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January 5, 2021
Dilaudid/HYDROmorphone Still Problematic
One of our most favorite patient safety targets over the years has been misuse of Dilaudid/HYDROmorphone. We were actually a bit surprised that it has been over 3 years since our last column on this issue.
But the problem has not gone away. ISMP Canada recently published its compilation of medications most frequently reported in harm incidents over the past 5 years (ISMP Canaada 2020). They categorized the involved medications by health care setting (hospital, long-term care, community pharmacy, and home and community care).
Two medications appear in the top 3 in multiple settings. HYDROmorphone was in the top 3 in all except community pharmacy. Insulin was the other medication in the top 3 (appearing in 2 institutional care settings). Notably, each of these 2 medications was cited twice as often as any other medication in harm incidents from all health care settings combined.
Moreover, HYDROmorphone was the medication named most often in reports with severe harm or death. It accounted for 11.1% of severe harm or death reports, almost double the next most frequent offender.
We hope you will go back to our previous columns on Dilaudid/HYDROmorphone (listed below). It’s especially worth reiterating some strategies from our June 20, 2017 Patient Safety Tip of the Week “Dilaudid Dangers #4” that you should consider to reduce the risk of Dilaudid/HYDROmorphone (and other opioid) adverse events:
Our prior columns on patient safety issues related to Dilaudid/HYDROmorphone:
References:
ISMP Canaada. Medications Most Frequently Reported in Harm Incidents over the Past 5 Years (2015–2020). ISMP Canada Safety Bulletin 2020; 20(11): 1-5
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January 12, 2021
Surgical Smoke
One safety topic we’ve been largely remiss in discussing is surgical smoke. Though a number of states have adopted specific legislation regarding the dangers of surgical smoke, most regulatory bodies and professional societies have been slow to adopt and enforce guidelines on the issue. Perhaps one of the few positive aspects arising from the COVID-19 pandemic has been increased attention to the dangers of aerosols produced by a variety of surgical procedures, and that should include surgical smoke.
In our July 28, 2020 Patient Safety Tip of the Week “Electrosurgical Safety” we did note that surgical smoke is a concern any time electrosurgery is used. The smoke generated during electrosurgical procedures can potentially contain viruses (such as HPV), bacteria, cancer cells, hazardous chemicals, and other fine, particulate matter. In the COVID-19 pandemic era, we’d also be concerned that coronavirus might also be aerosolized in surgical smoke, though it had not yet been known whether that happens (AORN 2020a). It's recommended you use smoke evacuation systems and fit-tested surgical N95 masks during procedures in which electrosurgery is used. The AORN Go Clear Award Program (AORN 2020b) has numerous resources and recommendations about surgical smoke generated by electrosurgery devices and any other type of device.
A review of the surgical smoke issue (Limchantra 2019) just prior to the COVID-19 pandemic acknowledged that surgical smoke is dangerous, but the severity of the risk has yet to be determined and that no safe level is known at this point. It recommended efforts be made to reduce and possibly eliminate smoke from the operating room and that research into cost-effective forms of smoke evacuation is necessary. It also noted the need for studies of respiratory and cancer sequelae of exposure to operating room smoke in personnel who have had long-term exposure to surgical smoke.
Surgical smoke consists of chemical compounds in the gaseous phase along with particles of cells, bacteria, and viruses. Viable bacteriophage has been found in surgical smoke, and transmission of human papillomavirus from the patient to operating personnel has occurred, even leading to laryngeal papillomatosis in an operating room nurse. Volatile organic compounds (VOC’s) may also be found in surgical smoke and may be impacted by medications the patient had been receiving. There is even concern about the possibility of viable cancer cells in surgical smoke.
The review goes on to note that the type of device creating the surgical smoke may also be relevant. Smoke produced by laser irradiation or harmonic scalpel is relatively cold compared with electrocautery smoke. That may present a biological hazard, because lower temperature plumes are expected to contain more infectious material than high-temperature plumes. Laser plume has been found to contain several potentially infectious components, such as viable bacteriophages, viable cells, and virus particles, and is believed to have a higher infectious potential than electrocautery smoke.
The Limchantra review discusses the various methods of surgical smoke evacuation that are in use currently, noting that they are all probably underused, and also discusses methods that might be used in the future.
Though the hazards of surgical smoke began to be described in the 1970’s, it wasn’t until the late 1990’s that awareness of concerns became more widespread. An excellent review by Ulmer in 2008 (Ulmer 2008) highlighted smoke production by electrosurgical units, lasers, ultrasonic devices, and high-speed electrical devices like bone saws, drills, and other high-speed electrical devices used to dissect and resect tissue. The review included a discussion of components of surgical smoke, including issues of particle size, chemical contents, and presence of blood particles, viruses, and bacteria in the smoke particulate matter. It also discussed how the surgical smoke is dispersed throughout the OR. It discussed the potential health risks to OR personnel and patients. It went on to discuss risk mitigation issues, including general OR ventilation, use of high filtration surgical masks, wall suction to remove smoke, portable smoke evacuation systems, and central smoke evacuation systems. It also discussed surgical smoke evacuation and filtration during laparoscopic procedures.
Two recent reviews in the nursing literature (Vortman 2020, Vortman 2021) also point out that surgical smoke exposure has been equated to smoking 27 to 30 unfiltered tobacco cigarettes, and that perioperative teams have reported twice as many respiratory health issues (headache, watery eyes, cough, rhinitis, sore throat, sneezing, etc.) as the general public. These two excellent articles discuss the economic, political, practical, ethical and legal factors bearing on the issue of management of surgical smoke.
They discuss 3 policy options for dealing with the surgical smoke issue:
Ultimately, they recommend adoption of Option 2: individual states enact smoke evacuation laws requiring facilities to adopt policies and procedures to evacuate surgical smoke.
Vortman and Thorlton (Vortman 2020) discuss the costs of surgical smoke evacuation devices that may dissuade particularly smaller hospitals from implementation but note that the costs related to adverse health effects on staff may outweigh such costs. They also note that some surgeons have complained of practical difficulties (noise, distraction, limited space) when using smoke evacuation devices. They note other reasons reported for lack of use include a misconception among surgeons that surgical smoke is harmless and that past surgical smoke evacuation devices were loud and designed with bulky tubing.
AORN (Association of periOperative Registered Nurses) for several years now has recommended organizations provide a surgical smoke–free environment by using smoke evacuator systems (AORN 2017). But other regulatory bodies and professional societies have been slow to make firm recommendations on surgical smoke.
The American College of Surgeons, in response to the COVID-19 pandemic, issued a statement “Covid-19: Considerations for Optimum Surgeon Protection Before, During, and After Operation” (ACS 2020) that states “Use smoke evacuator when electrocautery is used.”
Somewhat surprisingly, OSHA (The Occupational Safety and Health Administration), which requires employers to provide a work environment free of recognized hazards that may cause serious physical harm or death, does not have a specific standard addressing inhalation hazards of surgical smoke exposure.
NIOSH (National Institute for Occupational Safety and Health) supports and recommends local exhaust ventilation (LEV) to control perioperative team exposure to surgical smoke (NIOSH 2015) but, in a survey, found that only half of respondents reported that LEV was always used during laser surgery and only 15% reported LEV was always used during electrosurgery. The study also indicated that control of surgical smoke in workplaces may not be a priority, with nearly half of respondents reporting that they had never received training on the hazards of surgical smoke and one-third said that LEV use was not part of their workplace’s protocol. NIOSH also recommends general room ventilation in addition to LEV to control healthcare workers’ exposure to surgical smoke.
Finally, just this past December, The Joint Commission issued a Quick Safety Issue “Alleviating the dangers of surgical smoke.” (TJC 2020) that has the following recommendations:
The COVID-19 pandemic has raised concerns about any aerosol-generating procedure (AGP) , not just those producing traditional “surgical smoke”. A number of recent studies have tried to identify those AGP’s presenting a risk of respiratory transmission that merits use of a higher grade of PPE (personal protective equipment).
A recent viewpoint on aerosol-generating procedures (Klompas 2020) does not discuss surgical smoke per se but does outline the 4 key factors in respiratory transmission:
Certainly, in the OR where surgical smoke is generated, the latter two factors (distance and duration) place OR personnel at risk for respiratory transmission of pathogens and, undoubtedly, also the other untoward elements present in surgical smoke.
In the many studies on aerosol-generating procedures that have appeared since the COVID-19 pandemic began, it is surprising that there is little or no mention of the traditional surgical smoke generating procedures we’ve discussed above. A systematic review (Jackson 2020) categorized aerosol-generating procedures into 39 procedure groups, with comments on the strength of the evidence. Another review of aerosol-generating procedures with respect to infective risk to healthcare workers from SARS-CoV-2 does not even mention surgical smoke producing procedures like electrocautery or procedures using laser or ultrasonic devices (Harding 2020).
One excellent review (Howard 2020) does include laser procedures and electrocautery in its discussion of aerosol-generating procedures. This review has a nice discussion of the more advanced forms of PPE that must be used in the higher risk aerosol-generating procedures. This includes elastomeric respirators with various filters. Howard recommends that, for high-risk AGP’s, respiratory protection above N95 should be considered. Options for this include N-P 99 respirators, N-P 100 respirators, elastomeric respirators with filters type N-P 99-100 level, PAPR, or CAPR. Additionally, fitted goggles should be worn for eye protection; face shields are not adequate eye protection during high-risk AGP’s.
Thamboo et al. (Thamboo 2020) reviewed aerosol generating medical procedures in otolaryngology and head and neck surgery. They specifically note that HPV DNA can be present in the surgical smoke generated by CO2 lasers for the treatment of (laryngeal) papillomatosis and warts. They also note studies demonstrating the potential of virus transmission by surgical smoke produced by electrocautery, though they note the evidence for actual viral transmission following electrocautery is not strong. In addition to use of appropriate PPE, they recommend that aerosol-generating procedures (AGP’s) be performed in negative pressure rooms to minimize the risk of spread of contaminated aerosols. They do not specifically comment on use of LEV (local exhaust ventilation).
Orthopedic procedures are especially likely to generate not only what is technically “surgical smoke” but also generate a variety of aerosols. Sobti et al. (Sobti 2020) reviewed the literature and concluded that most orthopedic procedures are high-risk aerosol-generating procedures (AGP’s) and that, in the current era of COVID-19 pandemic, there is a significant risk to the transmission of infection to the OR staff. They note that conventional surgical masks do not offer protection against high-risk AGP’s. For protection against airborne transmission, appropriate masks should be used. These need proper fitting and sizing to ensure full protection when used. But they do not discuss what measures should be used to evacuate the aerosols from the OR environment. A recent article (Geevarughese 2020) on aerosol-generating procedures (AGP’s) in orthopedics does include surgical smoke that may accompany electrocauterization, laser procedures, and use of ultrasonically activated devices like the harmonic scalpel, but also notes that blood and irrigation fluid coming in close contact with high-speed instruments get aerosolized. The authors categorize high-, moderate- and low-risk procedures and provide recommendations for PPE (personal protective equipment) for each category. Though the article does not mention LEV (local exhaust ventilation), it does state that “high- and moderate-risk AGP’s should preferably be performed in a negative pressure room with a minimum of 12 air changes per hour, as it prevents dissemination outside the room. The exhaust air is filtered through HEPA filters, which are capable of filtering essentially all particles, including nanoparticles (<0.01 μm). The number of team members exposed should be minimized, movement in and out of the OR limited, only equipment and supplies required for the procedure should be retained in the theatre, and a runner should be stationed outside the OR to attend to additional supplies required.”
And, while most of the literature on surgical smoke is aimed at ensuring the safety of OR personnel, don’t forget that patients undergoing the procedures can also be potentially exposed to many of the untoward elements contained in surgical smoke.
The time has come for all hospitals, ambulatory surgery centers, and any venue performing procedures that generate surgical smoke to recognize this as a legitimate issue and follow the recommendations in that recent Joint Commission communication (TJC 2020).
References:
AORN. (Association of periOperative Registered Nurses). Smoke and COVID-19 FAQs. AORN 2020
https://aorn.org/education/facility-solutions/aorn-awards/aorn-go-clear-award/faq
AORN. (Association of periOperative Registered Nurses). AORN Go Clear Award Program. Accessed July 2020
Limchantra IV, Fong Y, Melstrom KA. Surgical Smoke Exposure in Operating Room Personnel: A Review. JAMA Surg 2019; 154(10): 960-967
https://jamanetwork.com/journals/jamasurgery/fullarticle/2748067
Ulmer BC. The Hazards of Surgical Smoke. AORN Journal 2008; 87(4):721-738
https://aornjournal.onlinelibrary.wiley.com/doi/abs/10.1016/j.aorn.2007.10.012
Vortman R, Thorlton J. Empowering Nurse Executives to Advocate for Surgical Smoke–Free Operating Rooms. Nurse Leader 2020; Published:November 20, 2020
https://www.nurseleader.com/article/S1541-4612(20)30283-4/fulltext
Vortman R, McPherson S, Wendler MC. State of the Science: A Concept Analysis of Surgical Smoke. AORN Journal 2021;. 113: 41-51
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13271
AORN (Association of periOperative Registered Nurses). Guideline Summary: Surgical Smoke Safety. AORN Journal 2017; 105(5): 498-500
https://aornjournal.onlinelibrary.wiley.com/doi/abs/10.1016/j.aorn.2017.02.008
ACS (American College of Surgeons). Covid-19: Considerations for Optimum Surgeon Protection Before, During, and After Operation. ACS 2020; April 1, 2020
https://www.facs.org/covid-19/clinical-guidance/surgeon-protection
NIOSH (National Institute for Occupational Safety and Health). NIOSH Study Finds Healthcare Workers’ Exposure to Surgical Smoke Still Common. NIOSH 2015; November 3, 2015
https://www.cdc.gov/niosh/updates/upd-11-03-15.html
TJC (The Joint Commission). Quick Safety Issue 56: Alleviating the dangers of surgical smoke. TJC 2020; December 2020
Klompas M, Baker M, Rhee C. What Is an Aerosol-Generating Procedure? JAMA Surg 2020; Published online December 15, 2020
https://jamanetwork.com/journals/jamasurgery/fullarticle/2774161
Jackson T, Deibert D, Wyatt G, et al. Classification of aerosol-generating procedures: a rapid systematic review. BMJ Open Respiratory Research 2020; 7: e000730.
https://bmjopenrespres.bmj.com/content/7/1/e000730
Harding H, Broom A, Broom J. Aerosol-generating procedures and infective risk to healthcare workers from SARS-CoV-2: the limits of the evidence. Journal of Hospital Infection 2020; 105(4): 717-725 August 01, 2020
https://www.journalofhospitalinfection.com/article/S0195-6701(20)30277-2/fulltext
Howard BE. High-Risk Aerosol-Generating Procedures in COVID-19: Respiratory Protective Equipment Considerations. Otolaryngology–Head and Neck Surgery 2020; 163(1): 98-103 First Published May 12, 2020
https://journals.sagepub.com/doi/full/10.1177/0194599820927335
Thamboo A, Lea J, Sommer DD, et al. Clinical evidence based review and recommendations of aerosol generating medical procedures in otolaryngology – head and neck surgery during the COVID-19 pandemic. J Otolaryngol Head & Neck Surg 2020; 49, 28 Published May 6, 2020
https://journalotohns.biomedcentral.com/articles/10.1186/s40463-020-00425-6#citeas
Sobti A, Fathi M, Mokhtar MA, et al. Aerosol generating procedures in trauma and orthopaedics in the era of the Covid-19 pandemic; What do we know? Surgeon 2020; [published online ahead of print, 2020 Aug 13]. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7425761/
Geevarughese NM, Ul-Haq R. Aerosol generating procedures in orthopaedics and recommended protective gear. J Clin Orthop Trauma. 2020; [published online ahead of print, 2020 Aug 25]
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7446649/
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January 19, 2021
Technology to Identify Fatigue?
