Tips, Tools, Techniques, and Resources You Can Use in Your Patient Safety and Quality Improvement Initiatives

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July 1, 2008

WHO's New Surgical Safety Checklist

The World Health Organizations Safe Surgery Saves Lives initiative has released a Surgical Safety Checklist and an article on its preliminary use was published online in Lancet on June 25, 2008.

It is fitting that co-author Atul Gawande played a key role in rolling out this tool that undoubtedly will prove to be very useful in reducing adverse events related to surgery. Most of you are very familiar with Dr. Gawandes published works in the peer-reviewed literature. But perhaps his best know publication was his treatise on The Checklist that appeared in The New Yorker. In that article, he eloquently expounded upon the simplicity and sophistication of Peter Pronovosts success in introducing the concept of the checklist to improve medical care. Gawande and his colleagues have run with that concept and developed a tool that can be applied to surgery throughout the world. Piloting the checklist at 8 sites worldwide, they demonstrated that adherence to several standards of surgical care were improved from 36% to 68%. Some hospitals achieved almost 100% adherence. Their preliminary data (in 1000 patients) suggests that there will be significant reductions in surgical morbidity and mortality.

The checklist has 3 phases:

• Sign In
• Time Out
• Sign Out

At each phase, a designated Checklist coordinator must confirm that all steps/tasks have been completed before the patient moves on to the next phase. That coordinator could be any member of the team, though it is anticipated a circulating nurse may fulfill this role in many organizations.

During the Sign In phase (done before induction of anesthesia), the patient identity, site, procedure, and informed consent are confirmed. The site marking is confirmed and completion of the anesthesia safety check is done. The presence of a pulse oximeter on the patient and that it is functional are confirmed. Other issues addressed are allergies, airway risk, aspiration risk, risk of blood loss, and presence of proper equipment/assistance to help in these cases.

The Time Out phase is done before the skin incision. All team members introduce themselves by name and role. The team again confirms the identity of the patient, site, and procedure and discusses anticipated critical events. Also confirmed are antibiotic prophylaxis and timing and display of imaging studies.

The Sign Out phase is completed before the patient leaves the operating room. The Checklist coordinator verbally confirms the name of the procedure, the instrument and sponge counts, correct labeling of any specimens, any equipment problems, and key concerns for postoperative care and recovery.

The Checklist and a short manual on how to best use it can both be downloaded from the WHO website. Facilities are encouraged to modify the Checklist and add safety steps that are important to their needs, though removal of any steps is discouraged. Modification of the Checklist for specific procedures is likely to occur, for instance confirmation of specific DVT prophylaxis for many specific procedures. Yet the beauty of the Checklist is its simplicity and the authors' caution against making it too complex.

Note that the importance of checklists has also made its way into the Joint Commissions National Patient Safety Goals (see our July 2008 Whats New in the Patient Safety World column Joint Commission 2009 National Patient Safety Goals).

References:

WHO surgical safety checklist

http://www.who.int/entity/patientsafety/safesurgery/tools_resources/SSSL_Checklist_finalJun08.pdf

Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WF, Gawande AA. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008 (early online publication 25 June 2008)

http://www.thelancet.com/journals/lancet/article/PIIS0140673608608788/abstract?isEOP=true

Gawande Atul. The Checklist. If something so simple can transform intensive care, what else can it do? The New Yorker. December 10, 2007

http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande

Print WHOs New Surgical Safety Checklist

July 8, 2008

Medical Helicopter Crashes

We had intended to discuss a root cause analysis of a fireworks accident for the 4^th of July. However, in our attempts to find a good RCA on fireworks, we kept coming across references related to the crash of 2 medical helicopters in Arizona that resulted in 7 deaths. Interestingly, I had just made the comment to my wife last month that theyve got to do something about these medical helicopter crashes theyre happening every other week. One had occurred in Arizona just a few days earlier and another in Texas in June. In May there had been crashes in Wisconsin and on a hospital rooftop in Michigan. Well it is not quite every other week but there has been a rash of such crashes in 2008 nine in all, resulting in 17 people dying. Those dying have included patients, nurses, doctors, technicians and pilots. Medical helicopter crashes had been frequent in the early 1980s but then tapered off until the last decade, during which the frequency increased to a peak of 18 deaths in 2004. That trend prompted the NTSB to do a special investigation in 2006 and issue a number of recommendations to the FAA for implementation. Not all those recommendations have yet been mandated by the FAA. And the trend in fatal crashes is disturbing.

The Air Medical Physician Assosiation (AMPA) did a safety report in 2002. It reviewed medical helicopter accident rates historically and looked at death and fatality rates, putting them in perspective compared to other industries. The death rate for helicopter medical personnel was 192 per 100,000 workers compared to a rate of 3.8 per 100,000 workers for all industries in general. That paper is an excellent source of information on factors contributing to medical helicopter accidents and things that can be done to avoid them or survive them.

Of interest is that we could not find a single comprehensive RCA on a medical helicopter crash, i.e. one that looked at all potential causative or contributory factors from stem to stern. Most RCAs just focused on the aviation aspects of the crash and few look at the factors on the medical side.

There are many factors that make accidents involving medical helicopters (and some other medical aviation) more likely to occur. Many medical flights occur at night or in inclement weather. The landing areas are also not nice ample open spaces like airport runways, but are often rather tight spaces with wires and other obstacles nearby. The emergent nature of the medical mission keeps the team from canceling the flight or diverting to safer routes. The time pressures may be great. If you are trying to get a true level I trauma patient to a level I trauma center within the golden hour, or a rural stroke patient to a stroke center within the 3-hour therapeutic window, or an MI patient to a site for thrombolytic therapy or primary angioplasty site within their respective windows, time is of the essence.

Medical helicopters also are often flying without the benefit of air traffic controllers or flight dispatchers. They most often fly by sight rules and have to visually look out for other aircraft and other obstacles. The NTSB report had pointed out that most medical helicopters do not make optimal use of night vision imaging systems or night vision goggles. One comment made after a recent crash was that it is difficult to obtain the night vision imaging equipment since it is being sent over to the wars in Iraq and Afghanistan. Most medical helicopters also do not utilize terrain awareness and warning systems, another safety feature recommended by the NTSB.

Surviving a medical helicopter crash may also be difficult for a number of reasons. Helmets, shown to help save lives and prevent head injuries in military helicopter crashes, are often not worn by all medical helicopter occupants. The same applies to shoulder harnesses. And there is some evidence that serious or fatal injuries are more likely to occur to those who are not in the front seats, that is those back in the cabin may be at more risk. And the lack of aviation flight risk evaluation programs by many helicopter EMS programs was also cited by the NTSB. They also noted that helicopter EMS accidents were more likely to occur when a patient is not on board (when rules and regulations are less stringent).

When we do an RCA in a hospital or other medical facility, one of the first questions we ask is did the patient have an appropriate indication for the procedure done?. That question seems to be asked far too infrequently when doing an RCA on a medical helicopter crash. Dr. Bryan Bledsoe, quoted in a NY Times and USA Today articles, noted that only a small subset of patients actually need emergency air transportation. In 2006. Bledsoe and his colleagues did a meta-analysis of helicopter transport of trauma patients. Using several widely-used injury severity or trauma scores, they showed that almost 2/3 trauma patients brought by helicopter to a trauma center had minor or nonlife-threatening injuries and that 25% were discharged from the hospital within 24 hours. They point out that numerous studies have begun to question the benefit of helicopter vs. ground transport for trauma patients. Particularly for trauma patients with less than 45 minutes of ground transport time, there does not appear to be a significant benefit for helicopter transport.

So the question should always be asked: Does the benefit of helicopter transport outweight the potential risks in this patient?. Remember, its not just your patients its your friends and colleagues who may be going on one of those ill-fated helicopter trips.

One does need to consider the risks of alternative transport as well. Certainly there are ambulance crashes. But they are not nearly as frequent as helicopter crashes.

Even if your organization does not own its own medical helicopter, there are things you can do to help ensure the safety of your staff and patients. First and foremost, make sure the benefit of the helicopter trip is likely to outweigh the risks. Second, make sure the company that runs the helicopter has a culture of safety. If it uses standardized dispatch protocols, has night vision imaging equipment and terrain awareness and warning systems, does risk assessments, is meticulous in maintenance, has (and enforces use of) helmets and shoulder harnesses, and has good training programs for its pilots and any of your staff that may fly thats the sort of partner you are looking for. You should be participating in simulation exercises and other crew resource management drills with them. Also, the medical helicopter transport is another great process to consider for one of your FMEA (Failure Mode and Effects Analysis) activities. And beware of the old adage that new safety technology may simply push the envelope there is a tendency to take more risks when the system is perceived to be safer. So a healthy dose of skepticism and vigilance is always a good thing.

And if you are not actually riding in the helicopter yourself, be sure you and all your staff know what to do when a helicopter lands at or near your facility (see Marshall 2007) to ensure safe transfer of the patient to your facility, while protecting you and your staff from injury.

References:

National Transportation Safety Board. Special Investigation Report: Emergency Medical Services (EMS) Operations NTSB Report Number: SIR-06-01, adopted on 1/25/2006 [Summary | PDF Document] NTIS Report Number: PB2006-917001

http://www.ntsb.gov/Publictn/A_Stu.htm

Air Medical Physician Assosiation. AMPA Safety Report: November 2002

http://www.astna.org/PDF/AMPASafetyReport.pdf

Bledsoe BE. Wesley AK. Eckstein M. Dunn TM. O'Keefe MF. Helicopter scene transport of trauma patients with nonlife-threatening injuries: a meta-analysis. [Review] [81 refs] Journal of Trauma-Injury Infection & Critical Care. 60(6):1257-65; discussion 1265-6, 2006 Jun. http://www.jtrauma.com/pt/re/jtrauma/abstract.00005373-200606000-00015.htm;jsessionid=LzvDYgJNbkdJpBhDDCFtr3VBPJJ6WwQ1bvdXstQHvMNQ7Lk0Mygl!447927974!181195628!8091!-1?index=1&database=ppvovft&results=1&count=10&searchid=1&nav=search

Marshall WJ. Get ready: a patient's arriving by helicopter. Prepare the equipment and yourself to ensure a safe transfer into the hospital. Nursing 2007; 37(11):46-9, 2007 Nov

http://www.ncbi.nlm.nih.gov/pubmed/17968273?dopt=Abstract

Print Medical Helicopter Crashes

July 15, 2008

Heparin Flushes.....Again!

Weve already written about the dangers of heparin flushes three times since December 2007 and guess what they are back in the news again. This time there is a slightly different nuance but the end result is the same multiple neonates were inadvertently exposed to dangerously high doses of heparin via heparin flushes. Somewhere between 14 and 17 neonates apparently were given heparin flushes with solutions containing about 100 times the expected concentration of heparin.

In our December 2007 and April 2008 Whats New in the Patient Safety World columns we pointed out many of the lessons learned from prior incidents in Indiana and California. ISMP (the Institute for Safe Medication Practices) has done a great service in its September 21, 2006 Newsletter and November 29, 2007 Newsletter disseminating useful tips on prevention of incidents related to heparin flushes and most of their recommendations are in the above columns. Then in our May 2008 Whats New in the Patient Safety World column we discussed the UK NPSAs alert Risks with Intravenous Heparin Flush Solutions. Their recommendations were based not only on a thorough root cause analysis of several cases similar to those reported in the US, but also a thorough search into the evidence base on the utility (or lack thereof) of heparin flushes in many situations. The latter led to the conclusion that heparin flushes have no advantage over normal saline for maintaining peripheral intravenous catheters (evidence is less clear for arterial catheters or central venous catheters).

It is our opinion that one of the biggest problems is that heparin flushes are often not considered drugs or medications. They (along with oxygen and intravenous fluids) are not treated with the same respect that is used when dealing with a chemotherapy agent or insulin or other drugs. We clearly need to think of the heparin flush not only as a drug/medication but in fact as a high risk medication. Joint Commissions 2009 National Patient Safety Goals would appear to exempt the heparin flush from its more rigourous standard (which does not apply to use of anticoagulants in a fashion not expected to significantly alter coagulation parameters). Well, these cases are good examples of what can happen even when you dont expect the coagulation parameters to be altered. And inclusion of heparin in the flush solution also exposes patients to the risk of allergy and heparin-induced thrombocytopenia.

We dont have enough details about the current Texas case to be certain, but we wonder whether the prior episodes may have actually made the current episode more likely. In all the prior cases, the person administering the heparin flush had drawn it up from a multidose vial. In the current case, multidose vials of heparin were not in floor stock. Rather, pharmacy was mixing up the heparin flush solutions and the error apparently happened during pharmacys mixing procedure and was not identified by a double check. We suspect they may have been doing this procedure with the good intention of removing this highly error-prone procedure from nursing staff. Unfortunately, it seems this just moved the smoking gun from one type of provider to another. If so, that is another lesson relearned: when you implement what you think is a good solution to a patient safety problem, you need to have some measurement or other methods of both demonstrating the solution leads to the desired outcome and some way of looking for undesirable unintended consequences.

