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July 5, 2011
Sidney Dekker: Patient Safety. A Human Factors Approach
Time for another of our traditional holiday book reviews. Many of you involved in patient safety are familiar with some of Sidney Dekkers previous books The Field Guide to Human Error Investigations (2002) and The Field Guide to Understanding Human Error (2006). Though much of his work has been in the aviation industry, Dekkers work in human factors and cognitive systems engineering is directly applicable to medicine and patient safety (see our April 2007 Whats New in the Patient Safety World column New Sidney Dekker Book).
Now he has actually written a book that focuses on patient safety from a human factors perspective: Patient Safety. A Human Factors Approach.
Dekker begins by discussions about our push for perfection in medicine and other healthcare professions, leading to focus on individuals rather than systems. He talks then of the bureaucraticization that can actually further perpetuate the focus on the individual, not only in healthcare but in other industries as well. There is a sort of heroism that comes from being able to get the job done despite all the barriers put in place by the system.
He then goes on to discsuss a variety of human factors concepts, including hindsight bias, counterfactuals, outcome bias, the local rationality principle, satisficing, conflicting goals and efficiency/safety tradeoffs, and coginitive concepts such as schemata. His discussion on focusing of attention is excellent. At one end of a continuum you might see cognitive fixation (where controverting evidence is ignored). At the other end is thematic vagabonding (where one jumps to new ideas with each new clue). The discussions on prospective memory (remembering to remember), distractions and interruptions, mental models and heuristics are very helpful in understanding some aspects of human behavior.
Then he goes into the most important concepts about how the environment and conditions in the system interact with humans. He has a great chapter on how new technologies change the system. Not only might they produce some improvements they intended to, but they may have numerous unintended consequences, including data overload, automation surprises, tighter coupling, new roles and new interpersonal conflicts, and redistribution of workloads. The latter include redistribution of worload among workers and redistribution in time (such that increased cognitive workloads may be required during rapidly evolving situations because of the technology).
He gives a great history of the evolution of human factors approaches to safety and accidents. Youll recognize many of the names from many of our prior columns (Reason, Rasmussen, Hollnagel, Klein, Perow, et al.). He moves from Turners man-made disaster theory to Reasons swiss cheese model, to Perows normal accident theory (where interactive complexity and tight coupling may lead to accidents even during normal operations). With each new disaster theories and models get redefined. The Challenger disaster, in particular, brought to light the importance of concepts like normalization of deviance where successes despite problems lead to the acceptance of such problems as normal and therefore tolerable. These are followed by extensive discussions on control theory and high reliability organizations.
Perhaps the most interesting contribution is Chapter 6 Practical Tools for Creating Safety. This chapter contains many lessons that we tend to overlook in our own patient safety endeavors. First he talks about event reporting systems. Weve always talked about the need for voluntary reporting systems that are nonpunitive so that appropriate events and near-misses get reported so that we may learn from them. He reiterates the need for protected reporting systems but notes they should be confidential rather than anonymous. If anonymous, one cannot contact the reporter for details or apprise the reporter of actions taken as a result of the report. He also notes that anonymous reporting systems have a tendency to receive many reports that are vitriol or bickering that just clog up the system with senseless items that lead to no learning. In a confidential system, the name of the reporter and any other identifying items get separated from the narrative.
He strongly stresses that the learning potential of reporting systems lies in the narratives and he does not like systems that pigeon-hole reports into categories. The latter tend to get reported out in bar graphs or pie charts as meaningless statistics that do not lead to organizational learning but may provide false impressions of improvement or lead to a false sense that the system is safe. Frequent readers of our columns have often heard us talk about stories, not statistics as being the heart and sole of the patient safety movement.
But Dekker also talks about what should get reported, noting that what are considered near-misses by some are not by others. The local rationality concept may lead to some practitioners considering some events as normal.
Getting people to report (and sustaining reporting) is all about building trust. And, interestingly, work of many researchers suggests that fear of punitive action or retribution is not the major reason people dont report. Rather it is lack of conviction that the organization will use the reports for meaningful learning. Building trust that such reports will lead to meaningful improvements in safety is empowering and apparently a much better incentive to sustain event reporting systems.
He goes on to describe what a safety department should look like and emphasizes the four Is: informed, independent, informative, and involved (noting that balancing some of the Is against one another is sometimes difficult). He makes a very strong case for the safety department to be independent, both from a political and financial perspective. While needing immediate access to top-level decision makers in the organization, it needs to be independent in dealing with the inevitable efficiency/safety tradeoffs that occur in any organization. Its budget, in particular, needs to be insulated from cost-cutting during periods of economic difficulties. Those are the times that safety issues are especially likely to occur, as other parts of the organization try to deliver outcomes despite resource challenges. Staying informed means keeping close to operational activities so one can understand workflows and factors related to actual operations and being able to convey to all levels of the organization the various perspectives on safety (and efficiency). Similarly, the safety department needs to be informative to both upper levels and the front line. Interestingly, he points out that part-time members of the safety department are especially valuable, because they typically also work in other areas of the organization at an operational level.
His discussion on adverse event investigations is excellent. He nicely discusses moving from a first story, where organizations tend to focus on blaming individuals and consider the system safe, to the human factors approach where the focus is not on individuals but rather on the system and how system factors influenced how individuals may have acted during an evolving event. He spends a lot of time on avoiding hindsight bias (and outcome bias). He also dislikes the term root cause analysis since most root causes identified are still quite subjective and prone to various biases. He prefers to focus more on the doables in an RCA or any adverse event investigation. The focus is really on putting yourselves in the minds of the event participants, trying to see what they were seeing as the event unfolded, how information was available to them, what conflicting goals they had, etc. Only then can the system be redesigned or otherwise altered to prevent the same thing from happening to other workers at the sharp end.
Involving practitioners who were actually participants in the event is important, not only because of their unique perspectives but also because it provides them a sense of contributing to meaningful safety improvements. Also, when potential solutions ultimately get implemented, most practitioners are influenced more by their peers than by top-down communication.
His section on communication and coordination is great. He discusses the technique of conversation analysis, often used in aviation event investigation. Research using that technique notes that sometimes two parties talk simultaneously (overlapping talk), sometimes there is no response when a response is clearly anticipated, and repair where there are attempts to recover from some other sort of communication problem. All are potential signs of problems. He goes on to discuss the research on mitigation which means reducing the severity, seriousness or painfulness of something. He does this with a healthcare anecdote about the need to giving a patient an additional 5 ml of a medication and shows six ways in which one practitioner may communicate that with another. The mitigated ways are not likely to get the job done. There is a great discussion about how social interaction and political correctness may interfere with effective communication in high-risk settings. NASA had established a group of recommendations for effective communication: opening (getting someones attention), concern (stating the level of concern), problem (clearly defining the problem at hand), solution (suggesting a possible course of action), and agreement. Note the similarities to the SBAR format we often recommend in healthcare for handoffs and other interactions?
Teamwork and crew resource management techniques are also important. An interesting fact that we were not previously aware of is that serious aviation accidents are more likely when the captain is flying the aircraft (ordinarily the captain and copilot split flying about 50/50, with the nonflying person attending to a whole host of other activities in addition to observing the pilot). This is likely a reflection of a hierarchical structure and failure to speak up. He spends a lot of time talking about methods to get people to speak up in a variety of settings (eg. preoperative briefings). And he really focuses on the need for diversity on healthcare teams. By that he means that it is important to have people on the team who bring different skills and expertise and have different perspectives. That is often helpful in a rapidly evolving situation, though he also cautions that too many participants may lead to groupthink which often ends up in more extreme solutions. In addition to briefings, he has a good discussion on checklists (which serve both as memory tools and means of communicating).
A full chapter on all the concepts involved in developing a just culture is very informative. And he finishes with a chapter on future thinking in healthcare, in which he makes the case that healthcare is complex rather than complicated. The distinction is not esoteric. Complicated systems are still stable, somewhat predictable systems whereas complex ones are dynamic, always changing and subject to multiple interactions with humans and the environment.
This is not the kind of book that you cant put down. You will gain the most from it by going back and reading it several times. But the concepts are most powerful and you cannot be involved in patient safety today without understanding all the research on human factors that is available. Dekker, as he has in all his prior works, does not disappoint. This is one solid addition to your patient safety library.
Reference:
Dekker S (2011): Patient Safety. A Human Factors Approach. Boca Raton: CRC Press. Taylor & Francis Group.
Print Sidney Dekker: Patient Safety. A Human Factors Approach
July 12, 2011
Psst! Pass it onHow a kids game can mold good handoffs
Remember a game you probably played as a kid youd start with a brief story and say Psst! Pass it on. By the time the story had been passed on to several people it may bear little semblance to the original story. Key elements get omitted and sometimes new irrelevant information or even erroneous information gets added. The same thing happens with verbal communications in real life, even in healthcare. A study on handoffs demonstrated that verbal-only handoffs are rife with errors (Bhabra 2007). The investigators constructed a simulated handoff scenario on 12 fictional patients with 20 data points per patient and then randomized residents to participate in handoffs that were either (1) purely verbal (2) verbal with the receiver taking notes or (3) typed on a formal sheet. In the verbal-only group, by 5 handoffs only 2.5% of the data points were retained. In the note-taking group 85% of data points were retained and in the formal typed sheet handoff 99% were retained after 5 handoffs. The lesson: verbal-only handoffs are very dangerous!
Note that a previous study on nursing handoffs (Pothier et al 2005) showed that pure verbal handoffs and note-taking style handoffs had high rates of data loss but that when a typed sheet was included with the verbal handoff, data loss was minimal.
The Royal College of Physicians (England) recently published a toolkit for handoffs (or handovers as they are called in England) that relied heavily on the Bhabra study. They call for formalization and standardization of the handoff process, recognizing though the need to tailor the process to unit/local needs. They stress the multiprofessional nature of many handoffs and stress that the handoff process should have leadership (and not necessarily medical staff). Part of the handoff is clearly delineating the change in responsibility that is occurring. Prioritization of needs and risks is important and they suggest a green-amber-red color scheme to denote the varying levels of patient risk. An important part of the process is monitoring the effectiveness of handoffs. They suggest auditing checklists and/or other written or computerized tools, getting feedback from participants, assessing efficiency (eg. LOS), and assessing patient satisfaction. They also provide some templates, a handover proceedings sheet and an out-of-hours-handover template.
Importantly, the RCP toolkit emphasizes that the handoff must be owned by the organization. That is, the organization (hospital, facility, or larger organization) must ensure that the systems and conditions are in place to allow effective handoff. Those include overlapping duty times (shifts), rationalization of shift patterns of different roles (doctors and nurses), and provision of an appropriate environment. How many of you can say with conviction that you provide all those?
A recent observational study of handoffs in the emergency department (Maughan 2011) confirmed a high number of omissions and errors. The authors observed over a hundred handoffs, involving almost 1000 patients. Typical handoffs between attending physicians included about 10 patients and lasted about 15 minutes (for residents the numbers were slightly smaller). They also had some team handoffs, though nursing was not included in any of their handoffs. Most of the handoffs occurred in a central ED area away from patient rooms. Incoming physicians referenced the EMR in 72% of the handoffs and written notes in 43%. Incoming physicians asked questions in about 40% of handoffs. The incoming physician repeated details of the handoff in only 6% of cases. The outgoing physician reported incorrect information in 0.7% of handoffs but the information was corrected prior to completion in all cases. In 0.3% of cases the incoming physician corrected the outgoing physician based on information available in the EMR.
Omissions in the physical examination occurred in 45% of handoffs and omissions in laboratory data occurred in 29%. Errors in the physical examination occurred in 13% and lab errors in 3.7% of handoffs. Longer average handoff duration per patient was associated with more errors. Longer ED lengths of stay were associated with fewer errors but more omissions. When the incoming physician used the EMR or took written notes there were fewer errors.
One very interesting finding was that team handoffs were somewhat more prone to errors of laboratory information. Also the number of laboratory errors was proportional to the ED length of stay.
Longer handoff duration per patient was also associated with more omissions. That sounds counterintuitive but the authors speculate that the overall duration might be increased by discussion of a few patients, with less time spent on the remaining patients perhaps leading to more omissions. The authors did note that about one interruption occurred per handoff but did not correlate these with errors or omissions.
The authors cite that error-reducing tools, like reference to the EMR or written notes, was useful in reducing errors but other error-reducing tools, like readback, were seldom used. They also noted that discussion of the patients outpatient medications seldom took place, suggesting this is an area for potential improvement.
In a recent letter to the editor (Ross 2011) a simple tool for handoffs in the ED was presented. The incoming physician serves as the scribe as the patient is presented. The form includes not only patient identifiers and assessment, but also notes pending studies and potential dispositions. Implementation of that form was well-received by emergency medicine residents, though formal impact on errors was not measured.
A recent article on fatigue in surgical residents (Kahol 2011) noted that, though the residents had considerable deficits in cognition and performance on a laparoscopic surgery simulator, they actually took considerably less time to complete their tasks post-call. The authors note that there may be a tendency to complete tasks in a rapid manner at the end of call, accepting an increased error rate, and speculate that this may have an untoward effect on handoffs.
Our April 13, 2010 Patient Safety Tip of the Week Update on Handoffs highlighted some statistics on the impact of faulty communication and handoffs on malpractice claims. There we noted an article by Cheung et al (Cheung et al 2010) that had some good advice regarding strategies to improve ED handoffs. Firstly, reduce the number of unnecessary handoffs, for example by scheduling overlapping shifts or protecting the departing physician from new patients toward the end of a shift (but beware of the unintended consequence of pushing the patient through the system too rapidly). Do the handoffs in a quiet, dedicated space to minimize distractions, leaving adequate time for discussion and questions. Balance completeness with succinctness in the handoff (if too much information is conveyed, the critical elements are often lost among the irrelevant ones). Prioritize patients who need to be seen first and communicate all outstanding issues (labs, radiology, consultations, etc.). Be sure to spell out authority issues (eg. when a consultant will be determining disposition of the patient) and let all the ED staff know that a transition of care has occurred.
One of the collaborative projects of the Joint Commission Center For Transforming Healthcare is on Hand-off Communications. The storyboards for that project detail many of the root causes identified from fumbled handoffs and provide useful examples of interventions to help avoid them. The focus needs to be as much or more on system issues than on individual issues. While they do talk about structured tools and using technology to improve the handoff process, they especially focus on the need to inculcate the importance of communication into the culture of the organization, establish workspace and conditions conducive to good handoffs, and intergrate the handoff process into the workflows of healthcare workers. They use the acronym SHARE (S standardize critical content, H hardwire within your system, A allow opportunity to ask questions, R reinforce quality and measurement, E educate and coach) to help all remember key elements of successful handoffs.
The February 2010 issue of Joint Commission Journal on Quality and Patient Safety was a theme issue on handoffs. One paper (Anderson 2010) demonstrated how standardized EMR-based handoff software improved data accuracy and content consistency, was well-received by users, and improved perceptions of handoff-related patient safety, quality, and efficiency. A second (Bernstein 2010) showed that integration of signout notes into an EMR also led to an improvement in physician workflow. A third (Patterson 2010) dealt with the complex problem of measuring the effectiveness of handoffs.
While SBAR is probably the structured format used most widely for handoffs in healthcare, a variety of different formats are available. An article in Hospitals & Health Systems a couple years ago (Runy 2008) summarized some of the structured techniques used in handoffs, including not only SBAR but also I PASS the BATON, and the US Department of Defense Handoff Model. And our June 30, 2009 Patient Safety Tip of the Week iSoBAR: Australian Clinical Handoffs/Handovers highlighted the iSoBAR format.
The AHRQ Patient Safety Primer Handoffs and Signouts also has links to some good resources on handoffs.
