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July 6, 2010
Book Reviews:
Pronovost and Gawande
We almost always follow a holiday weekend with a book review. This time we actually have reviews on books from 2 patient safety icons: Peter Pronovosts Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out and Atul Gawandes The Checklist Manifesto: How to Get Things Right.
Since the most famous patient safety checklist is the one devised by Peter Pronovost, you would expect his book to be about checklists. But his book is all about culture the culture of medicine and his struggle to create change in some of the toughest places to implement change. Youll love this book. It is full of characters you will readily recognize from your own hospital! Youll find yourself saying Hey, that surgeons just like Dr. ___! or Thats what happened when we tried to implement that here!.
About a year ago we reviewed John Nances book Why Hospitals Should Fly (see our June 2, 2009 Patient Safety Tip of the Week Why Hospitals Should FlyJohn Nance Nails It!). Nances basic premise was that, despite all the sound patient safety practices we know about, we have not significantly improved patient safety. And his explanation is that we have failed to change the culture of medicine. How true. Pronovost book expands on that concept. He gives anecdote after anecdote of the hierarchical structure of medicine interfering with good patient care.
And Pronovost did change culture. Whether dealing with reducing central line infections, ICU daily goals, handoffs/timeouts/debriefings, etc. he managed to create change. Up against a we already know how to do that attitude in his own department, his own hospital (Johns Hopkins), statewide hospital groups in several states, and multiple countries, he almost always got people to come around.
There were a number of key success factors he highlights. Foremost is doing it right. That meant that he had to collect valid data to show that the projects in fact were improving care. That commitment to scientific principle was a key in converting some skeptics. On several occasions, when physicians or other groups claimed they were already doing it well or could do it better, he challenged them to show him their data. When they couldnt, they usually came around to participating in the collaboratives. The second major success factor was involving and empowering front line people in development of the projects. He often pointed out that the front line people were more likely to get on board than were the experts. And a third major success factor was commitment from hospital executives. That was what kept several collaborative projects on target. His ability to get buy-in from executives was helpful not only in the projects but in day-to-day activities. He describes a harrowing experience where he, as the anesthesiologist, correctly suspected a deteriorating patient had a potentially life-threatening latex allergy during surgery. He implored the surgeon in every way possible to change his gloves to non-latex ones and the surgeon refused until Pronovost put out a page to the hospital administration!
Pronovosts book is a great collection of stories and great example of how to overcome adversity when youre dealing with something you are committed to.
Atul Gawandes book really is about checklists. Of course he talks about Peter Pronovosts checklist for preventing central line infections (remember he did that in his essay The Checklist that appeared in The New Yorker). In that essay, he eloquently expounded upon the simplicity and sophistication of Peter Pronovosts success in introducing the concept of the checklist to improve medical care.
But he goes on to talk about use of checklists in other industries before he describes his collaborative work in the development of the WHO Surgical Safety Checklist (see our July 1, 2008 Patient Safety Tip of the week WHOs New Surgical Safety Checklist.)
Most striking is his description of a building being constructed in Boston. He takes a tour inside as the building is going up and wonders at the incredible complexity requiring timely coordination of innumerable workers from multiple different companies a stark contrast to the often piecemeal, uncoordinated care we see in medicine. When he goes to the command center of that construction project he is amazed to see that it is really operated upon checklists one checklist after another after another!
After preliminary development of the WHO checklist, he tries it out himself and it fails miserably. He realizes it is too long, too unclear, too distracting. Shortly thereafter he pays a visit to Daniel Boorman, an expert on aviation checklists at Boeing. There he was introduced to tomes of manuals used in aviation that were really individual checklists. And there were checklists not only for the normal things encountered in flying but also ones for a whole host of abnormal conditions and events that might take place. Moreover, for those rare potentially catastrophic events, pilots can practice using the checklists in simulators. But, critically, pilots learn to trust the checklists.
At Boeing he was introduced to READ-DO checklists and DO-CONFIRM checklists. He also learned the characteristics of good and bad checklists. One important point is that there needs to be a natural pause before you would implement a checklist. Secondly, the checklist cannot be long not more than 7 to 9 items. If checklists are too long, they become distractions to other activities and people start taking shortcuts. Simple wording in the language of the profession is important and even the type of font used is important (sans serif fonts work best). Most importantly, you have to test the checklist in real world conditions and expect that most checklists will fail on first draft. And Boorman cautioned not to put on checklists those things that pilots never fail to do because they just become distractions.
By the way in our September 23, 2008 Patient Safety Tip of the Week Checklists and Wrong Site Surgery we referenced another excellent guidance from the UK Civil Aviation Authority on the proper design, presentation and use of checklists.
Even the issue of who initiates the checklist is important. In aviation, its usually begun by the pilot not flying so the pilot flying would not skip steps in the checklist because of other distractions. So they decided the circulating nurse should call the start of the checklist.
Gawande goes on to describe how the WHO collaborators tweaked the checklists, often compromising and lopping off items that were not absolutely essential in favor of keeping the checklist(s) brief. Getting a good baseline was critical to successful demonstration that the checklist actually improved care. Sampling data at multiple hospitals, they found as many as one third of appendectomy patients failed to get their pre-op antibiotics correctly. When they began to review the results after implementation of the WHO checklist at pilot hospitals in eight countries, Gawande was amazed at the outcomes and kept looking for flaws in the data. But there were none. The striking outcomes were published in the New England Journal of Medicine (See our January 20, 2009 Patient Safety Tip of the Week The WHO Surgical Safety Checklist Delivers the Outcomes). Mortality at 30-days post-op decreased from 1.5% before introduction of the checklist to 0.8% after. Rate of any complication decreased from 11% to 7%. Both these outcomes were highly statistically significant. Thats a relative risk reduction of approximately 36% for mortality and major morbidity! Of important specific surgery complications, both surgical site infections and unplanned reoperations decreased significantly. Improvements were seen at all participating sites.
But the book is also about culture. He encountered many of the same barriers that Peter Pronovost talked about in his book. He talks about how the checklist may have fostered better teamwork. He cites work done by Brian Sexton in which surgeons rate their impression of teamwork much better than do all other members of the team and how those measures of perception of teamwork improved after implementation of the checklist and pre-op huddles. He cites his own experience as a good example as well. He says that the introduction of all team members by name at first appeared hokie to him, but once team members got to know each other their communication ratings improved considerably.
Having surgical chiefs and other opinion leaders be first to implement the checklist at participating hospitals was helpful. He describes a unique approach to the checklist at Columbus Childrens Hospital. The head of surgical administration there, who was both a pediatric cardiac surgeon and a pilot, developed a Cleared for Takeoff theme with a checklist on the whiteboards in each OR room. But he also designed a little tent with the cleared for takeoff theme on it and it covered the surgical instrument, forcing the surgeon to do the checklist before using the instruments. Use of these devices eventually got them to 100% performance of the checklist. Though some might call this a forcing function, it is more along the lines of a nudge (see our July 7, 2009 Patient Safety Tip of the Week Nudge: Small Changes, Big Impacts).
In fact, one of the points of debate is whether the striking improvement is attributable to use of the checklist per se or to the change in culture that accompanied use of the checklist. To that debate we say who cares?. If merely using a checklist results in such powerful improvement in the culture of safety and promotion of better communication and teamwork, use it!!!
Gawande also talks about a trait of good pilots that is often missing in physicians discipline. He notes that this often takes a back seat to autonomy in medicine. But discipline is one of the things that helps pilots stay focused in even the most dire of emergencies.
Gawande is both a dedicated patient safety guru and master story teller. Youll enjoy this book.
References:
Pronovost P, Vohr E. Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out. Hudson Street Press 2010
Gawande A. The Checklist Manifesto.
The Checklist Manifesto: How to Get Things Right. Metropolitan Books 2010
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 Book Reviews: Pronovost and Gawande
July 13, 2010
Postoperative Opioid-Induced Respiratory Depression
Weve done several columns on postoperative respiratory depression related to opioid administration (see our Patient Safety Tips of the Week for June 10, 2008 Monitoring the Postoperative COPD Patient, May 12, 2009 Errors With PCA Pumps, and August 18, 2009 Obstructive Sleep Apnea in the Perioperative Period.).
A recent review article in Anesthesiology (Dahan 2010a) discusses some of the practical and theoretical considerations in monitoring and management of postoperative patients receiving opioid analgesics. The true incidence of respiratory depression in that population is not known because studies have used different definitions, different frequencies of monitoring, etc. Moreover, there are specific patient populations that are at greater risk (the very young and the very old, those with obesity, sleep apnea, neuromuscular diseases, COPD, and those in higher ASA classes). But it remains clear that the potential morbidity and mortality from such respiratory depression is substantial.
Perhaps the biggest problem is that the most commonly monitored parameters of respiratory function are respiratory rate and oxygen saturation. Neither are particularly good measures of opioid-induced respiratory depression. Substantial hypercapnia may occur before there is oxygen desaturation.
Naloxone remains the drug currently used to reverse the respiratory depressant effects of opioid analgesics. However, its efficacy depends on many factors, including the pharmacokinetics and pharmacodynamics of the individual opioid analgesic. One of the important risks to consider when using naloxone is the risk of renarcotization that occurs when there is a significant disparity between those pharmacokinetic and pharmacodynamic properties of the opioid and the naloxone. Therefore, titrating the naloxone to effect followed by continuous infusion of naloxone may be necessary in some cases. They also discuss some individual opioids that merit special consideration. For example, the dose response curve for naloxone in buprenorphine-induced respiratory depression is actually bell-shaped. For remifentanil, a higher dose of naloxone would be needed but the recommended course of action for remifentanil-induced respiratory depression, in view of its very short half-life, is actually just cessation of the remifentanil infusion.
Because of the risk of renarcotization (and the risk of other side effects of naloxone, such as those due to massive release of catecholamines) it is important to perform close cardiopulmonary monitoring while patients are receiving naloxone. The Dahan article also discusses some new promising agents in the pipeline that might be used to reverse opioid-induced respiratory depression.
Overdyk, in a letter commenting on the Dahan article, stresses the dangers in the postoperative patient on the general medical floors compared to ICUs, noting that preventable cardiopulmonary arrests are 5 times more likely on general medical floors. They also cite a study by Chen et al (Chen 2009) that we discussed in our December 29, 2009 Patient Safety Tip of the Week Recognizing Deteriorating Patients showing that recording of vital signs, particularly respiratory rate, is incomplete or missing in 77% of patients for whom a Code is called or a Rapid Response Team is summoned. Overdyk makes a case for using automated continuous vital sign monitoring in such patients.
Dahan et al (Dahan 2010b) affirm that respiratory rate and O2 saturation are not good measures of opioid-induced respiratory depression. They note that such respiratory depression is characterized by an initial period of irregular breathing without affecting the respiratory rate, followed by a period of cyclic breathing, and finally bradypnea and respiratory arrest. They thus argue that patients at risk for opioid-induced respiratory depression are best monitored in higher level units with not only close monitoring of vital signs but also end-tidal carbon dioxide and EKG monitoring. They note that tachycardia and arrhythmias may be the first signs of hypercapnia even when O2 saturations are adequate.
They also note an article we discussed in our March 2, 2010 Patient Safety Tip of the Week Alarm Sensitivity: Early Detection vs. Alarm Fatigue by Taenzer et al that discussed a new system of monitoring post-op orthopedic patients with continuous pulse oximetry. Data from continuous pulse oximetry was analyzed by computer and tied to a system of notifying the patients nurse by pager. Key concepts were setting thresholds that met a balance between high sensitivity and numbers of false alarms. They also incorporated a delay into the notification system to further minimize the number of false alarms that nurses would have to respond to. The ultimate triggers used were an oxygen saturation of less than 80% and a heart rate below 50 or greater than 140. Their preliminary results show a reduction in rescue events and fewer transfers to the ICU. There were also fewer deaths, though the numbers were too small to be considered significant. This is an exciting concept and suggests that noninvasive monitoring tied to computer algorithms might someday operate in the background to help identify patients in need of early intervention.
Obesity and sleep apnea, conditions that predispose further to opioid-induced respiratory depression, are also becoming more and more prevalent. See our July 2010 Whats New in the Patient Safety World column Obstructive Sleep Apnea in the General Inpatient Population for a recent study that found a potential 60% prevalence of obstructive sleep apnea in patients admitted to general medicine units in an urban academic hospital, most of whom had never been diagnosed with OSA.
Keep in mind that we have mostly been concerned about patients receiving intravenous opioids for postoperative pain control. However, other forms of opioid administration may also be associated with respiratory depression. There have been numerous incidents in which miscalculation of dosage has occurred when switching patients from one opioid to another. And more and more untoward incidents have been being reported related to Fentanyl patches (ISMP Canada 2009).
Also, dont forget that supplemental oxygen in patients at risk for hypercapnia may actually be harmful if too much is given (see our Patient Safety Tips of the Week for April 8, 2008 Oxygen as a Medication, June 10, 2008 Monitoring the Postoperative COPD Patient, and January 27, 2009 Oxygen Therapy: Everything You Wanted to Know and More!). In such patients who are at risk for hypercapnia, using lower oxygen saturation targets may be indicated.
So what should your organization be doing? Wed suggest the following:
Opioid analgesics have been very useful in the management of postoperative pain and there has been a push in recent years to ensure adequate pain management in all hospitalized patients, including those who are postoperative. Just be wary of the potential complications and be both vigilant for their occurrence and be prepared to deal appropriately with those complications that arise.
References:
Dahan, Albert; Aarts, Leon; Smith, Terry W. Incidence, Reversal, and Prevention of Opioid-induced Respiratory Depression. Anesthesiology. 112(1):226-238, January 2010
full text version:
Overdyk, Frank J. Postoperative Opioids Remain a Serious Patient Safety Threat.
Anesthesiology. 113(1): 259-260, July 2010
Dahan, Albert; Aarts, Leon; Smith, Terry. Postoperative Opioids Remain a Serious Patient Safety Threat. Anesthesiology. 113(1): 260-261, July 2010
Chen, Jack; Hillman, Ken; Bellomo, Rinaldo; Flabouris, Arthas; Finfer, Simon; Cretikos, Michelle. Resuscitation 2009; 80: 35-43
http://www.resuscitationjournal.com/article/S0300-9572(08)00716-8/abstract
Taenzer AH, Pyke JB, McGrath SP, Blike GT. Impact of Pulse Oximetry Surveillance on Rescue Events and Intensive Care Unit Transfers: A Before-and-After Concurrence Study. Anesthesiology 2010; 112(2): 282-287
Obstructive Sleep Apnea Prevalent in the Hospital Setting
Jim Kling. Medscape June 15, 2010
http://www.medscape.com/viewarticle/723566
ISMP Canada. Analysis of International Findings from Incidents Involving Fentanyl Transdermal Patches. ISMP Canada Safety Bulletin 2009; 10: 1-2 (December 30, 2009)
Print Postoperative Opioid-Induced Respiratory Depression
July 20, 2010
More on the Weekend Effect/
After-Hours Effect
We have discussed in several columns the increased incidence of adverse events and poor outcomes in the hospital at night and on weekends (see our Patient Safety Tips of the Week for February 26, 2008 Nightmares.The Hospital at Night and December 15, 2009 The Weekend Effect and our Whats New in the Patient Safety World columns for October 2008 Hospital at Night Project and September 2009 After-Hours Surgery Is There a Downside?).
Our December 15, 2009 Patient Safety Tip of the WeekThe Weekend Effect discussed how adding nonclinical administrative tasks to already overburdened nursing staff on weekends may be detrimental to patient care. Now a new study from the UK (Temple 2010) suggests a physician component as well is part of the weekend effect. The study found the death rate at hospitals across England increased by 7% at weekends over the 2005-06 period. They ascribed the increased mortality rates on weekends to primarily two causes: (1) reliance on more junior physicians and (2) lack of specialist services.
To that wed add a third contributing factor: physician cross-coverage is increased on weekends as well. That means that physicians who are much less knowledgeable about specific hospitalized patients may be covering.
A new systematic review and meta-analysis (Canallazzi 2010) found that there is an increased risk of death for patients admitted to an ICU over the weekend (about 8%) but not for those admitted at night. They suspect that organizational and staffing issues may explain the increased risk on weekends and note factors such as decreased physician-to-patient ratios, unavailability of board-certified intensivists, physician fatigue, and difficulty obtaining complex diagnostic tests as possible contributing factors.
Our September 2009 Whats New in the Patient Safety World columnAfter-Hours Surgery Is There a Downside?) noted a paper by Ricci et al showing that in orthopedic cases done after hours (4 PM to 6 AM) there was an increased need for reoperations for removal of painful fracture hardware. We discussed potential contributing factors such as loss of continuity of operating teams, different team dynamics, different staffing in postoperative areas, lack of familiarity with location of equipment, fatigue, lack of other support services (eg. radiology), etc.
Meanwhile, two recent studies using large national databases have looked at the influence of time of day and day of the week on perinatal outcomes. A Scottish study (Pasupathy 2010) showed about a 30% increased neonatal mortality for full-term deliveries taking place at all times other than Monday thru Friday from 9 AM to 5 PM. This was largely explained by an increased number of deaths attributed to intrapartum anoxia. After excluding elective Caesarean sections, the difference was attenuated but a significant association between time of delivery and outcome persisted.
A Dutch study (de Graaf 2010) found increased perinatal mortality and an increase in a combined perinatal adverse outcome measure in nontertiery hospitals during the evening and night and in tertiary hospitals at night.
Though the logical association here is with staffing patterns, neither study can directly link staffing patterns to the adverse outcomes and the authors of both studies point out that other factors may be important. While some past studies on time of day of deliveries had suggested fatigue as a potential factor, the fact that there was no difference between nighttime deliveries during weekdays and daytime deliveries on weekends in the Scottish study makes fatigue less likely an explanation.
