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January 3, 2023
Helping Inpatients Sleep - Failing Grades
Common sense tells us that helping inpatients get restful sleep is desirable and doing so without using sleep meds makes even more sense. We’ve done several columns highlighting the poor job we do at allowing patients to sleep when they are hospital inpatients (see our Patient Safety Tips of the Week for August 6, 2013 “Let Me Sleep!”, May 15, 2018 “Helping Inpatients Sleep”, and November 6, 2018 “More on Promoting Sleep in Inpatients”). Our November 6, 2018 Patient Safety Tip of the Week “More on Promoting Sleep in Inpatients” cited several studies showing inpatients average significantly less sleep in hospital compared to at home.
We know the many factors contributing to poor sleep in inpatients:
And we already have lots of tools and programs that can address many of those factors and make it easier for inpatients to sleep (see below for details). We want to avoid using sedative/hypnotic medications to induce sleep in such patients because they are risk factors for falls, delirium, medication-induced respiratory depression, and other undesirable complications.
So how are we doing? Pretty poorly, according to a recent study. Affini et al. (Affini 2022) surveyed and interviewed section chiefs of Hospital Medicine at the 2020 US News and World Report (USNWR) Honor Roll pediatric and adult hospitals. Nearly all (96%) hospitalist leaders at those top hospitals rated patient sleep as important, but fewer than half (43%) were satisfied with their institution's efforts to improve patient sleep.
Fifty-two percent of the surveyed institutions reported having no sleep-friendly practices in place. The most common practices in those that did have some practices included:
The researchers identified both barriers to adoption of sleep-promoting practices and factors that helped adoption of such practices. Barriers to success were related to the hospital environment and culture (e.g.,inflexible workflow, time conflicts, noisy alarms) and fixed standards of care (not differentiating low-risk and high-risk patients). A key contributor to successfully improving patient sleep was buy-in from hospital staff. Examples included providers reducing room entries through batched care or enforcing quiet hours among peers. External initiatives, such as patient care initiatives or funded innovation projects were also important for patient sleep.
Respondents also suggested that grouping tasks and decreasing interventions, when appropriate, would be opportunities for improvement.
Affini et al. also asked about sleep equity and found that only one hospital addressed sleep equity (but did not reveal how it did so). By sleep health equity the authors meant improving sleep for racial/ethnic minorities, patients with pre-existing risk factors, communication barriers, or limited familiarity with hospital services.
The authors conclude that some key reasons for slow progress are that (1) the culture is such that providers want to improve patient sleep, but not at the expense of changing standard workflow, and (2) there is a lack of incentives and programs to support changes. They call upon both clinicians and hospital leaders to address the issues, develop a culture that promotes sleep, and adopt best practices for patient sleep.
It's worth reiterating here recommendations from our prior columns. In our “Let Me Sleep!” column we noted that the Hospital Elder Life Program (HELP) program (Inouye 2013) includes a systemic effort to improve sleep in hospitalized patients by noise reduction, a nonpharmacologic sleep protocol, and coordination of nighttime care. Inouye points out that besides vital sign monitoring and blood draws, patients’ sleep is often disrupted by medication administration, IV changes or IV alarms, intermittent pneumatic compression devices, breathing treatments, fingersticks for glucose monitoring, paging systems, room or hallway lights, conversations, cleaning and waxing floors at night, etc. Moreover, Inouye notes there is often a striking lack of coordination amongst staff that could minimize these disruptions. Simply having the phlebotomist tag team with the nurse or aide doing vital signs could avoid one disruption.
Another study (Bartick 2010) implemented the “Somerville Protocol” and documented a 38% reduction in patients noting sleep disruption due to hospital staff and a 49% reduction in patients receiving prn sedatives (actually a 62% reduction for patients aged 65 and older). The protocol consisted of 10 components:
A couple of those interventions merit further discussion. At many (perhaps most) hospitals, the incoming nursing staff gets vital signs when their shift starts. Hence, many patients get their vital signs checked between 11PM and midnight. Simply changing policy and procedure so that vital signs are checked by the outgoing staff at 10PM can help avoid one obvious potential sleep disruption. (Of course, you’d have to look for potential unintended consequences such as interfering with shift handoffs).
Getting physicians to understand that “three times daily” and “every 8 hours”, for example, are not the same takes some time and hard work. If I order a medication today at 10AM and enter it as “every 8 hours” my patient will be wakened at 2AM to get a dose. On the other hand, if the order is written for “three times daily” the hospital will have standard times that such are given to avoid that disruptive nighttime dose. (Note that you have to be very careful. Today’s CPOE systems often don’t make it clear when the first dose will be given. We have seen some systems where the first dose or even all the first day’s doses will not be given when the order is written this way.)
A noise monitoring device for the nursing station doesn’t need to be expensive. If a teacher can use a free or $0.99 decibel meter for his/her iPhone to alert him/her to classroom noise exceeding a specified level, we can certainly find a cheap solution to avoiding excessive noise at the nursing station or elsewhere. But even Bartick and colleagues note that reduction in noise and light probably did not significantly improve patients’ sleep. Rather, a reduction in the physical disruptions probably played the major role.
There are, of course, several other protocols and programs for improving sleep in hospital inpatients. See our November 6, 2018 Patient Safety Tip of the Week “More on Promoting Sleep in Inpatients” for descriptions of the “Quiet Time”, Sommerville, and “TUCK-in” protocols, plus the Hospital Elder Life Program (HELP) program.
Promoting natural sleep is also not simply a nocturnal event. What you do during the daytime is also important in promoting sleep. Regular exercise is an example of an important contributor to nocturnal sleep. Reducing ambient light at night is highly recommended. But what about light levels at other times? In our December 2013 What's New in the Patient Safety World column “Lighten Up Your Patient’s Day” we noted a study (Bernhofer 2013) that used light meters and wrist actigraphy to assess the sleep-waking patterns of hospital inpatients and correlated those parameters with patients’ pain levels and mood. Light exposure levels were low and sleep time was poor and fragmented. There was little sleep–wake synchronization with light. Fatigue and total mood disturbance scores were high and inversely associated with light. Pain levels were also high and positively associated with fatigue, but not directly with light exposure. Low light exposure significantly predicted fatigue and total mood disturbance. They concluded that inpatients were exposed to light levels insufficient for circadian entrainment. Nevertheless, higher light exposure was associated with less fatigue and lower total mood disturbance in participants with pain. Though the study was small (40 total patients) this research demonstrates the need for further studies to see if altering light exposure for inpatients would be beneficial in affecting sleep–wake disturbances, mood and pain.
Our May 15, 2018 Patient Safety Tip of the Week “Helping Inpatients Sleep” also noted a non-pharmacologic multidimensional program at an academic tertiary care hospital which produced promising results (Herscher 2018). Components of the intervention were:
And see our March 16, 2021 Patient Safety Tip of the Week “Sleep Program Successfully Reduces Delirium” for a study by Gode et al. (Gode 2021) that successfully reduced delirium by focusing on a program to improve non-pharmacologic sleep in inpatients.
Avoiding sleep meds and using non-pharmacologic interventions to promote sleep is something every hospital should strive for. Don’t forget that we often have ourselves to blame. It is still common for physicians to leave orders for prn sleep meds in the admission orders, presumably so no phone call is needed at night requesting such. In our March 23, 2010 Patient Safety Tip of the Week “ISMP Guidelines for Standard Order Sets” we stressed the importance of avoiding inclusion of “prn” sleep meds in standard order sets. We also refer you back to our August 2019 What's New in the Patient Safety World column “Tools for Reducing Sleep Meds in Hospitals” for some interventions to avoid use of sleep medications in hospitalized patients.
We do have the means to promote non-pharmacologic sleep in our inpatients. We need to institutionalize the importance of this issue and foster a culture that is more patient-centered. That means abandoning some of our old customary practices
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”
January 4, 2022 “Spin or Not: A Useful Secondary Finding in a Study”
References:
Affini, MI, Arora, VM, Gulati, J, et al. Defining existing practices to support the sleep of hospitalized patients: A mixed-methods study of top-ranked hospitals. J Hosp Med. 2022; 17(8): 633-638
https://shmpublications.onlinelibrary.wiley.com/doi/10.1002/jhm.12917
Inouye SK. No Rest for the Weary…or the Sick: Comment on “A Prospective Study of Nitghtime Vital Sign Monitoring Frequency and Risk of Clinical Deterioration”. JAMA Intern Med. 2013; (): doi:10.1001/jamainternmed.2013.7809 Published online July 1, 2013
http://archinte.jamanetwork.com/article.aspx?articleid=1705720
Bartick MC, Thai X, Schmidt T, et al. Decrease in As-needed Sedative Use by Limiting Nighttime Sleep Disruptions from Hospital Staff. Journal of Hospital Medicine 2010; 5: E20–E24
Bernhofer EI, Higgins PA, Daly BJ, et al. Hospital lighting and its association with sleep, mood and pain in medical inpatients. Journal of Advanced Nursing 2013; Article first published online : 27 OCT 2013, DOI: 10.1111/jan.12282
http://onlinelibrary.wiley.com/doi/10.1111/jan.12282/abstract
Herscher M, Mikhaylov D, Turakhia P, et al. The Sleep Hygeine In The Hospital Project: Shh! Society of Hospital Medicine (HM) 2018 Annual Meeting: Abstract 413905. Presented April 9, 2018
https://www.shmabstracts.com/abstract/the-sleep-hygeine-in-the-hospital-project-shh/
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
ISMP (Institute for Safe Medication Practices). ISMP’s Guidelines for Standard Order Sets. 2010
https://www.ismp.org/guidelines/standard-order-sets
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January 10, 2023
Diagnostic Errors in the ED
AHRQ recently published a study (Newman-Toker 2022) on diagnostic errors in the emergency department that has garnered substantial interest from the lay press. The study has been largely criticized in that some of the data came from European or Canadian emergency departments, rather than US emergency departments, and that it unfairly targets ED physicians. But the authors make it very clear that the diagnostic error rates found in the ED are very comparable to those found in hospital inpatient care or primary care.
