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July 2, 2013
Issues in Alarm Management
Since Joint Commission published its Sentinel Event Alert on alarm safety and developed the new national patient safety goal (NPSG) on alarm management (see our What’s New in the Patient Safety World columns for February 2013 “Joint Commission Proposes New 2014 National Patient Safety Goal” and May 2013 “Joint Commission Sentinel Event Alert: Alarm Safety”) healthcare organizations have been frantically working to develop programs that will comply with the new NPSG.
But it shouldn’t have required actions by TJC to get healthcare organizations to pay more attention to alarm management and alarm safety issues. Issues with alarms in healthcare have been one of our dominant themes since we began publishing Tip of the Week back in 2007. Faulty response to alarms is one of the “big 3” problems encountered in many root cause analyses of sentinel events (the other 2 are communication failures and failure to buck the authority gradient). We’ve mentioned before that we often make amicable bets with CEO’s when we enter their facilities that we will find within a specified timeframe some alarms that have been disabled or otherwise manipulated. That’s a bet we win every time (but we don’t actually make them pay up!).
One of the best ways to understand the issues related to alarms is to go to a clinical area where alarms are prevalent (eg. ICU, OR/PACU, dialysis unit, ER, etc.) and sit and watch what goes on. The first thing you’ll probably notice is the ubiquity of alarms and the extreme frequency with which they go off. You’ll notice that the alarms will interrupt nurses and other staff from other activities. You’ll also notice that how fast someone responds to an alarm is extremely variable. And you’ll wonder how any patient could ever sleep with so many alarms going off. Then you’ll also notice the likely first action taken by the person responding to the alarm – they’ll probably turn off the alarm. Don’t be shocked! That’s human nature and we need to take that into account when we design alarm systems (see below).
Your organization needs to make alarm safety an organizational priority. It should be a topic that your Board and both your medical staff and administrative leadership hear about regularly in their meetings. Tying quality improvement goals to incentives at various levels may also be a way to emphasize that the organization is serious about alarm safety.
One of the Joint Commission recommendations is that each organization have a multidisciplinary team that addresses and oversees alarm safety. That team should include not only physicians and nurses, but also administrators, quality improvement personnel, respiratory therapists, monitoring technicians, biomedical engineers, and IT personnel amongst others. But you really need to address alarm management and safety on a unit-by-unit basis. You’ll find that the specific alarm issues as well as the culture and workaround issues differ on every unit. And don’t just include people in leadership roles. Make sure that front-line staff are included.
First and foremost, take an inventory of all your alarm systems. Then determine which ones are not necessary. In our February 23, 2010 “Alarm Issues in the News Again” where we discussed alarm fatigue we noted a study by Siebig and colleagues (Siebig et al 2010) in medical intensive care units that found only 15% of alarms were considered clinically relevant. Our November 2010 What’s New in the Patient Safety World column “Alarms in the Operating Room” noted another study (Schmid 2010) on 25 consecutive cardiac surgery cases. They noted an average of 1.2 alarms per minute and noted that approximately 80% of the alarms had no therapeutic consequences, a figure remarkably similar to that found in the Siebig study mentioned above. The new Joint Commission sentinel event alert cites the statistic that between 85% and 99% of alarm signals do not require clinical intervention.
The Joint Commission Alarm Safety Webinar in May 2013 included description of a Boston Medical Center initiative that did an alarm inventory and categorization of alarm types (eg. warning alarms vs. crisis alarms) and significantly reduced the overall number of audible alarms on cardiac patients. They achieved an 89% decrease in audible alarms! The major impact was on telemetry monitoring. It’s really worth your while listening to this webinar (or reading the transcript) to see how they went about this incredibly successful initiative. They describe the multidisciplinary team that developed the initiative, categorized the alarms, got buy-in from all stakeholders, developed standardized order sets, and got feedback. Staff and patient satisfaction also improved dramatically.
Telemetry is one technology we often see overutilized in many hospitals. The American Heart Association and American College of Cardiology (AHA/ACC) have published guidelines on telemetry monitoring and suggested criteria. Yet many hospitals have never developed local guidelines to help identify which patients should be monitored (and which should not). Moreover, criteria for continued monitoring are extremely important because all too often a physician orders telemetry and it gets continued indefinitely. Getting your physician staff involved early in developing your telemetry criteria is the key.
Alarm hazards have been a perennial topic on ECRI Institute’s Annual Top 10 Health Technology Hazards list and headed the list for 2013 (ECRI 2013). ECRI Institute, which has a great alarm management resources web page, has a poster that includes strategies you might use in your approach to improve alarm safety. It reminds you not to forget you probably already have many lessons learned pertaining to alarms in root cause analyses (RCA’s) of previous incidents or near-misses in your organization (or other organizations).
A timely new practice alert from the American Association of Critical-Care Nurses (AACN 2013) provides some good recommendations for alarm management but also shows that the evidence grades for most recommendations are those based on case reports, consensus opinions, expert opinions, etc. rather than being based on well-designed controlled trials. Nevertheless the recommendations make a great deal of sense:
Our February 23, 2010 Patient Safety Tip of the Week “Alarm Issues in the News Again”) discussed the excellent Boston Globe series (Kowalczyk 2011a, Kowalczyk 2011b) on problems related to alarms and especially the problem of alarm fatigue and efforts to develop alarm systems (“smart” alarms) that integrate multiple types of physiologic measurements to help better differentiate true emergencies from artifact. However, the problem of alarm fatigue is also deeply rooted in faulty design of alarm systems. In our April 2, 2007 Patient Safety Tip of the Week “More Alarm Issues” we pointed out the classic example (with a disastrous outcome) in which alarm volumes had been intentionally reduced because the noise was interfering with other activities. The fact that multiple providers turned down the volumes on one particular set of alarms belied the flawed design nature of the unit involved.
Delineation of responsibility for responding to alarms is important. A 2011 Pennsylvania Patient Safety Authority advisory noted multiple cases of inadequate responses to alarms (Lacker 2011). All too often staff, who may be busy with other activities, assume someone else will respond. Your policies and protocols should have mechanisms for escalating responses. Particularly in areas like ICU’s you can “partner” nurses and have tiers of responsibility for backup coverage (TJC 2011). So when you are sitting in an area observing all alarm-related activities, measure how long it takes for responses. One hospital found it took an average of 9.5 minutes for a clinician to respond to high-priority alarms. It implemented better communications systems to dramatically improve the response times (TJC 2011).
Checking alarms should be a regular component of your Patient Safety Walk Rounds. More importantly, it should be something your staff does daily on every unit that utilizes alarms of any type. Some units even do it on every shift. And when you find alarms that have been disabled or otherwise manipulated make sure you find out why. Such actions always have an underlying root cause that must be addressed.
You should include alarm status as part of your structured handoff tool used at changes of shift. And alarm status must be included in your “Ticket to Ride” tool for in-hospital transports (eg. to radiology). The 2011 PPSA Patient Safety Advisory (Lacker 2011) cited six fatal cases in which monitors were disconnected either while in radiology or were not reconnected upon return to the floor from diagnostic testing. A Joint Commission Perspectives on Patient Safety article in 2011 done in conjunction with the ECRI institute includes a sample “Ticket to Ride” form that includes comments on cardiac monitoring (TJC 2011).
You must also be able to recognize when a “false alarm” is, in fact, a true alarm. The most important example we have provided on numerous occasions is that which occurs in patients with obstructive sleep apnea (OSA) who are monitored only with pulse oximetry. In such patients the apnea occurs when they fall asleep. If the apnea is sufficiently long they develop hypoxemia and the pulse oximeter alarms once the oxygen saturation falls below the set threshold. However, when the nurse or other person responds they typically wake the patient and begin looking to see if there is something wrong with the sensor. Now the patient is awake and no longer apneic and, hence, no longer hypoxemic. So the alarm often gets written off as a “false” alarm. And since the majority of patients with OSA are undiagnosed that is the reason we recommend use of capnography and apnea monitoring universally in patients receiving opiate therapy or other potential respiratory depressants. If you do a failure mode and effects analysis (FMEA) or other sort of assessment of your alarm systems to determine your potential vulnerabilities, consideration of the diagnosed or undiagnosed OSA patient should be at the top of your list of potential gaps.