It should be kept in mind that despite the increased rates of neonatal adverse events and deaths after-hours, the overall absolute numbers remain quite small. That must be taken into account in any cost-effectiveness considerations about staffing, etc. However, the authors of the Scottish study, which looked only at mortality, point out that one might expect the same effect of after-hours delivery on infants who survive and might have long-lasting neurological and developmental handicaps.
One factor often overlooked is the impact of shift work. Both nurses and physicians often work in shifts where the time of day worked varies and it is clear that such practices may have a number of detrimental effects in any industry. A nice discussion of this was provided in an article by the BMA Scottish Junior Doctors Committee. Though that paper was aimed at the hours worked by residents, they discuss the implications of shift work in numerous industries and the potential impact on safety and the potential health implications. One statistic they quote is that the estimated risk of reported adverse incidents in industry increases to 6% on the second night shift, 17% on a third, and 36% higher risk on a fourth night shift worked (the corresponding numbers for consecutive day shifts are 2%, 7% and 17%).
Lastly, one area in which there is almost no literature is the occurrence of adverse patient events at night and on weekends for outpatient care. Continuity of care often is often disjointed during such times, particularly when electronic medical records are not readily available to the covering physicians. We strongly suspect analysis of such care is likely to demonstrate a significant number of adverse events due to the unique problems encountered by covering physicians who have limited knowledge of the patients.
References:
Temple J. Time for Training. A Review of the impact of the European Working Time Directive on the quality of training. May 2010
http://www.mee.nhs.uk/PDF/14274 Bookmark Web Version.pdf
Cavallazzi R, Marik PE, Hirani A, et al. ssociation Between Time of Admission to the ICU and Mortality: A Systematic Review and Metaanalysis.
Chest 2010; 138: 68-75
http://chestjournal.chestpubs.org/content/138/1/68.abstract
Ricci WM, Gallagher B, Brandt A, Schwappach J, Tucker M, Leighton R. Is After-Hours Orthopaedic Surgery Associated with Adverse Outcomes? A Prospective Comparative Study. J Bone Joint Surg Am. 2009;91: 2067-2072
http://www.ejbjs.org/cgi/content/abstract/91/9/2067
Pasupathy D, Wood AM, Pell JP, Fleming M, Smith GCS. Time of birth and risk of neonatal death at term: retrospective cohort study. BMJ2010;341:c3498, doi: 10.1136/bmj.c3498 (Published 15 July 2010)
http://www.bmj.com/cgi/content/abstract/341/jul15_1/c3498
full text:
http://www.bmj.com/cgi/reprint/341/jul15_1/c3498
de Graaf J, Ravelli A, Visser G, Hukkelhoven C, Tong W, Bonsel G, Steegers E. Increased adverse perinatal outcome of hospital delivery at night. BJOG 2010; 17: 10981107
http://www3.interscience.wiley.com/journal/123467987/abstract?CRETRY=1&SRETRY=0
BMA Scotland. Shift-work, Rest and Sleep: Minimising the Risks
Discussion paper by the BMA Scottish Junior Doctors Committee
February 2010
http://www.nursingtimes.net/Journals/2/Files/2010/5/28/shiftwork_tcm26-196305.pdf
Print More on the Weekend Effect/After-Hours Effect
July 27, 2010
EMRs Still Have A
Long Way To Go
Just as the final rule for meaningful use in adoption of electronic medical records (EMRs) has been released, several studies have shown that most off-the-shelf EMRs and even some highly sophisticated systems built in-house still lack some of the important clinical decision support tools we need to improve patient safety. Moreover, these studies highlight the need for practice and workflow transformation. You cant simply plop an EMR into a practice or a hospital and anticipate all your potential problems will disappear.
On the hospital side, The Leapfrog Group used its simulation tool to test how CPOE systems at over 200 hospitals would handle a variety of medication order entry scenarios. From June 2008 to January 2010, 214 hospitals used the Leapfrog web-based tool to test their CPOE systems ability to identify potential problems during medication order entry. The percentage of medication orders that did not receive an appropriate warning was 52% in adult hospitals and 42% in pediatric hospitals. Moreover, for potentially fatal orders, an appropriate warning was not given in about a third of cases at both adult and pediatric hospitals.
Fortunately, the simulation tool is having a positive impact. Nearly all the hospitals used the results of the simulation to improve their CPOE systems. Leapfrog is stressing that ongoing testing and monitoring of CPOE systems is crucial and that collaboration must take place between vendors and hospitals to identify best practices. They call for movement away from proprietary closed systems and call for better sharing of issues and solutions across vendors and across healthcare organizations.
On the outpatient side, Elder et al. looked at management of test results in primary care practices and found that, though those practices with EMRs did slightly better on certain processes in managing test results, they fell short on notifying patients and in documenting the interpretation and followup of abnormal test results. They did chart audits at 8 family medicine practices in Ohio and compared compliance with certain processes between those practices with and EMR and those without an EMR. Those with EMRs did have higher percentages of charts with test results in the correct place, signatures by clinicians acknowledging the test results, clinician interpretations of results, and patient notifications. And for the subset of those with abnormal test results 64% of those with an EMR had plans for followup documented, compared to only 40% of those without an EMR.
They also found that methods of patient notification differed between those offices with EMRs and those without EMRs. In those practices with EMRs more patients were notified of test results by mail and fewer were notified of their results only at an office visit.
Note that they also looked at the impact on formalized office processes for test result management. Interestingly, they found that practices with fewer standardized steps were actually more likely to document followup on abnormal test results but that none of the offices had standardized processes for that step.
They often found a discrepancy between high compliance with clinician signature and interpretation of test results but low documentation of followup plans. They point out that EMRs may automate and make easier the acknowledgement of test results but that does not guarantee the test results get adequate scrutiny and that a plan of action will be undertaken. That is one area where both further refinement of EMRs and other process changes in workflow and practice procedures will be required. Followup of test results is one of the areas stressed in those practices seeking to become patient-centered medical homes (PCMHs). Its also one of the patient safety areas we have most frequently talked about on the ambulatory care side (see our Patient Safety Tips of the Week for December 11, 2007 CommunicationCommunicationCommunication, May 1, 2007 The Missed Cancer, February 12, 2008 More on Tracking Test Results, October 13, 2009 Slipping Through the Cracks and our July 2009 Whats New in the Patient Safety World column Failure to Inform Patients of Clinically Significant Outpatient Test Results).
And on the e-prescribing side Matvey 2010 found frequent internal discrepancies in e-prescriptions between what was in structured fields and what was in associated free-text fields. Structured fields contain data such as the name of the drug, the dosage form, the route, the frequency, the duration, and the number of refills. The free text fields typically contain instructions like take with meals or more complex dosing regimens (eg. take a whole tablet on even days and a half tablet on odd days). They looked at e-prescribing in the ambulatory arena at Partners HealthCare, known for its relatively sophisticated electronic medical record system. Over 42% of such e-prescriptions contained such free text fields. A random sample of those that contained such free text found discrepancies in 16.1% of e-prescriptions. And over 80% of those with discrepancies were deemed potentially capable of leading to an adverse event (potentially severe in almost 17%).
While mismatches in frequency, route, dosage form, duration and quantity were relatively uncommon, the highest frequency of discrepancies (29% of those prescriptions having discrepancies) related to those having complex regimens. These include examples where a different dose is to be taken on different days of the week, regimens where the dosage or frequency of a drug is to be increased or tapered, etc.
Most importantly, the frequency of such discrepancies was much higher for 3 drugs that are already high alert drugs: coumadin, insulin, and digoxin. So these are already high risk drugs and ones for which complex dosing is often necessary and now ones for which internal discrepancies occur frequently.
This study has implications for the design of e-prescribing systems, the user interface and the training that must take place for all providers entering orders into the system. In addition, it highlights the need for pharmacists receiving such prescriptions to contact the ordering physician for clarification. The latter becomes especially problematic when the person who did the order entry is not available and the covering provider may not know what the ordering provider had in mind.
On the positive side, a poster presented by Helen Halpin at the recent annual APIC meeting demonstrated that hospitals using automated surveillance software to help identify infections more accurately and timely using data from multiple sources in the EMR were also more likely to have implemented best practice strategies to avoid infections. Whether that translates into actual lower infection rates remains to be demonstrated but these are best practices that are evidence-based. APIC has published a position paper recommending use of such automated surveillance technologies as part of an effective infection control program.
The key lessons from all these papers are that clinical decision support tools for electronic medical records are still evolving. Though they have a tremendous capability of improving quality of care and patient safety they are still being refined. Moreover, the best practices for delivering that clinical decision support are also just being discovered. And the biggest message is that EMRs are only a piece of the puzzle. We need to change practice workflows, responsibilities, and processes to redesign our practices around the EMR. During the transition period we need to be extremely vigilant and avoid overreliance on the EMR as a panacea.
References:
Center for Medicare and Medicaid Services (CMS). Final rule for meaningful use:
http://www.ofr.gov/OFRUpload/OFRData/2010-17207_PI.pdf
The Leapfrog Group. Leapfrog Group Report on CPOE Evaluation Tool Results June 2008 to January 2010. Executive Summary. June 2010
http://www.leapfroggroup.org/media/file/CPOEEvaluationToolResultsReport.pdf
Elder NC, McEwen TR, Flach J, Gallimore J, Pallerla H. The Management of Test Results in Primary Care: Does an Electronic Medical Record Make a Difference? Fam Med 2010; 42(5): 327-333
http://www.stfm.org/fmhub/fm2010/May/Nancy327.pdf
Matvey B, Palchuk MB, Fang EA, Cygielnik JM, et al. An unintended consequence of electronic prescriptions: prevalence and impact of internal discrepancies
JAMIA 2010;17:472-476
http://jamia.bmj.com/content/17/4/472.abstract?sid=9432e689-ba3b-4b8d-a0c6-7e3216bd44ce
Halpin H, Enanoria W, Vanneman M. Hospital Adoption of Automated Surveillance Technology and the Implementation of Infection Prevention and Control Programs. (Poster Presentation). APIC Annual Meeting July 13, 2010
APIC. Computerized Infection Monitoring Systems Enable Hospitals To Mount More Aggressive Efforts Against Healthcare-Associated Infections. APIC press release
July 12, 2010
Greene LR, Cain TA, Khoury R, et al. APIC Position Paper: The Importance of Surveillance Technologies in the Prevention of Healthcare-Associated Infections (HAIs)
APIC May 29, 2009
Print EMRs Still Have A Long Way To Go
August 10, 2010
It's Not Always About The Evidence
In the era of evidence-based medicine we often fall into the trap of evaluating the performance of an individual provider or a healthcare system by the degree to which they comply with clinical guidelines or best practices that are grounded in outcomes from randomized controlled trials. Yet, when we are asked by a friend or family member about a referral to an individual physician or a hospital, we always have a few that we preferentially recommend even though there are others that perform equally well (or even better) on the measures mentioned above. In effect, we are taking into account the art as well as the science of medicine.
Enter a very humbling paper (Weiner et al 2010) on contextual errors. Contextual errors are those errors where the clinician fails to take into account those elements of a patients environment or behavior that are relevant to their care. Examples of those elements might be a patients financial or employment status, social situation, health literacy, etc. How many times have you escalated a patients antihypertensive regimen, only to realize later that they were never compliant with any part of that regimen, either because they could not afford those medications or could not read the labels? Thats an example of a contextual error.
The study by Weiner et al. puts the frequency of such contextual errors in perspective and demonstrates why we so often fail to achieve the desired outcome despite adhering to the guidelines. Its also a good reminder that the idealized subjects in randomized controlled trials have been carefully selected to weed out many of these contextual issues and may explain some of the differences between clinical trial and real world outcomes.
The investigators trained actors in variants of 4 common clinical scenarios and sent them as unannounced standardized patients into the practices of 111 internal medicine attending physicians. For each scenario there were red flags that required further probing by the clinician. Red flags were either contextual (as above) or biomedical (for example, a nocturnal increase in wheezing or coughing that should prompt questions about possible esophageal reflux). So each scenario could have no red flags, a contextual red flag, a biomedical red flag, or both red flags.
As wed suspect, fewer clinicians probed further after the contextual red flags, but the impact on overall plans of care was striking. Error-free plans of care occurred in 73% of the uncomplicated (no red flags) cases but in only 38% of the biomedically complicated cases and 22% of the contextually complicated cases. And of those with both biomedical and contextual red flags a mere 9% of cases had error-free plans of care.
What a powerful demonstration that, as we strive to standardize care, we must not sacrifice the need to individualize care for each patient.
While we can program electronic medical records to remind you to add an ACE inhibitor is certain clinical situations, it is much more difficult to rely on technological solutions to address contextual issues. We need to do a better job of training our medical students and residents to consider these contextual issues as they interact with patients and their families. Most medical schools now include simulations (using actors or standardized patients) in teaching interview techniques. It would be easy to add the sort of contextual issues from the Weiner paper to those simulation training exercises.
But we have some other suggestions as well. The successful clinician is one who utilizes all members of the healthcare team in dealing with his or her patients. It is amazing how often a patient will confide some of these contextual issues to a nurse or clerical staff but would not disclose them to a physician. Sometimes they are too embarrassed to discuss them with the physician. Other times they may feel that the physician is too busy and they dont want to bother them with these issues. So sometimes it is okay to have one of your other team members broach the questions for you. (As an aside, weve seen many teens who are afraid to talk about issues like STDs but will listen to tapes on such topics or even talk to anonymous sources about such issues. Generation X also freely uses social media technology to discuss things they would never discuss in person.). The solution is that you need to have multiple means of communication available to your patients because they may all communicate in different ways.
Contextual issues can also pop up when you are doing team meetings in your practices. While most practices focus on issues such as billing, scheduling, etc. during team meetings, thats also a good time to say Were having trouble getting Mrs. Jones diabetes under control. Does anyone have any insights that might help us better manage her care?. Youd be surprised how often your staff will volunteer their insights and it also helps your staff take pride in helping all your patients.
You also need to include contextual issues in your plans of care. For example, even if you neglected to probe contextual issues when you first developed a plan of care, you should always ask the appropriate contextual questions when a patient has not responded as expected to a therapeutic intervention. While you should have a clear understanding about the financial impact of prescribing any new drug for a patient, it becomes absolutely crucial that you specifically inquire about cost issues if their blood pressure has not improved or their LDL has not moved a month after you started them on a new regimen.
It can be a humbling experience when you achieve a less than desired outcome because you didnt take the time to give your patient the individualized care he/she needed. This study by Weiner et al. is a real reminder that we still take care of patients one at a time and its a real contribution to helping us deliver safe and effective care.
References:
Saul J. Weiner SJ, Schwartz A, Weaver F, et al. Contextual Errors and Failures in Individualizing Patient Care: A Multicenter Study. Ann Intern Med 2010; 153: 69-75
http://www.annals.org/content/153/2/69.abstract?sid=076f5f8a-abf5-4fc5-9963-c795d39a4924
Print Its Not Always About The Evidence
August 17, 2010
Preoperative Consultation - Time to Change
For years we have criticized the preoperative consultation (often inappropriately referred to as medical clearance) as being nearly useless in the way it is currently done in most places. Similar to the situation for the annual physical examination, there is a dearth of evidence to demonstrate any real value of the preoperative consultation in terms of patient outcomes. Now a new study (Wijeysundera et al 2010) actually suggests that the preoperative consultation may cause unintended consequences and actually lead to adverse outcomes. That Canadian group looked at outcomes in patients in Ontario who underwent major elective noncardiac surgery and had a preoperative consultation and compared those outcomes to those of a matched cohort that did not have a preoperative consultation. They found that those having such consultation had higher mortality rates and longer hospital lengths of stay, plus more preoperative testing and pharmacological interventions. Note that the study period was prior to publication of the POISE trial (see our November 20, 2007 Patient Safety Tip of the Week New Evidence Questions Perioperative Beta Blocker Use and our November 4, 2008 Patient Safety Tip of the Week Beta Blockers Take More Hits), which showed that, though preoperative beta blockers prevented 15 MIs for every 1000 patients treated, there was an increased risk of stroke and an excess of 8 deaths per 1000 patients treated. The authors of the current study speculate, with some corroborating evidence, that the increased mortality and increased stroke occurrence in the patients having preoperative consultation may have resulted from increased use of beta blockers.
The Canadian study does rely on some assumptions and extrapolations. First response would be to say Of course they would do worse. Its the sicker and more high risk patients who get referred for preoperative consultation.. But the authors used some proxies and sensitivity analyses that suggest this was probably not the case. Their results also persisted after adjustment for a variety of potentially confounding factors and were seen across multiple subgroups studied. The study was restrospective and observational, not a randomized controlled trial. They used a previously validated algorhithm to identify likely preoperative consultations from administrative data. But the authors also admit that they have no idea how many cases might have had surgery cancelled because of the findings during a preoperative consultation.
The Canadian group had previousy done a retrospective cohort study (Wijeysundera et al 2010b) which found that noninvasive stress testing before major non-cardiac surgery was associated with improved one-year survival and shorter mean hospital length of stay. However, when patients were stratified by cardiac risk, the mortality benefit was primarily in those with high risk (Revised Cardiac Risk Index 3-6 points) and to a much lesser degree in those at intermediate risk (RCRI 1-2 points). Furthermore, such testing in those at low risk actually caused harm.
The current study does not suggest that the preoperative consultation should be abandoned. What the above says is that we need to apply the same principles to evaluate the effectiveness of the preoperative consultation that we apply to evaluation of any procedure, drug, etc. We clearly need to determine what aspects of a preoperative consultation are important in influencing patient outcomes.We also clearly need to consider changing the focus of the preoperative consultation. Traditionally, it has been focused on cardiac issues. Regular readers of this newsletter know we stress the preoperative evaluation of risk for other complications like delirium, post-op respiratory depression, etc.