Your nursing staff is probably pretty good at using structured formats for handoffs. Your housestaff is probably also pretty good at using structured handoff tools. You may even have electronic versions of such tools for them. But what about others who do handoffs? Attending physicians in academic settings (other than possibly emergency departments) probably dont do their own handoffs very often using structured formats. Attendings in community hospitals cross-covering for each other seldom use them. Nursing administrators and hospital administrators on-call almost never use them. And personnel in ancillary departments, like lab and radiology, may not use them either. The question is Why not?. We can give you anecdotes about fumbled handoffs in every one of those scenarios that had a real or potential impact on patient care.
We think that videotaping handoffs between a variety of healthcare workers and using those tapes to provide constructive feedback as a way to improve the handoff process also makes a lot of sense. They can provide one of the only ways to determine whether the handoff was truly a two-way communication, i.e. the receiver had the opportunity to ask questions and clarify issues. Though that is time consuming, the return on investment is immense when you think about the potential adverse outcomes that might be avoided with better handoffs.
Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:
August 28, 2007 Lessons Learned from Transportation Accidents
December 11, 2007 CommunicationCommunicationCommunication
February 26, 2008 Nightmares.The Hospital at Night
September 30, 2008 Hot Topic: Handoffs
November 18, 2008 Ticket to Ride: Checklist, Form, or Decision Scorecard?
December 2008 Another Good Paper on Handoffs.
June 30, 2009 iSoBAR: Australian Clinical Handoffs/Handovers
April 25, 2009 Interruptions, Distractions, InattentionOops!
April 13, 2010 Update on Handoffs
References:
Bhabra G, Mackeith S, Monteiro P, Pothier D. An experimental comparison of handover methods. Ann R Coll Surg Engl 2007; 89: 298300
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1964745/pdf/rcse8903-298.pdf
Pothier D, Monteiro P, Mooktiar M, Shaw A. Pilot study to show the loss of important data in nursing handover. British Journal of Nursing 2005; 14(20): 1090 - 1093
http://www.internurse.com/cgi-bin/go.pl/library/article.cgi?uid=20053;article=BJN_14_20_1090_1093
Royal College of Physicians. Acute Care Toolkit 1. Handover. May 2011.
http://www.rcplondon.ac.uk/sites/default/files/acute-medicine-toolkit-may-2011.pdf
templates:
handover proceedings sheet
http://www.rcplondon.ac.uk/sites/default/files/handover-proceedings-sheet.pdf
out-of-hours-handover
http://www.rcplondon.ac.uk/sites/default/files/out-of-hours-handover.pdf
Maughan BC, Lei L, Cydulka RK. ED handoffs: observed practices and communication errors. American Journal of Emergency Medicine, The Vol. 29, Issue 5, Pages 502-511
http://www.ajemjournal.com/article/S0735-6757(09)00626-3/abstract
Ross CT, Seupaul RA. Minimizing medical error: standardization of patient handoff in the ED. American Journal of Emergency Medicine, The Vol. 29, Issue 5, Pages 567-568
http://www.ajemjournal.com/article/S0735-6757(11)00078-7/fulltext
Kahol K, Smith M, Brandenberger J, et al. Impact of Fatigue on Neurophysiologic Measures of Surgical Residents. J Am Coll Surg 2011; 213: 29-36
http://www.journalacs.org/article/S1072-7515(11)00232-8/abstract
Cheung DS, Kelly JJ, Beach C, et al for the American College of Emergency Physicians Section of Quality Improvement and Patient Safety. Improving Handoffs in the Emergency Department. Annals of Emergency Medicine 2010; 55(2): 171-180 February 2010
http://www.annemergmed.com/article/S0196-0644(09)01261-X/abstract
Joint Commission Center For Transforming Healthcare. Hand-off Communications Project homepage.
http://www.centerfortransforminghealthcare.org/projects/display.aspx?projectid=1
Story Boards for the Hand-off Communications Project
http://www.centerfortransforminghealthcare.org/UserFiles/file/CTH Hand-off commun set final 2010.pdf
Joint Commission Journal on Quality and Patient Safety. Theme Issue on Handoffs. Volume 36, Issue 2. February 2010
http://www.ingentaconnect.com/content/jcaho/jcjqs/2010/00000036/00000002
Anderson J, Shroff D, Curtis A, Eldridge N, Cannon K, Karnani R, Abrams T, Kaboli P.
The Veterans Affairs Shift Change Physician-to-Physician Handoff Project. Joint Commission Journal on Quality and Patient Safety 2010; 36(2): 62-71 February 2010
http://www.ingentaconnect.com/content/jcaho/jcjqs/2010/00000036/00000002/art00003
Bernstein JA, Imler DL, Sharek P, Longhurst C. Improved Physician Work Flow After Integrating Sign-out Notes into the Electronic Medical Record. Joint Commission Journal on Quality and Patient Safety 2010; 36(2): 72-78 February 2010
http://www.ingentaconnect.com/content/jcaho/jcjqs/2010/00000036/00000002/art00004
Patterson ES, Wears RL. Patient Handoffs: Standardized and Reliable Measurement Tools Remain Elusive. Joint Commission Journal on Quality and Patient Safety 2010; 36(2): 52-61 February 2010
http://www.ingentaconnect.com/content/jcaho/jcjqs/2010/00000036/00000002/art00002
Runy LA. Patient Handoffs. Hospitals & Health Networks. May 2008
AHRQ. Patient Safety Primers. Handoffs and Signouts.
http://psnet.ahrq.gov/primer.aspx?primerID=9
Print Psst! Pass it onHow a kids game can mold good handoffs
July 19, 2011
Communications Across
Professions
Last week, in our Patient Safety Tip of the Week Psst! Pass it onHow a kids game can mold good handoffs we focused on communications issues related to handoffs, which are primarily done nurse-to-nurse, physician-to-physician, etc.
Well, communication across professional roles is even more important. Root cause analyses (RCAs) of serious incidents and sentinel events find communications problems in 70-80% or more of cases reviewed. And an equally high number of malpractice claims include examples of breakdowns in communication.
Several excellent recent papers highlight the role that physician-nurse communication, in particular, plays in some high-risk settings. First was a white paper Optimizing Physician-Nurse Communication in the Emergency Department from CRICO/RMF which, by the way, has a wealth of very useful patient safety educational and implementation materials. CRICO/RMF is the medical malpractice company and risk management foundation for the Harvard community. They have a large database of information from malpractice claims and regularly convene collaboratives to develop lessons learned and best practices to share in attempt to promote patient safety. From their claims database they determined that missed or delayed diagnoses in the ED are the leading cause of malpractice liability in emergency medicine. They convened their Emergency Medicine Leadership Council to look at the issues. But that group found that, rather than being caused primarily by cognitive errors, communication breakdowns were a major contributing factor.
Yes, they did identify the usual suspects such as delayed lab and radiology reports, lack of information from patients past medical history, problems with consultants, fumbled handoffs, etc. But they also identified barriers to effective communication between physicians and nurses taking care of the same patient and came up with good recommendations on strategies to improve such communication.
Failure to address abnormal vitals signs was a root cause found in many of their malpractice claims. That might be discharging a patient who still had abnormal vital signs or failure to promptly attend to a patient having deterioration of vitals signs while still in the ED. The example they provide for the former might be a patient who has a persistent tachycardia even after IV fluids. They recommend that all abnormal vital signs be reconciled prior to discharge, perhaps in a structured communication between physician and nurse. Similarly, setting up a system where abnormal vital signs trigger a change in triage can be important. They cite one hospital that set up such a trigger system and significantly cut the time to initial physician visit, time to first intervention, and LOS in the ED.
Structured communication events and physician/nurse huddles were also identified as important. During such events a nurse might convey important information about the ED as a whole (eg. capacity, bed availability, patient flow, etc.) but huddles specific to each patient are also important. Bedside rounding, which allows the patient and/or family to also be kept in the loop (and perhaps chime in with relevant information like no, he does not use insulin!), is also a good practice. One hospital developed the STOP format:
S significant issues
T therapies
O oxygen and last vital signs
P pending issues
A discharge timeout where the physician and nurse get together and go over all the issues relevant to discharge was noted to have identified many near misses that got fixed prior to actual discharge.
While many institutions have implemented hi-tech solutions for tracking patients in the ED, all agree that such need to be complemented by face-to-face communications.
They also discuss quality improvement activities, use of LEAN techniques, education and training, simulation and teamwork training, leadership skills, and clear delineation of roles and responsibilities as important in improving overall communication within the ED.
Two papers (Lyndon 2011a, Lyndon 2011b) from UCSF describe physician-nurse communications in labor and delivery. In the first paper, Lyndon and colleagues present a case scenario of a patient at 39 weeks of gestation in whom the physician wants to induce labor. The indication for induction is that the patient had an elevated blood pressure for 3 days (see our February 8, 2011 Patient Safety Tip of the Week Inducing Too Early for a good discussion on the issues surrounding labor induction) but the nurse has concerns about inducing. They present a dialogue that might have taken place between the physician and nurse and how communications breakdowns lead to unpleasant and escalating situations. They point out that such differences of opinion and communication breakdowns are actually quite common on labor & delivery units. Often it is differing world views, particularly on the topic of labor induction, at the root of communication breakdowns. They do a good discussion on the role that differing mental models and failure to make intentions and rationales clear up front. Just as important, they stress listening skills as critical to fostering a constructive dialogue in which opinions of all parties are both heard and appreciated and considered. Being respectful in these dialogues is critical. And, of course, they talk about some of the reasons that people are reluctant to speak up when they disagree with a course of action or see something potentially harmful. They then recreate the dialogue to show how more effective communication might have gone in the same scenario.
In their second paper (Lyndon 2011b) they embedded some questions about perception of potential harm and likelihood of speaking up about such potential harm into an assessment tool being used to assess overall safety climate on two labor and delivery units. It turns out that physicians typically had lower perceptions of potential harm than nurses did. About 12% of respondents indicated they were unlikely to speak up even when they perceived a high potential for harm (no surprise see our March 29, 2011 Patient Safety Tip of the Week The Silent Treatment: A Dose of Reality). This disparity in the perceptions of potential harm are obvious targets to work on in teamwork training and simulation exercises. The authors also speculate that this may be one of the reasons for consistent disparities in ratings of teamwork on formal culture of safety surveys (physicians always rate teamwork as having been much better than how nurses rate it). By the way, also see our September 7, 2010 Patient Safety Tip of the Week Patient Safety in Ob/Gyn Settings and our April 2011 Whats New in the Patient Safety World column Ob/Gyn Patient Safety Programs for descriptions of some comprehensive programs to improve patient safety in Ob/Gyn settings that also included interventions like teamwork training and simulation.
Breakdowns in communication on surgical services also may be problematic. One study observed communication failures in operating rooms (Halverson 2011) and found that communication errors related to equipment (36%) and related to keeping team members informed of the progress of the operation (24%) were the most common failures. After implementation of a teamwork training program, they noted a significant reduction in such communication failures.
And, while policy changes are usually considered relatively weak patient safety interventions, surgical services at four Harvard hospitals (working in conjunction with CRICO/RMF) saw improved resident/attending communications after implementation of several policy changes (Arriaga 2011). Their policy changes included requirements for residents to notify attendings of significant changes in patient status, daily attending-patient communication, and increased frequency of attending visits on weekends. They saw improvement in all 3 areas after implementation across the multiple hospital system. Though they did not measure actual impact on patient outcomes, they did note that the improved communication resulted in changes in patient care plans about a third of the time.
Lastly, one of the few studies tying actual hard outcomes to an intervention aimed at improving communication was just published (OLeary 2011). In this study, implementation of structured inter-disciplinary rounds (SIDR) was shown to result in a significant reduction in preventable adverse events on a medical floor compared to historical and concurrent controls. The rounds were held daily at 11 AM, led by the nurse manager and unit medical director, and attended by all nurses, resident physicians, and a pharmacist, social worker and case manager. The structured tool was modeled after the well-known Daily Goals tool and was formally used for discussing all new admissions. Daily plans of care on all other patients were also discussed, though the structured tool was only used on the new admissions. Preventable adverse events dropped from 2.1 per 100 patient days before the implementation down to 0.9 per 100 patient days (and the rate on a similar medical unit was 2.8 per 100 patient days). Moreover, they noted SIDR was well received by all professionals and nurses ratings of collaboration and teamwork improved significantly.
Sometimes the simplest elements are left out of critical communications. We cant tell you how many times weve encountered instances where nursing staff or the emergency department have said I really wanted the attending to see this patient and the attending said They never asked me to see the patient. Including that simple request in the communication is, thus, critical. If youre using SBAR format for your communications, its easy to add under the R (recommendation) I think you should come see the patient.
The value of good communication among all healthcare workers cannot be overestimated. Every organization needs to invest resources (time, personnel, money) into improving communication at every level. Weve noted before that unit-based quality improvement interventions have the highest likelihood of success. All the above examples really focused on unit-based interventions. So while some of the skills, training and techniques used are applicable to any area of your organization (hey, the same communication breakdowns probably happen daily in your finance, environmental services, HIT, etc. departments, too!) the best place to start working on improving communications is at the unit level. So focus first on your ED, or OR, or ICU or a specific unit. Build on your successes there. Identify your barriers (which probably are also often unit-specific). Then take your lessons learned to other parts of your organization. Of course, we dont like any organization working in silos and obviously communication across departments is also important. But if you start addressing better ways to communicate at the unit level, you will see better teamwork and safer patient care.
References:
CRICO/RMF. Optimizing Physician-Nurse Communication in the Emergency Department: Strategies for Minimizing Diagnosis-related Errors. Proceedings from the CRICO/RMF Strategies Emergency Medicine Leadership Council 2010; White paper February 14, 2011
http://www.rmf.harvard.edu/files/documents/ed_white_paper_min_diagnosis_errors.pdf
Lyndon A, Zlatnik MG, Wachter RM. Effective physician-nurse communication: a patient safety essential for labor and delivery. Am J Obstet & Gynecol 2011; 205: xx-xx
published online 18 April 2011
http://www.ajog.org/article/S0002-9378(11)00468-6/abstract
Lyndon A, Sexton JB, Simpson KR, et al. Predictors of likelihood of speaking up about safety concerns in labour and delivery. BMJ Qual Saf 2011; published online July 1, 2011 doi:10.1136/bmjqs.2010.050211
http://qualitysafety.bmj.com/content/early/2011/07/01/bmjqs.2010.050211.short?q=w_qshc_ahead_tab
Halverson AL, Casey JT, Andersson J, et al. Communication failure in the operating room. Surgery. 2011; 49(3): 305-310
http://www.sciencedirect.com/science/article/pii/S0039606010004393
Arriaga AF, Elbardissi AW, Regenbogen SE, et al. A policy-based intervention for the reduction of communication breakdowns in inpatient surgical care: results from a Harvard surgical safety collaborative. Ann Surg. 2011; 253(5): 849-854
OLeary KJ, Buck R, Fligiel HM, et al. Structured Interdisciplinary Rounds in a Medical Teaching Unit: Improving Patient Safety. Arch Intern Med. 2011; 171(7): 678-684
http://archinte.ama-assn.org/cgi/content/abstract/171/7/678
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July 26, 2011
Hourly Rounding
Weve been big advocates of hourly rounding, also known as purposeful rounding and other names. This concept has been employed in many healthcare settings and most people associate its widespread adoption to the advocacy of the Studer Group. While many organizations have adopted hourly rounding expressly to help improve patient satisfaction, hourly rounding clearly has an impact on patient safety, quality outcomes, workflow and efficiency improvement, and staff satisfaction.
