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January 4, 2022
Spin or Not: A Useful Secondary Finding in a Study
We ended 2021 with our December 21, 2021 Patient Safety Tip of the Week “Spinning Misinformation” discussing how publications often “spin” a study to show a positive result when the primary outcome was not met. Often, the authors do a post-hoc analysis and find a subgroup that seemed to have a benefit from the drug or procedure that was being studied. Such post-hoc analyses should be hypothesis-generating and lead to a randomized controlled trial in that subgroup population.
But sometimes a study that fails to meet its primary outcome may have another finding that was not even a secondary outcome parameter yet is clinically important. Case in point: a study just published in JAMA Internal Medicine. Najafi and colleagues (Najafi 2021) sought to see if an intervention promoting sleep would prevent delirium in hospitalized patients. Our many columns on diagnosis, prevention, and management of delirium (listed below) have emphasized that one of the factors contributing to development of delirium is lack of sleep or disruption of the normal sleep/waking cycle. We’ve also done many columns on promoting sleep in hospitalized patients and noted that waking the patients at night to take unnecessary vital signs is a major impediment to good sleep.
The Najafi study was a randomized controlled trial (RCT) on almost 1700 non-ICU patients on a general medical service at a tertiary care academic medical center. The intervention was a clinical decision support notification that informed the physician if the patient had a high likelihood of nighttime vital signs within the reference ranges based on a logistic regression model that used real-time patient data as input. The notification provided the physician an opportunity to discontinue measure of nighttime vital signs.
Results showed no significant difference between groups in the primary outcome, delirium incidence (11% in the intervention group vs 13% in the usual care group). But the study did show that nighttime vital signs can be reasonably safely discontinued in patients identified by their real-time data analysis tool. There was a significant decrease in the mean number of nighttime vital sign checks (0.97 in the intervention group vs 1.41 in the control group; P < .001) with no increase in intensive care unit transfers (5% in both groups) or code blue alarms (0.2% vs 0.9%; P = .07).
A secondary outcome, patient satisfaction with sleep was assessed by answers to the question on the HCAPS survey: “How often was the area around your room quiet at night?”. But postdischarge HCAPS surveys were completed by only 5% of the patients and revealed no significant difference for this issue.
In our August 6, 2013 Patient Safety Tip of the Week “Let Me Sleep!” and several of our other columns on promoting sleep in the hospital we have pointed out that patients’ sleep is often interrupted by blood drawing and/or taking vital signs and often there is no coordination between those doing either. And we’ve noted that we often fail to assess whether those nocturnal vital signs were even necessary. Rather, we often reflexly enter orders such as “Vital signs every 6 hours” without considering that such orders mean a patient will likely be wakened for such assessments. Don’t get us wrong – patients who are unstable do need to be wakened to take vital signs. And some patients, such as head trauma patients or patients with some neurological emergencies, also need to be wakened in order to assess level of arousal. But a substantial number of inpatients don’t need to be wakened for vital signs at night. The Najafi study showed that their algorithm predicting which patients were likely to have stable vital signs at night was, indeed, useful.
But their study also showed that some habits are hard to break. Physicians did not have to heed the clinical decision support notification. Some may have disagreed with the recommendation. But others may have simply ignored it. In fact, physicians did not order SPV (sleep promotion vitals) 40% of the time. Moreover, the SPV order, which would be carried out by the bedside patient-care assistant or nurse, was not carried out on 35% of the encounter-nights. The authors postulate that busy patient-care assistants and nurses may check vital signs out of habit without noticing that the order has changed for some of the patients. The authors also point out that other interruptions to sleep, such as phlebotomy, room cleaning, noise from another patient, etc., were not precluded by the SPV order. We’ll add that we often order medications in a manner that requires the patient to be wakened at night.
Does the negative primary outcome (failure to reduce delirium incidence) mean we should not consider avoidance of nocturnal vital signs in our delirium prevention programs? Of course not. Note that Najafi study did not include an assessment of delirium risk on all patients. The average age of the patients was only 53, likely meaning that older patients who are at greater risk of delirium were likely underrepresented in the study. The authors note that a study of their intervention on an acute geriatric unit might better assess its value in preventing delirium. Also, we note that some of the other risk factors for delirium might preclude use of the SPV order. And note that our March 16, 2021 Patient Safety Tip of the Week “Sleep Program Successfully Reduces Delirium” highlighted a study which showed a structured sleep promotion program successfully reduced the occurrence of delirium on a medical oncology unit and a surgical spine unit (Gode 2021).
But use of the Najafi predictive algorithm could still be applied to most patients. The editorial accompanying the Najafi study (Cho 2021) notes that the algorithms predicted normal nighttime vital signs 84% of the time and abnormal vital signs 70% of the time, “thereby alleviating cognitive burden to the clinician about vital sign stability and reducing alert fatigue from inappropriate notifications. By including a prompt to change vital sign orders, they also made it easy for physicians to change to a schedule that would not interfere with sleep.”
So, are we (and the authors of the study) spinning results of a study that did not meet its primary outcome? Perhaps. But it does mesh with a commonsense approach to do away with our age-old practice of ordering vital signs to be taken at night without thinking about their actual necessity. We like the introduction of the predictive algorithm used by Najafi et al. and the clinical decision support notification. The latter would be considered non-interruptive since it did not require an action or explanation from the clinician. Risking alert fatigue, perhaps requiring a response to the CDS notification would improve upon the substantial number of times clinicians did not comply with the suggested action.
We often do a disservice to our patients by practices that interrupt their natural sleep unnecessarily. This study is a step in the right direction.
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”
March 16, 2021 “Sleep Program Successfully Reduces Delirium”
Some of our prior columns on delirium assessment and management:
References:
Najafi N, Robinson A, Pletcher MJ, Patel S. Effectiveness of an Analytics-Based Intervention for Reducing Sleep Interruption in Hospitalized Patients: A Randomized Clinical Trial. JAMA Intern Med 2021; Published online December 28, 2021
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2787642
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
Cho HJ, Katz M. A Good Night’s Sleep in the Hospital. JAMA Intern Med 2021; Published online December 28, 2021
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2787646
Print “Spin or Not: A Useful Secondary Finding in a Study”
January 11, 2022
Documenting Distractions in the OR
We’ve done numerous columns on the occurrence and impact of distractions in the OR and other healthcare venues (see the full list below). And we’ve also done a number of columns on the use of video recording in the OR as a mechanism to identify various patient safety risks, among which distractions play a prominent role.
A recent pilot study used Operating Room Black Box (ORBB) technology to observe 25 patients undergoing total laparoscopic hysterectomy between May 2019 and February 2020 at a Canadian tertiary care academic hospital (Nensi 2021).
“Cognitive” distractions included time pressure and device absence or malfunction, each in 48% of the cases, and non-case-related conversations in 64% of cases. But perhaps the most striking finding was a median of 262 “auditory” distractions per case. “Auditory” distractions included :
Put in perspective, door opening occurred once every 1.8 minutes and a noise-related auditory distraction occurred on average once every 60 seconds.
Overall, there was a median of 3 safety threats identified per case and at least one error was identified in 11/25 cases (44%), even though only 2 actual adverse events occurred. A total of 23 errors were noted, with at least one error was identified in 11 (44%) cases. The majority of errors were related to unexpected bleeding, either during the ligation of the uterine arteries or during the colpotomy. All of these instances were rectified with no resultant adverse events. Only two intraoperative adverse events were noted among the 25 cases (both instances were injuries to the bladder with a sharp instrument secondary to inadequate visualization). But there was a median of 3 threats identified per case, with inadequate visualization noted 34 times in 18 different cases, loss of pneumoperitoneum identified nine times in nine different cases, tool failure identified 18 times in 12 cases, and technical threats (i.e., risk of injury or adverse event due to actions of the surgeon) identified 14 times in 12 cases.
The researchers also observed non-technical skills for surgeons, nurses, and anesthetists. The vast majority of observations for all three groups were positive. The most positive observations were for situational awareness and leadership among the surgical team and communication and teamwork among the nursing/scrub technician and anesthesia teams. The most common negative observation for the surgical team was in setting/providing and maintaining standards, and all 13 negative observations were related to a lack of maintaining sterile technique. There were no negative observations noted for the nursing/scrub technician or anesthesia teams.
The researchers were also able to determine valuable details about total procedure duration and duration of each procedure step from the ORBB. The authors note that these details allow for the identification of steps that have the potential to cause the most time delay.
We are struck by the number of door openings per case (median 89 per case, averaging once every 1.8 minutes). We’ve actually done multiple columns on door opening in the OR (see full list below). While our focus has mostly been on the impact of door opening and OR foot traffic on infection control issues, the distractions caused by such can obviously also impact team performance during surgery. Our prior columns discuss ways to reduce unnecessary door opening and OR foot traffic. But most facilities have no idea how often such events occur or why they occur. The only way to begin addressing that issue is to collect actual data on the frequency of and reasons for such door opening. Use of video and audio recordings such as those in the ORBB setup is a good way to capture at least some of that data. It may not always capture the reasons for the door opening, so you may need an additional way to capture the reasons. If you find staff are opening the door to obtain additional equipment or supplies, that becomes an important part of planning either for individual cases or for stocking frequently needed items in the OR itself.
One way to reduce distractions due to absent or malfunctioning equipment is to make better use of both pre-op “huddles” and post-op debriefings. The pre-op huddles help ensure that necessary equipment will be available for the case. Post-op debriefings should discuss, among other things, problems that occurred with a particular piece of equipment. We continue to see instances where an instrument or piece of equipment did not function properly, only to hear that it had also malfunctioned during a prior case.
Conversations not related to the case are more difficult to eliminate. However, simply making staff aware of how often they are participating in such conversations might have an impact. Bergstrom et al. (Bergström 2018) found that audio-video recording during laparoscopic surgery in a Swedish study reduced irrelevant conversations in the OR. Irrelevant conversation time fell from 4.2% of surgical time to 1.4% when both audio and video recordings were made.
Cellphones in the OR have been a frequent cause of distractions. It’s not just cellphones ringing with incoming calls. More often, it is the alert that sounds when a text message is received on the phone. And it is not just the sound that is a distraction. The surgeon (or other healthcare worker) receiving that text message is often distracted by concerns about what the content of the text message might be. Our February 23, 2021 Patient Safety Tip of the Week “Cellphones and the OR” discusses the pros and cons of allowing cellphones in the OR. Our personal recommendation is not to allow cellphones in the OR. They can either be “parked” with OR clerical or management staff, or the healthcare workers simply need to ensure that paging systems know they are in the OR and deliver any absolutely necessary messages via the OR clerical staff. At any rate, every facility should have a policy on cellphone use in the OR.
Our March 17, 2020 Patient Safety Tip of the Week “Video Recording in the OR” highlighted how Northwell Health used video/audio recording to help improve OR teamwork and communication (Cheney 2020). They use it proactively to improve coordination in the OR. They have used it to identify distractions and interruptions and, especially, people entering and leaving the room. But it’s also used in their quality improvement and educational activities. Interestingly, Northwell has also used it to cover some of the aspects we discuss during post-procedure “debriefings”. For example, they might identify issues related to equipment availability or other problems with equipment or supplies.
One major impediment to more widespread use of video recording in the OR or elsewhere has been the fear that some surgeons and hospital attorneys have about “discoverability”. Northwell Health made it clear that the recordings were being used to improve quality and safety, but it did more to alleviate those concerns. First, everything is de-identified. The cameras even blur the faces of the OR team! And second, the focus is to look at system issues, not individual human issues. They also note that de-identifying the data also protects patient privacy.
In our March 17, 2015 Patient Safety Tip of the Week “Distractions in the OR” we recommended video/audio recording in the OR with subsequent playback for all parties in a constructive fashion so they can see how well (or not so well) they communicated and how distractions and interruptions interfered with their communications. Jung et al. reported their first-year analysis of the operating room black box study (Jung 2020). They conducted a prospective cohort study in 132 consecutive patients undergoing elective laparoscopic general surgery at an academic hospital during the first year after the definite implementation of a multiport data capture system called the OR Black Box to identify intraoperative errors, events, and distractions. They found that auditory distractions occurred a median of 138 times per case and that at least 1 cognitive distraction appeared in 64% of cases. Medians of 20 errors and 8 events were identified per case. Both errors and events occurred often in dissection and reconstruction phases of operation. Technical skills of residents were lower than those of the attending surgeon.
We’ve often recommended doing video/audio recording in the OR and then play it back for all parties in a constructive fashion so they can see how well (or not so well) they communicated and how distractions or interruptions interfered with their communications. Teodor Grantcharov, MD, creator of surgery's 'black box' and senior author on the Jung study, noted in an interview that they’ve shown that coaching surgical teams with black box data reduces the rate of surgical errors by 50%. (Grantcharov 2019). He notes that the black box captures video and audio recordings of everything that happens in the OR, including what steps were completed, how well the team communicated, and includes physiological information from patient monitors and the physical environment of the room, including ambient temperature, decibel levels and how many times the door is opened. He notes that it's designed to identify near misses, understand the risks involved and proactively mitigate those risks. But he notes this isn't just about targeting errors and near-misses. They use the data to study successes in great detail, so they can identify and reinforce positive behaviors. They use the information to coach surgical teams on ways to improve their performances, using the analogy of how sports teams study videos and stats to enhance how they play.
Video/audio recording in the OR is a good way to identify potential distractions and interruptions. But it clearly also provides a lot of information that can be used constructively to improve a variety of OR issues. We remained puzzled that more organizations have not adopted its use.
Prior Patient Safety Tips of the Week dealing with interruptions and distractions:
Our prior columns focusing on surgical OR foot traffic and door opening:
Some of our previous columns discussing video recording:
September 23, 2008 “Checklists and Wrong Site Surgery”
December 6, 2010 “More Tips to Prevent Wrong-Site Surgery”
November 2011 “Restricted Housestaff Work Hours and Patient Handoffs”
March 2012 “Smile...You’re on Candid Camera!”
August 27, 2013 “Lessons on Wrong-Site Surgery”
March 17, 2015 “Distractions in the OR”
November 24, 2015 “Door Opening and Foot Traffic in the OR”
March 2019 “Another Use for Video Recording”
March 17, 2020 “Video Recording in the OR”
References:
Nensi A, Palter V, Reed C, et al. Utilizing the Operating Room Black Box to Characterize Intraoperative Delays, Distractions, and Threats in the Gynecology Operating Room: A Pilot Study. Cureus 2021; 13(7): e16218
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8341265/
Bergström, H., Larsson, L. & Stenberg, E. Audio-video recording during laparoscopic surgery reduces irrelevant conversation between surgeons: a cohort study. BMC Surg 2018; 18: 92
https://bmcsurg.biomedcentral.com/articles/10.1186/s12893-018-0428-x#citeas
Cheney C. Northwell Pioneers Black Boxes in Operating Rooms for Performance Improvement. HealthLeaders Media 2020; February 26, 2020
Jung JJ, Jüni P, Lebovic G, GrantcharovT. First-year Analysis of the Operating Room Black Box Study. Annals of Surgery 2020; 271(1): 122-127
Grantcharov T. Real-time OR Monitoring Leads to Better, Safer Surgery. QA with Teodor Grantcharov, MD, PhD, FACS, creator of surgery's 'black box' and believer that data doesn't lie. Outpatient Surgery Magazine 2019; April 3, 2019
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January 18, 2022
AORN on Specimen Management
Errors in specimen management can have a devastating impact to patients. Such errors can involve mixed-up specimens and lost specimens. A lost surgical specimen is likely irreplaceable, and a patient may be left in limbo with regard to diagnosis and management.