The incident highlights another point we have made over and over double checks are very weak safety interventions. From all industries we know that the error rate when a supervisor checks someone elses work may be 10% or higher. Note that we dont know what influence the double check has on the error rates of the original person. It is quite conceivable that the original person may make more errors if they feel that their errors will be intercepted by a second reviewer. We have certainly seen in some technology solutions that staff become so confident in the computers ability to capture errors that their own vigilance may wane. The UK NPSA study did acknowledge the controversy regarding double checks but notes that the literature supports a medication error reduction of about 30% when using a double check system.

In response to the current Texas incident, the Leapfrog Group released a statement again encouraging all hospitals to adopt CPOE and encouraging consumers to ask whether hospitals have CPOE before seeking care there. While we are, of course, huge advocates for CPOE, the Texas incident frankly would not likely have been prevented by CPOE. Note that we say not likely. The only way CPOE could have prevented this would be if heparin flushes required a specific physician order. Then, at the time of order entry, an alert could appear with links to the evidence base on use of heparin flushes in various settings.

This is clearly a situation where those who are looking for blood and someone to blame are way off base. Just look at some of the crude comments appearing about pharmacists and nurses and physicians and hospitals in many of the blogs in the LA Times and Wall Street Journal related to the heparin flush incidents. The two Texas pharmacists in the current episode are the two people in this entire country most likely to never have this happen again! Just as was the case with nurses getting fired after giving concentrated potassium solutions intravenously, looking at the role of individuals here takes away from getting to the root causes and coming up with viable solutions that need to be applied in all healthcare settings to prevent recurrence of these unfortunate events. Punishing those individuals would simply pave the way for a severely flawed system to be perpetuated.

So what are we to do? One solution is to use commercially available prefilled heparin flush syringes. However, those syringes must be clearly labeled in such a fashion that they are unlikely to be confused with or mistaken for similar-sized syringes filled with other medications. We have strong doubts that such a distinctive syringe can really be created. Using barcoding medication safety systems would improve that capability as long as the barcode on the prefilled syringe correctly matched the order in the system (which, in turn depends on the reliability of getting the correct concentration of heparin and correct barcode label at the factory).

Previous ISMP recommendations noted the hazards of stocking automated medication dispensing machines, especially on neonatal and pediatric units because they are especially high-risk patients. They noted that a double check of all medications as they leave the pharmacy is important but not fool-proof, as the current case demonstrates. They also made a renewed call for vigilance for look-alike/sound-alike (LASA) items and strongly recommended use of barcoding as a patient safety tool. They pointed out that even when bedside barcoding is not available, barcode systems are available for many of the automated dispensing machines to help ensure proper stocking of those machines. Previous NPSA recommendations on injectable medications included things such as only stocking low-dose heparin products in areas other than pharmacy, correctly labeling all syringes, and using double checking systems when preparing medication for injection and when administering such injections.

But perhaps the most important solution is to stop treating heparin flushes as something other than what they really are drugs and require a formal physician order for their use. Each institution clearly needs to look at their policies for use of heparin flushes and determine for which type of catheters and which type of patients is the evidence base solid enough to merit use of a heparin flush over a saline flush. Most facilities will find that they are currently using heparin flushes for many situations in which the evidence base is lacking. The UK NPSA alert recommends that heparin flushes should never be considered routine and should be used only when specifically prescribed.

And regarding the evidence base or lack thereof for some of the situations, this is where funding of multicenter randomized controlled trials by NIH or AHRQ should come in. No drug company is likely to sponsor such a study (since its conclusion could well be that the drug has no use in these situations) and many researchers will consider this too mundane an academic endeavor. However, this is exactly the kind of patient safety initiative that the Institute of Medicine (IOM) probably had in mind when it recommended legislation and creation of various methods of promoting clinical patient safety research.

We hope that the hospital in Texas will widely share the lessons learned from their root cause analysis on this incident. How many times have we already said that could happen at almost any hospital today? Lets solve this vexing issue like the concentrated potassium solution issue was solved.

Print Heparin Flushes.....Again!

July 22, 2008

Lots New in the Anticoagulation Literature

Even as the ACCP published its long awaited update Antithrombotic and Thrombolytic Therapy, 8th Ed: ACCP Guidelines, new articles are appearing in the literature that may lead to further changes in recommendations or new recommendations.

In this months issue of Archives of Neurology, Hallevi and colleagues at the stroke center at the University of Texas at Houston report their experience with cardioembolic strokes. Though it is a retrospective study and not a randomized controlled trial, the insights gleaned from their experiences is likely to change the way many neurologists and other physicians approach the issue of anticoagulation of cardioembolic stroke. While most agree on the value of long-term anticoagulation with warfarin for many cases of cardioembolic stroke, a key issue remains when and how to start anticoagulation. Though not part of any formal recommendations, a common practice has been bridging therapy in which full anticoagulation with either unfractionated heparin on low-molecular weight heparin (LMWH) is used while waiting for the INR to reach the target level as warfarin is initiated. We often do this because we are concerned that a new embolic event might occur while we are waiting for the INR to reach the therapeutic target range. However, recurrent embolic events in this short time frame are fairly infrequent. Another reason sometimes cited is the fear of the transient hypercoaguable state sometimes seen when warfarin is started without heparin that may lead to skin necrosis. The latter may be more common in patients with protein C deficiency.

The Texas group found that all their patients who suffered symptomatic hemorrhagic transformation of their cerebral infarcts were in the enoxaparin (LMWH) group. In fact, an alarming 10% of patients receiving full bridging anticoagulation with enoxaparin had symptomatic hemorrhagic transformation. They also found that cases of systemic bleeding occureed only during bridging therapy with full heparin anticoagulation (though this affected only 2 patients it was statistically significant). Interestingly, they noted that stroke progression was much more frequent in those patients treated with aspirin alone or no treatment, compared to those treated with warfarin alone or warfarin plus bridging anticoagulation. But, overall, the Texas experience would suggest that bridging therapy in this clinical circumstance may be dangerous. Whether it has a role in certain situations (eg. hypercoagulable states) remains to be determined. Their experience shows that starting warfarin at any point during the hospital stay (along with DVT prophylaxis doses of LMWH or unfractionaed heparin) is safe and effective in most cases. Further randomized controlled trials for specific clinical scenarios is desirable.

Another new article challenges current practices on DVT prophylaxis after knee arthroscopy, which do not recommend pharmacoprophylaxis for uncomplicated arthroscopy. Camporese et al in the Annals of Internal Medicine did a randomized controlled trial of graduated compression stocking vs. LMWH prophylaxis in patients undergoing knee arthroscopy. Patients with other preexisting DVT risk factors were excluded. Their primary efficacy endpoint was a cumulative composite of all-cause mortality, asymptomatic DVT, and symptomatic DVT at 3 months and occurred in 3.2% of patients in the stocking group and 0.9% of patients in the LMWH groups (they had a 7-day LMWH group and a 14-day LMWH group, the latter being subsequently stopped early though data was available). Much of the composite endpoint was made up by symptomatic distal DVT. Clinically significant bleeding was not statistically significantly different between the LMWH and stocking groups. Even the just released ACCP guidelines do not recommend pharmacoprophylaxis for routine knee arthroscopy in normal risk patients. It will be interesting to see if this new study significantly alters that practice. The incidence of serious outcomes in this population is relatively low. They did not see any cases of heparin-induced thrombocytopenia but they only had 1761 total patients in their study. But one would expect cases of HIT to occur if LMWH prophylaxis becomes more widespread after knee arthroscopy, which is the most common orthopedic procedure worldwide. So generalizing safety from a relatively small study to a population of potentially millions may be difficult.

Lastly, as followup to our recent articles on the dangers of heparin flushes, there is another update on heparin flushes in the ISMP July 17, 2008 Newsletter. It speculates on some of the possible errors that may have played a role in the recent incidents. And it notes new technology, aside from barcoding, may have a safety role. They describe use of a refractometer that can readily flag specimens which might have higher heparin concentrations. They also talk about the use of commercially-prepared heparin flush products that run batch assays to assure correct heparin concentrations. Perhaps most significantly, they note there was a conference of key stakeholders last week expected to produce wide-ranging recommendations. Stay tuned.

Well be commenting in future columns on some of the recommendations in the new ACCP guidelines. In the meantime, the executive summary of the guidelines is available on the ACCP website.

References:

ACCP. Antithrombotic and Thrombolytic Therapy, 8th Ed: ACCP Guidelines

Chest 2008; 133(6) suppl June, 2008 http://www.chestjournal.org/content/vol133/6_suppl/

Hirsh J, Gordon Guyatt G, Albers GW, Harrington R, Schnemann HJ. Executive Summary: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest Jun 2008: 71S109S. DOI 10.1378/chest.08-0693

http://www.chestjournal.org/cgi/reprint/133/6_suppl/71S

Hallevi H, Albright KC, Martin-Schild S, Barreto AD, Savitz SI, Escobar MA, Gonzales NR, Noser EA, Illoh K, Grotta JC. Anticoagulation After Cardioembolic Stroke.To Bridge or Not to Bridge? Arch Neurol.2008; 65(9):(doi:10.1001/archneur.65.9.noc70105) http://archneur.ama-assn.org/cgi/content/full/65.9.noc70105

Camporese G, Bernardi E, Prandoni P, Noventa F, Verlato F, Simioni P, Ntita K, Salmistraro G, Frangos C, Rossi F, Cordova R, Franz F, Zucchetta P, Kontothanassis D, Andreozzi GM for the KANT (Knee Arthroscopy Nadroparin Thromboprophylaxis) Study Group. Low-Molecular-Weight Heparin versus Compression Stockings for Thromboprophylaxis after Knee Arthroscopy. A Randomized Trial. Annals of Internal Medicine 2008; 149(2): 73-82 http://www.annals.org/cgi/content/abstract/149/2/73

Institute for Safe Medication Practices. Heparin errors continue despite prior, high-profile, fatal events. ISMP Newsletter July 17, 2008 http://www.ismp.org/Newsletters/acutecare/articles/20080717.asp

Print Lots New in the Anticoagulation Literature

July 29, 2008

Heparin-Induced Thrombocytopenia

We promised you wed be discussing a lot more topics from the recently published Antithrombotic and Thrombolytic Therapy, 8th Ed: ACCP Guidelines. Our last two Patient Safety Tip of the Week columns had piqued our interest as to the frequency of heparin-induced thrombocytopenia (HIT) after use of heparin flushes. As you might expect, there are no good epidemiological data to provide a good estimate. Many of the patients who developed HIT were receiving heparin therapeutically or for DVT prophylaxis in addition to receiving heparin flushes in attempt to maintain catheter patency. Nevertheless, there clearly are reports of patients developing HIT who only received heparin flushes (Kadidal 1999, Andreescu 2000, Frost 2005, McNulty 2005, Laird 2005). The 1999 paper by Kadidal et al noted 3 cases of HIT related to daily heparin flushes of central venous access devices and found only 29 previously reported cases in a review of the literature. However, the 2005 study by McNulty et al included 23 cases from one institution of HIT related solely to intravascular catheter or filter flush with heparin.

HIT is an immune-mediated disorder characterized by thrombocytopenia and propensity to both venous and arterial thromboses that occurs in patients exposed to heparin products. Other features may include skin lesions at the sites of heparin injections and some patients may suffer an anaphylactoid reaction after an IV bous of heparin. The definition of HIT has varied somewhat in the literature but most include a fall in platelet count of 50% or more from baseline. That assumes one knows the baseline platelet count prior to starting the heparin product. Note that it is possible for the platelet count to still be within the normal range at a time when it has already fallen 50%. Diagnosis requires confirmation of HIT antibodies in the serum. The reported incidence of HIT has been as high as 1-3%. However, the incidence depends upon characteristics of both the heparin products and patients themselves. The ACCP guideline Treatment and Prevention of Heparin-Induced Thrombocytopenia: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) places the overall incidence of HIT as being anywhere from less than 0.1% to 1-5%. Though the incidence may be lower with low-molecular weight heparins (LMWH) than unfractionated heparin (UFH), HIT does occur with LMWH.

The most typical course of HIT is development of thrombocytopenia 5 to 14 days after starting therapy with a heparin product. However, some patients (particularly those exposed to heparin products within the previous 100 days) may develop a more acute form that appears in the first few days after heparin is started.