Hourly rounding is a proactive intervention where nurses (or a combination of nurses and other healthcare workers) do bedside rounding on patients at regularly scheduled intervals, usually every hour. In some models, RNs will round every two hours and an LPN or nurses aide will round on the hour in between the RN rounds. The nurses attend to the patients on a regular, timely basis and anticipate their needs. By doing this they actually minimize the number of times patients need to use their nurse call lights, thus avoiding interruptions that fragment nurses workflows. Typically, nurses address the 3 Ps (pain, position, potty) during these rounds (many add a fourth P for proximity of personal items). These are the 3 things that patients most often use their nurse call lights for anyway. But when the patient knows and understands that the nurse will be in at a specified time, they are less likely to use the call light and will simply wait for the nurse to arrive at their next scheduled visit. Anticipating bathroom needs is often very helpful in reducing instances where patients try to get out of bed themselves to use the bathroom and end up falling.
There have been several articles recently discussing the evidence base for hourly rounding and some of the barriers to implementation. A recent review (Halm 2011) of 11 reports on outcomes of hourly rounding on a variety of hospital units (med/surg, orthopedic, telemetry, rehab, geriatrics, etc.) showed very positive outcomes. Overall patient satisfaction was improved in 8 of 9 studies, either on facility-administered patient satisfaction surveys or the publicly reported surveys like HCAPS. Call light use was reduced in 5 of 6 studies where it was specifically measured. One study even documented a reduction in the distance that nursing staff had to walk on a shift. Fall rates were reduced in 7 of 9 studies where specifically monitored. Some studies have documented reduction in pressure ulcer development and restraint use as well.
But there are challenges and barriers to implementation of a successful program (Deitrick 2011). There is often a disparity between leadership and frontline staff in understanding the purpose of and rationale behind hourly rounding. Similarly, even when the purpose is understood there may be inadequate education on the process and integration into the workflow. These factors often foster a lack of ownership by the staff and engender feelings that this is something that is being imposed upon them in a top-down fashion. Especially where the rounding will be shared the respective responsibilities are often not made clear. Accountability is usually monitored via rounding logs but staff are often reluctant to document on these (often fearing the logs might be used against them punitively) and in many cases the logs are not filled out at the time of the rounds but rather filled out at the end of the shift. And, importantly, the lack of feedback on the outcomes of the process has been problematic. If there is no measurement of outcome parameters staff are not reinforced or rewarded for their efforts. Deitrick et al. felt that implementing hourly rounding in a performance improvement fashion with PDSA cycles would be helpful. They also note that having a unit champion for hourly rounding is highly desirable. Many nurses have also felt that some of the scripting recommended for communication with patients has sounded too rigid and unnatural and would prefer that such communications be left up to them.
Halm had also noted challenges with documentation either on logs or on whiteboards but noted that such could be used to facilitate communication between staff (eg. documenting a patients preferred positioning on a whiteboard might be helpful for other staff).
Another challenge may be high acuity patients (Studer Group 2007) such as confused patients. The Studer Group also notes challenges that occur around scheduling breaks and changes of shift.
While sharing the hourly rounding between RNs and LPNs or aides is the model most commonly used, other models have popped up. Physical therapists as rounders were mentioned in the Halm paper. Another variant uses the concept of unit hostess (Ulanimo 2011), basically an unlicensed staff member who can perform rounding and monitoring that does not require interventions. This allowed prompt responses to call lights and improved patient satisfaction. One hospital even hired 21 hostesses to fill 10 vacant RN positions!
The Studer Group provides a wealth of resources on hourly rounding in addition to their training and implementation programs. A sample with multiple tools (Studer Group 2007) is a case study from Sacred Heart Hospital in Pensacola, Florida. That implementation produced a 71 percentile point improvement in patient satisfaction, while reducing call light utilization 40-50%, falls by 33% and new pressure ulcers by 56%. Pretty impressive! That downloadable sample has many good lessons for implemention.
Our experience is that when you first tell your staff about the concept of hourly rounding they think you are crazy. We dont have time for that! Were already too busy. So you have to start with a pilot implementation on one unit, making sure you have a unit-based champion for the program and good ways to measure patient outcomes, patient satisfaction, and staff satisfaction. Once other staff see that hourly rounding actually saves them time plus improves communication with patients, families, and other staff, they buy into the concept.
References:
Halm MA. Hourly Rounds: What Does the Evidence Indicate? Amer J Crit Care 2011; 18(6): 581-584
http://ajcc.aacnjournals.org/content/18/6/581.full
Deitrick LM, Baker K, Paxton H, et al. Hourly Rounding: Challenges With Implementation of an Evidence-Based Process. Journal of Nursing Care Quality., 5 July 2011
Ulanimo VM, Ligotti N. Patient Satisfaction and Patient Safety: Outcomes of Purposeful Rounding. VA National Center for Patient Safety TIPS 2011; 11(4): 1-4. July/August 2011
http://www.patientsafety.gov/TIPS/Docs/TIPS_JulAug11.pdf
Studer Group. Hourly Rounding Supplement. Best Practice: Sacred Heart Hospital, Pensacola, Florida. 2007
http://www.studergroup.com/hourly_rounding/hourly_rounding_supplement_sample_gs_1-5.pdf
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August 2, 2011 Hazards of e-Prescribing
Computerized physician order entry (CPOE) and electronic prescribing (eRx) have great potential to reduce medication errors and improve patient safety. The government and other payors have put megabucks into promoting use of both. But are we there yet? Weve done multiple articles on both the optimistic and pessimistic sides of the question regarding CPOE in general. Most articles on eRx have highlighted positive outcomes, though the reductions in numbers of medication errors have not fully translated into reduction in harm.
In general we have felt that the lack of robust clinical decision support tools has been a major reason for the limited success of CPOE and eRx. And the problem of alert fatigue keeps rearing its ugly head in those systems that do provide robust clinical decision support tools.
Weve always touted that just by doing away with the handwriting issue we would would likely see improved patient safety with eRx, though we were quick to point out that wed create some new errors (eg. the cursor error where one inadvertently clicks on the wrong item in a list).
But now a new study (Nanji 2011) shows that errors occur in almost 12% of all electronic prescriptions, a rate very similar to the rate of errors in handwritten prescriptions. Nanji and colleagues looked retrospectively at almost 4000 computer-generated prescriptions and found 11.7% of them had at least one error. And about a third of those could have caused potential adverse drug events.
There was, however, substantial variability by vendor (from 5.1% to 37.5%). Omitted information (eg. duration, dose, frequency) accounted for 60% of the errors.
That error rate is actually higher than the 7.6% error rate that Gandhi and colleagues (Gandhi 2005) had found for electronic and handwritten prescriptions combined. The Gandhi study did note that handwritten errors (11%) were more frequent than electronic ones (4.3%) but that difference was not statistically significant.
The Nanji article does, however, point out that many of the errors should be relatively easy to avoid. For example, using forcing functions to prevent omission of key elements or using dose range limits could substantially reduce the number of errors and potential adverse events. Even using a simple calculator could have eliminated 5.6% of the errors. So the promise of e-prescribing is still there we just have a way to go to get there!
This paper comes on the heels, however, of another disastrous incident in which an infant died because of a computer-related medication error (Graham 2011). In that incident, a data entry error resulted in an automated machine mixing a solution that resulted in a massive overdose of sodium to a premature baby. That IV compounding machine apparently had alerts capabilities but these had not been activated. Of course, as in almost all events with disastrous outcomes, there were other errors and conditions that contributed, such as a disparity between the label on the IV bag and the actual content and fact that a lab technician thought the infants blood sodium levels were so high they must be in error.
About a year ago there were a series of incidents related to confusion about weights in computerized medication prescribing systems. ISMP Canada first reported a case in which a chemotherapy agent was given in excessive dosage after the height and weight on a computerized order entry system were transposed (ISMP Canada 2010). They discussed several factors that contributed to the problem and had several excellent suggestions on ways to avoid this type of error. ISMP (US) reprinted this in August 2010 (ISMP 2010). ISMP and ECRI had co-authored an article on the importance of accurate patient weights in a 2009 PPSA Safety Advisory. That article mentioned several cases in which weights were incorrectly entered into computerized systems, confusing pounds with kilograms, resulting in overdosing or underdosing. The PPSA article notes that the weight issue is so important because most of the drugs that have weight-based dosing are hi-alert drugs.
When we have more sophisticated clinical decision support tools and, more importantly, forcing functions and constraints that can help us avoid erroneous order entry, well make the medication ordering phase much safer. However, we still also need better interoperability with other systems to integrate the EMR, lab and pharmacy systems from multiple healthcare organizations to better coordinate care across the entire continuum. So for the time being the promise of e-prescribing is exactly that a promise. We have a long way to go!
References:
Nanji KC, Rothschild JM, Salzberg C, et al. Errors associated with outpatient computerized prescribing systems. JAMIA 2011; Published Online First: 29 June 2011
http://jamia.bmj.com/content/early/2011/06/09/amiajnl-2011-000205.abstract
Gandhi TK, Weingart SN, Seger AC, et al. Outpatient prescribing errors and the impact of computerized prescribing. J Gen Intern Med 2005; 20: 837-841
http://www.springerlink.com/content/x8n184n534343138/
Graham J, Dizikes C. Baby's death spotlights safety risks linked to computerized systems. As hospitals rely more on electronic data, worries over potential errors grow. Chicago Tribune June 27, 2011
http://www.chicagotribune.com/health/ct-met-technology-errors-20110627,0,5447654.story
ISMP Canada. Vulnerabilities of Electronic Prescribing Systems: Height and Weight Mix-up Leads to an Incident with Panitumumab. ISMP Canada Safety Bulletin 2010; 10(5): 1-3 July 31, 2010
http://www.ismp-canada.org/download/safetyBulletins/ISMPCSB2010-05-ElectronicPrescribingSystems.pdf
ISMP. Electronic prescribing vulnerabilities: Height and weight mix-up leads to dosing error. ISMP Medication Safety Alert! Acute Care Edition 2010; August 26, 2010
http://www.ismp.org/Newsletters/acutecare/articles/20100826.asp
Pennsylvania Patient Safety Authority. ECRI, ISMP. Medication errors: significance of accurate weights. Pennsylvania Patient Safety Advisory 2009; 6(1): 10-15 www.patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/Mar6(1)/Pages/10.aspx
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August 9, 2011
Frailty and the Surgical Patient
In our August 17, 2010 Patient Safety Tip of the Week Preoperative Consultation Time to Change we made a case that we need to change the focus of any preoperative evaluation away from the traditional organ approach (such as assessing cardiac risk) and instead focus on the more global physiological reserve of patients. That would mean focusing on some of the multiple factors that might give rise to delirium and focusing on a variety of factors that collectively define frailty.
In our June 2010 Whats New in the Patient Safety World colum The Frailty Index and Surgical Outcomes we noted a 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.
In 2009 Robinson and colleagues (Robinson 2009) looked at outcomes in (mostly male) patients age 65 and older who were undergoing major elective surgical procedures in the VA medical system and correlated them with measures of frailty, disability, and comorbidity. Using a group of markers that were easy to use in a surgeons office setting they were able to predict 6-month postoperative mortality and post-discharge institutionalization. They did not use one of the existing frailty indices but rather constructed a tool based on the following variables: age, cognitive impairment, chronic malnutrition, falls, depression, anemia and supplemented these with the Katz disability scale and the Charlson comorbity index. Any functional dependence was the biggest sole risk predictor and four or more markers on any one patient predicted 6-month mortality with a sensitivity of 81% and specificity of 86%.
That group has now expanded their study to a total of 223 subjects (Robinson 2011) and focused on discharge to an institutional setting. The burden of comorbidity was assessed using the Charlson index, the ASA score, the total number of medications taken, and anemia. Function was measured by the Katz ADL score and a timed up-and-go test. Nutrition was assessed by BMI, albumin level, and weight loss. Cognitive function was assessed by the Mini-Cog test and the Two-Question Depression Screen. And they added a measure of geriatric syndromes (eg. falls) and extrinsic frailty (eg. social isolation). Overall, 30% of patients were discharged to institutional settings and another 17% needed home care. The 3 variables most predictive of institutionalization were a timed up-and-go >15 seconds, Charlson score 3 or greater, and hematocrit <35%. Three or more frailty characteristics had a sensitivity of 82% and specificity of 84% for predicting institutionalization. Interestingly, age itself was not a predictor but rather the measures of frailty, function, and comorbidities were most important.
The study we previously mentioned (Makary et al 2010) in our June 2010 Whats New in the Patient Safety World column The Frailty Index and Surgical Outcomes demonstrated that use of the frailty index greatly improves the ability to predict post-surgical outcomes (post-op complications, LOS, and discharge to an SNF or assisted living setting) much better than existing methods. They used the frailty index which assigns a score of 0 or 1 for each of five domains: weight loss, weakness, low physical activity, exhaustion, and slow walking speed. It takes about 10 minutes to administer the frailty index. Weakness is measured with a hand ergometer. Walking speed is measured by having the patient walk 15 feet and timing them. Weight loss is 10 or more pounds lost unintentionally in the past year. And the other 2 domains are assessed by asking simple questions. Patients scoring 4-5 are classified as being frail, those scoring 2-3 as intermediately frail. The frailty index has been validated and been predictive of outcomes in medical patients. However, the research group at Johns Hopkins assessed the ability of this index done preoperatively to predict certain post-surgical outcomes.
The frailty index turned out to be very good in its ability to predict surgical outcomes. For instance, the odds ratio for frail patients for postoperative complications after major surgery was 2.54, for length of stay 1.69, and for discharge to a skilled nursing facility or assisted living facility 20.48. Odds ratios for those with intermediate frailty were somewhat lower but still predictive of all the above. And the frailty index was better than other tools used to predict outcomes (ASA score, Lees revised cardiac risk index, and the Eagle score). Adding the frailty index to any of those tools significantly improved the predictability of outcomes.
It will be very interesting to see how the frailty index fares in other settings (eg. community hospitals, etc.). This could be an extremely helpful tool in helping to avoid some of the pain and suffering that occurs with surgery in the elderly and at least serve as a tool to help patients and families anticipate what to expect in patients undergoing surgery.
These predictive tools may help physicians, patients and families anticipate what to expect in patients undergoing surgery and in some cases may help with the informed decision on whether to proceed with surgery. A real value of either the frailty index or the composite used in the Robinson studies is that they are relatively brief and easy to administer in the surgeons office or preoperative clinic setting. But beyond the predictive value they currently 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. Were hoping future research will help us avoid the very outcomes these tools are good at predicting. But this is a good start at changing the way we think about patients before surgery.
References:
Robinson TN, Eiseman B, Wallace JI, et al. Redefining Geriatric Preoperative Assessment Using Frailty, Disability and Co-Morbidity. Annals of Surgery 2009; 250(3): 449-455, September 2009
Robinson TN, Wallace JI, Wu DS, et al. Accumulated Frailty Characteristics Predict Postoperative Discharge Institutionalization in the Geriatric Patient. J Am Coll Surg 2011; 213(1): 37-42, July 2011
http://www.journalacs.org/article/S1072-7515(11)00089-5/abstract
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
Print Frailty and the Surgical Patient
August 16, 2011
Crisis Checklists in the OR
There are some emergency situations that are so rare that it is hard to prepare for them, yet your actions during such situations may determine life or death. Pilots prepare for such emergencies (for example, they all have to simulate an aerodynamic stall so they know what steps to immediately take to right the aircraft). And pilots have standard operating procedures in their myriad of manuals pertaining to a whole host of seldom-encountered emergency situations. Often those standard operating procedures use checklists so that the crew can rapidly go through all the steps required in such emergencies.
Weve had some experience in setting up such checklists for contingencies in the OR. One example is for malignant hyperthermia, a relatively uncommon but potentially fatal condition that requires specific interventions. It is difficult for any anesthesiologist or OR team to know all the steps necessary in managing such patients (eg. identifying that this is likely malignant hyperthermia rather than a host of other conditions that might produce fever and tachycardia in the anesthetized patient, knowing where your MH kit is located, knowing what dosage of dantrolene to use, contacting the MH hotline, etc.). So putting those steps in a checklist can be very useful. Similarly, a checklist for what to do during a surgical fire is sometimes used but, frankly, surgical fires evolve so fast that you dont have time to pull out a checklist.