Our many columns listed below have highlighted the role fatigue in healthcare workers plays in medical errors and patient safety. A major problem is that we, ourselves, are not very good at recognizing when we are fatigued to a point that we are putting our patients in jeopardy. We’ve always suspected we will ultimately adopt technology as a means to identify fatigue earlier. In our July 29, 2014 Patient Safety Tip of the Week “The 12-Hour Nursing Shift: Debate Continues” we predicted that someday we will have the equivalent of the brief “sobriety” or “breathalyzer” test that can rapidly identify healthcare workers who are impaired by fatigue. We envision that at regular intervals beyond 8 hours (maybe even sooner) or during periods of prolonged concentration the healthcare worker will get buzzed on his/her smartphone and have to complete some simple test of reaction times or attention span. If the worker scores outside the established threshold the hospital will need to have resources in place to take over duties of that worker (completely or at least temporarily until fatigue is alleviated by, for example, a nap).
When driving long distances or at night, we use a cellphone app that uses the camera to focus on our face. When it detects any degree of eyelid drooping, it sounds an audible alarm to alert us. And it sounds an even louder alarm if it detects a repeat episode of eyelid drooping within a specified amount of time. But, obviously, we can’t wait for eyelid drooping to identify fatigue in healthcare workers on the job.
Fortunately, there are a variety of other ocular phenomena that can be used to detect early fatigue. In addition to eyelid drooping, alteration of saccadic eye movements, changes in the blink rate, and changes in pupillary responses may be early signs of fatigue. In our December 2, 2014 Patient Safety Tip of the Week “ANA Position Statement on Nurse Fatigue” we noted there are other technologies that might do the trick. Studies have demonstrated alteration of saccadic eye movement metrics correlate with fatigue in several settings and studies in surgical residents confirmed such a correlation (Di Stasi 2014). Such a test could probably be easily adapted to most of today’s smartphones.
Yamada and colleagues (Yamada 2018) developed a model to detect mental fatigue of younger and older adults in natural viewing situations. They collected eye-tracking data from younger and older adults as they watched video clips before and after performing cognitive tasks. Their model improved detection accuracy, achieving 91.0% accuracy, which was 13.9% higher compared with a model based on the previous studies.
Zargari Marandi et al. (Zargari Marandi 2018) similarly studied eye movements in young and older adults during a prolonged functional computer task. The task lasted 40 minutes involving 240 cycles divided into 12 segments. Each cycle consisted of a sequence involving memorization of a pattern, a washout period, and replication of the pattern using a computer mouse. The participants rated their perceived fatigue after each segment. Parameters they measured were blink duration (BD) and frequency (BF), saccade duration (SCD) and peak velocity (SPV), pupil dilation range (PDR), and fixation duration (FD), along with the task performance based on clicking speed and accuracy. They also used a subjective (self-reported) measure of fatigue. They found that BD, BF, and PDR increased whereas SPV and SCD decreased over time in the young and elderly groups. But there were some age-related differences. Longer FD, shorter SCD, and lower task performance were observed in the elderly compared with the young group.
The Yamada and Zargari Marandi studies assessed the value of oculometrics during prolonged mentally demanding computer tasks. So, how about healthcare professionals who might similarly be engaged in prolonged mentally demanding computer tasks? How about radiologists? Our April 2018 What's New in the Patient Safety World column “Radiologists Get Fatigued, Too” highlighted a study looking at the effect of overnight shifts on performance of radiologists (Hanna 2018). The researchers used a tool for measuring fatigue and advance eye tracking technology to assess the performance of radiologists (both attendings and residents). During each session, radiologists viewed 20 bone radiographs consisting of normal and abnormal findings. The Swedish Occupational Fatigue Inventory results demonstrated worsening in all five variables (lack of energy, physical exertion, physical discomfort, lack of motivation, and sleepiness) after overnight shifts. Not surprisingly, participants demonstrated worse diagnostic performance in the fatigued versus not-fatigued state. Viewing time per case was significantly prolonged when the radiologists were fatigued. Mean total fixations generated during the search increased by 60% during fatigued sessions. Mean time to first fixate on bone fractures increased by 34% during fatigued sessions. Moreover, dwell times associated with true- and false-positive decisions increased, whereas those with false negatives decreased. Effects of fatigue were more pronounced in residents. The authors concluded that further research is needed to address and reverse the impact of such fatigue-related changes. They speculate that environmental changes (eg. lighting) and activity changes (eg. periodic breaks, moving around, etc.) might help mitigate the adverse effects of fatigue on performance.
Then, in our August 25, 2020 Patient Safety Tip of the Week “The Off-Hours Effect in Radiology” we noted some other studies assessing the impact of fatigue on radiologist performance.
So, it’s no surprise that researchers have chosen radiologists as a good population in which to study the use of oculometrics for assessment of fatigue. Belgian researchers have done just that (Ward 2021). They measured saccades, blink rate, and the percentage of eyelid closure over the pupil over time. Their setup included four displays, three RGB (red, green, blue) cameras, a gaze tracker, keyboard/mouse input (no keystrokes, only number of actions per second), and acoustic information. (The Ward article has a photo of the equipment setup used by the Belgian researchers.) And the radiologists also completed a subjective assessment of fatigue every 20 minutes. Their data confirmed that self-scored fatigue labels underestimated the occurrence of fatigue. This is really a feasibility or proof-of-concept study on which to build. It demonstrates that objective measures can be easily recorded, and some day may be used to alert radiologists to the presence of fatigue that might impair their performance in imaging interpretation.
Similar technology was used in a UK study on radiologists reading digital breast tomosynthesis (DBT) cases (Ward 2020). The researchers simply modified the mammography reading station with a three-camera eye-tracking system. Measuring blinking as an indicator of fatigue, they found that after reading 20 DBT cases, individuals were beginning to show signs of visual fatigue onset. They concluded that taking a break after 20 reports might help eliminate mistakes.
The fact that the Yamada model could detect increased mental fatigue induced by the cognitive tasks with 91.0% accuracy from just 30 seconds worth of eye-tracking data suggests this could be the oculometric equivalent of the “breathalyzer” test! We could envision implementation of such systems on almost any computer terminal that might be used by physicians, nurses, pharmacists, etc. It might even be applied to any situation in which sustained concentration for long periods is required (eg. during a surgical procedure). It might provide an easy, inexpensive way to identify fatigue in healthcare workers. But the next question is whether interventions based upon such detection can actually reduce errors in patient care. It’s about time these relatively simple techniques find their niche in healthcare.
Some of our other columns on the role of fatigue in Patient Safety:
November 9, 2010 “12-Hour Nursing Shifts and Patient Safety”
April 26, 2011 “Sleeping Air Traffic Controllers: What About Healthcare?”
February 2011 “Update on 12-hour Nursing Shifts”
September 2011 “Shiftwork and Patient Safety
November 2011 “Restricted Housestaff Work Hours and Patient Handoffs”
January 2012 “Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety
January 3, 2012 “Unintended Consequences of Restricted Housestaff Hours”
June 2012 “June 2012 Surgeon Fatigue”
November 2012 “The Mid-Day Nap”
November 13, 2012 “The 12-Hour Nursing Shift: More Downsides”
July 29, 2014 “The 12-Hour Nursing Shift: Debate Continues”
October 2014 “Another Rap on the 12-Hour Nursing Shift”
December 2, 2014 “ANA Position Statement on Nurse Fatigue”
August 2015 “Surgical Resident Duty Reform and Postoperative Outcomes”
September 2015 “Surgery Previous Night Does Not Impact Attending Surgeon Next Day”
September 29, 2015 “More on the 12-Hour Nursing Shift”
September 6, 2016 “Napping Debate Rekindled”
April 18, 2017 “Alarm Response and Nurse Shift Duration”
July 11, 2017 “The 12-Hour Shift Takes More Hits”
February 13, 2018 “Interruptions in the ED”
April 2018 “Radiologists Get Fatigued, Too”
August 2018 “Burnout and Medical Errors”
September 4, 2018 “The 12-Hour Nursing Shift: Another Nail in the Coffin”
August 2020 “New Twist on Resident Work Hours and Patient Safety”
August 25, 2020 “The Off-Hours Effect in Radiology”
September 2020 “Daylight Savings Time Impacts Patient Safety?”
References:
Di Stasi LL, McCamy MB, Macknik, SL, et al. Saccadic Eye Movement Metrics Reflect Surgical Residents' Fatigue. Annals of Surgery 2014; 259(4): 824-829
Yamada Y, Kobayashi M. Detecting mental fatigue from eye-tracking data gathered while watching video: Evaluation in younger and older adults. Artificial Intelligence in Medicine 2018; 91: 39-48
https://www.sciencedirect.com/science/article/pii/S0933365717306140
Zargari Marandi R, Madeleine P, Omland Ø, et al. Eye movement characteristics reflected fatigue development in both young and elderly individuals. Scientific Reports 2018; 8: Article 13148
https://www.nature.com/articles/s41598-018-31577-1#citeas
Hanna TN, Zygmont ME, Peterson R, et al. The effects of fatigue from overnight shifts on radiology search patterns and diagnostic performance. J Am Coll Radiol 2018; 15(12): 1709-1716
https://www.jacr.org/article/S1546-1440(17)31661-7/fulltext
Ward P. Belgian team develops novel way to assess fatigue. AuntMinnieEurope.com 2021; January 12, 2021
https://www.auntminnieeurope.com/index.aspx?sec=sup&sub=pac&pag=dis&ItemID=619679
Ward P. What effect does fatigue have on reading breast scans? AuntMinnieEurope.com 2020; October 26, 2020
https://www.auntminnieeurope.com/index.aspx?sec=sup&sub=wom&pag=dis&ItemID=619432
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January 26, 2021
This Freezer Accident May Cost Lives
Generally, when we talk about alarm-related incidents, we immediately think about alarms that are attached to things directly attached to patients (like ventilators, physiologic monitors, etc.). But we’ve also done several columns where it was alarms on freezers that malfunctioned or went unheeded (see, in particular, our Patient Safety Tips of the Week for February 4, 2014 “But What If the Battery Runs Low?”, May 1 2018 “Refrigerator Alarms”, and October 8, 2019 “Another Freezer Accident”).
Now there has been an incident where multiple doses of COVID-19 vaccine were lost because of a freezer malfunction. Almost 2000 COVID-19 vaccine doses were ruined when a freezer malfunctioned at the Jamaica Plain VA Medical Center in Boston (Folk 2021, Fox 2021, CBS News 2021, WBZ 2021).
As is usual in such incidents, a cascade of events led to the untoward outcome. A 6-inch chiller pipe burst and flooded pharmacy where vaccines were kept. Contractors were brought in and, while doing cleanup and abatement, pulled the freezer out and apparently pulled out the electrical plug in doing so. They presumably were unaware they had dislodged the plug. The freezer did have an alarm but, apparently, it did not work. As a result, about 1900 doses of Moderna COVID-19 vaccine were compromised and are no longer viable. (The WBZ link (WBZ 2021) has a video which shows the freezer and both the electrical plug and the alarm setup.)
The VA hospital has since fixed the alarm but is looking for root causes. They rewired and reactivated the alarm and added a bracket to the electrical plug to prevent it from being inadvertently pulled out. They also have staff now checking on the freezer every hour.
While the supply of COVID-19 vaccines may be replenished at that particular facility, it means that there are 1900 fewer doses available to the US system as a whole, at a time when there is a critical shortage of vaccine doses. Both Moderna and Pfizer-BioNTech's COVID-19 vaccines require extremely cold temperatures for storage. Temperature issues have caused problems for vaccine rollouts in other states. Recently, health officials in Maine and Michigan said more than 16,000 doses spoiled because of temperature control problems during delivery and would probably have to be disposed of. Nearly 12,000 Moderna doses that were being shipped to Michigan also were spoiled after getting too cold. And, in Wisconsin, a pharmacist was charged with deliberately ruining hundreds of doses by removing them from refrigeration.
Our prior columns discussed incidents where freezer alarm issues led to loss of stem cells for pediatric cancer patients, embryos in fertility clinics, blood products, and orthopedic implants.
Though we don’t know full details about the current Boston incident, there are multiple lessons from the other incidents and several may be applicable to the Boston incident.
One important observation from other incidents worth reiterating is that periods around maintenance of equipment are vulnerable times. We discussed this in our August 7, 2007 Patient Safety Tip of the Week “Role of Maintenance in Incidents”, in which we discussed the excellent work of James Reason and Alan Hobbs plus that of Don Norman. In one of the fertility clinic incidents mentioned previously, maintenance issues may have played a role. Also, in our March 5, 2007 Patient Safety Tip of the Week “Disabled Alarms” and several other columns on alarms, we noted instances where the oxygen blender alarms on ventilators had been disabled during maintenance and were not corrected prior to use in patients. The current incident obviously occurred following maintenance for the burst chiller pipe and consequent flooding. When maintenance is done on any equipment, we recommend staff doing maintenance have a checklist to remind them of things they must do. And one of those items would be to restore any alarms they might have disabled during the maintenance. Don’t expect your outside contractors who come in to clean up after flooding to be aware of the nuances of your healthcare operation. They are there to mop up and disinfect and likely have not been trained about potential dangers to your equipment. Therefore, your internal staff responsible for the area where the maintenance is done also need to inspect all critical pieces of equipment and their electrical connections and any associated alarms.