Early recognition of HIT is important because of the potentially serious thrombotic complications that may occur. The thrombotic complications usually occur after the fall in platelet count has occurred but in almost 25% of cases the thrombotic complications may precede recognition of a falling platelet count. Early recognition is facilitated by monitoring the platelet count and then confirming serologically the presence of antibodies characteristic of HIT. The ACCP guideline makes its platelet count monitoring recommendations based upon the risk stratification of the patient. High-risk patients (those with risk of 1-5%) include postoperative orthopedic, cardiac and vascular surgery patients who are receiving unfractionated heparin as DVT prophylaxis for 1-2 weeks. They recommend these patients have at least every other day platelet count monitoring between postoperative days 4 to 14 (or until heparin is stopped, whichever occurs first). For patients with lesser risk (0.1% to 1%), such as medical and obstetrical patients receiving prophylactic UFH, or postoperative patients receiving LMWH after first receiving UFH, or post-operative patients receiving heparin flushes, they recommend platelet count monitoring every 2-3 days from day 4 to day 14. For the lowest risk group (risk less than 0.1%), such as medical and obstetrical patients receiving LMWH, they do not recommend routine platelet count monitoring. For patients who are starting either UFH or LMWH but who have been exposed to heparin within the past 100 days and thus are at risk for the rapid-onset type HIT, they recommend getting a baseline platelet count and a repeat within 24 hours of starting heparin. Those who have an anaphylactoid reaction to an IV bolus of heparin should have an immediate platelet count and comparison to recent prior plateley counts. For patients who are on full-dose heparin anticoagulation for treatment of venous or arterial thrombosis, the recommendation is for platelet count monitoring every 2-3 days from day 4 to day 14 (or until heparin is stopped, whichever is sooner). This group seems to be at lower risk than the group of postoperative patients on DVT prophylaxis.

Given the widespread use of heparin products in DVT prophylaxis, plus the use of heparin products for full-dose anticoagulation, plus the use (correctly or incorrectly) of heparin flushes to maintain patency of various catheters and lines, a large hospital may have several hundred patients at risk for HIT at any point in time. It is impractical to think that a physician would remember to order platelet monitoring in each of the above circumstances. A more comprehensive system for screening is desirable. Andreescu et al (Andreescu 2000) developed a pharmacy-based surveillance system to screen for HIT. They had pharmacists do chart reviews on all patients receiving 10,000 units or more of heparin products. They ensured that platelet counts were performed at least every other day on these patients. If they found the platelet count had fallen 50% from baseline or to below 100,000, the staff pharmacist contacted the pharmacist on the anticoagulation service who then coordinated management with the attending physician. Even so, they also identified some patients who were not being monitored that frequently, such as one patient who developed HIT while receiving heparin flushes only. In their study the incidence of definite HIT was 2.0 cases per 1000 heparin courses. If the cases of probable HIT were included, the incidence was 2.5 cases per 1000 heparin courses. If they considered only patients taking heparin for 5 days or more, the incidence was 12.2 cases per 1000 heparin courses. Though they recognized some limitations of their study, they felt that the surveillance program likely improved clinical outcomes and probably did so cost-effectively. In the current computer age, an automated surveillance system (using tools similar to the trigger tools we have previously described in our April 15, 2008 Patient Safety Tip of the WeekComputerizing Trigger Tools) makes more sense. One would have to identify which patients should have platelet count tracking at the time of physician order entry (note that this is another good reason why even heparin flushes should require a physician order), ensure a baseline platelet count has been obtained, prompt for the appropriate interval for tracking, and then flag for appropriate intervention any case in which the platelet count falls 50% or more (or falls below 100,000).

Of course, there is also a downside to close monitoring for HIT. There are costs associated with the frequent bloodwork, though these are relatively small compared to the costs that might be incurred in managing a case of HIT. But the most important unintended consequence would be in incorrectly identifying a patient with a platelet count that is falling for other reasons and then (while waiting for the serological confirmatory testing for HIT) either stopping the heparin that is beneficial to them or switching them to an alternative anticoagulant that may carry a higher risk of bleeding.

The management of HIT is beyond the scope of this column and we refer you to the ACCP guideline for that. Most important is discontinuation of the heparin and switching to an alternative anticoagulant. Since a high percentage of patients managed with simple discontinuation of the heparin product still develop thrombotic complications, use of alternative anticoagulants is usually recommended. The ACCP guideline does an excellent job of making recommendations for various clinical scenarios.

References:

Kadidal VV, Mayo DJ, Horne MK. Heparin-induced thrombocytopenia (HIT) due to heparin flushes: a report of three cases. Journal of Internal Medicine 1999; 246(3):325-329 http://www.journalofinfusionnursing.com/pt/re/jinfusionnurse/abstract.00004777-199909000-00012.htm;jsessionid=LNlVTvsb6SWprPG8QHySNv0VLx4F89Qd4Q2p51N02wgM5xdZNyCq!1629792715!181195629!8091!-1?nav=reference

McNulty I, Katz E, Kim KY. Thrombocytopenia Following Heparin Flush. Progress in Cardiovascular Nursing 2007; 20 (4):143-147 Published Online: 30Jan2007 http://www3.interscience.wiley.com/journal/118701380/abstract

Frost J, Mureebe L, Russo P, Russo J, Tobias JD. Heparin-induced thrombocytopenia in the pediatric intensive care unit population. Case Reports. Pediatric Critical Care Medicine 2005; 6(2):216-219 http://www.pccmjournal.com/pt/re/pccm/abstract.00130478-200503000-00018.htm;jsessionid=LNkVXtyn6N8nQrZ9lTQkSh0dC97K9l8X2gfwVb5GTlfG5nvtp2J4!523807009!181195628!8091!-1

Laird JH, Douglas K, Green R. Heparin-induced thrombocytopenia type II: A rare but significant complication of plasma exchange. Journal of Clinical Apheresis 2005; 21(2): 129-131 Published Online: 8Dec2005

http://www3.interscience.wiley.com/journal/112204776/abstract

Andreescu ACM, Possidente C, Hsieh M, Suchman M. Evaluation of a Pharmacy-Based Surveillance Program for Heparin-Induced Thrombocytopenia. Pharmacotherapy 2000; 20(8): 974-980 http://www.atypon-link.com/PPI/doi/abs/10.1592/phco.20.11.974.35264

Warkentin TE, Greinacher A, Koster A, Lincoff AM. Treatment and Prevention of Heparin-Induced Thrombocytopenia: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008: 340S380S. DOI 10.1378/chest.08-0677

http://www.chestjournal.org/cgi/content/abstract/133/6_suppl/340S

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August 12, 2008

Jerome Groopman's

"How Doctors Think"

Those of you who have followed our Tip of the Week column for over a year and a half now realize we usually do a book review when we return from vacation. This time were reviewing Jerome Groopmans How Doctors Think. I was a resident with Jerry at the Mass General and know firsthand his outstanding clinical acumen and great bedside manner. I had not realized what a great writer he is. This is one book that anyone involved in patient care, including patients and their families, should read.

In our discussions on root cause analysis in this column we have often talked about how physicians (and other healthcare workers) make decisions in acute or emergent conditions. We have stressed the work of people like Gary Klein (see our May 29, 2008 Patient Safety Tip of the Week If You Do RCAs or Design Healthcare ProcessesRead Gary Kleins Work) on pattern recognition and recognition-primed decision making. Jerry Groopman does discuss the importance of pattern recognition in physicians thinking. However, his main focus is not so much on acute situations but rather on the day to day thinking that takes place in interacting with patients. And he points out a whole variety of cognitive traps we all fall into in our thinking in such situations.

Two interesting cognitive error traps are the representativeness error and the attribution error. The former is when ones thinking is guided by a prototype and you fail to consider conditions that contradict that prototype. This tends to occur when you view a patient as a healthy, fit individual and think he would not be prone to some of the disease states that should be considered in your differential diagnosis. The attribution error is similar but more often feeds on negative cues. For example, the smell of alcohol on the breath of a patient may erroneously lead the physician to think the patient is an alcoholic, pushing the phyicians diagnostic thinking in the wrong direction. Throughout the book, Jerry reminds us that our own emotions as physicians may bias our thinking and lead us down some error paths. If we really like a patient, we may tend to underdiagnose because we subconsciously want a positive outcome for that patient. This is known as an affective error and in such cases we tend to value too highly information that fulfills our wish to see a positive outcome. That, of course, is a form of confirmation bias similar to that we often talk about in our root cause analyses where we seize upon data that seems to confirm our diagnosis and dismiss data that controverts it. Very interestingly, he discusses the potential role that patients and their families may play in helping the physician to avoid attribution errors.

Another phenomenon coloring our thinking is the availability phenomenon. This is where the most recent or most memorable cases from the past narrow our thinking about a current patient. We all know how a previous bad experience with use of a medication may influence us not to use it again, even when we know the medical evidence tells us we should use it (one of the reasons so many patients with atrial fibrillation are never placed on coumadin). He illustrates the availability error by providing a patient encounter during an epidemic of pneumonia cases in which an excellent physician did not consider aspirin toxicity because so many other patients had had pneumonia. Again this involves confirmation bias or cherry picking only a few key symptoms and rationalizing contradictory data. He also talks about anchoring where we latch onto a single possibility and fail to look for alternatives. He recommends that we should always generate at least a short list of alternative possibilities in all decision making to avoid anchoring and confirmation bias.

As an aside, weve mentioned anchoring previously and it becomes a more significant problem once a diagnosis or other decision has been declared publicly. Many of you have done an exercise in executive training where a scenario is presented in which you must state a position publicly. You are then given a bit of disconfirming evidence and a chance to change your decision. Almost no one changes their decision! (The scenario is actually a poorly disguised parallel of the Challenger disaster). Another example is when we point out that a geriatric patient is on a drug on Beers list. The physician almost never takes that patient off the drug but may in the future be less likely to prescribe that drug in other geriatric patients.

Back to Groopmans book. One way a patient can combat the anchoring and availability phenomena is to simply ask the physician Whats the worst thing this could be?. That often gets the physician to reassess his thinking and consider alternatives. Another question a patient could use is What body parts are near where Im having symptoms?. These simple, harmless questions presented in a nonconfrontational manner can influence a physician to reassess.

Using an example of a patient with a severe nutritional immunodeficiency erroneously felt to be a case of the rare hereditary disosrder severe combined immunodeficiency disorder (SCID). Here he discusses the phenomenon of diagnosis momentum in which a certain diagnosis becomes fixed in the physicians mind despite incomplete evidence. (This is somewhat similar to anchoring). And he talks about zebra retreat a term coined by Dr. Pat Croskerry. This refers to our old adage when you hear hoofbeats, think horses, not zebras. That, of course, means that common things occur commonly and we should think about atypical presentations of common things rather than rare things. Croskerry notes that weve taken that to the extreme and now often fail to consider the unusual conditions. And physicians also tend to use Ochams razor, where we try to simplify so that all symptoms are explained by one diagnosis. Some of the questions a patient might ask to avoid these sorts of errors in their physicians thinking are What else might this be? or Is it possible I might have more than one thing going on?.

Another interesting phenomenon, often seen in radiologists reviewing images, is that of search satisfaction. There the tendency is to fix on the most flagrant abnormality and fail to search for other abnormalities. You often see what you want to see.

In a discussion about approaches to cancer therapy, he talks about the tendency to keep doing the same thing even when it is not working. Often stepping back and saying What am I missing? may lead one to move on to another form of treatment that might work. His discussions stress the importance of knowing and understanding what a patients goals and hopes are when determining what to do next in complex problems.

Weve talked previously about the power of story telling. Jerry Groopman masterfully conveys the key points in this book by weaving them into stories, putting a face and personality on the patients and the physicians in each example. To be fair, Jerry attributes most of the key lessons to a host of other fine physicians. He also uses his own interactions with the healthcare system as a patient to illustrate numerous salient points. And he manages to weave into the background issues related to economic and time pressures in medicine, reimbursement and managed care issues, the double edged sword of technological advances, marketing and corporate medicine, and conflicts of interest. This book sends a powerful message to everyone in healthcare. You will see yourself on almost every page, whether you are a physician or patient, healthcare worker or family/friend. Trust me, if you are a physician you will find yourself saying I remember making that kind of error many times and hopefully your new insights will lead to more satisfying interactions with your patients. And he ends with an afterword, suggesting patients always help their physicians think openly by asking questions like What else could this be?, Could there be two things going on?, and Is there anything in my history or exam or lab tests that is at odds with the working diagnosis?.

References:

Groopman J. How Doctors Think. Boston: Houghton Mifflin, 2007 (Mariner Books 2008)

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August 19, 2008

Arterial Line Issues

The UK NHS NPSA (National Patient Safety Agency) has issued a new rapid response report highlighting Problems with infusions and sampling from arterial lines. This consists of the problem description and recommendations and the supporting information. They found 84 incidents (two fatal) where the wrong infusion was attached to the arterial line and 76 incidents where faulty sampling technique occurred, sometimes leading to patient harm. A variety of solutions have been inadvertently infused through arterial lines, including concentrated glucose, potassium-containing solutions, MRI contrast agents, mannitol, insulin, antibiotics and others.

Some of the factors predisposing to such mishaps have included look-alike labeling and packaging of the intravenous infusion bags. In some cases, covering the infusion bags with pressure bags led to obscuration of the label. Errors may be especially prone to occur when patients are transported to other sites and nursing and medical staffs at the secondary sites are unfamiliar the lines. Inadequate labeling of the lines has also prevented their identification as being arterial lines.

The reports cite the statistic that over half of arterial blood gas analyses done on samples from critical care units may be clinically not justified.