Atul Gawande, well-known for his work on checklists (see our Patient Safety Tips of the Week for July 6, 2010 Book Reviews: Pronovost and Gawande and January 20, 2009 The WHO Surgical Safety Checklist Delivers the Outcomes) and his colleagues (Ziewacz 2011) have just developed a series of crisis checklists for 12 of the most frequently occurring operating room crises and tested their use in a high-fidelity surgical simulator. They had OR teams in the surgical simulator address 4 crisis situations with checklists and 4 without. In simulated crises without checklists, the teams failure rate to perform critical steps was 24%. When using checklist, the failure rate was only 4%. Surveys of the participating OR teams found that the crisis checklists were very well-received, usable, and likely to prepare the teams well for real crises.
The authors do acknowledge that good performance in simulation is no guarantee that outcomes will be good in real-life OR crises and that there are no definitive studies in aviation or nuclear power that demonstrate simulation exercises improve safety, though simulation is widely accepted.
The conditions for which this group developed crisis checklists do include the above mentioned malignant hyperthermia and surgical fires and also include air embolism, anaphylaxis, unstable bradycardia, unstable tachycardia, cardiac arrest (asystolic and VF/VT), failed airway, unexpected hemorrhage, hypotension and hypoxia.
The appendices to the article contain the actual checklists they developed and, for each crisis a list of the key processes and steps identified as being important.
This is a really good article. Even if you dont have access to a surgical simulator, it would be well worth your while having your OR teams become familiar with these tools and run drills on each of these. Especially if you combine these with other team training programs, such as TeamSTEPPS, your OR teams will likely be better prepared to handle these relatively rare but critical scenarios.
References:
Ziewacz JE, Arriaga AF, Bader AM, Berry WR, et al. Crisis Checklis ts for the Operating Room: Development and Pilot Testing. J Am Coll Surg 2011; 213(2): 212-219
http://www.journalacs.org/article/S1072-7515(11)00343-7/abstract
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August 23, 2011
Catheter Misconnections
Back in the News
Its been over four years since we did our first column on catheter misconnections (see our July 10, 2007 Patient Safety Tip of the Week Catheter Connection Errors/Wrong Route Errors). That was followed by Whats New in the Patient Safety World columns in November 2007 More Patient Deaths from Luer Misconnections and August 2009 Catheter Misconnections Continue to Occur. But since that time there has been some hope that the medical device industry was working toward solutions that would prevent such errors from occurring (see our August 2010 Whats New in the Patient Safety World column ISMP Advice on Catheter Misconnections).
Not soon enough, however, Last month ISMP Canada reported two cases of infants being inadvertently given breastmilk intravenously (ISMP Canada 2011) and the issue also appeared in the Canadian press. The one example they give was a case where a premature infant was supposed to get breastmilk via an NG tube but received it via an intravenous line instead. The infants condition deteriorated shortly after the infusion and intubation and transfer to a tertiary NICU was required. They discuss three similar cases from the literature and then discuss multiple factors contributing to such cases. They note that enteral pumps designed for adults and older children, cannot deliver the smaller volumes and lower rates required for preterm infants. Apparently there are some enteral pumps designed for preterm infants but these are not available at all hospitals. ISMP Canada recommends that, even if you have the latter, you do a FMEA (Failure Mode and Effects Analysis) to determine your organizations potential vulnerabilities to such tragic events.
Its not the first time that mistake has been made with breastmilk, either. Probably the earliest report was in 1972 (Wallace 1972). In 2006 Ryan et al (Ryan 2006) reported a case and found 8 additional cases via a NICU-net discussion group.
Though the infant may survive with good supportive care, some infants die. Sepsis, multi-organ failure, hyperosmolarity, microembolism, disseminated intravascular coagulation, respiratory or cardiac arrest, and death may occur as a result of intravascular exposure to breastmilk, formula or other enteral feedings.
And, of course, there is usually a nurse at the sharp end of such incidents. The irony is that our system failed those nurses and patients by putting them in a position where a substance could be inadvertently given via the wrong catheter/route. Use of enteral systems that preclude misconnection to IV lines or IV access devices are available. Yet multiple recent publications (ISMP 2011, Grissinger 2010, Simmons 2011) note that staff not uncommonly still use enteral components that could be inadvertently connected to intravenous ones.
Ryan et al recommended use of color-coded enteral-administration sets and feeding tubes with Luer connections which are not compatible with intravenous cannulas. They also noted use of methylene blue in the tube feeding might help, as well as use of color-coded distal connecting tubing.
Recommendations to help avoid catheter misconnections and similar events have been made by Joint Commission, ISMP (US), ISMP Canada, and WHO, and others. These include:
While the forcing function of preventing the two types of devices and lines from being connected to one another is the single most important intervention, all the above may be useful in helping your organization avoid such incidents.
The general concepts of catheter misconnections and wrong route incidents were discussed in our previous columns and in the 2006 Joint Commission Sentinel Event Alert #36, the UK NPSA, the WHO/Joint Commission Collaborating Center for Patient Safety Solutions, the October 2007 issue of FDA Patient Safety News and multiple ISMP articles.
References:
ISMP Canada. ALERT: Reports of Severe Harm after Intravenous Administration of Breast Milk to Infants. ISMP Canada Safety Bulletin 2011; 11(5): 1-3. July 31, 2011
CTV News Staff. Group warns of feeding tube and IV line mixups. CTV News August 8, 2011
http://www.ctv.ca/CTVNews/Health/20110808/babies-newborns-iv-tube-feeding-breastmilk-110808/
Wallace JR, Payne RW, Mack AJ. Inadvertent intravenous infusion of milk. Lancet 1972; 299(7763): 12641266
http://www.sciencedirect.com/science/article/pii/S0140673672909841
Ryan CA, Mohammad I, Murphy B. Normal neurologic and developmental outcome after an accidental intravenous infusion of expressed breast milk in a neonate. Pediatrics 2006; 117(1): 236-238
http://pediatrics.aappublications.org/content/117/1/236.full.pdf
ISMP. Preventing accidental IV infusion of breast milk in neonates. ISMP Medication Safety Alert! Nurse Advise-ERR 2011; 9(6): 1-3. June 2011
http://www.ismp.org/Newsletters/nursing/Issues/NurseAdviseERR201106.pdf
Grissinger M. Preventing accidental infusion of breast milk in neonates. Pharm Ther. 2010; 35(3): 127, 178
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2844055/
Simmons D, Symes L, Guenter P, Graves K. Tubing Misconnections. Normalization of Deviance. Nutr Clin Pract. 2011; 26(3): 286-293
http://ncp.sagepub.com/content/26/3/286.abstract
The Joint Commission. Tubing misconnectionsa persistent and potentially deadly occurrence. Sentinel Event Alert 2006; Issue 36 April 3, 2006
http://www.jointcommission.org/assets/1/18/SEA_36.PDF
World Health Organization, The Joint Comission, Joint Commission International: WHO Collaborating Centre for Patient Safety Solutions. Avoiding catheter and tubing mis-connections. Patient Saf Solut. 2007; Volume 1. Solution 7. May 2007
http://www.ccforpatientsafety.org/common/pdfs/fpdf/presskit/PS-Solution7.pdf
National Patient Safety Agency (UK). Patient Safety Alert Promoting safer measurement and administration of liquid medicines via oral and other enteral routes March 28, 2007 http://www.npsa.nhs.uk/site/media/documents/2463_Oral_Liquid_Medicines_PSA_FINAL.pdf
FDA. More Patient Deaths from Luer Misconnections FDA Patient Safety News: Show #68, October 2007
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/printer.cfm?id=567
ISMP. Collection of all their catheter misconnection articles.
http://www.ismp.org/newsletters/acutecare/articles/Catheter-Misconnections.asp
Print Catheter Misconnections Back in the News
August 30, 2011
Unintentional
Discontinuation of
Medications After
Hospitalization
Weve written numerous columns on prescription of potentially inappropriate medications in the elderly and noted that such medications are often prescribed during an inpatient hospitalization. Many are started during ICU stays (see our March 2011 Whats New in the Patient Safety World column Inappropriate Medications Often Start in the ICU).
Now a new study (Bell 2011) focuses on just the opposite problem unintentional discontinuation of medications taken for chronic diseases in hospitalized patients. The authors looked at records in Ontario for almost 400,000 patients over a 12-year period for discontinuation of drugs in 5 specific categories (statins, levothyroxine, antiplatelet/anticoagulants, respiratory inhalers, gastric acid suppressants) for patients aged 66 and older. The control group was one with no hospitalizations. The other two groups were those hospitalized with an ICU stay and those hospitalized without an ICU stay.
Compared to the control group that had not been hospitalized, those patients who had been hospitalized had much higher rates of unintended medication discontinuation in all 5 drug categories. Hospitalized patients were almost 80% more likely to discontinue an antiplatelet/anticoagulant medication. Those patients having an ICU stay were statistically more likely to have a drug unintentionally discontinued in 4 of the 5 categories categories (statins, levothyroxine, antiplatelet/anticoagulants, gastric acid suppressants). Those having an ICU stay were almost 50% more likely to discontinue a statin and over twice as likely to discontinue an antiplatelet/anticoagulant medication.
Importantly, these discontinuations were not without consequences. For those patients in whom statins or antiplatelet/anticoagulant drugs were unintentionally discontinued, there was an increase in the composite outcome of death, emergency department visit, or hospitalization in the year following discontinuation.
The study did use administrative data and could not completely verify that the medication discontinuations in some cases were not intentional. However, they did take steps to minimize that possibility and a prior chart review study had provided similar findings.
Whether the findings are generalizable to other patient populations and other medication categories is unknown but we dont doubt that this problem is more widespread. It is a reflection on our system of fragmented care punctuated by numerous missed communication opportunities and problematic handoffs at multiple levels. Though we cannot take out the human element, there clearly is a system problem that is overriding and we need to redesign the system to make it easier for the players to do the right thing and harder to do the wrong thing.
Though most of us expect technological solutions to the nagging problem of medication reconciliation, some of the best systems weve seen have been strictly paper-based. But they require dedicated, focused processes where someone (pharmacist, pharmacy tech, nurse, midlevel, physician, etc.) develops a Best Possible Medication History using all available sources and that list is scrutinized by all relevant providers at every transition of care, not just on admission and discharge.
But we do need to utilize our information technologies to help. Maybe there is something to the concept in our August 2011 Whats New in the Patient Safety World column The Amazon.com Approach to Medication Reconciliation. Hasan and colleagues (Hasan 2011) borrowed the concept of collaborative filtering to help identify medications omitted from patient medication lists at the time of medication reconciliation. They determined, based on large population databases, that patients who take drug X also often take drug Y. They established multiple different algorithms and applied them to sample patient data. In fact, their algorithms were able to guess correctly an omitted drug within 10 guesses about 50% of the time (they did even better guessing the therapeutic class of a missing drug). They found some of their algorithms might work better in certain settings or with certain populations. Obviously, the principle might be extended to say patients who have condition X also often take drug Y. Yes, we are concerned that approach could have unintended consequencnes (i.e. erroneously starting some patients on new medications they were not previously taking) but there certainly is merit in further research into applying this concept to medication reconciliation.
The editorial accompanying the Bell article (Kahn 2011) points out another concerning problem in this population polypharmacy. They note that the hospitalized patients in the Bell study had a median of 12 medications and 75% received 9 or more medications. So hospitalization could represent an opportunity for medication optimization, not just reconciliation. Weve noted in multiple columns that the process of a comprehensive review of patients medications often uncovers therapeutic duplications or other unnecessary medications or drug combinations that may be problematic. We usually see an average of 2 medications per patient that might be discontinued or have the dosage altered. But such optimization requires involvement of the patient and the primary care provider. The latter is often not included in the medication reconciliation process that takes place at all transitions of care another communication failure within our system.
Some of our prior columns dealing with medication reconciliation:
References:
Bell CM, Brener SS, Gunraj N, et al. Association of ICU or Hospital Admission With Unintentional Discontinuation of Medications for Chronic Diseases. JAMA 2011; 306(8): 840-847
http://jama.ama-assn.org/content/306/8/840.short
Hasan S, Duncan GT, Neill DB, Padman R. Automatic detection of omissions in medication lists. JAMIA 2011; 18: 449-458 Published Online First: 29 March 2011
http://jamia.bmj.com/content/18/4/449.abstract
Kahn JM, Angus DC. Going Home on the Right Medications: Prescription Errors and Transitions of Care. JAMA 2011; 306(8): 878-879
http://jama.ama-assn.org/content/306/8/878.extract
Print Unintentional Discontinuation of Medications After Hospitalization
September 6, 2011
More Tips on PCA Safety
In our January 4, 2011 Patient Safety Tip of the Week Safer Use of PCA we focused on safety issues related to patient-controlled analgesia (PCA) and the issue of opiate-induced respiratory depression in general and provided a list of recommendations for improving PCA safety that we will repeat at the end of todays column. And in our May 17, 2011 Patient Safety Tip of the Week Opioid-Induced Respiratory Depression Again! we encouraged hospitals to perform their own FMEA (Failure Mode and Effects Analysis) on the PCA process and provided links to two tools we use when doing FMEAs of the PCA pump process: the PCA Pump Audit Tool and the PCA Pump Criteria. One other valuable resource we should have pointed out to you is a sample FMEA by ISMP for PCA.
In the January column we cited an excellent article on a McMaster University safety initiative to reduce PCA errors (Paul 2010) that stressed several key elements: smart pumps with both hard stops and soft stops, user-interface for programming the pumps that allowed visualization of all key parameters on one screen, pre-printed order forms, CPOE, independent double checks, review of all PCA program settings during each shift and on shift handovers, a rigorous program of education and training for nurses, and a mandatory critical incident reporting program.
One of the issues we have always included in our FMEAs is that of training, retraining, and competency assessments for all providers who will be involved in use PCA pumps. Obviously, standardizing the pumps to be used and restricting drugs that can be used and standardizing drug concentrations are important first steps. But you still need to ensure that all your staff understand fully the intricacies of PCA pumps. One hospital system, after recognizing an increase in frequency of incidents related to PCA pumps, combined quality improvement efforts with their staff development program to reduce PCA errors (Ferguson 2010). They mandated training for all RNs who use PCA pumps and did the training at a time and location away from direct patient care responsibilities. The format was standardized to include a 30-minute lecture and 30 minutes of hands-on time to practice programming the pumps. They then had to return and demonstrate their ability to properly program into the PCA pump a preprinted order set and also complete an online module and post-test. Training over 900 nurses, they found that the number of PCA programming errors went from 8 down to 1 over a comparable time period.
This months Pennsylvania Patient Safety Advisory (Ritter 2011) has an article summarizing PCA errors found in the PPSA database and FDAs MAUDE database. Not surprisingly, pump programming errors head up the list. They highlight such issues as the counterintuitive one in which programming the pump with a drug concentration that is too low actually results in overdosing the patient. Look-alike/sound-alike (LASA) errors are not uncommon and failure to perform independent double checks was also common. And many of the cases of respiratory depression noted were in patients receiving other drugs capable of depressing respiration in addition to the PCA opiates. They provide several useful recommendations, including the importance of proper patient selection for PCA but caution that even with proper selection patients may react differently to the same dose of opiates. They also discuss prescribing errors, drug product mixups, and PCA by proxy. They provide good discussion on use of standardized protocols and have a very good section on monitoring.