The alarm then failed to either detect the rise in temperature or failed to trigger an alert that would have summoned attention to the freezer. We do not know details about the particular alarm used there. Some freezer alarms are wired, and others are not wired (they often use WiFi). Some may run on AC electrical power, but others are battery operated. Either of the latter setups can be associated with its own problems.
It is worth repeating some of our observations and recommendations in our Patient Safety Tips of the Week for February 4, 2014 “But What If the Battery Runs Low?” and May 1, 2019 “Refrigerator Alarms”. In such cases, alarms would be set to trigger when a temperature sensor showed the freezer temperature had risen above a specified level. It should be no surprise that a freezer might fail or that a sensor might fail. So, you have to make sure your alarm will trigger when the freezer fails and that the alarm will trigger if the sensor were to fail or become disconnected. That calls for redundancy and backup systems.
The technology is available to indicate a sensor malfunction or disconnection. We get a “your motion camera has been disconnected” message by email and text message every time our motion detection camera gets disconnected from our WiFi system. We would assume similar capabilities should exist to alert someone when a freezer alarm system has been disconnected (but keep in mind there could also be an event that disables both your refrigerator alarm and your WiFi system).
In many cases, the alarm system is battery-powered. How do you know the alarm is powered and active? In our February 4, 2014 Patient Safety Tip of the Week “But What If the Battery Runs Low?” we gave the following anecdote: You have an alarm that responds to the temperature in a refrigerator dropping below a set value to protect against loss of the medical products inside. You took great care to make sure the thermometer was not on the same electrical supply as the refrigerator. However, the battery on the thermometer had not been checked recently and had no charge when the refrigerator actually lost power. All the medical products in the refrigerator are lost. The smoke detector or carbon monoxide detector in your home has a button you press that indicates the alarm is functional. Is there a similar capability on these freezer alarms? More importantly, is there a visual indicator of remaining battery capacity on such alarms? And then, do you have a protocol that requires someone to check that battery level every day?
What if your alarm is supplied by AC electrical current? Since an electrical failure could affect power to both the refrigerator and the alarm system, you probably don’t want both on the same circuit. We’ve previously discussed incidents where physiologic alarms were attached to the same electrical outlets as ventilators and when a circuit breaker tripped, removing power from the ventilator, the alarms also failed because their power had been cut off (see, for example, our September 15, 2020 Patient Safety Tip of the Week “An Eerily Familiar Incident”).
We don’t know whether the alarm in question actually failed to alarm or whether its alarm failed to trigger a response. So, let’s discuss the notification and response limbs of the alarm process. You can bet that an event might take place at a time when there is no one physically working near the freezer who might hear an audible alarm (did staff avoid working near this area because of the flooding?). So, you need to route the alarm to someone physically able to respond in a timely fashion. You’d expect this freezer alarm to notify pharmacy staff first. But what if that pharmacy is not staffed 24x7? In most hospitals, that “after hours” alert would probably go to the on-duty nursing supervisor, though it could also be someone in your 24x7 security department. They might be notified by a text message alert or other means, but you’ll also have to regularly test that such linkage is working. But now you need to make sure the person receiving the alert knows how to respond. There should be a checklist and set of instructions informing the person responding to the alarm what to do. Probably the best place to put this is right on the freezer unit. You don’t want to bury it in a thick policy manual where the respondent may not even find it in a timely fashion.
You also want to make sure that you have an appropriate “escalation” practice (i.e. who to call next if the first person called fails to respond in a timely fashion). While we have such escalation procedures in place for clinical staff, many facilities are less deliberate with regard to non-clinical staff escalation procedures.
Hopefully, the Jamaica Plain VA Medical Center will publish (or otherwise make available) the results of their root cause analysis (RCA) so that others may learn from this incident. The Boston incident already has highlighted one intervention most facilities should consider. That has to do with the ease with which an electrical plug can be dislodged when the freezer is moved for whatever reason. They installed a bracket to make it difficult for such dislodgement to occur when the freezer is moved.
It’s important to pay attention to safety issues regarding your freezers and refrigerators. They are usually being used to store items that are important for patient care. You need to ensure that they have all the protections that you would use if you were dealing with equipment directly attached to patients. The Boston incident is unfortunate but there are lessons that could (and should) help other hospitals and healthcare facilities from experiencing similar incidents.
Your facility probably has some refrigerators or freezer units that store important blood or tissue specimens or vaccines (we also know your IT server farm relies on optimal temperature ranges and could be vulnerable to similar alarm-related issues). But how many of you have ever questioned what would happen if there was an alarm malfunction in one of these units? Have you done a FMEA (failure mode and effects analysis) of such alarm systems? Do you look at these alarms when you are doing Patient Safety Walk Rounds? Are the appropriate people alerted when these alarms are triggered? Do those people know how to respond when such alarms trigger? Is there a checklist that helps responders take all necessary steps when such an alarm triggers? Do you know how such alarms are powered and what the impact of a power failure or battery failure might be? Do you have backup systems in place? If the alarm uses WiFi, what would happen if your facility WiFi system is down?
So, what should you be doing?
When we see an incident like this, you should be saying “Wow! I bet that could occur here! Far better to learn from incidents that occurred elsewhere rather than waiting to do a root cause analysis (RCA) on one that occurs in your own facility.
Prior Patient Safety Tips of the Week pertaining to alarm-related issues:
References:
Folk Z. Nearly 2,000 COVID-19 vaccines spoiled after Boston VA cleaner accidentally unplugs freezer. NY Post 2021; January 22, 2021
https://nypost.com/2021/01/22/nearly-2000-covid-vaccine-doses-spoiled-at-boston-va-facility/
Fox JC. COVID-19 vaccine doses spoiled at Jamaica Plain VA facility. Boston Globe 2021; ,Updated January 21, 2021
https://www.boston.com/news/coronavirus/2021/01/22/covid-vaccines-spoiled-jamaica-plain-va-hospital
CBS News. 1,900 COVID vaccine doses ruined at Boston VA hospital after freezer accidentally unplugged. CBS News 2021; January 22, 2021
https://www.cbsnews.com/news/1900-covid-vaccine-doses-spoiled-boston-va-hospital/
WBZ (Boston). Investigation Underway After COVID Vaccines Compromised At VA Hospital. January 22, 2021
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February 2, 2021
MGH Protocols Reduce Risk of Self-Harm in ED
Whether or not your hospital has a behavioral health unit, you will have patients come to your emergency department who have conditions which put them at risk for suicide or self-harm. You, therefore, need to plan for managing such patients safely. Massachusetts General Hospital recently published protocols and interventions it put in place to minimize the risk of self-harm (Donovan 2021).
They performed RCA’s (root cause analyses) of incidents in prior years and determined the areas for intervention: (1) safe bathrooms, (2) number and training of patient observers, (3) management of personal belongings, (4) clothing search or removal policies and training, and (5) additional protocols for high-risk patients.
Near the top of their list was one we have harped on for years. We sometimes, half in jest, bet hospital CEO’s that we will find at least 3 patient safety hazards or vulnerabilities within the first hour. When we do so, we head straight to the radiology suite or the ED, where we know we are likely to find bathrooms that patients could use for attempted suicide or self-harm. Bathrooms, of course, are common locations for in-hospital suicide attempts (see our August 29, 2017 Patient Safety Tip of the Week “Suicide in the Bathroom”). Well, the MGH protocols took care of at least the ED hazards in those bathrooms. Safety features they implemented included shatterproof fixtures and mirrors, paper wastebasket liners, minimal ligature risks, and mirrors and curtains allowing visibility while protecting privacy. The task force also included specific training for observers regarding ensuring adequate patient visualization in the bathroom with the least intrusion possible.
Our prior columns have focused on removing loopable fixtures or installing ligature-resistant fixtures in bathrooms. But the MGH took it a step further by considering that patients could use pieces of glass to harm themselves, hence the need to use shatterproof mirrors. Avoiding plastic waste basket lines also makes sense. They also focused on a point we’ve emphasized in our own prior columns – observation of patients in bathrooms has often been inadequate.
That universal observer training provided education about the critical role of constant observation to mitigate safety risks. It was a three-week orientation, with annual retraining, included training on key safety issues, including suicide risk, covert or surreptitious behavior, possession of dangerous items, ingestions, elopements, risk of harm to others, and responses for observation of concerning behavior.
They also created a checklist tool of safety concerns (for example, risk of harm to self, risk of harm to others, elopement risk), and goals for observation, including constant vigilance, using a safe bathroom, visualizing patient's hands and face continuously, and ensuring that no unsafe objects are in the environment. The observer responsible for that patient reviews the checklist with the patient's nurse, and both parties sign the tool.
Note that this is the sort of training we’ve recommended for “sitters” assigned to observe at-risk patients being temporarily housed on med/surg beds (see, for example, our several columns listed below on jumps from hospital windows).
The other key focus was on issues related to clothing and potential contraband that might be used for self-harm. They did decide to allow patients to have some personal belongings, such as books or cellphones, recognizing they might need some diversions if they were to spend long hours in the ED. However, such items would be kept in a secure locker and would be examined by staff (for potentially dangerous elements) before allowing patients to use these.
They encourage patients to change into safe clothing. But some patients will refuse such requests. They, therefore, require a risk assessment (performed by an ED physician) and only require “forced” disrobing for patients scoring at the highest risk levels. Note that they also considered “forced” disrobing to be the equivalent of using a “restraint”. Hence, such patients would also need to meet the criteria for restraint use and follow restraint protocols. (Note: we recommend you check the laws in your state regarding the disrobing and restraint issues.) For patients at lesser levels of risk for self-harm, interventions might include “reducing clothing to a single layer, turning pockets inside out, undergoing a pat-down, and removing high-risk items such as belts, drawstrings, and shoes.”
They also identified the “exceptionally high-risk patient”, such as one who had a history of numerous episodes of self-harm, often severe, in the ED, and created additional safety interventions for such patients. These interventions include 1:1 observation, additional or repeated searches of the patient or belongings (possibly including search of undergarments), and immediate psychiatry consultation to plan for patient safety. Such patients are flagged in the EHR (electronic health record) to alert providers about the exceptionally high risk and suggest these additional precautions.
The full MGH guidelines are also available in an appendix to the article.
In the 12 months prior to the protocol initiation, among 4,408 at-risk patients, there were 13 episodes of attempted self-harm (2.95 per 1,000 at-risk patients), and 6 that resulted in actual self-harm (1.36 per 1,000 at-risk patients). In the 12 months after the protocol was introduced, among the 4,523 at-risk patients, there were 6 episodes of attempted self-harm (1.33 per 1,000 at-risk patients) and only 1 that resulted in actual self-harm (0.22 per 1,000 at-risk patients). There were no deaths. Though these results did not meet criteria for statistical significance, they are nevertheless impressive.
The MGH team also audited compliance with the intervention and found only 42 breaches of the protocol out of 4,523 unique patient visits. 25 breaches were related to changing patients, 11 breaches related to patients having objects that could be used for self-harm, and 6 breaches related to observers (availability or performance). Significantly, though, in 3 of the 6 attempted self-harm events after protocol implementation, there were protocol breaches. Of those 3 breaches, 2 were related to observer performance (lack of observation in the bathroom). Many of the cases of suicide attempts we’ve previously discussed also occurred when staff failed to adequately observe patients in the bathroom. One suggestion we’ve made is that use of same-sex observers might minimize non-compliance with this aspect of observation.
The article goes on to discuss the costs of implementing such a safety program, including the costs of hiring and training observers, renovating bathrooms, providing storage areas for patient items, plus all the time and effort that went into planning and implementing.
This is really a useful study that almost every hospital can learn from. The legwork the MGH team has done should make it easier for you to begin such projects at your hospital. And, again, we recommend that you consider such a program not only for your ED, but also consider a nearly identical program for those med/surg floors that are, from time to time, required to care for patients at risk of suicide or self-harm. Lastly, don’t forget that these patients might also at some time require transport to Radiology or other area. You should make sure that your “Ticket to Ride” checklist and procedure includes all the important elements required to prevent self-harm during such transports.
Some of our prior columns on preventing hospital suicides:
Some of our past columns on issues related to behavioral health:
References:
Donovan AL, Aaronson EL, Black L, et al. Keeping Patients at Risk for Self-Harm Safe in the Emergency Department: A Protocolized Approach. Joint Commission Journal on Quality and Patient Safety 2021; 47(1): 23-30
https://www.jointcommissionjournal.com/article/S1553-7250(20)30215-4/fulltext
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February 9, 2021
Nursing Burnout
Burnout is a phenomenon that has impacted virtually every type of healthcare worker and the COVID-19 pandemic has clearly accentuated this problem. While we are concerned about burnout among our physician colleagues, we are even more concerned about the impact burnout is having among our nursing colleagues.
A 2019 survey (King 2019) found that 15.6% of all nurses reported feelings of burnout, and that increased to 41% in “unengaged” nurses. That report focused on nurse engagement and found the top three key drivers predicting nurses’ engagement were: autonomy, RN to RN Teamwork and collaboration, and leadership access & responsiveness.
Perhaps more bothersome in the report was that 50% of nurses who reported feeling burned out had no plans to leave their organization. That’s concerning since we know that burnout is associated with increased frequency of errors and missed care.
As you’d probably expect, burnout is more common in very high stress environments, such as ICU’s, the ER, and the OR.
The Joint Commission recognized nurse burnout as a significant issue and suggested multiple strategies to promote resilience to combat nurse burnout in a Quick Safety Issue in 2019 (TJC 2019).
Our numerous columns on nursing shifts and nurse workloads have highlighted the negative impacts the nursing work environment may have on job satisfaction, burnout, and staff turnover. Ultimately, negative impacts on nursing also get reflected in patient satisfaction and patient safety. Unless we mitigate the factors contributing to nurse burnout, we are destined for serious problems in patient care in the not-so-distant future.
A timely study in JAMA Network Open (Shah 2021) examined some of those factors contributing to nurse burnout. The researchers used data on almost 4 million nurses collected in 2018 in the National Sample Survey of Registered Nurses (NSSRN) in the US. Among nurses who reported leaving their job in 2017 (n = 418,769), 31.5% reported burnout as a reason. That is an increase from the 2008 NSSRN survey which showed that approximately 17% of nurses who left their position in 2007 cited burnout as the reason for leaving.
Work hours clearly play a role. Nurses who worked more than 40 hr/wk had a higher likelihood identifying burnout as a reason they left their job, compared with working less than 20 hr/wk (odds ratio 3.28).