Problems with sampling from arterial lines include cases where contamination from infusates has led to inappropriate therapy for patients. These have included cases in which false hyperglycemia led to fatal insulin overdosages. In others, failure to remove air bubbles from the samples have led to misinterpretation of results.

The recommended strategies to reduce risk are based on common sense, since no evidence base exists on such strategies. The recommended actions are:

• Sampling should only be done by competent, trained staff.
• Guidelines should include criteria for ABGs, sampling technique, monitoring and interpretation of results (including unexpected results).
• Clear identification of arterial lines (labeling or specifically marked lines).
• Any infusion attached to an arterial line must be prescribed and checked before administration.
• Staff should use only sodium chloride 0.9% to keep lines open.
• Labels should be clearly visible, even when pressure bags are used.

They also recommend asking some useful questions:

• Is there a clinical reason for inserting this line? Is it clearly marked as an arterial line?
• Do I need to take this sample?
• Do I know how to do this safely (eg. remove air from the sample)?
• Have I picked the right infusion bag? Did someone else check this?
• Can the label be seen, even if a pressure bag is used?
• Is the reading from the sample within the expected range? Could it have been contaminated?

Note that they have recommended saline rather than heparin flushes. They acknowledge that the evidence on the use of heparinised versus normal saline for arterial (and central venous) catheters is inconclusive (see our May 2008 Whats New in the Patient Safety World column in which we discussed the UK NPSAs alert Risks with Intravenous Heparin Flush Solutions.).

Speaking of heparin flushes, ISMP Canada has issued an alert on these with some excellent recommendations. They discuss the cases from Indiana, California, and Texas that we have previously discussed in our December 2007 and April 2008 Whats New in the Patient Safety World columns and our July 15, 2008 Patient Safety Tip of the Week. They have developed a toolkit being implemented in a group of Ontario hospitals currently. That toolkit is available to non-Ontario hospitals for $150 but they summarize the key recommendations in this alert. These include:

• Complete an audit of heparin storage areas throughout the hospital (including pharmacy) to identify high-risk situations.
• Assess current heparin utilization patterns and compare with best practices (eg. see the recent ACCP Antithrombotic and Thrombolytic Therapy, 8th Ed: ACCP Guidelines).
• Where possible, use alternative products or procedures for flushing and locking of access lines to limit exposure to unfractionated heparin.
• Consider low molecular weight heparin (LMWH) as an alternative to unfractionated heparin (UFH) where possible.
• Reduce the number of potentially high-risk situations where UFH is stored (eg. remove high-dose heparin products from floor stock, reduce availability of certain doses from patient care areas, develop protocols and guidelines for flushing lines, standardize products and consider one concentration hospital-wide, use single dose formats such as pre-filled syringes, and use clearcut labeling and physical separation of products in all areas, including the pharmacy)

References:

UK NHS National Patient Safety Agency. Rapid Response Report. Problems with infusions and sampling from arterial lines. July 28, 2008 http://www.npsa.nhs.uk/patientsafety/alerts-and-directives/rapidrr/arterial-lines/

UK NHS National Patient Safety Agency. Rapid Response Report. Problems with infusions and sampling from arterial lines. July 28, 2008 http://www.npsa.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=17801

UK NHS National Patient Safety Agency. Supporting Information for Rapid Response Report NPSA/2008/RRR06. Problems with infusions and sampling from arterial lines. July 28, 2008

http://www.npsa.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=17802

ISMP Canada. Safety Bulletin. Enhancing Safety with Unfractionated Heparin:

A National and International Area of Focus. July 25, 2008

http://www.ismp-canada.org/download/ISMPCSB2008-05UnfractionatedHeparin.pdf

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August 26, 2008

Pattern Recognition and CPOE

Weve done several previous columns which have focused on the importance of pattern recognition in influencing the thinking of physicians and other healthcare workers (see Patient Safety Tips of the Week for May 27, 2008 and August 12, 2008).

The transition to computerized physician order entry (CPOE) has often been particularly difficult for pharmacists. From our discussions with them, its apparent that one of the key reasons is the loss of pattern recognition that often occurs with CPOE. Previously, pharmacists would either see the whole patient chart or would get a faxed copy of the admission orders. Now, with CPOE, they may simply get several order strings for individual medications.

Consider the following set of admission orders:

• Admit to Medicine A (Attending: Dr. C)
• Diagnosis: pneumonia
• Condition: fair (CAP Risk Class IV)
• Activity: Out of bed to chair 3 times daily with assistance.
• Fall precautions
• Vital signs and pulse oximetry every 4 hours.
• Call house officer for respiratory rate greater than 20 or O2 saturation less than 88%.
• Strict Intake and Output monitoring.
• Daily weight
• Diet: 1800-calorie ADA diet
• Allergies: latex (contact allergy), no other known drug allergies
• O2 via nasal cannula at 2 liters/minute
• Heparin 5000 units subcutaneously every 8 hours
• Metformin 1000 mg. by mouth twice daily
• Lisinopril 10 mg. by mouth daily
• Lipitor 20 mg. by mouth daily
• Influenza and pneumonia vaccinations as per protocol
• IVs: normal saline with 10 mEq. KCl at 100 cc. per hour
• Ceftriaxone 1 gram IV every 24 hours
• Levofloxacin 500 mg. IV every 24 hours
• Labs: blood glucose today at 9 PM; blood glucose, lytes, creatinine, CBC & diff in AM
• If patient has not voided by 8 PM, straight cath and record volume. Send specimen to lab for routine U/A and Legionella and pneumococcal antigens
• PT consult: ambulation evaluation
• Advanced directives: copy of Health Care Proxy in chart

This single page of orders conveys an incredible amount of information and provides a snapshot of the patient. You can see the patient is a diabetic admitted because of pneumonia. But there is far more information in the pattern recognized. They convey the image of a patient with a certain amount of frailty. The physician put him on fall precautions. Perhaps he has a diabetic neuropathy causing ataxia or a diabetic autonomic neuropathy causing orthostatic hypotension. The pharmacist then recognizes to be alert for drugs that might further increase the patients fall risk. The physician was also concerned enough about the patients ambulation that she ordered a physical therapy evaluation. Sounds like he might be headed for a prolonged length of stay or maybe a trip to a subacute unit. Better keep an eye on the antibiotic duration he might be a candidate for a C. difficile nosocomial infection.

And hes on an ACE inhibitor. Dont know if that is for hypertension or CHF or for diabetic nephropathy but better pay attention to his renal function to see if any medication dosage adjustments will be needed. And the metformin could be risky if he has renal dysfunction. Will have to monitor his IV fluids and I&Os, too. And may need to hold the metformin if he needs a radiology study with contrast.

And he needs to be straight-cathed if he hasnt voided by 8 PM. Wonder if he has a diabetic neurogenic bladder or BPH. He could get a drug-resistant UTI if he needs a Foley. Better get his pneumonia antibiotics focused on a specific pathogen as soon as possible so we can get him off those broad spectrum antibiotics.

Looks like Dr. C remembered DVT prophylaxis and the screen for flu and pneumonia vaccinations. Better check on that vaccination status in a couple days. And hes on subcutaneous heparin prophylaxis. Better check the old records to see if he had any heparin exposure in the past 100 days that might require more frequent platelet count monitoring for HIT.

Dont see an order for aspirin. Wonder if thats an oversight in this diabetic patient with other CAD risk factors or whether Dr. C thought there is a contraindication. Will look for aspirin in the old chart and call Dr. C to discuss.

So you can see that seeing the whole order set is a lot different than seeing isolated orders for metformin, lisinopril, Lipitor, IV fluids, and the antibiotics!

Note that the same loss of pattern recognition may affect nurses and physicians to a lesser extent. Nurses used to take off all the physician orders so they had the opportunity to see that patient snapshot. Now the medication orders go directly to the pharmacy, PT orders to the therapy department, etc. and nursing may only see the nursing orders. Nurses often tell us that the admission orders plus the face sheet tell them much more than the admission H&P does!

So how do we deal with this lost opportunity to use pattern recognition? We need some way to restore that patient snapshot. One way is by customizing the computer screens for pharmacists and nurses, much the same way we allow physicians to customize the screen layouts to their liking. Most CPOE screens have the patient name, date of birth, other identifiers, room number, physician name or name of service, and allergies listed at the top of each screen. But the view can be customized to show select laboratory data, a problem list (though youd be surprised at the difficulties generating and maintaining good working problem lists!), and a full medication list. You can also show select data relevant to a specific order. For example, when a physician orders digoxin, we show him/her a popup screen with the most recent K+ level, creatinine or GFR, and any recent digoxin levels. No reason we cant popup that same screen for the pharmacist when he/she opens that order for digoxin.

But neither of those solutions provides all the things we saw when the full admission order set was visible. Therefore, ensuring that anyone can get a printout (yes, even a paperless facility can use paper sometimes!) or full screenshot of the full admission orders is advisable. The key point is that you need to work with your end-users when you are planning your CPOE rollout to find out what is important to them.

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September 2, 2008

Updates on VAP Prevention

Ventilator-associated pneumonia (VAP) remains a serious cause of morbidity, mortality and cost in our ICUs. VAP occurs in 25-30% of mechanically ventilated patients and has mortality rates of 20-70%, though mortality may be primarily due to underlying conditions. Mortality attributable to VAP itself has been estimated as 7.3% and the attributable extra hospital stay 10 days, with an extra cost of $15, 986 per episode of VAP (Hugonnet et al 2004). Other cost estimates attributable to VAP have ranged from just under $12, 000 (Warren 2003) to over $40,000 (Rello 2002)

Several new articles relevant to prevention of ventilator-associated pneumonia (VAP) have appeared in recent weeks.

NICE just released an evidenced based guidance on technical patient safety solutions for prevention of ventilator-associated pneumonia. This had two primary evidence-based conclusions:

• Mechanically ventilated patients who are intubated should be positioned with their upper body elevated (in a semi-recumbent or seated position) for as much of the time as possible. For some patients this will not be appropriate (for example, those with spinal injuries).

• Oral antiseptics (for example, chlorhexidine) should be included as part of the oral hygiene regimen for all patients who are intubated and receiving mechanical ventilation.

The also noted that evidence suggests that selective decontamination of the digestive tract (SDD) using topical antibiotics may reduce the incidence of VAP also reduce mortality. However, concerns about the risk of infection with Clostridium difficile and the induction and/or selection of resistant, including multiresistant, microorganisms as a result of SDD kept them from recommending this. They also noted that a lack of robust evidence prevented any recommendations for the use of kinetic beds. They did note that although the evidence supported the use of elements of care bundles, there was insufficient evidence to recommend a care bundle of any specific design.

Our own comment on bundles is that they are an excellent way to get a group involved to change behavior and reach a desired outcome. The literature is replete with examples of how adopting a multicomponent intervention may achieved desired outcomes, even though one may not know which individual components of that intervention are most successful. Many hospitals are already using IHIs VAP Bundle. The key components of that bundle are:

• Elevation of the Head of the Bed
• Daily "Sedation Vacations" and Assessment of Readiness to Extubate
• Peptic Ulcer Disease Prophylaxis
• Deep Venous Thrombosis Prophylaxis

Note that the PUD prophylaxis remains controversial since the evidence of its effect on the incidence and severity of VAP remains conflicting. Also, the DVT prophylaxis is a general intervention for most ICU patients rather than being specifically a VAP-prevention measure.

Even a focused educational intervention can significantly reduce the incidence of VAP (Zack 2002).

The second major recent VAP prevention item was an article on use of silver-coated endotracheal tubes to prevent VAP that appeared in the August 20, 2008 issue of JAMA (Kollef et al 2008). That article showed the silver-coated endotracheal tubes led to a relative risk reduction for VAP of 36% in patients who were intubated for at least 24 hurs. Certainly sounds impressive! However, closer scrutiny of the article raises numerous questions. The rationale for using silver-coated endotracheal tubes makes good sense from a biological standpoint. The diagnosis of VAP was based on quantitative culture of bronchoalveolar fluid if VAP was suspected on the basis of radiographic findings or other clinical signs including fever or hypothermia, leukocytosis or leukopenia, or purulent tracheal aspirate. However, when one looks at the data, the absolute risk reduction for VAP was only 2.7% and the NNT (number needed to treat) to prevent one case of VAP was 37. More importantly, the silver-coated endotracheal tube group showed no improvement in mortality, duration of intubation, or ICU or total LOS. Data on antibiotic use or costs was not provided.

Other issues with the study were lack of standardization of other interventions (in both the control and silver arms), single blinding (the investigators were not blinded), relatively low rates of VAP in both the silver and control groups, a disproportionate percentage of patients with COPD in the control group, a low percentage of patients able to provide informed consent, and industry funding for the study. Note also that the supplemental information referred to in the article (having to do with criteria for diagnosis of VAP) is not downloadable from the website address provided in the article.

So we are left with an intervention that requires a large NNT and fails to improve any of the really important clinical outcomes. Call us skeptics! Before you run out and purchase these new silver-coated endotracheal tubes, we suggest you await further RCTs that demonstrate improvement in the clinically relevant outcomes, not just reduction of bacteriologic outcomes. We think JAMA dropped the ball on this one, though the accompanying editorial takes a much more guarded and conservative view of the results.