ICSI (Institute for Clinical Systems Improvement) recently put out a guideline Preoperative Evaluation that you may find useful. It does note which recommendations are based in evidence and it has some nice preoperative questionnaires and forms. It also has a simple Patient Preoperative Guide for patients to use as they prepare for surgery. The history and physical examination, not the laboratory, remain the core of the preoperative consultation. First and foremost, the guideline emphasizes that routine testing should be minimized and that tests ordered should be individualized to the specific medical issues pertinent to each patient. That, of course, is a recommendation we have seen since the mid-1990s but we are amazed again and again at how many physicians and hospitals ignore that concept and do a whole host of preoperative tests that do not impact on the patients outcome. Remember, Joint Commission holds you to comply with whatever your policy says about preoperative testing. So dont put a whole lot of recommendations in such policy if they are not evidence-grounded.
We also need to think about who should do the preoperative consultation. Historically, it has usually been done by the primary care physician (PCP) or, in the case of patients with a known high risk condition such as coronary artery disease or stage 4 chronic kidney disease, by the specialist. But today many primary care physicians dont even come to the hospital. Inpatients are often managed or co-managed by hospitalists. So maybe the preoperative consultation might be more appropriately done by the hospitalist, who will be following the patient in the hospital. On the other hand, the PCP needs to be asking him/herself What will I need to do for this patient after discharge?. In our April 7, 2009 Patient Safety Tip of the Week Project RED and April 14, 2009 Patient Safety Tip of the Week More on Rehospitalization After Discharge) we noted a paper by Jencks et al 2009 that noted 72.6% of hospital 30-day Medicare readmissions in surgical patients are for medical (non-surgical) reasons. Very few of those readmissions had even seen their PCP between discharge and rehospitalization.
Note that co-management is another issue you need to address (see our October 27, 2009 Patient Safety Tip of the Week Co-Managing Patients: The Good, The Bad, and The Ugly). If you do co-manage, make sure that everyone knows who will be responsible for which aspects of care.
The timing of the preoperative consultation may also be important. Most such consultations tend to get done in the 1-2 weeks prior to the anticipated surgery. Yet that leaves insufficient time for some interventions, such as smoking cessation, withdrawal of certain medications, titration of beta-blockers in certain (fewer and fewer) patients, or correction of nutrional deficiencies.
Also note that the preoperative consultation is different from the preoperative evaluation done by anesthesiologists. The anesthesiologist needs to utilize much of the information gleaned from the preoperative medical consultation but the focus of the anesthesiologist visit tends to focus on things important for the operation and often fails to pay sufficient attention to other than immediate postoperative management.
There are a whole host of predictors of post-operative complications, some of which are patient-related and some of which are related to they type of surgery being performed. Patient-related factors include advanced age, comorbidities (especially pulmonary, cardiac, and renal), impaired cognitive function, malnutrition, and impairment of functional status. Interestingly obesity, by itself, has not been implicated as a risk factor for complications. However, the comorbidities of obesity, such as sleep apnea, may be significant risk factors. Surgical procedure-related risk factors include urgent or emergency surgery and the type of surgery (eg. cardiac surgery, major abdominal or thoracic surgery, vascular surgery, etc.). There has been conflicting evidence related to the type of anesthesia used but note that our August 2010 Whats New in the Patient Safety World column SCIP: Disappointing Outcomes on SSIs. Whats Next? noted a new population-based study (Chang 2010) showing that patients having total hip or total knee replacement surgery done under general anesthesia were 2.21 times more likely to develop an SSI within 30 days of surgery compared to those done under epidural or spinal anesthesia.
Assessing a patients ability to perform activities of daily living or a functional estimate of the METs a patient is capable of may predict their vulnerability to surgical complications. And there are a number of validated scoring instruments that are very good at predicting surgical complications and outcomes. These include the ASA score, Lees revised cardiac risk index, and the Eagle score. In our June 2010 Whats New in the Patient Safety World colum The Frailty Index and Surgical Outcomes we noted a new study (Makary et al 2010) demonstrating use of the frailty index greatly improved the ability to predict post-surgical outcomes much better than existing methods. These may help physicians, patients and families anticipate what to expect in patients undergoing surgery. But our concern is that they lack specific action items. Its one thing to say this is a high risk patient. Its another to say this is a risk factor that we can specifically do something about.
We cant do better outlining the cardiac portion of the consultation than what is in two recent editorials (Chopra et al 2010, Cheng et al 2010) that we discussed in our February 2010 Whats New in the Patient Safety World column Preoperative Testing for Non-Cardiac Surgery. Both suggest that perioperative tests and treatments improve cardiac outcomes only when targeted to clearly defined patient subsets and that clinical trials have shown no additional benefit of cardiac testing in patients at low to moderate risk for perioperative cardiovascular events. They recommend following the American College of Cardiology/American Heart Association Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery. They also note that doing so would reduce perioperative costs considerably.
So lets focus on some things we clearly can have an impact on. Weve talked previously about some of the dangers of obstructive sleep apnea (OSA) in the postoperative period and how to screen for them (see our Patient Safety Tips of the Week for June 10, 2008 Monitoring the Postoperative COPD Patient and August 18, 2009 Obstructive Sleep Apnea in the Perioperative Period and our July 2010 Whats New in the Patient Safety World column Obstructive Sleep Apnea in the General Inpatient Population). In patients scoring high on a tool like the STOP, you may need to approach them as likely having OSA even if they have not yet had confirmation by polysomnography.
In addition to sleep apnea, you need to consider whether the patient has any other conditions that may predispose them to respiratory depression when they are being managed with narcotic analgesics postoperatively. Such conditions might be COPD, severe chest wall or spinal deformities, certain neuromuscular disorders, etc. In such circumstances youll consider aiming for lower oxygen saturation targets and consider using end-tidal CO2 monitoring for hypercarbia.
The American College of Physicians released a guideline Risk Assessment for and Strategies To Reduce Perioperative Pulmonary Complications for Patients Undergoing Noncardiothoracic Surgery: A Guideline from the American College of Physicians in 2006. It stresses risk factors for post-op pulmonary complications, such as age greater than 60, COPD, ASA class II or above, CHF, functional dependence, and numerous characteristics of the surgery itself. A low serum albumin is a particularly strong predictive factor for pulmonary complications. Importantly, it stresses that performance of spirometry or chest x-ray are not routinely indicated preoperatively nor should right heart catheterization or total parenteral nutrition be used. It does recommend use of incentive spirometry or deep breathing exercises or other lung expansion modalities prior to a variety of surgeries.
Smoking cessation is useful not only in minimizing pulmonary complications but also in improving wound healing and reducing the risk of some infectious complications. The greater the interval between smoking cessation and the time of surgery, the better the outcomes.
The patients nutritional status needs to be evaluated. The best indicators of this are the BMI, a history of recent weight loss, and the serum albumin. While it would make sense to try to improve the patients nutritional status prior to surgery (one of the reasons youll want to do the consultation with ample time prior to surgery), the best way to manage that nutritional status and the evidence-based outcomes are not clear at this time.
Weve also discussed extensively the issue of postoperative delirium (see our October 2008 back-to-back columns Managing Delirium and Preventing Delirium and our March 31, 2009 Patient Safety Tip of the Week Screening Patients for Risk of Delirium and our January 26, 2010 Patient Safety Tip of the Week Preventing Postoperative Delirium). The most salient predictors of postoperative delirium are the presence of dementia or disordered executive function. You can screen for these using simple tests like the MMSE or the clock drawing test. Vision or hearing impairment are also risk factors and part of preventing or treating delirium is minimizing these sensory disorders by ensuring the patient has his/her glasses or hearing aid available in the hospital.
If you do identify patients at risk for postoperative delirium, you want to avoid certain drugs (benzodiazepines, anticholinergic agents, diphenhydramine, Demerol, etc.). You would also consider less depth of anesthesia or alternatives to general anesthesia and pay careful attention to minimize preoperative fasting to avoid dehydration and to preferentially use certain opiates. In the postoperative phase, careful attention to reorienting activities, use of familiar objects from home, support of family, promoting natural sleep, adequate pain management, early mobilization, avoiding restraints, etc. are important. Prophylactic use of haloperidol or other agents to prevent development of delirium (or minimize its duration) have produce mixed results.
Reviewing the patients medications, including over-the-counter medications and alternative medicines and nutritional supplements, is extremely important. When you do such reviews, youll be surprised how often you discover the patient is taking a medication no longer needed (eg. proton pump inhibitors begun prophylactically during a prior hospitalization) or that the patient is on duplicative therapy. So you may end up paring down his/her medication list. You also need to consider whether the patient is taking any medications (or alcohol) that may lead to withdrawal syndromes during a hospitalization. If the patient is on steroids for COPD or other comorbidity, youll need to consider whether using stress doses post-op will be necessary. Youll need to consider specific drugs that should be stopped during certain surgeries (eg. tamsulosin or other alpha blocker in cataract surgery). Youll need to consider which drugs may promote bleeding and discontinue them prior to surgery if necessary. And you will need to consider what will happen with certain drugs during the period when the patient cannot swallow (for example, some anti-Parkinsons medications and some anticonvulsants do not have intravenous formulations so alternative ways to ensure these are given must be considered). And in the diabetic patient, discussion of what the insulin needs are likely to be post-op become important. In addition to the drugs youd like to avoid in a patient at risk for delirium, drugs on Beers list (see our January 15, 2008 Patient Safety Tip of the Week Managing Dangerous Medications in the Elderly and June 2008 Whats New in the Patient Safety World Potentially Inappropriate Medication Use in Elderly Hospitalized Patients) should generally be avoided in the geriatric patient.
If the patient has chronic kidney disease (CKD), youll need to offer advice on dosing of a variety of drugs excreted via the kidneys. Hopefully your hospital has a computerized physician order entry (CPOE) system with good decision support that will help identify those drugs whose dose or dosing interval needs to be adjusted. Youll also have to consider the possibility that the surgery or other perioperative factors (eg. contrast used during CT scans) may precipitate acute worsening of renal function. And if the patient has more advanced degrees of renal dysfunction, youll need to suggest avoiding blood transfusions that might interfere with eventual kidney transplantation or avoiding IV lines, etc. in a limb that may need to be used for dialysis access (Krishnan 2002).
In addition to planning for discharge and ensuring appropriate medical followup in addition to the surgical followup, youll need to consider what venue the patient will likely need on discharge. Particularly in the elderly, bedrest may lead to deconditioning and a general decline in functional abilities. Many such patients may need a stay in subacute care after discharge. Others will need in-home nursing services. Youll have to plan for appropriate medical followup in those venues.
Lastly, dont forget to discuss advance directives and end-of-life issues during the pre-operative consultation. Many physicians find those sort of issues difficult to broach with patients and families but a preoperative consultation allows a natural segue into that discussion. Its easy to say something like We dont expect you are going to have any serious problems with your surgery, but and then ask what the patients wishes would be if any such disasters occurred.
References:
Wijeysundera DN, Austin PC, Beattie WS, Hux JE, Laupacis A.
Outcomes and Processes of Care Related to Preoperative Medical Consultation. Arch Intern Med. 2010; 170(15): 1365-1374
http://archinte.ama-assn.org/cgi/content/abstract/170/15/1365
Wijeysundera DN, Beattie WS, Austin PC, Hux JE, Laupacis A. Non-invasive cardiac stress testing before elective major non-cardiac surgery: population based cohort study
BMJ2010;340:b5526 (Published )
http://www.bmj.com/cgi/content/abstract/340/jan28_3/b5526
Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, et al; ACC/AHA Task Force Members.ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation. 2007; 116: e418-e500 http://circ.ahajournals.org/cgi/content/full/116/17/e418
ICSI (Institute for Clinical Systems Improvement). Preoperative Evaluation (Guideline). Released 06/2010
http://www.icsi.org/preoperative_evaluation/preoperative_evaluation_2328.html
Jencks SF, Williams MV, Coleman EA.. Rehospitalizations among Patients in the Medicare Fee-for-Service Program. NEJM 2009; 360: 1418-1428
http://content.nejm.org/cgi/content/short/360/14/1418
Chang C-C, Lin H-C; Lin H-W, Lin H-C. Anesthetic Management and Surgical Site Infections in Total Hip or Knee Replacement: A Population-based Study. Anesthesiology 2010; 113(2): 279-284 August 2010
Makary MA, Segeve DL, Pronovost PJ, et al. Frailty as a Predictor of Surgical Outcomes in Older Patients. Journal of the American College of Surgeons 2010;
DOI: 10.1016/j.jamcollsurg.2010.01.028
http://www.journalacs.org/article/S1072-7515(10)00059-1/abstract
Chopra V, Flanders SA, Froelich JB, Lau WC, Eagle KA. Perioperative Practice: Time to Throttle Back. Annals of Internal Medicine 2009. Published online before print November 30, 2009
http://www.annals.org/content/early/2009/11/19/0003-4819-152-1-201001050-00184.full?aimhp
Cheng D. Preoperative non-invasive stress testing should be reserved for patients at high risk of perioperative cardiac complications. BMJ 2010; 340: b5401
http://www.bmj.com/cgi/content/full/340/jan18_1/b5401
Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, et al; ACC/AHA Task Force Members.ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation. 2007; 116: e418-e500 http://circ.ahajournals.org/cgi/content/full/116/17/e418
Fleischer LA, Beckman JA, Brown KA, et al. ACC/AHA 2006 Guideline Update on Perioperative Cardiovascular Evaluation for Noncardiac Surgery: Focused Update on Perioperative Beta-Blocker Therapy. J Am Coll Cardiol 2006; 47: 2343-2355 http://content.onlinejacc.org/cgi/reprint/47/11/2343
Qasseem A, Snow V, Fitterman N, et al. for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Risk Assessment for and Strategies To Reduce Perioperative Pulmonary Complications for Patients Undergoing Noncardiothoracic Surgery: A Guideline from the American College of Physicians. Ann Intern Med 2006; 144: 575-580
http://www.annals.org/cgi/reprint/144/8/575.pdf
Krishnan M. Preoperative Care of Patients with Kidney Disease
Am Fam Physician.2002; 66(8): 1471-1477
http://www.aafp.org/afp/2002/1015/p1471.pdf
Print Preoperative Consultation Time to Change
August 24, 2010
The BP Oil Spill -
Analogies in Healthcare
We often like to use lessons learned from root cause analyses (RCAs) done in other industries to demonstrate by analogy what can go wrong in various healthcare settings (see, for example, our Patient Safety Tips of the Week for August 28, 2007 Lessons Learned from Transportation Accidents, October 2, 2007 Taking Off From the Wrong Runway, May 19, 2009 Learning from Tragedies, and May 26, 2009 Learning from Tragedies. Part II).
So weve been itching to do a column on lessons learned from the BP Gulf oil disaster because they will undoubtedly have resemblances to serious adverse events in healthcare. There are multiple investigations of this accident ongoing (BP itself, DOI MMS, Congress, special committee appointed by President Obama, DOJ, etc.). Unfortunately, the root cause analysis has not yet been completed (or, if it has, not all details have been released). We also find that interesting and ironic. In healthcare, almost every state mandates that a thorough and credible RCA be performed within a very short time frame (usually 30-45 days) and most healthcare organizations perform them much sooner. Admittedly, some aspects may take longer for proper understanding and corrective action but in most cases we are interested in taking necessary steps to help prevent similar untoward incidents from occurring. Quite frankly, given the lack of transparency surrounding the BP spill, well be surprised if the results of a thorough and credible RCA are ever released publicly.
However, there have been a series of reports in The Wall Street Journal and other conventional media on testimony in some of the above hearings and we are beginning to see Wikipedia and multiple blog sites releasing plausible root causes for the BP spill even in the absence of complete objective facts about that event. Most of what is out there is about events leading up to the disaster. Little has yet been published on root causes in the response to the event. But there are probably enough lessons learned to date for us to apply to healthcare.
The TapRoot website has an excellent blog on the BP gulf oil spill that includes many preliminary facts and findings from BPs interim incident investigation and from an independent investigation done by Dr. Robert Bea at UC, Berkeley. Wikipedia does a nice job on the chronology and background, plus provides many of the facts available to date. An excellent blog from safety expert Tom Krause focuses on failures of leadership, at both the private corporate and governmental levels, primarily because virtually every major disaster tends to have such leadership failures as root causes.
Richard Posners blog on the Gulf oil leak draws many analogies to the recent collapse of the financial systems and our economy. One of the root causes he notes in both disasters is the rapid and relentless advance of technology. Regulators, whether overseeing financial organizations or oil companies, typically lag behind the advances in technology that move forward very rapidly.
Sound familiar? How many new drugs or technologies in healthcare get endorsed and heavily promoted based on preliminary studies, only to be associated with serious consequences when science catches up with hope and hype.
Posner also talks about some of the attributes of risk taking. When the probability of failure or disaster is perceived to be low, companies or organizations or individuals tend to take risks. No one gets credit for preventing a disaster that was considered unlikely in the first place. We reward the gambler and the swashbuckler. Also, the riskier the venture, the more likely the return on investment will be high. He also notes that the overcautious business will lose profits, investors and staff to bolder competitors.
The healthcare analogy: local medical arms races where hospitals throw caution to the wind because they fear the hospital down the street will put in that new program or new piece of equipment before they do. Community hospitals began bariatric surgery programs, which have steep learning curves, and mortality/morbidity rates soared. Hospitals raced to implement high dose radiation therapy programs or the newest CT technologies without adequate training of all staff, and patients suffered radiation overdoses.
When we talk about root cause analyses we always mention our Big 3 that show up in almost every incident having a serious untoward outcome:
The BP Gulf oil disaster was no exclusion to that.
Warning signs were not heeded.
In the CNN interview workers noted that the well would frequently kick, meaning that gas was ascending up through the mud and one mechanic noted the pressures were much higher than he had seen in other drilling. In a letter to the Wall St. Journal (Barr 6/11/10) Terry Barr noted multiple red flags that went unheeded. He notes that the fact that the cementing job did not go completely as expected and should have been a red flag. A pressure test performed was a second red flag that should have pointed out the cement had failed to form a seal. But most importantly data from pressure monitoring as the mud was being replaced with lighter sea water should have led to the conclusion that hydrocarbons were flowing within the well and that the pressure was not being controlled because more fluid was being pushed out than was being pumped in. Barr asserts that at this point the BP supervisors should have gone into a well kill operation and begun pumping the heavier mud back in to control the pressure.