Alarms should be designed to point the responder to the problem at hand. In our March 26, 2007 Patient Safety Tip of the Week “Alarms Should Point to the Problem” we described an incident where a low pressure dialysis alarm went off (designed to alert staff that a needle may have come out of an access site). The nurse turned off the alarm and eyeballed the patient and saw no blood. Nothing further was done. Soon thereafter the low pressure alarm triggered again. This time it was recognized that the dialysis catheter had indeed become dislodged and the patient had, in fact, had considerable blood loss. It had not been appreciated immediately because a blanket had been covering up the catheter site and the blood, rather than being visible on the floor, had been pooling in the webbing of the lounge chair in which the patient was reclining. The equipment and alarm were on the side of the patient opposite from the involved limb so that the visual attention of the responder was not directed immediately to the site the alarm was drawing attention to. If we can make copy machines that tell us exactly where to look when the alarm goes off that there is a paper jam, why can’t critical medical monitoring devices do the same thing?!!! Proper design of medical equipment necessitates seeing how humans will respond to it in the typical medical setting. When Microsoft develops new software, it puts real people in a real-life setting and sees exactly how people are likely to respond to various scenarios. Why can’t all medical device manufacturers learn from this?
In our June 19, 2007 Patient Safety Tip of the Week “Unintended Consequences of Technological Solutons” we described a case in which telemetry transmitters were transposed on two patients, leading to an erroneous response to one patient’s room while the patient in true ventricular fibrillation down the hall died. That illustrates a principle that must be strictly adhered to: never allow anyone to take out two transmitters at the same time. Each hookup should be handled independently and completed before the next is done.
Another important lesson was in our March 5, 2007 Patient Safety Tip of the Week “Disabled Alarms” where we described a case in which a piece of tape had been placed over the blender alarm on a ventilator, presumably to prevent the alarm from alarming while the machine was being serviced without use of oxygen. One of the lessons from that case is that any time you set up a new piece of equipment on a patient you use a checklist specific to that piece of equipment that forces you to verify that all alarms are appropriately set and functional and that parameters chosen are appropriate. We also recommend you review some of the useful tips we’ve included in our February 23, 2010 Patient Safety Tip of the Week “Alarm Issues in the News Again” and the several other columns noted below.
Don’t forget to include alarm considerations in some of your financial decisions as well. When purchasing new equipment, consider how alarms differ from old equipment.
Education of staff on all levels is critical to maintaining high levels of alarm safety. And we are not talking about just physicians and nurses. Even your non-clinical staff need this education. The receptionist on the floor needs to know to immediately call a nurse when the transport team brings that patient back up from radiology without his monitor hooked up! And don’t forget patient and family education. ECRI Institute has a short video on the Four “A’s” for Alarms (Advocate, Active, Ask, Alert) that is quite useful.
Developing a culture of patient safety is critical. When you use multidisciplinary teams, keep all stakeholders informed, focus on a unit level, and get regular feedback from frontline staff you’ll start to see that culture develop. Transparency and participation are key to success.
Our alarm systems still leave a lot to be desired. Most are threshold-based and there are significant theoretical and practical considerations regarding the utility of any threshold-based alarms. Those discussions are beyond the scope of today’s column but those who are interested should read our Patient Safety Tips of the Week for March 2, 2010 “Alarm Sensitivity: Early Detection vs. Alarm Fatigue” and February 22, 2011 “Rethinking Alarms”. In particular, we’ve often mentioned the provocative article by Lynn and Curry (Lynn 2011) on alarms and their failure to identify deteriorating patients early.
The Physician-Patient Alliance for Health & Safety, which has done such a great job promoting safe practices for patient-controlled analgesia (PCA) and other narcotic safety issues has also begun to focus on alarm safety issues and we expect to see more from them in the future.
Prior Patient Safety Tips of the Week pertaining to alarm-related issues:
References:
The Joint Commission. Medical device alarm safety in hospitals. The Joint Commission Sentinel Event Alert 2013; 50: 1-3 April 8, 2013
http://www.jointcommission.org/assets/1/18/SEA_50_alarms_4_5_13_FINAL1.PDF
Siebig S, Kuhls S; Imhoff M, et al. Intensive care unit alarms - How many do we need? Critical Care Medicine 2010; 38(2): 451-456
Schmid F, Goepfert MS, Kuhnt D, et al. The Wolf Is Crying in the Operating Room: Patient Monitor and Anesthesia Workstation Alarming Patterns during Cardiac Surgery. Anesth Analg 2010; ANE.0b013e3181fcc504; published ahead of print October 21, 2010, doi:10.1213/ANE.0b013e3181fcc504
http://www.anesthesia-analgesia.org/content/early/2010/10/21/ANE.0b013e3181fcc504.abstract
The Joint Commission. Alarm safety webinar – May 1, 2013
http://www.jointcommission.org/alarm_safety_webinar/
ECRI Institute. ECRI Institute 2013 Top 10 Health Technology Hazards.
https://www.ecri.org/Forms/Pages/ECRI-Institute-2013-Top-10-Hazards.aspx
ECRI Institute. Alarm Safety Resources.
https://www.ecri.org/Forms/Pages/Alarm_Safety_Resource.aspx
ECRI Institute. Strategies to Improve Monitor Alarm Safety (poster).
https://www.ecri.org/Documents/Monitor%20Alarm%20Safety_Poster%20Presentation.pdf
AACN (American Association of Critical-Care Nurses). AACN PracticeAlert. Alarm Management. April 2013
http://www.aacn.org/wd/practice/docs/practicealerts/alarm-management-practice-alert.pdf
Kowalczyk L. For nurses, it’s a constant dash to respond to alarms. (first of two parts)
Boston Globe February 13, 2011
Kowalczyk L. No easy solutions for alarm fatigue. (second of two parts).
Boston Globe February 14, 2011
http://www.boston.com/lifestyle/health/articles/2011/02/14/no_easy_solutions_for_alarm_fatigue/
Lacker C. Pennsylvania Patient Safety Authority (PPSA). Patient Safety Advisory. Physiologic Alarm Management. Pa Patient Saf Advis 2011; 8(3):105-108
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2011/sep8%283%29/Pages/105.aspx
The Joint Commission. Sound the Alarm: Managing Physiologic Monitoring Systems. The Joint Commission Perspectives on Patient Safety 2011; 11(12): 6-11 December 2011
ECRI Institute. Four “A’s” for Alarms (video for patients and families).
https://www.ecri.org/Video/RM_eSource/March_2011/Default.html
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
Physician-Patient Alliance for Health & Safety
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July 9-30, 2013
Tip of the Week on Vacation
August 6, 2013
Let Me Sleep!
In June 2013 physician Peter Ubel wrote an article in The Atlantic about his own experience as a hospital patient (Ubel 2013). His sleep was disrupted for routine vital sign monitoring, blood draws, and the alarm on his IV pump sounding. He notes that between 10 PM and 6 AM he did not go more than an hour without some sort of interruption. Unfortunately, his experience is the norm for hospitalized inpatients.
There are a number of interventions we can do that improve sleep in hospitalized patients. However, the two most important potentially avoidable interruptions to patient sleep in the hospital are vital sign monitoring and blood draws. Don’t get us wrong! Patients should be awakened for vital signs when appropriate (see our February 12, 2013 Patient Safety Tip of the Week “CDPH: Lessons Learned from PCA Incident”). But very often we wake patients who are clinically stable, in whom a set of middle-of-the-night vital signs may have no clinical impact.
A new study looked at ward inpatients stratified by the MEWS (Modified Early Warning Score) score (Yoder 2013). Patients with a MEWS score of 1 or less had an adverse event rate of 5.0 per 1000 patient-days whereas those with a MEWS score of 7 or more had an adverse event rate of 157.3 per 1000 patient-days. Yet the number of nighttime vital sign interruptions was no different, averaging 2 vital sign check per patient per night. At least one vital sign interruption occurred for 99% of nights. Almost half the nighttime vital sign interruptions occurred in patients with MEWS score of 1 or less.
The obvious implication is that we might be able to avoid sleep interruptions in a large proportion of hospitalized patients by tailoring vital sign frequency to the clinical risk profile of the patients, improving their sleep and overall health and, at the same time, potentially reducing costs associated with that monitoring.
Just as we often automatically (and inappropriately) order prn sleep meds in admission orders, we also often order without much thought vital signs at a frequency that is unnecessary. Moreover, a frequency of vital signs that may be appropriate on admission or in the perioperative period may no longer be necessary several days later. Yet we seldom review and modify such orders. Simply tying vital sign frequency to a MEWS score might be risky. For example, it is conceivable that a patient at risk for neurological deterioration might have a low MEWS score yet need frequent nocturnal vital sign monitoring. Perhaps a better way would be to use computerized systems to prompt the clinician to review the need for frequent vital signs when the MEWS score is low.