Our November 24, 2020 Patient Safety Tip of the Week “Specimen Management” discussed the AORN “Guideline on specimen management”. A new AORN Journal article discusses the guideline recommendations for intraoperative team communication, transfer from the sterile field, containment, transport, and quality (Link 2021).
Multiple steps are involved in management of OR specimens. Link notes that perioperative personnel prepare for specimen collection, review the surgeon’s orders, and then handle, contain, label, and transport the specimen. She further notes there are multiple specimen handovers, involving numerous individuals (eg, surgeon, scrub person, RN circulator, relief personnel, transporter, pathology laboratory personnel).
Intraoperative team communication plays an important role in preventing specimen errors. Link notes that communication failures during the handover process involving relief personnel in the OR can contribute to specimen management errors,
One of our recommendations is echoed by the AORN guideline: during the preprocedural briefing (aka the “preop huddle”), the perioperative team discuss any specimens that the surgeon plans to obtain during the procedure. Remember, we have also recommended that your surgical booking forms include a checkbox indicating whether surgical specimens are expected. And we also think it is a good idea to include anticipated specimens as an item on your Surgical Safety Checklist or whatever type checklist you use for your surgical timeouts.
When there is a handover (eg. relief personnel coming on), AORN recommends the handover review specimens that are anticipated but not yet excised, and the name, type, and location of surgical specimens that are on the sterile field, in the room, or have been sent to pathology laboratory. AORN suggests that read-back be used during that handover.
In addition, the post-procedure debriefing should be used to verify that the surgeon collected all anticipated specimens and that required labels and requisition forms contain the correct identification information. Personnel should verify that all specimens are secured in appropriately sized containers with the required amount of fixative when needed. Personnel also should verify that no specimens remain on the sterile field.
While we agree discussion of specimens should be part of the post-procedure debriefing, we think an important step may be missed. We’ve seen cases where one or more of multiple specimens get tossed into a waste basket or get lost in a body cavity. Hence, we recommend that a “specimen count” be made part of the “surgical count”, just like you are counting sponges.
Link goes on to discuss transfer and containment of specimens. The guideline recommends that, to minimize specimen compromise on the sterile field, the scrub person should handle the specimen as little as possible, keep the specimen moist and contained, and place it in a safe area on the sterile field. Link notes that specimen errors that can occur during transfer from the sterile field include loss of integrity from lack of moisture, contamination from airborne sources, and specimen loss from insufficient labeling or inadequate containment before transfer.
AORN recommends that personnel transfer specimens from the sterile field as soon as possible, using sterile technique and standard precautions and avoiding crushing, twisting, or compacting. Personnel should ensure that the specimen containers are large enough to fully contain the specimen and that there is adequate fixative (when applicable) to contact all surfaces. AORN recommends that perioperative personnel contain and label specimens immediately upon receipt from the sterile field.
AORN recommends the specimen transport process be standardized via input from an interdisciplinary team of personnel involved in transporting surgical specimens to the
pathology laboratory.
AORN recommends that, when possible, personnel should transport specimens to the receiving department immediately and the receiving department personnel should verify receipt of the specimen. (Our comment: if you had done a proper FMEA to see what could go wrong, you would add to your process a contingency for what to do when specimens are collected “after hours” when lab personnel may be absent.)
Transporting the specimen(s) immediately and not “batching” is important in our mind. Batching, where multiple specimens are placed in one location and taken to the lab only once a certain volume is accumulated, likely increases the risks that a specimen will be misplaced, lost, or mixed up with another specimen.
AORN recommends that specimen management be a regular part of your quality management processes. Personnel should monitor the rate, type, phase (eg, preanalytical), contributing factors, and level of harm for specimen errors and near-miss events. These should be used to identify trends and provide data for quality initiatives.
Link then goes on to describe a scenario at a community hospital, where an interdisciplinary team reviewing incident reports identifies that several specimen-related errors occurred during the preanalytical phase. The majority of the specimens come from the hospital’s multispecialty outpatient surgery department, and all of the specimens required special handling. Moreover, the pathology laboratory is in another building and some specimens require transport to laboratories away from the hospital campus.
The scenario is very complicated and we encourage you to read it in its entirety. But it includes nuances that undoubtedly occur at other facilities as well. Examples included:
The article also contains a nice table showing a sample FMEA (failure modes and effects analysis) showing the steps involved in breast specimen management, what could go wrong and why at each step, probabilities of both occurrence (frequency) and detection, and potential severity of outcome of such failures.
Our November 24, 2020 Patient Safety Tip of the Week “Specimen Management” also included more detail about issues such as specimen labeling and problems with containers and preservatives. It highlighted the excellent review of 648 surgical specimen events by Steelman et al. (Steelman 2016). It also included some “pearls” from Temple University Hospital (AORN 2019): One of the problems they identified was that there was not an adequate space to collect and label specimens in the OR. So, they created a mobile specimen table for each OR. Each table is labeled with a brightly colored decal to identify it as the dedicated specimen table. The decal on the table also outlines their standardized specimen management protocol. The tables receive appropriate cleaning and can be wheeled from near the sterile field to the computer workstation for documentation. They also created the position of “specimen nurse” That nurse works 9AM to 3PM, when most specimens are generated. The specimen nurse responds to the text alerts by going into the OR when specimens are being generated to ensure proper labeling and documentation, provide guidance to the staff members, and solicit their feedback on the process. The specimen nurse also meets the transporter when the transporter is removing specimens from the OR refrigerator and taking them to the laboratory. Together, the transporter and specimen nurse verify correct labeling on the specimen containers and laboratory requisitions.
That column also described another quality improvement project at the Hospital of the University of Pennsylvania (Morris 2020) which did process mapping and found there were over 30 steps in specimen management and that there was variation depending on the specimen type, time of day, day of the week, surgical specialty, and OR location. Lack of interoperability between the lab IT system and the nursing IT system precluded use of computer-generated specimen labels that could reduce the risk for misspellings, illegibility, and transcription errors that often occur with handwritten labels. That precluded implementation of barcode technology for surgical specimen labeling. So perioperative nurses had to type the specimen description into the electronic record plus handwrite the specimen’s description on both the label used on the specimen container and the label used in the logbook hand over to laboratory staff members.
Chain of custody is critical in specimen management. They identified that labeling is the first step in establishing the chain of custody. Read-back is key to confirming specimen identification verbally and documenting it accurately, legibly, and completely. That must include patient identifiers, source of the specimen, and laterality and avoid using any confusing abbreviations. Read-back may also need to include spelling out specific words to avoid errors.
One key process change that they (and other hospitals) made was to have the specimen handed over directly to a pathology clerk in the OR. That eliminates the need for the RN circulator to leave the OR during the procedure to deliver the specimen to a refrigerator. It also ensures the chain of custody is maintained and provides the opportunity to engage the surgeon and identify any inaccuracies in specimen description or testing requests immediately before the specimen leaves the OR. Moreover, it eliminates the need for a logbook and the subsequent duplication of illegible documentation. We like that idea since it potentially eliminates at least one handoff. In our November 16, 2010 Patient Safety Tip of the Week “Lost Lab Specimens” we described how a pathology department decided that it would take ownership of the transport process from the OR to the lab. That effectively reduced the number of handoffs. Handoffs are always opportunities for errors to occur so anything that reduces the number of handoffs generally improves safety.
And we always come back to a question we ask over and over – why can’t hospitals be more like your local supermarket or Amazon? They track everything in detail, using a variety of tracking technologies. The postal service and companies like UPS and FedEx scan barcodes at every step along the way to track where your packages are at any point in time. Hospitals should be able to do the same. Yu et al. (Yu 2019) investigated the use of barcode technology in a Taiwanese hospital as a method to improve the accuracy of pathology specimen labeling and patient safety. They found fewer specimen management errors after implementation of the barcode system and found that use of this technology significantly enhanced nurses’ satisfaction. Our June 16, 2020 Patient Safety Tip of the Week “Tracking Technologies” discussed multiple technologies used for tracking things.
Of course, all facilities should review any RCA’s (root cause analyses) of incidents involving specimen mishaps. But performing a FMEA on specimen management should be a primary focus at all facilities, regardless of whether you have already had a specimen mishap. You’ll be surprised at the number of potential vulnerabilities you identify.
Some of our other columns on errors related to laboratory studies:
References:
Link T. Guidelines in Practice: Specimen Management. AORN Journal 2021; 114(5): 443-455
https://aornjournal.onlinelibrary.wiley.com/action/showCitFormats?doi=10.1002%2Faorn.13518
Steelman VM, Williams TL, Szekendi MK, et al. Surgical specimen management: a descriptive study of 648 adverse events and near Misses. Arch Pathol Lab Med. 2016; 140(12): 1390-1396
AORN. Reducing Specimen Errors. AORN Journal 2019; 109(4): 496-499
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12658
Morris AM. A Multidisciplinary Approach for Reducing Lost Surgical Specimens. AORN Journal 2020; 111(6): 691-698
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13061
Yu M-H, Lee T-T, Mills ME. The Effect of Barcode Technology Use on Pathology Specimen Labeling Errors. AORN Journal 2019; 109(2): 183-191 First Published:29 January 2019
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12585
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January 25, 2022
More on Dental Patient Safety Issues
It’s been a while since we did a column on dental patient safety. In today’s column we have some old issues and some new ones.
We thought we had covered just about every conceivable problem in our March 15, 2016 Patient Safety Tip of the Week “Dental Patient Safety”. But here’s a new one on us: amaurosis following injection of inferior alveolar nerve! Yes, blindness following just that injection! Fortunately, it was temporary, though it was very disturbing. A 37-year-old patient was administered an inferior alveolar nerve block for a root canal procedure (Pandey 2018, Murphy 2018). Immediately after the administration of local anesthesia, the patient reported complete loss of vision. The patient recovered completely after 15 minutes.
The dentist used a 30-mm-long, 28-gauge aspirating syringe to administer anesthesia (1.8-mL lidocaine with 1:100,000 adrenaline) targeting the right inferior alveolar nerve. Aspiration was negative. Immediately after receiving the anesthesia, the patient reported blurred vision in his right eye. About 30 seconds later, he said that his vision was completely gone. Attempting to read a nearby letter chart, his vision was normal in his left eye, but he had no vision in his right eye. Other than this, the patient showed no physical symptoms or changes in speech or mental acuity.
Actually, there have been a handful of similar cases reported in the literature. The blindness usually resolved in about 20-30 minutes. Only two case reports have described permanent vision loss. The theory is that the local anesthetic is accidentally injected under pressure into the inferior alveolar artery, which lies adjacent to the inferior alveolar nerve, and backflow carries it into the maxillary artery and middle meningeal artery, where it’s eventually delivered into the central artery of the retina, resulting in vision and/or temporary vision loss. And needle size may be important. A smaller-gauge needle is more likely to be deflected when passing through the tissues.
Here's another new one – a swallowed dental needle. A 29-year-old woman presented with throat pain that had lasted 12 days (Mohammed 2020). She attributed onset of the pain to a meal containing duck, assuming she had swallowed a duck bone. A primary health care center prescribed painkillers and antibiotics for pharyngitis, but no imaging was performed. Her pain persisted over the following few days and now a soft tissue neck x-ray was taken, which revealed a foreign body. Referral to an ENT department was made. X-ray showed a long, thin, smooth, and impinged foreign body at the C5–C6 level, lying lateral to the esophagus, confirmed by computed tomography to be 3 cm in length. Neck exploration and removal of foreign body under general anesthesia was performed. The foreign body was identified as an injection needle with a bore and a pinged proximal end suggesting that it had broken from its base.
When the needle was shown to the patient, she recalled having a dental procedure in which she was given an intraoral local anesthesia, the same day she had consumed the duck meal. No official records of the denial procedure were able to be reviewed. Although there is no definitive evidence that the foreign body originated from this dental procedure, it appears to be the most logical explanation. The authors performed a simulation, using a 23-gauge needle and bending it as if preparing for an intraoral injection. The removed foreign body was almost identical to the needle that was used in the simulation.
The authors cite a prior publication of a case series of 16 patients with broken local anesthetic needles (Pogrel 2009). Of the 16 needle fractures, 15 occurred in connection with an inferior alveolar nerve block, and one occurred in connection with a posterior superior alveolar block. Of the 16 fractures, 13 involved a 30-gauge needle. Five of the patients involved were younger than 10 years, who often moved suddenly and violently as the dentist gave the injection. Porgrel concluded that dentists should avoid burying any needle up to the hub (so as to ensure the possibility of immediately retrieving the needle intraorally), avoid using 30-gauge needles to administer inferior alveolar nerve blocks and avoid bending the needle before inserting it.
Likewise, Mohammed et al. conclude that “the majority of intraoral needle breakages occur during the administration of inferior alveolar nerve blocks or a root canal wash, and in patients who suddenly move as the injection is being administered. Needles should not be bent prior to injections being administered. Additionally, needles should not be inserted up to their base to help facilitate their retrieval if an accidental breakage occurs intraorally. Clinicians performing intraoral procedures should also use larger-gauge needles when possible, as smaller needles are more susceptible to accidental breakages.”
Another intraoral injection incident raises an old issue – misidentification of injected solutions. Hiremath et al. (Hiremath 2016) reported a case where 2% chlorhexidine gluconate was mistaken for an anesthetic solution and infiltrated into the buccal vestibule during routine root canal treatment. The patient experienced pain and a burning sensation over the injected area shortly after injection and developed swelling with extraoral redness over the right cheek area. The patient was immediately administered dexamethasone intramuscularly, and was prescribed antibiotics, analgesics, and antihistamines. The patient complained of a loss of sensation over the right cheek by the 15th day. The swelling reduced gradually over a period of 15 days and reversal of sensation was attained after 35 days. This incident brings to mind the devastating incidents where chlorhexidine antiseptic solution was mistaken for radiographic contrast media and injected intra-arterially (see our June 23, 2015 Patient Safety Tip of the Week “Again! Mistaking Antiseptic Solution for Radiographic Contrast”). Hiremath et al. note other reports of unintended injection of formalin, hydrogen peroxide, and sodium hypochlorite instead of local anesthetic, citing various reasons such as the widespread practice of using local anesthetic in bottles, reuse of local anesthetic bottles in dental operatory, nonavailability of professionally trained or educated dental assistants, and improper handling techniques.