We are very surprised at the conclusions of this paper. The authors of this paper are well respected and have published numerous excellent articles on both the pathophysiology and prevention of ICU infections. This is not one of them. Were going to start using this article when we teach our students and residents how to read journal articles and differentiate true evidence-based medicine from industry spin. Had this been sponsored by a neutral organization, such as NIH, the title of this one would have read Silver-Coated Endotracheal Tubes Fail to Reduce Mortality, Ventilator Time, ICU or Hospital LOS, or Resource Utilization. And the first half of the comment section would not have been spent touting the benefits of the device tested. And it would not flout that preventing cases of VAP could save many lives and up to $40,000 per case when, in fact, the device tested saved no resources and was associated with more deaths (though not statistically significant).

While silver-coated endotracheal tubes may someday be shown in good randomized controlled double-blinded studies to impact on clinically relevant outcomes, well wait for those studies before jumping on board.

References:

Hugonnet S, Eggimann P, Borst F, Maricot P, Chevrolet J-C, Pittet D. Impact of Ventilator-Associated Pneumonia on Resource Utilization and Patient Outcome.

Infection Control and Hospital Epidemiology 2004; 25(12): 10901096, Dec 2004 http://www.journals.uchicago.edu/doi/pdf/10.1086/502349

Warren DK, Shukla SJ, Olsen MA, et al. Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center. Crit Care Med. 2003;31:1312-1317 http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-200305000-00003.htm;jsessionid=L66RdxRLr4JQcQ1nKtQRC95nT60Nlhf3rD0vbmyy0JdQtSK1VjP9!-1705959712!181195629!8091!-1

Rello J, Ollendorf DA, Oster G, Vera-Llonch M, Bellm L, Redman R, Kollef MH.
Epidemiology and Outcomes of Ventilator-Associated Pneumonia in a Large US Database. Chest, Dec 2002; 122: 2115 - 2121. http://www.chestjournal.org/cgi/reprint/122/6/2115?maxtoshow=&HITS=25&hits=25&RESULTFORMAT=1&author1=rello&andorexacttitle=and&andorexacttitleabs=and&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT

Rello J, Lorente C, Diaz E, et al. Incidence, etiology, and outcome of nosocomial pneumonia in ICU patients requiring percutaneous tracheotomy for mechanical ventilation. Chest. 2003;124:2239-2243 http://www.chestjournal.org/cgi/reprint/124/6/2239?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=1&author1=rello+j&andorexacttitle=and&andorexacttitleabs=and&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT

Zack JE, Garrison T, Trovillion E, et al. Effect of an education program aimed at reducing the occurrence of ventilator-associated pneumonia. Crit Care Med. 2002;30:2407-2412 http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-200211000-00001.htm;jsessionid=L8xVLZYC3pPJWVnLhXkW1l6RzkG9gKnYWvkQL1nNyM90h2Q1vhyF!-711215224!181195629!8091!-1?index=1&database=ppvovft&results=1&count=10&searchid=1&nav=search

NICE. PSG002 Technical patient safety solutions for prevention of ventilator-associated pneumonia in adults: guidance. 27 August 2008 http://www.nice.org.uk/nicemedia/pdf/PSG002Guidance.pdf

Kollef MH. Afessa B. Anzueto A. Veremakis C. Kerr KM. Margolis BD. Craven DE. Roberts PR. Arroliga AC. Hubmayr RD. Restrepo MI. Auger WR. Schinner R. NASCENT Investigation Group. Silver-coated endotracheal tubes and incidence of ventilator-associated pneumonia: the NASCENT randomized trial. JAMA 2008; 300(7):805-13 http://jama.ama-assn.org/cgi/content/abstract/300/7/805

Chastre, Jean MD Preventing Ventilator-Associated Pneumonia: Could Silver-Coated Endotracheal Tubes Be the Answer?. JAMA 2008; 300(7):842-844 http://jama.ama-assn.org/cgi/content/extract/300/7/842

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September 9, 2008

Less is More....and Do You Really Need that Decimal?

Patient-controlled analgesia (PCA) pumps have revolutionized pain management in the acute hospital as well as other sites. They allow analgesia to be delivered to a patient at a time when it is most needed not on a nursing or pharmacy schedule but rather when the patient indicates he/she is still perceiving significant pain. And they minimize the need for guessing about how much analgesic will be needed by the patient. The overall safety record of patient-controlled analgesia is quite good and an improvement upon previous methods of administering patient analgesia. Nevertheless, there have been some significant concerns about certain aspects of patient safety with PCA.

ISMP published an outstanding monograph about patient safety issues involved in PCA in 2006. PCA By Proxy is perhaps the best know safety issue with PCA. This, of course, means the pressing of the infusion administration button by someone other than the patient. This is most often a friend or family member but could be a member of the healthcare team. In most cases, the person pressing the PCA button thinks they are helping the patient avoid pain. They may not recognize the problem of overdosage from the narcotics. One of the built-in safety features of PCA is that when a patient gets sedated from too much analgesic, they can no longer press the PCA button to get more analgesic. That safety measure is bypassed in PCA by Proxy. In fact, the occurrence of incidents involving PCA by Proxy was significant enough for Joint Commission to issue a Sentinel Event Alert in 2004.

A recent ISMP Safe Medication Alert Misprogramming PCA concentration leads to dosing errors points out another very significant and somewhat paradoxical problem with PCA pump programming. If one programs in too high of a concentration, the patient tends to get underdosed (so may suffer continued pain). If one programs in too low a concentration, the patient actually gets overdosed! This seems counterintuitive. But think about it the patient asks for a certain dose of the narcotic and the pump delivers the volume it is programmed for to meet that request. If the concentration was erroneously too low, the pump has now given a higher volume and, hence, a higher actual narcotic dose. And often a warning on the pump that the concentration is too low may be overridden because the nurse or physician feels less concerned about too low than too high. ISMP makes some specific recommendations to reduce the risk of such errors. One is to make the too low concentration warning a hard warning that must be acknowledged and reprogrammed rather than simply being overridden. They strongly suggest organizations assess their current vulnerabilities to mistakes of this sort (perhaps do a FMEA on PCA pumps) and increase staff awareness of the results. Limiting stock to a single standard concentration of each of the PCA drugs may also help. They discuss numerous aspects of proper labeling and stress that there must be a very distinctive label for any nonstandard concentrations. They also recommend use of double checks and bar-coding and smart pump technology.

Our March 12, 2007 Patient Safety Tip of the Week 10x Overdoses pointed out another potential problem with misprogramming PCA (or other infusion) pumps. The data entry person may double press a key (or the key may become stuck) resulting in, for example, 88 instead of 8. Also, during data entry it is possible to think one hit a decimal point but it fails to print out. These types of data entry error have recently been noted in programmable intravenous infusion pumps and there have been several occurrences of 10x overdoses with those pumps. Therefore, a policy of having a second independent observer verify the dosage or rate on such pumps makes sense (however, keep in mind that error rates from other industries tell us that one who oversees someone elses work typically does so in error up to 10% of the time!).

Speaking of decimal points, when do you really need them? You all know you should never use a trailing zero, i.e. a zero following a decimal point, because if the decimal point is not seen there is a risk of a 10-fold (or higher) overdose. But what about other numbers following a decimal point? They are important in certain circumstances (eg. a dose of 0.3 mg or 2.7 mg). However, at higher doses they become much less relevant. For example, lets say you performed a calculation and the result was a recommended dose of a drug is 72.2 mg. Is there really a difference if the patient gets 72 mg. or 72.2 mg of most drugs? Yet ordering the latter dosage increases the risk that the decimal point may not be seen or not input into a computer or missed in a faxed order and the patient gets a 10x overdose. So we strongly recommend that in writing medication orders one specifically decides whether such fractional doses are important or merely place the patient at increased risk of an error.

The 2006 ISMP monograph also discusses other issues regarding misprogramming PCA pumps and several other issues, including selecting appropriate patients for PCA, monitoring patients, setting up quality indicators, and performing FMEA.

In our June 10, 2008 Patient Safety Tip of the Week Monitoring the Postoperative COPD Patient we also noted some important points about monitoring patients on PCA pumps. These included identifying high-risk patients, using sedation scales properly, and using capnography in addition to pulse oximetry in certain high-risk patients.

References:

Cohen MR, Weber RJ, Moss J (Institute for Safe Medication Practices). Patient-Controlled Analgesia: Making it Safer for Patients. A continuing education program for pharmacists and nurses. ISMP. April 2006 http://www.ismp.org/profdevelopment/PCAMonograph.pdf

http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_33.htm

ISMP. Misprogramming PCA concentration leads to dosing errors. Medication Safety Alert Newsletter (Acute Care Edition). August 28, 2008 http://www.ismp.org/Newsletters/acutecare/articles/20080828.asp

Print Less is More.and Do You Really Need that Decimal?

September 16, 2008

More on Radiology as a High Risk Area

Several of our most popular articles in the past have dealt with patient safety in the radiology suite. Our October 16, 2007 Patient Safety Tip of the Week Radiology as a Site at High-Risk for Medication Errors focused on the fact that many incidents and adverse events occurring in the radiology suite have little to do with radiology per se. And on February 19, 2008 we looked at MRI Safety.

But our interest was piqued again when we came across an article on, of all things, the economic justification of a dedicated portable CT scanner at the Cleveland Clinic (Masaryk 2008). Note that the online link has the authors and title transposed with those of another article. The article demonstrates the cost effectiveness of having a dedicated portable CT scanner to scan ICU patients. It projected a net economic benefit of $264,658 in the first year and total benefit of $2.6 million over 5 years (the savings coming from decreased transport costs plus freeing up the scanner to do more outpatient scans).

But the real beauty of the Masaryk article is the reference list, which includes several articles from the 1980s and 1990s on issues related to transport of ICU patients to radiology. A paper by Smith et al (Smith 1990) noted adverse events during 34% of all ICU transports. Specifically, transport of ICU patients to the CT suite was associated with a 71% incidence of adverse events. Adverse events included disconnection of monitoring equipment, interruption of vasoactive medication drips, unintentional extubations, etc. Another study (Indeck 1988) showed 68% of all transports from trauma ICUs for diagnostic studies experienced serious physiologic changes of 5 minutes duration. However, a subsequent study (Hurst 1992) that used a matched control group in the ICU that was not transported showed significant physiologic changes in 68% of transported patients but also in 60% of control ICU patients. A program at the University of Missouri (Stearley 1998) showed that use of a specifically trained ICU transport team had an overall complication rate of only 15.5%, most of the complications being minor.

USPs 2007 MEDMARX Data Report A Chartbook of 20002004 Findings from Intensive Care Units and Radiological Services showed that though the overall number of medication errors in radiology areas was small, the percentage of cases resulting in patient harm was considerably higher than seen with medication errors elsewhere. 12% of the medication errors in these areas were considered harmful to patients, about 7 times higher than the percentage in the overall MEDMARX database.

Our July 31, 2007 Tip of the Week on Dangers of Neuromuscular Blocking Agents gave an example of an incident where an emergency room resident inadvertently administered a neuromuscular blocking agent to a patient he had accompanied to the radiology suite for a CT scan. ISMP (ISMP 2005) has also noted cases of neuromuscular blocking agents being inadvertently given in radiology areas.

In fact, doing a search on the ISMP website for events related to radiology results in many hits. A patient suffered a fatal arrest when given 20 mg. of labetalol by rapid IV push as the patient was being rapidly transported to radiology (ISMP 2003). And the types of misadventures reflect many of those seen elsewhere in the hospital, including connecting blood pressure monitoring tubing to IV ports (ISMP 2003b), fatal gas line mixups (ISMP 2004), administration of chloral hydrate syrup by the IV route when a nurse in radiology confused the Roman numeral IV in the Drug Enforcement Agency (DEA) class four controlled substance symbol (C-IV) as intravenous.(ISMP 2008), incorrect doses of epinephrine (ISMP 2002), and the fatal injection of antiseptic skin prep solution that was in an unlabeled basin and was confused with contrast solution (ISMP 2004b).

An AHRQ Web M&M case (Foley 2005) described a case where a non-radiology nurse administered oral contrast for a radiology procedure intravenously.

In our October 16, 2007 Patient Safety Tip of the Week Radiology as a Site at High-Risk for Medication Errors we noted at least 14 factors that make adverse events more likely in the radiology suite. Undoubtedly there are many more contributing factors and conditions.

So it is quite clear that the radiology suite serves as a microcosm of all the adverse patient safety events that occur throughout a hospital. A good patient safety program in radiology would include both continuous surveillance for error-prone practices and a proactive approach using FMEA. One possible approach is that taken at Partners Healthcare System (Kahlon 2006). They focus on several specific areas of interest and utilize both RCAs and FMEA. Wed recommend expanding that radiology patient safety team to include representatives from other services (eg. medicine, surgery, nursing, anesthesiology, respiratory therapy, pharmacy, etc.). We also strongly recommend that the radiology suite be one area frequently visited during patient safety walkrounds. Consideration for special designated transport teams, such as that described in the Stearley article, might be reasonable for ICU patients though wed like to see some more research on that topic.