The accompanying editorial by Sharon Inouye outlines the many hospital factors that impair patients’ sleep in the hospital and the potential adverse effects on their health (Inouye 2013). Many of you will recognize Dr. Inouye for her work on the Hospital Elder Life Program (HELP). In that program a systemic effort is made to improve sleep in hospitalized patients by noise reduction, a nonpharmacologic sleep protocol, and coordination of nighttime care. Inouye points out that besides vital sign monitoring and blood draws, patients’ sleep is often disrupted by medication administration, IV changes or IV alarms, intermittent pneumatic compression devices, breathing treatments, fingersticks for glucose monitoring, paging systems, room or hallway lights, conversations, cleaning and waxing floors at night, etc. Moreover, she notes there is often a striking lack of coordination amongst staff that could minimize these disruptions. Simply having the phlebotomist tag team with the nurse or aide doing vital signs could avoid one disruption.
In addition to the interventions in the HELP program there have been a few intervention programs tailored to improve hospitalized patients’ sleep. One study (Bartick 2010) implemented the “Somerville Protocol” and documented a 38% reduction in patients noting sleep disruption due to hospital staff and a 49% reduction in patients receiving prn sedatives (actually a 62% reduction for patients aged 65 and older). The protocol consisted of 10 components:
A couple of those interventions merit further discussion. At many (perhaps most) hospitals, the incoming nursing staff gets vital signs when their shift starts. Hence, many patients get their vital signs checked between 11PM and midnight. Simply changing policy and procedure so that vital signs are checked by the outgoing staff at 10PM can help avoid one obvious potential sleep disruption. (Of course, you’d have to look for potential unintended consequences such as interfering with shift handoffs).
Getting physicians to understand that “three times daily” and “every 8 hours”, for example, are not the same takes some time and hard work. If I order a medication today at 10AM and enter it as “every 8 hours” my patient will be wakened at 2AM to get a dose. On the other hand, if the order is written for “three times daily” the hospital will have standard times that such are given to avoid that disruptive nighttime dose. (Note that you have to be very careful. Today’s CPOE systems often don’t make it clear when the first dose will be given. We have seen some systems where the first dose or even all the first day’s doses will not be given when the order is written this way.)
A noise monitoring device for the nursing station doesn’t need to be expensive. If a teacher can use a free or $0.99 decibel meter for his/her iPhone to alert him/her to classroom noise exceeding a specified level, we can certainly find a cheap solution to avoiding excessive noise at the nursing station or elsewhere.
But even Bartick and colleagues note that reduction in noise and light probably did not significantly improve patients’ sleep. Rather reduction in the physical disruptions probably played the major role.
Ubel, in his Atlantic article (Ubel 2013), notes that even if your hospital has such a protocol to reduce sleep disruptions we need to ensure physicians order it. He points out that making it the default option is a great way to implement change. See our July 7, 2009 Patient Safety Tip of the Week “Nudge: Small Changes, Big Impact” for more on use of the default option.
Note that we have largely avoided reference to use of sleep meds in hospitalized patients. We’ve written numerous columns on the downside of sleep meds (see the list at the end of today’s column).
In our August 2009 What’s New in the Patient Safety World column “Bold Experiment: Hospitals Saying No to Sleep Meds” we wrote about a Pennsylvania hospital’s attempt to avoid sleep meds in attempt to reduce falls and other adverse events. Doylestown Hospital implemented a significant noise reduction program and implemented other interventions to help foster natural sleep including lowering the lights, closing doors, allowing masks or earplugs, using more private rooms, and allowing personal stereos to be used.
Our March 23, 2010 Patient Safety Tip of the Week “ISMP Guidelines for Standard Order Sets” and several of our other columns have cautioned against including “prn” sleep meds in any standard order sets. And our What’s New in the Patient Safety World columns for May 2012 “Safety of Hypnotic Drugs”, November 2012 “More on Safety of Sleep Meds”, March 2013 “Sedative/Hypnotics and Falls”, and June 2013 “Zolpidem and Emergency Room Visits” highlighted many of the safety issues associated with sleep meds.
A 2009 review of sleep disturbances in hospitalized patients (Young 2009) has a good algorithm and several tables for how to approach the hospitalized patient with a sleep disturbance. While it does cover pharmacologic interventions, it also discusses non-pharmacologic interventions to help improve sleep.
Prescribing sleep meds, whether for inpatients or outpatients, is often done without much thought. All too often they are thought of as being relatively harmless. Knowing the downside is an important first step. But putting in place various system fixes (eg. removing them from standardized order sets, using clinical decision support tools, etc.) may play a more important role. Knowing and understanding how to promote good sleep hygiene is extremely important in helping patients avoid the need for such drugs in the first place.
What is your hospital doing to avoid unnecessary sleep disruptions in your inpatients?
Some of our previous columns on safety issues associated with sleep meds:
August 2009 “Bold Experiment: Hospitals Saying No to Sleep Meds”
March 23, 2010 “ISMP Guidelines for Standard Order Sets”
May 2012 “Safety of Hypnotic Drugs”
November 2012 “More on Safety of Sleep Meds”
March 2013 “Sedative/Hypnotics and Falls”
June 2013 “Zolpidem and Emergency Room Visits”
References:
Ubel P. Sleep Deprivation in Hospitals Is a Real Problem. Simple changes can make recovery more restful, and better overall. The Atlantic 2013; June 19, 2013
Yoder JC, Yuen TC, Churpek MM, et al. A Prospective Study of Nighttime Vital Sign Monitoring Frequency and Risk of Clinical Deterioration (Research Letter). JAMA Intern Med. 2013; (): Published online July 1, 2013
http://archinte.jamanetwork.com/article.aspx?articleid=1705722
Inouye SK. No Rest for the Weary…or the Sick: Comment on “A Prospective Study of Nitghtime Vital Sign Monitoring Frequency and Risk of Clinical Deterioration”. JAMA Intern Med. 2013; (): doi:10.1001/jamainternmed.2013.7809 Published online July 1, 2013
http://archinte.jamanetwork.com/article.aspx?articleid=1705720
Bartick MC, Thai X, Schmidt T, et al. Decrease in As-needed Sedative Use by Limiting Nighttime Sleep Disruptions from Hospital Staff. Journal of Hospital Medicine 2010; 5: E20–E24
Young JS, Bourgeois JA, Hilty DM, Hardin KA. Sleep in Hospitalized Medical Patients, Part 2: Behavioral and Pharmacological Management of Sleep Disturbances. Journal of Hospital Medicine 2009; 4: 50-59
http://onlinelibrary.wiley.com/doi/10.1002/jhm.397/pdf
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August 13, 2013
Adverse Events in
Home Care
Adverse events, of course, occur across all venues in the healthcare continuum. We tend to focus most on hospitals, ambulatory surgical centers, and ambulatory care sites. But one particular venue that has been underrepresented in the patient safety literature is home care. As hospitals have ratcheted down lengths of stay and with the increasing focus on avoiding readmissions, home care has taken on an increasingly important role in quality improvement and patient safety. Home care often deals with patients during their most vulnerable transitions of care. Yet we’ve largely ignored it for many years.
Now our Canadian colleagues have taken the lead in a series of studies analyzing adverse events occurring in the home care setting (Sears 2013, Blais 2013, Doran 2013). The first study analyzed adverse events in 430 patients in 3 publicly funded home care programs in Ontario, Canada (Sears 2013). In the second study, the authors did chart review of 1200 patients receiving publicly funded home care randomly selected in 3 Canadian other provinces (Blais 2013). The third study (Doran 2013) includes many of the authors of the other two publications and uses some of the same data sources but further expands on some of the contributing factors. Though there may be differences in the health systems between Canada and the US we suspect that most of the findings and lessons learned apply equally to home care in the US.
The studies used a dual chart review technique. Nurses did chart abstractions and reviews and flagged cases meeting pre-specified screening criteria for adverse events (AE’s). Then physician reviewers did chart reviews to determine the presence of adverse events and assessed the preventability of those events.
The Sears study found 66.5% of charts reviewed were positive for one or more of the screening criteria. Adverse events were found in 12.8% of patients sampled and after adjustment for the number of patients at each site determined the overall AE rate was 13.2%. Overall a third of the AE’s (32.7%) were rated as preventable.
The Blais study found that 4.2% of patients discharged from the home care programs in a 12-month period experienced an adverse event. However, to account for varying lengths of time patients were receiving home care services the authors converted the rates to an adverse event per client-year rate. That adverse event rate was 10.1% per client-year. Importantly, over half the events (56%) were considered potentially preventable by the reviewers.