In our June 23, 2015 Patient Safety Tip of the Week “Again! Mistaking Antiseptic Solution for Radiographic Contrast” we noted that incidents involving injection of the wrong substance when two look-alike substances are in proximity and are unlabeled have occurred in multiple venues (angiography suites, cath labs, dialysis units, hospital OR’s, ambulatory surgery centers, and others). Most hospitals have really focused on enforcing the “no unlabeled syringes” and “no unlabeled solutions in basins” in the OR. But it may be that those other areas (radiology suites, cath labs, dialysis units, etc.) may be even more vulnerable to such incidents. Add the dental office to that list. And don’t forget bedside procedures. They are probably even more prone to such mistakes. Clear, colorless skin antiseptics might be easily confused with substances intended for spinal injection or injection into other body cavity.
There’s always that tendency to think “I know what’s in that basin” and “there will only be one basin”. Then another basin shows up with a substance similar in appearance, often unbeknownst to the person who will actually be injecting. There’s also a tendency to keep the skin antiseptics around “just in case we might need them”. Once you’ve prepped the skin, the antiseptic agent should be removed from the sterile field (and even adjacent stands). There is usually easy access to these in most venues if you really do need them again so there is little reason to “keep them around just in case you might need them again”. And remember that the alcohol-based antiseptics are also flammable so you especially don’t want them sitting around where they might get ignited by a heat source during a procedure.
In our experience, dental offices have been very good at complying with recommendations once they reopened during the COVID-19 pandemic. But the dental community continues to look for ways to further improve COVID-19 safety. A recent study (Roy 2021) suggests that adding a small amount of hydrogen peroxide to the water in ultrasonic scalers used to clean teeth might help mitigate the risk of spreading airborne diseases, including COVID-19, in dental environments. The study did not test droplets that actually contained virus but looked at droplet size and the spread of droplets after the addition of low-dose hydrogen peroxide. Further research is necessary to determine whether this has practical application in dental practice.
Incidents like the swallowed needle and the incorrect injections would be examples of events we think should never occur. We have lists of never events for The Joint Commission and most state health departments. What about dental never events? An expert panel used the Delphi method to come up with candidate items for a dental never event list (Ensaldo-Carrasco 2018). They identified candidate events in several categories:
During routine assessment:
During the preoperative stage:
During the intraoperative stage:
During the postoperative stage:
One of our best tools for avoiding never events or other adverse events is use of checklists. We’ve done multiple columns on the WHO surgical safety checklist. So why not one for dental procedures? Using the Delphi technique, another expert panel assessed and adapted the WHO Surgical Safety Checklist to develop “The WHO Dental Safe Surgery Checklist” (Wright 2018). See the article itself for a sample of the checklist. Another surgical safety checklist was developed for dental implants (Bidra 2017). Use of that checklist 8 prosthodontic residents was assessed in 120 dental implant surgeries encompassing 262 implants over an academic year cycle (Remiszewski 2019). There was a 100% compliance rate for surgical safety checklist completion by all 8 prosthodontic residents. Within the checklists, the rate of incomplete responses or omissions was 2.4%.
Now back to an old issue – safety of sedation/anesthesia for dental procedures. In 2019 the American Academy of Pediatrics (AAP) published a joint statement with the American Academy of Pediatric Dentistry (AAPD) updating the AAP sedation guideline (Cote 2019). We discussed the updated guideline in our September 2019 What's New in the Patient Safety World column “New Guidelines for Pediatric Dental Sedation”. Perhaps the most important item in the guideline is a requirement that such procedures be done in the presence of two qualified individuals. That means that the dentist or oral surgeon performing the dental or oral surgery procedure cannot be the individual administering and monitoring the sedation. This ensures that individuals are attending to one primary task and not involved in two different tasks simultaneously. The guideline also clarifies that deep sedation or general anesthesia must be administered by a qualified anesthesia provider (a physician anesthesiologist, certified registered nurse anesthetist, dentist anesthesiologist or second oral surgeon). Because children commonly pass from an intended sedation level to an unintended deeper level of sedation, practitioners of sedation must have the skills to rescue the patient from a deeper level than that intended for the procedure. The ability to rescue means that practitioners must be able to recognize the various levels of sedation and have the skills and age- and size-appropriate equipment necessary to provide appropriate cardiopulmonary support if needed.
Cote et al. (Cote 2021), in a letter to the editor of the APSF Newsletter, raise concerns about some subsequent actions. They note that, in response to the 2016 joint AAP/AAPD guideline on sedation, the oral surgery community developed a Dental Anesthesia Assistant National Certification Examination (DAANCE) with no pre-examination educational requirements. It consists of 36 hours of internet study. A person with no practical or clinical experience could be certified to be the independent observer based on just 36 hours of internet reading. It would not require hands-on medical training to deal with a life-threatening emergency. Cote et al. note that the 2019 sedation guideline now states explicitly that deep sedation/anesthesia must be provided by an anesthesia-trained provider and the operating dentist must be currently PALS-certified to assist the anesthesia provider with an adverse event. This provides a ready-to-respond sedation team on site. The single-provider-operator-anesthetist oral surgery model must be replaced with the multiple-provider-sedation-care team AAP/AAPD model.
Persistent disagreements over safety of dental anesthesia and the single provider issue were also discussed in Anesthesiology News (Vlessides 2020), with comments on laws passed in California. One solution would be to do all cases requiring sedation/anesthesia in a hospital-based setting. But another option raised is using mobile anesthesiologists for dental procedures (Seidman 2021).
Issues related to training and qualifications pertinent to pediatric dental sedation were front and center in a 2018 trial about the tragic 2014 death of a 3-year-old during a dental procedure. Though the dentist was ultimately found not guilty of criminal manslaughter in the case, there were some striking revelations (KHON News 2018). The three sedating medications were administered by the receptionist, who was not licensed in any way, and the dentist was not present at the time they were administered. The dentist testified that she “was unable to force a pipe down Finley’s throat to provide her with necessary oxygen as the toddler’s muscles had contracted” (Schladebeck 2018).
We think the 2019 updated AAP/AAPD sedation guideline (Cote 2019) has all the safety requirements we would want in place if one of our own grandchildren were having sedation for a dental procedure. We’d want one person focusing on the procedure and another focusing on monitoring the sedation/anesthesia. And we’d certainly want to know that one or both are certified in PALS (note that most states that certify dentists for sedation in the office include a requirement for certification in PALS or equivalent).
Our July 2019 What's New in the Patient Safety World column “Dental Prescribing Called Into Question” discussed possible overprescribing of opioid analgesics and antibiotics by dentists. Regarding antibiotics, the major issue is whether prophylactic antibiotics should be given prior to invasive dental procedures in patients with prosthetic joints. Following a systematic review (Sollecito 2015), the ADA (American Dental Association) issued a guideline, last updated this January (ADA 2022). The guideline states “In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection.” Unfortunately, the orthopedic specialty societies have not endorsed that guideline and have largely left decisions up to individual orthopedic surgeons. As a result, some patients with prosthetic joints get prophylactic antibiotics prior to invasive dental procedures, while others don’t. (Note that f”or patients with a history of complications associated with their joint replacement surgery who are undergoing dental procedures that include gingival manipulation or mucosal incision, prophylactic antibiotics should only be considered after consultation with the patient and orthopedic surgeon; in cases where antibiotics are deemed necessary, it is most appropriate that the orthopedic surgeon recommend the appropriate antibiotic regimen and, when reasonable, write the prescription.”). Now a study just published in JAMA Open Network (Thornhill 2022) analyzed late prosthetic joint infections in England (where prophylactic antibiotics are not recommended). The researchers found no temporal association between late prosthetic joint infections and invasive dental procedures. The authors conclude that their findings suggest that there is no rationale to administer antibiotic prophylaxis before invasive dental procedures in patients with prosthetic joints. They state “The continuing use of antibiotic prophylaxis represents a large and unnecessary financial burden on individuals and the health care system as well as an unnecessary risk to patients, from adverse drug reactions, and society, owing to the potential development of antibiotic resistant bacteria, and should cease.” It remains to be seen whether this additional research finding changes current practices.
Lastly, what do dentists do when there is an adverse event to one (or more) of their patients? Our regular readers know we have long been strong advocates for disclosure and apology. The American Dental Association, and its ADA Council on Advocacy for Access and Prevention, is offering a free webinar "Communicating With Patients When Things Go Wrong In Dentistry" on two separate dates: January 19, 2022 at noon CST and February 1, 2022 at 6:30 p.m. CST (ADA 2022). The webinar highlights the importance of transparency and focuses on best practices for communicating with patients who have been involved in a “near miss” or adverse incident, while being able to describe how these skills reinforce the key behaviors needed to support patients and drive learning in dentistry. Since an incident in a dental practice could conceivably affect multiple patients (for example, exposure to contaminated instruments), you may also want to go back to our June 16, 2009 Patient Safety Tip of the Week “Disclosing Errors That Affect Multiple Patients”.
We’re delighted to see that our dental colleagues have taken a serious interest in patient safety.
Some of our previous columns on dental patient safety issues:
March 15, 2016 “Dental Patient Safety”
August 2016 “Guideline Update for Pediatric Sedation”
March 28, 2017 “More Issues with Dental Sedation/Anesthesia”
August 8, 2017 “Sedation for Pediatric MRI Rising”
November 28, 2017 “More on Dental Sedation/Anesthesia Safety”
July 2019 “Dental Prescribing Called Into Question”
September 2019 “New Guidelines for Pediatric Dental Sedation”
May 5, 2020 “COVID-19 and the Dental Office”
References:
Pandey R, Dixit, N, Kixit KK, et al. Amaurosis, an Unusual Complication Secondary to Inferior Alveolar Nerve Anesthesia: A Case Report and Literature Review. Journal of Endodontics 2018; 44(9): 1442-1444
https://www.jendodon.com/article/S0099-2399(18)30318-2/abstract
Murphy J. Rare complication causes temporary blindness during routine procedure. MDLinx 2018; October 30, 2018
Mohammed H, Shallik N, Barsoum M, et al. Dental needle foreign body in the neck: a case report. J Dent Anesth Pain Med 2020; 20(2): 83-87
https://jdapm.org/DOIx.php?id=10.17245/jdapm.2020.20.2.83
Pogrel MA. Broken local anesthetic needles: a case series of 16patients, with recommendations. J Am Dent Assoc 2009; 140: 1517-1522
https://jada.ada.org/article/S0002-8177(14)61556-7/fulltext
Hiremath H, Agarwal RS, Patni P, Chauhan S. Accidental injection of 2% chlorhexidine gluconate instead of an anesthetic agent: A case report. J Conserv Dent 2016; 19(1): 106-108
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4760004/
Roy T, Damoulakis G, Komperda J, et al. Effect of H2O2 Antiseptic on Dispersal of Cavitation-Induced Microdroplets. J Dent Res. 2021; 100(11): 1258-1264
https://journals.sagepub.com/eprint/WBYNS2EXMN6NY5TGXQTY/full
Ensaldo-Carrasco E, Carson-Stevens A, Cresswell K, et al. Developing agreement on never events in primary care dentistry: an international eDelphi study, BDJ 2018; 224: 733-740
https://www.nature.com/articles/sj.bdj.2018.351
Wright S. Ucer TC, Crofts G. The adaption and implementation of the WHO surgical safety checklist for dental procedures. British Dental Journal 2018; 225(8), 727-729
https://www.nature.com/articles/sj.bdj.2018.861
Bidra AS. Surgical safety checklist for dental implant and related surgeries. J Prosthet Dent 2017; 118: 442-444
https://www.thejpd.org/article/S0022-3913(17)30157-9/fulltext
Remiszewski DP, Bidra AS. Implementation of a surgical safety checklist for dental implant surgeries in a prosthodontics residency program. J Prosthet Dent. 2019; 122(4): 371-375
https://www.thejpd.org/article/S0022-3913(19)30200-8/fulltext
Coté CJ, Wilson S. Guidelines for monitoring and management of pediatric patients before, during, and after sedation. Pediatrics 2019; 143: 6 e1-31
Cote CJ, Brown R, Kaplan A. The Single-Provider-Operator-Anesthetist Model for Dental Deep Sedation/Anesthesia: A Major Safety Issue for Children. APSF Newsletter 2021; 36(1): 33 February 2021
Vlessides M. Disagreements Persist Over Safety of Dental Anesthesia. Anesthesiology News 2020; September 28, 2020 (and Moore LJ. A Response to the Single Provider Issue in Dental Anesthesia)
Seidman P. How Mobile Anesthesiologists Can Help Provide Hospital-Grade Care for Dental Procedures. Anesthesiology News 2021; May 19, 2021
KHON News. Receptionist who administered drugs that killed Finley Boyle testifies . KHON News 2018; November 7, 2018
https://www.khon2.com/news/receptionist-who-administered-drugs-that-killed-finley-boyle-testifies/
Schladebeck J. Former dentist accused of causing death of 3-year-old patient breaks down on the stand. New York Daily News 2018; November 17, 2018
Sollecito TP, Abt E, Lockhart PB, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints. The Journal of the American Dental Association 2015; 146(1): 11-16.e8
https://jada.ada.org/article/S0002-8177(14)00019-1/fulltext
ADA (American Dental Association). Antibiotic Prophylaxis Prior to Dental Procedures.
Last uupdated January 5, 2022
Thornhill MH, Crum A, Rex S, et al. Analysis of Prosthetic Joint Infections Following Invasive Dental Procedures in England. JAMA Netw Open 2022; 5(1): e2142987
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2788219
ADA (American Dental Association). Communicating with patients when things go wrong in dentistry. Free webinar to highlight importance of transparency. ADA 2022; January 7, 2022
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February 1, 2022
Perioperative Delirium is Not Just Postoperative
We’ve done many columns on postoperative delirium. But delirium in the perioperative period is not limited to the postoperative period. It may also occur pre-operatively or during the operative period itself. A recent study from the Pennsylvania Patient Safety Authority (Taylor 2021) discussed delirium in these other periopeative periods and its association with anesthetics and adjunct agents.
The researchers queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) database for event reports to identify bouts of delirium/ agitation associated with anesthetics and/or adjunct agents that occurred during the pre-, intra-, or postoperative period and identified 97 event reports from 63 healthcare facilities over a two-year period. While postoperative delirium was most commonly seen (84%), delirium was also seen preoperatively in 8% and intraoperatively in 8%.
An example of a pre-operative bout of delirium/agitation was a patient scheduled for an esophagogastroduodenoscopy (EGD who was given propofol in preparation for the procedure. He became extremely agitated and thrashed on the stretcher. The physician then canceled the procedure and recommended the patient have the procedure completed at a hospital and under general anesthesia.