We have stressed the problems with monitoring patients receiving opiates on multiple occasions. Weve noted several times the excellent article by Lynn and Curry (Lynn 2011) on alarms and their failure to identify deteriorating patients early, highlighted in our February 22, 2011 Patient Safety Tip of the Week Rethinking Alarms.
The APSF (Anesthesia Patient Safety Foundation) has just released a summary of their Conclusions and Recommendations from June 08, 2011 Conference on Electronic Monitoring Strategies to Detect Drug-Induced Postoperative Respiratory Depression. They again make a cogent argument for continuous physiological monitoring of all patients receiving post-op opiates, including continuous pulse oximetry (and capnography for all patients receiving supplemental oxygen). And though they note the importance of identifying patients with conditions that place them at higher risk of respiratory depression, they note that selective monitoring of these would miss respiratory depression in patients without these risk factors. They again make the case that threshold-based alarm systems remain problematic and stress the need for systems that allow for earlier recognition of respiratory depression.
One development we consider exciting in the field of monitoring is an apnea prevention device (Zornow 2011). The author developed a device that takes input from a pulse oximeter into a laptop computer that has algorithms to identify episodes of oxygen desaturation, and delivers a series of stimuli to the patient (first verbal, then cutaneous stimuli via a nerve stimulator) to stimulate breathing. The device was tested in 10 extubated patients in a post-anesthesia care unit (PACU) who were at high risk for respiratory depression (known sleep apnea, morbid obesity, smokers, patients expected to need large doses of narcotics, etc.). Success of the intervention was defined as the patient taking a large tidal volume breath followed by an improvement in oxygen saturation. A total of 125 interventions occurred in the 10 patients with an overall success rate of 97%. Actually, though verbal stimuli occasionally failed, electrical stimuli followed by verbal stimuli were always successful. The author also looked at a subset of 5 patients to compare the number of required nursing interventions to stimulate respiration with the apnea prevention device turned on or off. He found patients needed a nursing respiratory-related intervention on the average every 2.3 minutes with the device off and only every 47 minutes with the device on.
This was just a proof of concept study but it is very promising. Obviously a large randomized controlled study needs to be done. But the author is already planning further enhancements to the device, such as adding input from a respiratory movement sensor, capnometers, etc. plus improvements to allow use of the device on wards as opposed to PACUs. Hes even considering a feedback loop that will automatically prevent a PCA pump from delivering further doses of narcotics once certain thresholds are exceeded. The author has also recognized that the response parameters must balance the number of false alarms vs. the number of conditions truly needing an intervention and is planning all the outcome variables that will need to be tracked, including unintended consequences.
So, again, here is what your organization should be doing:
PCA is a great therapeutic intervention that has lots of positives but it also has its downsides and risks that your must try to minimize.
Prior Patient Safety Tips of the Week pertaining to opioid-induced respiratory depression and PCA safety:
References:
Paul JE, Bertram B, Antoni K, et al. Impact of a Comprehensive Safety Initiative on Patient-controlled Analgesia Errors. Anesthesiology. 113(6): 1427-1432, December 2010
ISMP (Institute for Safe Medication Practices). Example of a Health Care Failure Mode and Effects Analysis for IV Patient Controlled Analgesia (PCA). 2005
http://www.ismp.org/Tools/FMEAofPCA.pdf
Ferguson R, Williams ML, Beard B. Combining Quality Improvement and Staff Development Efforts to Decrease Patient-Controlled Analgesia Pump Errors. Journal for Nurses in Staff Development JNSD 2010; 26(5): E1-E4 September/October 2010.
Ritter HTM (Pennsylvania Patient Safety Authority). Making Patient-Controlled Analgesia Safer for Patients. Pa Patient Saf Advis 2011 Sep; 8(3): 94-9 http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2011/sep8(3)/Pages/94.aspx
Lynn LA, Curry JP. Patterns of unexpected in-hospital deaths: a root cause analysis. Patient Safety in Surgery 2011, 5:3 (11 February 2011)
http://www.pssjournal.com/content/pdf/1754-9493-5-3.pdf
APSF (Anesthesia Patient Safety Foundation). Conclusions and Recommendations from June 08, 2011 Conference on Electronic Monitoring Strategies to Detect Drug-Induced Postoperative Respiratory Depression. 2011
http://www.apsf.org/announcements.php?id=7
Zornow MH. Clinical Testing of the Apnea Prevention Device: Proof of Concept Data. Anesth Analg 2011; 112:;582-586
http://www.anesthesia-analgesia.org/content/112/3/582.abstract
Print More Tips on PCA Safety
September 13, 2011
Do You Use Fentanyl Transdermal Patches Safely?
In our June 28, 2011 Patient Safety Tip of the Week Long-Acting and Extended-Release Opioid Dangers we discussed potential dangers of a number of long-acting opiates. One of those was the fentanyl transdermal patch. While this opioid preparation has a very important role to play in patients with chronic pain who are opiate-tolerant, it is extremely dangerous when used in patients who are not opiate-tolerant and even has dangers in those who are.
The California Department of Public Health recently released its summary of deficiencies and plans of correction for serious events occurring at California hospitals in 2010. One of those related to deficiencies in use of fentanyl transdermal patches in 7 patients at one hospital (CDPH 2011). Though that hospital apparently was fined as a result of the findings, we discuss the issue not in a punitive light but rather to point out that similar deficiencies likely exist in multiple healthcare organizations. We hope that the lessons learned will help all organizations take steps to ensure that these patches are utilized in a safe manner for appropriate patients.
The document identifies a common theme in most of the cases: the indications for use of the fentanyl transdermal patches were not documented, there was no pharmacist review of the orders for appropriateness or for establishing that the patient was opiate-tolerant, failure to document pain levels or response to medications, and the doses were often escalated without appropriate review. They review on a case-by-case basis what prior doses of opiates the patient would have had to been receiving to qualify as opiate-tolerant. They cite the FDA alert about dangers of fentanyl transdermal patches and the manufacturers warnings in the package insert regarding use of the fentanyl transdermal patch in the elderly. They note that reduced fat stores, muscle wasting, and reduced elimination of the drug from the body increase the sensitivity of the elderly to the effects of fentanyl and that respiratory depression is the main hazard of this drug in the elderly.
Though the CDPH document focuses on chronic pain as the sole indication for fentanyl transdermal patches, the description of some of the cases suggests it might have been being used for management of dyspnea in a palliative manner. Note that such is an off-label use of the fentanyl patches. While it is well known that opiates (morphine, oxycodone, fentanyl, methadone) are often used in the palliative care setting for management of dyspnea, usually much lower doses are needed for dyspnea than for pain. So the fentanyl transdermal patch would not be expected to be used for this purpose.
So now is a good time for you to review your policies and procedures relating to fentanyl transdermal patches. At a minimum your programs should include the following:
Youll recall a host of good resources weve cited before on the dangers of transdermal fentanyl patches, including a series of alerts in the newsletters regarding the dangers (ISMP 2007) and ISMP Canadas review of over 3000 incidents related to fentanyl patches (ISMP Canada 2009), including 271 resulting in harm and 8 resulting in death. And dont forget ISMPs Michael Cohens article warning of the dangers and the risks taken by providers who prescribe transdermal fentanyl patches for acute pain (Cohen 2010), and the dangers that children may mistake such transdermal patches for Band-Aids, tattoos or stickers and may put them on their skin with devastating, even fatal, outcomes (Cohen 2011).
References:
California Health and Human Services Agency. Department of Public Health. State of Deficiencies and Plan of Correction. 2011
FDA. Public Health Advisory: Fentanyl Transdermal System (marketed as Duragesic) Information. 2005, updated 2007.
FDA. Public Health Advisory: Risk of Burns during MRI Scans from Transdermal Drug Patches with Metallic Backings. 3/5/2009; updated 3/9/2009
ISMP. Fentanyl patches brochure. 2011
http://www.ismp.org/download/files/ismp-Brochure-fentanyl--Dec_2010.pdf
ISMP. Ongoing, Preventable Fatal Events With Fentanyl Transdermal Patches Are Alarming! ISMP Medication Safety Alert! Acute Care Edition. June 28, 2007
http://www.ismp.org/Newsletters/acutecare/articles/20070628.asp
ISMP Canada. Analysis of International Findings from Incidents Involving Fentanyl Transdermal Patches. ISMP Canada Safety Bulletin 2009; 10: 1-2 (December 30, 2009)
Cohen M. Doctors risk patient safety by prescribing fentanyl painkiller for short-term pain. Philly.com November 8, 2010
Cohen M. Warning! Kids may mistake drug patches as Band-Aids, tattoos or stickers. Philly.com January 3, 2011
Print Do You Use Fentanyl Transdermal Patches Safely?
September 20, 2011
When Practice Changes
the Evidence:
The CKD Story
In our January 2011 Whats New in the Patient Safety World column No Improvement in Patient Safety: Why Not? we focused on our failure to change the culture as the main reason we have not moved the bar much in the patient safety movement. However, we also noted that we have ourselves to blame in that many of the patient safety interventions we have implemented have turned out to adversely affect patient outcomes. In retrospect, the evidence for some of these interventions was soft. We hyped perioperative beta blockers for just about anyone undergoing surgery. Now weve learned that they may actually increase mortality. We overdid it on prophylactic use of agents for gastric acid suppression. Now we realize they may have played a role in development of C. difficile infections and may even have increased the risk for ventilator-associated pneumonia (VAP), the very condition for which they were commonly being used. We made antibiotics within 4 hours for community-acquired pneumonia a quality and pay-for-performance standard, only to see many patients who turned out not to have pneumonia being unnecessarily treated with antibiotics. Even SCIP (Surgical Care Improvement Project) showed little impact of adherence to individual practices on patient outcomes (see our August 2010 Whats New in the Patient Safety World column SCIP: Disappointing Outcomes on SSIs. Whats Next?).
And there are other quality improvement initiatives we undertook based on a good evidence base that have failed to produce the desired outcomes because changes in practice changed the evidence. The story of chronic kidney disease (CKD) illustrates this well. Back in the early 2000s the evidence base was convincing that, among patients who eventually went on dialysis, those who had late referral to a nephrologist had substantially increased mortality and costs in the first year on dialysis. So we all made concerted efforts to identify patients with progressing CKD and get them to nephrologists earlier. In Western New York we had a coalition of physicians (in both primary care and nephrology), hospitals, consumer advocacy group, payors and the business community that addressed the issue. We became the first community to get all laboratories to use the MDRD equation to provide an estimated glomerular filtration rate (eGFR) each time they reported a serum creatinine. And we developed tools to help PCPs better manage CKD at each stage and facilitate early referral to the nephrologists. We clearly succeeded in increasing the number of CKD patients getting early referral, as the rest of the country has now also done. The number of CKD patients who see a nephrologist at least a year before starting dialysis nationwide increased from about 30% in 1996 to almost 50% in 2006 (Winkelmayer 2011).
But we made a fundamental mistake in our community CKD collaboarative. Those of you involved in quality improvement who use the model espoused in The Improvement Guide (Langley 1996) know that the key question after you identify something you want to change is How will we know that the change is an improvement?, i.e. how will we measure the effects (both intended and unintended) of our efforts. We certainly had a plan and identified sources for measurement of the surrogate measures (like % with eGFR reported and % of patients with early nephrology referral). But our ultimate goals were to (1) prevent or delay the need for dialysis in CKD patients (2) reduce the mortality of those patients who do need dialysis (3) improve quality of life in the CKD population and (4) reduce overall costs of managing the CKD population. Basically, these were Triple Aim goals. The measures for all the above were longer term outcome measures and we simply did not have the infrastructure in place at the time to ensure that wed adequately measure these more important outcomes down the line.
But now we know what the outcome likely was. A new study (Winkelmayer 2011), using national data from the United States Renal Data System and Medicare claims, shows that early referral to nephrologists has resulted in essentially no improvement in survival rates for patients one year after initiation of dialysis.
So what happened? How could the previous evidence on early vs. late referral have been so wrong? The answer is that it was probably not wrong at the time. What happened was that early referral coincided with (and perhaps inadvertently caused) some changes in clinical management of CKD patients.
Two significant trends were noted in the Winkelmayer study over the 10-year period. One was that dialysis was increasingly initiated at higher GFR levels (i.e. the patients had more preserved renal function when dialysis was begun). And there was a substantial increase in the usage of erythropoiesis-stimulating agents (ESAs). You are all aware of the recent attention to the detrimental effects of aggressive erythropoiesis-stimulating agent use (the CREATE, CHOIR, and TREAT studies). Winkelmayer et al. also note that recent studies have also questioned the efficacy of several other interventions, such as aggressive blood pressure lowering, renal artery revascularization, statin use, and management of metabolic bone disease in CKD.
There has been a striking trend over the last decade or so of earlier initiation of dialysis (that is, dialysis is being started in patients with higher eGFR levels). The recently completed IDEAL trial (Cooper 2010) showed no benefit from earlier initiation of dialysis and another recent analysis of national data (Rosansky 2011) actually suggests that early initiation of dialysis may be harmful. And another study (Tamura 2009) showed a substantial and sustained decline in functional status in nursing home patients initiated on dialysis.
Moreover, the cost effectiveness analysis accompanying the IDEAL trial (Harris 2011) showed that early initiation of dialysis resulted in higher costs (almost $16,000 higher) and did not improve quality of life.
In the previous literature, the prime driver of both mortality/morbidity and cost in patients during the first year of dialysis was that dialysis was often started emergently. The patient was often admitted to a hospital for an intercurrent medical or surgical problem and the renal status deteriorated to the point that dialysis was necessary. That dialysis thus had to begin when the patient had suboptimal vascular access for dialysis (i.e. they did not have a mature fistula what would be used for ongoing dialysis).
But one wonders if even such well-intentioned programs like the Fistula First program may have played a role in the changes in practice. Clearly, having a mature fistula in place when dialysis is initiated is beneficial. However, one wonders whether having those fistulas ready may also play a role in the trend toward initiating dialysis in patients with more preserved renal function.
But you have to look at root causes to see how things can get out of hand. Many of the root causes in the CKD story are related to conflicts of interest at multiple levels. A commentary (Senekjian 2011) noted that there are numerous financial incentives for nephrologists in the US to initiate dialysis early. In addition, the use of erythropoiesis-stimulating agents (ESAs) was also impacted by conflicts of interest. Of course, pharmaceutical companies benefit from their use. But in most cases so do the providers who prescribe them. Even some of the disease management companies that focused on CKD used their purchasing clout to get better pricing on ESAs that they passed on to their clients. But in doing so, they probably contributed to the aggressive use of ESAs that, retrospectively, may have contributed to harmful outcomes in some patients. And one needs to look at the process of guideline development and the means of funding the sponsoring group(s). Youll find that, even though they may be consumer advocacy groups, they derive much of their funding from industry. We found it most interesting when the consumer advocacy group in the Western New York collaborative volunteered to help put together the educational materials for PCPs to help manage CKD. Chapter One of the proposed materials was Management of Anemia!