We’ve long criticized the landmark report “To Err Is Human” in that it sensationalized statistics that garnered attention for a short period and ultimately did little to improve patient safety over the next decade. So, let’s cast aside the criticisms of the new AHRQ study, ignore the focus on statistics, and instead focus on the important lessons learned from the study.
The emergency department, by its very nature, is a high-risk venue. Interactions with patients are generally for a short period of time, often done under time pressure and multiple potential distractions. Most importantly, the clinician doing the ED evaluation may never see that patient again. Ensuring a proper handoff to the clinician who will next care for the patient is critical. Our current systems for care coordination are not very good. We can’t tell you the number of times we hear a primary care physician say “I didn’t even know {my patient} had been in the ED”. Patients are often discharged from the ED before final imaging reports are available and we’ve all seen patients “fall through the cracks” when an important imaging finding is never communicated to someone who would ensure follow-up. Particularly in small rural hospitals, lack of specialty consultants may be a further problem. Add to all this the problem of overdiagnosis and impact of the “diagnostic cascade” that can itself lead to patient harm and add to healthcare expenditures.
The study was really a systematic review and meta-analysis based on an extensive review of the literature, encompassing 279 studies. An estimated 5.7% of all ED visits had at least one diagnostic error. Estimated preventable adverse event rates were 2.0% for any harm severity, 0.3% for any serious harms, and 0.2% for deaths. That translates to about 1 in 18 ED patients receiving an incorrect diagnosis, 1 in 50 suffering an adverse event, and 1 in 350 suffering permanent disability or death. Again, these rates are comparable to those seen in primary care and hospital inpatient care.
So those are the statistics. Yes, those are the ones garnering all the headlines in the lay press (New York Times, Boston Globe, CNN, and multiple others). And the statistics do little to help us improve patient safety. Rather, we must look at the real opportunities to improve patient safety. The more important questions to ask are “what are the serious conditions that are more likely to be missed?” and “what are the presenting symptoms that often lead to missed diagnoses?”. When seeing patients in any healthcare venue, the two most important questions we usually ask ourselves are “What could I be missing?” and “What’s the most serious thing I could be missing?”.
The top 15 clinical conditions associated with serious misdiagnosis-related harms, accounting for 68% of serious harms, were (in order of frequency):
The top five conditions noted above account for 39 percent of serious misdiagnosis-related harms.
But even knowing the clinical conditions most often missed is not enough. Patients don’t come to the ED with a complaint “possible spinal cord compression”. While it is nice to know the conditions most often missed, it would also be nice to know which diagnoses made were most often in error. For example, if it turns out a diagnosis of “vestibular neuritis” was erroneous 15% of the time, that might prompt ED clinicians to always think twice any time they consider such a diagnosis. And our focus should be on the presenting symptoms most often associated with missed diagnoses.
The AHRQ study did find that clinical presentation was important. For example, the average rate for missed stroke was 17% but it was 40% when the presenting symptom was dizziness/vertigo vs. 4% when the presenting symptom was weakness. The authors found that nonspecific, mild, transient, or “atypical” symptoms frequently contributed to missed diagnoses. In fact, atypical or non-specific symptoms were the strongest and most consistent predictors of increased risk for a missed diagnosis across diseases studied.
The authors provided a table with the most common “atypical” presenting symptoms and their related misdiagnosed diseases:
Abdominal pain | Myocardial infarction, aortic aneurysm/dissection, appendicitis, diverticulitis, ovarian disease, gallbladder pathology, cancer |
Back pain | Spinal abscess or other spinal cord compression, myelitis, aortic aneurysm/dissection |
Dyspnea/shortness of breath | Myocardial infarction, aortic aneurysm/dissection |
Fever | Sepsis, aortic aneurysm/dissection (aortitis) |
Headache | Stroke, (other diseases with headaches as a more “typical” presentation include subarachnoid hemorrhage, meningitis/encephalitis, raised intracranial pressure, and giant cell arteritis) |
Syncope/fall | Myocardial infarction, aortic aneurysm/dissection, venous thromboembolism, stroke |
Altered mental status/confusion | Stroke, sepsis |
Dizziness/vertigo | Stroke |
Fatigue/malaise/generalized weakness | Myocardial infarction, stroke, sepsis |
Gait disturbance | Stroke |
Nausea/vomiting | Stroke, appendicitis, myocardial infarction |
Atypical or non-specific symptoms were the strongest and most consistent predictors of increased risk for a missed diagnosis across diseases studied.
Patient age, gender, and race may impact error rates. For example, older age increases risk of missed appendicitis, while younger age increases risk of missed stroke 6.7-fold. The lay press (Medaris 2022) recently highlighted the latter problem, describing 3 patients in their 20’s whose strokes were misdiagnosed as being due to migraine or drugs.
Female sex and non-White race were often associated with important (20–30%) increases in misdiagnosis risk in the AHRQ study. There was also significant variation by hospital (for example, the rate of missed myocardial infarction varied from 0% to 29% across hospitals within a one study). Other notable predictors of misdiagnosis included care provided by less experienced clinicians, at non-teaching hospitals, with high ED discharge fraction, and during off hours. The diagnostic performance gap with academic (teaching) ED’s having lower false negative rates than community (non-teaching) ED’s was a fairly consistent finding, but it is unknown whether lower academic false-negative rates were achieved through greater overall diagnostic accuracy or by favoring overutilization, leading to arbitrarily greater admission fractions and resulting in higher false-positive rates.
The AHRQ study also cites previous work from malpractice claims on factors contributing to ED diagnostic error. Such factors include failure/delay in ordering diagnostic test; lack of/inadequate patient assessment with premature discharge; narrow diagnostic focus in patient assessment with failure to establish differential diagnosis; failure to appreciate and reconcile relevant signs, symptoms, or test results; failure/delay in obtaining a consultation or referral; misinterpretation of diagnostic test studies (e.g., X-rays); issues related to lack of health insurance; inadequate communication among providers regarding the patient’s condition; off-hours care (weekend, night shift, or holiday); inadequate history or physical examination.
Of course, we always need to balance the risk of misdiagnosis against the risk of overdiagnosis or unintentionally initiating the “diagnostic cascade”. For example, though stroke was often misdiagnosed when vertigo/dizziness was a presenting symptom, we certainly don’t want every patient with vertigo or dizziness to get a CT scan or MRI scan. We know that the diagnostic cascade not only adds to the cost of healthcare but may also lead to unnecessary procedures that, in turn, may lead to patient harm.
From the studies done on diagnostic error in the ED, it is also difficult to understand the likely role of fatigue, which we know increases error rates in a variety of venues. There is also one other consideration never assessed in these studies. We’ve often cited a study on shift workers in fields other than healthcare (Folkard 2003) which showed that the risk of incidents increased each consecutive day worked. For example, on average for night shifts risk was 6% higher on the second night, 17% higher on the third night, and 36% higher on the fourth night (for morning/day shifts the corresponding risks were 2%, 7% and 17%). There’s little reason to think that such trends might not also occur in healthcare, particularly in the ED where long consecutive-day shifts are common.
The AHRQ study wasn’t the only recent study on diagnostic errors in the ED. Baartmans et al. (Baartmans 2022) studied 23 serious error event reports of diagnostic events in emergency departments of Dutch general hospitals and identified human errors. Twenty-one reports contained a diagnostic error, in which the authors identified 73 human errors. These were mainly based on intended actions (n = 69) and could be classified as mistakes (n = 56) or violations (n = 13). Most human errors occurred during the assessment and testing phase of the diagnostic process.
Similar to the AHRQ report, most prevalent missed or delayed final diagnoses were cardiovascular (n = 11) or neurological (n = 5) conditions, such as aorta dissection, ruptured abdominal aortic aneurysm, subarachnoid hemorrhage, and spinal cord injury. They found that diagnostic errors occurred most often in the assessment and testing domains. Other human errors sometimes occurred during referral or consultation, history taking, the physical exam, follow-up, and at access to care or presentation. Most human errors involved a failure or delay in recognizing the urgency of the situation or putting too much weight on a competing or coexisting diagnosis (for example, the working diagnosis of a migraine disrupted the search for other causes of the symptoms of a patient with a subarachnoid hemorrhage). Other recurring themes were the failure or delay to consider a diagnosis, failed or delayed follow-up of (abnormal) test results, failure or delay in ordering needed tests, wrong test orders, and failure or delayed communication or follow-up of a consultation.
The authors note that hospitals seldom propose overarching interventions to support the diagnostic process, for example, evidence-based strategies to improve specific knowledge, reforming training methods, structural feedback and reflection on diagnostic discrepancies, implementation of diagnostic decision support systems to improve diagnostic calibration, or implementing team-based diagnosis. They also note that system-aimed interventions (e.g., lowering work pressure and crowding in the ED, improving patient safety culture, teamwork interventions, and cultural aspects) are also rarely proposed, while these types of recommendations may have a better chance of being effective in preventing similar cases and to improve diagnostic safety.
Diagnostic error remains our greatest patient safety challenge. It’s an area for which we’ve had the fewest solutions to date, and it applies to every healthcare venue, not just the ED. Sensationalizing the statistics is not likely to lead to any productive changes. Rather, focusing on the nature of the errors and factors contributing to them is much more likely to lead to productive changes. In that regard, the AHRQ study is a useful beginning.
References:
Newman-Toker DE, Peterson SM, Badihian S, et al. Diagnostic Errors in the Emergency Department: A Systematic Review. Comparative Effectiveness Review No. 258. (Prepared by the Johns Hopkins University Evidence-based Practice Center under Contract No. 75Q80120D00003.) AHRQ Publication No. 22(23)-EHC043. Rockville, MD: Agency for Healthcare Research and Quality; December 2022
Medaris A. Doctors dismissed these 3 young people's symptoms as migraines or drug-related — but they were really having strokes. Insider 2022; Dec 26, 2022
https://www.insider.com/doctors-dismissed-young-peoples-strokes-as-drugs-alcohol-migraines-2022-11
Folkard S, Tucker P. Shift work, safety and productivity. Occupational Medicine 2003; 53: 95-101
Baartmans MC, Hooftman J, Zwaan L, et al. What Can We Learn From In-Depth Analysis of Human Errors Resulting in Diagnostic Errors in the Emergency Department: An Analysis of Serious Adverse Event Reports. Journal of Patient Safety 2022; 18(8): e1135-e1141
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January 17, 2023
Patient Safety with NOAC’s and DOAC’s
Oral anticoagulants are the mainstay for prevention of stroke in patients with atrial fibrillation. With the advent of non-vitamin K antagonist oral anticoagulants (NOAC’s)/direct oral anticoagulants (DOAC’s), many of the safety concerns we had when using warfarin were expected to be bypassed. These new oral anticoagulants no longer needed to be titrated to a lab value and had fewer drug and food interactions than seen with warfarin. And clinical trials of most of these newer agents showed efficacy at least as good as warfarin along with fewer serious bleeding consequences. So, combining simpler regimens with better safety profiles has led to greater uptake of these agents in patients with atrial fibrillation, including their use in patients in whom we’d previously have been wary of using warfarin.