Delirium/agitation during the intra- or postoperative period, when compared with preoperative, was related with more severe patient behavior, injuries, and additional healthcare services or monitoring. During the intra- and postoperative periods, patients had dangerous behavior themes described in 75% and 74% of the event reports, respectively, compared with only 25% in the preoperative events. Only 13% of the preoperative events had an injury while 38% and 43% of the intra- and postoperative events had an injury, respectively.
The adverse behaviors encountered in the reports included combativeness, agitation, kicking, thrashing, exiting or attempting to exit from a bed or table, and disruption, removal or attempted removal of apparatus such as intravenous lines, catheters, oxygen, and nasogastric tubes. Some of the specific patient injuries included abrasions, bruises, lacerations, or skin tears, prolapse/dehiscence, tooth loss, asphyxiation, hematoma, and progressive ischemia.
While those with a preoperative bout of delirium or agitation suffered minimal harm, 88% of the preoperative events resulted in a procedure cancellation.
But the PPSA study showed delirium has an impact beyond the patient. 54% of reports mentioned at least one unique behavior that represented an immediate and high risk of staff harm. Five reports explicitly stated that staff were physically impacted and possibly harmed. For example, in one of those 5 events a staff member was kicked in the face. There may be numerous effects on staff and the healthcare organization. It could lead to difficulty completing an ongoing procedure and procedures scheduled for the remainder of the day. They also point out here could be longer-term implications of a staff injury, which may include the following: staff pain and suffering, burnout, service line or department loss of productivity due to understaffing, and financial burden for both the injured staff and organization. They conclude that the potential impact of perioperative delirium/agitation on patients, staff, and the organization would justify a robust intervention package to reduce risk.
Speaking of interventions, a recent German study (Deeken 2021) showed that a multifaceted multidisciplinary prevention intervention reduced postoperative delirium occurrence and days with delirium in older patients undergoing different elective surgical procedures but not cardiac procedures. First, structured delirium education was provided to clinical caregivers at each site. Then, the study delirium prevention team assessed patient delirium risk factors and symptoms daily. Prevention was tailored to individual patient needs and could include: cognitive, motor, and sensory stimulation; meal companionship; accompaniment during diagnostic procedures; stress relaxation; and sleep promotion. Overall, the intervention reduced postoperative delirium incidence (odds ratio, 0.87, P = .02) and percentage of days with delirium (intervention 5.3% vs. control 6.9%; P = .03). The effect was significant in patients undergoing orthopedic or abdominal surgery (odds ratio 0.59, P = .047) but not cardiac surgery (odds ratio, 1.18).
In the PPSA article, Taylor et al. offer an intervention package, based on previous literature and ongoing practices at VA Pittsburgh Healthcare System, that staff should critically review and consider implementing at their facility. That includes screening for risk factors for delirium ahead of the procedure and meeting with the high-risk patient and family to identify triggers that may influence or exacerbate a bout of delirium/agitation. It involves adjusting the environment, preparing the bed or table to prevent patient harm, and securing any IV access to minimize the risk of dislodging. Choice of anesthetics/sedating agents is discussed, especially avoiding benzodiazepines. The package also suggests considering either dexmedetomidine and/or ketamine (keep in mind the evidence for use of these agents is still weak in our opinion). During the surgical/procedural timeout, staff should be reminded that the patient is at high risk for delirium. As case concludes, staff should call ahead to recovery room/post-anesthesia care unit (PACU) to initiate intervention protocol for emergence of the high-risk patient. Postoperatively, triggers should be avoided, and the bed should be configured to help avoid patient injury should agitation occur (eg. padding on siderails). A debriefing meeting with patient and family should be considered, as well as a debriefing meeting among staff. The authors add the caveat that this proposed intervention package as a whole has not been experimentally evaluated for efficacy nor the risk of unintended consequences.
See our many prior columns (listed below) for discussion of other nonpharmacological interventions to prevent and manage delirium (eg. the HELP program, ABCDE bundle, etc.).
The PPSA study focused on delirium or agitation in relation to anesthetics and adjunct agents. The role of anesthetic agents and adjuncts during surgery in causing post-op delirium has long been debated. A recent study (Li 2021) found that, in patients aged 65 years and older undergoing hip fracture surgery, regional anesthesia without sedation did not significantly reduce the incidence of postoperative delirium compared with general anesthesia. The study was a randomized, allocation-concealed but open-label, multicenter clinical trial of 950 patients, aged 65 years and older, with or without preexisting dementia, and a fragility hip fracture requiring surgical repair from 9 university teaching hospitals in China. Postoperative delirium occurred in 6.2% in the regional anesthesia group vs 5.1% in the general anesthesia group.
But there are certainly questions about that study. The incidence of delirium was way lower than we would expect in an elderly population undergoing surgical repair for hip fracture. The accompanying editorial (Avidan 2021) also comments on that disparity and notes some methodological issues with the Li study. But it does point out that other recent studies have also failed to show that general anesthesia is associated with higher rates of post-op delirium than spinal or regional anesthesia. REGAIN trial (Regional vs General Anesthesia for Promoting Independence after Hip Fracture) was a randomized trial to evaluate spinal anesthesia as compared with general anesthesia in over 1600 previously ambulatory patients 50 years of age or older who were undergoing surgery for hip fracture at 46 US and Canadian hospitals (Neuman 2021). There was no significant difference in the incidence of postoperative delirium, which occurred in 20.5% of patients in the spinal anesthesia group vs 19.7% in the general anesthesia group.
Delirium is a common complication of elderly patients having surgery or acutely hospitalized for a variety of medical conditions. It is associated with a number of poor patient outcomes, such as longer hospital stays, increased risk of post-hospital institutionalization, and accelerated cognitive decline. Patients with delirium have an increased mortality rate, not only for the current hospitalization but also in the year following the episode of delirium. Diwell et al. (Diwell 2018) looked at mortality rates for patients with full-blown delirium and those with “subsyndromal” delirium. The hazard ratio (HR) for full-blown delirium was 2.31, and for “subsyndromal” delirium 1.26. After adjustment the HR remained significant for the full-blown syndrome but not for the “subsyndromal” delirium. Two items from the CAM (Confusion Assessment Method) assessment tool were significantly associated with mortality following adjustment: acute onset and disorganized thinking. The authors conclude there is a dose-response relationship between mortality and delirium, with full-blown delirium having the greatest risk and “subsyndromal” delirium having intermediate risk.
Our understanding of the underlying mechanisms of delirium is yet evolving. Its underlying mechanism is undoubtedly multifactorial and we know of many contributing factors and precipitating factors. The reason(s) for the increased mortality are also unclear. As Diwell et al. point out, some of the features of delirium itself may lead to complications that could lead to death. For example, falls are common in those with full-blown delirium and those with hypoactive delirium might be more prone to aspiration pneumonia. On the other hand, the nature of the underlying medical conditions that led to delirium may play a big role in mortality risk. Our personal view is that delirium is a state of reduced physiologic “reserve”, much like the reduced physiologic reserve seen in frailty which is a frequent accompaniment of delirium. That reduced reserve may render patients more vulnerable both acutely and in the longer run.
While delirium thus has prognostic significance, we still need to take steps to prevent its occurrence and manage it as best we can when it does occur.
Some of our prior columns on delirium assessment and management:
References:
Taylor MA, Pileggi W. Perioperative Delirium/Agitation Associated With the Use of Anesthetics and/or Adjunct Agents: A Study of Patient Behaviors, Injuries, and Interventions to Mitigate Risk. Patient Safety 2021; 3(4): 16-27 published December 2021
https://patientsafetyj.com/index.php/patientsaf/article/view/periop-delirium/printer-friendly
Deeken F, Sánchez A, Rapp MA, et al. Outcomes of a Delirium Prevention Program in Older Persons After Elective Surgery: A Stepped-Wedge Cluster Randomized Clinical Trial. JAMA Surg 2021; Published online December 15, 2021
https://jamanetwork.com/journals/jamasurgery/fullarticle/2787212
Li T, Li J, Yuan L, et al. Effect of Regional vs General Anesthesia on Incidence of Postoperative Delirium in Older Patients Undergoing Hip Fracture Surgery: The RAGA Randomized Trial. JAMA 2021; Published online December 20, 2021
https://jamanetwork.com/journals/jama/fullarticle/2787494
Avidan MS, Whitlock EL, Mashour GA. General Anesthesia and Postoperative Neurocognitive Outcomes. JAMA 2021; Published online December 20, 2021
https://jamanetwork.com/journals/jama/article-abstract/2787496
Neuman MD, Feng R, Carson JL, et al. for the REGAIN Investigators. Spinal anesthesia or general anesthesia for hip surgery in older adults. N Engl J Med 2021; 385(22): 2025-2035
https://www.nejm.org/doi/10.1056/NEJMoa2113514
Diwell RA, Davis DH, Vickerstaff V, Sampson EL. Key components of the delirium syndrome and mortality: greater impact of acute change and disorganised thinking in a prospective cohort study. BMC Geriatr 2018; 18(1): 24 Published 2018 Jan 25.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5785815/
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February 8, 2022
ED to Inpatient Delays Increase Mortality
A study from England has revealed a disturbing finding regarding the relationship between long stays in emergency departments before admission to the hospital and mortality rates. Jones et al. (Jones 2022) found that delays to hospital inpatient admission for patients in excess of 5 hours from time of arrival at the ED are associated with an increase in all-cause 30-day mortality. In fact, there was a predictable dose–response effect for delays between 5 and 12 hours (accurate data were not available beyond 12 hours). For every 82 admitted patients whose time to inpatient bed transfer is delayed beyond 6 to 8 hours from time of arrival at the ED, there is one extra death.
There was a 10% increase in the SMR (standardized mortality rate) within 30 days for admitted patients remaining in the ED between 8 and 12 hours in comparison with those who leave the ED within 6 hours
Below are the adjusted absolute mortality rates as a function of time spent in the ED:
up to 4 hours 8.2%
4-6 hours 9.2%
6-8 hours 9.9%
8-12 hours 10.1%
We’ve long recognized the impact posed by delays in moving patients from the ED to inpatient beds. In our January 29, 2013 Patient Safety Tip of the Week “A Flurry of Activity on Handoffs” we noted that back in the 1990’s we realized that patients with community-acquired pneumonia at some renowned organizations were not getting their first dose of antibiotics for up to 18 hours. That, of course, was related to bottlenecks in moving patients from the ED to the floor and problems with handoffs (relating to both information transfer and transfer of responsibility for managing the patients). Fortunately, we had performance improvement projects that focused on ensuring timely administration of the antibiotics regardless of physical location of the patient.
The authors of the Jones study pose several potential explanations for their findings:
We’ll add several of our own potential explanations. Several things happen when there are long delays before patients are admitted from the ED to the inpatient services, each of which may contribute to worse patient outcomes:
Focusing on the bottleneck(s) elsewhere in the hospital is of utmost importance. Having a nursing “bed coordinator” may be useful. That individual works with the clinical teams to identify patients ready for discharge today or “likely to be ready for discharge tomorrow”. During periods of high inpatient occupancy, a “discharge lounge”, where patients simply waiting for transportation home, may make sense. Sometimes, even the simplest of problems can delay freeing up inpatient beds. We’ve seen cases where hospitals are unaware of where all their wheelchairs are located, leading to delays in moving patients out (good opportunity for some of the tracking technologies we discussed in our June 16, 2020 Patient Safety Tip of the Week “Tracking Technologies”). And we also often see cases where a patient has physically left their inpatient room but there is a delay in notification of the staff to clean the room for the next occupant.
And, in teaching hospitals, we often see teams deferring discharge orders and arrangements until completion of rounds rather than addressing those early, taking a break to do the discharge work, then reconvening for complete rounds.
One critical bottleneck we see is in opening up ICU beds. Many of the patients with long waits in the ED are awaiting ICU beds. As a hospital medical director, we’d often round with our Director of Nursing in the ICU’s in the morning. We’d routinely find patients who no longer required “intensive care”. Physicians often equate “severity” of a condition with the need for intensive care without consideration of what actual nursing care is needed. For example, a neurologist or neurosurgeon may consider a patient with a subarachnoid hemorrhage to be “critical” because of the potential for deterioration rather than recognizing that the nursing care needs for a stable patient may not be so great.
Similarly, the bottleneck may be in telemetry units. In our numerous columns on alarm fatigue, we often recommend hospitals first focus on use of telemetry. Hospitals should have policies that spell out the evidence-based indications for telemetry and make sure that the criteria for stay on a telemetry unit are complied with (both for admission to such units and continued stay on such units).
In addition to focusing on removing the bottlenecks, the most critical element needed is clear-cut transfer of responsibility and accountability to the clinical teams (both physician and nursing). While such transfer to the inpatient physician team takes some burden off the ED physician team, there may also be downsides. It is difficult to care for multiple patients when they are not all clustered or cohorted on one unit, but we’ve all had to deal from time to time with some of our patients being “boarded” in other sites. Perhaps more important is delineation of nursing responsibility and accountability. Obviously, some of the monitoring of the patient needs to be done by the nurse on location (i.e. the ED nurse). But the ED nurse and the inpatient nurse need to review any admission orders and ensure that there is clarification of who will administer medications, etc.
ED staffing patterns may occasionally contribute to the problem. Most ED’s already plan their ER staffing according to expected use, increasing staffing during the times of day when they historically see more patients. But an unexpected surge of patients in the ED may stress the system and lead to longer patient stays in the ED. Trauma centers usually have mechanisms in place to deal with the surge you might see with a multi-casualty event. But a small rural hospital may only have one ED physician working at any time.
And note that long ED wait times may have an impact not just on patients admitted to the hospital but also on patients discharged from the ED. A Canadian study (Guttmann 2011) found that presenting to an emergency department during shifts with longer waiting times, reflected in longer mean length of stay, was associated with a greater risk in the short term of death and admission to hospital in patients who are well enough to leave the department. Patients who leave without being seen were not at higher risk of short-term adverse events. Those authors felt that delays in treatment alone were not likely the cause of the adverse outcomes. Examples they gave of potential contributing factors included reluctance to order time consuming tests or consultations and shortened observation periods (both of which could increase missed diagnoses), incomplete treatment, or inadequate planning and communication of care after discharge. An increased risk of adverse events for low acuity patients in their study suggested that processes might be more likely to break down if patients are thought to be low risk. They point out that patients initially thought to be low acuity can, with careful evaluation, be discovered to have serious illnesses and require hospital admission.