References:

Masaryk T, Kolonick R, Painter T, Weinreb DB. The Economic and Clinical Benefits of Portable Head/Neck CT Imaging in the Intensive Care Unit. Radiology Management. Mar-Apr2008

http://www.ahra.com/RM/NEWRMShow.asp?ID=778

Smith I, Fleming S, Cernaianu A. Mishaps during transport from the intensive care unit. Critical Care Medicine. 1990; 18(3):278-281

http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-199003000-00006.htm;jsessionid=LTPGG1QpccT2RZ3RjFNl8g2QmdKQ2GjPp6vyvtxZP7ZBlRQJ66pl!-2013963969!181195629!8091!-1?index=1&database=ppvovft&results=1&count=10&searchid=1&nav=search

Indeck M, Peterson S, Smith J, et al. Risk, cost, and benefit of transporting ICU patients for special studies. J Trauma. 1988; 28(7): 10201025

http://www.jtrauma.com/pt/re/jtrauma/abstract.00005373-198807000-00018.htm;jsessionid=LPqHnZbyD1J0RnJq4PX3nvr9wJgK1v5CjvLRzjRzLvkRfWsmJqzG!-2013963969!181195629!8091!-1?index=1&database=ppvovft&results=1&count=10&searchid=1&nav=search

Hurst JM, Davis K Jr, Johnson DJ, et al. Cost and complications during in-hospital transport of critically ill patients: a prospective cohort study. J Trauma. 1992; 33(4): 5825 http://www.jtrauma.com/pt/re/jtrauma/abstract.00005373-199210000-00014.htm;jsessionid=LPqHnZbyD1J0RnJq4PX3nvr9wJgK1v5CjvLRzjRzLvkRfWsmJqzG!-2013963969!181195629!8091!-1?index=11&database=ppvovft&results=1&count=10&searchid=3&nav=search

Stearley HE. Patients' outcomes: intrahospital transportation and monitoring of critically ill patients by a specially trained ICU nursing staff. American Journal of Critical Care. 1998; 7(4):282-7

http://ajcc.aacnjournals.org/cgi/content/abstract/7/4/282?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=1&author1=stearley&andorexacttitle=and&andorexacttitleabs=and&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT

ISMP. Medication Safety Alert. Paralyzed by mistakes. Preventing errors with neuromuscular blocking agents. Medication Safety Alert Acute Care Edition. September 22, 2005

http://www.ismp.org/Newsletters/acutecare/articles/20050922.asp

ISMP. Medication Safety Alert. How fast is too fast for IV push medications? Medication Safety Alert Acute Care Edition. May 15, 2003

http://www.ismp.org/Newsletters/acutecare/articles/20030515.asp

ISMP. Medication Safety Alert. Blood pressure monitor tubing may connect to IV ports. ISMP Medication Safety Alert Acute Care Edition. June 12, 2003 http://www.ismp.org/Newsletters/acutecare/articles/20030612.asp?ptr=y

ISMP. Medication Safety Alert. Fatal gas line mix-up: How to avoid making this "gastly" mistake. ISMP Medication Safety Alert Acute Care Edition. December 16, 2004

http://www.ismp.org/Newsletters/acutecare/articles/20041216_2.asp

ISMP. Medication Safety Alert Acute Care Edition. Safety Brief: C-IV mistaken as IV. Medication Safety Alert Acute Care Edition. July 17, 2008

http://www.ismp.org/Newsletters/acutecare/archives/July08.asp#17

ISMP. Medication Safety Alert Acute Care Edition. It doesn't pay to play the percentages. Medication Safety Alert Acute Care Edition. October 16, 2002

http://www.ismp.org/Newsletters/acutecare/articles/20021016.asp

ISMP. Medication Safety Alert. Loud wake-up call: Unlabeled containers lead to patient's death. ISMP Medication Safety Alert Acute Care Edition. December 2, 2004

http://www.ismp.org/Newsletters/acutecare/articles/20041202.asp

Foley ME. AHRQ Web M&M Case & Commentary. Infused, not Ingested. November 2005.

http://www.webmm.ahrq.gov/case.aspx?caseID=108&searchStr=oral+contrast

Kahlon, Prerna S.Patient safety: a collaborative, blame-free, team approach.
SourceRadiology Management. 2006; 28(1):47-50
http://www.ahra.com/RM/NEWRMShow.asp?ID=600&type=basic

Print More on Radiology as a High Risk Area

September 23, 2008

Checklists and Wrong Site Surgery

Headlines continue to highlight cases of wrong site surgery. In the last few months, cases have even occurred at well-respected academic facilities such as the Beth Israel Hospital in Boston and the Miriam Hospital in Rhode Island. In the former case, a surgical timeout apparently did not take place. In the latter, the error occurred despite a surgical timeout. It is not clear whether either organization utilizes the checklist approach that we strongly advocate.

Joint Commissions 2009 National Patient Safety Goals (see our July 2008 Whats New in the Patient Safety World column Joint Commission 2009 National Patient Safety Goals) have a requirement for use of a checklist during the pre-procedure verification process. The checklist can be paper or electronic or even on a wall-mounted white board and needs to include elements such as the H&P, anesthesia assessment, completed informed consent, appropriate diagnostic and imaging reports or images, and any required implants, devices, special equipment or blood products that will be needed.

WHOs new Surgical Safety Checklist (see our July 2, 2008 Patient Safety Tip of the Week WHOs New Surgical Safety Checklist) actually consists of 3 checklists, one for the period prior to induction of anesthesia, one for the timeout (prior to skin incision), and one before the patient leaves the OR. The Checklist and a short manual on how to best use it can both be downloaded from the WHO website. Facilities are encouraged to modify the Checklist and add safety steps that are important to their needs, though removal of any steps is discouraged. Modification of the Checklist for specific procedures is likely to occur, for instance confirmation of specific DVT prophylaxis for many specific procedures. Yet the beauty of the Checklist is its simplicity and the authors caution against making it too complex.

But even more comprehensive checklists have been developed for specific surgical settings. Use of a 28-item structured checklist (Verdaasdonk 2008) addressing problems with laparoscopic equipment resulted in a 53% reduction of incidents related to such equipment.

A few weeks ago, at one of our patient safety presentations, a surgeon expressed concern about the amount of time added to procedures by following Universal Protocol and doing the surgical timeout. The answer is that following the protocol in most cases adds no more than 1-2 minutes per case. Even in the busiest of ORs that does not add a significant burden to the OR schedule. The beauty of checklists is that they are both simple and save time in the long run. Even the 28-item laparoscopic checklist in the Verdaasdonk article took only an average of 3.3 minutes to complete. Though they did not specifically measure it, we suspect that there was far more time savings on the back end, i.e. the time saved by avoiding equipment problems probably far exceeded the 3.3 minutes taken on the front end.

One important point to remember is that developing checklists is not enough. You must audit the use of and adherence to the checklists you develop. Some organizations do video monitoring of surgical procedures, including recording of the timeout procedure. That allows analysis of the completeness of the surgical timeout and can be a valuable tool in promoting a culture of safety and improving communication within the OR. Other organizations are too fearful of litigation to do video recording. Those organizations should at least perform sample audits of the timeout procedure (by having someone in the OR audit the timeout) but those need to be done in a manner in which the presence of the auditor does not bias the procedure. Walking into the OR and announcing Im here to audit the timeout almost guarantees that timeout will be done correctly. While we advocate openness and frankness in quality improvement activities, sometimes a secret shopper type audit needs to be done to get a true picture of how often the timeout is being done and being done properly and completely. The audit should be done for anything you develop a checklist for, not just a safe surgery checklist.

Atul Gawande, a coauthor of the WHO checklist may be best known for his treatise on The Checklist that appeared in The New Yorker. In that article, he eloquently expounded upon the simplicity and sophistication of Peter Pronovosts success in introducing the concept of the checklist to improve medical care. We recommend use of checklists for multiple different types of processes in healthcare such as:

• Peter Pronovost-type checklist for ICU procedures like central line insertion
• WHO Safe Surgery Checklist
• Pre-procedure verification checklist
• Serious Incident Response checklist (see our July 24, 2007 Patient Safety Tip of the Week Serious Incident Response Checklist)
• Checklist for VAP prevention
• Checklist for any procedure (eg. thoracentesis)
• Checklist for equipment maintenance (see our March 5, 2007 Patient Safety Tip of the Week Disabled Alarms)
• Checklist for room decontamination

Checklists can also be a part of your own personal life. We have a little cabin on an island in northern Ontario. It takes 6-7 hours to get there so anything we overlook either when we are going there or coming back can lead to major problems. So we use checklists! We have one for all the things we need to make the trip up there and another for all the things we need to do when we are leaving the cabin. We even have a checklist for inventory of common items we keep at the cabin. Sometimes time pressures (theres a thunderstorm coming in lets get going!) have caused us to shortcut the checklist. Almost invariably when we skip things on the checklist it comes back to haunt us. So weve learned the hard way if you make a check list, use it correctly!

Checklists are some of the most valuable tools we have available in quality improvement and patient safety. They are also the least expensive of all tools. But the ROI on checklists is incredibly high, both in human terms and financial terms.

The Verdaasdonk article also references an excellent guidance from the UK Civil Aviation Authority on the proper design, presentation and use of checklists.

References:

Joint Commission. 2009 National Patient Safety Goals.

http://www.jointcommission.org/NR/rdonlyres/31666E86-E7F4-423E-9BE8-F05BD1CB0AA8/0/09_NPSG_HAP.pdf

WHO surgical safety checklist

http://www.who.int/entity/patientsafety/safesurgery/tools_resources/SSSL_Checklist_finalJun08.pdf

Verdaasdonk EG, Stassen LP, Hoffman WF, van der Elst M, Dankelman J. Can a structured checklist prevent problems with laparoscopic equipment. Surgical Edoscopy 2008; 22: 2238-2243 (accessed online 9/22/2008) http://www.springerlink.com/content/1845j684574501v2/

Gawande Atul. The Checklist. If something so simple can transform intensive care, what else can it do? The New Yorker. December 10, 2007

http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande

Civil Aviation Authority (UK). CAP 676: Guidance on the Design, Presentation and Use

of Emergency and Abnormal Checklists. January 2006.

http://www.avhf.com/html/Publications/Outside_Pubs/CAA CAP676.pdf

Print Checklists and Wrong Site Surgery

September 30, 2008

Hot Topic: Handoffs

There has been a striking number of publications in the last 2 months about problems related to handoffs. That shouldnt be surprising in and of itself since we know that problems related to faulty communication underlie many patient safety problems. Its well known that problematic communication is a root cause in about 70% of all sentinel events in the Joint Commission Sentinel Event Database. Several of our previous columns have focused on communications and handoffs.

Separate studies coming out of Harvard and Yale provide real estimates of the frequency with which faulty handoffs result in both patient harm and inefficiencies and redundancies in care. Horwitz and colleagues (Horwitz 2008) at Yale did a prospective study in which they reviewed in detail both oral and written signouts and then reviewed patient cases to determine whether problems with care had occurred. Of 88 such signouts, problems were identified in 24 cases. This included adverse clinical consequences for 5 patients (delays in diagnosis or treatment) and 4 near-misses. Just as importantly, in 15 cases the care was either inefficient or resulted in duplicative efforts. They provide specific examples of some of the problems encountered. In many cases, the housestaff ended up spending much wasted time that could have been avoided by spending more time up front on a good handoff.

A somewhat similar study was done at the Massachusetts General Hospital (Kitch 2008). They surveyed medicine and surgery residents about events related to handoffs that had occurred in their most recent rotation. 58.3% reported that at least one patient had experienced minor harm and 12.3% reported at least one patient had experienced major harm. A third of the residents surveyed reported their overall experience with handoffs to be poor or only fair. By location, handoffs from the emergency department or from other hospitals were the most problematic. Though most of the handoffs were conducted face-to-face, they were seldom done under ideal circumstances. Almost half reported that handoffs seldom took place in a quiet, private setting and more than a third said that interruptions occurred during most handoffs. The average time spent on a signout was about 20 minutes plus another 20 minutes preparing for the signout. This study also provides some examples of the types of specific clinical information omitted during the signouts that might have been helpful.

We previously discussed many of the issues around handoffs in our February 26, 2008 Patient Safety Tip of the Week Nightmares.The Hospital at Night, including lessons learned from considerable research done in other industries (Lardner 1996). Information at handoffs should be repeated by more than one method. For example, the communication may be written but then should be conveyed by a second method, such as a face-to-face verbal communication. Cues such as speech inflection and body language may convey important messages during such face-to-face communications, enhancing memory of the salient points. The verbal face-to-face contact also provides the opportunity for 2-way communication and feedback, both of which are essential in ensuring that both parties understand the information conveyed. Adding structure to written documents and defining what should be included in handoffs are very helpful. Hence, the popularity of techniques like SBAR (Situation-Background-Assessment-Recommendation). And eliminating unnecessary information may be very important. Lastly, training and education in handoffs should be a priority for organizations, as should providing adequate time for such handoffs. Since then we also came across a comprehensive internet-based bibliography on handoffs put together by Ingrid Philibert of the ACGME that provides a wealth of resources on handoffs primarily from the medical literature.