Ko et al. (Ko 2022) looked at trends between 2010 and 2020 in initiation of oral anticoagulants in Medicare Advantage patients age 65 and older with atrial fibrillation. Indeed, rates improved from 20.2% to 32.9% (with the rate of DOAC uptake increasing from 1.1% to 30.9%). Over the same period, warfarin initiation decreased from 19.1% to 2.0%. Among patients who were initiated on oral anticoagulants, there was an increase in DOAC uptake from 5.4% in 2010 to 93.9% in 2020. Moreover, nonadherence rates decreased from 52.2% to 39.0%. But patients with dementia, frailty, and anemia were still less likely than patients without those conditions to have an oral anticoagulant initiated. The authors conclude that, despite the improved rates of oral anticoagulation, such management has remained suboptimal. They call for additional strategies to improve stroke prophylaxis in all older adults with atrial fibrillation including those with coexisting dementia, frailty, and anemia.
A recent Medscape article (Wajngarten 2022) summarized several recent studies on safety issues with NOAC’s/DOAC’s in patients with atrial fibrillation. He cited a a systematic review and meta-analysis by Caso et al. (Caso 2022) that found frequent inappropriate dosing of non-vitamin K antagonist oral anticoagulants (NOAC’s) in patients with atrial fibrillation. Compared with recommended DOAC dosing, overdosing was associated with an increased risk of major bleeding, as expected. Underdosing was associated with a null effect on stroke outcomes and bleeding outcomes (the latter unexpected) but an increased risk of all-cause mortality. Increased age, history of minor bleeds, hypertension, congestive heart failure and low creatine clearance were associated with an increased risk of underdosing.
Physicians have been reluctant to use anticoagulants in patients at risk for falls. We’ve done several columns on the risk of intracranial hemorrhage after head trauma in patients taking oral anticoagulants, with studies offering mixed conclusions. Wajngarten cited a new Canadian study (Grewal 2021) that found patients on warfarin seen in the emergency department with a head injury had higher relative risks of intracranial hemorrhage than matched patients on a DOAC and patients not on anticoagulation, respectively. The risk of intracranial hemorrhage for patients on a DOAC was not significantly different compared with no anticoagulation.
Another patient group in which anticoagulant prescription has been low is those with frailty. Wajngarten cited a recent study (Kim 2022) that showed in frail patients with AF, oral anticoagulant treatment was associated with a positive net clinical outcome. DOAC’s provided lower incidences of stroke, bleeding, and mortality, compared with warfarin.
Taken together, these studies suggest that many of the barriers to prescribing oral anticoagulants in patients with atrial fibrillation still exist, despite evidence that their use in such patients might be justified, particularly when NOAC’s/DOAC’s are used rather than warfarin.
Some of our previous columns on head trauma in the anticoagulated patient:
April 16, 2007 “Falls With Injury”
July 17, 2007 “Falls in Patients on Coumadin or Heparin or Other Anticoagulants”
June 5, 2012 “Minor Head Trauma in the Anticoagulated Patient”.
July 8, 2014 “Update: Minor Head Trauma in the Anticoagulated Patient”
August 21, 2018 “Delayed CT Scan in the Anticoagulated Patient”
September 21, 2021 “Repeat CT in Anticoagulated Patients After Minor Head Trauma Not Cost-Effective”
December 14, 2021 “Delayed Hemorrhage After Head Trauma in Anticoagulated Patients”
References:
Ko D, Lin KJ, Bessette LG, et al. Trends in Use of Oral Anticoagulants in Older Adults With Newly Diagnosed Atrial Fibrillation, 2010-2020. JAMA Netw Open 2022; 5(11): e2242964
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2798659
Wajngarten M. Oral Anticoagulant Mistakes to Avoid in Older Adults With AF. Medscape Medical News 2022; December 23, 2022
https://www.medscape.com/viewarticle/986128?src=WNL_dne1_221226_MSCPEDIT&uac=14695HV&impID=5032296
Caso V, de Groot JR, Sanmartin Fernandez M, et al. Outcomes and drivers of inappropriate dosing of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation: a systematic review and meta-analysis. Heart. 2022; Published Online First: 31 October 2022
https://heart.bmj.com/content/early/2022/10/31/heartjnl-2022-321114.long
Grewal K, Atzema CL, Austin PC et al. Intracranial hemorrhage after head injury among older patients on anticoagulation seen in the emergency department: a population-based cohort study. CMAJ 2021; 193(40): E1561-E1567
https://www.cmaj.ca/content/193/40/E1561.long
Kim D, Yang PS, Sung JH, et al. Effectiveness and Safety of Anticoagulation Therapy in Frail Patients With Atrial Fibrillation. Stroke 2022; 53(6): 1873-1882
https://www.ahajournals.org/doi/10.1161/STROKEAHA.121.036757
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January 24, 2023
Tale of 2 Graces
Our December 17, 2019 Patient Safety Tip of the Week “Tale of Two Tylers” showed a healthcare mix-up of a hockey player and a basketball player, both named Tyler Ennis. X-rays of one Tyler Ennis were mistaken for those of the other Tyler Ennis. Fortunately, there were no adverse consequences from the mix-up but there could have been.
While it is not, per se, a patient safety example, a recent Kaiser Health News story (Kreidler 2022) showed how the same type of patient misidentification can lead to nightmares for a patient. The snafu involved 31-year-old Grace E. Elliott and 81-year-old Grace A. Elliott. Grace E. had a hospital visit with a small bill 8 years earlier while visiting her parents in Venice, Florida. Grace A. had an expensive shoulder replacement at the same hospital years later. But a bill addressed to Grace E. was sent to Grace E’s mother with charges for a shoulder replacement (Grace E. was no longer living in Florida). Initially suspecting possible identity theft, Grace E. contacted the hospital. After several weeks and multiple phone calls, the corporate office for the hospital let Grace E. know of the hospital’s error and promised to correct it. But, in the interim, the account had been turned over to a collection agency and the misidentification was not communicated to the collection agency. Two appeals to the collection agency were denied. It was only after involvement of a reporter that the snafu was ultimately resolved. In all, it took nearly a year of hours-long phone calls to undo the damage.
In addition to the patient identification error, there were obviously communication errors. Hospital ownership had changed, and the hospital had actually closed prior to this case being resolved. Moreover, in one of the collection agency’s denial letters several pages of the older woman’s medical information were disclosed (certainly sounds to us like there may be HIPAA implications). Though the case involves billing records, the latter issue also raises the question about whether any medical information has been incorrectly included in the medical records of either or both of these patients.
Correct patient identification is the responsibility of all hospital personnel, not just clinicians. Two-factor identification is the minimum requirement. Most hospitals and healthcare facilities use patient name and date of birth as the two identifiers. Grace E. and Grace A. had different dates of birth. But even using date of birth may not be an adequate safeguard. In our March 26, 2019 Patient Safety Tip of the Week “Patient Misidentification” we noted a near-miss when two patients had the same name and same date of birth and noted the fact that, in one hospital district in Texas, 2488 patients were named Maria Garcia, and 231 of these (9.3%) also shared the same date of birth! (Lippi 2017).
Our December 17, 2019 Patient Safety Tip of the Week “Tale of Two Tylers” showed a glaring example of how patient photographs in the EMR might prevent a wrong patient error. Obviously in the current case photographs could also have easily distinguished patients of widely different ages.
Our December 17, 2019 Patient Safety Tip of the Week “Tale of Two Tylers” also has a discussion on how a long-overdue national patient identifier (NPI) system could serve as a means of preventing patient misidentification.
We recommend you read the entire Kaiser Health News story (Kreidler 2022) for all the details of the current example. This is an excellent story you should include in your orientation of non-clinical personnel in your organization to emphasize the importance of correct patient identification at all times.
Some of our prior columns related to patient identification issues:
May 20, 2008 “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?”
November 17, 2009 “Switched Babies”
July 17, 2012 “More on Wrong-Patient CPOE”
June 26, 2012 “Using Patient Photos to Reduce CPOE Errors”
April 30, 2013 “Photographic Identification to Prevent Errors”
August 2015 “Newborn Name Confusion”
January 12, 2016 “New Resources on Improving Safety of Healthcare IT”
January 19, 2016 “Patient Identification in the Spotlight”
August 1, 2017 “Progress on Wrong Patient Orders”
June 19, 2018 “More EHR-Related Problems”
November 2018 “More on Hearing Loss”
March 26, 2019 “Patient Misidentification”
May 21, 2019 “Mixed Message on Number of Open EMR Records”
September 10, 2019 “Joint Commission Naming Standard Leaves a Gap”
December 17, 2019 “Tale of Two Tylers”
March 24, 2020 “Mayo Clinic: How to Get Photos in Your EMR”
June 16, 2020 “Tracking Technologies”
November 17, 2020 “A Picture Is Worth a Thousand Words”
August 3, 2021 “Obstetric Patients More At-Risk for Wrong Patient Orders”
Some of our prior columns on use of patient photographs in patient safety:
December 2008 “Patient Photographs Improve Radiologists’ Performance”
January 12, 2010 “Patient Photos in Patient Safety”
June 26, 2012 “Using Patient Photos to Reduce CPOE Errors”
April 30, 2013 “Photographic Identification to Prevent Errors”
January 19, 2016 “Patient Identification in the Spotlight”
March 26, 2019 “Patient Misidentification”
November 12, 2019 “Patient Photographs Again Help Radiologists”
December 17, 2019 “Tale of Two Tylers”
March 24, 2020 “Mayo Clinic: How to Get Photos in Your EMR”
November 17, 2020 “A Picture Is Worth a Thousand Words”
References:
Kreidler M. The case of the two Grace Elliotts: A medical billing mystery. Kaiser Health News 2022; December 21, 2022
https://khn.org/news/article/mistaken-identity-two-grace-elliotts-medical-billing-mystery/
Lippi G, Chiozza L, Mattiuzzi C, Plebani M. Patient and Sample Identification. Out of the Maze? J Med Biochem 2017; 36(2): 107-112. Published online 2017 Apr 22
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5471642/
Print “Tale of 2 Graces”
January 31, 2023
Alert on Oxygen Cylinder Use
We’ve written about problems with oxygen cylinders in several columns (see our What's New in the Patient Safety World columns for November 2016 “Oxygen Tank Monitoring” and February 2018 “Oxygen Cylinders Back in the News”). And, of course, running out of oxygen during patient transports was a major reason that the “Ticket to Ride” checklist was developed (see below for our many columns on the “Ticket to Ride”).