Jones et al. note that several prior studies with limited numbers of patients or hospitals had also shown increased mortality in patients admitted to hospitals after long ED stays. But the Jones study used a database of over 7 million ED visits with matched hospital inpatient admissions. Note that the period of the Jones study was between April 2016 and March 2018, thus prior to the COVID-19 pandemic. It is quite likely that the surge demands on hospitals due to COVID-19 has increased delays in admissions from the ED to an even greater degree. That makes it even more important that hospitals have good systems in place to address the issues raised above.
References:
Jones S, Moulton C, Swift S, et al. Association between delays to patient admission from the emergency department and all-cause 30-day mortality. Emergency Medicine Journal 2022; Published Online First: 18 January 2022
https://emj.bmj.com/content/early/2022/01/03/emermed-2021-211572
Guttmann A, Schull MJ, Vermeulen MJ, et al. Association between waiting times and short term mortality and hospital admission after departure from emergency department: population based cohort study from Ontario, Canada. BMJ 2011; 342: d2983
https://www.bmj.com/content/342/bmj.d2983
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February 15, 2022
Wrong-Side Chest Tubes
Anderson et al. recently published an excellent comprehensive review on chest tube management (Anderson 2022). But they omitted a key essential step – ensuring that the chest tube will be inserted on the correct side. In the early 1990’s, wrong-side chest tube insertion was one of the leading “wrong site” procedures in our New York Patient Occurrence Reporting and Tracking System (NYPORTS). Failure to perform the same sort of timeout and verification process that we use in the OR is a major reason that we still see wrong-side chest tube insertions.
In our July 2014 What's New in the Patient Safety World column “Wrong-Sided Thoracenteses” we noted some factors identified from wrong-side thoracenteses that would likely also contribute to wrong-side chest tube insertions. Miller et al. (Miller 2014) reported on 14 cases of thoracenteses performed on the wrong side outside the OR setting. A resident performed the procedure in 10 of the cases and an attending performed 2. An attending was present in 6 cases and a nurse was present in just 3 cases.
The most frequent associated factor was failure to perform a timeout (12 of the 14 cases). Laterality was missing from the consent form in 10 cases and the site was not marked in 12 cases. Medical image verification was not done in 7 of the 10 cases where information was available.
They found 30 root causes in the 14 cases (average 2.1 root causes per event). These most often included communication issues, failure to follow policy or procedures, and equipment issues. In several cases, the images were not available at the time of the procedure. That is particularly problematic in today’s computerized environment. If the PACS system is down, you may not have immediate access to the images. In the old days we’d bring the actual films with us to the bedside. Today there are no films, only the images on the computer system.
The authors also note that right-left confusion is a common human error in many scenarios. They note one resident knew the pleural effusion was on the left side on the x-ray but when he went behind the patient the x-ray image in his mind reversed.
Miller et al. note a number of strategies that are helpful in preventing such events. First is formal standardization of Universal Protocol and timeouts for invasive procedures anywhere, not just in the OR. Checklists, site marking, and ultrasound localization are also useful. Learning and practicing the procedures in a simulation environment is also encouraged. Development of a culture of patient safety and good communication is also critical.
While education, training, and simulation are all important, our own approach would incorporate forcing functions or constraints, which are much more effective interventions in most solutions. There are two good ways to ensure that a timeout gets done and force all the appropriate elements to prevent a wrong-site, wrong-side, or wrong-patient procedure. One is to prevent a physician from accessing the procedure tray all alone. That is best done by requiring an order for the tray, which would require a nurse to access the tray and accompany the physician to the patient’s room (or other site where the procedure will be performed) and participate in the timeout and the procedure. Second is to include on the outside of the sterile procedure tray a checklist that must be completed prior to opening the sterile tray. That checklist, of course, would include the items typically in the Universal Protocol and timeouts (things like consent, verification of the patient, procedure, laterality including review of relevant imaging studies, etc.).
That approach is borne out by another study (Barsuk 2011) that looked at lumbar punctures, thoracenteses and paracenteses done on the medicine services at their facilities (see our June 6, 2011 Patient Safety Tip of the Week “Timeouts Outside the OR”). Analyzing their processes, they found that staff were often unaware of Universal Protocol (or perhaps unaware that it was required not just for OR procedures, but for bedside procedures as well) and that nurses were frequently never notified by physicians when their patients were undergoing such procedures. In their redesigned process the physician initiates the process by entering an order via CPOE with an anticipated time. This order would automatically populate the nurse’s alert list and provide the nurse with a timeout form and notice of a procedure-specific supply kit to procure. Only the nurse has a key to those procedure kits. This is a forcing function that forces the physician-nurse communication to take place. The nurse brings the timeout checklist and the kit to the bedside at the specified time and the nurse and physician go through the timeout procedure, which gets documented in the EMR. Compliance with Universal Protocol went from 16% before to 94% after implementation of this redesigned process.
Good chest tube management includes all the elements elegantly outlined by Anderson et al., but also begins by including these important steps prior to breaking the seal on the procedure kit.
Some of our prior columns related to wrong-site surgery:
September 23, 2008 “Checklists and Wrong Site Surgery”
June 5, 2007 “Patient Safety in Ambulatory Surgery”
July 2007 “Pennsylvania PSA: Preventing Wrong-Site Surgery”
March 11, 2008 “Lessons from Ophthalmology”
July 1, 2008 “WHO’s New Surgical Safety Checklist”
January 20, 2009 “The WHO Surgical Safety Checklist Delivers the Outcomes”
September 14, 2010 “Wrong-Site Craniotomy: Lessons Learned”
November 25, 2008 “Wrong-Site Neurosurgery”
January 19, 2010 “Timeouts and Safe Surgery”
June 8, 2010 “Surgical Safety Checklist for Cataract Surgery”
December 6, 2010 “More Tips to Prevent Wrong-Site Surgery”
June 6, 2011 “Timeouts Outside the OR”
August 2011 “New Wrong-Site Surgery Resources”
December 2011 “Novel Technique to Prevent Wrong Level Spine Surgery”
October 30, 2012 “Surgical Scheduling Errors”
January 2013 “How Frequent are Surgical Never Events?”
January 1, 2013 “Don’t Throw Away Those View Boxes Yet”
August 27, 2013 “Lessons on Wrong-Site Surgery”
September 10, 2013 “Informed Consent and Wrong-Site Surgery”
July 2014 “Wrong-Sided Thoracenteses”
March 15, 2016 “Dental Patient Safety”
May 17, 2016 “Patient Safety Issues in Cataract Surgery”
July 19, 2016 “Infants and Wrong Site Surgery”
September 13, 2016 “Vanderbilt’s Electronic Procedural Timeout”
May 2017 “Another Success for the Safe Surgery Checklist”
May 2, 2017 “Anatomy of a Wrong Procedure”
June 2017 “Another Way to Verify Checklist Compliance”
March 26, 2019 “Patient Misidentification”
May 14, 2019 “Wrong-Site Surgery and Difficult-to-Mark Sites”
May 2020 “Poor Timeout Compliance: Ring a Bell?”
September 14, 2021 “Wrong Eye Injections”
October 5, 2021 “Wrong Side Again”
November 9, 2021 “Ensuring Safe Site Surgery”
References:
Anderson D, Chen SA, Godoy LA, et al. Comprehensive Review of Chest Tube Management: A Review. JAMA Surg 2022; Published online January 26, 2022
https://jamanetwork.com/journals/jamasurgery/fullarticle/2788397
Miller KE, Mims M, Paull DE, et al. Wrong-Side Thoracentesis: Lessons Learned From Root Cause Analysis. JAMA Surg. 2014; 149(8): 774-779
https://jamanetwork.com/journals/jamasurgery/fullarticle/1879844
Barsuk JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV. Process Changes to Increase Compliance With the Universal Protocol for Bedside Procedures. Arch Intern Med. 2011; 171(10): 941-954
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/487053
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February 22, 2022
Medication Reconciliation at ICU Exit
Most studies on medication reconciliation have focused on processes at admission or discharge. But medication reconciliation is critical at every transition of care. That includes patient transfers from floor to floor, service to service, and one level of care to another. It is especially important to perform medication reconciliation when patients are transferred from intensive care units. Some medications are only indicated while a patient is in the ICU and, unfortunately, we often see patients discharged from the hospital on those medications when there is failure of medication reconciliation at the transition from the ICU to the floor. The most common examples of the latter are proton pump inhibitors (PPI’s). PPI’s are often prescribed in critically ill patients to prevent GI bleeding. But they are not intended to be continued once the patient is no longer “critical”. Yet we continue to see patients on PPI’s, sometimes for years, when they were only intended for the original ICU stay. On the other hand, some important medications that patients were taking prior to admission get discontinued while the patient is in the ICU and never get restarted after the patient leaves the ICU or the hospital.
A new systematic review and meta-analysis does focus on medication reconciliation on transition from adult intensive care settings (Bourne 2022). Bourne et al. included 17 studies, 15 of which were uncontrolled before-after studies, focusing on the interventions used and identifying both facilitators and barriers to effective deprescribing. Pooled analysis of all interventions overall reduced risk of inappropriate medication continuation both at ICU discharge (OR=0.45) and at hospital discharge (OR=0.39). Interestingly, multicomponent interventions, based on education of staff and guidelines, did not show significant difference in inappropriate medication continuation at the ICU discharge point (OR 0.5), but were very effective in increasing deprescribing outcomes on hospital discharge (OR 0.26).
The authors point out the complex nature of ICU stays, often with polypharmacy, frequent medication changes, and fragmentation of care. They note that medication errors are common in adult ICU patients at the interface of transfer to the hospital ward, with errors reported to occur in 46% to 74% of patients.
The key intervention components they found in the included studies were education of staff, medication review, guidelines, electronic transfer/hand-over checklist or letter and medicines reconciliation. Most targeted inappropriate medication continuation at transfer points.
Whereas we consider all of these to be elements of “medication reconciliation”, Bourne et al. considered medication reconciliation more narrowly and separated it out from the other interventions noted above. They found 4 studies that focused on this process, which required review and authorization by medical staff, with pharmacist medication review and advice. Other studies focused on communication at the handoff between ICU staff and the ward staff.
Participation by a clinical pharmacist was the most important facilitator, whether in the educational or review interventions. Technologies and tools that served as facilitators included autopopulation of discharge information, checklists, guidelines with supporting information, and a tailored discharge letter. Barriers included educational gaps, increased workload due to the process, patient discharge during off-hours, and short discharge time frames.
Data on actual patient outcomes, however, was limited. There was also limited information about economic considerations. The authors also noted that none of the studies included the patient and/or family in the processes, despite other studies showing engagement of patients and family being a facilitator to the provision of high-quality care for ICU patients transferring to a hospital ward.
When we use the term “deprescribing”, we are often talking about discontinuing potentially inappropriate medications (PIM’s) in the elderly patient. Ironically, a hospitalization is often a facilitator for that process. In our June 29, 2021 Patient Safety Tip of the Week “Barriers to Deprescribing” we noted a study by Edey and colleagues (Edey 2019) on pharmacist-led deprescribing rounds upon hospital discharge at a Canadian tertiary care hospital. Deprescribing rounds resulted in significantly more medications deprescribed compared to control (65% vs. 38%). The rates of readmission and emergency department visits were reduced in the arm receiving deprescribing rounds.
The Bourne systematic review shows that multicomponent interventions based on education of staff and guidelines are effective at achieving almost four times more de-prescribing of inappropriate medication by the time of patient hospital discharge and serves as a reminder of the importance of medication reconciliation at every transition of care.
Review of medications at hospital admission, discharge, and every transition of care within the hospital provide a good way to ensure that patients are on “optimal” medication regimens. Good medication reconciliation focuses not only on discontinuation of potentially inappropriate medications and reduction in polypharmacy, but also on ensuring patients are taking those medications that are indicated for the various conditions they have. In our October 19, 2010 Patient Safety Tip of the Week “Optimizing Medications in the Elderly” we noted that underutilization of appropriate drugs may also be problematic.
And, lest we forget, don’t assume the medications you discontinue actually are discontinued. Several of our prior columns (listed below) have noted that poor communication with patients, their other clinicians, and the pharmacies may result in patients continuing to receive those medications you had intended to discontinue. We’ve also noted how the electronic medical record may perpetuate use of some medications, particularly when the “copy & paste” function is used inappropriately.
Some of our previous columns on medication reconciliation:
October 23, 2007 “Medication Reconciliation Tools”
December 30, 2008 “Unintended Consequences: Is Medication Reconciliation Next?”
May 13, 2008 “Medication Reconciliation: Topical and Compounded Medications”
September 8, 2009 “Barriers to Medication Reconciliation”
August 2011 “The Amazon.com Approach to Medication Reconciliation”
January 2012 “AHRQ’s New Medication Reconciliation Tool Kit”
September 2012 “Good News on Medication Reconciliation”
October 1, 2019 “Electronic Medication Reconciliation: Glass Half Full or Half Empty?”
July 2020 “Not Following Medication Changes after Hospitalization?”
April 2021 “Anticonvulsants High Risk: How Did We Miss That?”
November 2, 2021 “Adverse Drug Events After Hospitalization”
Some of our past columns on deprescribing:
Some of our other columns on failed discontinuation of medications:
May 27, 2014 “A Gap in ePrescribing: Stopping Medications”
March 2017 “Yes! Another Voice for Medication e-Discontinuation!”
February 2018 “10 Years on the Wrong Medication”
August 28, 2018 “Thought You Discontinued That Medication? Think Again”
December 18, 2018 “Great Recommendations for e-Prescribing”
August 2019 “Including Indications for Medications: We Are Failing”
August 6, 2019 “Repeat Adverse Drug Events”
October 2021 “Tool to Prevent Discontinued Medications from Being Dispensed”
References:
Bourne RS, Jennings JK, Panagioti M, et al. Medication-related interventions to improve medication safety and patient outcomes on transition from adult intensive care settings: a systematic review and meta-analysis. BMJ Quality & Safety 2022; Published Online First: 18 January 2022
https://qualitysafety.bmj.com/content/early/2022/01/17/bmjqs-2021-013760
Edey R, Edwards N, Von Sychowski J, et al. Impact of deprescribing rounds on discharge prescriptions: an interventional trial. Int J Clin Pharm 2019; 41(1): 159-166
https://link.springer.com/article/10.1007/s11096-018-0753-2
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March 1, 2022
Including the Indication on Prescriptions
In the early 1990’s, when we first began doing “Introduction to Patient Safety” for all incoming residents in the SUNY Buffalo system, we began including a slide stressing how inclusion of indication for a medication can help reduce medication errors. We’re, of course, not the only ones calling for this simple, yet frequently overlooked, patient safety intervention. ISMP (ISMP 2010) stressed this in its guidelines for standard order sets (see our March 23, 2010 Patient Safety Tip of the Week “ISMP Guidelines for Standard Order Sets”). And Schiff et al. made a plea to incorporate indication into medication ordering in a New England Journal of Medicine piece in 2016 (Schiff 2016). And it was one of the key elements in the article by Schiff et al. (Schiff 2018) that we highlighted in our December 18, 2018 Patient Safety Tip of the Week “Great Recommendations for e-Prescribing”.