In healthcare, issues related to alarms or failure to heed alarms are a big problem (see our Patient Safety Tips of the Week March 5, 2007 Disabled Alarms, March 26, 2007 Alarms Should Point to the Problem, April 2, 2007 More Alarm Issues, June 19, 2007 Unintended Consequences of Technological Solutons, April 1, 2008 Pennsylvania PSAs FMEA on Telemetry Alarm Interventions, February 23, 2010 Alarm Issues in the News Again, March 2, 2010 Alarm Sensitivity: Early Detection vs. Alarm Fatigue).
Failure to buck the authority gradient.
On April 20 (the day the well erupted and the explosion occurred) there apparently was a disagreement (Casselman & Gold, WSJ 5/27/10) about the decision to replace the heavy drilling mud, which was keeping pressure down, with much lighter seawater. That was one of the most crucial decisions in the cascade of events leading to the disaster. Concerns of those workers on the rig were apparently overruled by BP. The culture aboard the drilling rig apparently was not one where contrary viewpoints were sought out. A CNN report on interviews with survivors of the blast talked about that argument that took place on the morning of the blast. The survivors said it was commonly perceived that you could get fired if you expressed concerns about safety that might delay drilling and that some workers had already been fired.
The healthcare analogy is obvious. In almost every serious event we see there was someone who knew that something was wrong but was afraid to speak up, usually because the culture of the organization was too hierarchical and did not foster open expression of opinions.
Failure of communications.
While we have not seen in the reports evidence of fumbled handoffs or similar communication breakdowns in the days proximate to the disaster, some of the testimony at the various hearings has focused on communication and chain of command issues (Weber & Plushnik-Masti 8/23/10). Investigators noted that the person in charge of keeping the crew and vessel safe and preventing pollution actually had little say and awareness of what was going on in terms of risk.
Workarounds, Cutting Corners, and Efficiency-Thoroughness Tradoffs (ETTOs)
A series of decisions were crucial in the chain of events leading up to the explosion. In testimony before a federal panel (Weber 8/24/10) a Haliburton official noted he had recommended BP use 21 centralizers to help create a good seal on the well. BP instead opted to use only 6, citing the extra 10 hours it would take to install the larger number. A decision to use seawater rather than much denser mud (Bea 5/20/10) removed a pressure barrier that had been keeping oil and gas from moving up the well. Another decision (King & Gold, WSJ 6/15/10) involved using a long string design in which a pipe runs all the way from the sea floor to the bottom of the well, allowing gas to potentially rise straight to the top. This was considerably less expensive and faster to implement than the alternative design which would added other barriers to prevent any gas from flowing unchecked to the surface. Another decision was made not to take 12 hours to completely circulate the heavy drilling fluid (helps check for leaking gas) and another to forgo a test to determine if the cement had properly bonded that would also have taken about another 12 hours. Congressmen Henry Waxman and Bart Stupak noted that all these decisions were trade-offs between cost and safety (see our September 15, 2009 Patient Safety Tip of the Week ETTOs: Efficiency-Thoroughness Trade-Offs about Erik Hollnagels book on ETTOs).
The healthcare analogy comes right from Erik Hollnagels book on ETTOs: He describes a case in which both a patient and his oncologist each had reasons to initiate chemotherapy before the final pathology report on a gastric tumor was available. The patient died after 5 months, receiving the wrong chemotherapy (his tumor actually had a good prognosis had the correct chemotherapy been given).
There clearly were also time pressures. One interview by CNNs Anderson Cooper (Bronstein & Drash, CNN 6/9/10) noted the project was costing $750,000 per day and was already 5 wks late.
Note that we cannot find any reference as to whether any of the decision makers had personal financial incentives to finish the job earlier or at lower cost. Such incentives, of course, would clearly tip the ETTO balance in favor of efficiency over safety and, if so, would clearly be an important root cause. In healthcare, where bonuses and incentives typically comprise part of executive salaries, one must be very careful to ensure that such incentives do not lead to projects being pushed to early completion at the expense of proper attention to safety issues.
Overreliance on the Blowout Preventer (BOP)
It also is quite apparent that there was an overreliance on the BOP (blowout preventer). Throughout, it seems that both those designing and those implementing the drilling technology were confident that if something went wrong the BOP would shut down the well and prevent a disaster. The healthcare analogy: overreliance on the computer and other high tech devices. Weve written extensively on this site about the unintended consequences of technology. One of those consequences is putting too much trust into the computer system and feeling that the computer will capture any errors we make.
The BOP (blowout preventer) apparently had several potential means of activation (see Wikipedia article). One method of communication may have been lost due to the explosion. A second involved a dead man switch but examination of at least one of the units controlling that switch showed a dead battery. Also, a (hydraulic) leak in the blowout preventer had been noted about 2 weeks prior to the accident. Those were obviously latent errors in the system that contributed to the disaster once more immediate causes occurred. Also during the federal investigation issues were raised about the most recent safety inspection of the blowout preventer.
No one really knew what the risk of a blowout was (all assumed it to be low despite frequency of such in the oil industry). Tom Krause notes the influence of recency bias in that regard, noting that there had been no serious explosions in the Gulf since 1979 (in fact, that very bias may have played a role in the Obama administrations decision to allow expansion of off-shore drilling just days before this disaster). That sort of bias has been seen in many previous disasters such as the space shuttle disaster due to damage to the thermal insulating tiles. NASA had over the years stretched its tolerance for complying with standards related to those tiles because the shuttle had flown so many times without problem. (You may recognize the latter phenomenon as normalization of deviance where an organization comes to accept a deviation from best practice as the new standard practice, i.e. a workaround becomes the norm). How many of you know of examples in your organizations where there is a workaround around a faulty piece of equipment or a faulty procedure that has now become accepted standard practice? If you dont start looking today youll find them!
Where was the FMEA?
One of the apparent key issues in the BP oil spill was the lack of an effective plan to mitigate the disaster once it happened. In all industries we pride ourselves in doing FMEAs (failure mode and effects analyses). In these we flowchart all the steps in a process and try to anticipate what could go wrong at each step. We then develop plans to prevent such things from going wrong or to mitigate the effects of that step going wrong. That includes planning for how to mitigate when the ultimate step goes wrong. We assume that BP and the other contractors must have performed a FMEA prior to beginning their Gulf operations. Surely, the regulators would require submission of a FMEA before granting approval of a drilling operation, wouldnt they? But we have not yet seen any publication of that FMEA.
Even if the statistical likelihood of an untoward outcome like a blowout is low, one still needs a plan of action should that outcome actually occur. In healthcare, we have discussed that in our April 6, 2010 Patient Safety Tip of the Week Cancer Chemotherapy Accidents.
In healthcare, we do FMEAs both for processes we perform frequently and for those issues for which we think untoward outcomes are unlikely but would be disastrous if they occurred. For example, we recommend those organizations doing obstetrics do a FMEA on the potential of switched babies (see our Patient Safety Tips of the Week for November 17, 2009 Switched Babies).
The Public Relations Debacle
Lastly, the public relations response to the disaster by all involved parties leaves a lot to be desired. Had BP and others just admitted upfront that mistakes were made and apologized and not tried to downplay the magnitude of the disaster and focused on learning for the entire industry, the public might have been more understanding. Quite frankly, one suspects that this sort of disaster could have happened on any of the deep sea oil drilling rigs run by any number of companies. But the way the events were handled by BP focused the wrath of the public upon them. In healthcare we have learned that disclosure and apology are the right thing to do (see our June 22, 2010 Patient Safety Tip of the Week Disclosure and Apology: How to Do It).
Summary
In many respects the BP Gulf oil spill illustrates multiple points that one often sees in healthcare cases with adverse outcomes (cascade of errors, latent errors, violations, unsafe workarounds, communication breakdowns, failure to heed alarms, multiple design flaws, safety culture issues, time pressures, workflow issues, and technological advances with unintended consequences) similar to many of the healthcare cases we have discussed in the past (see, for example our April 2, 2007 Patient Safety Tip of the Week More Alarm Issues).
References:
TapRoot. Root Cause Analysis Blog.
BPs Deepwater Horizon interim incident investigation. May 24, 2010. Downloaded from TapRoot website.
http://www.taproot.com/wordpress/wp-content/uploads/2010/07/BPInvestigationPresentation2.pdf
Bea R. Deepwater Horizon Study Group (Center for Catastrophic Risk Management; University of California, Berkeley). Failures of the Deepwater Horizon Semi-Submersible Drilling Unit. May 20, 2010. Downloaded from TapRoot website.
http://www.taproot.com/wordpress/wp-content/uploads/2010/07/BobBeaPreliminaryAnalyses.pdf
Wikipedia. Deepwater Horizon oil spill.
http://en.wikipedia.org/wiki/Deepwater_Horizon_oil_spill
Krause TR. What Caused the Gulf Oil Spill?. Corporate Social Responsibility Newswire August 21, 2010
http://www.csrwire.com/press_releases/30321-What-Caused-the-Gulf-Oil-Spill-
The Becker-Posner Blog.
http://www.becker-posner-blog.com/2010/07/the-gulf-oil-leakposner.html
Bronstein S, Drash W. Rig survivors: BP ordered shortcut on day of blast.
CNN June 9, 2010
Barr T. The Oil Disaster Is About Human, Not System, Failure (letter). The Wall Street Journal. June 11, 2010
http://online.wsj.com/article/SB10001424052748703303904575293270746496824.html?mod=googlenews_wsj
Casselman B, Gold R. BP Decisions Set Stage for Disaster. The Wall Street Journal. May 27, 2010
http://online.wsj.com/article/SB10001424052748704026204575266560930780190.html?KEYWORDS=BP
Weber HR, Plushnick-Masti R. Associated Press. Oil spill probe focuses on communication among key players. Buffalo News August 23, 2010
http://www.buffalonews.com/world-nation/article170013.ece
Weber HR, Plushnick-Masti R. Associated Press. Oil spill panel hears about Halliburton warning. Buffalo News August 24, 2010
http://www.buffalonews.com/business/24-hour-business-news/article170895.ece
King N, Gold R. BP Crew Focused on Costs: Congress. The Wall Street Journal. June 15, 2010
http://online.wsj.com/article/SB10001424052748704324304575306800201158346.html
Wilson AB. BP's Disaster: No Surprise to Folks in the Know.
CBS News June 22, 2010
http://www.cbsnews.com/stories/2010/06/22/opinion/main6605248.shtml
Print The BP Oil Spill Analogies in Healthcare
August 31, 2010
Postoperative Delirium
While we were preparing our August 17, 2010 Patient Safety Tip of the Week Preoperative Consultation Time to Change we came across a good article on postoperative delirium (Mantz 2010) in the anesthesiology literature. Weve previously discussed extensively the issue of postoperative delirium (see our October 2008 back-to-back columns Managing Delirium and Preventing Delirium and our March 31, 2009 Patient Safety Tip of the Week Screening Patients for Risk of Delirium and our January 26, 2010 Patient Safety Tip of the Week Preventing Postoperative Delirium). In those prior columns weve discussed the incidence of postoperative delirium and the serious long-term effects and the cost burden of delirium. A recent meta-analysis (Witlox 2010) confirmed the significant risks of death, institutionalization, and dementia in patients discharged after a bout of delirium.
But the Mantz article does a nice job of summarizing some of the practical aspects of preventing, identifying and managing postoperative delirium. It includes a case report (with the nuance that the patient also has a second discrete episode of delirium), and a good description of the clinical features of delirium and the tools used to help identify it. They note that the CAM-ICU may be inferior to some of the other tools in patients in the PACU (remember, their perspective is that of the anesthesiologist). They have a thorough discussion of the causes and precipitating factors, stressing some that are especially likely to be present in the PACU (eg. pain from bladder distension, hypoxemia related to residual neuromuscular relaxation, residual effects of anesthetic agents or sedating agents or anticholinergic agents). In their case they suspect the initial episode of delirium was related to occult infection (it was a clue she had peritonitis) and a second episode several days later may have been related to benzodiazepine withdrawal. Potential pathophysiological mechanisms underlying delirium are discussed, including the potential influence of many of the drugs used perioperatively on some of the postulated neurotransmitter abnormalities in delirium. They also discuss many of the components of a multimodality approach that is discussed below in more detail. And they provide the view of the geriatrician (one of the authors is a geriatrician), which stresses the relationships of delirium to dementia and depression and the issues of physical and cognitive autonomy and activities of daily living.
In the prior columns we noted above we have discussed identification of risk factors for postoperative delirum. The most salient predictors of postoperative delirium are the presence of dementia or disordered executive function. Those previous columns noted some of the validated prediction tools that can be used but often you can screen for delirium risk using simple tests like the MMSE or the clock drawing test. Our August 17, 2010 Patient Safety Tip of the Week Preoperative Consultation Time to Change also discussed the importance of preoperative assessment for vision or hearing impairment, thorough review of the patients medications, and preparation of the patient and family/caregivers for the possibility of delirium.
NICE has just published a 662-page guidance DELIRIUM: diagnosis, prevention and management that is probably the most comprehensive single-source document available on all aspects of delirium. Fortunately, the important lessons have been distilled into a much more manageable summary document and a recent BMJ issue had an even briefer summary. The most important recommendation from the NICE guidance is: THINK DELIRIUM. Basically, we need a high index of suspicion in patients with risk factors for delirium and constant awareness of factor that might precipitate delirium and then constant vigilance to identify it early and manage it effectively.
NICE identifies 4 risk factors for delirium as really standing out:
They stress, both at presentation and throughout the patients course, asking about and observing for signs of change in behavior or fluctuations in behavior. Family or caregivers may first point these out. In particular, the hypoactive form of delirium may be the hardest to detect. Look also for changes in cognitive function, perception, physical function, and social behavior. While we typically think about confusion, hallucinations, delusions, agitation, restlessness, and sleep disturbances as signs of delirium, those with hypoactive delirium may have poor concentration, slowed responses, reduced mobility and reduced movements, changes in appetite, and social withdrawal. If signs suggestive of possible delirium are present, someone trained in delirium recognition should do a formal clinical assessment. They discuss the use of validated tools such as the CAM and CAM-ICU to screen for delirium. Note there was also just published a review (Wong 2010) on multiple different tools that are used to screen for delirium, comparing the pros and cons of each and including such practical considerations as how long the provider can spend doing such assessments. While they concur that the CAM is probably the best tool to use, they point out the simple GAR (Global Attentiveness Rating) may also be an effective tool. In the GAR you simply have a 2-minute conversation with the patient and ask yourself how well did the patient keep his mind on interacting with you during the interview? (you rate him on a 1-to-10 visual analogue scale).
In addition to identifying and managing underlying causes and precipitating factors (eg doing a full drug review, looking for electrolyte disturbances, hypoxemia, infection, etc.), they offer practical suggestions on managing the patient with delirium:
They note the importance of documenting the occurrence of delirium not just in the hospital record but also in the ambulatory record, given the serious long-term associations seen with delirium.
We also refer you back to our January 26, 2010 Patient Safety Tip of the Week Preventing Postoperative Delirium) for a discussion on the role of depth of sedation/anesthesia, type of opioids used, and pre-op hydration management in preventing postoperative delirium.
References:
Mantz J, Hemmings H, Boddaert J. Case Scenario: Postoperative Delirium in Elderly Surgical Patients. Anesthesiology 2010. 112(1): 189-195 January 2010
Wong CL; Holroyd-Leduc J, Simel DL, Straus SE. Does This Patient Have Delirium?: Value of Bedside Instruments. JAMA 2010; 304(7): 779-786
http://jama.ama-assn.org/cgi/content/abstract/304/7/779
Witlox J, Eurelings LSM, de Jonghe JFM et al. Delirium in Elderly Patients and the Risk of Postdischarge Mortality, Institutionalization, and Dementia: A Meta-analysis. JAMA. 2010; 304(4):443-451
http://jama.ama-assn.org/cgi/content/abstract/304/4/443
NICE (National Institute for Clinical Excellence). National National Clinical Guideline Centre. DELIRIUM: diagnosis, prevention and management. Clinical Guideline 103. July 2010
full guidance:
http://www.nice.org.uk/nicemedia/live/13060/49908/49908.pdf
NICE (National Institute for Clinical Excellence). National National Clinical Guideline Centre. DELIRIUM: diagnosis, prevention and management. Clinical Guideline 103. July 2010
summary document:
http://www.nice.org.uk/nicemedia/live/13060/49909/49909.pdf
Young J, Murthy L, Westby M, Akunne A, OMahony R, on behalf of the Guideline Development Group.Guidelines: Diagnosis, prevention, and management of delirium: summary of NICE guidance. BMJ 341:doi:10.1136/bmj.c3704 (Published 28 July 2010)
http://www.bmj.com/content/341/bmj.c3704.extract?sid=4453e855-9632-412d-9028-89422c5ff442
Print Postoperative Delirium
September 7, 2010
Patient Safety in Ob/Gyn Settings
Patient safety in ob/gyn is facing some old and some new challenges. Ob/gyn has been a leader in the use of simulation techniques to help healthcare teams prepare for dealing with a variety of emergency situations. And many of the fine teamwork training exercises in programs such as TeamSTEPPS have their foundations in ob/gyn teams working together. But there are other areas where success is less obvious. Recent data (Zhang 2010) shows a continued rise in the rate of cesarean sections in the United States and the problem is not simply repeat C-sections. Now almost of third of all deliveries in first pregnancies are by C-section. There may also be an association between induction of labor and subsequent C-section. We will undoubtedly see renewed efforts to try to match labor induction and C-sections to medically appropriate indications.
But in the meantime we have seen several other important initiatives in the field of patient safety:
Patient Safety in the Surgical Environment
ACOG has announced release of a new guidance to prevent surgical errors. Committee Opinion Number 464 Patient Safety in the Surgical Environment is a set of recommendations on patient safety for ob/gyns in the operating environment but is good advice for anyone in the operating environment.