Long shifts foster nurse burnout and job dissatisfaction. Multiple studies, discussed in our prior columns, have described the negative effects of 12-hour shifts on nurse health, well-being, and job satisfaction. In our September 29, 2015 Patient Safety Tip of the Week “More on the 12-Hour Nursing Shift” we noted another RN4CAST study that provides insight into the impact of 12-hour shifts on nurse well-being (Dall’Ora 2015). Those researchers found that, while all shift lengths greater than 8 hours were associated with more nurse adverse outcomes, nurses working shifts ≥12 h were more likely to experience burnout, have emotional exhaustion, depersonalization, and low personal accomplishment. Moreover, they were more likely to have job dissatisfaction, dissatisfaction with work schedule flexibility, and report intention to leave their job due to dissatisfaction. Nurses working shifts of 12 hours or more were 40% more likely to report job dissatisfaction and 29% more likely to report their intention to leave their job due to dissatisfaction. (Note: Long shifts can include both scheduled 12-hour shifts and instances of “forced” overtime. We suspect the latter give rise to even more job dissatisfaction and burnout than the former.)
Staffing levels and the work environment were important factors in the Shah study as well. Respondents who reported leaving or considering leaving their job owing to burnout reported a stressful work environment (68.6% and 59.5%, respectively) and inadequate staffing (63.0% and 60.9%, respectively).
There were some geographic differences in some of the findings. For example, of those nurses who left their jobs in 2017, there were lower proportions of nurses reporting burnout in the West (16.6%) and higher proportions in the Southeast (30.0%).
While better pay or benefits were often cited as reasons for leaving or considering leaving jobs, more frequently cited reasons were stressful work environments, inadequate staffing, and lack of good management or leadership.
Lack of collaboration/communication between health care professionals was another reason sometimes cited. We’ve done multiple columns on “the culture of disrespect” and how even subtle physician behaviors can have a toxic influence on the workplace. “Interpersonal differences” with colleagues or supervisors was also mentioned by some. We note that there has been an increasingly frequent literature on bullying and “lateral” violence in the nursing literature.
The most common signs of burnout, which define “burnout syndrome” include: emotional exhaustion, depersonalization, and lack of personal accomplishment (LeVeck 2018). LeVeck also noted some other risk factors for nurse burnout:
Notably absent in the Shah study is any mention of the role of the electronic health record (EHR), which is a major factor in promoting burnout in physicians. A recent systematic review on factors associated with nurse well-being in relation to electronic health record use (Nguyen 2020) found worse nurse well-being was associated with EHR’s compared with paper charts. Moreover, the researchers found that nurses have valuable insight into ways to reduce EHR-related burden. Studies on nurse-level factors suggest that personal digital literacy is one modifiable factor to improving well-being. Additionally, EHR’s with integrated displays were associated with improved well-being.
A survey of nurses (Frellick 2019) had some very interesting findings. It found licensed practical nurses (LPN’s) and registered nurses (RN’s) all had satisfaction rates from 94% to 96%. But, when the question was asked a different way (whether respondents would choose nursing again if they could do it over), fewer among the 10,284 total nurses who responded to the online survey said “yes”. Only 76% of RN’s answered this question “yes”. Even fewer would choose the same practice setting again. “Helping people” was the most common answer when asked about the most rewarding aspect of their job. Least rewarding aspects for LPN’s and RN’s were administrative tasks and workplace politics, with about a quarter stating that choice, and paperwork. So, somewhat similar to those factors leading to physician burnout, the EHR, paperwork, and administrative tasks had a negative impact on nurses.
While it is not clear what exactly was meant by “workplace politics” in the above survey, we surmise that includes things like the culture of disrespect, hierarchical structures, bullying, and “lateral” or “horizontal” violence.
So, how do we avoid nurse burnout? Shah and colleagues recommend health systems should focus on implementing known strategies to alleviate burnout, including adequate nurse staffing and limiting the number of hours worked per shift.
Several other strategies have been suggested to combat burnout in nursing and increase nurse resiliency.
LeVeck (LeVeck 2018) notes her “Top 4 Tips For Burnout Prevention”:
Cheryl Commors (Connors 2019) described the RISE (Resilience in Stressful Events) program at Johns Hopkins Hospital to help care providers dealing with the trauma of a tragic patient event (we described that program in our August 2017 What's New in the Patient Safety World column “ROI for a Second Victim Program”). She notes that debriefing after stressful incidents is important and that nurses need an outlet to talk about a stressful experience and receive support from a peer. The debrief should focus on the nurse's emotional and/or psychological experience associated with the event, not details of the event itself. This really fits under the category “strong coworker relationships” noted by LeVeck.
The Joint Commission (TJC 2019) recommends the following safety actions directed toward leaders:
Inform leaders in your organization about the professional factors that foster resilience:
Develop and practice leader empowering behaviors by:
Ensure that leaders engage in discussions and have a physical presence in the department.
They also note actions to help nurses develop resilience in order to combat burnout:
Lastly, it’s important to recognize the role for medical leadership in combating burnout, not just physician burnout but also nursing burnout. For medical directors and medical staff leaders, it’s critical that a culture of respect be fostered. That means zero tolerance for behaviors that are disruptive or degrading. It means establishing an environment where nurses are encouraged to speak up without concern for retribution. There is nothing worse for nursing morale than when a nurse speaks up about counterproductive physician behavior and then nothing is done, or worse yet, the nurse is somehow treated badly because he/she raised the issue. That sort of toxic environment has a lasting impact on morale and is a major reason for nurses leaving their positions.
Our previous columns on the 12-hour nursing shift:
November 9, 2010 “12-Hour Nursing Shifts and Patient Safety”
February 2011 “Update on 12-hour Nursing Shifts”
November 13, 2012 “The 12-Hour Nursing Shift: More Downsides”
July 29, 2014 “The 12-Hour Nursing Shift: Debate Continues”
October 2014 “Another Rap on the 12-Hour Nursing Shift”
December 2, 2014 “ANA Position Statement on Nurse Fatigue”
September 29, 2015 “More on the 12-Hour Nursing Shift”
July 11, 2017 “The 12-Hour Shift Takes More Hits”
May 29, 2018 “More on Nursing Workload and Patient Safety”
September 4, 2018 “The 12-Hour Nursing Shift: Another Nail in the Coffin”
Some of our other columns on nursing workload and missed nursing care/care left undone:
November 26, 2013 “Missed Care: New Opportunities?”
May 9, 2017 “Missed Nursing Care and Mortality Risk”
March 6, 2018 “Nurse Workload and Mortality”
May 29, 2018 “More on Nursing Workload and Patient Safety”
October 2018 “Nurse Staffing Legislative Efforts”
February 2019 “Nurse Staffing, Workload, Missed Care, Mortality”
July 2019 “HAI’s and Nurse Staffing”
September 1, 2020 “NY State and Nurse Staffing Issues”
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”
January 21, 2020 “Disruptive Behavior and Patient Safety: Cause or Effect?”
References:
King C, Bradley LA. PRC National Nursing Engagement Report. PRCCustomResearch.com 2019
The Joint Commission. Developing Resilience to Combat Nurse Burnout. The Joint Commission 2019; Quick Safety Issue 50: 1-4
Shah MK, Gandrakota N, Cimiotti JP, Ghose N, Moore M, Ali MK. Prevalence of and Factors Associated With Nurse Burnout in the US. JAMA Netw Open 2021; 4(2): e2036469
Dall'Ora C, Griffiths P, Ball J, et al Association of 12 h shifts and nurses’ job satisfaction, burnout and intention to leave: findings from a cross-sectional study of 12 European countries. BMJ Open 2015; 5: e008331
https://bmjopen.bmj.com/content/5/9/e008331
LeVeck D. Nurse Burnout Is Real: 7 Risk Factors And The Top 3 Symptoms. Nurse.org 2018; October 2, 2018
https://nurse.org/articles/risks-for-nurse-burnout-symptoms/
Nguyen OT, Shah S, Gartland AJ, et al. Factors associated with nurse well-being in relation to electronic health record use: A systematic review. Journal of the American Medical Informatics Association 2020; Published: 23 December 2020
Frellick M. Nurses Largely Satisfied, but Many Would Change Path. Medscape Medical News 2019; January 24, 2019
Connors C. 3 Ways to Build Nurse Resiliency in 2019. AORN The Periop Life Blog 2019; January 27, 2019
https://www.aorn.org/blog/nurse-resiliency
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February 16, 2021
New Methods for QTc Monitoring
Torsade de pointes (TdP) is a form of ventricular tachycardia, often fatal, in which the QRS complexes become “twisted” (changing in amplitude and morphology) but is best known for its occurrence in patients with long QT intervals. (See our earlier columns on the several methods of measuring the QT interval and criteria for QTc prolongation). Though cases of the long QT interval syndrome (LQTS) may be congenital, many are acquired and due to a variety of drugs that we prescribe. The syndrome is more common in females and many have a genetic predisposition. Underlying heart disease, electrolyte abnormalities (eg. hypokalemia, hypomagnesemia, hypocalcemia), renal or hepatic impairment, and bradycardia may be precipitating factors. This list of medications that may prolong the QT interval is substantial and continues to grow. For a full list of drugs that commonly cause prolongation of the QT interval and may lead to Torsade de Pointes, go to the CredibleMeds® website. That extremely valuable site provides frequent updates when new information becomes available about drugs that may prolong the QT interval.
Particularly when we start patients on a medication known to increase the QTc, we would like to be able to monitor trends in the QTc. But that has been impractical and costly in most situations. The need for a convenient and inexpensive way to monitor the QTc was highlighted when some began hyping chloroquine or hydroxychloroquine plus azithromycin for COVID-19 (see our April 7, 2020 Patient Safety Tip of the Week “Patient Safety Tidbits for the COVID-19 Pandemic”).
Researchers at the Mayo Clinic (Giudicessi 2021) have now developed an artificial intelligence (AI)-enabled 12-lead electrocardiogram (ECG) algorithm to determine the QTc, and then prospectively test this algorithm on tracings acquired from a smartphone-enabled mobile ECG device.
They used data from over 1.6 million 12-lead ECG’s to derive and validate a deep neural network (DNN) to predict the QTc interval. They then prospectively tested the ability of this DNN to detect clinically relevant QTc prolongation (e.g. QTc ≥ 500 ms) on 686 genetic heart disease patients (50% with LQTS) with QTc values obtained from both a 12-lead ECG and a prototype mobile ECG device equivalent to a well-known commercially-available mobile ECG device (the AliveCor KardiaMobile 6L). When applied to mECG tracings, the DNN's ability to detect a QTc value ≥ 500 ms yielded an area under the curve, sensitivity, and specificity of 0.97, 80.0%, and 94.4%, respectively. The negative predictive value was 99.2% for detecting a QTc value ≥ 500 ms.
Giudicessi and colleagues note that studies from their institution and others have demonstrated that ~1% of all individuals who receive an inpatient or outpatient 12-lead ECG have a QTc ≥ 500 ms and that when this QTc threshold is met or exceeded, there is a 2- to 4-fold increased risk of death. They note that the identification of substantial QTc prolongation provides an important opportunity to identify vulnerable, at-risk hosts and make potentially lifesaving change(s) (i.e. initiation of β-blockers, discontinuation of QTc-prolonging medications, or correction of hypokalemia and hypomagnesemia) needed to mitigate the risk of TdP and sudden cardiac death.
Giudicessi et al. discuss the potential applications of an AI-enabled mobile ECG device approach to QTc assessment and monitoring. That could include universal screening for the early detection of congenital LQTS, plus monitoring patient prescribed QTc prolonging drugs.
Our June 25, 2019 Patient Safety Tip of the Week “Found Dead in a Bed – Part 2” noted many of the QTc prolonging drugs commonly prescribed and also mentioned the importance of combinations of such drugs.
While the Giudicessi study focused on specific QTc intervals, don’t forget that trends in the QTc interval may also be important. In our June 10, 2014 Patient Safety Tip of the Week “Another Clinical Decision Support Tool to Avoid Torsade de Pointes” we discussed a study by Tisdale et al. (Tisdale 2014) which demonstrated that use of CDSS (clinical decision support systems) and computerized alerts can reduce the risk of QT interval prolongation. Their system would trigger an alert when the QTc interval was >500 ms or there was an increase in QTc of ≥60 ms from baseline. It would be important to see how the metrics of the Giudicessi tool stack up when evaluating change in QTc from baseline.
Quite frankly, we see this new tool being even more valuable in the inpatient setting. There are a number of reasons why this syndrome is more likely to both occur and result in death in hospitalized patients. So, for those patients not being monitored in ICU settings or via remote monitoring, wearing a watch or wearable device capable of trending the QTc interval in real time could help identify patients at risk for Torsade. Hospitalized patients have a whole host of other factors that may help precipitate malignant arrhythmias in vulnerable patients. They tend to have underlying heart disease, electrolyte abnormalities (eg. hypokalemia, hypomagnesemia, hypocalcemia), COPD, renal or hepatic impairment, and bradycardia, all of which may be precipitating factors. More importantly, hospitalized patients may have the sorts of conditions for which we prescribe the drugs that are primarily responsible for prolonging the QT interval (eg. haloperidol, antiarrhythmic agents, etc.). And many of those drugs are given intravenously and in high doses in the hospital as compared to the outpatient arena. Rapid intravenous infusion of such drugs may be more likely to precipitate TdP than slow infusion.
And think of the application of this tool in patients prescribed psychotropic medications. A whole host of medications commonly prescribed for psychiatric disorders may prolong the QT interval. The new Mayo tool could provide a convenient, inexpensive way to monitor the QTc on either outpatients or those inpatients on behavioral health units who are prescribed such drugs.
This work by Giudicessi and colleagues at the Mayo Clinic may be a real game changer! Mobile ECG devices such as the AliveCor KardiaMobile 6L are relatively inexpensive and easy to use. And, as the quality of ECG tracings from smartwatches has improved, we anticipate the smartwatch may ultimately be a most valuable tool for monitoring QTc intervals in at-risk patients.
Artificial intelligence (AI) and neural networks are being used with increasing frequency in medicine. The same Mayo Clinic researchers also recently published a study (Bos 2021) in which AI-ECG was found to distinguish patients with electrocardiographically “concealed” LQTS from those discharged without a diagnosis of LQTS. About 40% of patients with genetically confirmed LQTS have a normal corrected QT (QTc) at rest. The neural network they developed provided a nearly 80% accurate pregenetic test anticipation of LQTS. The authors suggest this model may aid in the detection of LQTS in patients presenting to an arrhythmia clinic and, with validation, may be the stepping stone to similar tools to be developed for use in the general population.
We refer you back to our June 25, 2019 Patient Safety Tip of the Week “Found Dead in a Bed – Part 2” and our other columns on torsade (listed below) to see what your hospital or healthcare organization should be doing to reduce the risk you’ll find a patient “dead in a bed” from torsade de pointes.