Why is it important? In our December 18, 2018 Patient Safety Tip of the Week “Great Recommendations for e-Prescribing” we gave several reasons for including the indication for a medication when entering a prescription or order for a medication. Providing the indication for a prescription is important for more than one reason. First, there are many medications that are used for treating multiple conditions. For example, beta blockers may be used in the treatment of MI, CHF, migraine, essential tremor, hypertension, etc. Knowing the reason for the initial prescription, thus, is important when decisions about discontinuation are being pondered.
Second, seeing the indication may help a pharmacist recognize when a wrong drug has been prescribed. That is especially important when LASA (“look-alike, sound-alike”) errors are made. For example, if a prescriber erroneously clicked on “Dilaudid” instead of “Dilantin” but a pharmacist saw the indication was “for seizures”, the pharmacist would recognize a problem and contact the prescriber for clarification. The same concept should be used at the time of order entry to prevent prescribing the wrong medication. In the example above, if you looked for “seizures” as an indication in a drop-down box under the erroneously chosen “Dilaudid” you’d realize you had chosen the wrong drug.
Third, seeing the indication can help avoid wrong-dosing errors. For example, we’ve discussed the methotrexate problem in multiple columns. That is when methotrexate is ordered for treating an autoimmune condition, like rheumatoid arthritis, rather than for oncologic conditions. For the former, once weekly dosing is used rather than daily dosing. So, if the pharmacist saw an order for daily methotrexate and the indication was “rheumatoid arthritis”, the pharmacist might recognize the dosing error.
Fourth, it may help even with longer term medication management. Let’s say I am doing medication reconciliation at a transition of care, or I am doing an annual “brown bag” medication review on a patient, and I see they are taking a proton pump inhibitor (PPI). Knowing whether that PPI was prescribed for GERD or whether it had been started as prophylaxis while that patient had been in an ICU would be extremely important (and many patients might not be able to answer that question themselves).
A recent review of the literature (Mercer 2021) found that including the reason for use on a prescription can help the pharmacist catch more errors, reduce the need to contact prescribers, support patient counseling, impact communication, and improve patient safety. The authors also noted that concerns about workflow, time required to enter the indication, and privacy were impediments to adding reason for use information on the prescriptions. However, they note that only 1 paper (Garada 2017) examined privacy concerns and concluded that while pharmacists and physicians were concerned about privacy, patients were not generally concerned with the privacy implications of documenting reason for use on a prescription. And one could certainly make the argument that the slight additional time required to enter the indication would be offset by the time spent on clarification phone calls with pharmacists.
Three of the studies they reviewed also noted that inclusion of reason for use is important in pharmacists’ providing accurate patient counseling. Without knowledge of the indication for a medication, a pharmacist can counsel a patient about how to take a medication and what potential side effects might occur but would be unable to discuss what beneficial effects to look for.
Mercer et al. point out that, despite the potential benefits of including indication for medication, the reason for use is not identified as a core measure included in the electronic health record in most hospital systems (Adler-Milstein 2017). Since almost all prescribing in the US today is done electronically, there is no reason for failure to include a field for the indication in CPOE and ePrescribing systems.
There is some debate as to what should be input into an “indication” field. Should it be a diagnosis? Some physicians have suggested it should be in plain language rather than medical terminology (Garada 2017). Our own recommendation is perhaps a hybrid approach. CPOE and ePrescribing systems should have drop-down lists of common reasons for ordering each medication but would also need an “other” category for entering free text if the indication is something other than the common ones presented. While we always like to avoid free text entries, you might not be able to predict what the entry might be. So, there need to be alerts for identifying mistakes in that latter circumstance. For example, in the scenario we mentioned above when the clinician mistakenly orders “Dilaudid” instead of “Dilantin”, the script for an alert would have to recognize “seizures” or “epilepsy” in the free text entered under “other”. Moreover, it would have to recognize typos, so it would have to employ natural language processing or similar tool to recognize those words. In addition, all the standing order sets in your system will need to be redone to include indications for any medications included. All CPOE and ePrescribing systems also need to have mechanisms for updating the indications in the drop-down lists when indications may change.
The concept of using plain language for patients is a good one but that would be more appropriate for inputting into a “sig:” (patient directions) field that would be applied to the label on the medication dispensed to the patient.
Equally important is the need for documenting reasons for discontinuations of medications. We discussed this in our August 2019 What's New in the Patient Safety World column “Including Indications for Medications: We Are Failing” and multiple other columns listed below. It may be important to know whether a medication was discontinued because of:
For example, I might consider prescribing a beta blocker for migraine prophylaxis and the patient tells me that he/she was once on that medication. It would be important for me to know whether it had been discontinued because it was ineffective for the initial indication (other than migraine prophylaxis) or because of an untoward side effect or true allergy.
Not only do we lack systems for documenting reasons for discontinuation, we also do a poor job in communicating when a drug has been discontinued. The columns listed below have all dealt with the issue of documenting drug discontinuation, not only to other potential prescribers for a patient, but also to pharmacies that might continue to dispense drugs that had been discontinued. And keep in mind that, even if your CPOE or ePresribing software includes a field for “reason for discontinuation” there must be a mechanism for transmitting that information to pharmacies.
Our August 2019 What's New in the Patient Safety World column “Including Indications for Medications: We Are Failing” cited a study (Salazar 2019) that found indications included in only 7.41%, of over 4 million prescriptions. We don’t know of any updated statistics since that article, but our own experience is that we are still far behind in achieving what should be a “no brainer” for patient safety.
Some of our other columns on including indication for medication orders:
March 23, 2010 “ISMP Guidelines for Standard Order Sets”
December 18, 2018 “Great Recommendations for e-Prescribing”
August 2019 “Including Indications for Medications: We Are Failing”
Some of our other columns on failed discontinuation of medications:
May 27, 2014 “A Gap in ePrescribing: Stopping Medications”
March 2017 “Yes! Another Voice for Medication e-Discontinuation!”
February 2018 “10 Years on the Wrong Medication”
August 28, 2018 “Thought You Discontinued That Medication? Think Again”
December 18, 2018 “Great Recommendations for e-Prescribing”
August 2019 “Including Indications for Medications: We Are Failing”
August 6, 2019 “Repeat Adverse Drug Events”
October 2021 “Tool to Prevent Discontinued Medications from Being Dispensed”
References:
ISMP (Institute for Safe Medication Practices). Guidelines for Standard Order Sets. January 12, 2010
https://www.ismp.org/guidelines/standard-order-sets
Schiff GD, Seoane-Vazquez E, Wright A. Incorporating indications into medication ordering—time to enter the age of reason. N Engl J Med 2016; 375(4): 306-309
https://www.nejm.org/doi/full/10.1056/NEJMp1603964
Schiff G, Mirica MM, Dhavle AA, Galanter WL, et al. A Prescription For Enhancing Electronic Prescribing Safety. Health Affairs 2018; 37(11): 1877-1883
https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2018.0725
Mercer K, Carter C, Burns C, Tennant R, Guirguis L, Grindrod K. Including the Reason for Use on Prescriptions Sent to Pharmacists: Scoping Review. JMIR Hum Factors 2021; 8(4): e22325
https://humanfactors.jmir.org/2021/4/e22325
Adler-Milstein J, Holmgren A, Kralovec P, Worzala C, Searcy T, Patel V. Electronic health record adoption in US hospitals: the emergence of a digital "advanced use" divide. J Am Med Inform Assoc 2017; 24(6): 1142-1148
http://europepmc.org/article/MED/29016973
Garada M, McLachlan AJ, Schiff GD, Lehnbom EC. What do Australian consumers, pharmacists and prescribers think about documenting indications on prescriptions and dispensed medicines labels?: A qualitative study. BMC Health Serv Res 2017; 17(1): 734
https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-017-2704-3
Salazar A, Karmiy SJ, Forsythe KJ, et al. How often do prescribers include indications in drug orders? Analysis of 4 million outpatient prescriptions. American Journal of Health-System Pharmacy 2019; 76(13): 970-979
https://academic.oup.com/ajhp/article-abstract/76/13/970/5519760?redirectedFrom=fulltext
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March 8, 2022
Update on Retained Surgical Items
Retained surgical items (RSI’s) continue to be a problem despite numerous interventions to address the issue. Weprin et al. (Weprin 2021a) point out that the landscape of RSI’s is changing. Whereas, historically, “soft” items (sponges, packing, towels, etc.) have always been the predominant RSI’s, we are seeing more and more incidents of retained “hard” items (needles, blades, instruments, guidewires, fragments). They note that the overall incidence of RSI's has remained steady, despite a decline in the incidence of soft RSI’s. They attribute the reduction in soft RSI’s to better use of OR protocols and use of sponge detection technologies. They also note that most RSI’s continue to occur in the context of reportedly “normal” operative counts. They also note the limited ability of radiographic imaging to improve on the rates of these RSI’s.
Weprin et al. further describe the problem of retained surgical “sharps” in another article (Weprin 2021b). They surveyed different OR team members about the occurrence of retained surgical sharps and “near-misses” and concluded that the rates of each are likely underreported in published articles and statistics garnered by regulatory bodies. They did find a significant difference between the anesthesiologist, surgeon, and nurse/technologist groups regarding the number of lost sharps not recovered per 10,000 surgeries. But all the groups noted x-ray offered poor effectiveness (26–50%) and added 31-40 minutes each time x-ray was used. An average of 21-30 minutes was spent managing each near-miss, making a lost sharp event result in up to 70 minutes of added OR time.
AORN recently updated its guideline on RSI’s (the previous update had been in 2016) and the major changes were recently emphasized (Croke 2021). The AORN guideline now recommends that adjunct technology should be used to supplement the manual counting processes for surgical soft goods. The previous update simply stated that adjunct technology “may” be used. Our October 27, 2020 Patient Safety Tip of the Week “Conflicting Studies on Technology to Reduce RSI’s” discussed some of the studies looking at the impact of adoption of those technologies, some of which did not show a reduction in RSI’s (Gunnar 2020). But it is now widely accepted that appropriate use of such adjunct technology does reduce the rates of “soft” RSI’s. The updated AORN guideline recommends that such adjunct technology should be used even when the count is “correct” (since we know many instances of RSI’s occur despite counts that were correct). Since adjunct technology devices that use radiofrequency and radiofrequency identification may potentially impact on devices such as pacemakers and implantable cardiac defibrillators, the manufacturer’s instructions for use should be followed and policies should specify whether pacemakers and implantable cardiac defibrillators should be set to an asynchronous mode when using these devices.
The guideline also recommends that policies should specify under what conditions use of the adjunct tracking technology might be waived.
A recent Outpatient Surgery article (Marsh 2021) discussed implementation of either barcode scanning or radiofrequency identification to confirm the accuracy of manual counts for soft goods. Marsh noted that there is often pushback to use of these adjunct technologies, usually with the thinking that they add time to procedures. However, in our October 27, 2020 Patient Safety Tip of the Week “Conflicting Studies on Technology to Reduce RSI’s” we noted an observational study evaluating the effect of a radiofrequency (RF) surgical‐sponge detection system on time spent searching for surgical sponges (Steelman 2019) that showed time spent searching for sponges was reduced by 79.58%, the percentage of unreconciled counts was reduced by 71.28%, and time spent using radiography to rule out a retained sponge was reduced by 46.31%. This also resulted in a significant reduction of costs.
Marsh notes that the updated AORN guideline does not favor one adjunct technology over another. She goes on to describe how a facility should go about choosing a technology, and then performing education and training and how to best roll out the new technology. She suggests that the size of the facility might drive whether you launch the use of the chosen new technology incrementally or all at once. Larger facilities should consider using it for one surgical team or procedure at first, then expanding to other teams or surgical cases over a standard timeline set for implementation. On the other hand, the new AORN guideline recommends that adjunct technology should be implemented throughout the organization at the same time (Croke 2021). Marsh goes on to emphasize that the new technologies support rather than replace the manual count.
A second major change in the updated AORN guideline is a focus on device fragments. Since more and more endovascular procedures are being performed, guidewires and guidewire fragments have become more frequent RSI’s. The updated guideline suggests use of a standardized checklist for insertion of devices with guidewires and there should be two-person verbal confirmation that the guidewire is removed and intact. Moreover, insertion and removal of devices with guidewires should be considered a critical phase during which distractions should be minimized.
There is also a new section on foam pieces and negative-pressure wound therapy (NPWT) devices. The foam used in dressings for NPWT devices is not typically radiopaque so it would not be identifiable on radiographic images. The guideline has several recommendations about counting and locating the foam pieces and team communication about them.
A recent AORN Guideline Quick View (AORN 2022) contained some important practical points for RSI prevention. One of the roles of the RN circulator is to ensure that nothing from a prior case might lead to an inappropriate count. That means surveying the room for potentially countable items left over from a prior case. It also means verifying that the count board or count sheets do not contain information from a prior procedure. He/she should also begin the count and record in a visible location (eg. the count board) the count of all the soft goods, sharps, and miscellaneous items placed in the patient. Instrument counts should be recorded on preprinted count sheets.
The scrub person needs to be aware of the location of any soft goods, sharps, and instrumentation on the sterile field or in the patient and have knowledge of the parts and configuration of all medical devices used during the procedure (to be aware of any potential missing pieces or parts). The integrity and completeness of all items returned from the surgical site should be verified. Any item that is passed or dropped from the sterile field should be retrieved, shown to the scrub person, and included in the final count.
Before initiating the final count, the team should be asked whether any additional supplies are going to be needed. Items added after the count has begun are a potential source for incorrect or discrepant counts.
Retained surgical items are a significant patient safety issue and an added burden on our healthcare system. The Weprin articles stress the need for more research in preventing retention of “hard” items. In the meantime, the AORN articles and guidelines outline best practices currently available for RSI prevention.
In addition to the new AORN guideline and our many prior columns on RSI’s/RFO’s listed below, there are many good resources available to help prevent these. NoThing Left Behind® (NoThing Left Behind®) is the preeminent resource. Others include AORN (AORN 2022b), the American College of Surgeons (ACS 2016), The Joint Commission (TJC 2017, TJC 2013), Pennsylvania Patient Safety Authority (Wallace 2017). Verna Gibbs, founder and director of NoThing Left Behind®, also has provided some great tips for surgeons, nurses, and all OR staff for avoiding RSI’s (Gibbs 2019). And Victoria Steelman, author of so many publications on RSI’s, and her colleagues have also published recent articles on RSI’s (Steelman 2018, Steelman 2019, Steelman 2019b).