Another recent paper by Berkenstadt et al (Berkenstadt 2008) used direct observations of critical care nursing handoffs to develop a handoff protocol and incorporation of handoff training into a simulation-based teamwork and communications workshop. The intervention resulted in improvement of communicating certain specific information during handoffs.

And from the surgical literature, Lingard et al (Lingard 2008) used a checklist to structure short team briefings and documented both reduction in the number of communication failures and other utility of the intervention.

And lastly, a slightly different sort of handoff studied (Gandara 2008) involved the information about anticoagulation for treatment or prophylaxis of thromboembolic disease transmitted to subacute rehabilitation facilities on discharge from acute care hospitals. Only 45% of patients discharged on heparin (unfractionated or low-molecular weight heparin) and 16% of patients discharged on warfarin had all the required information in the discharge summary.

These papers all highlight the pressing need for organizations to develop structured tools for handoffs, whether they are paper-based or electronic, but that those tools must be used in conjunction with a verbal face-to-face handoff in an optimal setting to convey the most important information needed to care for patients. Review of your handoff experiences, like Yale and the MGH did, may highlight for you the current weaknesses in your system and suggest specific measures you need to include in the training programs you set up to improve handoff skills, whether they are aimed at medical staff, housestaff, nursing staff, or any other members of the healthcare team. The time spent in doing handoffs well is more than made up by avoiding duplication and other inefficiencies and obviously leads to better and safer patient care.

Update: see also Our December 2008 Whats New in the Patient Safety World column Another Good Paper on Handoffs.

References:

Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Consequences of Inadequate Sign-out for Patient Care. Arch Intern Med.2008;168(16):1755-1760.

http://archinte.ama-assn.org/cgi/content/abstract/168/16/1755

Kitch BT, Cooper JB, Zapol WM, Marder JE, Karson A, Hutter M, Campbell EG. Handoffs Causing Patient Harm: A Survey of Medical and Surgical Housestaff. The Joint Commission Journal on Quality and Patient Safety 2008; 34: 563-570

http://www.ingentaconnect.com/content/jcaho/jcjqs/2008/00000034/00000010/art00001

Lardner R. Offshore Technology Report OTO 96 003. Effective Shift Handover A Literature Review. Health & Safety Executive, 1996

http://www.hse.gov.uk/research/otopdf/1996/oto96003.pdf

Philibert I. Selected Articles on the Patient Hand-off Compiled by Ingrid Philibert, Updated December 2007

http://www.acgme.org/acwebsite/dutyhours/dh_annotatedbibliography_patienthandoff_1207.pdf

Berkenstadt H, Haviv Y, Tuval A, Shemesh Y, Megrill A, Perry A. Rubin O, Ziv A. Improving Handoff Communications in Critical Care: Utilizing Simulation-Based Training Toward Process Improvement in Managing Patient Risk. Chest 2008; 134:158162

http://www.chestjournal.org/cgi/content/abstract/134/1/158

Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D, Espin S, Bohnen J, Whyte S. Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures in Communication. Arch Surg, Jan 2008; 143: 12-17

http://archsurg.ama-assn.org/cgi/content/abstract/143/1/12?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=lingard&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

Gandara E, Moniz TT, Ungar J, Lee J, Chan-Macrae M, O'Malley T, Schnipper JL. Deficits in Discharge Documentation in Patients Transferred to Rehabilitation Facilities on Anticoagulation: Results of a Systemwide Evaluation.The Joint Commission Journal on Quality and Patient Safety 2008; 34: 460-463

http://www.ingentaconnect.com/content/jcaho/jcjqs/2008/00000034/00000008/art00004

Print Hot Topic: Handoffs

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Sleep Program Successfully Reduces Delirium

March 9, 2021

Update: Disclosure and Apology: How to Do It

March 2, 2021

Barriers to Timely Catheter Removal

February 23, 2021

Cellphones and the OR

February 16, 2021

New Methods for QTc Monitoring

February 9, 2021

Nursing Burnout

February 2, 2021

MGH Protocols Reduce Risk of Self-Harm in ED

January 26, 2021

This Freezer Accident May Cost Lives

January 19, 2021

Technology to Identify Fatigue?

January 12, 2021

Surgical Smoke

January 5, 2021

Dilaudid/HYDROmorphone Still Problematic

December 29, 2019

Tip of the Week on Vacation

December 22, 2019

Tip of the Week on Vacation

December 15, 2020

Our Perennial Pre-Holiday Warning: “Be Careful Out There!”

December 8, 2020

Maternal Mortality: Looking in All the Wrong Places?

December 1, 2020

An Early Warning System and Response System That Work

November 24, 2020

Specimen Management

November 17, 2020

A Picture Is Worth a Thousand Words

November 10, 2020

More on Infusion Pump Errors

November 3, 2020

Reminder: Infant Abduction Risk

October 27, 2020

Conflicting Studies on Technology to Reduce RSI’s

October 20, 2020

More on Post-operative Risks for Patients with OSA

October 13, 2020

Night-Time Surgery

October 6, 2020

Successfully Reducing Opioid-Related Adverse Events

September 29, 2020

ISHAPED for Nursing Handoffs

September 22, 2020

VA RCA’s: Suicide Risks Vary by Site

September 15, 2020

An Eerily Familiar Incident

September 8, 2020

Follow Up on Tests Pending at Discharge

September 1, 2020

NY State and Nurse Staffing Issues

August 25, 2020

The Off-Hours Effect in Radiology

August 18, 2020

More Caution on Double Checks

August 11, 2020

Above-Door Alarms to Prevent Suicides

August 4, 2020

Intravenous Issues

July 28, 2020

Electrosurgical Safety

July 21, 2020

Is This Patient Allergic to Penicillin?

July 14, 2020

A Thesis on Intrahospital Transports

July 7, 2020

Another Patient Found Dead in a Stairwell

June 30, 2020

What Happens after Hospitalization?

June 23, 2020

Telemetry Incidents

June 16, 2020

Tracking Technologies

June 9, 2020

Perioperative Medication Safety

June 2, 2020

Perioperative Hypothermia

May 26, 2020

Early Warning Scores

May 19, 2020

Reminder on Telephone or Verbal Orders

May 12, 2020

Lab Errors and COVID-19

May 5, 2020

COVID-19 and the Dental Office

April 28, 2020

Can the Lab Spot Frailty?

April 21, 2020

Parenteral Nutrition Safety Issues

April 14, 2020

Patient Safety Tidbits for the COVID-19 Pandemic

April 7, 2020

From Preoperative Assessment to Preoperative Optimization

March 31, 2020

Intrahospital Transport Issues in Children

March 24, 2020

Mayo Clinic: How to Get Photos in Your EMR

March 17, 2020

Video Recording in the OR

March 10, 2020

Medication Harm in the Elderly

March 3, 2020

Opportunities to Reduce Unnecessary Contact Precautions

February 25, 2020

More on Perioperative Gabapentinoids

February 18, 2020

More Nudges

February 11, 2020

ERAS Rocks!

February 4, 2020

Drugs and Chronic Kidney Disease

January 28, 2020

Dang Those Cell Phones!

January 21, 2020

Disruptive Behavior and Patient Safety: Cause or Effect?

January 14, 2020

More on Newborn Falls

January 7, 2020

Even More Concerns About MRI Safety

December 31, 2019

Tip of the Week on Vacation

December 14, 2019

Tip of the Week on Vacation

December 17, 2019

Tale of Two Tylers

December 10, 2019

Dialysis Line Dislodgements

December 3, 2019

Overlapping Surgery Back in the News

November 26, 2019

Pennsylvania Law on Notifying Patients of Test Results

November 19, 2019

An Astonishing Gap in Medication Safety

November 12, 2019

Patient Photographs Again Help Radiologists

November 5, 2019

A Near-Fatal MRI Incident

October 29, 2019

Tip of the Week on Vacation

October 22, 2019

Tip of the Week on Vacation

October 15, 2019

Lots More on MRI Safety

October 8, 2019

Another Freezer Accident

October 1, 2019

Electronic Medication Reconciliation: Glass Half Full or Half Empty?

September 24, 2019

EHR-related Malpractice Claims

September 17, 2019

American College of Surgeons Geriatric Surgery Verification Program

September 10, 2019

Joint Commission Naming Standard Leaves a Gap

September 3, 2019

Lessons from an Inpatient Suicide

August 27, 2019

Double Check on Double Checks

August 20, 2019

Yet Another (Not So) Unusual RSI

August 13, 2019

Betsy Lehman Center Report on Medical Error

August 6, 2019

Repeat Adverse Drug Events

July 30, 2019

Lessons from Hospital Suicide Attempts

July 23, 2019

Order Sets Can Nudge the Right Way or the Wrong Way

July 16, 2019

Avoiding PICC’s in CKD

July 9, 2019

Spinal Injection of Tranexamic Acid

July 2, 2019

Tip of the Week on Vacation

June 25, 2019

Found Dead in a Bed – Part 2

June 18, 2019

Found Dead in a Bed

June 11, 2019

ISMP’s Grissinger on Overreliance on Technology

June 4, 2019

Medication Errors in the OR – Part 3

May 28, 2019

The Older Physician

May 21, 2019

Mixed Message on Number of Open EMR Records

May 14, 2019

Wrong-Site Surgery and Difficult-to-Mark Sites

May 7, 2019

Simulation Training for OR Fires

April 30, 2019

Reducing Unnecessary Urine Cultures

April 23, 2019

In and Out the Door and Other OR Flow Disruptions

April 16, 2019

AACN Practice Alert on Alarm Management

April 9, 2019

Handoffs for Every Occasion

April 2, 2019

Unexpected Events During MRI

March 26, 2019

Patient Misidentification

March 19, 2019

Updated Beers Criteria

March 12, 2019

Update on Overlapping Surgery

March 5, 2019

Infusion Pump Problems

February 26, 2019

Vascular Access Device Dislodgements

February 19, 2019

Focus on Pediatric Patient Safety

February 12, 2019

From Tragedy to Travesty of Justice

February 12, 2019

2 ER Drug Studies: Reassurances and Reservations

February 5, 2019

Flaws in Our Medication Safety Technologies

January 29, 2018

National Patient Safety Goal for Suicide Prevention

January 22, 2019

Wandering Patients

January 15, 2019

Another Plus for Prehabilitation

January 8, 2019

Maternal Mortality in the Spotlight

January 1, 2019

More on Automated Dispensing Cabinet (ADC) Safety

December 25, 2018

Happy Holidays!

December 18, 2018

Great Recommendations for e-Prescribing

December 11, 2018

Another NMBA Accident

December 4, 2018

Don’t Use Syringes for Topical Products

November 27, 2018

Focus on Deprescribing

November 20, 2018

Checklist Implementation

November 13, 2018

Antipsychotics Fail in ICU Delirium

November 6, 2018

More on Promoting Sleep in Inpatients

October 30, 2018

Interhospital Transfers

October 23, 2018

Lessons From Yet Another Aviation Incident

October 16, 2018

Burnout

October 9, 2018

More on Lab Specimen Mixups

October 2, 2018

Speaking Up About Disruptive Behavior

September 25, 2018

Foley Follies

September 18, 2018

More on Hospital Suicides

September 11, 2018

Lessons from a Surgical Fire

September 4, 2018

The 12-Hour Nursing Shift: Another Nail in the Coffin

August 28, 2018

Thought You Discontinued That Medication? Think Again

August 21, 2018

Delayed CT Scan in the Anticoagulated Patient

August 14, 2018

ISMP Canada’s Updated “Do Not Use” Abbreviation List

August 7, 2018 

Tip of the Week on Vacation

July 31, 2018

Surgery and the Opioid-Tolerant Patient

July 24, 2018

More on Speech Recognition Software Errors

July 17, 2018

OSA Screening in Stroke Patients

July 10, 2018

Another Jump from a Hospital Window

July 3, 2018

Tip of the Week on Vacation

June 26, 2018

Infection Related to Colonoscopy

June 19, 2018

More EHR-Related Problems

June 12, 2018

Adverse Events in Cancer Patients

June 5, 2018

Pennsylvania Patient Safety Authority on Iatrogenic Burns

May 29, 2018

More on Nursing Workload and Patient Safety

May 22, 2018

Hazardous Intrahospital Transport

May 15, 2018

Helping Inpatients Sleep

May 8, 2018

Heparin Overdose

May 1, 2018

Refrigerator Alarms

April 24, 2018

Review on Hourly Rounding

April 17, 2018

More on Tests Pending at Discharge

April 10, 2018

Prepping the Geriatric Patient for Surgery

April 3, 2018

Cost of a CAUTI

March 27, 2018

PICC Use Persists

March 20, 2018

Minnesota Highlights Lost Tissue Samples

March 13, 2018

Intercepting Errors

March 6, 2018

Nurse Workload and Mortality

February 27, 2018

Update on Patient Safety Walk Rounds

February 20, 2018

Delirium and Falls

February 13, 2018

Interruptions in the ED

February 6, 2018

Adverse Events in Inpatient Psychiatry

January 30, 2018

Texting Errors Revealed

January 23, 2018

Unintentional Hypothermia Back in Focus

January 16, 2018

Just the Fax, Ma’am

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

More on Overlapping Surgery

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

OR to ICU Handoff Success

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

Texting – We Told You So!