It is highly likely that these AE rates represent underestimates of the actual rates. The Blais study found a significant discrepancy between adverse events found by the chart reviewers and those actually documented as such in the patient charts. Only 17.3% of such charts indicated that an incident report had been completed.
The most common adverse events encountered in the Blais study were falls, wound infections, medication errors, and psychosocial, behavioral or mental health problems. In the Sears study the most commonly encountered adverse events were falls, medication errors, decubiti/skin breakdown, general decline, and delayed healing or infection.
As expected, some patient level factors were associated independently with the risk of adverse events. In the Blais study these included the number of comorbid conditions and impairment of the ability to perform activities of daily living. Sears et al. also found number of comorbid conditions and impaired ADL’s as risk factors. They also found age >65, living alone, communications difficulties due to cognition, history of falls, use of psychotropic medications, depression, anxiety and anger, and social isolation as risk factors for adverse events in the home care setting.
Blais et al. point out that one of the most significant differences between hospital care and home care is that in home care the patient and family or other informal caregiver provide much of the care. So, while the authors found the healthcare personnel contributed to 46% of the adverse events, they also found that patients themselves and informal caregivers contributed to 48.4% and 20.4% of adverse events, respectively. Similarly, Sears et al. found that decisions and care provided by healthcare workers likely contributed to adverse events in 29.5% of cases, informal care giving by family or friends in 27.9%, and patient self-care in 52.6% but in many cases there were multiple contributing sources.
The Doran study (Doran 2013) identified six safety-related themes:
In addressing the first theme they note that homes, particularly those of the chronically ill, are rarely suited to the provision of safe healthcare, often being run down, cluttered, dirty, with icy walkways, halls blocked by wheelchairs and walkers, and cramped spaces with little room for treatment-related equipment. They often also have hazards related to snow, tobacco smoke and pets.
The second theme deals with a host of system issues that make it difficult to provide and receive care in the home. They note that the services tend to come from multiple sources and the providers are ever-changing. Patients have difficulty finding out about available programs and how to apply for services. Staff turnover is high in the home care field and communication poor. The communication deficiencies impact not only the patients but also the home care worker, perhaps contributing to the high turnover. There may be waiting times for equipment and therapists. Standards, formal training and certification of HC workers are needed to improve safety.
Regarding duty creep, unpaid caregivers often have to cut down their own work hours or even quit their jobs. They have less time for their regular family responsibilities and for the activities that they would normally enjoy.
“Doing what it takes to stay at home”: Clients and caregivers have a tendency to hide their needs and even to refuse care out of fear that they might have to give up living independently. Some take fewer services than they are entitled to because they do not want strangers coming into their homes.
Caregivers are often elderly spouses or retired children and the physical and emotional demands of caring can lead to serious declines in their health with stress, isolation, depression and anxiety.
Doran et al. also identified four themes dealing with systemic weaknesses:
Examples of inconsistently planned and delivered care include that most of the falls-related incidents occurred with clients who had well-established histories of falls and in most cases medication was a contributing factor. There was often ambiguity regarding which of the healthcare workers had the responsibility and authority to act and what options they had available. Once allocated home care services reached their maximum case managers had little or no authority to increase needed care. Poor documentation and communication in a setting of frequently changing providers often resulted in failure to identify patient deterioration. Typically there was no single person who had a complete overview of the patient.
Lack of an interdisciplinary health care team, like we usually utilize in hospitalized patients, is also problematic. An example they give is a home care patient with multiple comorbidities and multiple medications who develops urinary urgency, possibly related to a change in medication, and then falls during one of many increased trips to the bathroom, suffering a fractured hip. Communication from the primary care provider or pharmacist to the home care workers that might have helped avoid this adverse event did not occur.
Packaging of medication and direction for its use is often problematic for home care patients. Similarly for care-associated equipment there are variations in makes, models, and instructions-for-use that often lead to confusion. Standardization in both areas is much needed.
Lastly, balancing a patient’s right to autonomy, independence and ultimate decision-making against the risk those decisions might put the patient’s safety in jeopardy is difficult. Efforts to provide the patient and informal care givers with the necessary training is critical.
The Doran paper goes on to make a series of recommendations for organizations, policy makers, and researchers. For organizations they recommend offering unpaid caregivers training, ongoing support, counseling and health assessments. They also recommend a focus on implementing policies and procedures to safely manage medication in the HC setting. And, perhaps most important in our mind, they recommend assigning a case manager for each home care client. That case manager should have skills across the continuum of care, be knowledgable across disciplines, and be vested with the authority and responsibility required to ensure the planning and delivery of a consistent quality of safe care and basically act as “a quarterback”. Development of a “transitions checklist” for each home care patient is also a recommendation.
Recommendations for policymakers include developing standard competencies for home support workers, exploring opportunities for increased collaboration between home care and institutional care, building integrated, interdisciplinary healthcare teams to ensure continuity across all transitions, implementing a common electronic chart accessible by all caregivers from all sectors, expanding the use of electronic reporting and communication tools, and standardizing medication packaging and equipment. Also, because they had noted that patients with COPD often ran out of oxygen they recommended that restrictions on supply of portable oxygen be lifted.
For researchers they recommend development of a national set of reportable adverse events and development and standardization of policies specific to the process and timing for risk assessments.
One of the problems we commonly see in the US in the home care setting is that one physician (often a hospitalist or hospital-based specialist) may make the initial referral to home care but never again actually care for that patient. The patient’s primary care physician often gets subsequent calls and questions about that patient and he/she may not have even seen the patient in the interim. For that reason we usually recommend that the hospitalist make a physician-to-physician contact with the PCP at discharge or that the PCP actually be invited to call in to the interdisciplinary meeting occurring in preparation for hospital discharge.
The lack of integration or interoperability between medical records in the hospital and ambulatory setting and the home care agency has been another major problem in the US. The development of RHIO’s and HIE’s is a first step but full integration is a long way off.
Home care in the US is plagued by the same high turnover rates and lack of continuity found by the Canadian researchers. In addition, in many areas hours of availability of home care workers is a major issue. And in rural areas home care availability is considerably less than in urban areas.
Access to homes may be problematic. As in the Canadian studies, we often see that patients are reluctant, for a variety of reasons, to let strangers enter their homes. That is where we have found that use of the community health worker may be beneficial. Such workers are lay people who are well-known and trusted in their communities who may be able to improve communication between patients and the medical community.
In the US, the move to develop accountable care organizations (ACO’s) has prompted groups to integrate care across the entire continuum. Yet one of the weakest links we have seen in accountable care organizations has been home care. Often home care is not considered a core service of the ACO and is “farmed out” or contracted out to existing home care agencies. The result is often a lack of common incentives.
Particularly in recent years in the US there has been a downturn in the financial viability of home care agencies and a decline in reimbursement for many home care services. So many are getting out of the home care business as a business per se. Yet from a system perspective (eg. ACO) the reimbursements for individual home care services is of lesser importance compared to the potential savings from avoiding adverse events that might lead to emergency department visits or hospital admissions.
Commentaries from readers in the Toronto, Ontario media after publication of the Canadian reports are also very revealing and help point out some of the likely root causes contributing to adverse events in the home care setting (Goar 2013, Readers’ Letters 2013). They note that that home care workers generally earn 5-6 dollars less than similar workers based in hospitals. They often also lack pensions and other benefits. They also often have sparse work hours and may not be paid for time spent between clients.
We find particularly compelling the arguments about salary levels for home care workers. The average payments for nurses and aides providing home care is generally less than that paid in hospital or office or other traditional ambulatory settings. In addition, home care workers often are part-time. Having pay scales and working conditions more conducive to avoiding the high turnover rates might be cost-effective in the long run if it helped avoid unnecessary visits to the emergency department or unnecessary hospitalizations.
We think you’ll find these 3 excellent Canadian studies to be extremely helpful if you are already an ACO or are contemplating becoming one. You have to recognize the key role that home care plays in the big picture. Even if you are not considering becoming an ACO you need to recognize the risks for your patients in home care and what you can do to mitigate those risks. Lastly, hospitals at risk for readmission penalties need to recognize that adverse events related to home care are a major factor in readmissions.