So are there lessons learned here? Yes, there are several:
References:
Winkelmayer WC, Liu J, Chertow GM, Tamura MK. Predialysis Nephrology Care of Older Patients Approaching End-stage Renal Disease. Arch Intern Med. 2011; 171(15): 1371-1378
http://archinte.ama-assn.org/cgi/content/abstract/171/15/1371
Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP, The Improvement Guide. A Practical Approach to Enhancing Organizational Performance. San Francisco: Jossey-Bass Publishers, 1996
http://www.amazon.com/Improvement-Guide-Organizational-Performance-Jossey-Bass/dp/0787902578
Dreke TB, Locatelli F, Clyne N; et al, CREATE Investigators. Normalization of hemoglobin level in patients with chronic kidney disease and anemia. N Engl J Med. 2006; 355(20): 2071-2084
http://www.nejm.org/doi/pdf/10.1056/NEJMoa062276
Singh AK, Szczech L, Tang KL; et al, CHOIR Investigators. Correction of anemia with epoetin alfa in chronic kidney disease. N Engl J Med. 2006; 355(20): 2085-2098
http://www.nejm.org/doi/pdf/10.1056/NEJMoa065485
Pfeffer MA, Burdmann EA, Chen C-Y; et al, TREAT Investigators. A trial of darbepoetin alfa in type 2 diabetes and chronic kidney disease. N Engl J Med. 2009; 361(21): 2019-2032
http://www.nejm.org/doi/pdf/10.1056/NEJMoa0907845
Cooper BA, Branley P, Bulfone L, et al. A Randomized, Controlled Trial of Early versus Late Initiation of Dialysis. N Engl J Med 2010; 363: 609-619
http://www.nejm.org/doi/pdf/10.1056/NEJMoa1000552
Rosansky SJ, Eggers P, Jackson K, et al. Early Start of Hemodialysis May Be Harmful
Arch Intern Med, Mar 2011; 171: 396 403
Tamura MK, Covinsky KE, Chertow GM, et al. Functional Status of Elderly Adults before and after Initiation of Dialysis. N Engl J Med 2009; 361: 1539-1547
http://www.nejm.org/doi/pdf/10.1056/NEJMoa0904655
Harris A, Cooper BA, Li JJ, et al. Cost-Effectiveness of Initiating Dialysis Early: A Randomized Controlled Trial. Am J Kidney Dis 2011; 57(5): 707-715
http://www.ajkd.org/article/S0272-6386(11)00049-7/abstract
Senekjian HO. Regarding Early Initiation of Dialysis. Am J Kidney Dis 2011; 58(3): 492
http://www.ajkd.org/article/S0272-6386(11)01040-7/fulltext
Print When Practice Changes the Evidence: The CKD Story
September 27, 2011
The Canadian Suicide Risk
Assessment Guide
The Joint Commission issued a Sentinel Event Alert relating to suicides in 2010 with a focus on locations other than behavioral health units (see our December 2010 What’s New in the Patient Safety World column “Joint Commission Sentinel Event Alert on Suicide Risk Outside Psych Units”). This was an update to an earlier Sentinel Event Alert. The issue continues to be one of the hot buttons during Joint Commission surveys. They also recently released a BoosterPak relating to suicide.
We previously discussed multiple issues related to suicide on inpatient units in our Patient Safety Tips of the Week for January 6, 2009 “Preventing Inpatient Suicides” and February 9, 2010 “More on Preventing Inpatient Suicides”. Those contain numerous useful tips and links to valuable resources and should help you identify vulnerable aspects within your health care system.
A great new resource on suicide risk assessment was just released last week by the Canadian Patient Safety Institute and the Ontario Hospital Association (Perlman 2011). The Canadian guide addresses not only the general suicide risk assessment but also that in multiple different situations, including primary care, emergency care, and mental health settings.
The Canadian Guide stresses that the assessment must look not only at what risk factors are present but also at what protective factors may be present. They also discuss that some risk factors are long-term associations with suicide, others are potentiating factors, and others are warning signs in the short term.
They talk about the mental illnesses that are associated with suicide but also note that some patients who commit suicide have no mental illness at all. The concept of “predicament suicide” is discussed, in which the patient has a set of unacceptable circumstances from which he cannot find an acceptable alternative means of escape.
Their principle #1 in assessing suicide risk is to develop a therapeutic relationship with the patient, showing empathy, respect, and genuineness, with active listening. They stress that helping the patient see his or her strengths may help the patient regain his or her control over their situation. In principle #2 – communication and collaboration - they stress the importance of maintaining communication, not only with the patient but also with the support network, whether formal or informal, and the healthcare team.
Principle #3 relates to documentation of the assessment. They note that chart notes must clearly identify the patient’s level of risk and the plans for treatment and preventive care. They provide a detailed list of all the elements that need to be documented. Then they discuss the importance of documentation at transitions of care, particularly from the hospital back to the community. The importance of suicide risk assessment is essential when the timing of discharge is considered. Specifically, persons in hospital or the emergency department for suicidality should be discharged with a specific safety plan, with strategies for staying safe, early warning signs, grounding techniques, coping strategies and crisis contact numbers.
Principle #4 is cultural awareness. In some communities it is considered taboo to discuss suicide. Recognition of that is important in identifying barriers to implementation of a safety plan and support systems in the community.
The guiding principles for suicide risk assessment are presented in a tabular format with key bullet points highlighted.
They go on to discuss suicide assessment in specific settings. They note the challenges in the primary care setting, including time constraints and lack of systems for dealing with patients screened positive. They discuss the role of education, skills-based training, and collaboration for primary care practices to successfully approach the issues.
Time constraints are also problematic in the emergency setting, where a key role is identification of the true intent of the patient. It is extremely important to get information from collateral sources (families, friends, ambulance attendants, police, etc.) in such cases. They discuss the risk assessment in the mental health setting, then also discuss the issue relating to patients in long-term care settings.
Their discussion on the environment of care is thorough and informative. As we have discussed in our own prior columns on suicide risk, the hazards in the different settings vary considerably.
Risks in special circumstances, such as specific age groups, are dealt with in detail. In the young, “contagious” clusters of suicide can be problematic. Therefore, it is important in the risk assessment to know whether the youth knows anyone who has committed or contemplated suicide, how recent that was, and how the youth is coping with that. In older persons, somatic symptoms or feelings of despair rather than mention of suicidal ideation tend to predominate. In fact, older persons will seldom mention suicidal ideation to a healthcare professional unless specifically asked, though many will have mentioned it to their own family or friends. And they discuss issues specific to the gay and lesbian community, military personnel, and native populations.
The next section is a critical review of 15 suicide risk assessment tools from the literature. We obviously don’t have the time or space to discuss them here but it is a kind of “everything you wanted to know” presentation of these tools. They are quick to point out that there is no one “best” tool and that none can predict suicide. However, they point out the strengths of each in decision making and how to choose tools adapted to the particular setting of care. They also point out that “scores” to predict suicide are not very useful. Instead, they note that the specific information in the questions underlying the score may be more important. As an example they state that knowing a person has developed a specific suicide plan may be more important than knowing he scored x out of 20 on a tool.
The last section focuses on the quality improvement aspects related to suicide risk assessment. Elements discussed include the initial screening, the focused risk assessment, how the assessment is integrated into the collaborative care of the patient, care planning and intervention implementation, and monitoring and reassessment of the patient. It includes specific elements to be monitored in your quality improvement process.
In addition to suicidal ideation they do discuss the concept of self-harm, which is not always synonymous with suicidal intent. In fact, they note that the majority of patients who self-harm do not wish to die. Nevertheless, some who self-harm may inadvertently commit suicide. Note, however, a new paper on patients discharged from emergency departments after self-harm (Olfson 2011) finds that many do not get emergency mental health assessments or followup mental health care.
Whether you are a hospital with behavioral health units or a general hospital that must deal with potentially suicidal patients in your emergency department, med/surg units, or outpatient practices, you will find this Canadian resource to be both comprehensive and extremely informative.
Some of our prior columns on preventing hospital suicides:
References:
The Joint Commission. A follow-up report on preventing suicide: Focus on medical/surgical units and the emergency department. Sentinel Event Alert 2010; 46: 1-5 November 17, 2010
The Joint Commission. Inpatient Suicides: Recommendations for Prevention. Sentinel Event Alert 1998; 7: 1-2 November 6, 1998
New on Connect! Standards BoosterPak™ for assessing suicide risk
Joint Commission Online. June 22, 2011
http://www.jointcommission.org/assets/1/18/jconline_June_22_11.pdf
Perlman C, Goy, M, Hirdes JP. Suicide Risk Assessment Inventory: A Resource Guide for Canadian Health Care Organizations. Toronto, Ontario: Canadian Patient Safety Institute (CPSI) and Ontario Hospital Association (OHA). 2011
http://www.oha.com/KnowledgeCentre/Documents/2247_Risk_Assessment_Guide_FNL.pdf
Olfson M, Marcus SC, Bridge JA. Emergency Treatment of Deliberate Self-harm. Arch Gen Psychiatry. Published online September 5, 2011
http://archpsyc.ama-assn.org/cgi/content/abstract/archgenpsychiatry.2011.108
Print “The Canadian Suicide Risk Assessment Guide”
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Repeat CT in Anticoagulated Patients After Minor Head Trauma Not Cost-Effective
September 14, 2021
September 7, 2021
The Vanderbilt Tragedy Gets Uglier
August 31, 2021
The Community Pharmacy and Patient Safety
August 24, 2021
More Home Infusion Safety Issues
August 17, 2021
Tip of the Week on Vacation
August 10, 2021
Tip of the Week on Vacation
August 3, 2021
Obstetric Patients More At-Risk for Wrong Patient Orders
July 27, 2021
July 20, 2021
FDA Warning: Magnets in Consumer Electronics May Affect Medical Devices
July 13, 2021
The Skinny on Rapid Response Teams
July 6, 2021
Tip of the Week on Vacation
June 29, 2021
June 22, 2021
Remotely Monitoring Suicidal Patients in Non-Behavioral Health Areas
June 15, 2021
What’s Happened to Your Patient Safety Walk Rounds?
June 8, 2021
Cut OR Traffic to Cut Surgical Site Infections
June 1, 2021
Stronger Magnets, More MRI Safety Concerns
May 25, 2021
Yes, Radiologists Have Handoffs, Too
May 18, 2021
Medical Overuse Is Not Just An Economic Problem
May 11, 2021
How Are Alerts in Ambulatory CPOE Doing?
May 4, 2021
More 10x Dose Errors in Pediatrics
April 27, 2021
Errors Common During Thrombolysis for Acute Ischemic Stroke
April 20, 2021
Taser “Slip and Capture Error” Again!
April 13, 2021
Incidental Findings – What’s Your Strategy?
April 6, 2021
March 30, 2021
Need for Better Antibiotic Stewardship
March 23, 2021
Nursing Staffing and Sepsis Outcomes
March 16, 2021
Sleep Program Successfully Reduces Delirium
March 9, 2021
Update: Disclosure and Apology: How to Do It
March 2, 2021
Barriers to Timely Catheter Removal
February 23, 2021
February 16, 2021
New Methods for QTc Monitoring
February 9, 2021
February 2, 2021
MGH Protocols Reduce Risk of Self-Harm in ED
January 26, 2021
This Freezer Accident May Cost Lives
January 19, 2021
Technology to Identify Fatigue?
January 12, 2021
January 5, 2021
Dilaudid/HYDROmorphone Still Problematic
December 29, 2019
Tip of the Week on Vacation
December 22, 2019
Tip of the Week on Vacation
December 15, 2020
Our Perennial Pre-Holiday Warning: “Be Careful Out There!”
December 8, 2020
Maternal Mortality: Looking in All the Wrong Places?
December 1, 2020
An Early Warning System and Response System That Work
November 24, 2020
November 17, 2020
A Picture Is Worth a Thousand Words
November 10, 2020
November 3, 2020
Reminder: Infant Abduction Risk
October 27, 2020
Conflicting Studies on Technology to Reduce RSI’s
October 20, 2020
More on Post-operative Risks for Patients with OSA
October 13, 2020
October 6, 2020
Successfully Reducing Opioid-Related Adverse Events
September 29, 2020
September 22, 2020
VA RCA’s: Suicide Risks Vary by Site
September 15, 2020
September 8, 2020
Follow Up on Tests Pending at Discharge
September 1, 2020
NY State and Nurse Staffing Issues
August 25, 2020
The Off-Hours Effect in Radiology
August 18, 2020
August 11, 2020
Above-Door Alarms to Prevent Suicides
August 4, 2020
July 28, 2020
July 21, 2020
Is This Patient Allergic to Penicillin?
July 14, 2020
A Thesis on Intrahospital Transports
July 7, 2020
Another Patient Found Dead in a Stairwell
June 30, 2020
What Happens after Hospitalization?
June 23, 2020
June 16, 2020
June 9, 2020
Perioperative Medication Safety
June 2, 2020
May 26, 2020
May 19, 2020
Reminder on Telephone or Verbal Orders
May 12, 2020
May 5, 2020
COVID-19 and the Dental Office
April 28, 2020
April 21, 2020
Parenteral Nutrition Safety Issues
April 14, 2020
Patient Safety Tidbits for the COVID-19 Pandemic
April 7, 2020
From Preoperative Assessment to Preoperative Optimization
March 31, 2020
Intrahospital Transport Issues in Children
March 24, 2020
Mayo Clinic: How to Get Photos in Your EMR
March 17, 2020
March 10, 2020
Medication Harm in the Elderly
March 3, 2020
Opportunities to Reduce Unnecessary Contact Precautions
February 25, 2020
More on Perioperative Gabapentinoids
February 18, 2020
February 11, 2020
February 4, 2020
Drugs and Chronic Kidney Disease
January 28, 2020
January 21, 2020
Disruptive Behavior and Patient Safety: Cause or Effect?
January 14, 2020
January 7, 2020
Even More Concerns About MRI Safety
December 31, 2019
Tip of the Week on Vacation
December 14, 2019
Tip of the Week on Vacation
December 17, 2019
December 10, 2019
December 3, 2019
Overlapping Surgery Back in the News
November 26, 2019
Pennsylvania Law on Notifying Patients of Test Results
November 19, 2019
An Astonishing Gap in Medication Safety
November 12, 2019
Patient Photographs Again Help Radiologists
November 5, 2019
October 29, 2019
Tip of the Week on Vacation
October 22, 2019
Tip of the Week on Vacation
October 15, 2019
October 8, 2019
October 1, 2019
Electronic Medication Reconciliation: Glass Half Full or Half Empty?
September 24, 2019
EHR-related Malpractice Claims
September 17, 2019
American College of Surgeons Geriatric Surgery Verification Program
September 10, 2019
Joint Commission Naming Standard Leaves a Gap
September 3, 2019
Lessons from an Inpatient Suicide
August 27, 2019
August 20, 2019
Yet Another (Not So) Unusual RSI
August 13, 2019
Betsy Lehman Center Report on Medical Error
August 6, 2019
July 30, 2019
Lessons from Hospital Suicide Attempts
July 23, 2019
Order Sets Can Nudge the Right Way or the Wrong Way
July 16, 2019
July 9, 2019
Spinal Injection of Tranexamic Acid
July 2, 2019
Tip of the Week on Vacation
June 25, 2019
June 18, 2019
June 11, 2019
ISMP’s Grissinger on Overreliance on Technology
June 4, 2019
Medication Errors in the OR – Part 3
May 28, 2019
May 21, 2019
Mixed Message on Number of Open EMR Records
May 14, 2019
Wrong-Site Surgery and Difficult-to-Mark Sites
May 7, 2019
Simulation Training for OR Fires
April 30, 2019
Reducing Unnecessary Urine Cultures
April 23, 2019
In and Out the Door and Other OR Flow Disruptions
April 16, 2019
AACN Practice Alert on Alarm Management
April 9, 2019
Handoffs for Every Occasion
April 2, 2019
Unexpected Events During MRI
March 26, 2019
March 19, 2019
March 12, 2019
Update on Overlapping Surgery
March 5, 2019
Infusion Pump Problems
February 26, 2019
Vascular Access Device Dislodgements
February 19, 2019
Focus on Pediatric Patient Safety
February 12, 2019
From Tragedy to Travesty of Justice
February 12, 2019
2 ER Drug Studies: Reassurances and Reservations
February 5, 2019
Flaws in Our Medication Safety Technologies
January 29, 2018
National Patient Safety Goal for Suicide Prevention
January 22, 2019
Wandering Patients
January 15, 2019
Another Plus for Prehabilitation
January 8, 2019
Maternal Mortality in the Spotlight
January 1, 2019
More on Automated Dispensing Cabinet (ADC) Safety
December 25, 2018
Happy Holidays!