Our prior columns on retained surgical items/retained foreign objects (RSI’s/RFO’s):
References:
Weprin SA, Moore RH, Meyer D, Autorino R. Retained Surgical Items: A Changing Landscape, Journal of Patient Safety 2021; 17(1): e41
Weprin SA, Meyer D, Li R, et al. Incidence and OR team awareness of “near-miss” and retained surgical sharps: a national survey on United States operating rooms. Patient Saf Surg 2021; 15: 14
https://pssjournal.biomedcentral.com/articles/10.1186/s13037-021-00287-5
Croke L. Guideline First Look. Guideline for prevention of unintentionally retained surgical items. AORN Journal 2021; 114(6); P4-P6
https://aornjournal.onlinelibrary.wiley.com/doi/abs/10.1002/aorn.13579?af=R
Gunnar W, Soncrant C, Lynn MM, et al. The Impact of Surgical Count Technology on Retained Surgical Items Rates in the Veterans Health Administration, Journal of Patient Safety 2020; 6(4); 255-258
Marsh V. Tap Into Technology to Prevent Retained Surgical Items. Innovative systems ensure sponges are located and accounted for before procedures end. Outpatient Surgery 2021; Publish Date: October 26, 2021
Steelman VM, Schaapveld AG, Storm HE, et al. The Effect of Radiofrequency Technology on Time Spent Searching for Surgical Sponges and Associated Costs. AORN Journal 2019; 109(6): 718-727
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12698
AORN (Association of periOperative Registered Nurses). Guideline Quick View: Retained Surgical Items. AORN Journal 2022; 15(2): 197-202 First Published:27 January 2022
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13632
AORN (Association of periOperative Registered Nurses). Retained Surgical Items (resources). AORN 2022; Accessed February 23, 2022
NoThing Left Behind®: A National Surgical Patient Safety Project to Prevent Retained Surgical Items
ACS (American College of Surgeons). Revised statement on the prevention of unintentionally retained surgical items after surgery. October 1, 2016
TJC (The Joint Commission). New Sentinel Event Alert video: Preventing Unintended Retained Foreign Objects. Joint Commission Online 2017; October 25, 2017
TJC (The Joint Commission). Sentinel Event Alert. Preventing unintended retained foreign objects. Issue 51 October 17, 2013
http://www.pwrnewmedia.com/2013/joint_commission/urfo/downloads/SEA_51_URFOs.pdf
Wallace SC. PPSA (Pennsylvania Patient Safety Authority). Retained Surgical Items: Events and Guidelines Revisited. Pennsylvania Patient Safety Advisory 2017; 14(1): 27-35
http://patientsafety.pa.gov/ADVISORIES/Pages/201703_RSI.aspx
Gibbs V. 5 Keys to Preventing Retained Surgical Items. Use these strategies so there's nothing left behind. Outpatient Surgery 2019; XX(4): April 2019
Steelman, V.M., Shaw, C., Shine, L. et al. Retained surgical sponges: a descriptive study of 319 occurrences and contributing factors from 2012 to 2017. Patient Saf Surg 2018; 12, 20
https://pssjournal.biomedcentral.com/articles/10.1186/s13037-018-0166-0#citeas
Steelman VM. Retained Surgical Items: Evidence Review and Recommendations for Prevention. AORN Journal 2019; 110(1): 92-96
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12740
Print “Update on Retained Surgical Items”
March 15, 2022
Medication Errors in Home Care
We’ve done multiple columns (listed below) detailing the complexities and challenges of delivering safe care in the patient’s home. Of course, some of the most frequent problems encountered are related to medications. Dionisis et al. (Dionisis 2021) recently published a comprehensive systematic review and meta-analysis on medication errors and their causes in the home care setting. Their final analysis included 17 studies, which they listed in tabular format with summaries of the main findings and implications for practice.
Of the 17 studies in the Dionisis systematic review, there are a few we feel summarized the most salient problems and barriers related to medication safety in the home care setting.
Meyer-Massetti et al. (Meyer-Massetti 2018a) did an observational study on medication-related problems during transfer from hospital to home care. Though the study took place in Switzerland, the findings are likely applicable in the US as well. They found 3 major themes: (1) fragmented interprofessional communication (2) unreliable availability of drugs and (3) poor prescription quality.
Among the 100 patients included in the study, a complete set of written discharge information was available for the first home care visit in only 5 patients. The discharge documents most often unavailable were the discharge medication prescription (78 patients) and the prescription for home care services (46 patients). The physician discharge report was available for only 55 patients, the nursing discharge report for 63 patients. For 13 patients, neither a medication list nor a medication discharge prescription was available. The prescription was unclear in many cases, necessitating communication with other professionals (not always successfully). Clarification was achieved in only 65% by the second home visit.
A total of 22 medication errors were associated with unclear prescriptions, most often resulting in a delayed intake. In 20 patients, medications were unavailable at the time of the first home care visit, necessitating 25 phone calls (75% to the primary care provider and 25% to the public pharmacy). Medication errors due to missing medications were reported in 19 cases, most often due to delayed (N = 4) or no intake/administration (N = 6).
After the follow-up visit, communication with a primary care provider took place 15 times to clarify medication-related issues. However, the provider could be reached directly in only 4 of the 15 cases. We’ll add that confusion about who is the responsible physician for continuing care is a problem we often see and, as mentioned elsewhere, the primary care physician is often “out-of-the-loop” and has not received a copy of a hospital discharge summary or even made aware his/her patient had been hospitalized.
The medication lists in 67 of the 100 patients required some clarification. 16% of prescribed drugs were considered to be ambiguous. Examples of missing information included: exact drug name, dosage form or strength, and frequency. Allergy information was available in only 20 patients. The corresponding diagnosis was missing for 303 out of 984 drugs (31%). Our March 1, 2022 Patient Safety Tip of the Week “Including the Indication on Prescriptions” discussed the importance of including the indication for medications in all prescriptions. Absolute or relative contraindications were seen in 23 patients and clinically significant interactions were present for 99 drug combinations. Drug duplications and PIM’s (potentially inappropriate medications) were also found in a few patients.
An average of 2.2 drugs per patient taken before hospital admission were not prescribed at discharge, without explanation. Additional unexplained changes included dosage change, drug product/substance switch, switch from regular to as-needed medication, change of administration time, and duplication with an over-the-counter therapy. Hospital discharge information was incongruent with the discharge prescription in 30 patients.
Meyer-Massetti et al. suggest that involving clinical pharmacists in the discharge procedure is an important option to improve medication safety associated with transfer from the acute care to the home care setting.
Meyer-Massetti et al. (Meyer-Massetti 2018b) also did a systematic review of drug-related problems in the home care setting. PIM’s (potentially inappropriate medications) ranged in frequency from 19.8 to 48.4%. Polypharmacy and increasing age were the most common risk factors for drug-related problems. Insufficient interdisciplinary teamwork and inconsistent performance of medication reviews were also risk factors for drug-related problems. Patients and/or caregivers were responsible for 42.3% of drug-related problems.
Sarzynski et al. (Sarzynski 2019) studied hospital-to-home-health-care transitions for older adults with heart failure in a single Michigan healthcare system using two commercially available electronic health record (EHR) vendors. They found with 4 main themes with hospital-to-home-health-care information exchange: (1) poor medication management, (2) ineffective communication, (3) technology issues, and (4) patient factors.
They also identified specific barriers to safe medication management in home care, including: (a) discordant HER-generated medication lists, (b) issues clarifying medication regimens, (c) barriers to filling medications, (d) complexity of medication self-management tasks, and (e) side effects affecting quality of life.
There were often discrepancies in the medication lists embedded within the “After Visit Summary” intended for patients and discharge summary intended for receiving clinicians. That is despite the fact that both come off of the same EHR. Reconciling these discordant medication lists is a time-consuming process, since nurses must contact providers (often multiple) to clarify discrepancies, then calling the patient back and telling them what to take.
Since the Sarzynski study was on older adults with heart failure, one glaring omission noted by the home care nurses was lack of a patient's ideal weight. We’ve always stressed that each patient’s own list of their medications should also list their current or usual weight. But in a heart failure patient it is important for the patient and the home care nurses to know what their target or ideal weight is and that is often absent in all the documents generated at hospital discharge.
Weekends posed special problems. Communication with providers is more difficult when offices are closed, and “on-call” physicians are largely unaware of patients’ complex post-acute care plans. In addition, there was often difficulty troubleshooting issues with technology outside of normal business hours.
Technology issues included information sometimes including conflicting or incomplete information from the two different EHR systems used. There were also issues with home care nurses’ hardware and software, and sometimes internet connections were lost when providing care in patients’ homes.
They also identified patient-related factors that contributed to potential problems. They often encountered patients with limited health literacy and found that EHR-generated discharge documents rarely incorporate health literacy best practices. For example, those documents often fail to take into account whether the patient recognizes a medication by its trade name or generic name. Another problem is that patients are often overwhelmed during their hospital stays, which may limit the effectiveness of hospital-based educational strategies. (That is also why we always recommend a phone call to patients 24 to 48 hours following discharge to clarify any issue and questions a patient may have.)
Finally, nurses often had concerns about the reliability of patients’ informal caregivers. One example given was a family member “fills the pillbox, then takes the pills [bottles] home or something, and then you don't know what's in there. . . You don't know if they're getting the right dose of Lasix.”
Nurses in the Sarzynski study were “frustrated by ambiguity in clinicians’ roles and accountability during the immediate post-discharge period”. A major problem we continue to see is lack of communication between hospital-based personnel and primary care clinicians (or other clinician who will be primarily responsible for the patient’s continued care as an outpatient). We still hear PCP’s telling their patient “I had no idea you were even in the hospital.” Most EHR’s have a field for inputting the patient’s PCP (primary care physician) but they are often not accurate, fail to be updated, or are used for other purpose. The hospital discharge summary is often not conveyed promptly, if at all, to the PCP. So, it should come as no surprise that the PCP is unaware of any new medications prescribed or any old medications discontinued.
Notably absent in these studies on medication safety in home care is any mention of infusion errors. Our multiple columns on safety of infusions have included incidents related to infusion errors in the home. The most serious of such errors occurs when an infusion intended to be given over several days ends up being infused over several hours. Particularly with some chemotherapeutic agents, that may be a fatal error. Our number one recommendation regarding infusions, whether at home or in the hospital or other facility, is that you should never include a dose of a medication that could be fatal if the infusion were to accidentally be completed much faster than intended.
Home care is an important part of our healthcare system. Patient safety in home care should receive no less attention than it receives in other healthcare venues. Your organization likely would benefit from the sort of analysis done in the studies discussed in today’s column. You don’t have to analyze every home care visit. Rather, you can do a sampling of cases transitioned from the hospital to home care. We’ll bet you will identify many of the same problems noted in these studies. By the way, many of the same problems likely are seen in those patients transitioned from the acute care hospital to long term care facilities or other post-acute care facilities.
Some of our prior columns on patient safety issues in the home:
Our prior columns related to infusion pump issues:
References:
Dionisis S, Di Simone E, Liquori G, et al. Medication errors' causes analysis in home care setting: a systematic review. Public Health Nurs 2021; Epub 2021 Dec 31
https://onlinelibrary.wiley.com/doi/10.1111/phn.13037
Meyer-Massetti C, Hofstetter V, Hedinger-Grogg B, et al. Medication-related problems during transfer from hospital to home care: Baseline data from Switzerland. International. Journal of Clinical Pharmacy 2018; 40(6); 1614-1620
https://link.springer.com/article/10.1007/s11096-018-0728-3
Meyer-Massetti C, Meier CR, Guglielmo BJ. The scope of drug-related problems in the home care setting. International Journal of Clinical Pharmacy 2018; 40(2): 325-334
https://link.springer.com/article/10.1007/s11096-017-0581-9
Sarzynski, E., Ensberg, M., Parkinson, A., Fitzpatrick, L., Houdeshell, L.,
Given, C., & Brooks, K. (2019). Eliciting nurses’ perspectives to improve
health information exchange between hospital and home health care. Geriatric Nursing 2019; 40(3): 277-283
https://www.sciencedirect.com/science/article/abs/pii/S0197457218303616
Print “Medication Errors in Home Care”
March 22, 2022
Not Just Politicians Behaving Badly
It seems these days that disrespect and rude behavior have become “normalized” in many facets of our society. One need only look at behavior of politicians or interchanges on social media. Healthcare is not immune to this phenomenon.
ISMP (Institute for Safe Medication Practices) was one of the first organizations to describe such behavior in healthcare and point out how it serves as a barrier to a culture of safety. In 2004 (ISMP 2004) reported on responses to a 2003 survey. Respondents noted that intimidating behaviors were not attributable to physicians/prescribers alone. They encountered a surprising degree of intimidation among other healthcare providers as well and repeated occurrences of intimidating behavior did not arise from a single menacing individual. Subtle forms of intimidation were more frequent than more explicit forms. 88% of respondents encountered condescending language or voice intonation (21% often); 87% encountered impatience with questions (19% often); and 79% encountered a reluctance or refusal to answer questions or phone calls (14% often). Almost half of the respondents reported more explicit forms of intimidation, such as strong verbal abuse (48%) or threatening body language (43%). Incredibly, 4% of respondents even reported physical abuse.
Another ISMP survey in 2013 (ISMP 2013) largely echoed the 2003 survey. ISMP concluded “The results of our 2003 and 2013 surveys expose healthcare’s continued tolerance and indifference to disrespectful behavior. These behaviors are clearly learned, tolerated, and reinforced in the healthcare culture, and little improvement has been made during the last decade.”
In 2005 a very valuable contribution to patient safety came from AACN (American Association of Critical-Care Nurses): “Silence Kills. The Seven Crucial Conversations for Healthcare” (AACN 2005), results of a survey of nurses, physicians, administrators and a variety of healthcare workers. The survey highlighted 7 issues of concern that have largely flown under the radar. One of those 7 issues was “Disrespect”. The survey revealed that 77 percent of nurses and other clinical-care providers work with some who are condescending, insulting, or rude. 33 percent work with a few who are verbally abusive—yell, shout, swear, or name call. Many of the issues were considered “undiscussable”. Even the nursing supervisors participating in the study admitted that they often did not confront the offending party or take appropriate action.
So, why don’t people speak up and share their full concerns? 59% of nurses and other clinical-care providers said that it was difficult or impossible to confront the person showing disrespect or abuse. Lack of ability, belief that it is “not their job,” and low confidence that it will do any good to have the conversation were the three primary obstacles to direct communication. Other obstacles include time and fear of retaliation. Some don’t want to make others angry or undercut their working relationships, so they leave difficult discussions to others or to another time, and never get back to the person.
But a quarter to half of the respondents did discuss the problem with coworkers or with the person’s manager. But they often noted that the purpose for discussing these problems with coworkers was not to solve problems. Rather, it was to “work around them, warn others about them, and blow off steam”.