England’s NHS (National Health Service) recently issued a patient safety alert regarding oxygen cylinders (NHS 2023). NHS saw an increased number of incidents involving oxygen cylinders as there was a surge in demand for oxygen for respiratory-related illnesses. That surge raised issues around oxygen cylinders regarding not only patient safety, but also fire safety and physical safety. It found 120 patient safety incidents related to oxygen cylinders over a 12 month period. These included incidents such as:
Some of these reports described compromised oxygen delivery to the patient, leading to serious deterioration and cardiac or respiratory arrest. In addition, there is a need to conserve oxygen cylinder use to ensure a robust supply chain process.
NHS recommends that hospitals and healthcare facilities undertake a risk assessment, including attention to the following:
NHS also notes that priority should be given to escalation/transient areas being used to acutely care for patients (eg corridors, non-inpatient areas such as physiotherapy departments, ambulances outside emergency departments).
NHS had also just released a guidance “Safe Use of Oxygen Cylinders” that stresses patient safety issues, fire safety, physical safety, and conservation of resources. It begins by reminding us that oxygen treatment should be optimized to target saturation ranges as recommended in BTS Guideline for oxygen use in adults in healthcare and emergency settings (O'Driscoll 2017). Fixed performance (or "Venturi") masks should be used preferentially to ensure that oxygen saturations remain within the target range. Organizations should ensure that these are available in sufficient quantities. NHS England support patients requiring CPAP or non-invasive ventilation, especially if in an ambulance, to be prioritized for transfer to a clinical area where oxygen via the MGPS (medical gas pipeline systems) is available. If this is not possible, use the lowest flow device available. It stresses ongoing clinical checks, with oxygen saturation checks using appropriate oximeter positioning and probes, and both initial and regular flow checks to ensure oxygen is flowing to the patient.
Regarding patient safety issues, it recommends:
Because of the current supply issue, the guidance notes it is important the cylinders are used until the cylinder content display is nearing empty, to ensure maximal use. But that also has important patient safety implications. It is therefore essential when using any oxygen cylinder to always check the cylinder contents display and estimate the approximate residual volume according to the prescribed flow rate. (A generic guide covering commonly used cylinders can be downloaded and displayed in clinical areas or laminated and tagged to standalone cylinders). Care must be taken that cylinders do not fully empty, and patients no longer receive oxygen. On transfer: ensure patients requiring oxygen are transferred with an oxygen cylinder and that there is sufficient oxygen left to facilitate the transfer and/or the time to undertake diagnostic tests. That is a point we emphasize in our columns on the “Ticket to Ride” checklist. On arrival to ward, ensure patient is attached to oxygen via MGPS (medical gas pipeline systems), eliminating the risk of inadvertent connection to medical air via a flowmeter and oxygen cylinders are returned as soon as possible.
Regarding physical safety issues, the guidance recommends:
The NHS guidance discusses fire safety issues as well. It recommends:
Our October 2022 What's New in the Patient Safety World column “Portable Oxygen and Ambulance Fire” discussed the role of portable oxygen in a fatal ambulance fire. The recent NHS guidance specifically addresses the use of oxygen in ambulances, noting that prolonged use of supplemental oxygen in an enclosed ambulance “saloon” may increase the risk of fire due to raised ambient oxygen concentrations. To minimize this risk the following should be considered:
With extended use of supplemental oxygen in the ambulance “saloon” it may be necessary to change onboard cylinders during deployment. Care should be taken to ensure that all valves, regulators and fitments are clean, dry and free from grease or any other contaminant before re-attachment to a cylinder. Following reattachment, valves should be opened slowly into an open supply, i.e. with the flowmeter open, to reduce the risk of fire or explosion from “adiabatic compression” – following instructions for use available for medical gas cylinder supplier. It provides a link to a very interesting discussion about an oxygen cylinder that caught fire whilst being prepared for a patient who was being transferred to another hospital (Kelly 2014). That fire seemed to arise from within the cylinder and they discuss and the article discusses both the potential fuels within a cylinder plus the “adiabatic” heating of the gases that could lead to combustion.
Don’t forget oxygen cylinders have been projectiles in fatal MRI accidents (see our many columns on MRI safety listed below). We’ve also recommended you carry out simulations or drills with your local police or fire departments. You don’t want any of their personnel entering an MRI suite with an oxygen cylinder.
Our February 2018 What's New in the Patient Safety World column “Oxygen Cylinders Back in the News” was triggered by a previous NHS safety alert based on over 400 incidents involving oxygen cylinders. We hope you’ll go back to that column for our comments. We criticized that NHS alert because the recommended actions were primarily educational, and we’ve often pointed out that educational interventions are among the least effective interventions. We are pleased to see that the current NHS alert goes well beyond recommendations for educational interventions.
The current “tripledemic” of respiratory illnesses has undoubtedly resulted in potential problems in use, storage, and transport of oxygen cylinders. Now is a good time to review your own vulnerabilities to incidents involving oxygen cylinders. Even if you don’t have a Medical Gas Committee you should at least incorporate assessment of oxygen cylinders into your Patient Safety Walk Rounds (not only assessing cylinders in storage areas but also checking safety issues any time you find an oxygen cylinder with a patient during an intrahospital transport). And for those of you looking for a topic for a FMEA (Failure Mode and Effects Analysis), this is a good topic.
Some of our prior columns on potential harmful effects of oxygen and other oxygen issues:
April 8, 2008 “Oxygen as a Medication”
January 27, 2009 “Oxygen Therapy: Everything You Wanted to Know and More!”
April 2009 “Nursing Companion to the BTS Oxygen Therapy Guidelines”
October 6, 2009 “Oxygen Safety: More Lessons from the UK”
July 2010 “Cochrane Review: Oxygen in MI”
December 6, 2011 “Why You Need to Beware of Oxygen Therapy”
February 2012 “More Evidence of Harm from Oxygen”
March 2014 “Another Strike Against Hyperoxia”
June 17, 2014 “SO2S Confirms Routine O2 of No Benefit in Stroke”
December 2014 “Oxygen Should Be AVOIDed”
August 11, 2015 “New Oxygen Guidelines: Thoracic Society of Australia and NZ”
November 2016 “Oxygen Tank Monitoring”
November 2016 “More on Safer Use of Oxygen”
October 2017 “End of the Oxygen in MI and Stroke Debate?”
February 2018 “Oxygen Cylinders Back in the News”
June 2018 “Too Much Oxygen”
July 2021 “Unique Way to Rapidly Identify Oxygen Flow”
October 2022 “Portable Oxygen and Ambulance Fire”
January 2023 “Oxygen During Surgery”
Some of our prior columns on intrahospital transports and the “Ticket to Ride” concept:
Some of our prior columns on patient safety issues related to MRI:
References:
NHS England. Patient Safety Alert. Use of oxygen cylinders where patients do not have access to medical gas pipeline systems. NHS England 2023; January 10, 2023
NHS England. Safe Use of Oxygen Cylinders. NHS England 2023; 5 January 2023, Version 1
O'Driscoll BR, Howard LS, Earis J on behalf of the British Thoracic Society Emergency Oxygen Guideline Group, et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax 2017; 72(Supplement 1): ii1-ii90
https://thorax.bmj.com/content/72/Suppl_1/ii1
Kelly, F.E., Hardy, R. and Henrys, P. Oxygen cylinder fire – an update. Anaesthesia 2014; 69: 511-513
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.12698
Print “Alert on Oxygen Cylinder Use”
February 7, 2023
Reducing Unnecessary Telemetry
When hospitals ask “Where should we start?” in addressing alarm fatigue, we always tell them the first place to look is at unnecessary telemetry. There are two key elements in programs to reduce such use:
A hospital system recently did just that (Patidar 2022). They did 2 key interventions across 4 hospitals (a large academic quaternary center, a tertiary care center, a small community hospital, and a large community hospital) with a total of 1700 beds. The 2 key elements were:
There was a statistically and clinically significant 24% decrease in telemetry duration between pre- and post-intervention time periods (P < 0.0001). Mean telemetry duration was 4.11 and 2.36 days in pre- and post-intervention periods, respectively, a 1.75 day reduction across each of the four hospitals.
The authors projected a substantial cost avoidance from this project. Though they did not measure it, there was also likely also a substantial reduction in alarm fatigue as a result of the project.
The Patidar article details the project planning by a multidisciplinary team and the communication rollout that was important in preparing for the implementation of the automated protocol.
The results are remarkably similar to a program we highlighted in our October 2014 What's New in the Patient Safety World column “Alarm Fatigue: Reducing Unnecessary Telemetry Monitoring”, in which researchers at Christiana Care Health System successfully reduced unnecessary non-ICU telemetry and achieved substantial financial savings while not adversely impacting patient safety (Dressler 2014). A multidisciplinary team designed the program and ensured appropriate training of impacted departments. The key component was hardwiring the AHA guidelines into their electronic ordering system. Providers were now required to choose an indication from a list, each of which included a duration based upon the AHA guidelines. In addition, they removed telemetry orders from order sets for conditions where monitoring was not supported by the AHA guidelines. Also, guidelines were established for automatic discontinuation of telemetry monitoring. After implementation there was a 70% reduction in the mean daily number of patients being monitored by telemetry. The mean weekly number of telemetry orders dropped 43% and the mean duration of telemetry dropped by 47%.