References:
Sears N, Baker GR, Barnsley J, et al. The incidence of adverse events among home care patients. Int J Qual Health Care 2013; 25:16–2
http://intqhc.oxfordjournals.org/content/25/1/16.full.pdf+html
Blais R, Sears NA, Doran D, et al. Assessing adverse events among home care clients in three Canadian provinces using chart review. BMJ Qual Saf doi:10.1136/bmjqs-2013-002039 (published online first 4 Jul 2013)
http://qualitysafety.bmj.com/content/early/2013/07/02/bmjqs-2013-002039.short?g=w_qs_ahead_tab
Doran D, Blais R, et al. Safety at Home. A Pan-Canadian Home Care Safety Study. Canadian Patient Safety Institute 2013
Goar C. Ontario home care more hazardous than families told: Goar. Research by two professors shows that home care is less safe than institutional elder care. Toronto Star 2013; July 5, 2013
Readers’ Letters. Home care safer for most than hospital. Toronto Star 2013; July 10, 2013
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August 20, 2013
Lessons from Canadian Analysis of Medical Air Transport Cases
We’ve done numerous columns about fatal accidents involving medical helicopter services or other medical air transport services (see list at the end of today’s column). We’ve often focused on the question of whether there was a legitimate indication for air transport (as opposed to ground transport).
Unfortunately, in the US there is little oversight of medical air transport services. The FAA has limited jurisdiction over such services. The NTSB reports of such accidents do a great job looking at the mechanical, environmental, and human factors involved in such crashes. However, they never delve into the question of necessity for air transport. Many trauma systems do review air transport cases as part of the quality assurance activities. However, most other cases of medical air transport are never reviewed for necessity by either the sending or receiving hospitals and there are few or no state agencies overseeing the medical air transport industry.
In Ontario, Canada a commission was recently appointed to study deaths related to air ambulance services and that commission has just released its report (Muir 2013). Note that this was not a study of helicopter (or other air transport vehicle) crashes but rather a study looking at deaths of patients who had been transported by air ambulance. Cases were identified via a variety of flags but ultimately 40 cases were included in the final review by an expert panel. Cases were stratified by the likelihood that the air ambulance transport had had an impact on the fatal patient outcome. The report has 25 recommendations. We dare say that most apply equally to the medical air transport industry in the US.
Decision-making was a major theme identified. The panel noted that for any given patient transport, decisions must be made regarding both medical and operational issues. Medical professionals need to make medical decisions and operational professionals need to make operational decisions. The Expert Panel found that there were issues with decision-making in 21 of 40 cases. In many of these cases, medical professionals were making operational decisions and vice versa.
The review determined that many avoidable delays occurred when the responsibility for different aspects of the decision-making became blurred. They note that this also involves information exchange with sending and receiving facilities, caregivers and associated land transportation providers and that often the most appropriate form of transportation is not via air ambulance. They also note that when timelines are impacted by unforeseen developments during the course of a transport, revised decisions may be needed and communicated to all parties.
They go on: “When many people become involved in the decision-making on a given case, the ability to maintain situational awareness may become compromised. For instance, when multiple call takers and flight planners take part in coordinating a flight, incomplete or inaccurate information hand-offs and lack of awareness of “the big picture” may result in incorrect decision-making. While such scenarios were noted to be a concern in only a relatively small number of cases included in the Review, the importance of this cannot be overstated.”
“Finally, a common misperception exists that air ambulance transport is the fastest, and therefore the most effective and efficient form of transport. This, however, is not always the case and needs to be considered in full when making decisions surrounding air versus land transport. The Expert Panel identified that appropriateness of transport was an issue in 15 of the 40 cases reviewed.”
A specific recommendation on decision making: “Decision-making around mode of transport (air versus land) for inter-facility transfers should be coordinated between the Transport Medicine Physician, operations staff, and, where possible, the sending and receiving physician(s). This should include a consideration of the various options available, including the expected transfer times via each route.”
Another recommendation: “If, in the course of a transport, it appears that an unanticipated delay will occur (due to weather or mechanical issues), the Transport Medicine Physician should be consulted so that a decision can be made whether or not to proceed with air versus land transport. Whenever possible, decision-making in such situations should involve input from the sending and receiving physicians.”
Another recommendation is that at the communications center all reasonable efforts should be made to minimize hand-offs of a given call between call-takers and other staff, and to ensure that all staff maintain situational awareness of calls in progress, assets available, and other critical operational information. In several cases decision-making was hampered by a lack of complete awareness on the part of the call-taker about both the call details and the options available for response. The problem was compounded when multiple calls were in progress simultaneously, and when multiple persons within the Communication Centre were managing the call.
Other recommendations had to do with response processes, scene (of accident) responses, and special considerations such as remote locales, international transports, communication, aircraft/equipment, staffing, paramedic training/education/certification, and investigation/quality assurance.
With the exception of some trauma hospitals, most hospitals we’ve seen in the US (whether sending or receiving hospitals) don’t do quality assurance reviews on their air transport cases. Both hospitals need to be aware of the previous track record of such transports to and from specific locations. Without that it is difficult to render the most appropriate patient care. For example, if a remote hospital is transporting a patient to a tertiary center for percutaneous coronary angioplasty for an MI and the statistics suggest that such patients seldom arrive within the standard window for PTCA, the remote hospital should consider giving thrombolytic therapy before sending the patient. The real question you should always be asking is “What’s the fastest way to get the patient/victim the medical interventions he needs?” and then assessing the risk:benefit ratio of air vs. ground transport.
Surprisingly little information is shared between sending and receiving hospitals. Sometimes the air ambulance company may provide logs of takeoff and arrival times but seldom does the receiving hospital get back to the sending hospital regarding outcomes and full timelines (eg. time to PTCA).
Does your hospital do quality assurance and improvement activities related to air transports? Do you share it with the sending (or receiving) hospital? Do you include statistics about air transport with your new ER providers during their orientation? Do you regularly assess your transports by clinical type (eg. MI, stroke, neonatal, trauma, etc.)? How often have you reassessed your decision about mode of transport when an unexpected delay pops up?
Not included in the Canadian report was a fatal air ambulance (helicopter) crash that occurred in Ontario in May 2013. But it does have some safety implications. In that incident, 2 pilots and 2 paramedics died in a crash of a helicopter that had just taken off in northern Ontario to pick up a patient. It was a nighttime flight. In northern Ontario there are broad swaths of land having no lights, often referred to by pilots as “black holes”. Such absolute darkness can be extremely disorienting for pilots. This particular helicopter apparently had neither a ground proxmity warning system, also known as a terrain awareness and warning system (Campion-Smith B May 31, 2013, Campion-Smith B June 24, 2013), nor night vision goggles (Campion-Smith B July 20, 2013), 2 types of equipment that have been strongly recommended for medical ambulance services in the US. In Canada the terrain proximity warning systems are required for fixed wing aircraft but not helicopters.
Though the investigation by the Transportation Safety Board of Canada won’t be complete for about a year, there were likely other root causes. The Toronto Star had done multiple articles about problems with ORNGE, the air ambulance service. Such included bringing the fleet and oversight of the aviation issues internally (Campion-Smith B June 22, 2013). Previously the aviation services had been provided by Canadian Helicopters, Ltd. which had operated Ontario’s medical helicopters since 1977 without fatalities. Many felt that ORNGE did not have the internal expertise to oversee the fleet. They had also centralized command operations in southern Ontario, removing some personnel that had been based at local bases. Apparently there had been an exodus of experienced pilots in recent months. Multiple issues had been raised regarding pilots meeting required training updates (Campion-Smith B July 15, 2013). They had even suspended night flights in some locales until training in night flights was done. In addition, specific training for flying in the “black holes” was in 2 parts, one a simulation and the other practical. It turns out that the simulation training was done on a helicopter simulator different from the helicopters typically flown by ORNGE. The pilot and first officer, while both experienced pilots, apparently were relatively new to their current assignments and some have felt that violated the rule not to pair “green-on-green”, i.e. 2 inexperienced pilots should not be assigned together.
Reports in the media don’t mention the nature of the medical condition necessitating the helicopter transport. However, it should be noted that towns are few and far between in this rather remote area of northern Ontario so it is usually much easier to justify air transport there than in southern Ontario, which is much more urban.