Some of our prior columns on QT interval prolongation and Torsade de Pointes:
June 29, 2010 “Torsade de Pointes: Are Your Patients At Risk?”
February 5, 2013 “Antidepressants and QT Interval Prolongation”
April 9, 2013 “Mayo Clinic System Alerts for QT Interval Prolongation”
June 10, 2014 “Another Clinical Decision Support Tool to Avoid Torsade de Pointes”
April 2015 “Anesthesia and QTc Prolongation”
October 10, 2017 “More on Torsade de Pointes”
June 25, 2019 “Found Dead in a Bed – Part 2”
April 7, 2020 “Patient Safety Tidbits for the COVID-19 Pandemic”
References:
CredibleMeds® website
Giudicessi JR, Schram M, Bos JM, et al. Artificial Intelligence-Enabled Assessment of the Heart Rate Corrected QT Interval Using a Mobile Electrocardiogram Device. Circulation 2021; Originally published 1 Feb 2021
https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.050231
Tisdale JE, Jaynes HA, Kingery J, et al. Effectiveness of a Clinical Decision Support System for Reducing the Risk of QT Interval Prolongation in Hospitalized Patients. Circulation: Cardiovascular Quality and Outcomes 2014; 7(3): 381-390 Published online before print May 6, 2014
https://www.ahajournals.org/doi/full/10.1161/CIRCOUTCOMES.113.000651
Bos JM, Attia ZI, Albert DE, Noseworthy PA, Friedman PA, Ackerman MJ. Use of Artificial Intelligence and Deep Neural Networks in Evaluation of Patients With Electrocardiographically Concealed Long QT Syndrome From the Surface 12-Lead Electrocardiogram. JAMA Cardiol 2021; Published online February 10, 2021
https://jamanetwork.com/journals/jamacardiology/fullarticle/2776241
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February 23, 2021
Cellphones and the OR
It’s been a year since our last soapbox rant about cellphones in the OR (see our January 28, 2020 Patient Safety Tip of the Week “Dang Those Cell Phones!”). A recent “Viewpoint” in JAMA Surgery has rekindled the debate about cellphones in the OR. Cohen et al. (Cohen 2020) reviewed the benefits and harms of personal communication devices (PCD’s) or smartphones in the OR. They summarized the benefits and harms of PCD’s:
Benefits
Harms
We’ll be quick to point out that most of the benefits listed by Cohen et al. do not necessitate cellphones being in the OR. Also, the important access to medical imaging and access to tools such as medication dosing apps are already available on the computers currently in the OR, so we don’t need cellphones for access to those in the OR.
But the potential harms listed by Cohen et al. are real, particularly the unwanted disruptions and distractions and cognitive disengagement from other tasks. A previous study by Cohen et al. (Cohen 2018) had looked at the impact of PCD’s during cardiovascular surgeries. They identified a total of 545 PCD-related events during 25 cases. While most individuals spent less than a few minutes attending to their PCD’s, a handful of these disruptions lasted an abnormally long time. On average, each of the 545 events took 1 min, 26 s (SD = 1 min, 40 s) of attention. Most PCD use events took place during bypass (n = 233) followed by pre-bypass (n = 197) and post-bypass (n = 115). Of the 545 events, nearly half (48.81%) involved the anesthesia team, followed by the perfusion team (30.28%), circulating nurse (16.70%) and surgeon (4.22%).
While the authors could not determine exactly how the devices were being used in some of the cases, they were able to document behaviors such texting, emailing, phone calls, and non-hospital related use. Thus, the device itself resulted in multiple types of distractions distributed across the different phases surgery.
The authors also point out that their data do not support the commonly used argument that PCD use is restricted to non-critical phases of surgery. Their data showed team members were engaged with their PCD’s for approximately a minute and a half regardless of the stage of the operation. Additionally, the greatest number of PCD-use events occurred during the most critical phase of surgery, bypass.
One example provided was that the surgeon was opening patient chest when his personal cell phone started ringing. He stopped opening so that the circulating nurse could get his cell phone out of his pocket and hold up the phone to his ear so he could answer. In our August 20, 2019 Patient Safety Tip of the Week “Yet Another (Not So) Unusual RSI” we described a case that resulted in a retained surgical item (RSI). In that case, one of the likely contributing factors was that the surgeon’s phone rang several times during the third count, before being answered by the anesthesiologist.
Cohen et al. discuss several factors that may explain such behavior in the operating room. These include comfort with the procedure and equipment, complacency, boredom in what are typically hours-long procedures, and feeling the societal pressure to answer texts, calls, and emails as soon as possible.
A 2016 APSF (Anesthesia Patient Safety Foundation) conference “Distractions in the Anesthesia Work Environment: Impact on Patient Safety” (van Pelt 2017) noted several issues related to personal electronic devices (PED’s) in the OR:
In addition to our example above of a surgeon’s phone ringing several times during a surgical count as 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. We have yet to see a cogent argument as to why cellphones are actually needed 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.
Our January 28, 2020 Patient Safety Tip of the Week “Dang Those Cell Phones!” noted an AORN (Association of periOperative Registered Nurses) proposal having 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 recommendation was 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 another AORN Journal article (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.
Every facility and organization needs to have a PED policy. A report from the ECRI Institute (Rose 2019) had some very good suggestions for facilities to develop policies for use of personal electronic devices. Such policies should balance the needs of staff members, residents, visitors, and the institution as a whole while clearly defining when, where, and for what purposes PED’s may be used. The policy should also include a clear definition of data ownership—that is, which data are considered owned by the facility and which are considered owned by the PED user—and clearly identify what constitutes sensitive information. It also discusses 3 approaches to allowing PED’s in the facility: (1) facility-provided devices, (2) “Bring your own device” (BYOD), and (3) a hybrid approach. The facility/organization should have a committee that decides where PED’s may be used. It may decide to ban PED’s from certain areas or to restrict them to certain areas, such as common areas or staff lounges. It also has practical recommendations on what information may be accessed or stored on PED’s, how PED’s will be managed, what to do if a PED is lost or stolen, and how restrictions on PED use or misuse will be enforced.
Prior Patient Safety Tips of the Week dealing with cell phones:
See our other Patient Safety Tip of the Week columns dealing with texting:
Prior Patient Safety Tips of the Week dealing with interruptions and distractions:
References:
Cohen TN, Jain M, Gewertz BL. Personal Communication Devices Among Surgeons—Exploring the Empowerment/Enslavement Paradox. JAMA Surg 2020; Published online December 23, 2020
Cohen TN, Shappell SA, Reeves ST, Boquet AJ. Distracted doctoring: the role of personal electronic devices in the operating room. Perioper Care Oper Room Manag 2018; 10: 10-13
https://www.sciencedirect.com/science/article/abs/pii/S2405603017300365?via%3Dihub
van Pelt M, Weinger MB. Distractions in the anesthesia work environment: impact on patient safety? Report of a meeting sponsored by the Anesthesia Patient Safety Foundation. Anesth Analg. 2017; 125(1): 347-350
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
Rose VL Foundations of a Personal Electronic Device Policy. Ann Longterm Care 2019; 27(6): e5-e7
https://www.managedhealthcareconnect.com/articles/foundations-personal-electronic-device-policy
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March 2, 2021
Barriers to Timely Catheter Removal
CAUTI’s (catheter-associated urinary tract infections) and CLABSI’s (central line-associated bloodstream infections) remain serious hospital-acquired infections (HAI’s). The best way to avoid them is to avoid the use of urinary or vascular catheters in the first place. Fortunately, there are good guidelines for determining the appropriateness of such catheters. But, obviously, some are needed. The next most important facet of preventing CAUTI’s and CLABSI’s is removal of the catheters as soon as they are no longer needed.
Urinary catheters are the leading cause of hospital-acquired urinary tract infections (see our many prior columns listed below). And urinary catheters are associated with many non-infectious complications and adverse effects, including GU trauma, reduced mobility (the “one-point restraint”), falls, and delirium.
While we will use the term “intravascular catheters” in this column, we are talking about central venous catheters and PICC lines. Our prior columns on such lines (listed below) also note there are other potential complications from these catheters besides CLABSI’s.
The University of Michigan has been at the forefront of the campaign to eliminate CAUTI’s and CLABSI’s. They previously reported on many of the barriers to successful CAUTI prevention (see our June 2013 What's New in the Patient Safety World column “Barriers to CAUTI Prevention”).
Despite all these efforts, we continue to see infections related to such catheters. The Michigan team also led a multi-state quality improvement initiative aimed at reducing CAUTI’s and CLABSI’s in ICU’s having high rates of such infections (Meddings 2020). But that initiative yielded no statistically significant reduction in CLABSI, CAUTI or catheter utilization in the first two of six planned cohorts.
So, the University of Michigan group did observations and in-person interviews with clinicians working on a progressive care unit of a large hospital in attempt to identify barriers to timely catheter removal (Quinn 2021). The researchers found five distinct themes related to the organizational culture of catheter removal:
The EHR should play a critical role, but it often does not. The researchers found that information on catheters, such as catheter presence, when it was inserted, and the medical indication for it, was hard to find and often not accurate in the EHR. We have always recommended that order entry screens for catheter insertion include a field for indication (listing appropriate indications in a checkbox format). There should be a flag set on every patient having a catheter in place. That way, a nurse or physician can see a daily listing of which patients have catheters in place. Moreover, clinical decision support systems can alert clinicians to reassess the need for continued catheter use on a daily basis. The real problem arises when someone simply takes a Foley catheter kit or intravascular catheter kit to the bedside and no CPOE order is created for that catheter. We’ve done multiple columns highlighting that often a clinician is “surprised” to find his/her patient has an indwelling catheter (see our May 8, 2007 Tip of the Week “Doctor, when do I get this red rubber hose removed?”, and our What's New in the Patient Safety World columns for December 2014 “Surprise Central Lines” and July 2016 “Holy Moly, My Patient has a FOLEY!”). Such catheters are often inserted at night by covering physicians, not recorded in the EHR, and poorly communicated with the daytime clinician team. And we often don’t notice the patient has a catheter because it may be obscured by blankets or gowns. We think the solution there lies in use of barcoding to tie the catheter to a specific patient. Such barcoding could tie to the MAR (medication administration record) as a means of interfacing with the EHR and require that an indication be input. Note that we have previously also suggested that every catheter kit have a checklist that must be filled out before use and one of the items on that checklist would be indication. However, unless the MAR is clearly linked to the EHR and CPOE system, someone would still have to manually input the data from that checklist into the EHR if the EHR is to be utilized for tracking catheter use and generating alerts.
Quinn et al. found that catheter data in the EHR were not readily available during morning rounds because these physician teams did not typically round with laptops or tablets. It’s easy enough to get a printout of all patients belonging to an individual clinician or service who have a catheter in place. That paper printout can be taken on rounds when the rounding team is not using laptops or tablets. Our own experience is that nurses are much more reliable than physicians in paying attention to catheter use. Hopefully, the rounding team includes a head nurse or other nurse who could have the printout.
The second theme, that catheter removal is not a priority, is perhaps the most important barrier. The researchers found that both physicians and nurses are very busy attending to multiple medical problems in multiple patients and often attention to catheters falls to the bottom of their list of priorities. The second part of that theme, however, is much more problematic. That is the observation that sometimes nurses may like having either a urinary or intravascular catheter in place for convenience. Convenience, of course, is not a legitimate indication for continued catheter use (except possibly in a patient receiving only end-of-life care). Ideally, any CDSS-generated alert asking about continued catheter use should require input of the indication for continued use.
The third theme was confusion exists about who has the authority to remove catheters. The hospital did have a policy in place that allowed nursing staff to remove urinary catheters without a physician order if certain criteria were met. However, in practice, many physicians were unaware of the policy and many nurses were reluctant to remove the catheters without a physician order.
Theme 4 was lack of agreement on, and awareness of, standard protocols and indications for removal of catheters. While organizations may have clearly stated criteria for insertion of urinary or intravascular catheters, few specifically delineate criteria for discontinuation or removal of them. Quite frankly, we think they should be the same for initial insertion and continuation, so each day the clinical team should be asking whether the criteria continue to be met.
Theme 5 should surprise no one: communication barriers create challenges. The researchers found that physicians seldom spoke to each other about catheters and communication between physicians and nurses was particularly poor. While we mentioned above that we expect the rounding team would have a designated nurse participating, that was often not practical because of large nursing workloads or timing of the rounds (rounds often being done while nursing change of shift was occurring). The Michigan group previously reported on a more detailed examination of communication barriers between physicians and nurses about appropriate catheter use (Manojlovich 2019).
Quinn et al. note that implementation of improvement efforts such as EHR reminders and stop orders, nurse empowerment policies, and standardized protocols have become more common. But they note one substantial unmet need: there is a current lack of system for displaying information about catheters at the bedside in a readily visible format. Such display should indicate the presence of a catheter, duration of use, and indication. Such a system should prompt discussion about its continued necessity, help facilitate removal, and prompt recognition and correction of any incorrect catheter data in the EHR.
This is yet another valuable contribution from the University of Michigan researchers on ways to prevent CAUTI’s and CLABSI’s (and other adverse consequences of catheters).
Our other columns on urinary catheter-associated UTI’s:
Some of our other columns on IV access, central venous catheters and PICC lines:
January 21, 2014 “The PICC Myth”
December 2014 “Surprise Central Lines”
July 2015 “Reducing Central Venous Catheter Use”
October 2015 “Michigan Appropriateness Guide for Intravenous Catheters”
March 27, 2018 “PICC Use Persists”
February 26, 2019 “Vascular Access Device Dislodgements”
July 16, 2019 “Avoiding PICC’s in CKD”
References:
Meddings J, Greene MT, Ratz D, et al. Multistate programme to reduce catheter-associated infections in intensive care units with elevated infection rates. BMJ Quality & Safety 2020; 29: 418-429
https://qualitysafety.bmj.com/content/29/5/418
Quinn M, Ameling JM, Forman J, et al. Persistent Barriers to Timely Catheter Removal Identified from Clinical Observations and Interviews. The Joint Commission Journal on Quality and Patient Safety 2021;46(2): 99-108
https://www.sciencedirect.com/science/article/pii/S1553725019304210
Manojlovich M, Ameling JM, Forman J, et al. Contextual Barriers to Communication Between Physicians and Nurses About Appropriate Catheter Use. Am J Crit Care 2019; 28(4): 290-298
http://ajcc.aacnjournals.org/content/28/4/290.abstract
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March 9, 2021
Update: Disclosure and Apology: How to Do It
We’ve come a long way in our responses to medical errors. It’s now widely accepted that disclosure and sincere apology to patients and their families or significant others are the right thing to do following errors that lead to adverse patient outcomes (and even those that do not lead to patient harm).