Another striking reduction in telemetry was achieved on a hospitalist service (Edholm 2018). Interventions included education, process change, routine feedback, and a financial incentive. A system-wide change to the telemetry ordering process was also introduced without the other components. Among hospitalist service patients, telemetry utilization was reduced by 69%. On the non-hospitalist services the reduction was a less marked 22%. There were no significant increases in mortality, code event rates, or care escalation, and there was a trend toward improved utilization appropriateness. The EHR telemetry order was modified to discourage unnecessary telemetry monitoring. The new order required providers ordering telemetry to choose a clinical indication and select a duration for monitoring, after which the order would expire and require physician renewal or discontinuation. These were the only changes that occurred for nonhospitalist providers.
The authors also noted there had been an immediate decrease in telemetry orders after removing the telemetry order from their admission order set. They also attributed success on the hospitalist service to standardization of rounds to include daily discussion of telemetry and the provision of routine feedback. They could not discern whether other components of the program (such as the financial incentives) contributed more or less to the program, though the sum of these interventions produced an overall program that required substantial buy in and sustained focus from the hospitalist group.
Our own take on these programs is that there are some key success factors:
Though such programs likely achieve significant financial savings, you staffs are more likely interested in outcomes other than financial ones. Though measurement of alarm fatigue is difficult, you can at least do informal surveys of stakeholders about the perceived benefit as it pertains to alarm fatigue.
Prior Patient Safety Tips of the Week pertaining to alarm-related issues:
Some of our prior columns on the hazards associated with telemetry:
References:
Patidar V, Park JM, Khasnavis T, et al. Evaluation of a Multifaceted Protocol in Reducing Unnecessary Telemetry Monitoring Across a Large Healthcare System. South Med J 2022; 115(12): 930-935
Dressler R, Dryer MM, Coletti C, et al. Altering Overuse of Cardiac Telemetry in Non–Intensive Care Unit Settings by Hardwiring the Use of American Heart Association Guidelines. (Research Letter). JAMA Intern Med 2014; 174(11): 1852-1854 published online first September 22, 2014
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1906998
Edholm K, Kukhareva P, Ciarkowski C, et al. Decrease in Inpatient Telemetry Utilization Through a System-Wide Electronic Health Record Change and a Multifaceted Hospitalist Intervention. Journal of Hospital Medicine 2018; 13: 531-536
https://shmpublications.onlinelibrary.wiley.com/doi/abs/10.12788/jhm.2933
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February 14, 2023
Code Terminology Still Problematic
In our September 18, 2007 Patient Safety Tip of the Week “Wristbands: The Color-Coded Conundrum” we noted the lack of standardization of color-coding of wristbands was problematic. Problems may arise when a healthcare worker who usually works at another facility is now exposed to a colored wristband at a new facility that has a different meaning.
The same problem can occur with the nomenclature of emergency “codes”. In our October 15, 2013 Patient Safety Tip of the Week “Missing Patients” we noted a good piece of advice from the Minnesota Hospital Association (MHA 2011). Most of you are aware of the movement to replace “codes” with plain language for paging emergencies in hospitals (and other healthcare settings). Again, that is because a “Code Yellow” may mean one thing at one hospital and a different thing at another hospital.
So, are we doing any better? Apparently not, according to a new study. Harris et al (Harris 2022) sought to assess the ability of clinical and non-clinical employees across the State of Georgia to correctly identify their facility’s emergency codes.
Anonymous electronic surveys asked 304 employees at 5 facilities to identify the codes for 14 different emergencies. Participants correctly identified the emergency codes with only 44.37% accuracy on average. Codes for fire, infant abduction, and cardiac arrest were most commonly identified correctly (≥90%). Codes for hostage situation, internal disaster, pediatric emergency, and mass casualty incident were incorrectly identified by more than 85% of participants.
They also sought to identify significant predictors of emergency code identification accuracy. Code identification accuracy was significantly higher in participants who received training at employee orientation, had knowledge of emergency code activation procedures, and had worked at their current facility for two to five years. However, accuracy was lower in employees who had worked at four to five facilities in their careers, suggesting that code confusion becomes particularly pronounced after having more than three healthcare employers.
They also assessed employees’ opinions of emergency alert systems. Most survey participants favored a color-code-based alert system over a plain language-based alert system, citing concerns of causing panic in patients and visitors, and of maintaining confidentiality and discretion. But, obviously, the color-code-based systems are not cutting it. Most code systems in the US use color-based codes (e.g., “Code Red” for a fire), predicated on the idea that colors are easier to remember and serve as a tool to increase encoding among a target audience. But individuals often associate specific colors with specific images that may not be universal.
Harris et al. point out that approximately one in five healthcare workers has at least two jobs, and each employer may have its own emergency code designations. Moreover, staffing issues have resulted in many new or temporary healthcare workers at any facility, particularly since the COVID-19 era began.
Hospital associations in more than 25 states in the US have recommended the introduction of a standardized set of emergency codes and multiple hospital associations have advocated using “plain language” codes (Wallace 2015).
There is currently no national standard in the United States for such warning systems in healthcare facilities. Harris et al. conclude that transitioning to plain language overhead emergency alerts will better position employees, as well as patients and visitors, to effectively respond to emergencies and disasters occurring within a healthcare facility. They note that both the U.S. Federal Emergency Management Agency (FEMA) and the Department of Health and Human Services (DHHS) advocate for plain language communications in all emergency and disaster communications.
The commonly cited reasons against plain language-based alerts are fear of causing panic in patients and visitors, and of maintaining confidentiality and discretion. We’ll counter that by noting that patients and visitors can play an important role in resolution of the incident leading to the alert. They might not know what a “Code Gray” or “Code Pink” means, but they could certainly help identify a wandering patient or abducted infant if the alert was more specific.
The Harris study showed that both clinical and non-clinical employees have limited accuracy in identifying their hospital’s emergency codes. Code identification accuracy was significantly associated with training at orientation, knowledge of emergency code activation procedures, facility experience, and total facilities in the career. The majority of survey participants favored a code-based alert system over a plain language-based alert system, citing concerns of causing panic in patients and visitors and maintaining confidentiality and discretion. The Harris study and the Wallace study cite several other studies demonstrating “code confusion”.
Hasn’t the time come for standardization of emergency alerts in healthcare? While the time-honored use of colors in naming codes could be standardized, we strongly favor transition to plain language-based alerts.
References:
MHA (Minnesota Hospital Association). Plain Language Overhead Emergency Paging. Implementation Toolkit. 2011
http://www.mnhospitals.org/Portals/0/Documents/ptsafety/overhead-paging-toolkit-2011.pdf
Harris C, Zerylnick J, McCarthy K, et al. Breaking the Code: Considerations for Effectively Disseminating Mass Notifications in Healthcare Settings. Int J Environ Res Public Health 2022; 19(18): 11802
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9517086/
Wallace SC, Finley E. Standardized Emergency Codes May Minimize “Code Confusion”. Pa Patient Saf Advis 2015; 12(1): 1-6
http://patientsafety.pa.gov/ADVISORIES/Pages/201503_01.aspx
Print “Code Terminology Still Problematic”
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February 14, 2023
Code Terminology Still Problematic
February 7, 2023
Reducing Unnecessary Telemetry
January 31, 2023
January 24, 2023
January 17, 2023
Patient Safety with NOAC’s and DOAC’s
January 10, 2023
January 3, 2023
Helping Inpatients Sleep – Failing Grades
December 27, 2022
Tip of the Week on Vacation
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Amazing Results from I-PASS Implementation
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Surgical Teams – the “Consistency Score”
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Rare Risk – Defibrillator Fires
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The Apple Watch and Patient Safety
November 15, 2022
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APSF on Criminalization of Medical Error
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Methotrexate Again, With a Twist
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Good Intentions, Unintended Consequences
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Successfully Reducing OR Traffic
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Smart Socks and Robots for Fall Prevention?
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AORN and Others on Retained Surgical Items
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Yes, There is a Proper Way to Assess Orthostatic Hypotension
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Tip of the Week on Vacation
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More Risks in the Radiology Suite
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Tip of the Week on Vacation
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NHS Serious Incident Response Framework
May 24, 2022
Requiring Indication for Antibiotic Prescribing
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Patient Harm in Medicare Inpatients
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A Healthcare Worker’s Worst Fear
April 5, 2022
Follow-up on Incidental Findings
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Disturbing Stats on Perioperative Benzodiazepine Use in Elderly Patients
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March 8, 2022
Update on Retained Surgical Items
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ED to Inpatient Delays Increase Mortality
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Perioperative Delirium is Not Just Postoperative
January 25, 2022
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December 21, 2021
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November 9, 2021
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Opioid-Induced Respiratory Depression Costly in Fiscal as Well as Human Terms
October 19, 2021
COVID-19 Vaccine/ Flu Vaccine Mixups
October 12, 2021
FDA Approval of Concussion Tool – Why Not a Fatigue Detection Tool?
October 5, 2021
September 28, 2021
Barcoding Better? Not So Fast!
September 21, 2021
Repeat CT in Anticoagulated Patients After Minor Head Trauma Not Cost-Effective
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The Vanderbilt Tragedy Gets Uglier
August 31, 2021
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August 24, 2021
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August 17, 2021
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Tip of the Week on Vacation
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July 6, 2021
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June 15, 2021
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June 8, 2021
Cut OR Traffic to Cut Surgical Site Infections
June 1, 2021
Stronger Magnets, More MRI Safety Concerns
May 25, 2021
Yes, Radiologists Have Handoffs, Too
May 18, 2021
Medical Overuse Is Not Just An Economic Problem
May 11, 2021
How Are Alerts in Ambulatory CPOE Doing?
May 4, 2021
More 10x Dose Errors in Pediatrics
April 27, 2021
Errors Common During Thrombolysis for Acute Ischemic Stroke
April 20, 2021
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April 13, 2021
Incidental Findings – What’s Your Strategy?