The guidance notes risk factors for wrong site surgery such as multiple surgeons, multiple procedures, unusual patient physical characteristics, and time pressures and stresses use of both Joint Commissions universal protocol and the WHO Surgical Safety Checklist. They stress ensuring that all documents, materials and instruments are reviewed before surgery. They note the preoperative briefing is important for assigning roles and setting expectations. Other parts of the universal protocol include appropriate site marking and the time out done for patient/procedure verification just prior to surgical incision. They note other important issues (prophylactic antibiotics, DVT prophylaxis, etc.) may also be discussed as part of the time out.
Importantly, they stress a variety of patient safety principles that are not unique to surgery but remain important in the surgical environment. Medication safety is one of those. They note that medication safety is vulnerable in the OR environment because so many orders are given verbally and many of the medication safety tools we use elsewhere in the hospital (eg. CPOE, barcoding) are not usually available in the OR. The urgent pace and stresses and confusion during rapidly evolving events in the OR may further facilitate medication errors. Therefore, good communication amongst all parties and using readback/hearback are very important. They also suggest teams develop and use protocols for administering commonly used medications.
They note the importance of fatigue in creating surgical errors. This applies not only to residents, for whom formal work hour guidelines exist, but also for all participating surgeons and other staff. They note that all members of the team must be vigilant to identify fatigue in other members of the team and have appropriate backup available.
A section on retained foreign objects recommends following the ICSI protocol for avoiding retained foreign objects during vaginal surgery.
Especially important are their comments on avoiding distractions. They stress the concept of the sterile cockpit and recommend postponing any nonessential conversation until surgery is completed. They recommend things like beepers, radios and telephone calls be avoided if at all possible. They also suggest careful consideration be given to the presence of any nonessential personnel in the room that might be additional distractions.
The guidance also includes a section on issues related to new surgical procedures (privileges, familiarity with equipment and the procedure, presence of nonsurgical personnel, etc.).
Lastly, they note that their recommendations apply to any venue where surgery is being done the hospital OR, an ambulatory surgery unit, or an office setting.
The MOREOB Program
The first outcomes of a comprehensive obstetrical patient safety program in Canada have been published (Thanh 2010). Multiple hospitals in Alberta participated in the 3-year long MOREOB Program (Managing Obstetrical Risk Efficiently). Severe newborn morbidity was significantly reduced and maternal outcomes (reduced third- and fourth-degree tears and reduced lengths of stay) were also improved.
The MOREOB Program focuses on communication and teamwork building, skill building, culture of safety, emergency skill drills, education, and use of patient safety tools like RCA, FMEA, near miss reviews, audits, etc.The program has reduced NICU admission and resulted in fewer neonates with respiratory distress, sepsis, CNS hemorrhage, and a variety of other neonatal and maternal outcomes.
Peripheral Nerve Injuries During Gynecologic Surgery
Weve done previous columns on peripheral nerve injuries related to anesthesia and surgery (see our September 29, 2009 Patient Safety Tip of the Week Perioperative Peripheral Nerve Injuries). This months Obstetric and Gynecology Clinics of North America has an excellent article on peripheral nerve injuries complicating gynecological surgery (Bradshaw 2010). It uses 9 case histories to highlight the mechanisms of injury to a variety of peripheral nerves during a variety of different gynecological procedures. Most such injuries are related to compression from either improper positioning or compression from surgical retractors. They point out the positions and circumstances that place various nerves in vulnerable positions and make recommendations for actions to avoid such injuries.
Matching Newborns to Correct Mothers Breast Milk
In our November 17, 2009 Patient Safety Tip of the Week Switched Babies we also discussed the issue of newborn infants being inadvertently fed breast milk from other mothers. In that we suggested use of barcoding technology to help avert such mixups. We recentl came across an article describing such a system that not only aids in identification of correct baby and correct milk but also ensures the milk being given is fresh.
References:
Zhang J, Troendle J, Reddy UM, et al. Contemporary cesarean delivery practice in the United States. Amer J Ob Gyn 2010; 203: x-ex-x-ex (published online August 13, 2010)
http://www.ajog.org/article/S0002-9378(10)00838-0/abstract
ACOG press release. Ob-Gyns Issue Guidance to Prevent Surgical Errors. August 23, 2010
http://www.acog.org/from_home/publications/press_releases/nr08-23-10-2.cfm
ACOG. Committee on Patient Safety and Quality Improvement. Committee Opinion Number 464. Patient Safety in the Surgical Environment. September 2010. Obstetrics & Gynecology 2010; 116(3): 786-790
http://journals.lww.com/greenjournal/Citation/2010/09000/Committee_Opinion_No__464__Patient_Safety_in_the.42.aspx
ICSI (Institute for Clinical Systems Improvement). Retained Foreign Objects During Vaginal Deliveries, Prevention of Unintentionally (Protocol) 11/24/2009
Thanh NX, Jacobs P, Wanke MI, et al. Outcomes of the Introduction of the MOREOB Continuing Education Program in Alberta. J Obstet Gynaecol Can 2010; 32(8): 749755 http://www.sogc.org/jogc/abstracts/201008_Obstetrics_4.pdf
MOREOB Program
Bradshaw AD, Advincula AP. Postoperative Neuropathy in Gynecologic Surgery. Obstetric and Gynecology Clinics of North America 2010; 37(3): 451-459
http://www.obgyn.theclinics.com/article/S0889-8545(10)00065-3/abstract
EMR-linked system matches premature babies with breast milk.
MedCity News August 10, 2010
http://www.massdevice.com/news/emr-linked-system-matches-premature-babies-with-breast-milk
Print Patient Safety in Ob/Gyn Settings
September 14, 2010
Wrong-Site Craniotomy:
Lessons Learned
There has really been a dearth of lessons learned on wrong-site neurosurgical procedures in the literature. Our November 25, 2008 Patient Safety Tip of the Week Wrong-Site Neurosurgery discussed some of those lessons that are available.
Now a new study (Cohen 2010) analyzes 35 cases of wrong-site craniotomy and provides insights into the factors which may contribute. The authors readily point out that the errors were recognized in most cases before the dura mater was violated so most affected patients did not end up with severe neurological deficits but the potential for disasters existed in all cases. They categorized root causes in 4 main areas:
They mention working with unfamiliar staff as an example of communication breakdown. Keep in mind that doing a pre-op huddle is especially important when working with unfamiliar staff and part of either the universal protocol or the WHO surgical safety checklist includes adequate introduction of all staff in the OR.
Similar names were a factor in one case. And in others the communication breakdowns took place prior to the case reaching the OR.
But some of those cases were actually due to failure to buck the authority gradient, where someone in the OR recognized the laterality error but either failed to speak out or did speak out and was ignored.
Mislabeling of images or reports were contributory factors in several cases. In several others, changes in the conventions used for laterality were important. See our November 25, 2008 Patient Safety Tip of the Week Wrong-Site Neurosurgery for other comments about the potential for errors related to imaging in the OR.
One of the technical factors noted was absence of necessary equipment at the beginning of a procedure. As above, a pre-op huddle is especially important in identifying equipment that may be needed during a procedure and planning for contingencies. See our Patient Safety Tips of the Week December 9, 2008 Huddles in Healthcare and January 19, 2010 Timeouts and Safe Surgery for discussions on the pre-op huddle.
Failures in preoperative protocols contributed to almost half the cases and most of these were potentially preventable. These included things like failure to check the medical records or failure to mark the site. Failure to identify the laterality on the consent form was another contributory factor. (Note also that our Whats New in the Patient Safety World column for August 2010 Surgical Case Listing Accuracy mentioned the most common error in case listings booked for surgery was lack of laterality). But note that failure to use imaging studies properly in the preoperative assessment contribute frequently. This included absence of imaging studies, images belonging to the wrong patient, or scans hung backward.
Human Error
While one might argue that all the above also included some element of human error, the authors included several other contributing factors under the category human error. These included cases where faulty assumptions were made, especially when the patient was prepared for surgery by someone other than the surgeon him/herself. They also include time constraints, emergency cases, late night hours, and fatigue under this category.
They point out that critical steps in the verification process are often skipped because of the emergent nature of the cases. But the major adverse outcome in most of these cases is the delay in doing the surgery on the correct side.
Though the authors did not specifically comment on it, we suspect that most of the patients involved in these incidents did not have significant unilateral paralysis that should have alerted the neurosurgeons to the errors. Rather, most had non-focal neurological abnormalities or at least non-motor deficits. They also do not comment on whether the patient was capable of participating in the preoperative verification procedures or site markings (eg. were some patients aphasic, confused or demented?).
As per the Cohen article and the accompanying editorial (Cima 2010), one of the most striking facts is that only one of the 35 cases came from the peer-reviewed medical literature. Most of their cases were identified from media reports or malpractice databases. That is a clear indictment of a system (our current legal system and also our medical system) that suppresses the dissemination of lessons learned which could be used to prevent similar occurrences.
The authors discuss things that need to be done to prevent such wrong-site cases. They, of course, stress all the elements of universal protocol but especially focus on some of the factors they identified above. The importance of recording laterality on the consent (and booking) and review of all relevant pre-op medical record components by all staff cannot be overstressed. Verification of the patient using multiple identifiers and including the patient and/or family in the identification and marking processes is important. They have a good discussion of site marking for craniotomies. And they really focus on avoiding laterality issues with imaging studies. They discuss high tech solutions like software that accurately determines laterality and use of intraoperative computerized navigation devices. But they also discuss low tech solutions like placing a radio-opaque object on the side of the lesion so that the correct side will always be identified on any images done during the procedure.
Speaking of documentation of laterality, an article on wrong-site surgery in orthopedics (Masini 2010) addresses the issue of use of abbreviations in the consent form (or other parts of the medical record). Specifically, we often record in the medical record abbreviations like RT LT R L instead of spelling out right and left. It is much easier to misread or misinterpret the abbreviations.
We refer you back to our November 25, 2008 Patient Safety Tip of the Week Wrong-Site Neurosurgery for lots of other useful tips on how to avoid wrong-site cases in your organization.
References:
Cohen FL, Mendelsohn D, Bernstein M. Wrong-site craniotomy: analysis of 35 cases and systems for prevention Clinical article 461. Journal of Neurosurgery 2010; 113: 461473 (Posted online on 1 Sep 2010.)
http://thejns.org/doi/pdf/10.3171/2009.10.JNS091282
Cima RR. Editorial Wrong-stie craniotomy 458.Response. Cohen FL, Mendelsohn D, Bernstein M . J Neurosurg 2010; 113: 458460 http://thejns.org/doi/pdf/10.3171/2009.10.JNS091399
Masini M. Recommendations offered to avoid wrong-site surgery in patients with multiple procedures. ORTHOPEDICS TODAY September 1, 2010
http://www.orthosupersite.com/view.aspx?rid=68098
Print Wrong-Site Craniotomy: Lessons Learned
September 21, 2010
Dilaudid Dangers
One of the topics we seem to keep returning to is respiratory depression due to intravenous opioids. Our most recent column was our July 13, 2010 Patient Safety Tip of the Week Postoperative Opioid-Induced Respiratory Depression, in which we highlighted the inherent difficulties in monitoring patients on intravenous opioids.
While all opioids may cause respiratory depression, we have always been surprised that Dilaudid (HYDROmorphone) seems to pop up as a cause in a disproportionate number of cases. Were not the only ones! Some recent published reports seem to have come to that same conclusion. About a year ago The Doctors Company (Marcus 2009) published several cases from their claims database that highlighted some of the lessons learned in cases of Dilaudid-induced respiratory depression. And the Pennsylvania Patient Safety Authority (PPSA 2010) just highlighted issues with hydromorphone in their most recent Patient Safety Advisory.
But problems with Dilaudid are not new. ISMP Canada (ISMP Canada 2006) noted that Dilaudid ranked third on their list of drugs most frequently reported as causing harm. They found that 9.3% of all their reported cases of medications causing harm or death were attributed to Dilaudid.
The Doctors Company paper cites several cases of fatalities or serious neurological damage in patients where Dilaudid contributed to respiratory depression. They cite a number of reasons for this adverse consequence. First and foremost is the issue of improper dosage. Most physicians and nurses dont realize how potent Dilaudid is on a mg to mg basis compared to morphine sulfate. While estimates of equipotency vary considerably in the literature, most now agree that 1 mg. of Dilaudid is probably the equivalent of 7 mg. of morphine. Chang and colleagues (Chang 2010) had noted several years ago that emergency room physicians and nurses who were hesitant to administer 7 to 10 mg. of morphine were not reluctant to administer 1 to 1.5 mg. of Dilaudid. They point out this is an illusion that less narcotic is being used with that Dilaudid dose.
Ironically, Dilaudids problems may be an unintended consequence of a patient safety initiative taken by most facilities. Demerol (meperidine) was removed from many formularies a number of years ago because a toxic metabolite was causing significant untoward effects. It was replaced in most cases by Dilaudid and most healthcare workers were much less familiar with Dilaudid.
The look-alike/sound-alike (LASA) issue obviously also pops up, in which hydromorphone and morphine are mixed up. In fact, this is said to be one of the most frequent drug pairs involved in LASA errors. Use of tall man lettering (HYDROmorphone) is advised but, frankly, many healthcare workers still mistakenly assume that HYDROmorphone is an equipotent form of morphine. An outstanding published RCA (root cause analysis) done by ISMP Canada on a fatal Dilaudid overdose highlighted not only the fact that hydromorphone sounds like morphine but at that time also came in packaging that looked similar to that for morphine. Note that even the tall man lettering standard for Dilaudid has been controversial. At one time hydromorPHONE was used. But in response to an ISMP survey done in 2007, the standard was changed to the currently used HYDROmorphone.
The recent Pennsylvania Patient Safety Advisory noted over 1600 reports of medication errors related to hydromorphone in a period of less than two years (PPSA 2010). Of these, 1.8% resulted in patient harm. They highlighted wrong dose errors, wrong drug errors, and monitoring errors and noted problems in the prescribing, dispensing and administration phases of medication safety. They offer numerous recommendations to improve safety when using hydromorphone.
In many of the cases in the Doctors Company paper the patients also received other agents (sedative/hypnotic drugs) capable of potentiating the respiratory depressant effects of Dilaudid. And beware when using supplemental oxygen in such patients. Not only does supplemental oxygen render pulse oximetry less reliable in detecting early respiratory depression but it may also contribute to depression of respiration in patients prone to hypercapnia (see our Patient Safety Tips of the Week for April 8, 2008 Oxygen as a Medication, June 10, 2008 Monitoring the Postoperative COPD Patient, and January 27, 2009 Oxygen Therapy: Everything You Wanted to Know and More!). In such patients who are at risk for hypercapnia, using lower oxygen saturation targets may be indicated.
The ISMP Canada study noted that mixups between hydromorphone and morphine were the most common substitution errors in their analysis. They especially noted that availability of higher-concentration vials of hydromorphone (10 mg/mL) seemed to increase the likelihood of confusion with morphine. And while they noted that unfamiliarity with appropriate dosages of hydromorphone were the most common reason for incorrect doses, they also cited poor communication of orders (eg. verbal, telephone or written), lack of a preceding 0 before decimal points, and cognitive lapses as contributing factors. Errors in programming infusion pumps were frequent causes of harm. And they noted that the monitoring protocols typically used are often inadequate in high risk patients. We will focus on that latter point later because the problems we have encountered with Dilaudid have occurred most frequently in such high risk patients (eg. those with morbid obesity and /or sleep apnea).
Double checks are often recommended when we are dealing with administration of high-risk medications. Even though we have emphasized that double checks are a relatively weak intervention (we know from all industries that the error rate when a supervisor checks someone elses work may be 10% or higher), the literature supports a medication error reduction of about 30% when using a double check system (see our July 15, 2008 Patient Safety Tip of the Week Heparin Flushes.....Again!). Also, for any high-risk medications you need to do truly independent double checks (see our March 30, 2010 Patient Safety Tip of the Week Publicly Released RCAs: Everyone Learns from Them for a description of independent double checks). Another nice article on independent double checks in preventing medication errors (ISMP Canada 2005) describes the independent double check process and calculates that independent double checks would reduce the error rate of a process having an error rate of 5% all the way down to 1 in 400.
A large number of claims and settlements in anesthesiology cases involving postoperative care had respiratory depression secondary to opioid analgesics as a central issue (Bird 2001). Many of the reported cases have occurred in patients with known sleep apnea or with suspected sleep apnea and morbid obesity. Sleep apnea patients are vulnerable to the respiratory depressant effects of opioids and there often seems to be a disproportionate effect on respiration compared to depression of the level of arousal.
In a well-done FMEA on PCA therapy, Moss (Moss 2010) also highlighted some of the problems noted above. She noted that, as in most facilities, Dilaudid had replaced Demerol in the formularies but that most physicians and nurses and pharmacists had much less experience with Dilaudid than with Demerol. That group then made use of standardized order sets to help reduce the errors. A second key vulnerability point they identified was patient selection. Patients using PCA must have both cognitive and physical capabilities to operate the pumps. However, at-risk patients (for PCA using any opioid) are those at the extremes of age, those with COPD, end-stage renal disease, and especially obesity and sleep apnea. They emphasized the need for careful monitoring with pulse oximetry and capnography if PCA is to be used in such patients.
The Anesthesia Patient Safety Foundation (APSF) in 2006 held a workshop focusing on postoperative opioid therapy and respiratory depression (Weinger 2007). They emphasized the risk of respiratory depression occurs with patient controlled analgesia (PCA), neuraxial opioid anesthesia, and intermittent dosing of opioids. And their findings and recommendations obviously apply not to just postoperative settings but to any time such opioid therapy is being used. While they recognize that current fiscal realities and limitations of monitoring technologies might limit special monitoring to high risk patients, they readily point out that you cannot always identify high risk patients (eg. many OSA patients are undiagnosed) and that even young healthy patients may suffer respiratory depression from opioid therapy. Their recommendations therefore are for continuous monitoring of patients on such opioid therapy, using continuous pulse oximetry plus capnography or other advanced technologies. But they also emphasize the importance of having a system that leads to timely responses to changes detected by such monitoring systems so that a healthcare professional capable of appropriate management is summoned to the bedside rapidly.
