009
Is Your Do Not Use Abbreviations List Adequate?
July 7, 2009
Nudge: Small Changes, Big Impacts
June 30, 2009
iSoBAR: Australian Clinical Handoffs/Handovers
June 23, 2009
June 16, 2009
Disclosing Errors That Affect Multiple Patients
June 9, 2009
CDC Update to the Guideline for Prevention of CAUTI
June 2, 2009
Why Hospitals Should FlyJohn Nance Nails It!
May 26, 2009
Learning from Tragedies. Part II
May 19, 2009
May 12, 2009
May 5, 2009
Adverse Drug Events in the ICU
April 28, 2009
Ticket Home and Other Tools to Facilitate Discharge
April 21, 2009
April 14, 2009
More on Rehospitalization After Discharge
April 7, 2009
March 31, 2009
Screening Patients for Risk of Delirium
March 24, 2009
March 17, 2009
March 10, 2009
Prolonged Surgical Duration and Time Awareness
March 3, 2009
Overriding AlertsLike Surfin the Web
February 24, 2009
Discharge Planning: Finally Something That Works!
February 17, 2009
Reducing Risk of Overdose with Midazolam Injection
February 10, 2009
Sedation in the ICU: The Dexmedetomidine Study
February 3, 2009
NTSB Medical Helicopter Crash Reports: Missing the Big Picture
January 27, 2009
Oxygen Therapy: Everything You Wanted to Know and More!
January 20, 2009
The WHO Surgical Safety Checklist Delivers the Outcomes
January 13, 2009
January 6, 2009
December 30, 2008
Unintended Consequences: Is Medication Reconciliation Next?
December 23, 2008
December 16, 2008
Joint Commission Sentinel Event Alert on Hazards of Healthcare IT
December 9, 2008
December 2, 2008
Playing without the ballthe art of communication in healthcare
November 25, 2008
November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
November 11, 2008
November 4, 2008
October 28, 2008
More on Computerized Trigger Tools
October 21, 2008
October 14, 2008
October 7, 2008
Lessons from Falls....from Rehab Medicine
September 30, 2008
September 23, 2008
Checklists and Wrong Site Surgery
September 16, 2008
More on Radiology as a High Risk Area
September 9, 2008
Less is More.and Do You Really Need that Decimal?
September 2, 2008
August 26, 2008
August 19, 2008
August 12, 2008
Jerome Groopmans How Doctors Think
August 5, 2008
July 29, 2008
Heparin-Induced Thrombocytopenia
July 22, 2008
Lots New in the Anticoagulation Literature
July 15, 2008
July 8, 2008
July 1, 2008
WHOs New Surgical Safety Checklist
June 24, 2008
Urinary Catheter-Related UTIs: Bladder Bundles
June 17, 2008
Technology Workarounds Defeat Safety Intent
June 10, 2008
Monitoring the Postoperative COPD Patient
June 3, 2008
UK Advisory on Chest Tube Insertion
May27, 2008
If You Do RCAs or Design Healthcare ProcessesRead Gary Kleins Work
May20, 2008
CPOE Unintended Consequences Are Wrong Patient Errors More Common?
May13, 2008
Medication Reconciliation: Topical and Compounded Medications
May 6, 2008
Preoperative Screening for Obstructive Sleep Apnea
April 29, 2008
ASA Practice Advisory on Operating Room Fires
April 22, 2008
CMS Expanding List of No-Pay Hospital-Acquired Conditions
April 15, 2008
April 8, 2008
April 1, 2008
Pennsylvania PSAs FMEA on Telemetry Alarm Interventions
March 25, 2008
March 18, 2008
Is Desmopressin on Your List of Hi-Alert Medications?
March 11, 2008
March 4, 2008
Housestaff Awareness of Risks for Hazards of Hospitalization
February 26, 2008
Nightmares.The Hospital at Night
February 19, 2008
February 12, 2008
February 5, 2008
Reducing Errors in Obstetrical Care
January 29, 2008
Thoughts on the Recent Neonatal Nursery Fire
January 22, 2008
More on the Cost of Complications
January 15, 2008
Managing Dangerous Medications in the Elderly
January 8, 2008
Urinary Catheter-Associated Infections
January 1, 2008
December 25, 2007
December 18, 2007
December 11, 2007
CommunicationCommunicationCommunication
December 4, 2007
November 27,2007
November 20, 2007
New Evidence Questions Perioperative Beta Blocker Use
November 13, 2007
AHRQ's Free Patient Safety Tools DVD
November 6, 2007
October 30, 2007
Using IHIs Global Trigger Tool
October 23, 2007
Medication Reconciliation Tools
October 16, 2007
Radiology as a Site at High-Risk for Medication Errors
October 9, 2007
October 2, 2007
Taking Off From the Wrong Runway
September 25, 2007
Lessons from the National Football League
September 18, 2007
Wristbands: The Color-Coded Conundrum
September 11, 2007
Root Cause Analysis of Chemotherapy Overdose
September 4, 2007
August 28, 2007
Lessons Learned from Transportation Accidents
August 21, 2007
Costly Complications About To Become Costlier
August 14, 2007
More Medication-Related Issues in Ambulatory Surgery
August 7, 2007
Role of Maintenance in Incidents
July 31, 2007
Dangers of Neuromuscular Blocking Agents
July 24, 2007
Serious Incident Response Checklist
July 17, 2007
Falls in Patients on Coumadin or Other Anticoagulants
July 10, 2007
Catheter Connection Errors/Wrong Route Errors
July 3, 2007
June 26, 2007
Pneumonia in the Stroke Patient
June 19, 2007
Unintended Consequences of Technological Solutions
June 12, 2007
Medication-Related Issues in Ambulatory Surgery
June 5, 2007
Patient Safety in Ambulatory Surgery
May 29, 2007
Read Anything & Everything Written by Malcolm Gladwell!
May 22, 2007
May 15, 2007
Communication, Hearback and Other Lessons from Aviation
May 8, 2007
Doctor, when do I get this red rubber hose removed?
May 1, 2007
April 23, 2007
April 16, 2007
April 9, 2007
Make Your Surgical Timeouts More Useful
April 2, 2007
March 26, 2007
Alarms Should Point to the Problem
March 19, 2007
Put that machine back the way you found it!
March 12, 2007
March 5, 2007
February 26, 2007
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