Our previous columns have many of the questions that should be being asked when considering air vs. ground transport for transfers. We think you’ll find them of interest from both a clinical and system perspective:
July 8, 2008 “Medical Helicopter Crashes”
October 2008 “More Medical Helicopter Crashes”
February 3, 2009 “NTSB Medical Helicopter Crash Reports: Missing the Big Picture”
September 1, 2009 “The Real Root Causes of Medical Helicopter Crashes”
November 2010 “FAA Safety Guidelines for Medical Helicopters Short-Sighted”
March 2012 “Helicopter Transport and Stroke”
April 16, 2013 “Distracted While Texting”
References:
Muir C, et al. Review of Ornge Air Ambulance Transport Related Deaths. Office of the Chief Coroner for Ontario. July, 2013
Provincial air ambulance deaths lead to 25 recommendations
Tuesday, July 16, 2013 by: SooToday.com Staff
http://www.sootoday.com/content/news/details.asp?c=59393
Pilot questions need hard answers in ORNGE copter crash: Editorial
thestar.com June 25, 2013
Campion-Smith B. ORNGE chopper lacked safety system. ORNGE helicopter involved in fatal crash lacked a ground proximity warning system that may have alerted pilots to imminent collision with the ground. thestar.com June 24, 2013
http://www.thestar.com/news/canada/2013/06/24/ornge_chopper_lacked_safety_system.html
Campion-Smith B. ORNGE helicopter crash: “Black hole” effect could have brought down air ambulance. “Black hole” effect, mechanical failure and pilot error among possible causes as probe begins into crash of ORNGE air ambulance in northern Ontario. thestar.com May 31, 2013
Campion-Smith B. Ornge helicopter crash prompts safety concerns. Fatal helicopter crash sparks concerns about Ornge's management of its chopper fleet. thestar.com June 22, 2013
http://www.thestar.com/news/canada/2013/06/22/ornge_helicopter_crash_prompts_safety_concerns.html
Campion-Smith B. ORNGE: Inspection revealed pilot training woes at ORNGE. Four months before a fatal crash, ORNGE was forced to suspend operations and ground pilots after problems uncovered with training and paperwork. thestar.com July 15, 2013
Campion-Smith B. ORNGE considers night-vision goggles for its aircraft. Two nighttime crashes prompt a second look at goggles that help pilots see their surroundings and avoid disorientation in deep darkness. thestar.com July 20, 2013
Crash prompts ORNGE to consider night vision goggles.
EMS Flight Crew blog
http://emsflightcrew.com/blogs/crash-prompts-ornge-consider-night-vision-goggles
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August 27, 2013
Lessons on Wrong-Site Surgery
Once again we can benefit from lessons learned in the most recent California Department of Public Health release of root cause analyses and plans of correction for serious events (CDPH 2013). Of the 10 cases in this most recent release, 2 involved wrong-site surgery and we think that many of the contributing factors are still commonplace occurrences at many other hospitals.
The first case involved removal of the wrong kidney (CDPH 4PPX11). An elderly man had suspected cancer involving the left kidney seen on a CT scan. However, when he was admitted for surgery the healthy kidney (right kidney) was removed rather than the left kidney. As we usually see in cases where errors lead to patient harm, there was a cascade of errors and contributing factors that led to the untoward outcome.
First, and foremost, was the fact that the CT scan images were not present in the OR. The CT scan had been performed at a hospital other than the one where the surgery was being performed and those images were not available either in hard copy or on the PACS system. Moreover, the reports of the CT scan were in the surgeon’s office and were not available in the OR.
We discussed in detail issues related to availability of images in the OR in our January 1, 2013 Patient Safety Tip of the Week “Don’t Throw Away Those View Boxes Yet”. We encourage you to read that since it had many insights into issues with images in the OR.
Remember, your surgical timeout procedure must include verification of correct patient (using multiple identifiers), the surgical procedure(s) to be done, the side or site of surgery, and must use multiple primary documentation sources in this process. Primary source materials include things like the H&P, the booking form, the consent form, and imaging studies. Yet we commonly see that failure to review imaging studies (or even the reports) occurs frequently.
In the January 1, 2013 column we noted that having all necessary images available in the OR is important for the surgeon but, frankly, may not help much in the verification process during the surgical timeout. That’s because all the other personnel in the room (nurses, surgical techs, CRNA’s and anesthesiologists) may not be able to interpret the images and thus might not appreciate which is the correct side to be operated on. In some images the most salient feature may, in fact, be an incidental finding and not relevant to the reason for which the surgery is being done. So from the standpoint of the verification during the surgical timeout you are probably better off having a copy of the radiology report and all parties should rely on that report as a primary source document for site verification.
We strongly recommend that you not schedule surgery until you (the hospital or ASC) have in hand copies of the H&P, the booking form, the consent form, and imaging studies. While you might provide a tentative date and time for surgery you must have a “drop dead” date on which you will cancel that tentatively scheduled slot if you have not received these items. Things like the H&P may need updating to meet regulatory time frames but you should have available at least the H&P from the office at the time the case was originally scheduled.
Our June 5, 2007 Patient Safety Tip of the Week “Patient Safety in Ambulatory Surgery” noted that ambulatory surgery is particularly vulnerable to missing documents because those documents are usually in the surgeon’s office rather than at the hospital. That is why you need to be firm in your requirement for such documents before cases are scheduled.
Your surgeons may be unhappy with such requirements at the beginning and you may even incur the wrath of some patients when you cancel a tentative case in which the documents were not provided. But once they understand you mean business that will become a normal part of their workflow as well.
By the way, errors and miscommunications during the surgical booking and scheduling process are major contributors to wrong-site surgery. See our October 30, 2012 Patient Safety Tip of the Week “Surgical Scheduling Errors” for details and more recommendations about scheduling and booking.
A second major contributory factor was the fact that the patient said the surgery was to be on the right side. While Joint Commission and other regulators require involvement of the patient in the site verification process (and we concur with that) we have also seen numerous cases of wrong-site surgery in which the patient has incorrectly identified the site (in fact, in the wrong kidney case in our January 1, 2013 Patient Safety Tip of the Week “Don’t Throw Away Those View Boxes Yet” the patient also indicated the wrong side). So while the patient should be involved, you must still use all your primary source verification resources and don’t be overconfident with the patient’s identification of site.
A third contributory factor was the level of involvement of all members of the surgical team. The anesthesiologist stated that he did not ordinarily meet with the surgeon and go over the imaging studies and did not typically review test results (X-rays) “as it was not a standard of care”. Well, guess what – it is a standard of care to do verification using primary source documents and that includes radiology reports. So while the anesthesiologist need not be expert at interpretation of all radiology imaging, he/she must still look at reports to ensure that the site and laterality of the imaging finding correspond to the site and laterality identified by the H&P, consent, booking form, and site marking.
Another possible contributory factor was change in personnel. The circulating nurse was 10 minutes late so asked a second to interview the patient in the OR. In addition, the assistant surgeon originally scheduled to help on the case called in sick so a different assistant surgeon had to be called in. That assistant surgeon entered the OR after the initial incision had been made. It does not sound from the case description that a second time out occurred. Good practice dictates that whenever a second surgeon is not present for the time out, a second time out should take place.
The plan of corrections (POC) submitted by the hospital included revision of the Universal Protocol policy to specifically include language that all relevant images or studies be displayed and reviewed as part of the time out. They also developed a standardized checklist to ensure that relevant documentation, including any imaging studies or pathology reports, be available before the start of the procedure. And they added requests for such images or studies to the surgical scheduling process. The POC also included a plan for auditing for compliance with the image/report requirements.
The second case (CDPH ZGPR11) involved an initial incision made on wrong side for a planned left inguinal orchiectomy. Once again, multiple factors contributed. Apparently no surgical site marking was done. The surgeon went to see the patient pre-op but the anesthesiologist was with the patient and the surgeon did not return to mark the site. A pre-op nurse documented on the pre-op checklist that the site had been marked but, when interviewed, said she “assumed” the surgeon had marked the site. However, she also stated that she had not checked off “site initialed” on the Surgical Passport (a handoff tool with required items before a patient can be transferred to the OR). Though a time out was said to have taken place in the OR there was obviously no verification of the site marking and the surgeon had a nurse shave and prep the right inguinal region and he then made an initial small incision before the surgical team realized this was to be a left inguinal orchiectomy. The surgeon did promptly notify the patient and his wife immediately after the surgery of the error.
Also, though the H&P had noted that an ultrasound had documented the testicular lesion there was no indication as to whether the ultrasound image or report was present in the OR and used as part of the site verification process.
The real lesson here is, unfortunately, that in some OR’s corners are cut, assumptions made, and the degree of focus and participation in the time out is suboptimal. Though a checklist designed to prevent the patient from entering the OR without verification of all items had some items not checked, the patient was still moved to the OR. That is likely an example of “normalization of deviance” where successes despite problems lead to the acceptance of such problems and deviations as “normal” and therefore tolerable (akin to the Challenger disaster and described in our July 5, 2011 Patient Safety Tip of the Week “Sidney Dekker: Patient Safety. A Human Factors Approach”).