In our experience, monitoring patients on intravenous opioids has been the most problematic area. Others have also noted that monitoring is critical to preventing patient harm. Studies looking at malpractice claims noted that over half of respiratory events in patients on central neuraxial narcotics and almost three-quarters of those on PCA were potentially preventable using better monitoring (Weinger 2007). All such patients need to be monitored both for efficacy of pain treatment and for dangerous side effects. As such, in addition to the typical visual analog scale pain measurement (1 to 10) patients should also have their level of arousal assessed by a validated tool such as the Richmond Agitation Sedation Scale (RASS) or equivalent. And, of course, they need their vital signs monitored, including continuous monitoring of oxygen saturation by pulse oximetry. Keep in mind that pulse oximetry may provide a false sense of security, particularly when patients are on supplemental oxygen. You can have significant hypercapnia when your saO2 is still in the normal range. For high risk patients we therefore also recommend capnography.
There are several caveats about monitoring. Most importantly, when you arouse a patient who is oversedated with opioids they may, in fact, appear to be breathing at a normal rate and be able to respond appropriately to questions. Therefore, observing the patient before you stimulate them is extremely important. Anecdotally, there are also many reports of patients having respiratory depression at times when their level of arousal appears to be reasonably normal. And respiratory rate is a notoriously poor predictor of opioid-induced respiratory depression. The respiratory rate may be normal despite significant hypoventilation. Also mentioned anecdotally (Weinger 2007) is that changes in patient status may take place very rapidly and not be detected by conventional monitoring techniques used in most settings today.
Just as important is having in place a system to ensure the monitoring actually takes place. While your nursing plans of care may include all the above elements in a pain management module, youd be surprised at how often various elements are omitted. We therefore recommend that you use some sort of forcing function to ensure they are done. For example, you could program your bedside medication verification (barcoding) system to require input of the RASS before a opioid medication may be given. Or you could require the RASS score be entered into your automated dispensing cabinet (ADC) before a nurse can take the opioid out of the ADC. You should also periodically audit compliance with your pain management monitoring.
Then clearly tie your monitoring process to the administration of opioid doses. You need clearcut instructions on withholding doses or contacting the physician when the RASS score is above certain levels or when monitoring of vital signs or saO2 or capnography demonstrates abnormalities or trends. In our June 10, 2008 Patient Safety Tip of the Week Monitoring the Postoperative COPD Patient we noted a simple system used by our colleagues in the field of pain management. (Pasero and McCaffery 2002):
S = Sleep, easy to arouse (acceptable; no action necessary)
1 = Awake and alert (acceptable; no action necessary)
2 = Slightly drowsy, easily arousable (acceptable; no action necessary)
3 = Frequently drowsy, arousable, drifts off to sleep during conversation (unacceptable; decrease opioid dose by 25-50%, add an opioid-sparing analgesic, and monitor the patients level of sedation and respiratory status closely)
4 = Somnolent, minimal or no response to physical stimulation (unacceptable; stop opioid, consider administering naloxone)
The above stresses assessing the level of arousal before administering the next dose of the opioid. Addressing the level of arousal after a dose may be equally important. One hospital system (Marcus 2009) implemented a system of checking level of arousal 15-30 minutes after a Dilaudid dose.
Where your patients should be monitored is another issue you need to address. The dangers in the postoperative patient on the general medical floors compared to ICUs have been stressed, noting that preventable cardiopulmonary arrests are 5 times more likely on general medical floors (Overdyk 2010). We recommend that at least for high-risk patients you consider monitoring them in an ICU setting.
We are also advocates of keeping a cumulative dose record readily available for opioids administered. Unfortunately, there is no evidence base available to guide how you use such cumulative dose records. However, the mere fact that such would pop up may be an alert that the patient might be at risk of excessive opioid use.
And you need in place protocols whereby nursing may administer narcotic antagonists such as naloxone without having to first call a physician. Keep in mind we have previously seen cases of acute narcotic withdrawal precipitated by administration of Narcan (see our February 26, 2007 Patient Safety Tip of the Week Unintended Consequences) but those have usually occurred in patients on long-standing narcotics and, on the whole, the risk of not administering Narcan typically outweighs the very small risk of precipitating withdrawal. Also keep in mind the risk of renarcotization that may occur when there are disparities between the half life of the opioid and the half life of naloxone (see our July 13, 2010 Patient Safety Tip of the Week Postoperative Opioid-Induced Respiratory Depression). That Tip of the Week also contains a discussion of the nuances of monitoring the patient on IV opioids.
Here are some strategies you should consider to reduce the risk of Dilaudid (and other opioid) adverse events:
And dont forget these standard medication safety considerations:
Weve done several other columns on postoperative respiratory depression related to opioid administration (see our Patient Safety Tips of the Week for June 10, 2008 Monitoring the Postoperative COPD Patient, May 12, 2009 Errors With PCA Pumps, and August 18, 2009 Obstructive Sleep Apnea in the Perioperative Period.).
Opioid analgesics have been very useful in the management of acute pain and postoperative pain and there has been a push in recent years to ensure adequate pain management in all hospitalized patients. Just be wary of the potential complications and be both vigilant for their occurrence and be prepared to deal appropriately with those complications that arise.
Opioids are one of your high-alert medications. How they are used and monitored in your facility is another excellent topic for a FMEA (failure mode and effects analysis).
References:
Marcus H. Dilaudid-Related Morbidity and Mortality from Respiratory Depression. The Doctors Company. The Doctors Advocate. Third Quarter 2009.
http://www.thedoctors.com/KnowledgeCenter/Publications/TheDoctorsAdvocate/CON_ID_002959
Pennsylvania Patient Safety Authority. Adverse Drug Events with HYDROmorphone: How Preventable are They? Pa Patient Saf Advis 2010 Sep;7(3):69-75
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2010/Sep7(3)/Pages/69.aspx
ISMP Canada. Shared Learning Reported Incidents Involving Hydromorphone. ISMP Canada Safety Bulletin. December 28, 2006
http://www.ismp-canada.org/download/safetyBulletins/ISMPCSB2006-09Hydromorphone.pdf
Chang AK, Bijur PE, Meyer RH, et al. Safety and Efficacy of Hydromorphone as an Analgesic Alternative to Morphine in Acute Pain: A Randomized Clinical Trial.
Ann Emerg Med 2006; 48: 164-172
http://www.annemergmed.com/article/S0196-0644(06)00398-2/abstract
ISMP Canada. Event Analysis Report: Hydromorphone/Morphine Event - Red Deer Regional Hospital. Red Deer, Alberta. 2004
ISMP Canada. Lowering the Risk of Medication Errors: Independent Double Checks. ISMP Canada Safety Bulletin. January 2005
http://www.ismp-canada.org/download/safetyBulletins/ISMPCSB2005-01.pdf
Bird M : Acute Pain Management: A New Area of Liability for Anesthesiologist. ASA
Newsletter 71(8), 2007
Moss J. Reducing Errors During Patient-Controlled Analgesia Therapy Through Failure Mode and Effects Analysis. The Joint Commission Journal on Quality and Patient Safety 2010; 36(8): 359-364
http://www.ingentaconnect.com/content/jcaho/jcjqs/2010/00000036/00000008/art00004
Weinger MB. Dangers of Postoperative Opioids. APSF Workshop and White Paper Address Prevention of Postoperative Respiratory Complications. APSF Newsletter 2007; 21(4): 61, 63-67
http://apsf.org/newsletters/html/2007/winter/01_opioids.htm
Pasero C, McCaffery M. Monitoring Sedation: It's the key to preventing opioid-induced respiratory depression. AmericanJournal of Nursing. 2002; 102(2):67-69
Overdyk, Frank J. Postoperative Opioids Remain a Serious Patient Safety Threat.
Anesthesiology. 113(1): 259-260, July 2010
Print Dilaudid Dangers
September 28, 2010
Diagnostic Error
This month we saw a host of articles and resources dealing with diagnostic error. The category of diagnostic error is the one most frequently involved malpractice claims and settlements. In fact, claims for diagnostic error surpass all other claims combined. Yet there is very little focus on diagnostic error in patient safety programs today.
Bob Wachter (Wachter 2008) and Peter Pronovost (Newman-Toker 2009), two of the most widely recognized proponents in the patient safety field, both identified diagnostic error as a neglected area for investigation and intervention that could become the next big target in patient safety. And that appears to be the case. Wachter, in a new Health Affairs article (Wachter 2010) presents a number of logical arguments as to why that is the case and discusses both barriers and potential solutions. And a review article by the Pennsylvania Patient Safety Authority (PPSA 2010) reviews both the scantly reported diagnostic errors and the literature on diagnostic errors.
Wachter notes that autopsy series over the years have consistently demonstrated missed findings that could have impacted on care of the patient in about 10% of all autopsies. Unfortunately, in the era of high tech imaging too many physicians think (obviously erroneously) that there is little to be learned from autopsies. Actually, we think the real reason for fewer autopsies is the fear, in our litiginous society, that something potentially treatable will be found! But the point is that diagnostic errors are very common. Unfortunately, we have no good current ways of measurement for diagnostic errors.
Wachter points out that diagnostic errors are more common than medication errors but even the landmark IOM Report To Err is Human mentions diagnostic errors only twice but medication errors 70 times. He notes that we have tended to focus on those sorts of medical errors where easy system fixes are likely and that it is much more difficult to address diagnostic errors, where cognitive processes are primarily involved.
We have previously discussed the cognitive processes and decision making processes that healthcare workers use. We have discussed 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 that typically takes place in more acute scenarios and the work of Jerry Groopman (see our August 12, 2008 Patient Safety Tip of the Week Jerome Groopmans How Doctors Think) on the day-to-day thinking that takes place in interacting with patients. Both types of cognitive approaches have their upsides and downsides but both also tend to fall into similar cognitive error traps.
The new PPSA review discusses many of the same cognitive biases we discussed in our review of Jerry Groopmans book, including the availability bias, confirmation bias (and its corollary dismissing contrary evidence), anchoring and others, such as premature closure, context errors, and satisficing (accepting any satisfactory solution rather than an optimal one). And it talks about communication issues across the continuum of care. But, importantly, it emphasizes that system-related factors (remember: the system is usually much easier to change than the human factors) do commonly contribute to diagnostic errors and that strategies to minimize those may reduce diagnostic errors. Such system-related factors include things like specimen labeling, communication of abnormal results to physicians, communication of revised reports to physicians, physician followup with patients, and managing the patients across transitions of care.
One of our most common cognitive errors leading to diagnostic errors is anchoring, where we latch onto a single possibility and fail to look for alternatives. We then look for information that tends to confirm our first diagnosis (confirmation bias) and tend to ignore evidence that might controvert that diagnosis. Closely related is premature closure where we limit the differential diagnoses to too narrow a list and fail to consider alternatives. 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.
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). The same obviously applies to diagnosis. We tend to think of a patient who had presented with a similar set of symptoms and may focus on the diagnosis that earlier patient or patients had.
Both Bob Wachter and Jerry Groopman recommend stepping back and saying What am I missing?. Alternatively, ask yourself What is the worst thing this could be?. Both questions may help the clinician refocus and avoid anchoring, premature closure, and other cognitive biases.
Many of the biases described above do not occur in isolation. Rather they tend to often work in conjunction with each other to lead to erroneous clinical diagnoses. Mamede and colleagues (Mamede 2010) point out that we may use the availability heuristic (tendency to consider things most easily recalled), then use confirmation bias and fail to look for disconfirming evidence, to become anchored in our first diagnosis and fail to consider alternatives. They went on to design a study that had internal medicine residents review several case histories and then review similar ones in non-analytic reasoning (pattern recognition-type) setting and again in a reflective reasoning setting. They demonstrated that availability bias did indeed influence their diagnoses when in the non-analytic reasoning mode and that more senior residents were more likely to demonstrate that bias. Importantly, the fact that the correct diagnoses were often arrived at during the subsequent reflective reasoning setting offers hope that anything that might shift thinking into that mode may help reduce diagnostic errors.
It has been difficult in the past to get clinicians to admit to diagnostic errors they have made. The PPSA article actually speaks about the overconfidence that clinicians have in their diagnostic capabilities and attributes some of that overconfidence to the fact they often get no feedback about when their diagnoses are wrong. But a couple recent studies, based on anonymous surveys, actually shows clinicians are now more cognizant of diagnostic errors they make. Schiff and colleagues (Schiff 2009) asked their colleagues in internal medicine to report 3 cases of diagnostic errors and found that they readily reported such (they were involved in about a third of those and observed the others) and were quite willing to share insights into both the seriousness and likely causes of such errors. And Singh and colleagues (Singh 2010) found that over half of pediatric respondents to a similar questionnaire admitted to making diagnostic errors at least once to twice a month. And many of the errors in both studies were considered by the respondents to be serious or actually caused harm to patients. In the Schiff study, some of the more common missed or delayed diagnoses involved conditions such as stroke, MI, pulmonary embolism, and various cancers. In the Singh study, the most common error was diagnosing viral illnesses as bacterial but they also found misdiagnoses of appendicitis, medication side effects, and psychiatric disorders. The Schiff study found that failure to order, report or followup laboratory or radiology studies was the most frequent factor contributing to diagnostic error. Discounting or overweighing alternative diagnoses was another frequent contributing factor. The Singh study also points out the relative lack of training on diagnostic errors that occurs in typical medical schools and residency programs.
Respondents in the Singh study noted 2 strategies to be likely to help prevent diagnostic errors: use of electronic medical records and closer followup of patients. Schiff and Bates (Schiff & Bates 2010), while admitting the deficiencies of current electronic medical records, also point out the potential of electronic documentation to significantly reduce diagnostic errors. They describe a number of functionalities that must be incorporated into the electronic medical record in order to be successful in that goal. EMRs have not only the ability to collect all the necessary patient information into one accessible place but also to filter it and display it in ways to make it relevant to the diagnostic process. EMRs also can be structured to allow better tracking over time so as to improve recognition of changes. They are especially likely to be helpful in tracking test results and preventing tests from slipping through the cracks, a problem we have highlighted in several columns. They should be helpful in creating and maintaining problem lists and, through well-designed clinical support tools, be capable of providing prompts to key questions that need to be asked. The authors point out that it will be critical for clinicians to play a key role in the redesign of these EMR systems to incorporate these functionalities in a way that is not intrusive and does not distract the clinician from the important interaction with the patient. They also point out that the EMR can be used for providing feedback to clinicians so they can get a better perception of how often diagnostic errors occur and the factors contributing to those.
Equally thoughtful is a recent blog by Gordon Schiff (Schiff 2010), an investigator well known in the nascent field of diagnostic error. He expands upon Bob Wachters premises and notes that the systems vs. cognitive polarity may be artificial. He notes that many of the potential IT solutions are currently poorly developed and he, like Wachter, suggests that as IT interventions to prevent or mitigate diagnostic errors become evidence-based they should be incorporated into meaningful use requirements. He also makes a case for empowering patients and getting them involved in preventing diagnostic errors. He notes that the third AHRQ-sponsored International Conference on Diagnostic Errors in Medicine will take place in Toronto in October.
The PPSA review also provides a couple nice tools to help clinicians identify and avoid diagnostic errors. One is a chart audit tool to help identify errors adopted from the article by Schiff et al (Schiff 2009). The other is a simple checklist the clinician can use to help focus the things he/she needs to do to in each case avoid diagnostic errors.
More focus on diagnostic decision making is in our medical schools and residency programs is needed. Many of our medical schools already utilize simulations involving trained actors to improve our interviewing skills and diagnostic skills. Our August 10, 2010 Patient Safety Tip of the Week Its Not Always About The Evidence discussed contextual errors and provided examples of how simulation exercises can be used to point out how contextual red flags may be missed, resulting in erroneous care.
Involving patients to help avoid diagnostic errors is potentially very valuable. You can remind them of things like if you have not heard your test results from me by next week, make sure you call me or if this medication has not produced the desired effect within 2 weeks, call me so we can consider alternatives. But one of the problems we have in involving patients is our fear of provoking undue anxiety. For example, a neurologist may begin a search for a peripheral nerve lesion to explain a patients sensory or motor symptoms, even though his/her differential diagnoses may include central nervous system possibilities like multiple sclerosis. If we tell a patient that multiple sclerosis is in the differential diagnosis, it may conjure up terribly negative images for that patient. We often also try to look for diagnoses that are most positive for our patients (affective bias). Jerry Groopman suggests one way a patient can combat the anchoring and availability phenomena is to simply ask the physician Whats the worst thing this could be? or What else could this be? or Could there be two things going on? or Is there anything in my history or exam or lab tests that is at odds with the working diagnosis?. These simple, harmless questions presented in a nonconfrontational manner can influence a physician to reassess.
Keep in mind that we can make the same sorts of cognitive errors when doing our root cause analyses (RCAs). Anchoring, availability bias, confirmation bias, and satisficing are common mistakes we make that may prevent us from coming up with the best solutions in RCAs.
And dont forget that the same cognitive biases that affect our healthcare lives may also impact our decision-making processes in our day-to-day lives!