April 6, 2021
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Need for Better Antibiotic Stewardship
March 23, 2021
Nursing Staffing and Sepsis Outcomes
March 16, 2021
Sleep Program Successfully Reduces Delirium
March 9, 2021
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February 23, 2021
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MGH Protocols Reduce Risk of Self-Harm in ED
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January 12, 2021
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December 8, 2020
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November 24, 2020
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Patient Photographs Again Help Radiologists
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Yet Another (Not So) Unusual RSI
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April 2, 2019
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Happy Holidays!
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April 24, 2018
April 17, 2018
More on Tests Pending at Discharge
April 10, 2018
Prepping the Geriatric Patient for Surgery
April 3, 2018
March 27, 2018
March 20, 2018
Minnesota Highlights Lost Tissue Samples
March 13, 2018
March 6, 2018
February 27, 2018
Update on Patient Safety Walk Rounds
February 20, 2018
February 13, 2018
February 6, 2018
Adverse Events in Inpatient Psychiatry
January 30, 2018
January 23, 2018
Unintentional Hypothermia Back in Focus
January 16, 2018
January 9, 2018
More on Fire Risk from Surgical Preps
January 2, 2018
Preventing Perioperative Nerve Injuries
December 26, 2017
Tip of the Week on Vacation
December 19, 2017
December 12, 2017
Joint Commission on Suicide Prevention
December 5, 2017
Massachusetts Initiative on Cataract Surgery
November 28, 2017
More on Dental Sedation/Anesthesia Safety
November 21, 2017
OSA, Oxygen, and Alarm Fatigue
November 14, 2017
Tracking C. diff to a CT Scanner
November 7, 2017
Perioperative Neuropathies
October 31, 2017
Target Drugs for Deprescribing
October 24, 2017
Neurosurgery and Time of Day
October 17, 2017
Progress on Alarm Management
October 10, 2017
More on Torsade de Pointes
October 3, 2017
Respiratory Compromise: One Size Does Not Fit All
September 26, 2017
Tip of the Week on Vacation
September 19, 2017
Tip of the Week on Vacation
September 12, 2017
Can You Hear Me Now?
September 5, 2017
Another Iatrogenic Burn
August 29, 2017
Suicide in the Bathroom
August 22, 2017
August 15, 2017
Delayed Emergency Surgery and Mortality Risk
August 8, 2017
Sedation for Pediatric MRI Rising
August 1, 2017
Progress on Wrong Patient Orders
July 25, 2017
Can We Influence the “Weekend Effect”?
July 18, 2017
Another Hazard from Alcohol-Based Hand Gels
July 11, 2017
The 12-Hour Shift Takes More Hits
July 4, 2017
Tip of the Week on Vacation
June 27, 2017
June 20, 2017
June 13, 2017
June 6, 2017
NYS Mandate for Sepsis Protocol Works
May 30, 2017
Errors in Pre-Populated Medication Lists
May 23, 2017
May 16, 2017
Are Surgeons Finally Ready to Screen for Frailty?
May 9, 2017
Missed Nursing Care and Mortality Risk
May 2, 2017
Anatomy of a Wrong Procedure
April 25, 2017
April 18, 2017
Alarm Response and Nurse Shift Duration
April 11, 2017
Interruptions: The Ones We Forget About
April 4, 2017
Deprescribing in Long-Term Care
March 28, 2017
More Issues with Dental Sedation/Anesthesia
March 21, 2017
Success at Preventing Delirium
March 14, 2017
More on Falls on Inpatient Psychiatry
March 7, 2017
February 28, 2017
February 21, 2017
Yet More Jumps from Hospital Windows
February 14, 2017
February 7, 2017
January 31, 2017
More Issues in Pediatric Safety
January 24, 2017
Dexmedetomidine to Prevent Postoperative Delirium
January 17, 2017
January 10, 2017
The 26-ml Applicator Strikes Again!
January 3, 2017
What’s Happening to “I’m Sorry”?
December 27, 2016
Tip of the Week on Vacation
December 20, 2016
End-of-Rotation Transitions and Mortality
December 13, 2016
More on Double-Booked Surgery
December 6, 2016
Postoperative Pulmonary Complications
November 29, 2016
Doubling Down on Double-Booked Surgery
November 22, 2016
Leapfrog, Picklists, and Healthcare IT Vulnerabilities
November 15, 2016
November 8, 2016
Managing Distractions and Interruptions
November 1, 2016
CMS Emergency Preparedness Rule
October 25, 2016
Desmopressin Back in the Spotlight
October 18, 2016
Yet More Questions on Contact Precautions
October 11, 2016
New Guideline on Preop Screening and Assessment for OSA
October 4, 2016
September 27, 2016
September 20, 2016
Downloadable ABCDEF Bundle Toolkits for Delirium
September 13, 2016
Vanderbilt’s Electronic Procedural Timeout
September 6, 2016
August 30, 2016
Can You Really Limit Interruptions?
August 23, 2016
ISMP Canada: Automation Bias and Automation Complacency
August 16, 2016
How Is Your Alarm Management Initiative Going?
August 9, 2016
August 2, 2016
Drugs in the Elderly: The Goldilocks Story
July 26, 2016
Confirmed: Keep Your OR Doors Closed
July 19, 2016
Infants and Wrong Site Surgery
July 12, 2016
Forget Brexit – Brits Bash the RCA!
July 5, 2016
Tip of the Week on Vacation
June 28, 2016
Culture of Safety and Catheter-Associated Infections
June 21, 2016
Methotrexate Errors in Australia
June 14, 2016
Nursing Monitoring of Patients on Opioids
June 7, 2016
CPAP for Hospitalized Patients at High Risk for OSA
May 31, 2016
More Frailty Measures That Predict Surgical Outcomes
May 24, 2016
Texting Orders – Is It Really Safe?
May 17, 2016
Patient Safety Issues in Cataract Surgery
May 10, 2016
Medical Problems in Behavioral Health
May 3, 2016
Clinical Decision Support Malfunction
April 26, 2016
Lots More on Preventing Readmissions But Where's the Beef?
April 19, 2016
Independent Double Checks and Oral Chemotherapy
April 12, 2016
April 5, 2016
Workarounds Overriding Safety
March 29, 2016
March 22, 2016
Radiology Communication Errors May Surprise You
March 15, 2016
March 8, 2016
Tip of the Week on Vacation
March 1, 2016
February 23, 2016
February 16, 2016
February 9, 2016
February 2, 2016
January 26, 2016
More on Frailty and Surgical Morbidity and Mortality
January 19, 2016
Patient Identification in the Spotlight
January 12, 2016
New Resources on Improving Safety of Healthcare IT
January 5, 2016
Lessons from AirAsia Flight QZ8501 Crash
December 29, 2015
More Medical Helicopter Hazards
December 22, 2015
The Alberta Abbreviation Safety Toolkit
December 15, 2015
Vital Sign Monitoring at Night
December 8, 2015
Danger of Inaccurate Weights in Stroke Care
December 1, 2015
TALLman Lettering: Does It Work?
November 24, 2015
Door Opening and Foot Traffic in the OR
November 17, 2015
Patient Perspectives on Communication of Test Results
November 10, 2015
Weighing in on Double-Booked Surgery
November 3, 2015
Medication Errors in the OR - Part 2
October 27, 2015
Sentinel Event Alert on Falls and View from Across the Pond
October 20, 2015
Updated Beers List
October 13, 2015
Dilaudid Dangers #3
October 6, 2015
Suicide and Other Violent Inpatient Deaths
September 29, 2015
More on the 12-Hour Nursing Shift
September 22, 2015
The Cost of Being Rude
September 15, 2015
Another Possible Good Use of a Checklist
September 8, 2015
TREWScore for Early Recognition of Sepsis
September 1, 2015
August 25, 2015
Checklist for Intrahospital Transport
August 18, 2015
Missing Obstructive Sleep Apnea
August 11, 2015
New Oxygen Guidelines: Thoracic Society of Australia and NZ
August 4, 2015
Tip of the Week on Vacation
July 28, 2015
July 21, 2015
Avoiding Distractions in the OR
July 14, 2015
July 7, 2015
June 30, 2015
What Are Appropriate Indications for Urinary Catheters?
June 23, 2015
Again! Mistaking Antiseptic Solution for Radiographic Contrast
June 16, 2015
June 9, 2015
Add This to Your Fall Risk Assessment
June 2, 2015
May 26, 2015
May 19, 2015
May 12, 2015
More on Delays for In-Hospital Stroke
May 5, 2015
Errors with Oral Oncology Drugs
April 28, 2015
April 21, 2015
April 14, 2015
Using Insulin Safely in the Hospital
April 7, 2015
March 31, 2015
Clinical Decision Support for Pneumonia
March 24, 2015
Specimen Issues in Prostate Cancer
March 17, 2015
March 10, 2015
FDA Warning Label on Insulin Pens: Is It Enough?
March 3, 2015
Factors Related to Postoperative Respiratory Depression
February 24, 2015
More Risks with Long-Acting Opioids
February 17, 2015
Functional Impairment and Hospital Readmission, Surgical Outcomes
February 10, 2015
The Anticholinergic Burden and Dementia
February 3, 2015
CMS Hopes to Reduce Antipsychotics in Dementia
January 27, 2015
The Golden Hour for Stroke Thrombolysis
January 20, 2015
He Didn’t Wash His Hands After What!