Ever since we set up our first guidelines on responding to serious incidents in the early 1990’s (see our July 24, 2007 Patient Safety Tip of the Week “Serious Incident Response Checklist”) we have always included a section in our “Serious Event Response Checklist” for notifying the patient and/or family that errors had occurred in their care. Yet we continue to see hospitals and physicians struggle with “how do we do it?” even once they have bought into the basic concept.
Physicians have historically been poorly prepared to undertake disclosure and apology. In the past, legal concerns have made physicians reluctant to discuss such errors with patients and families. But even as disclosure and apology and communication and resolution programs have become accepted, many physicians feel awkward in communications with the involved parties.
We did discuss how to undertake such communication back in our June 22, 2010 Patient Safety Tip of the Week “Disclosure and Apology: How to Do It” and multiple other columns listed at the end of today’s column.
An excellent recent review (Kaldjian 2020) discusses all the elements necessary to make such conversations productive. These involve respect, compassion, and commitment by providing information, acknowledging harm, and maintaining trust through a process of dialogue that involves multiple conversations.
Kaldjian begins with a succinct summary: “Communication about medical errors with patients and families demonstrates respect, compassion, and commitment to patients and families after an error has occurred by providing information, acknowledging harm, and maintaining trust through a process of dialogue that involves multiple conversations.”
It is especially important that any apology is sincere and honest. It must be delivered with empathy and respect.
Patients and families also want to hear that you will be using lessons learned from the event to ensure similar errors do not occur in the future and impact other patients. One of the most important points, from our perspective, is letting them know that you will be having multiple conversations with them, periodically keeping them up to date with regards to the status of your investigation and RCA (root cause analysis) and the steps you take to prevent recurrence of such errors.
You also want to let them know about continued care for the patient (assuming it was not a fatal error), what harm the error may have caused, and how what will be done about that harm.
Kaldjian outlines the key elements of a medical error discussion:
We note one important consideration missing from the otherwise excellent Kaldjian review: the venue for the discussion. You need to make the patient/family comfortable and encourage them to engage in dialogue. The worst mistake we see is holding the discussion in the board room of a hospital with multiple hospital figures dressed in white coats or suits and ties sitting across from them. That is an intimidating environment and almost immediately puts the family in a defensive posture. We recommend the discussion take place in a small room with comfortable seating and no table or other furniture in the way.
We recommend you keep the number of hospital personnel to a minimum. That should include the clinician providing the disclosure. That is usually the attending physician, though in some cases it may be someone else, such as a medical director or department head. It’s good to have one other “hospital” person in the room. That might be a risk manager or the person who will lead the RCA sessions, though it could also be a patient advocate if your organization has such a position. Or it might be a nurse or other healthcare worker who has developed a good rapport with the family. Patients and families often look to that other person for support and clarification. That person also may be more experienced in these discussions and can keep the clinician focused on the key elements of the discussion. And the patient or family may come to that person with questions they are afraid to ask the physician.
One other issue not discussed in the Kaldjian review is the question “When should you notify the patient and family?”. In our June 22, 2010 Patient Safety Tip of the Week “Disclosure and Apology: How to Do It” we recommended that you let the patient/family know about the incident as soon as possible. Obviously, you need to know enough about the event or incident to be able to discuss it with them. But sometimes you may not have all the details early on (for example, you may not yet have done your root cause analysis). It is okay to tell them that a serious incident did take place and that your investigation will be taking place within a few days and that you will keep them posted regularly on the status of that investigation. Let them know that you are doing this to help ensure that similar events will be prevented in the future. You need to show honesty, contrition, and empathy in order to build a trusting relationship with that patient or family. If you wait to disclose that an incident occurred, the patient or family is likely to find out about it in other ways, your credibility will suffer, and you will lose the opportunity to develop a rapport with them.
Kaldjian notes that a variety of strategies may be used to help train clinicians for the process: didactic lectures, videos, training-level-appropriate clinical scenarios, discipline-specific considerations, role play (preferably with realistic simulated settings), standardized patients, patient perspectives, and assessment of error disclosure skills. We like using simulations. While some will use actors during the simulations, we prefer that the “actors” be experienced clinicians who have participated in real life disclosure and apology sessions.
When to begin training for disclosure and apology is not clear. We think it should begin in medical school, where we need to make it clear that errors will occur and prepare medical students to recognize errors and understand what to do when errors occur. But, we think the most important training should take place during residency. The ACGME (Accreditation Council for Graduate Medical Education) has a core requirement for residency programs to incorporate training in error disclosure. It states “Patient-centered care requires patients, and when appropriate families, to be apprised of clinical situations that affect them, including adverse events. This is an important skill for faculty physicians to model, and for residents to develop and apply.” It requires that all residents must receive training in how to disclose adverse events to patients and families. Furthermore, residents should have the opportunity to participate in the disclosure of patient safety events, real or simulated.
We cannot overemphasize the importance of role models in this regard. The response to errors is molded by how residents perceive their attendings and mentors respond to errors. Unfortunately, that has not always been productive. When attendings are hesitant to reveal errors to patients and families, residents pick up on that and may adopt similar attitudes toward disclosure. On the other hand, seeing an attending physician be forthright in disclosure and meet with patients or families in a respectful, compassionate manner can positively impact a resident’s attitude toward disclosure and apology.
Borz-Baba et al. (Borz-Baba 2020) conducted a cross-sectional survey of medical residents in the Yale Primary Care Residency Program, who were working in a community hospital in an underserved area. They observed that 62.5% of the residents were not familiar with the error-reporting process at their institution. General concerns about disclosing errors were related primarily to negative patient reactions (66.7%). The majority (58.3%) of the trainees' negative psychological experience after an unanticipated outcome resulting in harm has caused increased anxiety about future errors. Residents also expressed concerns about malpractice litigation, professional discipline, and harm to professional reputation.
While a majority of the residents were hypothetically familiar with the steps necessary to disclose medical errors, none had undergone training in disclosure. There is a gap between the hypothetical attitude and real practice. Their hospital did have in place a policy for disclosure of the outcome of care but there was no formal process that clarifies what information the patient communication should contain. The authors state this reveals the “need for a more comprehensive program that addresses the pre-disclosure action plan, the content of the error disclosure, and the techniques to be adopted for delivering a well-formulated message”.
Borz-Baba et al. recommend the implementation of both lecture-based educational strategies and simulated patient-training sessions. The lecture-based educational sessions would include an e-learning session that will review the definition and types of errors, the disclosure conversation process, and disclosure content. This would be mandatory for all medical residents in the first year of training. Yearly conferences would revisit the reporting system used at their institution and a practice session with core teaching to promote a positive role-modeling approach. They would also present and discuss the pre-disclosure and post-disclosure support system developed with the participation of risk management. The standardized patient-simulation session would briefly review the content of the disclosure discussion and the message errors to avoid. This would be followed by actual practice, reflection on the discussion, and feedback sessions on the performance. Simulation of real-life experience would allow trainees to become more confident with the conversation flow and prepare them to embrace an attitude or style that emphasizes preserving a trustworthy patient-doctor rapport.
Our June 22, 2010 Patient Safety Tip of the Week “Disclosure and Apology: How to Do It” included examples from the Harvard and Canadian guidelines (listed below) of the types of words and phrases that should and shouldn’t be used in communicating with patients and families after a medical error has occurred.
We always remind all of the old adage “90% of communication is non-verbal”. That point should be included in all your simulations and other training activities on disclosure and apology. The critical importance of “body language” in fostering trust during these discussion with patients and families cannot be overstated. So, it is important in critiquing simulation exercises that attention to body language is as important as attending to the words actually spoken.
Having real patients or families who have experienced a medical error discuss their experience is very useful. We can usually find families who have had a positive experience willing to speak to students or residents. But we can probably learn even more from those families whose experience with the process was unsatisfactory.
The organizational culture is equally important. We’ve seen too many organizations dominated by attorneys whose attitude has been “say as little as possible”. Fortunately, the literature over the past 2 decades has shown that disclosure and apology has resulted in less litigation expenses and settlements, while maintaining the trust of patients and families.
In fact, that trust is far more important than the direct financial issues resulting from adverse medical incidents. Prentice and colleagues studied the long-term impact after a medical error and its relationship to how openly healthcare providers communicate (Prentice 2020). They did a survey in Massachusetts assessing experience with medical error and re-contacted respondents several years later and assessed “open communication” with six questions assessing different communication elements. Of respondents self-reporting a medical error 3–6 years previously, 51% reported at least one current emotional impact; 57% reported avoiding doctor/facilities involved in error; 67% reported loss of trust. Open communication varied: 34% reported no communication and 24% reported ≥5 elements. Respondents reporting the most open communication had significantly lower odds of persisting sadness (OR=0.17), depression (OR=0.16) or feeling abandoned or betrayed (OR=0.10) compared with respondents reporting no communication. Open communication significantly predicted less doctor/facility avoidance, but was not associated with medical care avoidance or healthcare trust.
Our many prior columns have also discussed the trend toward using “communication-and-resolution” programs (CRP’s). After an initial flurry of positive reports on the success of communication-and-resolution programs, other reports did not paint as rosy a picture. Mello and colleagues (Mello 2020) did a comprehensive review of the factors contributing to success of these programs. They found facilitators of success:
Gallagher et al. (Gallagher 2020) make a point we thoroughly agree with: trying to “market” CRP programs by highlighting potential fiscal savings is not likely to be productive. They state “Honesty, transparency and an overriding urgency to improve the safety of clinical care represent goals with intrinsic value and resonate with patients, caregivers and healthcare organizations alike. When those goals and values, not dollars, sit at the center of an organization’s efforts, it is far more likely that an authentic CRP will take hold.” We couldn’t agree more. We do disclosure and apology because “it’s the right thing to do”. If you are contemplating developing a CRP program, keep your core values as the main impetus.
Equally important is organizational training to recognize what clinicians involved in medical errors (the “second victims”) go through. All too often those clinicians, already riddled with guilt, become isolated or even ostracized because of lack of support from their colleagues, peers, and organization. Incorporating into the training on disclosure comments from such “second victims” can be very beneficial when it demonstrates how clinicians felt better about themselves after successful disclosure and apology.
We always seem to be talking about hospitals in our discussion on medical error disclosure and apology. Kaldjian is quick to point out that medical errors occur in all venues of care, not just inpatient care. So, it is equally important to take into consideration how to prepare for and handle such discussion when they occur in outpatient settings and other venues. And all specialties must adopt disclosure and apology approaches, even those in which the opportunity to develop a rapport with the patient is less likely, such as pathology and radiology. Brown et al. published an excellent review of the barriers involved in radiology error disclosure and steps that need to be taken to get the issue into the mainstream of radiology practice (Brown 2019).
How is your organization ensuring that your physicians are proprerly prepared for communicating with patients and families after a medical error?
Some of our prior columns on Disclosure & Apology:
July 24, 2007 “Serious Incident Response Checklist”
June 16, 2009 “Disclosing Errors That Affect Multiple Patients”
June 22, 2010 “Disclosure and Apology: How to Do It”
September 2010 “Followup to Our Disclosure and Apology Tip of the Week”
November 2010 “IHI: Respectful Management of Serious Clinical Adverse Events”
April 2012 “Error Disclosure by Surgeons”
June 2012 “Oregon Adverse Event Disclosure Guide”
December 17, 2013 “The Second Victim”
July 14, 2015 “NPSF’s RCA2 Guidelines”
June 2016 “Disclosure and Apology: The CANDOR Toolkit”
August 9, 2016 “More on the Second Victim”
January 3, 2017 “What’s Happening to “I’m Sorry”?”
October 2017 “More Support for Disclosure and Apology”
April 2018 “More Support for Communication and Resolution Programs”
August 13, 2019 “Betsy Lehman Center Report on Medical Error”
September 2019 “Leapfrog’s Never Events Policy”
Other very valuable resources on disclosure and apology:
Some of our prior columns on “the second victim”:
References:
Our “Serious Event Response Checklist”
docs/Serious_Event_Response_Checklist.htm
Kaldjian LC. Communication about medical errors. Patient Education and Counseling 2020; Published online November 28, 2020
https://www.sciencedirect.com/science/article/abs/pii/S0738399120306595?via%3Dihub
Borz-Baba C, Johnson M, Gopal V. Designing a Curriculum for the Disclosure of Medical Errors: A Requirement for a Positive Patient Safety Culture. Cureus 12(2): e6931 February 10, 2020
Prentice JC, Bell SK, Thomas EJ, et al Association of open communication and the emotional and behavioural impact of medical error on patients and families: state-wide cross-sectional survey. BMJ Quality & Safety 2020; 29(11): 883-894 Published Online First: 20 January 2020
https://qualitysafety.bmj.com/content/29/11/883
Mello MM, Roche S, Greenberg Y, et al. Ensuring successful implementation of communication-and-resolution programmes. BMJ Quality & Safety 2020; 29(11): 895-904
https://qualitysafety.bmj.com/content/29/11/895
Gallagher TH, Boothman RC, Schweitzer L, et al Key marketing message for communication and resolution programmes: the authors reply. BMJ Quality & Safety 2020; 29(9): 779 Published Online First: 12 June 2020
https://qualitysafety.bmj.com/content/29/9/779
Brown SD, Bruno MA, Shyu JY, et al. Error Disclosure and Apology in Radiology: The Case for Further Dialogue. Radiology 2019; 293(1): 30-35
https://pubs.rsna.org/doi/full/10.1148/radiol.2019190126
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March 16, 2021
Sleep Program Successfully Reduces Delirium
We’ve done several columns highlighting the poor job we do at allowing patients to sleep when they are hospital inpatients (see our Patient Safety Tips of the Week for August 6, 2013 “Let Me Sleep!”, May 15, 2018 “Helping Inpatients Sleep”, and November 6, 2018 “More on Promoting Sleep in Inpatients”). Our November 6, 2018 Patient Safety Tip of the Week “More on Promoting Sleep in Inpatients” cited several studies showing inpatients average significantly less sleep in hospital compared to at home.
In the inpatient setting we see excessive noise, light exposure, and other environmental factors like temperature, combine with physiological factors like pain, stress related to the medical condition, and psychological stress to disrupt patient sleep patterns.
But, in delivering care, we often introduce other factors that disrupt sleep. At many (perhaps most) hospitals, the incoming nursing staff gets vital signs when their shift starts. Hence, many patients get their vital signs checked between 11PM and midnight. Simply changing policy and procedure so that vital signs are checked by the outgoing staff at 10PM can help avoid one obvious potential sleep disruption. (Of course, you’d have to look for potential unintended consequences such as interfering with shift handoffs). Sometimes, a patient might be wakened to take vital signs and then wakened a short time later for blood drawing. Simply changing timing so such interventions coincide can reduce the number of such wakenings. A ‘late” dose of a diuretic can cause a patient to waken to urinate in the middle of the night.