The Joint Commission issued its Sentinel Event Alert #40 “Behaviors that undermine a culture of safety” in 2008 (TJC 2008). It cited the 2004 ISMP report and indicated that both overt activities and more passive examples of disruptive behavior can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators, and managers to seek new positions in more professional environments. It issues suggested actions for hospitals, including “zero tolerance” for intimidating and/or disruptive behaviors.
But it was Lucian Leape and colleagues (Leape 2012a, Leape 2012b) who really got the attention of the medical community with their series on the “Culture of Disrespect” (see our July 2012 What's New in the Patient Safety World column “A Culture of Disrespect”). He and his colleagues described disrespectful behavior in 6 categories. While we all easily recognize the first category – the disruptive physician – such account for a relatively small proportion of the problem. Moreover, the disruptive physician is easiest to recognize and probably easiest to take action on. But Leape’s main point is that the behaviors in the other categories are the more subtle parts of the continuum of disrespect and collectively the far bigger problem. Most of the culture of disrespect is rooted more deeply in the highly hierarchical environment in medicine where the physician has been traditionally accorded a stature at a different level than everyone else. Leape notes that remains a huge barrier in a time when we have to rely on growing multidisciplinary teams to manage increasingly complex medical conditions.
Importantly, while some aspects of disrespect are due to characteristics of individuals, Leape emphasizes that disrespectful behavior is also learned, tolerated and reinforced by the hierarchical hospital culture.
Most recently, ISMP reported on yet another survey done in 2021 (ISMP 2022) and it showed that disrespectful behaviors in healthcare continue to occur at an alarming rate, demonstrating little or no improvement, and in some cases, worsening. In 2021, respondents reported that “disrespectful behaviors persist unchecked, they are not isolated events, they are not limited to only one or two offenders of a single gender, and they occur in both lateral (peer-to-peer) and hierarchical working relationships.”
The prevalence and frequency of the disrespectful behaviors was largely similar among the 3 ISMP surveys, though between 2013 and 2021 there was an increase in making negative comments about colleagues and leaders.
Importantly, most respondents have not been satisfied with organizational efforts to address disrespectful behaviors. 70% of the respondents in 2003, 52% in 2013, and 65% in 2021 reported that their organization or manager would support them if they reported disrespectful behavior, but only about one-quarter of all respondents (39%, 25%, 25% respectively) felt that their organization had effectively dealt with disrespectful behaviors.
The COVID-19 pandemic may have exacerbated the problem, with a more stressful healthcare environment, poor staffing levels, excessive workloads, power imbalances, and the ever-changing science and data associated with COVID-19 treatments.
And the issues clearly have a potential impact on patient safety. 47% of respondents admitted to feeling pressured to accept an order, dispense a product, or administer a drug despite concerns about its safety, and 35% had concerns about a medication order but assumed it was correct rather than interact with a particular prescriber.
Guo et al. just published a systematic review on the impact of unacceptable behavior between healthcare workers on clinical performance and patient outcomes (Guo 2022). After winnowing down a huge list of articles dealing with unacceptable behavior, they were left with 36 studies for inclusion in the review. They found considerable variability in the quality and methodology of the included studies. In general, the studies reporting on perception of respondents demonstrated a negative impact on quality of care, patient outcomes, patient safety, and workplace productivity. This was substantiated by a smaller number of higher quality studies with more rigorous methodology and more objective outcome measures. We also discussed some of the consequences of rude and disrespectful behavior in our September 22, 2015 Patient Safety Tip of the Week “The Cost of Being Rude” and our August 2019 What's New in the Patient Safety World column “More on the Cost of Rudeness”.
The term “microaggressions” has been used to refer to ‘commonplace behavioral indignities whether intentional or unintentional communicating hostile, derogatory or negative attitudes toward marginalized groups.’ Implicit bias, microaggression, prejudice, and stereotyping may play a role in the persistent healthcare disparities seen among marginalized groups (Ehie 2021).
Even academic medicine is not immune to disrespectful behavior, as evidenced by a recent exchange at an oncology conference in which several participants were rude or condescending (Nelson 2022).
It’s clearly not just physicians that are exhibiting intimidating, rude, or disrespectful behavior. Over the past decade there has been much written about so-called “lateral violence” and bullying among nurses. And responses from administrators have often been less than satisfying. An article in Becker’s Hospital Review (Becker 2016) described the acronym L.I.S.T.E.N. used by Phyllis Quinlan, PhD, RN, an authority on bullying in multiple venues, to guide nurse leaders in investigating nurse bullying:
L: Lean into the situation.
I: Insight is the goal.
S: Solving the reason for the behavior is not your job.
T: Take notes.
E: Engage human resources early.
N: Never share an opinion.
The really bad behavior in our minds is that clinical leaders and hospital administrators often tolerate the disrespectful behavior, thereby sanctioning it and inadvertently leading to its adoption by others. Medical students, resident physicians, nursing students, etc. all see examples of disrespectful behavior that go unchallenged and then begin to adopt such behavior themselves as the “norm”.
A recent article on patient safety “culture” (French 2022) in InSight+, a newsletter of the Medical Journal of Australia, described 4 characteristics of organizational culture as described in an article from the Harvard Business Review (Groysberg 2018). Culture is:
Unfortunately, those same 4 characteristics we see in positive cultures may also be features of organizational cultures that are counterproductive (i.e. when the disrespectful behavior is what is shared, pervasive, enduring, and implicit). Which type of culture best describes that of your organization?
Stay tuned! The upcoming Part II of ISMP’s 2022 report will explore how to address disrespectful behaviors in healthcare.
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?”
April 6, 2021 “ISMP on Just Culture”
Some of our prior columns related to the “culture of safety”:
April 2009 “New Patient Safety Culture Assessments”
June 2, 2009 “Why Hospitals Should Fly...John Nance Nails It!”
January 2011 “No Improvement in Patient Safety: Why Not?”
March 2011 “Michigan ICU Collaborative Wins Big”).
March 29, 2011 “The Silent Treatment: A Dose of Reality”
May 24, 2011 “Hand Hygiene Resources”
March 2012 “Human Factors and Operating Room Safety”
July 2012 “A Culture of Disrespect”
July 2013 “"Bad Apples" Back In?”
July 22, 2014 “More on Operating Room Briefings and Debriefings”
October 7, 2014 “Our Take on Patient Safety Walk Rounds”
July 7, 2015 “Medical Staff Risk Issues”
September 22, 2015 “The Cost of Being Rude”
May 2016 “ECRI Institute’s Top Ten Patient Safety Concerns for 2016”
June 28, 2016 “Culture of Safety and Catheter-Associated Infections”
April 2017 “Relation of Complaints about Physicians to Outcomes”
April 2017 “Joint Commission Sentinel Event Alert on Safety Culture”
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?”
April 6, 2021 “ISMP on Just Culture”
July 27, 2021 “Sustainability”
September 2021 “Ambiguous Language in the OR”
References:
ISMP (Institute for Safe Medication Practices). Intimidation: Practitioners Speak Up About This Unresolved Problem (Part I). ISMP Medication Safety Alert! Acute Care Edition 2004; March 11, 2004
https://www.ismp.org/resources/intimidation-practitioners-speak-about-unresolved-problem-part-i
American Association of Critical-Care Nurses (AACN) and VitalSmarts. Silence Kills. The Seven Crucial Conversations for Healthcare. AACN 2005
ISMP (Institute for Safe Medication Practices). Unresolved Disrespectful Behavior in Healthcare - Practitioners Speak Up Again (Part I). ISMP Medication Safety Alert! Acute Care Edition 2013; October 3, 2013
ISMP (Institute for Safe Medication Practices). Survey Suggests Disrespectful Behaviors Persist in Healthcare: Practitioners Speak Up (Yet Again) – Part I. ISMP Medication Safety Alert! Acute Care Edition 2022; February 24, 2022
Guo L, Ryan B, Leditschke IA, et al. Impact of unacceptable behaviour between healthcare workers on clinical performance and patient outcomes: a systematic review. BMJ Quality & Safety 2022; Published Online First: 19 January 2022
https://qualitysafety.bmj.com/content/early/2022/01/18/bmjqs-2021-013955
The Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event Alert #40. TJC 2008; July 9, 2008, updated June 18, 2021
Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Acad Med 2012; 87(7): 845-852
Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 2: creating a culture of respect. Acad Med 2012; 87(7): 853-858
Ehie O, Muse I, Hill L, Bastien A. Professionalism: microaggression in the healthcare setting, Current Opinion in Anaesthesiology 2021; 34(2); 131-136
Nelson R. Twitter storm over ‘reprehensible behavior’ at conference podium. MDedge 2022; Publish date: February 22, 2022
Becker’s Hospital Review. Use this acronym to guide investigations into nurse bullying
Becker’s Hospital Review 2016; August 16, 2016
French J, Sutcliffe K. Patient safety: what’s culture got to do with it? InSight+ 2022; 28 February 2022
https://insightplus.mja.com.au/2022/7/patient-safety-whats-culture-got-to-do-with-it/
Groysberg B, Lee J, Price J, Cheng J. The Leader’s Guide to Corporate Culture. How to manage the eight critical elements of organizational life. Harvard Business Revieww 2018; January–February 2018)
https://hbr.org/2018/01/the-leaders-guide-to-corporate-culture
Print “Not Just Politicians That Behave Badly”
March 29, 2022
Disturbing Stats on Perioperative Benzodiazepine Use in Elderly Patients
One of the most well-recognized risk factors for delirium in elderly patients is use of benzodiazepines. So, some recent statistics about perioperative benzodiazepine use in elderly surgical patients are particularly troublesome.
Cozowicz et al. analyzed a database of almost 3 million patients undergoing total knee or hip arthroplasty from 2006 to 2019 (Cozowicz 2022). Benzodiazepine use on the day of surgery occurred in 80.5% of TKA’s (72.6% short-acting and 7.9% long-acting) and 76.1% of THA’s (68.4% short-acting and 7.7% long-acting). Midazolam was by far the most frequently used benzodiazepine (89.5%), with lorazepam, diazepam, alprazolam, and clonazepam each less than 3%. Benzodiazepine use increased from 2006, peaking in 2011, then decreasing to just below 2006 levels by 2019.
While short-acting benzodiazepines were predominant, long-acting formulations were administered in approximately 8% of cases. Benzodiazepine use was also associated with significantly increased opioid consumption, especially in patients receiving long-acting benzodiazepines. Benzodiazepine use was more frequent in “younger” patients (median age 69!).
The authors note that, despite growing evidence and several guidelines supporting cautious use of benzodiazepines, the persistent high utilization rate across the 14-year study period is surprising, especially given the increasing number of elderly patients receiving THA and TKA. Use of long-acting benzodiazepines is known to be associated with higher rates of postoperative delirium. They also note a disturbing association of increased opioid use in patients receiving benzodiazepines.
The authors call for future research to provide evidence-based guidelines on appropriate use and indications for benzodiazepines in the perioperative period.
A second study looked at the association between perioperative medication use and postoperative delirium and cognition in adults ≥70 years without dementia undergoing elective noncardiac surgery (Duprey 2022). While hospitalized, patients were assessed daily for delirium using the CAM (Confusion Assessment Method) and a validated chart review method. Cognition was evaluated preoperatively and 1 month after surgery using a neurocognitive battery. Among 560 patients enrolled, 134 (24%) developed delirium during hospitalization. While prehospital benzodiazepine use was not associated with post-op delirium, postoperative hospital benzodiazepine use was associated with greater delirium (adjusted hazard ratio 3.23). But association between inhospital, postoperative medication use and cognition at 1 month, independent of delirium, was not detected.
Neither study was able to determine the incidence of frailty in their population undergoing the elective surgical procedures. A recent meta-analysis (Gracie 2021) of articles on patients who were undergoing elective, nonemergent inpatient surgery confirmed a significant association between preoperative frailty and postoperative delirium in elective surgical patients age 65 years or older. It would be of interest to know whether the presence of frailty further increases the risk of postoperative delirium in patients receiving perioperative benzodiazepines.
An interesting study analyzed risk factors for postoperative delirium in critically ill patients the surgical ICU (Chaiwat 2019). Of 250 patients enrolled, delirium was found in 61 (24.4%). Independent risk factors for delirium were age, diabetes mellitus, severity of disease (SOFA score), perioperative use of benzodiazepine, and mechanical ventilation. They then developed a predictive score, weighting each of those 6 variables. That predictive score had a sensitivity of 72.13% and a specificity of 80.95% at their suggested cut point. Note that hospital mortality rate was significantly greater among the delirious than the non-delirious patients (25% vs. 6%).
Sharon Inouye, one of the world’s leading delirium researchers and key architect of HELP (Hospital Elder Life Program), described a case of postoperative delirium in a New England Journal of Medicine “Perspective” – the patient was her own father (Inouye 2020). She discussed the multiple contributing factors and fact that multiple caregiver teams “each prescribed many drugs to address his ailments, seemingly without consideration of drug interactions, renal dose-adjustment protocols, or his heightened sensitivity to psychoactive drugs”. At one point, he was on more than 20 medications, including a benzodiazepine for sleep and several other drugs with psychoactive effects. Asking herself whether her father’s delirium could have been prevented, she responds “I believe so. Indeed, all the precipitating factors were potentially reversible or remediable. Yet I realized that no person working alone — not even a delirium expert — can prevent delirium. It takes an enlightened, coordinated health care system with motivated interdisciplinary health care professionals working together to improve care for older adults.” Delirium prevention truly requires a coordinated system with all healthcare workers working together.
Managing delirium is difficult, so preventing it is of utmost importance. Exposure to benzodiazepines is one of the contributing factors that all healthcare workers must recognize in elderly patients undergoing surgery.
Some of our prior columns on delirium assessment and management:
References:
Cozowicz C, Zhong H, Illescas A, et al. The Perioperative Use of Benzodiazepines for Major Orthopedic Surgery in the United States. Anesthesia & Analgesia 2022; 134(3); 486-495
Duprey MS, Devlin JW, Griffith JL, et al. Association Between Perioperative Medication Use and Postoperative Delirium and Cognition in Older Adults Undergoing Elective Noncardiac Surgery. Anesthesia & Analgesia 2022; Published ahead of print February 24, 2022
Gracie TJ, Caufield-Noll C, Wang N-Y, et al. The Association of Preoperative Frailty and Postoperative Delirium: A Meta-analysis. Anesthesia & Analgesia 2021; 133(2); 314-323
Chaiwat O, Chanidnuan M, Pancharoen W, et al. Postoperative Delirium in Critically Ill Surgical Patients. Incidence, Risk Factors, and Predictive Scores. BMC Anesthesiol 2019; 19(39)
https://bmcanesthesiol.biomedcentral.com/articles/10.1186/s12871-019-0694-x
Inouye SK. Joining Forces against Delirium — From Organ-System Care to Whole-Human Care. N Engl J Med 2020; 382(6): 499-501
https://www.nejm.org/doi/full/10.1056/NEJMp1910499
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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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