The time out obviously missed the fact that there was no surgical site marking. And though all participants apparently concurred that the procedure was to be a left inguinal orchiectomy, the surgeon proceeded to do an incision on the wrong inguinal region and no one immediately corrected him. Perhaps this was an example of “inattentional blindness” (see our February 7, 2012 Patient Safety Tip of the Week “Another Neuromuscular Blocking Agent Incident”). But suffice it to say that we often see OR’s in which some or all members of the surgical team go through the time out in a perfunctory manner. All members of the team should take an active role in the time out. It is not acceptable for any of them to simply nod their concurrence. Each should actively state all the elements of the verification process. We also like the “Minnesota Timeout” concept in which someone other than the surgeon leads the time out process. That helps prevent team members from simply agreeing with the surgeon.
The hospital’s plan of correction (POC) had lots of education about compliance with the Time Out process and the Passport (handoff) tool. But it also included direct observational audits.
While we are strong advocates of the observational audit (see our March 5, 2013 Patient Safety Tip of the Week “Underuitilized Safety Tools: The Observational Audit”) the presence of an “outside” observer in the OR often leads to behaviors other than the usual behavior. An alternative approach we’ve espoused on numerous occasions is using audio/video recording of OR cases. When such are used in a constructive, nonpunitive manner they can be very helpful in demonstrating team communication issues. They can also be extremely helpful in demonstrating how well the Time Out is being done.
Use of checklists has been very helpful in improving outcomes and reducing complications in surgery (see our Patient Safety Tips of the Week for September 23, 2008 “Checklists and Wrong Site Surgery”, July 1, 2008 “WHO’s New Surgical Safety Checklist”, and January 20, 2009 “The WHO Surgical Safety Checklist Delivers the Outcomes”). However, the impact of checklists on wrong-site surgery remains difficult to quantify. And the case above illustrates some of the problems with compliance with checklists.
Two recent papers also highlight issues with compliance with checklists. One paper in press (Sparks 2013) demonstrates how poorly we might comply with the Surgical Safety Checklist. While participation in the checklist at a large tertiary teaching center improved to 94% over a year, accuracy of completion of the checklist was only 54% at one year. Though compliance with the “time out” portion of the checklist was better than other portions, the authors conclude that significant barriers remain and there is much room for improvement.
A second study (Aveling 2013) compared compliance with the WHO Surgical Safety Checklist between high- and low-income countries. Though it found considerably more difficulties with compliance in the low-income countries (for a variety of reasons but mostly lack of resources and cultural issues), it also identified issues even in high-income countries like the UK. While use and completeness of the checklists was high in the UK, “fidelity” was often problematic. The researchers found that sometimes staff was “distracted, dismissive, or absent” during checks. Full attention and focus were not always happening and sometimes the Sign In portion was done at the same time as the Time Out portion after the patient was already anesthetized. The study really focused on hierarchical influences and the culture of safety and teamwork.
The factors and circumstances that contribute to wrong-site surgery are manifold and complex. You’ve all put in place policies and procedures that you think will help avoid such incidents. But how closely does your organization follow those procedures? The “fidelity” of the “Time Out” or the “Sign In” or the pre-op huddle is critical. Most organizations really have little idea of how well those are done. We hope you’ll read some of our many previous columns relating to wrong-site surgery listed below.
Some of our prior columns related to wrong-site surgery:
Patient Safety Tip of the Week columns:
September 23, 2008 “Checklists and Wrong Site Surgery”
June 5, 2007 “Patient Safety in Ambulatory Surgery”
March 11, 2008 “Lessons from Ophthalmology”
July 1, 2008 “WHO’s New Surgical Safety Checklist”
January 20, 2009 “The WHO Surgical Safety Checklist Delivers the Outcomes”
September 14, 2010 “Wrong-Site Craniotomy: Lessons Learned”
November 25, 2008 “Wrong-Site Neurosurgery”
January 19, 2010 “Timeouts and Safe Surgery”
June 8, 2010 “Surgical Safety Checklist for Cataract Surgery”
December 6, 2010 “More Tips to Prevent Wrong-Site Surgery”
June 6, 2011 “Timeouts Outside the OR”
October 30, 2012 “Surgical Scheduling Errors”
January 1, 2013 “Don’t Throw Away Those View Boxes Yet”
August 27, 2013 “Lessons on Wrong-Site Surgery”
What’s New in the Patient Safety World columns:
July 2007 “Pennsylvania PSA: Preventing Wrong-Site Surgery”
August 2011 “New Wrong-Site Surgery Resources”
December 2011 “Novel Technique to Prevent Wrong Level Spine Surgery”
January 2013 “How Frequent are Surgical Never Events?”
References:
CDPH (California Department of Public Health). CDPH Issues Penalties to Ten Hospitals. CDPH 2013 8/15/2013
http://www.cdph.ca.gov/Pages/NR13-036.aspx
CDPH (California Department of Public Health). Event ID ZGPR11
http://www.cdph.ca.gov/certlic/facilities/Documents/2567SharpMemorial-ZGPR11-SanDiegoCounty.pdf
CDPH (California Department of Public Health). Event ID 4PPX11
http://www.cdph.ca.gov/certlic/facilities/Documents/2567StJudeMedicalCenter-4PPX11-OrangeCounty.pdf
Sparks EA, Wehbe-Janek H, Johnson RL, et al. Surgical Safety Checklist Compliance: A Job Done Poorly! Abstract presented at the American College of Surgeons 98th Annual Clinical Congress, Surgical Forum, Chicago, IL, 2012. Journal of the American College of Surgeons 2013; DOI: 10.1016/j.jamcollsurg.2013.07.393 published online 22 July 2013.
http://www.journalacs.org/article/S1072-7515%2813%2900902-2/abstract
Aveling, EL, McCulloch P, Dixon-Woods M. A qualitative study comparing experiences of the Surgical Safety Checklist in hospitals in high and low-income countries. BMJ Open 2013; 16 Aug 2013 3:e003039 doi:10.1136/bmjopen-2013-003039
http://bmjopen.bmj.com/content/3/8/e003039.full
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September 3, 2013
Predicting Perioperative Complications: Slow and Simple
We’ve long advocated major change in the way we prepare patients, particularly the elderly, for surgery (see our August 17, 2010 Patient Safety Tip of the Week “Preoperative Consultation – Time to Change” and the multiple columns listed at the end of this column). Historically the pre-op workup has included multiple testing that has little impact on patient outcomes. Unfortunately, past habits are hard to break and we continue to see lots of unnecessary testing and lack of focus on potentially more meaningful evaluations. For example, identification of patients at risk for delirium, those who are frail, and those who have diagnosed or undiagnosed sleep apnea is much more likely to identify patients at risk for complications than doing extensive cardiac studies in patients lacking a history of heart disease.
There has been some progress in doing a more streamlined assessment to predict the risk of complications in patients undergoing surgery. This past year the ACS NSQIP Surgical Risk Calculator has received some attention as a relatively simple-to-administer tool to help predict surgical risk based upon nature of the surgical procedure and assessment of multiple patient risk factors. Based on data from over 1.4 million patients in the American College of Surgeons NSQIP database, the calculator has been shown to be useful in predicting complications for most common surgical procedures (Bilimoria 2013). We think that this is an excellent tool and should be used in just about all patients contemplating surgery. We expect that surgeons will use the estimated risk prediction in their informed consent discussions with their patients.
But we still need to address simplification and optimization of the pre-op evaluations commonly performed by primary care physicians. We’ve done multiple columns on the ability of measures of frailty to predict postoperative complications, morbidity and mortality, and discharge to institutional settings. We have previously highlighted the contributions by Makary and colleagues (Makary et al 2010) and Robinson and colleagues in predicting postoperative complications based on frailty measures (Robinson 2009, Robinson 2011).
Now Robinson and colleagues have again demonstrated in two new studies the value of measures of frailty in predicting postoperative complications and morbidity. In the first study (Robinson 2013a) the authors looked at 7 frailty traits in patients 65 years or older who were undergoing either major colorectal surgery or cardiac surgery. The frailty traits were a Katz score less than or equal to 5, Timed Up and Go test greater than or equal to 15 seconds, Charlson Index greater than or equal to 3, anemia less than 35%, Mini-Cog score less than or equal to 3, albumin less than 3.4 g/dL, and 1 or more falls within 6 months. Patients were considered nonfrail if they had 0 to 1 of these traits, prefrail if they had 2 to 3 traits, and frail if they had 4 or more traits. Preoperative frailty was associated with increased postoperative complications after colorectal (nonfrail: 21%, prefrail: 40%, frail: 58%) and cardiac operations (nonfrail: 17%, prefrail: 28%, frail: 56%). The findings remained significant even after adjustment for age. Frail individuals in both groups also had longer hospital stays and higher 30-day readmission rates.