We also mentioned how physicians may inadvertently cause some of those disruptions. Getting physicians to understand that “three times daily” and “every 8 hours”, for example, are not the same takes some time and hard work. If I order a medication today at 10AM and enter it as “every 8 hours” my patient will be wakened at 2AM to get a dose. On the other hand, if the order is written for “three times daily” the hospital will have standard times that such are given to avoid that disruptive nighttime dose. (Note that you have to be very careful. Today’s CPOE systems often don’t make it clear when the first dose will be given. We have seen some systems where the first dose or even all the first day’s doses will not be given when the order is written this way.) And we often reflexly order vital signs to be taken “every 4 hours” or “every 6 hours” when they really don’t need to be taken during the wee hours of the morning (being careful not to overlook times when vital signs really do need to be taken so frequently).
It's certainly logical to focus on noise reduction as one strategy to promote more natural sleep in your inpatients. But your program needs to be a multiple component one and we think the primary focus needs to be on coordinating care so that interruptions are kept to a minimum.
Lastly, don’t forget one of our goals is to minimize use of sedative/hypnotic drugs and their detrimental side effects. It is still common for physicians to leave orders for prn sleep meds in the admission orders, presumably so no phone call is needed at night requesting such. In our March 23, 2010 Patient Safety Tip of the Week “ISMP Guidelines for Standard Order Sets” we stressed the importance of avoiding inclusion of “prn” sleep meds in standard order sets.
Avoiding sleep meds and using non-pharmacologic interventions to promote sleep is something every hospital should strive for. We want to avoid using sedative/hypnotic medications to induce sleep in such patients because they are risk factors for falls, delirium, medication-induced respiratory depression, and other undesirable complications.
We’ve also pointed out in our many columns on delirium (see the full list below) that disruption of sleep-waking cycles is an important factor contributing to the occurrence of delirium. Sleep disruption is one of the few potentially modifiable risk factors for development of delirium.
This month there is an interesting study addressing both these issues. Gode et al. (Gode 2021) did an internal assessment at their hospital and found that up to 25% of all patients on their medical-surgical units had a diagnosis of delirium while in the hospital. So, they implemented a project to reduce the development of delirium through sleep promotion on 2 inpatient units, using evidence-based practices.
They began with an environmental assessment of each unit to identify loud noises that could wake a patient; One example they found was that, on the medical oncology unit, there was a positive air pressure handler that was being reset daily at 2 AM, It produced a noise described by patients as sounding “like a jet airplane taking off” and consistently woke patients from sleep. The air handler was successfully rescheduled to reset instead at 2 PM when patients are typically awake.
They developed a sleep “menu” for what they named their “No Wake Zone” (NWZ). Menu items, in a checkbox format, included:
Patients were identified as candidates for the NWZ if they were medically stable and were a minimum of 24 hours after admission or surgery. The tool used for delirium screening was the Nursing Delirium Screening Scale (NuDESC). Patients were educated on the NWZ program and allowed to choose items from the menu that they wanted implemented.
They also included an often overlooked step - review of the medication profile by a pharmacist, who can recommend changing the timing of doses of some medications that might interfere with sleep.
They did not, as we recommended above, stop the vital signs and nursing assessments that took place shortly after the 11 PM nursing change of shift. Instead, they designated a 5-hour period from 1 AM to 6 AM as the timeframe to maximize sleep.
An order for the NWZ was required in the electronic medical record (EMR). The nursing team would then establish a sleep plan for the patient. Such would include bundling patient care activities, medication, laboratory timing, and bathroom needs. While the patient sleeps, nurses continue to perform safety assessments without waking the patient. (Keep in mind that certain patients, particularly those with some neurological conditions, may actually need to be wakened for assessments).
Their efforts appear to have paid off, both clinically and financially. Answers to the HCAHPS question “During this hospital stay, how often was the area around your room quiet at night?” showed a statistically significant increase. Positive delirium risk screening decreased from 26.3% to 17.9% on the medical oncology unit (a 33% decrease) and from 14.1% to 7.8% on the surgical spine unit (a 45% decrease). Estimated cost avoidance was $160,505 for the medical oncology unit and $241,802 for the surgical spine unit.
Significant education of all staff, using multiple modalities, had to take place prior to the program’s initiation and discussion of the NWZ program during rounds was important.
They identified both barriers and facilitators to success. Barriers and challenges included prompting the provider to order the NWZ for eligible patients, because of weekly rotation of hospitalist coverage. There was also difficulty in identifying when patients on the medical oncology unit were medically appropriate to initiate the NWZ due to the complexity of their condition and “nebulous” trajectory.
Facilitators included use of an interprofessional team approach, involvement of frontline nurses and support staff, and involvement of the pharmacist reviewers. In addition, an advanced practice nurse practitioner on the surgical spine unit consistently ordered the NWZ once patients met eligibility criteria.
There are, of course, several other protocols and programs for improving sleep in hospital inpatients. See our November 6, 2018 Patient Safety Tip of the Week “More on Promoting Sleep in Inpatients” for descriptions of the “Quiet Time”, Sommerville, and “TUCK-in” protocols, plus the Hospital Elder Life Program (HELP) program.
The Gode study shows such programs can improve inpatient sleep and reduce delirium rates, positively impacting both patient outcomes and satisfaction and the bottom line.
Some of our previous columns on safety issues associated with sleep meds and promoting sleep in inpatients:
August 2009 “Bold Experiment: Hospitals Saying No to Sleep Meds”
March 23, 2010 “ISMP Guidelines for Standard Order Sets”
May 2012 “Safety of Hypnotic Drugs”
November 2012 “More on Safety of Sleep Meds”
March 2013 “Sedative/Hypnotics and Falls”
June 2013 “Zolpidem and Emergency Room Visits”
August 6, 2013 “Let Me Sleep!”
June 3, 2014 “More on the Risk of Sedative/Hypnotics”
May 15, 2018 “Helping Inpatients Sleep”
June 2018 “Deprescribing Benzodiazepine Receptor Agonists”
November 6, 2018 “More on Promoting Sleep in Inpatients”
June 2019 “FDA Boxed Warning on Sleep Meds”
August 2019 “Tools for Reducing Sleep Meds in Hospitals”
Some of our prior columns on delirium assessment and management:
References:
Gode A, Kozub E, Elizabeth Joerger K, et al. Reducing Delirium in Hospitalized Adults Through a Structured Sleep Promotion Program. Journal of Nursing Care Quality 2021; 36(2): 149-154
Print “Sleep Program Successfully Reduces Delirium”
March 23, 2021
Nursing Staffing and Sepsis Outcomes
Our June 6, 2017 Patient Safety Tip of the Week “NYS Mandate for Sepsis Protocol Works” reported on the successful reduction in sepsis mortality in New York State after the New York State Department of Health mandated that hospitals begin using protocols to help with early identification and treatment of sepsis. Hospitals began implementing these protocols in 2014. By the third quarter of 2016, 84.7% of adult patients and 85.3% of pediatric patients with severe sepsis or septic shock were treated using protocols (NYSDOH 2017). Adult in-hospital mortality fell from 30.2% in early 2014 to 25.4% by late 2016. Pediatric mortality rates were more variable without a clearcut trend. After adjusting for patient factors, the NYSDOH analysis of the data showed that the odds of dying were 21% less for adult patients who received protocol-driven treatments compared to patients who do not receive protocol-driven treatments. The time frame for management was also critical. After adjustment, the NYSDOH analysis showed that the odds of dying were 27% less for adult patients who received all of the recommended treatments within three hours compared to patients who did not receive all of the recommended treatments.
Seymour et al. dove deeper into the data (Seymour 2017). Supporting the importance of early treatment, they found that each hour of time to the completion of the 3-hour bundle was associated with higher mortality (odds ratio of death until completion of 3-hour bundle, 1.04 per hour). Patients who had the bundle completed during hours 3 through 12 had 14% higher odds of dying in the hospital than those whose bundle was completed by 3 hours. Those same odds (1.04 per hour) were seen for time to administration of antibiotics and in-hospital mortality and patients who received first dose of antibiotics during hours 3 through 12 had 14% higher odds of dying in the hospital than those receiving antibiotics by 3 hours.
But there may be more to the story of the New York State experience. Lasater et al. (Lasater 2020) looked at New York State hospital data from 2017 and found a significant relationship between sepsis mortality and hospital nurse-to-patient staffing ratios. They found that each additional patient per nurse was associated with 12% higher odds of in-hospital mortality, 7% higher odds of 60-day mortality, 7% higher odds of 60-day readmission, and longer lengths of stay, even after accounting for patient and hospital covariates including hospital adherence to SEP-1 bundles. And, while adherence to SEP-1 bundles was associated with lower in-hospital mortality and shorter lengths of stay, the effects were markedly smaller than those observed for nursing staffing. Each additional patient per nurse is associated with 12% higher odds of in-hospital mortality compared with a 10% change in SEP-1 adherence associated with only a 5% change in in-hospital mortality. Higher SEP-1 scores were also associated with shorter lengths of stay, but staffing had more than twice as large an effect on shorter lengths of stay, even when accounting for hospitals’ SEP-1 scores. Moreover, the effect of staffing was large and significant in terms of 60-day mortality and readmissions, while the SEP-1 scores revealed no association.
So, how does this relate to the prior NYS studies? They emphasized that adherence to the sepsis protocols in the first 3 hours was important. So how does that relate to nursing staffing? Our June 6, 2017 Patient Safety Tip of the Week “NYS Mandate for Sepsis Protocol Works” also noted a study (Peltan 2017) that showed a relationship between adherence to protocols and how busy the emergency departments are. They found that patients received antibiotics within three hours in 83 percent of cases in uncrowded ERs, but only 72 percent of the time when the ER was crowded (exceeded the ERs’ licensed beds). Such might reflect nursing staffing ratios in the ER.
But the Lasater study used nursing staffing ratios on med/surg units, not the ER. Nurses on the med/surg units would be more likely to be involved in the 6-hour bundle, which included fluid administration, vasopressors for refractory hypotension, and reassessment of serum lactate levels. But there is another important consideration. The original New York State studies reported only the relationship of mortality to the timing of the first dose of antibiotics. But it turns out that the subsequent administration of antibiotics may also be important. Another study (Leisman 2017) found that major second antibiotic dose delays were common. They observed an association between major second dose delay and increased mortality, length of stay, and mechanical ventilation requirement. In fact, in their multivariable analysis, major delay was associated with a 61% increased odds of hospital mortality. Interestingly, they found that major delays in second doses were paradoxically more frequent for patients receiving compliant initial care. It’s quite conceivable that better nurse:patient ratios on the med/surg units might reduce such delays in administration of the second antibiotic dose.
Whatever the actual reasons, the Lasater study suggests that better nurse:patient ratios are beneficial for outcomes in patients with sepsis. That shouldn’t be surprising, since there have been a number of studies showing reduced patient mortality, in general, when there are fewer patients per nurse (see the list of our prior columns on nursing staffing below). However, we’ll reiterate a point we make in almost each of those columns – the nurse:patient ratio is likely less important that the actual nurse workload, which is more difficult to quantitate.
The Lasater study is a valuable addition to the growing body of evidence linking patient outcomes to nursing staffing.
Some of our other columns on nursing workload and missed nursing care/care left undone:
November 26, 2013 “Missed Care: New Opportunities?”
May 9, 2017 “Missed Nursing Care and Mortality Risk”
March 6, 2018 “Nurse Workload and Mortality”
May 29, 2018 “More on Nursing Workload and Patient Safety”
October 2018 “Nurse Staffing Legislative Efforts”
February 2019 “Nurse Staffing, Workload, Missed Care, Mortality”
July 2019 “HAI’s and Nurse Staffing”
September 1, 2020 “NY State and Nurse Staffing Issues”
February 9, 2021 “Nursing Burnout”
Our other columns on sepsis:
References:
NYSDOH (New York State Department of Health). New York State report on sepsis care improvement initiative: hospital quality performance. March 2017 https://www.health.ny.gov/press/reports/docs/2015_sepsis_care_improvement_initiative.pdf
Seymour CW, Gesten F, Prescott HC, et al. Time to Treatment and Mortality during Mandated Emergency Care for Sepsis. NEJM 2017; Online First May 23, 2017
http://www.nejm.org/doi/full/10.1056/NEJMoa1703058?query=featured_home
Lasater KB, Sloane DM, McHughMD, et al. Evaluation of hospital nurse-to-patient staffing ratios and sepsis bundles on patient outcomes. American Journal of Infection Control 2020; Published online December 10, 2020
https://www.sciencedirect.com/science/article/pii/S0196655320310385
Peltan ID, Bledsoe JR, Oniki TA, et al. Increasing ED Workload Is Associated with Delayed Antibiotic Initiation for Sepsis. Abstract 5505. 2017 American Thoracic Society International Conference. Presented May 21, 2017
http://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2017.195.1_MeetingAbstracts.A1155
Leisman D, Huang V, Zhou Q, et al. Delayed Second Dose Antibiotics for Patients Admitted From the Emergency Department With Sepsis: Prevalence, Risk Factors, and Outcomes. Critical Care Medicine 2017; 45(6): 956-965, June 2017
Print “Nursing Staffing and Sepsis Outcomes”
March 30, 2021
Need for Better Antibiotic Stewardship
Inappropriate use of antimicrobials remains problematic from a number of perspectives. It gives rise to bacterial antibiotic resistance, allergies, complications like diarrhea and C. difficile infections, and it can be expensive.
Two recent publications highlight the need for better antimicrobial stewardship. On the inpatient side, Magill et al. (Magill 2021) used data from 192 US hospitals participating in the CDC’s Emerging Infections Program (EIP) surveillance network to evaluate the appropriateness of antimicrobial use for hospitalized patients treated for community-acquired pneumonia (CAP) or urinary tract infection (UTI) present at admission or for patients who had received fluoroquinolone or intravenous vancomycin treatment. Overall, treatment was unsupported for 55.9% of patients, including 27.3% who received vancomycin, 46.6% who received fluoroquinolones, 76.8% with a diagnosis of UTI, and 79.5% with a diagnosis of CAP. Common reasons for unsupported use included long duration, antimicrobial selection that deviated from guidelines, absence of documented signs or symptoms of infection, and lack of microbiologic evidence of infection.
A report by the Pew Charitable Trusts (Pew 2021) used the same data and an expert panel set to national targets to improve prescribing.