January 13, 2015
January 6, 2015
Yet Another Handoff: The Intraoperative Handoff
December 30, 2014
Data Accumulates on Impact of Long Surgical Duration
December 23, 2014
Iatrogenic Burns in the News Again
December 16, 2014
More on Each Element of the Surgical Fire Triad
December 9, 2014
December 2, 2014
ANA Position Statement on Nurse Fatigue
November 25, 2014
Misdiagnosis Due to Lab Error
November 18, 2014
Handwashing Fades at End of Shift, ?Smartwatch to the Rescue
November 11, 2014
Early Detection of Clinical Deterioration
November 4, 2014
Progress on Fall Prevention
October 28, 2014
RF Systems for Retained Surgical Items
October 21, 2014
The Fire Department and Your Hospital
October 14, 2014
October 7, 2014
Our Take on Patient Safety Walk Rounds
September 30, 2014
More on Deprescribing
September 23, 2014
Stroke Thrombolysis: Need to Focus on Imaging-to-Needle Time
September 16, 2014
Focus on Home Care
September 9, 2014
The Handback
September 2, 2014
Frailty and the Trauma Patient
August 26, 2014
Surgeons’ Perception of Intraoperative Time
August 19, 2014
Some More Lessons Learned on Retained Surgical Items
August 12, 2014
Surgical Fires Back in the News
August 5, 2014
Tip of the Week on Vacation
July 29, 2014
The 12-Hour Nursing Shift: Debate Continues
July 22, 2014
More on Operating Room Briefings and Debriefings
July 15, 2014
Barriers to Success of Early Warning Systems
July 8, 2014
Update: Minor Head Trauma in the Anticoagulated Patient
July 1, 2014
Interruptions and Radiologists
June 24, 2014
Lessons from the General Motors Recall Analysis
June 17, 2014
SO2S Confirms Routine Oxygen of No Benefit in Stroke
June 10, 2014
Another Clinical Decision Support Tool to Avoid Torsade de Pointes
June 3, 2014
More on the Risk of Sedative/Hypnotics
May 27, 2014
A Gap in ePrescribing: Stopping Medications
May 20, 2014
May 13, 2014
Perioperative Sleep Apnea: Human and Financial Impact
May 6, 2014
Monitoring for Opioid-induced Sedation and Respiratory Depression
April 29, 2014
More on the Unintended Consequences of Contact Isolation
April 22, 2014
Impact of Resident Workhour Restrictions
April 15, 2014
Specimen Identification Mixups
April 8, 2014
FMEA to Avoid Breastmilk Mixups
April 1, 2014
Expensive Aspects of Sepsis Protocol Debunked
March 25, 2014
March 18, 2014
Systems Approach Improving Stroke Care
March 11, 2014
We Miss the Graphic Flowchart!
March 4, 2014
Evidence-Based Prescribing and Deprescribing in the Elderly
February 25, 2014
Joint Commission Revised Diagnostic Imaging Requirements
February 18, 2014
February 11, 2014
Another Perioperative Handoff Tool: SWITCH
February 4, 2014
But What If the Battery Runs Low?
January 28, 2014
Is Polypharmacy Always Bad?
January 21, 2014
January 14, 2014
Diagnostic Error: Salient Distracting Features
January 7, 2014
Lessons From the Asiana Flight 214 Crash
December 24-31, 2013
Tip of the Week on Vacation
December 17, 2013
December 10, 2013
Better Handoffs, Better Results
December 3, 2013
Reducing Harm from Falls on Inpatient Psychiatry
November 26, 2013
Missed Care: New Opportunities?
November 19, 2013
Can We Improve Dilaudid/HYDROmorphone Safety?
November 12, 2013
More on Inappropriate Meds in the Elderly
November 5, 2013
Joint Commission Sentinel Event Alert: Unintended Retained Foreign Objects
October 29, 2013
PAD: The Pain, Agitation, and Delirium Care Bundle
October 22, 2013
How Safe Is Your Radiology Suite?
October 15, 2013
October 8, 2013
October 1, 2013
Fuels and Oxygen in OR Fires
September 24, 2013
Perioperative Use of CPAP in OSA
September 17, 2013
September 10, 2013
Informed Consent and Wrong-Site Surgery
September 3, 2013
Predicting Perioperative Complications: Slow and Simple
August 27 2013
Lessons on Wrong-Site Surgery
August 20 2013
Lessons from Canadian Analysis of Medical Air Transport Cases
August 13 2013
August 6, 2013
July 9-30, 2013
Tip of the Week on Vacation
July 2, 2013
June 25, 2013
June 18, 2013
DVT Prevention in Stoke – CLOTS 3
June 11, 2013
June 4, 2013
May 28, 2013
The Neglected Medications: IV Fluids
May 21, 2013
May 14, 2013
Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)
May 7, 2013
April 30, 2013
Photographic Identification to Prevent Errors
April 23, 2013
Plethora of Medication Safety Studies
April 16, 2013
April 9, 2013
Mayo Clinic System Alerts for QT Interval Prolongation
April 2, 2013
Absconding from Behavioral Health Services
March 26, 2013
Failure to Recognize Sleep Apnea Before Surgery
March 19, 2013
Dealing with the Violent Patient in the Emergency Department
March 12, 2013
More on Communicating Test Results
March 5, 2013
Underutilized Safety Tools: The Observational Audit
February 26, 2013
Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?
February 19, 2013
Practical Postoperative Pain Management
February 12, 2013
CDPH: Lessons Learned from PCA Incident
February 5, 2013
Antidepressants and QT Interval Prolongation
January 29, 2013
A Flurry of Activity on Handoffs
January 22, 2013
You Don’t Know What You Don’t Know
January 15, 2013
January 8, 2013
More Lessons Learned on Retained Surgical Items
January 1, 2013
Don’t Throw Away Those View Boxes Yet
December 25, 2012
Tip of the Week on Vacation
December 18, 2012
Unintended Consequences of the CAUTI Measure?
December 11, 2012
December 4, 2012
Unintentional Perioperative Hypothermia: A New Twist
November 27, 2012
November 20, 2012
Update on Perioperative Management of Obstructive Sleep Apnea
November 13, 2012
The 12-Hour Nursing Shift: More Downsides
November 6, 2012
Using LEAN to Improve Stroke Care
October 30, 2012
October 23, 2012
Latent Factors Lurking in the OR
October 16, 2012
What is the Evidence on Double Checks?
October 9, 2012
Call for Focus on Diagnostic Errors
October 2, 2012
Test Results: Everyone’s Worst Nightmare
September 25, 2012
Preoperative Assessment for Geriatric Patients
September 18, 2012
September 11, 2012
In Search of the Ideal Early Warning Score
September 4, 2012
August 28, 2012
New Care Model Copes with Interruptions Better
August 21, 2012
More on Missed Followup of Tests in Hospital
August 14, 2012
August 7, 2012
Cognition, Post-Op Delirium, and Post-Op Outcomes
July 31, 2012
Surgical Case Duration and Miscommunications
July 24, 2012
FDA and Extended-Release/Long-Acting Opioids
July 17, 2012
July 10, 2012
Tip of the Week on Vacation
July 3, 2012
Recycling an Old Column: Dilaudid Dangers
June 26, 2012
Using Patient Photos to Reduce CPOE Errors
June 19, 2012
More Problems with Faxed Orders
June 12, 2012
Lessons Learned from the CDPH: Retained Foreign Bodies
June 5, 2012
Minor Head Trauma in the Anticoagulated Patient
May 29, 2012
Falls, Fractures, and Fatalities
May 22, 2012
Update on Preoperative Screening for Sleep Apnea
May 15, 2012
May 8, 2012
Importance of Nontechnical Skills in Healthcare
May 1, 2012
April 24, 2012
Fire Hazard of Skin Preps Oxygen
April 17, 2012
April 10, 2012
April 3, 2012
New Risk for Postoperative Delirium: Obstructive Sleep Apnea
March 27, 2012
March 20, 2012
Adverse Events Related to Psychotropic Medications
March 13, 2012
Medical Emergency Team Calls to Radiology
March 6, 2012
February 28, 2012
AACN Practice Alert on Delirium in Critical Care
February 21, 2012
Improving PCA Safety with Capnography
February 14, 2012
Handoffs More Than Battle of the Mnemonics
February 7, 2012
Another Neuromuscular Blocking Agent Incident
January 31, 2012
January 24, 2012
Patient Safety in Ambulatory Care
January 17, 2012
Delirium and Contact Isolation
January 10, 2012
January 3, 2012
Unintended Consequences of Restricted Housestaff Hours
December 20, 2011
December 13, 2011
December 6, 2011
Why You Need to Beware of Oxygen Therapy
November 29, 2011
November 22, 2011
Perioperative Management of Sleep Apnea Disappointing
November 15, 2011
November 8, 2011
WHOs Multi-professional Patient Safety Curriculum Guide
November 1, 2011
So Whats the Big Deal About Inserting an NG Tube?
October 25, 2011
October 18, 2011
October 11, 2011
October 4, 2011
Radiology Report Errors and Speech Recognition Software
September 27, 2011
The Canadian Suicide Risk Assessment Guide
September 20, 2011
When Practice Changes the Evidence: The CKD Story
September 13, 2011
Do You Use Fentanyl Transdermal Patches Safely?
September 6, 2011
August 30, 2011
Unintentional Discontinuation of Medications After Hospitalization
August 23, 2011
Catheter Misconnections Back in the News
August 16, 2011
August 9, 2011
Frailty and the Surgical Patient
August 2, 2011
July 26, 2011
July 19, 2011
Communication Across Professions
July 12, 2011
Psst! Pass it onHow a kids game can mold good handoffs
July 5, 2011
Sidney Dekker: Patient Safety. A Human Factors Approach
June 28, 2011
Long-Acting and Extended-Release Opioid Dangers
June 21, 2011
June 14, 2011
June 6, 2011
May 31, 2011
Book Review Human Factors and Team Psychology in a High Stakes Environment
May 24, 2011
May 17, 2011
Opioid-Induced Respiratory Depression Again!
May 10, 2011
Preventing Preventable Readmissions: Not As Easy As It Sounds
May 3, 2011
April 26, 2011
Sleeping Air Traffic Controllers: What About Healthcare?
April 19, 2011
DVT Prophylaxis in Acute Stroke: Controversy Reappears
April 12, 2011
Medication Issues in the Ambulatory Setting
April 5, 2011
March 29, 2011
The Silent Treatment:A Dose of Reality
March 22, 2011
An EMR Feature Detrimental to Teamwork and Patient Safety
March 15, 2011
March 8, 2011
Yes, Physicians Get Interrupted Too!