December 18, 2018
Great Recommendations for e-Prescribing
December 11, 2018
December 4, 2018
Don’t Use Syringes for Topical Products
November 27, 2018
November 20, 2018
November 13, 2018
Antipsychotics Fail in ICU Delirium
November 6, 2018
More on Promoting Sleep in Inpatients
October 30, 2018
October 23, 2018
Lessons From Yet Another Aviation Incident
October 16, 2018
October 9, 2018
October 2, 2018
Speaking Up About Disruptive Behavior
September 25, 2018
Foley Follies
September 18, 2018
September 11, 2018
September 4, 2018
The 12-Hour Nursing Shift: Another Nail in the Coffin
August 28, 2018
Thought You Discontinued That Medication? Think Again
August 21, 2018
Delayed CT Scan in the Anticoagulated Patient
August 14, 2018
ISMP Canada’s Updated “Do Not Use” Abbreviation List
August 7, 2018
Tip of the Week on Vacation
July 31, 2018
Surgery and the Opioid-Tolerant Patient
July 24, 2018
More on Speech Recognition Software Errors
July 17, 2018
OSA Screening in Stroke Patients
July 10, 2018
Another Jump from a Hospital Window
July 3, 2018
Tip of the Week on Vacation
June 26, 2018
Infection Related to Colonoscopy
June 19, 2018
June 12, 2018
Adverse Events in Cancer Patients
June 5, 2018
Pennsylvania Patient Safety Authority on Iatrogenic Burns
May 29, 2018
More on Nursing Workload and Patient Safety
May 22, 2018
Hazardous Intrahospital Transport
May 15, 2018
May 8, 2018
May 1, 2018
April 24, 2018
April 17, 2018
More on Tests Pending at Discharge
April 10, 2018
Prepping the Geriatric Patient for Surgery
April 3, 2018
March 27, 2018
March 20, 2018
Minnesota Highlights Lost Tissue Samples
March 13, 2018
March 6, 2018
February 27, 2018
Update on Patient Safety Walk Rounds
February 20, 2018
February 13, 2018
February 6, 2018
Adverse Events in Inpatient Psychiatry
January 30, 2018
January 23, 2018
Unintentional Hypothermia Back in Focus
January 16, 2018
January 9, 2018
More on Fire Risk from Surgical Preps
January 2, 2018
Preventing Perioperative Nerve Injuries
December 26, 2017
Tip of the Week on Vacation
December 19, 2017
December 12, 2017
Joint Commission on Suicide Prevention
December 5, 2017
Massachusetts Initiative on Cataract Surgery
November 28, 2017
More on Dental Sedation/Anesthesia Safety
November 21, 2017
OSA, Oxygen, and Alarm Fatigue
November 14, 2017
Tracking C. diff to a CT Scanner
November 7, 2017
Perioperative Neuropathies
October 31, 2017
Target Drugs for Deprescribing
October 24, 2017
Neurosurgery and Time of Day
October 17, 2017
Progress on Alarm Management
October 10, 2017
More on Torsade de Pointes
October 3, 2017
Respiratory Compromise: One Size Does Not Fit All
September 26, 2017
Tip of the Week on Vacation
September 19, 2017
Tip of the Week on Vacation
September 12, 2017
Can You Hear Me Now?
September 5, 2017
Another Iatrogenic Burn
August 29, 2017
Suicide in the Bathroom
August 22, 2017
August 15, 2017
Delayed Emergency Surgery and Mortality Risk
August 8, 2017
Sedation for Pediatric MRI Rising
August 1, 2017
Progress on Wrong Patient Orders
July 25, 2017
Can We Influence the “Weekend Effect”?
July 18, 2017
Another Hazard from Alcohol-Based Hand Gels
July 11, 2017
The 12-Hour Shift Takes More Hits
July 4, 2017
Tip of the Week on Vacation
June 27, 2017
June 20, 2017
June 13, 2017
June 6, 2017
NYS Mandate for Sepsis Protocol Works
May 30, 2017
Errors in Pre-Populated Medication Lists
May 23, 2017
May 16, 2017
Are Surgeons Finally Ready to Screen for Frailty?
May 9, 2017
Missed Nursing Care and Mortality Risk
May 2, 2017
Anatomy of a Wrong Procedure
April 25, 2017
April 18, 2017
Alarm Response and Nurse Shift Duration
April 11, 2017
Interruptions: The Ones We Forget About
April 4, 2017
Deprescribing in Long-Term Care
March 28, 2017
More Issues with Dental Sedation/Anesthesia
March 21, 2017
Success at Preventing Delirium
March 14, 2017
More on Falls on Inpatient Psychiatry
March 7, 2017
February 28, 2017
February 21, 2017
Yet More Jumps from Hospital Windows
February 14, 2017
February 7, 2017
January 31, 2017
More Issues in Pediatric Safety
January 24, 2017
Dexmedetomidine to Prevent Postoperative Delirium
January 17, 2017
January 10, 2017
The 26-ml Applicator Strikes Again!
January 3, 2017
What’s Happening to “I’m Sorry”?
December 27, 2016
Tip of the Week on Vacation
December 20, 2016
End-of-Rotation Transitions and Mortality
December 13, 2016
More on Double-Booked Surgery
December 6, 2016
Postoperative Pulmonary Complications
November 29, 2016
Doubling Down on Double-Booked Surgery
November 22, 2016
Leapfrog, Picklists, and Healthcare IT Vulnerabilities
November 15, 2016
November 8, 2016
Managing Distractions and Interruptions
November 1, 2016
CMS Emergency Preparedness Rule
October 25, 2016
Desmopressin Back in the Spotlight
October 18, 2016
Yet More Questions on Contact Precautions
October 11, 2016
New Guideline on Preop Screening and Assessment for OSA
October 4, 2016
September 27, 2016
September 20, 2016
Downloadable ABCDEF Bundle Toolkits for Delirium
September 13, 2016
Vanderbilt’s Electronic Procedural Timeout
September 6, 2016
August 30, 2016
Can You Really Limit Interruptions?
August 23, 2016
ISMP Canada: Automation Bias and Automation Complacency
August 16, 2016
How Is Your Alarm Management Initiative Going?
August 9, 2016
August 2, 2016
Drugs in the Elderly: The Goldilocks Story
July 26, 2016
Confirmed: Keep Your OR Doors Closed
July 19, 2016
Infants and Wrong Site Surgery
July 12, 2016
Forget Brexit – Brits Bash the RCA!
July 5, 2016
Tip of the Week on Vacation
June 28, 2016
Culture of Safety and Catheter-Associated Infections
June 21, 2016
Methotrexate Errors in Australia
June 14, 2016
Nursing Monitoring of Patients on Opioids
June 7, 2016
CPAP for Hospitalized Patients at High Risk for OSA
May 31, 2016
More Frailty Measures That Predict Surgical Outcomes
May 24, 2016
Texting Orders – Is It Really Safe?
May 17, 2016
Patient Safety Issues in Cataract Surgery
May 10, 2016
Medical Problems in Behavioral Health
May 3, 2016
Clinical Decision Support Malfunction
April 26, 2016
Lots More on Preventing Readmissions But Where's the Beef?
April 19, 2016
Independent Double Checks and Oral Chemotherapy
April 12, 2016
April 5, 2016
Workarounds Overriding Safety
March 29, 2016
March 22, 2016
Radiology Communication Errors May Surprise You
March 15, 2016
March 8, 2016
Tip of the Week on Vacation
March 1, 2016
February 23, 2016
February 16, 2016
February 9, 2016
February 2, 2016
January 26, 2016
More on Frailty and Surgical Morbidity and Mortality
January 19, 2016
Patient Identification in the Spotlight
January 12, 2016
New Resources on Improving Safety of Healthcare IT
January 5, 2016
Lessons from AirAsia Flight QZ8501 Crash
December 29, 2015
More Medical Helicopter Hazards
December 22, 2015
The Alberta Abbreviation Safety Toolkit
December 15, 2015
Vital Sign Monitoring at Night
December 8, 2015
Danger of Inaccurate Weights in Stroke Care
December 1, 2015
TALLman Lettering: Does It Work?
November 24, 2015
Door Opening and Foot Traffic in the OR
November 17, 2015
Patient Perspectives on Communication of Test Results
November 10, 2015
Weighing in on Double-Booked Surgery
November 3, 2015
Medication Errors in the OR - Part 2
October 27, 2015
Sentinel Event Alert on Falls and View from Across the Pond
October 20, 2015
Updated Beers List
October 13, 2015
Dilaudid Dangers #3
October 6, 2015
Suicide and Other Violent Inpatient Deaths
September 29, 2015
More on the 12-Hour Nursing Shift
September 22, 2015
The Cost of Being Rude
September 15, 2015
Another Possible Good Use of a Checklist
September 8, 2015
TREWScore for Early Recognition of Sepsis
September 1, 2015
August 25, 2015
Checklist for Intrahospital Transport
August 18, 2015
Missing Obstructive Sleep Apnea
August 11, 2015
New Oxygen Guidelines: Thoracic Society of Australia and NZ
August 4, 2015
Tip of the Week on Vacation
July 28, 2015
July 21, 2015
Avoiding Distractions in the OR
July 14, 2015
July 7, 2015
June 30, 2015
What Are Appropriate Indications for Urinary Catheters?
June 23, 2015
Again! Mistaking Antiseptic Solution for Radiographic Contrast
June 16, 2015
June 9, 2015
Add This to Your Fall Risk Assessment
June 2, 2015
May 26, 2015
May 19, 2015
May 12, 2015
More on Delays for In-Hospital Stroke
May 5, 2015
Errors with Oral Oncology Drugs
April 28, 2015
April 21, 2015
April 14, 2015
Using Insulin Safely in the Hospital
April 7, 2015
March 31, 2015
Clinical Decision Support for Pneumonia
March 24, 2015
Specimen Issues in Prostate Cancer
March 17, 2015
March 10, 2015
FDA Warning Label on Insulin Pens: Is It Enough?
March 3, 2015
Factors Related to Postoperative Respiratory Depression
February 24, 2015
More Risks with Long-Acting Opioids
February 17, 2015
Functional Impairment and Hospital Readmission, Surgical Outcomes
February 10, 2015
The Anticholinergic Burden and Dementia
February 3, 2015
CMS Hopes to Reduce Antipsychotics in Dementia
January 27, 2015
The Golden Hour for Stroke Thrombolysis
January 20, 2015
He Didn’t Wash His Hands After What!
January 13, 2015
January 6, 2015
Yet Another Handoff: The Intraoperative Handoff
December 30, 2014
Data Accumulates on Impact of Long Surgical Duration
December 23, 2014
Iatrogenic Burns in the News Again
December 16, 2014
More on Each Element of the Surgical Fire Triad
December 9, 2014
December 2, 2014
ANA Position Statement on Nurse Fatigue
November 25, 2014
Misdiagnosis Due to Lab Error
November 18, 2014
Handwashing Fades at End of Shift, ?Smartwatch to the Rescue
November 11, 2014
Early Detection of Clinical Deterioration
November 4, 2014
Progress on Fall Prevention
October 28, 2014
RF Systems for Retained Surgical Items
October 21, 2014
The Fire Department and Your Hospital
October 14, 2014
October 7, 2014
Our Take on Patient Safety Walk Rounds
September 30, 2014
More on Deprescribing
September 23, 2014
Stroke Thrombolysis: Need to Focus on Imaging-to-Needle Time
September 16, 2014
Focus on Home Care
September 9, 2014
The Handback
September 2, 2014
Frailty and the Trauma Patient
August 26, 2014
Surgeons’ Perception of Intraoperative Time
August 19, 2014
Some More Lessons Learned on Retained Surgical Items
August 12, 2014
Surgical Fires Back in the News
August 5, 2014
Tip of the Week on Vacation
July 29, 2014
The 12-Hour Nursing Shift: Debate Continues
July 22, 2014
More on Operating Room Briefings and Debriefings
July 15, 2014
Barriers to Success of Early Warning Systems
July 8, 2014
Update: Minor Head Trauma in the Anticoagulated Patient
July 1, 2014
Interruptions and Radiologists
June 24, 2014
Lessons from the General Motors Recall Analysis
June 17, 2014
SO2S Confirms Routine Oxygen of No Benefit in Stroke
June 10, 2014
Another Clinical Decision Support Tool to Avoid Torsade de Pointes
June 3, 2014
More on the Risk of Sedative/Hypnotics
May 27, 2014
A Gap in ePrescribing: Stopping Medications
May 20, 2014
May 13, 2014
Perioperative Sleep Apnea: Human and Financial Impact
May 6, 2014
Monitoring for Opioid-induced Sedation and Respiratory Depression
April 29, 2014
More on the Unintended Consequences of Contact Isolation
April 22, 2014
Impact of Resident Workhour Restrictions
April 15, 2014
Specimen Identification Mixups
April 8, 2014
FMEA to Avoid Breastmilk Mixups
April 1, 2014
Expensive Aspects of Sepsis Protocol Debunked
March 25, 2014
March 18, 2014
Systems Approach Improving Stroke Care
March 11, 2014
We Miss the Graphic Flowchart!
March 4, 2014
Evidence-Based Prescribing and Deprescribing in the Elderly
February 25, 2014
Joint Commission Revised Diagnostic Imaging Requirements
February 18, 2014
February 11, 2014
Another Perioperative Handoff Tool: SWITCH
February 4, 2014
But What If the Battery Runs Low?
January 28, 2014
Is Polypharmacy Always Bad?
January 21, 2014
January 14, 2014
Diagnostic Error: Salient Distracting Features
January 7, 2014
Lessons From the Asiana Flight 214 Crash
December 24-31, 2013
Tip of the Week on Vacation
December 17, 2013
December 10, 2013
Better Handoffs, Better Results
December 3, 2013
Reducing Harm from Falls on Inpatient Psychiatry
November 26, 2013
Missed Care: New Opportunities?
November 19, 2013
Can We Improve Dilaudid/HYDROmorphone Safety?
November 12, 2013
More on Inappropriate Meds in the Elderly
November 5, 2013
Joint Commission Sentinel Event Alert: Unintended Retained Foreign Objects
October 29, 2013
PAD: The Pain, Agitation, and Delirium Care Bundle
October 22, 2013
How Safe Is Your Radiology Suite?
October 15, 2013
October 8, 2013
October 1, 2013
Fuels and Oxygen in OR Fires
September 24, 2013
Perioperative Use of CPAP in OSA
September 17, 2013
September 10, 2013
Informed Consent and Wrong-Site Surgery
September 3, 2013
Predicting Perioperative Complications: Slow and Simple
August 27 2013
Lessons on Wrong-Site Surgery
August 20 2013
Lessons from Canadian Analysis of Medical Air Transport Cases
August 13 2013
August 6, 2013
July 9-30, 2013
Tip of the Week on Vacation
July 2, 2013
June 25, 2013
June 18, 2013
DVT Prevention in Stoke – CLOTS 3
June 11, 2013
June 4, 2013
May 28, 2013
The Neglected Medications: IV Fluids
May 21, 2013
May 14, 2013
Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)
May 7, 2013
April 30, 2013
Photographic Identification to Prevent Errors
April 23, 2013
Plethora of Medication Safety Studies
April 16, 2013
April 9, 2013
Mayo Clinic System Alerts for QT Interval Prolongation
April 2, 2013
Absconding from Behavioral Health Services
March 26, 2013
Failure to Recognize Sleep Apnea Before Surgery
March 19, 2013
Dealing with the Violent Patient in the Emergency Department
March 12, 2013
More on Communicating Test Results
March 5, 2013
Underutilized Safety Tools: The Observational Audit
February 26, 2013
Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?