For community-acquired pneumonia (CAP) the expert panel concluded that medically justifiable exceptions to the treatment guidelines occur in about 10% of all CAP cases (eg. when a patient has a particularly severe CAP infection or may need additional antibiotic therapies because of secondary complications). The experts therefore determined that 90% of the inappropriate use should be eliminated. They also recommended there be focus on ensuring the appropriate duration of treatment.
Similarly, for urinary tract infections, the experts estimated that in about 10% of UTI cases, circumstances such as secondary complications or severe infections may allow for exceptions to the treatment recommendations. The panel therefore recommended a national target to reduce inappropriate UTI prescribing by 90%.
For fluoroquinolone use, the expert panel set a target of a 95% reduction in this use, which allows room for rare exception events. They recommend that, given the high risks of toxicity and adverse events associated with fluoroquinolone use, alternative and equally effective antibiotic agents should always be favored over fluoroquinolones when available.
Vancomycin should be used only when necessary, and treatment guidelines recommend close monitoring of dosing to avoid dangerous side effects. The expert panel set a target of a 95% reduction in unsupported use of vancomycin.
The Pew report notes that these recommendations should be applied to the adult population and did not make recommendations for the pediatric population.
The report goes on to describe antibiotic stewardship programs, noting that there is no “one-size-fits-all” approach to antibiotic stewardship. Hospitals vary in terms of size, patient population, needs, and resources. To address these differences, the CDC created two guides, “The Core Elements of Hospital Antibiotic Stewardship Programs” and “Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals” that describe a wide variety of interventions that hospitals can tailor to meet their own needs.
Things aren’t any better on the outpatient side either. A study of outpatient antibiotic prescribing using data from a US commercial insurance database found that 23.2% of prescriptions were inappropriate, 35.5% were potentially appropriate, and 28.5% were not associated with a recent diagnosis code (Chua 2019). Approximately 1 in 7 enrollees filled at least one inappropriate antibiotic prescription in 2016.
And another study in a Medicaid population (Fischer 2020) showed that large fractions of antibiotic prescriptions are filled without evidence of infection-related diagnoses or accompanying clinician visits. The authors found 55 percent of antibiotic prescriptions were for clinician visits with an infection-related diagnosis, but 17 percent were for clinician visits without an infection-related diagnosis, and 28 percent were not associated with a visit. The authors suggest that current ambulatory antibiotic stewardship policies miss about half of antibiotic prescribing.
Another study (Tribble 2020) looked at inappropriate antibiotic prescribing in children’s hospitals. The researchers found that 35.0% of children had ≥ 1 active antibiotic order. Among those receiving antibiotics for infectious use, 25.9% were prescribed ≥ 1 suboptimal antibiotic, and 21.0% of antibiotic orders prescribed for infectious use were considered suboptimal. Most common reasons for inappropriate use were bug–drug mismatch (27.7%), surgical prophylaxis > 24 hours (17.7%), overly broad empiric therapy (11.2%), and unnecessary treatment (11.0%). The majority of recommended modifications were to stop (44.7%) or narrow (19.7%) the drug. Of significance is that 46.1% of suboptimal use was not captured by current antibiotic stewardship practices.
One group of patients receiving inappropriate antibiotics in an ambulatory setting are older adults (Pulia 2020). Pulia et al. identified multiple factors contributing to inappropriate antibiotic use in this setting. One theme was diagnostic uncertainty and associated concern for potential deterioration resulting in hospital admission or death, especially the concern for progression of UTI’s or other bacterial infections to sepsis. These concerns often led to a lower threshold to initiate antibiotics without a clear indication, preferential use of broad-spectrum agents, longer treatment courses, and more frequent hospital referrals for initiation of intravenous antibiotics. Other contributing factors included time pressures and patient demands.
Pulia et al. note that studies in ambulatory care settings have found that the following interventions show promise in improving antibiotic stewardship:
The article goes on to discuss antibiotic prescribing in other venues, such as the emergency department, urgent and retail care clinics, and telemedicine visits.
Another factor influencing inappropriate antibiotic prescribing is patients’ prior care experiences. Shi et al. (Shi 2020) used data from a national US insurer to identify patients <65 years old with an index acute respiratory illness (ARI) during an urgent care center visit. They were able to determine provider prescribing rates as well. In the year after the index ARI visit, patients seen by the highest-prescribing clinicians received more ARI antibiotics compared to those seen by the lowest-prescribing clinicians. Interestingly, the increase in antibiotics was also observed among the patients’ spouses.
And we often forget about dental practices. Dentists actually prescribe about 10% of all outpatient antibiotics and unnecessary dental prophylaxis may be associated with serious adverse effects (Gross 2019, Suda 2019). Up to 80% of antibiotics prescribed prophylactically prior to dental procedures may be unnecessary. Gross et al. found that, even though antibiotic prophylaxis is prescribed for a short duration (≤2 days), it is not without risk. They found that 3.8% of unnecessary prescriptions were associated with an antibiotic-related adverse event. And, since most antibiotic-related adverse events are diagnosed in medical settings, dentists may not be aware of these adverse effects.
Hopefully, you’ve upgraded your antimicrobial stewardship programs in keeping with last year’s CMS mandate.
Incorporating “the 4 moments of antibiotic decision making” into clinical practice is recommended as a way to reduce inappropriate antibiotic prescribing (Tamma 2019). The 4 “moments” are:
Note that an Australian hospital adopted a stewardship program based on the “5 Moments of Antimicrobial Prescribing” (Ghizzone 2019). The “5 Moments” included:
The CDC does acknowledge that some progress has been made in antibiotic stewardship. A CDC report found that the number of hospitals that reported having an antibiotic stewardship program meeting all seven of CDC’s Core Elements of Hospital Antibiotic Stewardship Programs almost doubled from 2014 to 2017 (CDC 2019). (The seven core elements are leadership commitment, accountability, drug expertise, action, tracking, reporting and education.) Of the 4,992 acute care hospitals responding to the 2017 National Healthcare Safety Network (NHSN) Annual Hospital Survey, 3,816 (76.4%) reported uptake of all seven Core Elements. They attributed this increase to a number of factors, including new accreditation requirements for hospitals.
But the report also identified the following opportunities to improve antibiotic prescribing:
The CDC report has links to many useful resources for antibiotic stewardship.
The Pulia article mentioned above (Pulia 2020) noted that clinical decision support was sometimes of help as an antibiotic stewardship tool. Another study from the UK (Gulliford 2019) evaluated an antimicrobial stewardship intervention comprised a brief training webinar, automated monthly feedback reports of antibiotic prescribing, and electronic decision support tools to inform appropriate prescribing. Compared to usual care, electronically delivered interventions, integrated into practice workflow, resulted in moderate reductions of antibiotic prescribing for respiratory tract infections in adults. There was no evidence of effect for children younger than 15 or people aged 85 years and older. Importantly, there was no evidence of an increase in serious bacterial complications.
Goss et al. (Goss 2020) evaluated an indication‐based clinical decision support tool to improve antibiotic prescribing in the emergency department for skin and soft tissue infections, respiratory infections, and urinary infections. For those conditions, selection rate of a guideline‐approved antibiotic for a given indication improved from 67.1% to 72.2%. When duration of therapy is included as a criterion, selection of a guideline‐approved antibiotic was lower and improved from 24.7% to 31.4%, highlighting that duration of therapy is often missing at the time of prescribing. The most substantial improvements were seen for pneumonia and pyelonephritis with an increase from 87.9% to 97.5% and 62.8% to 82.6%, respectively. They conclude that antibiotic prescribing can be improved both at the drug and duration of therapy level using a non‐interruptive and indication based‐clinical decision support approach. They note that incorporation of duration of therapy guidelines into the antibiotic prescribing process is needed.
All these studies show that we still have lots of opportunities to improve our antimicrobial stewardship programs. CDC’s two guides, “The Core Elements of Hospital Antibiotic Stewardship Programs” and “Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals” are great resources to help you improve your antimicrobial stewardship programs. The 2019 CDC report (CDC 2019) also has links to some good resources.
Some of our prior columns on antibiotic stewardship:
References:
Magill SS, O’Leary E, Ray SM, et al. Assessment of the Appropriateness of Antimicrobial Use in US Hospitals. JAMA Netw Open 2021; 4(3): e212007
The Pew Charitable Trusts. Health Experts Establish Targets to Improve Hospital Antibiotic Prescribing. National data shows inappropriate prescribing, opportunities for improvements. Report March 19, 2021
CDC. The Core Elements of Hospital Antibiotic Stewardship Programs. Page last reviewed: March 19, 2021
https://www.cdc.gov/antibiotic-use/core-elements/hospital.html
CDC. Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals. Page last reviewed: February 6, 2020
https://www.cdc.gov/antibiotic-use/core-elements/small-critical.html
Chua K-P. Appropriateness of outpatient antibiotic prescribing among privately insured US patients: ICD-10-CM based cross sectional study. BMJ 2019; 364 :k5092
https://www.bmj.com/content/364/bmj.k5092
Fischer MA, Mahesri M, Lii J, Linder JA. Non-Infection-Related And Non-Visit-Based Antibiotic Prescribing Is Common Among Medicaid Patients. Health Affairs 2020; 39(2): 280-288
https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2019.00545?journalCode=hlthaff
Tribble AC, Lee BR, Flett KB, et al.on behalf of the SHARPS Collaborative. Appropriateness of Antibiotic Prescribing in U.S. Children’s Hospitals: A National Point Prevalence Survey, Clinical Infectious Diseases 2020; 71(8):, e226–e234
Pulia MS, Keller SC, Crnich CJ, et al. Antibiotic Stewardship for Older Adults in Ambulatory Care Settings: Addressing an Unmet Challenge. J Am Geriatr Soc 2020; 68(2): 244-249
https://onlinelibrary.wiley.com/doi/10.1111/jgs.16256
Shi Z, Barnett ML, Jena AB, et al, Association of a clinician’s antibiotic prescribing rate with patients’ future likelihood of seeking care and receipt of antibiotics, Clinical Infectious Diseases 2020; ciaa1173 Published 10 August 2020
https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1173/5890453
Gross AE, Suda KJ, et al. Abstract 1895 - SHEA Featured Oral Abstract: Serious Antibiotic-Related Adverse Effects Following Unnecessary Dental Prophylaxis in the United States. SHEA 2019 October 4, 2019
https://www.eventscribe.com/2019/IDWeek/fsPopup.asp?Mode=presInfo&PresentationID=582703
Suda KJ, Calip GS, Zhou J, et al. Assessment of the Appropriateness of Antibiotic Prescriptions for Infection Prophylaxis Before Dental Procedures, 2011 to 2015. JAMA Netw Open 2019; 2(5): e193909 May 31, 2019
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2734798
Tamma PD, Miller MA, Cosgrove SE. Rethinking How Antibiotics Are Prescribed. Incorporating the 4 Moments of Antibiotic Decision Making Into Clinical Practice. JAMA 2019; 321(2): 139-140
https://jamanetwork.com/journals/jama/article-abstract/2719862
Ghizzone M. ‘5 Moments of Antimicrobial Prescribing’ metric increases prescribing appropriateness. Helio Infectious Disease 2019; August 20, 2019
CDC. Antibiotic Use in the United States, 2018 Update: Progress and Opportunities. Atlanta, GA: US Department of Health and Human Services, CDC; 2019
https://www.cdc.gov/antibiotic-use/stewardship-report/pdf/stewardship-report-2018-508.pdf
Gulliford M C, Prevost A T, Charlton J, et al. Effectiveness and safety of electronically delivered prescribing feedback and decision support on antibiotic use for respiratory illness in primary care: REDUCE cluster randomised trial. BMJ 2019; 364: l236
https://www.bmj.com/content/364/bmj.l236
Goss FR, Bookman K, Baron M, et al. Improved antibiotic prescribing using indication‐based clinical decision support in the emergency department. JACEP Open 2020; 1-8
https://onlinelibrary.wiley.com/doi/full/10.1002/emp2.12029
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July 27, 2021
July 20, 2021
FDA Warning: Magnets in Consumer Electronics May Affect Medical Devices
July 13, 2021
The Skinny on Rapid Response Teams
July 6, 2021
Tip of the Week on Vacation
June 29, 2021
June 22, 2021
Remotely Monitoring Suicidal Patients in Non-Behavioral Health Areas
June 15, 2021
What’s Happened to Your Patient Safety Walk Rounds?
June 8, 2021
Cut OR Traffic to Cut Surgical Site Infections
June 1, 2021
Stronger Magnets, More MRI Safety Concerns
May 25, 2021
Yes, Radiologists Have Handoffs, Too
May 18, 2021
Medical Overuse Is Not Just An Economic Problem
May 11, 2021
How Are Alerts in Ambulatory CPOE Doing?
May 4, 2021
More 10x Dose Errors in Pediatrics
April 27, 2021
Errors Common During Thrombolysis for Acute Ischemic Stroke
April 20, 2021
Taser “Slip and Capture Error” Again!
April 13, 2021
Incidental Findings – What’s Your Strategy?
April 6, 2021
March 30, 2021
Need for Better Antibiotic Stewardship
March 23, 2021
Nursing Staffing and Sepsis Outcomes
March 16, 2021
Sleep Program Successfully Reduces Delirium
March 9, 2021
Update: Disclosure and Apology: How to Do It
March 2, 2021
Barriers to Timely Catheter Removal
February 23, 2021
February 16, 2021
New Methods for QTc Monitoring
February 9, 2021
February 2, 2021
MGH Protocols Reduce Risk of Self-Harm in ED
January 26, 2021
This Freezer Accident May Cost Lives
January 19, 2021
Technology to Identify Fatigue?
January 12, 2021
January 5, 2021
Dilaudid/HYDROmorphone Still Problematic
December 29, 2019
Tip of the Week on Vacation
December 22, 2019
Tip of the Week on Vacation
December 15, 2020
Our Perennial Pre-Holiday Warning: “Be Careful Out There!”
December 8, 2020
Maternal Mortality: Looking in All the Wrong Places?
December 1, 2020
An Early Warning System and Response System That Work
November 24, 2020
November 17, 2020
A Picture Is Worth a Thousand Words
November 10, 2020
November 3, 2020
Reminder: Infant Abduction Risk
October 27, 2020
Conflicting Studies on Technology to Reduce RSI’s
October 20, 2020
More on Post-operative Risks for Patients with OSA
October 13, 2020
October 6, 2020
Successfully Reducing Opioid-Related Adverse Events
September 29, 2020
September 22, 2020
VA RCA’s: Suicide Risks Vary by Site
September 15, 2020
September 8, 2020
Follow Up on Tests Pending at Discharge
September 1, 2020
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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