March 1, 2011
February 22, 2011
February 15, 2011
Controversies in VTE Prophylaxis
February 8, 2011
February 1, 2011
January 25, 2011
Procedural Sedation in Children
January 18, 2011
More on Medication Errors in Long-Term Care
January 11, 2011
NPSA (UK) How to Guide: Five Steps to Safer Surgery
January 4, 2011
December 28, 2010
HAIs: Looking In All The Wrong Places
December 21, 2010
More Bad News About Off-Hours Care
December 14, 2010
NPSA (UK): Preventing Fatalities from Medication Loading Doses
December 6, 2010
More Tips to Prevent Wrong-Site Surgery
November 30, 2010
SURPASS: The Mother of All Checklists
November 23, 2010
Focus on Cumulative Radiation Exposure
November 16, 2010
November 9, 2010
12-Hour Nursing Shifts and Patient Safety
November 2, 2010
Insulin: Truly a High-Risk Medication
October 26, 2010
Confirming Medications During Anesthesia
October 19, 2010
Optimizing Medications in the Elderly
October 12, 2010
October 5, 2010
September 28, 2010
September 21, 2010
September 14, 2010
Wrong-Site Craniotomy: Lessons Learned
September 7, 2010
Patient Safety in Ob/Gyn Settings
August 31, 2010
August 24, 2010
The BP Oil Spill Analogies in Healthcare
August 17, 2010
Preoperative Consultation Time to Change
August 10, 2010
Its Not Always About The Evidence
August 3, 2010
Tip of the Week on Vacation
July 27, 2010
EMRs Still Have A Long Way To Go
July 20, 2010
More on the Weekend Effect/After-Hours Effect
July 13, 2010
Postoperative Opioid-Induced Respiratory Depression
July 6, 2010
Book Reviews: Pronovost and Gawande
June 29, 2010
Torsade de Pointes: Are Your Patients At Risk?
June 22, 2010
Disclosure and Apology: How to Do It
June 15, 2010
Dysphagia in the Stroke Patient: the Scottish Guideline
June 8, 2010
Surgical Safety Checklist for Cataract Surgery
June 1, 2010
May 25, 2010
May 18, 2010
Real-Time Random Safety Audits
May 11, 2010
May 4, 2010
More on the Impact of Interruptions
April 27, 2010
April 20, 2010
HITs Limited Impact on Quality To Date
April 13, 2010
April 6, 2010
March 30, 2010
Publicly Released RCAs: Everyone Learns from Them
March 23, 2010
ISMPs Guidelines for Standard Order Sets
March 16, 2010
A Patient Safety Scavenger Hunt
March 9, 2010
Communication of Urgent or Unexpected Radiology Findings
March 2, 2010
Alarm Sensitivity: Early Detection vs. Alarm Fatigue
February 23, 2010
Alarm Issues in the News Again
February 16, 2010
Spin/HypeKnowing It When You See It
February 9, 2010
More on Preventing Inpatient Suicides
February 2, 2010
January 26, 2010
Preventing Postoperative Delirium
January 19, 2010
January 12, 2010
Patient Photos in Patient Safety
January 5, 2010
December 29, 2009
Recognizing Deteriorating Patients
December 22, 2009
December 15, 2009
December 8, 2009
December 1, 2009
Patient Safety Doesnt End at Discharge
November 24, 2009
Another Rough Month for Healthcare IT
November 17, 2009
November 10, 2009
Conserving ResourcesBut Maintaining Patient Safety
November 3, 2009
Medication Safety: Frontline to the Rescue Again!
October 27, 2009
Co-Managing Patients: The Good, The Bad, and The Ugly
October 20, 2009
Radiology AgainBut This Time Its Really Radiology!
October 13, 2009
October 6, 2009
Oxygen Safety: More Lessons from the UK
September 29, 2009
Perioperative Peripheral Nerve Injuries
September 22, 2009
Psychotropic Drugs and Falls in the SNF
September 15, 2009
ETTOs: Efficiency-Thoroughness Trade-Offs
September 8, 2009
Barriers to Medication Reconciliation
September 1, 2009
The Real Root Causes of Medical Helicopter Crashes
August 25, 2009
Interruptions, Distractions, InattentionOops!
August 18, 2009
Obstructive Sleep Apnea in the Perioperative Period
August 11, 2009
August 4, 2009
July 28, 2009
Wandering, Elopements, and Missing Patients
July 21, 2009
Medication Errors in Long Term-Care
July 14, 2009
Is Your Do Not Use Abbreviations List Adequate?
July 7, 2009
Nudge: Small Changes, Big Impacts
June 30, 2009
iSoBAR: Australian Clinical Handoffs/Handovers
June 23, 2009
June 16, 2009
Disclosing Errors That Affect Multiple Patients
June 9, 2009
CDC Update to the Guideline for Prevention of CAUTI
June 2, 2009
Why Hospitals Should FlyJohn Nance Nails It!
May 26, 2009
Learning from Tragedies. Part II
May 19, 2009
May 12, 2009
May 5, 2009
Adverse Drug Events in the ICU
April 28, 2009
Ticket Home and Other Tools to Facilitate Discharge
April 21, 2009
April 14, 2009
More on Rehospitalization After Discharge
April 7, 2009
March 31, 2009
Screening Patients for Risk of Delirium
March 24, 2009
March 17, 2009
March 10, 2009
Prolonged Surgical Duration and Time Awareness
March 3, 2009
Overriding AlertsLike Surfin the Web
February 24, 2009
Discharge Planning: Finally Something That Works!
February 17, 2009
Reducing Risk of Overdose with Midazolam Injection
February 10, 2009
Sedation in the ICU: The Dexmedetomidine Study
February 3, 2009
NTSB Medical Helicopter Crash Reports: Missing the Big Picture
January 27, 2009
Oxygen Therapy: Everything You Wanted to Know and More!
January 20, 2009
The WHO Surgical Safety Checklist Delivers the Outcomes
January 13, 2009
January 6, 2009
December 30, 2008
Unintended Consequences: Is Medication Reconciliation Next?
December 23, 2008
December 16, 2008
Joint Commission Sentinel Event Alert on Hazards of Healthcare IT
December 9, 2008
December 2, 2008
Playing without the ballthe art of communication in healthcare
November 25, 2008
November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
November 11, 2008
November 4, 2008
October 28, 2008
More on Computerized Trigger Tools
October 21, 2008
October 14, 2008
October 7, 2008
Lessons from Falls....from Rehab Medicine
September 30, 2008
September 23, 2008
Checklists and Wrong Site Surgery
September 16, 2008
More on Radiology as a High Risk Area
September 9, 2008
Less is More.and Do You Really Need that Decimal?
September 2, 2008
August 26, 2008
August 19, 2008
August 12, 2008
Jerome Groopmans How Doctors Think
August 5, 2008
July 29, 2008
Heparin-Induced Thrombocytopenia
July 22, 2008
Lots New in the Anticoagulation Literature
July 15, 2008
July 8, 2008
July 1, 2008
WHOs New Surgical Safety Checklist
June 24, 2008
Urinary Catheter-Related UTIs: Bladder Bundles
June 17, 2008
Technology Workarounds Defeat Safety Intent
June 10, 2008
Monitoring the Postoperative COPD Patient
June 3, 2008
UK Advisory on Chest Tube Insertion
May27, 2008
If You Do RCAs or Design Healthcare ProcessesRead Gary Kleins Work
May20, 2008
CPOE Unintended Consequences Are Wrong Patient Errors More Common?
May13, 2008
Medication Reconciliation: Topical and Compounded Medications
May 6, 2008
Preoperative Screening for Obstructive Sleep Apnea
April 29, 2008
ASA Practice Advisory on Operating Room Fires
April 22, 2008
CMS Expanding List of No-Pay Hospital-Acquired Conditions
April 15, 2008
April 8, 2008
April 1, 2008
Pennsylvania PSAs FMEA on Telemetry Alarm Interventions
March 25, 2008
March 18, 2008
Is Desmopressin on Your List of Hi-Alert Medications?
March 11, 2008
March 4, 2008
Housestaff Awareness of Risks for Hazards of Hospitalization
February 26, 2008
Nightmares.The Hospital at Night
February 19, 2008
February 12, 2008
February 5, 2008
Reducing Errors in Obstetrical Care
January 29, 2008
Thoughts on the Recent Neonatal Nursery Fire
January 22, 2008
More on the Cost of Complications
January 15, 2008
Managing Dangerous Medications in the Elderly
January 8, 2008
Urinary Catheter-Associated Infections
January 1, 2008
December 25, 2007
December 18, 2007
December 11, 2007
CommunicationCommunicationCommunication
December 4, 2007
November 27,2007
November 20, 2007
New Evidence Questions Perioperative Beta Blocker Use
November 13, 2007
AHRQ's Free Patient Safety Tools DVD
November 6, 2007
October 30, 2007
Using IHIs Global Trigger Tool
October 23, 2007
Medication Reconciliation Tools
October 16, 2007
Radiology as a Site at High-Risk for Medication Errors
October 9, 2007
October 2, 2007
Taking Off From the Wrong Runway
September 25, 2007
Lessons from the National Football League
September 18, 2007
Wristbands: The Color-Coded Conundrum
September 11, 2007
Root Cause Analysis of Chemotherapy Overdose
September 4, 2007
August 28, 2007
Lessons Learned from Transportation Accidents
August 21, 2007
Costly Complications About To Become Costlier
August 14, 2007
More Medication-Related Issues in Ambulatory Surgery
August 7, 2007
Role of Maintenance in Incidents
July 31, 2007
Dangers of Neuromuscular Blocking Agents
July 24, 2007
Serious Incident Response Checklist
July 17, 2007
Falls in Patients on Coumadin or Other Anticoagulants
July 10, 2007
Catheter Connection Errors/Wrong Route Errors
July 3, 2007
June 26, 2007
Pneumonia in the Stroke Patient
June 19, 2007
Unintended Consequences of Technological Solutions
June 12, 2007
Medication-Related Issues in Ambulatory Surgery
June 5, 2007
Patient Safety in Ambulatory Surgery
May 29, 2007
Read Anything & Everything Written by Malcolm Gladwell!
May 22, 2007
May 15, 2007
Communication, Hearback and Other Lessons from Aviation
May 8, 2007
Doctor, when do I get this red rubber hose removed?
May 1, 2007
April 23, 2007
April 16, 2007
April 9, 2007
Make Your Surgical Timeouts More Useful
April 2, 2007
March 26, 2007
Alarms Should Point to the Problem
March 19, 2007
Put that machine back the way you found it!
March 12, 2007
March 5, 2007
February 26, 2007
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