References:
Wachter RM. Why Diagnostic Errors Dont Get Any Respect And What Can Be Done About It. Wachters World (blog). June 2, 2008
Newman-Toker DE, Pronovost PJ. Diagnostic ErrorsThe Next Frontier for Patient Safety. JAMA.2009; 301(10): 1060-1062
http://jama.ama-assn.org/cgi/content/short/301/10/1060
Wachter RM. Why Diagnostic Errors Dont Get Any Respect And What Can Be Done About Them. Health Affairs 2010; 29(9): 1605-1610
http://content.healthaffairs.org/cgi/content/abstract/29/9/1605
Pennsylvania Patient Safety Authority (PPSA). Diagnostic Error in Acute Care. Pa Patient Saf Advis 2010 Sep;7(3):76-86
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2010/Sep7(3)/Pages/76.aspx
Groopman J. How Doctors Think. Boston: Houghton Mifflin, 2007 (Mariner Books 2008)
Mamede S, van Gog T, van den Berge K, et al. Effect of Availability Bias and Reflective Reasoning on Diagnostic Accuracy Among Internal Medicine Residents. JAMA. 2010;304(11):1198-1203
http://jama.ama-assn.org/cgi/content/abstract/304/11/1198
Schiff GD, Hasan O, Kim S; et al. Diagnostic Error in Medicine: Analysis of 583 Physician-Reported Errors. Arch Intern Med, Nov 2009; 169: 1881 1887
Singh H, Thomas EJ, Wilson L, et al. Errors of Diagnosis in Pediatric Practice: A Multisite Survey. Pediatrics, Jul 2010; 126: 70 79
Schiff GD, Bates DW. Can Electronic Clinical Documentation Help Prevent Diagnostic Errors? N Engl J Med 2010; 362: 1066-1069
http://www.nejm.org/doi/pdf/10.1056/NEJMp0911734
Schiff G. Respecting And Reflecting On Diagnostic Errors. Health Affairs Blog 2010. September 16, 2010
http://healthaffairs.org/blog/2010/09/16/respecting-and-reflecting-on-diagnostic-errors/
The Diagnostic Error in Medicine
3rd International Conference
October 25-27, 2010
Sheraton Centre Toronto Hotel
Toronto, Ontario, Canada
http://www.smdm.org/diagnostic_errors/2010DEM.shtml
DEER Taxonomy Chart Audit Tool
http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/diagnosis/Documents/audit.pdf
Pennsylvania Patient Safety Authority. A Physician Checklist for Diagnosis.
Print Diagnostic Error
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November 19, 2019
An Astonishing Gap in Medication Safety
November 12, 2019
Patient Photographs Again Help Radiologists
November 5, 2019
October 29, 2019
Tip of the Week on Vacation
October 22, 2019
Tip of the Week on Vacation
October 15, 2019
October 8, 2019
October 1, 2019
Electronic Medication Reconciliation: Glass Half Full or Half Empty?
September 24, 2019
EHR-related Malpractice Claims
September 17, 2019
American College of Surgeons Geriatric Surgery Verification Program
September 10, 2019
Joint Commission Naming Standard Leaves a Gap
September 3, 2019
Lessons from an Inpatient Suicide
August 27, 2019
August 20, 2019
Yet Another (Not So) Unusual RSI
August 13, 2019
Betsy Lehman Center Report on Medical Error
August 6, 2019
July 30, 2019
Lessons from Hospital Suicide Attempts
July 23, 2019
Order Sets Can Nudge the Right Way or the Wrong Way
July 16, 2019
July 9, 2019
Spinal Injection of Tranexamic Acid
July 2, 2019
Tip of the Week on Vacation
June 25, 2019
June 18, 2019
June 11, 2019
ISMP’s Grissinger on Overreliance on Technology
June 4, 2019
Medication Errors in the OR – Part 3
May 28, 2019
May 21, 2019
Mixed Message on Number of Open EMR Records
May 14, 2019
Wrong-Site Surgery and Difficult-to-Mark Sites
May 7, 2019
Simulation Training for OR Fires
April 30, 2019
Reducing Unnecessary Urine Cultures
April 23, 2019
In and Out the Door and Other OR Flow Disruptions
April 16, 2019
AACN Practice Alert on Alarm Management
April 9, 2019
Handoffs for Every Occasion
April 2, 2019
Unexpected Events During MRI
March 26, 2019
March 19, 2019
March 12, 2019
Update on Overlapping Surgery
March 5, 2019
Infusion Pump Problems
February 26, 2019
Vascular Access Device Dislodgements
February 19, 2019
Focus on Pediatric Patient Safety
February 12, 2019
From Tragedy to Travesty of Justice
February 12, 2019
2 ER Drug Studies: Reassurances and Reservations
February 5, 2019
Flaws in Our Medication Safety Technologies
January 29, 2018
National Patient Safety Goal for Suicide Prevention
January 22, 2019
Wandering Patients
January 15, 2019
Another Plus for Prehabilitation
January 8, 2019
Maternal Mortality in the Spotlight
January 1, 2019
More on Automated Dispensing Cabinet (ADC) Safety
December 25, 2018
Happy Holidays!
December 18, 2018
Great Recommendations for e-Prescribing
December 11, 2018
December 4, 2018
Don’t Use Syringes for Topical Products
November 27, 2018
November 20, 2018
November 13, 2018
Antipsychotics Fail in ICU Delirium
November 6, 2018
More on Promoting Sleep in Inpatients
October 30, 2018
October 23, 2018
Lessons From Yet Another Aviation Incident
October 16, 2018
October 9, 2018
October 2, 2018
Speaking Up About Disruptive Behavior
September 25, 2018
Foley Follies
September 18, 2018
September 11, 2018
September 4, 2018
The 12-Hour Nursing Shift: Another Nail in the Coffin
August 28, 2018
Thought You Discontinued That Medication? Think Again
August 21, 2018
Delayed CT Scan in the Anticoagulated Patient
August 14, 2018
ISMP Canada’s Updated “Do Not Use” Abbreviation List
August 7, 2018
Tip of the Week on Vacation
July 31, 2018
Surgery and the Opioid-Tolerant Patient
July 24, 2018
More on Speech Recognition Software Errors
July 17, 2018
OSA Screening in Stroke Patients
July 10, 2018
Another Jump from a Hospital Window
July 3, 2018
Tip of the Week on Vacation
June 26, 2018
Infection Related to Colonoscopy
June 19, 2018
June 12, 2018
Adverse Events in Cancer Patients
June 5, 2018
Pennsylvania Patient Safety Authority on Iatrogenic Burns
May 29, 2018
More on Nursing Workload and Patient Safety
May 22, 2018
Hazardous Intrahospital Transport
May 15, 2018
May 8, 2018
May 1, 2018
April 24, 2018
April 17, 2018
More on Tests Pending at Discharge
April 10, 2018
Prepping the Geriatric Patient for Surgery
April 3, 2018
March 27, 2018
March 20, 2018
Minnesota Highlights Lost Tissue Samples
March 13, 2018
March 6, 2018
February 27, 2018
Update on Patient Safety Walk Rounds
February 20, 2018
February 13, 2018
February 6, 2018
Adverse Events in Inpatient Psychiatry
January 30, 2018
January 23, 2018
Unintentional Hypothermia Back in Focus
January 16, 2018
January 9, 2018
More on Fire Risk from Surgical Preps
January 2, 2018
Preventing Perioperative Nerve Injuries
December 26, 2017
Tip of the Week on Vacation
December 19, 2017
December 12, 2017
Joint Commission on Suicide Prevention
December 5, 2017
Massachusetts Initiative on Cataract Surgery
November 28, 2017
More on Dental Sedation/Anesthesia Safety
November 21, 2017
OSA, Oxygen, and Alarm Fatigue
November 14, 2017
Tracking C. diff to a CT Scanner
November 7, 2017
Perioperative Neuropathies
October 31, 2017
Target Drugs for Deprescribing
October 24, 2017
Neurosurgery and Time of Day
October 17, 2017
Progress on Alarm Management
October 10, 2017
More on Torsade de Pointes
October 3, 2017
Respiratory Compromise: One Size Does Not Fit All
September 26, 2017
Tip of the Week on Vacation
September 19, 2017
Tip of the Week on Vacation
September 12, 2017
Can You Hear Me Now?
September 5, 2017
Another Iatrogenic Burn
August 29, 2017
Suicide in the Bathroom
August 22, 2017
August 15, 2017
Delayed Emergency Surgery and Mortality Risk
August 8, 2017
Sedation for Pediatric MRI Rising
August 1, 2017
Progress on Wrong Patient Orders
July 25, 2017
Can We Influence the “Weekend Effect”?
July 18, 2017
Another Hazard from Alcohol-Based Hand Gels
July 11, 2017
The 12-Hour Shift Takes More Hits
July 4, 2017
Tip of the Week on Vacation
June 27, 2017
June 20, 2017
June 13, 2017
June 6, 2017
NYS Mandate for Sepsis Protocol Works
May 30, 2017
Errors in Pre-Populated Medication Lists
May 23, 2017
May 16, 2017
Are Surgeons Finally Ready to Screen for Frailty?
May 9, 2017
Missed Nursing Care and Mortality Risk
May 2, 2017
Anatomy of a Wrong Procedure
April 25, 2017
April 18, 2017
Alarm Response and Nurse Shift Duration
April 11, 2017
Interruptions: The Ones We Forget About
April 4, 2017
Deprescribing in Long-Term Care
March 28, 2017
More Issues with Dental Sedation/Anesthesia
March 21, 2017
Success at Preventing Delirium
March 14, 2017
More on Falls on Inpatient Psychiatry
March 7, 2017
February 28, 2017
February 21, 2017
Yet More Jumps from Hospital Windows
February 14, 2017
February 7, 2017
January 31, 2017
More Issues in Pediatric Safety
January 24, 2017
Dexmedetomidine to Prevent Postoperative Delirium
January 17, 2017
January 10, 2017
The 26-ml Applicator Strikes Again!
January 3, 2017
What’s Happening to “I’m Sorry”?
December 27, 2016
Tip of the Week on Vacation
December 20, 2016
End-of-Rotation Transitions and Mortality
December 13, 2016
More on Double-Booked Surgery
December 6, 2016
Postoperative Pulmonary Complications
November 29, 2016
Doubling Down on Double-Booked Surgery
November 22, 2016
Leapfrog, Picklists, and Healthcare IT Vulnerabilities
November 15, 2016
November 8, 2016
Managing Distractions and Interruptions
November 1, 2016
CMS Emergency Preparedness Rule
October 25, 2016
Desmopressin Back in the Spotlight
October 18, 2016
Yet More Questions on Contact Precautions
October 11, 2016
New Guideline on Preop Screening and Assessment for OSA
October 4, 2016
September 27, 2016
September 20, 2016
Downloadable ABCDEF Bundle Toolkits for Delirium
September 13, 2016
Vanderbilt’s Electronic Procedural Timeout
September 6, 2016
August 30, 2016
Can You Really Limit Interruptions?
August 23, 2016
ISMP Canada: Automation Bias and Automation Complacency
August 16, 2016
How Is Your Alarm Management Initiative Going?
August 9, 2016
August 2, 2016
Drugs in the Elderly: The Goldilocks Story
July 26, 2016
Confirmed: Keep Your OR Doors Closed
July 19, 2016
Infants and Wrong Site Surgery
July 12, 2016
Forget Brexit – Brits Bash the RCA!
July 5, 2016
Tip of the Week on Vacation
June 28, 2016
Culture of Safety and Catheter-Associated Infections
June 21, 2016
Methotrexate Errors in Australia
June 14, 2016
Nursing Monitoring of Patients on Opioids
June 7, 2016
CPAP for Hospitalized Patients at High Risk for OSA
May 31, 2016
More Frailty Measures That Predict Surgical Outcomes
May 24, 2016
Texting Orders – Is It Really Safe?
May 17, 2016
Patient Safety Issues in Cataract Surgery
May 10, 2016
Medical Problems in Behavioral Health
May 3, 2016
Clinical Decision Support Malfunction
April 26, 2016
Lots More on Preventing Readmissions But Where's the Beef?
April 19, 2016
Independent Double Checks and Oral Chemotherapy
April 12, 2016
April 5, 2016
Workarounds Overriding Safety
March 29, 2016
March 22, 2016
Radiology Communication Errors May Surprise You
March 15, 2016
March 8, 2016
Tip of the Week on Vacation
March 1, 2016
February 23, 2016
February 16, 2016
February 9, 2016
February 2, 2016
January 26, 2016
More on Frailty and Surgical Morbidity and Mortality
January 19, 2016
Patient Identification in the Spotlight
January 12, 2016
New Resources on Improving Safety of Healthcare IT
January 5, 2016
Lessons from AirAsia Flight QZ8501 Crash
December 29, 2015
More Medical Helicopter Hazards
December 22, 2015
The Alberta Abbreviation Safety Toolkit
December 15, 2015
Vital Sign Monitoring at Night
December 8, 2015
Danger of Inaccurate Weights in Stroke Care
December 1, 2015
TALLman Lettering: Does It Work?
November 24, 2015
Door Opening and Foot Traffic in the OR
November 17, 2015
Patient Perspectives on Communication of Test Results
November 10, 2015
Weighing in on Double-Booked Surgery
November 3, 2015
Medication Errors in the OR - Part 2
October 27, 2015
Sentinel Event Alert on Falls and View from Across the Pond
October 20, 2015
Updated Beers List
October 13, 2015
Dilaudid Dangers #3
October 6, 2015
Suicide and Other Violent Inpatient Deaths
September 29, 2015
More on the 12-Hour Nursing Shift
September 22, 2015
The Cost of Being Rude
September 15, 2015
Another Possible Good Use of a Checklist
September 8, 2015
TREWScore for Early Recognition of Sepsis
September 1, 2015
August 25, 2015
Checklist for Intrahospital Transport
August 18, 2015
Missing Obstructive Sleep Apnea
August 11, 2015
New Oxygen Guidelines: Thoracic Society of Australia and NZ
August 4, 2015
Tip of the Week on Vacation
July 28, 2015
July 21, 2015
Avoiding Distractions in the OR
July 14, 2015
July 7, 2015
June 30, 2015
What Are Appropriate Indications for Urinary Catheters?
June 23, 2015
Again! Mistaking Antiseptic Solution for Radiographic Contrast
June 16, 2015
June 9, 2015
Add This to Your Fall Risk Assessment
June 2, 2015
May 26, 2015
May 19, 2015
May 12, 2015
More on Delays for In-Hospital Stroke
May 5, 2015
Errors with Oral Oncology Drugs
April 28, 2015
April 21, 2015
April 14, 2015
Using Insulin Safely in the Hospital
April 7, 2015
March 31, 2015
Clinical Decision Support for Pneumonia
March 24, 2015
Specimen Issues in Prostate Cancer
March 17, 2015
March 10, 2015
FDA Warning Label on Insulin Pens: Is It Enough?
March 3, 2015
Factors Related to Postoperative Respiratory Depression
February 24, 2015
More Risks with Long-Acting Opioids
February 17, 2015
Functional Impairment and Hospital Readmission, Surgical Outcomes
February 10, 2015
The Anticholinergic Burden and Dementia
February 3, 2015
CMS Hopes to Reduce Antipsychotics in Dementia
January 27, 2015
The Golden Hour for Stroke Thrombolysis
January 20, 2015
He Didn’t Wash His Hands After What!
January 13, 2015
January 6, 2015
Yet Another Handoff: The Intraoperative Handoff
December 30, 2014
Data Accumulates on Impact of Long Surgical Duration
December 23, 2014
Iatrogenic Burns in the News Again
December 16, 2014
More on Each Element of the Surgical Fire Triad
December 9, 2014
December 2, 2014
ANA Position Statement on Nurse Fatigue
November 25, 2014
Misdiagnosis Due to Lab Error
November 18, 2014
Handwashing Fades at End of Shift, ?Smartwatch to the Rescue
November 11, 2014
Early Detection of Clinical Deterioration
November 4, 2014
Progress on Fall Prevention
October 28, 2014
RF Systems for Retained Surgical Items
October 21, 2014
The Fire Department and Your Hospital
October 14, 2014
October 7, 2014
Our Take on Patient Safety Walk Rounds
September 30, 2014
More on Deprescribing
September 23, 2014
Stroke Thrombolysis: Need to Focus on Imaging-to-Needle Time
September 16, 2014
Focus on Home Care
September 9, 2014
The Handback
September 2, 2014
Frailty and the Trauma Patient
August 26, 2014
Surgeons’ Perception of Intraoperative Time
August 19, 2014
Some More Lessons Learned on Retained Surgical Items
August 12, 2014
Surgical Fires Back in the News
August 5, 2014
Tip of the Week on Vacation
July 29, 2014
The 12-Hour Nursing Shift: Debate Continues
July 22, 2014
More on Operating Room Briefings and Debriefings
July 15, 2014
Barriers to Success of Early Warning Systems
July 8, 2014
Update: Minor Head Trauma in the Anticoagulated Patient
July 1, 2014
Interruptions and Radiologists
June 24, 2014
Lessons from the General Motors Recall Analysis
June 17, 2014
SO2S Confirms Routine Oxygen of No Benefit in Stroke
June 10, 2014
Another Clinical Decision Support Tool to Avoid Torsade de Pointes
June 3, 2014
More on the Risk of Sedative/Hypnotics
May 27, 2014
A Gap in ePrescribing: Stopping Medications
May 20, 2014
May 13, 2014
Perioperative Sleep Apnea: Human and Financial Impact
May 6, 2014
Monitoring for Opioid-induced Sedation and Respiratory Depression
April 29, 2014
More on the Unintended Consequences of Contact Isolation
April 22, 2014
Impact of Resident Workhour Restrictions
April 15, 2014
Specimen Identification Mixups
April 8, 2014
FMEA to Avoid Breastmilk Mixups
April 1, 2014
Expensive Aspects of Sepsis Protocol Debunked
March 25, 2014
March 18, 2014
Systems Approach Improving Stroke Care
March 11, 2014
We Miss the Graphic Flowchart!
March 4, 2014
Evidence-Based Prescribing and Deprescribing in the Elderly
February 25, 2014
Joint Commission Revised Diagnostic Imaging Requirements
February 18, 2014
February 11, 2014
Another Perioperative Handoff Tool: SWITCH
February 4, 2014
But What If the Battery Runs Low?
January 28, 2014
Is Polypharmacy Always Bad?