February 19, 2013
Practical Postoperative Pain Management
February 12, 2013
CDPH: Lessons Learned from PCA Incident
February 5, 2013
Antidepressants and QT Interval Prolongation
January 29, 2013
A Flurry of Activity on Handoffs
January 22, 2013
You Don’t Know What You Don’t Know
January 15, 2013
January 8, 2013
More Lessons Learned on Retained Surgical Items
January 1, 2013
Don’t Throw Away Those View Boxes Yet
December 25, 2012
Tip of the Week on Vacation
December 18, 2012
Unintended Consequences of the CAUTI Measure?
December 11, 2012
December 4, 2012
Unintentional Perioperative Hypothermia: A New Twist
November 27, 2012
November 20, 2012
Update on Perioperative Management of Obstructive Sleep Apnea
November 13, 2012
The 12-Hour Nursing Shift: More Downsides
November 6, 2012
Using LEAN to Improve Stroke Care
October 30, 2012
October 23, 2012
Latent Factors Lurking in the OR
October 16, 2012
What is the Evidence on Double Checks?
October 9, 2012
Call for Focus on Diagnostic Errors
October 2, 2012
Test Results: Everyone’s Worst Nightmare
September 25, 2012
Preoperative Assessment for Geriatric Patients
September 18, 2012
September 11, 2012
In Search of the Ideal Early Warning Score
September 4, 2012
August 28, 2012
New Care Model Copes with Interruptions Better
August 21, 2012
More on Missed Followup of Tests in Hospital
August 14, 2012
August 7, 2012
Cognition, Post-Op Delirium, and Post-Op Outcomes
July 31, 2012
Surgical Case Duration and Miscommunications
July 24, 2012
FDA and Extended-Release/Long-Acting Opioids
July 17, 2012
July 10, 2012
Tip of the Week on Vacation
July 3, 2012
Recycling an Old Column: Dilaudid Dangers
June 26, 2012
Using Patient Photos to Reduce CPOE Errors
June 19, 2012
More Problems with Faxed Orders
June 12, 2012
Lessons Learned from the CDPH: Retained Foreign Bodies
June 5, 2012
Minor Head Trauma in the Anticoagulated Patient
May 29, 2012
Falls, Fractures, and Fatalities
May 22, 2012
Update on Preoperative Screening for Sleep Apnea
May 15, 2012
May 8, 2012
Importance of Nontechnical Skills in Healthcare
May 1, 2012
April 24, 2012
Fire Hazard of Skin Preps Oxygen
April 17, 2012
April 10, 2012
April 3, 2012
New Risk for Postoperative Delirium: Obstructive Sleep Apnea
March 27, 2012
March 20, 2012
Adverse Events Related to Psychotropic Medications
March 13, 2012
Medical Emergency Team Calls to Radiology
March 6, 2012
February 28, 2012
AACN Practice Alert on Delirium in Critical Care
February 21, 2012
Improving PCA Safety with Capnography
February 14, 2012
Handoffs More Than Battle of the Mnemonics
February 7, 2012
Another Neuromuscular Blocking Agent Incident
January 31, 2012
January 24, 2012
Patient Safety in Ambulatory Care
January 17, 2012
Delirium and Contact Isolation
January 10, 2012
January 3, 2012
Unintended Consequences of Restricted Housestaff Hours
December 20, 2011
December 13, 2011
December 6, 2011
Why You Need to Beware of Oxygen Therapy
November 29, 2011
November 22, 2011
Perioperative Management of Sleep Apnea Disappointing
November 15, 2011
November 8, 2011
WHOs Multi-professional Patient Safety Curriculum Guide
November 1, 2011
So Whats the Big Deal About Inserting an NG Tube?
October 25, 2011
October 18, 2011
October 11, 2011
October 4, 2011
Radiology Report Errors and Speech Recognition Software
September 27, 2011
The Canadian Suicide Risk Assessment Guide
September 20, 2011
When Practice Changes the Evidence: The CKD Story
September 13, 2011
Do You Use Fentanyl Transdermal Patches Safely?
September 6, 2011
August 30, 2011
Unintentional Discontinuation of Medications After Hospitalization
August 23, 2011
Catheter Misconnections Back in the News
August 16, 2011
August 9, 2011
Frailty and the Surgical Patient
August 2, 2011
July 26, 2011
July 19, 2011
Communication Across Professions
July 12, 2011
Psst! Pass it onHow a kids game can mold good handoffs
July 5, 2011
Sidney Dekker: Patient Safety. A Human Factors Approach
June 28, 2011
Long-Acting and Extended-Release Opioid Dangers
June 21, 2011
June 14, 2011
June 6, 2011
May 31, 2011
Book Review Human Factors and Team Psychology in a High Stakes Environment
May 24, 2011
May 17, 2011
Opioid-Induced Respiratory Depression Again!
May 10, 2011
Preventing Preventable Readmissions: Not As Easy As It Sounds
May 3, 2011
April 26, 2011
Sleeping Air Traffic Controllers: What About Healthcare?
April 19, 2011
DVT Prophylaxis in Acute Stroke: Controversy Reappears
April 12, 2011
Medication Issues in the Ambulatory Setting
April 5, 2011
March 29, 2011
The Silent Treatment:A Dose of Reality
March 22, 2011
An EMR Feature Detrimental to Teamwork and Patient Safety
March 15, 2011
March 8, 2011
Yes, Physicians Get Interrupted Too!
March 1, 2011
February 22, 2011
February 15, 2011
Controversies in VTE Prophylaxis
February 8, 2011
February 1, 2011
January 25, 2011
Procedural Sedation in Children
January 18, 2011
More on Medication Errors in Long-Term Care
January 11, 2011
NPSA (UK) How to Guide: Five Steps to Safer Surgery
January 4, 2011
December 28, 2010
HAIs: Looking In All The Wrong Places
December 21, 2010
More Bad News About Off-Hours Care
December 14, 2010
NPSA (UK): Preventing Fatalities from Medication Loading Doses
December 6, 2010
More Tips to Prevent Wrong-Site Surgery
November 30, 2010
SURPASS: The Mother of All Checklists
November 23, 2010
Focus on Cumulative Radiation Exposure
November 16, 2010
November 9, 2010
12-Hour Nursing Shifts and Patient Safety
November 2, 2010
Insulin: Truly a High-Risk Medication
October 26, 2010
Confirming Medications During Anesthesia
October 19, 2010
Optimizing Medications in the Elderly
October 12, 2010
October 5, 2010
September 28, 2010
September 21, 2010
September 14, 2010
Wrong-Site Craniotomy: Lessons Learned
September 7, 2010
Patient Safety in Ob/Gyn Settings
August 31, 2010
August 24, 2010
The BP Oil Spill Analogies in Healthcare
August 17, 2010
Preoperative Consultation Time to Change
August 10, 2010
Its Not Always About The Evidence
August 3, 2010
Tip of the Week on Vacation
July 27, 2010
EMRs Still Have A Long Way To Go
July 20, 2010
More on the Weekend Effect/After-Hours Effect
July 13, 2010
Postoperative Opioid-Induced Respiratory Depression
July 6, 2010
Book Reviews: Pronovost and Gawande
June 29, 2010
Torsade de Pointes: Are Your Patients At Risk?
June 22, 2010
Disclosure and Apology: How to Do It
June 15, 2010
Dysphagia in the Stroke Patient: the Scottish Guideline
June 8, 2010
Surgical Safety Checklist for Cataract Surgery
June 1, 2010
May 25, 2010
May 18, 2010
Real-Time Random Safety Audits
May 11, 2010
May 4, 2010
More on the Impact of Interruptions
April 27, 2010
April 20, 2010
HITs Limited Impact on Quality To Date
April 13, 2010
April 6, 2010
March 30, 2010
Publicly Released RCAs: Everyone Learns from Them
March 23, 2010
ISMPs Guidelines for Standard Order Sets
March 16, 2010
A Patient Safety Scavenger Hunt
March 9, 2010
Communication of Urgent or Unexpected Radiology Findings
March 2, 2010
Alarm Sensitivity: Early Detection vs. Alarm Fatigue
February 23, 2010
Alarm Issues in the News Again
February 16, 2010
Spin/HypeKnowing It When You See It
February 9, 2010
More on Preventing Inpatient Suicides
February 2, 2010
January 26, 2010
Preventing Postoperative Delirium
January 19, 2010
January 12, 2010
Patient Photos in Patient Safety
January 5, 2010
December 29, 2009
Recognizing Deteriorating Patients
December 22, 2009
December 15, 2009
December 8, 2009
December 1, 2009
Patient Safety Doesnt End at Discharge
November 24, 2009
Another Rough Month for Healthcare IT
November 17, 2009
November 10, 2009
Conserving ResourcesBut Maintaining Patient Safety
November 3, 2009
Medication Safety: Frontline to the Rescue Again!
October 27, 2009
Co-Managing Patients: The Good, The Bad, and The Ugly
October 20, 2009
Radiology AgainBut This Time Its Really Radiology!
October 13, 2009
October 6, 2009
Oxygen Safety: More Lessons from the UK
September 29, 2009
Perioperative Peripheral Nerve Injuries
September 22, 2009
Psychotropic Drugs and Falls in the SNF
September 15, 2009
ETTOs: Efficiency-Thoroughness Trade-Offs
September 8, 2009
Barriers to Medication Reconciliation
September 1, 2009
The Real Root Causes of Medical Helicopter Crashes
August 25, 2009
Interruptions, Distractions, InattentionOops!
August 18, 2009
Obstructive Sleep Apnea in the Perioperative Period
August 11, 2009
August 4, 2009
July 28, 2009
Wandering, Elopements, and Missing Patients
July 21, 2009
Medication Errors in Long Term-Care
July 14, 2009
Is Your Do Not Use Abbreviations List Adequate?
July 7, 2009
Nudge: Small Changes, Big Impacts
June 30, 2009
iSoBAR: Australian Clinical Handoffs/Handovers
June 23, 2009
June 16, 2009
Disclosing Errors That Affect Multiple Patients
June 9, 2009
CDC Update to the Guideline for Prevention of CAUTI
June 2, 2009
Why Hospitals Should FlyJohn Nance Nails It!
May 26, 2009
Learning from Tragedies. Part II
May 19, 2009
May 12, 2009
May 5, 2009
Adverse Drug Events in the ICU
April 28, 2009
Ticket Home and Other Tools to Facilitate Discharge
April 21, 2009
April 14, 2009
More on Rehospitalization After Discharge
April 7, 2009
March 31, 2009
Screening Patients for Risk of Delirium
March 24, 2009
March 17, 2009
March 10, 2009
Prolonged Surgical Duration and Time Awareness
March 3, 2009
Overriding AlertsLike Surfin the Web
February 24, 2009
Discharge Planning: Finally Something That Works!
February 17, 2009
Reducing Risk of Overdose with Midazolam Injection
February 10, 2009
Sedation in the ICU: The Dexmedetomidine Study
February 3, 2009
NTSB Medical Helicopter Crash Reports: Missing the Big Picture
January 27, 2009
Oxygen Therapy: Everything You Wanted to Know and More!
January 20, 2009
The WHO Surgical Safety Checklist Delivers the Outcomes
January 13, 2009
January 6, 2009
December 30, 2008
Unintended Consequences: Is Medication Reconciliation Next?
December 23, 2008
December 16, 2008
Joint Commission Sentinel Event Alert on Hazards of Healthcare IT
December 9, 2008
December 2, 2008
Playing without the ballthe art of communication in healthcare
November 25, 2008
November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
November 11, 2008
November 4, 2008
October 28, 2008
More on Computerized Trigger Tools
October 21, 2008
October 14, 2008
October 7, 2008
Lessons from Falls....from Rehab Medicine
September 30, 2008
September 23, 2008
Checklists and Wrong Site Surgery
September 16, 2008
More on Radiology as a High Risk Area
September 9, 2008
Less is More.and Do You Really Need that Decimal?
September 2, 2008
August 26, 2008
August 19, 2008
August 12, 2008
Jerome Groopmans How Doctors Think
August 5, 2008
July 29, 2008
Heparin-Induced Thrombocytopenia
July 22, 2008
Lots New in the Anticoagulation Literature
July 15, 2008
July 8, 2008
July 1, 2008
WHOs New Surgical Safety Checklist
June 24, 2008
Urinary Catheter-Related UTIs: Bladder Bundles
June 17, 2008
Technology Workarounds Defeat Safety Intent
June 10, 2008
Monitoring the Postoperative COPD Patient
June 3, 2008
UK Advisory on Chest Tube Insertion
May27, 2008
If You Do RCAs or Design Healthcare ProcessesRead Gary Kleins Work
May20, 2008
CPOE Unintended Consequences Are Wrong Patient Errors More Common?
May13, 2008
Medication Reconciliation: Topical and Compounded Medications
May 6, 2008
Preoperative Screening for Obstructive Sleep Apnea
April 29, 2008
ASA Practice Advisory on Operating Room Fires
April 22, 2008
CMS Expanding List of No-Pay Hospital-Acquired Conditions
April 15, 2008
April 8, 2008
April 1, 2008
Pennsylvania PSAs FMEA on Telemetry Alarm Interventions
March 25, 2008
March 18, 2008
Is Desmopressin on Your List of Hi-Alert Medications?
March 11, 2008
March 4, 2008
Housestaff Awareness of Risks for Hazards of Hospitalization
February 26, 2008
Nightmares.The Hospital at Night
February 19, 2008
February 12, 2008
February 5, 2008
Reducing Errors in Obstetrical Care
January 29, 2008
Thoughts on the Recent Neonatal Nursery Fire
January 22, 2008
More on the Cost of Complications
January 15, 2008
Managing Dangerous Medications in the Elderly
January 8, 2008
Urinary Catheter-Associated Infections
January 1, 2008
December 25, 2007
December 18, 2007
December 11, 2007
CommunicationCommunicationCommunication
December 4, 2007
November 27,2007
November 20, 2007
New Evidence Questions Perioperative Beta Blocker Use
November 13, 2007
AHRQ's Free Patient Safety Tools DVD
November 6, 2007
October 30, 2007
Using IHIs Global Trigger Tool
October 23, 2007
Medication Reconciliation Tools
October 16, 2007
Radiology as a Site at High-Risk for Medication Errors
October 9, 2007
October 2, 2007
Taking Off From the Wrong Runway
September 25, 2007
Lessons from the National Football League
September 18, 2007
Wristbands: The Color-Coded Conundrum
September 11, 2007
Root Cause Analysis of Chemotherapy Overdose
September 4, 2007
August 28, 2007
Lessons Learned from Transportation Accidents
August 21, 2007
Costly Complications About To Become Costlier
August 14, 2007
More Medication-Related Issues in Ambulatory Surgery
August 7, 2007
Role of Maintenance in Incidents
July 31, 2007
Dangers of Neuromuscular Blocking Agents
July 24, 2007
Serious Incident Response Checklist
July 17, 2007
Falls in Patients on Coumadin or Other Anticoagulants
July 10, 2007
Catheter Connection Errors/Wrong Route Errors
July 3, 2007
June 26, 2007
Pneumonia in the Stroke Patient
June 19, 2007
Unintended Consequences of Technological Solutions
June 12, 2007
Medication-Related Issues in Ambulatory Surgery
June 5, 2007
Patient Safety in Ambulatory Surgery
May 29, 2007
Read Anything & Everything Written by Malcolm Gladwell!
May 22, 2007
May 15, 2007
Communication, Hearback and Other Lessons from Aviation
May 8, 2007
Doctor, when do I get this red rubber hose removed?
May 1, 2007
April 23, 2007
April 16, 2007
April 9, 2007
Make Your Surgical Timeouts More Useful
April 2, 2007
March 26, 2007
Alarms Should Point to the Problem
March 19, 2007
Put that machine back the way you found it!
March 12, 2007
March 5, 2007
February 26, 2007
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