June 20, 2017

Dilaudid Dangers #4

June 13, 2017

Layering Up

June 6, 2017

NYS Mandate for Sepsis Protocol Works

May 30, 2017

Errors in Pre-Populated Medication Lists

May 23, 2017

Trolling the RCA

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

Dialysis and Alarm Fatigue

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

Nested Interruptions

February 28, 2017

The Copy and Paste ETTO

February 21, 2017

Yet More Jumps from Hospital Windows

February 14, 2017

Alarm Fatigue in the ED

February 7, 2017

Maternal Safety Bundles

January 31, 2017

More Issues in Pediatric Safety

January 24, 2017

Dexmedetomidine to Prevent Postoperative Delirium

January 17, 2017

Pediatric MRI Safety

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

Surgical Specimen Mishaps

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

More on After-Hours Surgery

September 27, 2016

Lab Errors Costly

September 20, 2016

Downloadable ABCDEF Bundle Toolkits for Delirium

September 13, 2016

Vanderbilt’s Electronic Procedural Timeout

September 6, 2016

Napping Debate Rekindled

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

More on the Second Victim

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

Falls from Hospital Windows

April 5, 2016

Workarounds Overriding Safety

March 29, 2016

Inappropriate Lab Testing

March 22, 2016

Radiology Communication Errors May Surprise You

March 15, 2016

Dental Patient Safety

March 8, 2016

Tip of the Week on Vacation

March 1, 2016

Colonoscopy Complications

February 23, 2016

Weekend Effect Solutions?

February 16, 2016

Fall Prevention Failing?

February 9, 2016

It was just a matter of time…

February 2, 2016

Success Against Sepsis

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

Smarter Checklists

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

Not All Falls Are the Same

July 21, 2015

Avoiding Distractions in the OR

July 14, 2015

NPSF’s RCA2 Guidelines

July 7, 2015

Medical Staff Risk Issues

June 30, 2015

What Are Appropriate Indications for Urinary Catheters?

June 23, 2015

Again! Mistaking Antiseptic Solution for Radiographic Contrast

June 16, 2015

Updates on Delirium

June 9, 2015

Add This to Your Fall Risk Assessment

June 2, 2015

Reminders of Dilaudid Dangers

May 26, 2015

How Safe is the Lab You Use?

May 19, 2015

Dueling Chlorhexidine Studies

May 12, 2015

More on Delays for In-Hospital Stroke

May 5, 2015

Errors with Oral Oncology Drugs

April 28, 2015

Failure to Escalate

April 21, 2015

Slip and Capture Errors

April 14, 2015

Using Insulin Safely in the Hospital

April 7, 2015

Missing Patients and Death

March 31, 2015

Clinical Decision Support for Pneumonia

March 24, 2015

Specimen Issues in Prostate Cancer

March 17, 2015

Distractions in the OR

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

More on Numeracy

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

More Trouble with NMBA’s

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

Antibiotic Stewardship

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

Ophthalmology: Blue Dye Mixup

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

Melatonin and Delirium

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

Nudged, But Who Nudged Who?

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

The PICC Myth

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

The Second Victim

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

Missing Patients

October 8, 2013

EMR Problems in the ED

October 1, 2013

Fuels and Oxygen in OR Fires

September 24, 2013

Perioperative Use of CPAP in OSA

September 17, 2013

First MEWS, Now PEWS

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

Adverse Events in Home Care

August 6, 2013

Let Me Sleep!

July 9-30, 2013

Tip of the Week on Vacation

July 2, 2013

Issues in Alarm Management

June 25, 2013

Update on Surgical Fires

June 18, 2013

DVT Prevention in Stoke – CLOTS 3

June 11, 2013

Amphotericin Mixups Continue

June 4, 2013

Reducing Unnecessary CT Scans

May 28, 2013

The Neglected Medications: IV Fluids

May 21, 2013

Perioperative Distractions

May 14, 2013

Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)

May 7, 2013

Drug Errors in the Home

April 30, 2013

Photographic Identification to Prevent Errors

April 23, 2013

Plethora of Medication Safety Studies

April 16, 2013

Distracted While Texting

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

Falls on Inpatient Psychiatry

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

Breastfeeding Mixup Again

December 4, 2012

Unintentional Perioperative Hypothermia: A New Twist

November 27, 2012

Dealing with Distractions

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

Surgical Scheduling Errors

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

Insulin Pump Safety

September 11, 2012

In Search of the Ideal Early Warning Score

September 4, 2012

More Infant Abductions

August 28, 2012

New Care Model Copes with Interruptions Better

August 21, 2012

More on Missed Followup of Tests in Hospital

August 14, 2012

Gait Speed: A New Vital Sign?

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

More on Wrong-Patient CPOE

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

Diagnostic Error Chapter 3

May 8, 2012

Importance of Nontechnical Skills in Healthcare

May 1, 2012

More LEAN Successes

April 24, 2012

Fire Hazard of Skin Preps Oxygen

April 17, 2012

10x Dose Errors in Pediatrics

April 10, 2012

Error Disclosure by Surgeons

April 3, 2012

New Risk for Postoperative Delirium: Obstructive Sleep Apnea

March 27, 2012

Action Plan Strength in RCAs

March 20, 2012

Adverse Events Related to Psychotropic Medications

March 13, 2012

Medical Emergency Team Calls to Radiology

March 6, 2012

Lab Error

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

Medication Safety in the OR

January 24, 2012

Patient Safety in Ambulatory Care

January 17, 2012

Delirium and Contact Isolation

January 10, 2012

Verbal Orders

January 3, 2012

Unintended Consequences of Restricted Housestaff Hours

December 20, 2011

Infant Abduction

December 13, 2011

Surgical Fires Again

December 6, 2011

Why You Need to Beware of Oxygen Therapy

November 29, 2011

More on Diagnostic Error

November 22, 2011

Perioperative Management of Sleep Apnea Disappointing

November 15, 2011

Rethinking Colonoscopy

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

Renewed Focus on MRI Safety

October 18, 2011

High-Risk Surgical Patients

October 11, 2011

LEAN in the Lab

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

More Tips on PCA Safety

August 30, 2011

Unintentional Discontinuation of Medications After Hospitalization

August 23, 2011

Catheter Misconnections Back in the News

August 16, 2011

Crisis Checklists for the OR

August 9, 2011

Frailty and the Surgical Patient

August 2, 2011

Hazards of e-Prescribing

July 26, 2011

Hourly Rounding

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

STOPP Using Beers List?

June 14, 2011

Failure to Follow Up

June 6, 2011

Timeouts Outside the OR

May 31, 2011

Book Review Human Factors and Team Psychology in a High Stakes Environment

May 24, 2011

Hand Hygiene Resources

May 17, 2011

Opioid-Induced Respiratory Depression Again!

May 10, 2011

Preventing Preventable Readmissions: Not As Easy As It Sounds

May 3, 2011

Its All in the Timing

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

More Aviation Principles

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

Early Warnings for Sepsis

March 8, 2011

Yes, Physicians Get Interrupted Too!

March 1, 2011

Tests Pending at Discharge

February 22, 2011

Rethinking Alarms

February 15, 2011

Controversies in VTE Prophylaxis

February 8, 2011

Inducing Too Early

February 1, 2011

MRI Safety Audit

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

Safer Use of PCA

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

Lost Lab Specimens

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

Slowing Down in the OR

October 5, 2010

More Iatrogenic Burns

September 28, 2010

Diagnostic Error

September 21, 2010

Dilaudid Dangers

September 14, 2010

Wrong-Site Craniotomy: Lessons Learned

September 7, 2010

Patient Safety in Ob/Gyn Settings

August 31, 2010

Postoperative Delirium

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

Iatrogenic Burns

May 25, 2010

Propofol Issues

May 18, 2010

Real-Time Random Safety Audits

May 11, 2010

Delayed Diagnosis of Cancer

May 4, 2010

More on the Impact of Interruptions

April 27, 2010

Infusion Pump Safety

April 20, 2010

HITs Limited Impact on Quality To Date

April 13, 2010

Update on Handoffs

April 6, 2010

Cancer Chemotherapy Accidents

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

The Hazards of Radiation

January 26, 2010

Preventing Postoperative Delirium

January 19, 2010

Timeouts and Safe Surgery

January 12, 2010

Patient Photos in Patient Safety

January 5, 2010

Hows Your Hand Hygiene?

December 29, 2009

Recognizing Deteriorating Patients

December 22, 2009

Falls on Toileting Activities

December 15, 2009

The Weekend Effect

December 8, 2009

Prescribing Errors

December 1, 2009

Patient Safety Doesnt End at Discharge

November 24, 2009

Another Rough Month for Healthcare IT

November 17, 2009

Switched Babies

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

Slipping Through the Cracks

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

The Radiology SuiteAgain!

August 4, 2009

Faulty Fall Risk Assessments?

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

More on Delirium in the ICU

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

Learning from Tragedies

May 12, 2009

Errors With PCA Pumps

May 5, 2009

Adverse Drug Events in the ICU

April 28, 2009

Ticket Home and Other Tools to Facilitate Discharge

April 21, 2009

Still Futzing with Foleys?

April 14, 2009

More on Rehospitalization After Discharge

April 7, 2009

Project RED

March 31, 2009

Screening Patients for Risk of Delirium

March 24, 2009

Medication Errors in the OR

March 17, 2009

More on MRI Safety

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

Lab Errors in the News

January 6, 2009

Preventing Inpatient Suicides

December 30, 2008

Unintended Consequences: Is Medication Reconciliation Next?

December 23, 2008

Why Safety Alerts Often Fail

December 16, 2008

Joint Commission Sentinel Event Alert on Hazards of Healthcare IT

December 9, 2008

Huddles in Healthcare

December 2, 2008

Playing without the ballthe art of communication in healthcare

November 25, 2008

Wrong-Site Neurosurgery

November 18, 2008

Ticket to Ride: Checklist, Form, or Decision Scorecard?

November 11, 2008

Probiotics and VAP Prevention

November 4, 2008

Beta Blockers Take More Hits

October 28, 2008

More on Computerized Trigger Tools

October 21, 2008

Preventing Delirium

October 14, 2008

Managing Delirium

October 7, 2008

Lessons from Falls....from Rehab Medicine

September 30, 2008

Hot Topic: Handoffs

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

Updates on VAP Prevention

August 26, 2008

Pattern Recognition and CPOE

August 19, 2008

Arterial Line Issues

August 12, 2008

Jerome Groopmans How Doctors Think

August 5, 2008

Tip of the Week on Vacation

July 29, 2008

Heparin-Induced Thrombocytopenia

July 22, 2008

Lots New in the Anticoagulation Literature

July 15, 2008

Heparin Flushes.....Again!

July 8, 2008

Medical Helicopter Crashes

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

Computerizing Trigger Tools

April 8, 2008

Oxygen as a Medication

April 1, 2008

Pennsylvania PSAs FMEA on Telemetry Alarm Interventions

March 25, 2008

More on MRSA

March 18, 2008

Is Desmopressin on Your List of Hi-Alert Medications?

March 11, 2008

Lessons from Ophthalmology

March 4, 2008

Housestaff Awareness of Risks for Hazards of Hospitalization

February 26, 2008

Nightmares.The Hospital at Night

February 19, 2008

MRI Safety

February 12, 2008

More on Tracking Test Results

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

Fall Prevention

December 25, 2007

Happy Holidays

December 18, 2007

Bed Rails

December 11, 2007

CommunicationCommunicationCommunication

December 4, 2007

Surgical Fires

November 27,2007

More on Rapid Response Teams

November 20, 2007

New Evidence Questions Perioperative Beta Blocker Use

November 13, 2007

AHRQ's Free Patient Safety Tools DVD

November 6, 2007

Don Norman Does It Again!

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

Errors in the Laboratory

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

Workarounds as a Safety Issue

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

Tip of the Week on Vacation

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

More on TeamSTEPPS

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

The Missed Cancer

April 23, 2007

Predictable Errors

April 16, 2007

Falls with Injury

April 9, 2007

Make Your Surgical Timeouts More Useful

April 2, 2007

More Alarm Issues

March 26, 2007

Alarms Should Point to the Problem

March 19, 2007

Put that machine back the way you found it!

March 12, 2007

10x Overdoses

March 5, 2007

Disabled Alarms

February 26, 2007

Unintended Consequences