January 21, 2014
January 14, 2014
Diagnostic Error: Salient Distracting Features
January 7, 2014
Lessons From the Asiana Flight 214 Crash
December 24-31, 2013
Tip of the Week on Vacation
December 17, 2013
December 10, 2013
Better Handoffs, Better Results
December 3, 2013
Reducing Harm from Falls on Inpatient Psychiatry
November 26, 2013
Missed Care: New Opportunities?
November 19, 2013
Can We Improve Dilaudid/HYDROmorphone Safety?
November 12, 2013
More on Inappropriate Meds in the Elderly
November 5, 2013
Joint Commission Sentinel Event Alert: Unintended Retained Foreign Objects
October 29, 2013
PAD: The Pain, Agitation, and Delirium Care Bundle
October 22, 2013
How Safe Is Your Radiology Suite?
October 15, 2013
October 8, 2013
October 1, 2013
Fuels and Oxygen in OR Fires
September 24, 2013
Perioperative Use of CPAP in OSA
September 17, 2013
September 10, 2013
Informed Consent and Wrong-Site Surgery
September 3, 2013
Predicting Perioperative Complications: Slow and Simple
August 27 2013
Lessons on Wrong-Site Surgery
August 20 2013
Lessons from Canadian Analysis of Medical Air Transport Cases
August 13 2013
August 6, 2013
July 9-30, 2013
Tip of the Week on Vacation
July 2, 2013
June 25, 2013
June 18, 2013
DVT Prevention in Stoke – CLOTS 3
June 11, 2013
June 4, 2013
May 28, 2013
The Neglected Medications: IV Fluids
May 21, 2013
May 14, 2013
Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)
May 7, 2013
April 30, 2013
Photographic Identification to Prevent Errors
April 23, 2013
Plethora of Medication Safety Studies
April 16, 2013
April 9, 2013
Mayo Clinic System Alerts for QT Interval Prolongation
April 2, 2013
Absconding from Behavioral Health Services
March 26, 2013
Failure to Recognize Sleep Apnea Before Surgery
March 19, 2013
Dealing with the Violent Patient in the Emergency Department
March 12, 2013
More on Communicating Test Results
March 5, 2013
Underutilized Safety Tools: The Observational Audit
February 26, 2013
Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?
February 19, 2013
Practical Postoperative Pain Management
February 12, 2013
CDPH: Lessons Learned from PCA Incident
February 5, 2013
Antidepressants and QT Interval Prolongation
January 29, 2013
A Flurry of Activity on Handoffs
January 22, 2013
You Don’t Know What You Don’t Know
January 15, 2013
January 8, 2013
More Lessons Learned on Retained Surgical Items
January 1, 2013
Don’t Throw Away Those View Boxes Yet
December 25, 2012
Tip of the Week on Vacation
December 18, 2012
Unintended Consequences of the CAUTI Measure?
December 11, 2012
December 4, 2012
Unintentional Perioperative Hypothermia: A New Twist
November 27, 2012
November 20, 2012
Update on Perioperative Management of Obstructive Sleep Apnea
November 13, 2012
The 12-Hour Nursing Shift: More Downsides
November 6, 2012
Using LEAN to Improve Stroke Care
October 30, 2012
October 23, 2012
Latent Factors Lurking in the OR
October 16, 2012
What is the Evidence on Double Checks?
October 9, 2012
Call for Focus on Diagnostic Errors
October 2, 2012
Test Results: Everyone’s Worst Nightmare
September 25, 2012
Preoperative Assessment for Geriatric Patients
September 18, 2012
September 11, 2012
In Search of the Ideal Early Warning Score
September 4, 2012
August 28, 2012
New Care Model Copes with Interruptions Better
August 21, 2012
More on Missed Followup of Tests in Hospital
August 14, 2012
August 7, 2012
Cognition, Post-Op Delirium, and Post-Op Outcomes
July 31, 2012
Surgical Case Duration and Miscommunications
July 24, 2012
FDA and Extended-Release/Long-Acting Opioids
July 17, 2012
July 10, 2012
Tip of the Week on Vacation
July 3, 2012
Recycling an Old Column: Dilaudid Dangers
June 26, 2012
Using Patient Photos to Reduce CPOE Errors
June 19, 2012
More Problems with Faxed Orders
June 12, 2012
Lessons Learned from the CDPH: Retained Foreign Bodies
June 5, 2012
Minor Head Trauma in the Anticoagulated Patient
May 29, 2012
Falls, Fractures, and Fatalities
May 22, 2012
Update on Preoperative Screening for Sleep Apnea
May 15, 2012
May 8, 2012
Importance of Nontechnical Skills in Healthcare
May 1, 2012
April 24, 2012
Fire Hazard of Skin Preps Oxygen
April 17, 2012
April 10, 2012
April 3, 2012
New Risk for Postoperative Delirium: Obstructive Sleep Apnea
March 27, 2012
March 20, 2012
Adverse Events Related to Psychotropic Medications
March 13, 2012
Medical Emergency Team Calls to Radiology
March 6, 2012
February 28, 2012
AACN Practice Alert on Delirium in Critical Care
February 21, 2012
Improving PCA Safety with Capnography
February 14, 2012
Handoffs More Than Battle of the Mnemonics
February 7, 2012
Another Neuromuscular Blocking Agent Incident
January 31, 2012
January 24, 2012
Patient Safety in Ambulatory Care
January 17, 2012
Delirium and Contact Isolation
January 10, 2012
January 3, 2012
Unintended Consequences of Restricted Housestaff Hours
December 20, 2011
December 13, 2011
December 6, 2011
Why You Need to Beware of Oxygen Therapy
November 29, 2011
November 22, 2011
Perioperative Management of Sleep Apnea Disappointing
November 15, 2011
November 8, 2011
WHOs Multi-professional Patient Safety Curriculum Guide
November 1, 2011
So Whats the Big Deal About Inserting an NG Tube?
October 25, 2011
October 18, 2011
October 11, 2011
October 4, 2011
Radiology Report Errors and Speech Recognition Software
September 27, 2011
The Canadian Suicide Risk Assessment Guide
September 20, 2011
When Practice Changes the Evidence: The CKD Story
September 13, 2011
Do You Use Fentanyl Transdermal Patches Safely?
September 6, 2011
August 30, 2011
Unintentional Discontinuation of Medications After Hospitalization
August 23, 2011
Catheter Misconnections Back in the News
August 16, 2011
August 9, 2011
Frailty and the Surgical Patient
August 2, 2011
July 26, 2011
July 19, 2011
Communication Across Professions
July 12, 2011
Psst! Pass it onHow a kids game can mold good handoffs
July 5, 2011
Sidney Dekker: Patient Safety. A Human Factors Approach
June 28, 2011
Long-Acting and Extended-Release Opioid Dangers
June 21, 2011
June 14, 2011
June 6, 2011
May 31, 2011
Book Review Human Factors and Team Psychology in a High Stakes Environment
May 24, 2011
May 17, 2011
Opioid-Induced Respiratory Depression Again!
May 10, 2011
Preventing Preventable Readmissions: Not As Easy As It Sounds
May 3, 2011
April 26, 2011
Sleeping Air Traffic Controllers: What About Healthcare?
April 19, 2011
DVT Prophylaxis in Acute Stroke: Controversy Reappears
April 12, 2011
Medication Issues in the Ambulatory Setting
April 5, 2011
March 29, 2011
The Silent Treatment:A Dose of Reality
March 22, 2011
An EMR Feature Detrimental to Teamwork and Patient Safety
March 15, 2011
March 8, 2011
Yes, Physicians Get Interrupted Too!
March 1, 2011
February 22, 2011
February 15, 2011
Controversies in VTE Prophylaxis
February 8, 2011
February 1, 2011
January 25, 2011
Procedural Sedation in Children
January 18, 2011
More on Medication Errors in Long-Term Care
January 11, 2011
NPSA (UK) How to Guide: Five Steps to Safer Surgery
January 4, 2011
December 28, 2010
HAIs: Looking In All The Wrong Places
December 21, 2010
More Bad News About Off-Hours Care
December 14, 2010
NPSA (UK): Preventing Fatalities from Medication Loading Doses
December 6, 2010
More Tips to Prevent Wrong-Site Surgery
November 30, 2010
SURPASS: The Mother of All Checklists
November 23, 2010
Focus on Cumulative Radiation Exposure
November 16, 2010
November 9, 2010
12-Hour Nursing Shifts and Patient Safety
November 2, 2010
Insulin: Truly a High-Risk Medication
October 26, 2010
Confirming Medications During Anesthesia
October 19, 2010
Optimizing Medications in the Elderly
October 12, 2010
October 5, 2010
September 28, 2010
September 21, 2010
September 14, 2010
Wrong-Site Craniotomy: Lessons Learned
September 7, 2010
Patient Safety in Ob/Gyn Settings
August 31, 2010
August 24, 2010
The BP Oil Spill Analogies in Healthcare
August 17, 2010
Preoperative Consultation Time to Change
August 10, 2010
Its Not Always About The Evidence
August 3, 2010
Tip of the Week on Vacation
July 27, 2010
EMRs Still Have A Long Way To Go
July 20, 2010
More on the Weekend Effect/After-Hours Effect
July 13, 2010
Postoperative Opioid-Induced Respiratory Depression
July 6, 2010
Book Reviews: Pronovost and Gawande
June 29, 2010
Torsade de Pointes: Are Your Patients At Risk?
June 22, 2010
Disclosure and Apology: How to Do It
June 15, 2010
Dysphagia in the Stroke Patient: the Scottish Guideline
June 8, 2010
Surgical Safety Checklist for Cataract Surgery
June 1, 2010
May 25, 2010
May 18, 2010
Real-Time Random Safety Audits
May 11, 2010
May 4, 2010
More on the Impact of Interruptions
April 27, 2010
April 20, 2010
HITs Limited Impact on Quality To Date
April 13, 2010
April 6, 2010
March 30, 2010
Publicly Released RCAs: Everyone Learns from Them
March 23, 2010
ISMPs Guidelines for Standard Order Sets
March 16, 2010
A Patient Safety Scavenger Hunt
March 9, 2010
Communication of Urgent or Unexpected Radiology Findings
March 2, 2010
Alarm Sensitivity: Early Detection vs. Alarm Fatigue
February 23, 2010
Alarm Issues in the News Again
February 16, 2010
Spin/HypeKnowing It When You See It
February 9, 2010
More on Preventing Inpatient Suicides
February 2, 2010
January 26, 2010
Preventing Postoperative Delirium
January 19, 2010
January 12, 2010
Patient Photos in Patient Safety
January 5, 2010
December 29, 2009
Recognizing Deteriorating Patients
December 22, 2009
December 15, 2009
December 8, 2009
December 1, 2009
Patient Safety Doesnt End at Discharge
November 24, 2009
Another Rough Month for Healthcare IT
November 17, 2009
November 10, 2009
Conserving ResourcesBut Maintaining Patient Safety
November 3, 2009
Medication Safety: Frontline to the Rescue Again!
October 27, 2009
Co-Managing Patients: The Good, The Bad, and The Ugly
October 20, 2009
Radiology AgainBut This Time Its Really Radiology!
October 13, 2009
October 6, 2009
Oxygen Safety: More Lessons from the UK
September 29, 2009
Perioperative Peripheral Nerve Injuries
September 22, 2009
Psychotropic Drugs and Falls in the SNF
September 15, 2009
ETTOs: Efficiency-Thoroughness Trade-Offs
September 8, 2009
Barriers to Medication Reconciliation
September 1, 2009
The Real Root Causes of Medical Helicopter Crashes
August 25, 2009
Interruptions, Distractions, InattentionOops!
August 18, 2009
Obstructive Sleep Apnea in the Perioperative Period
August 11, 2009
August 4, 2009
July 28, 2009
Wandering, Elopements, and Missing Patients
July 21, 2009
Medication Errors in Long Term-Care
July 14, 2009
Is Your Do Not Use Abbreviations List Adequate?
July 7, 2009
Nudge: Small Changes, Big Impacts
June 30, 2009
iSoBAR: Australian Clinical Handoffs/Handovers
June 23, 2009
June 16, 2009
Disclosing Errors That Affect Multiple Patients
June 9, 2009
CDC Update to the Guideline for Prevention of CAUTI
June 2, 2009
Why Hospitals Should FlyJohn Nance Nails It!
May 26, 2009
Learning from Tragedies. Part II
May 19, 2009
May 12, 2009
May 5, 2009
Adverse Drug Events in the ICU
April 28, 2009
Ticket Home and Other Tools to Facilitate Discharge
April 21, 2009
April 14, 2009
More on Rehospitalization After Discharge
April 7, 2009
March 31, 2009
Screening Patients for Risk of Delirium
March 24, 2009
March 17, 2009
March 10, 2009
Prolonged Surgical Duration and Time Awareness
March 3, 2009
Overriding AlertsLike Surfin the Web
February 24, 2009
Discharge Planning: Finally Something That Works!
February 17, 2009
Reducing Risk of Overdose with Midazolam Injection
February 10, 2009
Sedation in the ICU: The Dexmedetomidine Study
February 3, 2009
NTSB Medical Helicopter Crash Reports: Missing the Big Picture
January 27, 2009
Oxygen Therapy: Everything You Wanted to Know and More!
January 20, 2009
The WHO Surgical Safety Checklist Delivers the Outcomes
January 13, 2009
January 6, 2009
December 30, 2008
Unintended Consequences: Is Medication Reconciliation Next?
December 23, 2008
December 16, 2008
Joint Commission Sentinel Event Alert on Hazards of Healthcare IT
December 9, 2008
December 2, 2008
Playing without the ballthe art of communication in healthcare
November 25, 2008
November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
November 11, 2008
November 4, 2008
October 28, 2008
More on Computerized Trigger Tools
October 21, 2008
October 14, 2008
October 7, 2008
Lessons from Falls....from Rehab Medicine
September 30, 2008
September 23, 2008
Checklists and Wrong Site Surgery
September 16, 2008
More on Radiology as a High Risk Area
September 9, 2008
Less is More.and Do You Really Need that Decimal?
September 2, 2008
August 26, 2008
August 19, 2008
August 12, 2008
Jerome Groopmans How Doctors Think
August 5, 2008
July 29, 2008
Heparin-Induced Thrombocytopenia
July 22, 2008
Lots New in the Anticoagulation Literature
July 15, 2008
July 8, 2008
July 1, 2008
WHOs New Surgical Safety Checklist
June 24, 2008
Urinary Catheter-Related UTIs: Bladder Bundles
June 17, 2008
Technology Workarounds Defeat Safety Intent
June 10, 2008
Monitoring the Postoperative COPD Patient
June 3, 2008
UK Advisory on Chest Tube Insertion
May27, 2008
If You Do RCAs or Design Healthcare ProcessesRead Gary Kleins Work
May20, 2008
CPOE Unintended Consequences Are Wrong Patient Errors More Common?
May13, 2008
Medication Reconciliation: Topical and Compounded Medications
May 6, 2008
Preoperative Screening for Obstructive Sleep Apnea
April 29, 2008
ASA Practice Advisory on Operating Room Fires
April 22, 2008
CMS Expanding List of No-Pay Hospital-Acquired Conditions
April 15, 2008
April 8, 2008
April 1, 2008
Pennsylvania PSAs FMEA on Telemetry Alarm Interventions
March 25, 2008
March 18, 2008
Is Desmopressin on Your List of Hi-Alert Medications?
March 11, 2008
March 4, 2008
Housestaff Awareness of Risks for Hazards of Hospitalization
February 26, 2008
Nightmares.The Hospital at Night
February 19, 2008
February 12, 2008
February 5, 2008
Reducing Errors in Obstetrical Care
January 29, 2008
Thoughts on the Recent Neonatal Nursery Fire
January 22, 2008
More on the Cost of Complications
January 15, 2008
Managing Dangerous Medications in the Elderly
January 8, 2008
Urinary Catheter-Associated Infections
January 1, 2008
December 25, 2007
December 18, 2007
December 11, 2007
CommunicationCommunicationCommunication
December 4, 2007
November 27,2007
November 20, 2007
New Evidence Questions Perioperative Beta Blocker Use
November 13, 2007
AHRQ's Free Patient Safety Tools DVD
November 6, 2007
October 30, 2007
Using IHIs Global Trigger Tool
October 23, 2007
Medication Reconciliation Tools
October 16, 2007
Radiology as a Site at High-Risk for Medication Errors
October 9, 2007
October 2, 2007
Taking Off From the Wrong Runway
September 25, 2007
Lessons from the National Football League
September 18, 2007
Wristbands: The Color-Coded Conundrum
September 11, 2007
Root Cause Analysis of Chemotherapy Overdose
September 4, 2007
August 28, 2007
Lessons Learned from Transportation Accidents
August 21, 2007
Costly Complications About To Become Costlier
August 14, 2007
More Medication-Related Issues in Ambulatory Surgery
August 7, 2007
Role of Maintenance in Incidents
July 31, 2007
Dangers of Neuromuscular Blocking Agents
July 24, 2007
Serious Incident Response Checklist
July 17, 2007
Falls in Patients on Coumadin or Other Anticoagulants
July 10, 2007
Catheter Connection Errors/Wrong Route Errors
July 3, 2007
June 26, 2007
Pneumonia in the Stroke Patient
June 19, 2007
Unintended Consequences of Technological Solutions
June 12, 2007
Medication-Related Issues in Ambulatory Surgery
June 5, 2007
Patient Safety in Ambulatory Surgery
May 29, 2007
Read Anything & Everything Written by Malcolm Gladwell!
May 22, 2007
May 15, 2007
Communication, Hearback and Other Lessons from Aviation
May 8, 2007
Doctor, when do I get this red rubber hose removed?
May 1, 2007
April 23, 2007
April 16, 2007
April 9, 2007
Make Your Surgical Timeouts More Useful
April 2, 2007
March 26, 2007
Alarms Should Point to the Problem
March 19, 2007
Put that machine back the way you found it!
March 12, 2007
March 5, 2007
February 26, 2007
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