In the second study (Robinson 2013b) the authors looked at the ability of the Timed Up and Go test (see our November 2011 What’s New in the Patient Safety World column “Timed Up-and-Go Test and Surgical Outcomes”) to predict postoperative morbidity and 1-year mortality, and to compare the Timed Up and Go to the standard-of-care surgical risk calculators for prediction of postoperative complications. The Timed Up and Go test was performed preoperatively in a cohort of patients 65 years and older undergoing elective colorectal and cardiac operations. This timed test starts with the subject standing from a chair, walking 10 feet, returning to the chair, and ends after the subject sits. Timed Up and Go results were grouped as fast <= 10 seconds, intermediate = 11-14 seconds, and slow >= 15 seconds.
They found that slower Timed Up and Go predicted increased postoperative complications and 1-year mortality across surgical specialties and that, regardless of operation performed, the Timed Up and Go compared favorably to more complex risk calculators at forecasting postoperative complications.
For colorectal surgery patients the rates of postoperative complications were 13%, 29%, and 77% for the fast, intermediate, and slow categories respectively. For cardiac surgery patients the rates of postoperative complications were 11%, 26%, and 52% for the fast, intermediate, and slow categories respectively.
The authors note that the Timed Up and Go detects multidimensional clinical deficits of the older adult, capturing the broader concept of frailty. For example, a slower Timed Up and Go is closely related with impaired cognition. They also note that there is a close correlation between the Time Up and Go and gait speed in general.
However, since we stress the value of evidence-based medicine, we need to ask the question “Does the ability to predict this increased risk of complications make a difference in outcomes?”. Robinson and colleagues are quick to point out that, to date, there is no evidence that suggests measurement of a preoperative Timed Up and Go can improve outcomes. They suggest a logical step after identification of a slow Time Up and Go test result might be pre-op physical therapy but such has not been shown to reduce complications or mortality in previous studies. However, since the test is really a measure of more global capacity we really would not expect an intervention aimed purely at mobility improvement to alter outcomes substantially. Rather, we might expect that upon identification of a slow Timed Up and Go test result patients might be shunted into a program like HELP (the Hospital Elder Life Program). In our September 2011 What’s New in the Patient Safety World column “Modified HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery” we discussed studies (Inouye 1999, Chen 2011) demonstrating improved outcomes after such multicomponent interventions.
The Timed Up and Go or gait speed in general have utility far beyond just predicting surgical complications. In our August 14, 2012 Patient Safety Tip of the Week “Gait Speed: A New Vital Sign?” we noted the relationship between gait slowness and overall survival, cognitive dysfunction, and others. A couple new studies published this year also demonstrate the utility of gait speed measurement. One study (Roshanravan 2013) in patients with stage 2-4 CKD showed that adding gait speed to a model that included estimated GFR significantly improved the prediction of 3-year mortality. Another (Chaudhry 2013) showed that CHF patients with slow gait were 28% more likely to be hospitalized for heart failure than those without slow gait.
Determination of walking speed is a simple, quick and inexpensive test easily performed in any office setting. A recent Spanish study (Castell 2013) found that measurement of walking speed is a good indicator of health and survival in older adults, especially after age 75. They found that a walking speed of ≥0.9 m/s rules out the presence of frailty, and that a walking speed of ≤0.8 m/s doubles the probability of a diagnosis of frailty.
Isn’t it time that we begin to incorporate such simple objective measures into our routine assessments of patients, particularly the elderly?
Some of our prior columns on preoperative assessment and frailty:
References:
ACS NSQIP Surgical Risk Calculator
http://www.riskcalculator.facs.org/
Bilimoria KY, Liu Y, Paruch JL, et al. Development and Evaluation of the Universal ACS NSQIP Surgical Risk Calculator: A Decision Aide and Informed Consent Tool for Patients and Surgeons. J American College of Surgeons 2013; Published online 17 July 2013
http://www.journalacs.org/article/S1072-7515%2813%2900894-6/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; 210(6): 901-908, June 2010
http://www.journalacs.org/article/S1072-7515%2810%2900059-1/fulltext
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%2811%2900089-5/abstract
Robinson TN, Wu DS, Pointer L, et al. Simple frailty score predicts postoperative complications across surgical specialties. Am J Surg 2013; published online 22 July 2013
http://www.americanjournalofsurgery.com/article/S0002-9610%2813%2900363-2/abstract
Robinson TN, Wu DS, Sauaia A, et al. Slower Walking Speed Forecasts Increased Postoperative Morbidity and 1-Year Mortality Across Surgical Specialties. Annals of Surgery 2013; Published ahead of print 23 August 2013
doi: 10.1097/SLA.0b013e3182a4e96c
Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM. A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients. NEJM 1999; 340: 669-676
http://content.nejm.org/cgi/reprint/340/9/669.pdf
Chen C C-H, Lin M-T, Tien Y-W, Yen C-J, Huang G-H, Inouye SK. Modified Hospital Elder Life Program: Effects on Abdominal Surgery Patients. J Amer Coll Surg 2011; 213(2): 245-252
http://www.journalacs.org/article/S1072-7515%2811%2900342-5/abstract
Roshanravan B, Robinson-Cohen C, Patel KV, et al. Association between Physical Performance and All-Cause Mortality in CKD. JASN 2013; April 30, 2013 24: 822-830; published ahead of print April 18, 2013, doi:10.1681/ASN.2012070702
http://jasn.asnjournals.org/content/24/5/822.abstract?sid=76ae4fd6-6c14-4d04-b985-1c9c8a5c1bf6
Chaudhry SI, Gail McAvay G, Chen S, et al. Risk Factors for Hospital Admission Among Older Persons With Newly Diagnosed Heart Failure: Findings From the Cardiovascular Health Study. J Am Coll Cardiol 2013; 61(6): 635-642. doi:10.1016/j.jacc.2012.11.027
http://content.onlinejacc.org/article.aspx?articleid=1567645
Castell M-V, Sánchez M, Julián R, et al. Frailty prevalence and slow walking speed in persons age 65 and older: implications for primary care. BMC Family Practice 2013; 14:86 (19 June 2013)
http://www.biomedcentral.com/1471-2296/14/86
Print “Predicting Perioperative Complications: Slow and Simple”
September 10, 2013
Informed Consent and Wrong-Site Surgery
In our August 27, 2013 Patient Safety Tip of the Week “Lessons on Wrong-Site Surgery” we discussed the importance of all parties reviewing primary source documents for verifying patient, procedure and correct site for invasive procedures. In that column and in our January 1, 2013 Patient Safety Tip of the Week “Don’t Throw Away Those View Boxes Yet” we focused especially on the unavailability of images or imaging reports as being problematic.
However, all the other documents are equally important. One that has received relatively little attention is the informed consent. While putting together our August 27, 2013 column we came across two papers on wrong-site surgery in which problems with informed consents contributed to the errors.
In a root cause analysis (RCA) of a case of removal of the wrong kidney in a patient in the UK (Tallents 2008) at least 3 issues related to informed consent were raised. One was that because the patients were often admitted outside normal working hours the admission workup was often done by members of a surgical team other than the surgical team which would actually be performing the surgery. Those team members often felt uncomfortable obtaining informed consent for the surgical procedure. Hence, they might obtain a general consent for hospitalization but not one for the specific surgery. Moreover, it was noted that the formal consent was generally taken by surgeons who were not competent to perform the procedure. These were often surgical house officers who had to rely on notes that were in the chart. Moreover, they were unlikely to review any relevant imaging studies before taking consent (since they often felt unqualified to read those imaging studies). A major recommendation coming from that RCA was that the hospital should implement a process for initiating formal consent in outpatients when the patient is seen by a clinician who is personally competent to do the procedure and review the imaging.
A second paper performed a common cause analysis (CCA) after a series of wrong-site surgical events in a US hospital (Mallett 2012). Basically, a common cause analysis involves identification of themes common to events found in RCA’s done after the individual events. One of the themes they identified was related to documents used in verification. They found that the consents were not always placed in the correct location in the medical record, were not available to be reconciled, did not specify laterality, and were not obtained by the practitioner performing or involved in the procedure. One of their solutions was revision of the consent form to include a legend (right, left, and bilateral) next to where the practitioner writes the name of the procedure to be performed. That provides a visual cue to the practitioner to ensure laterality during the informed consent procedure. Secondly, they implemented a policy that informed consent must be only obtained by the physician/practitioner performing the procedure or by the resident/fellow who will be performing or assisting with the procedure.
A third timely paper from researchers at Johns Hopkins that does not deal with wrong-site surgery provides additional useful information about problems related to informed consent (Garonzik-Wang 2013). This study found that almost two thirds of patients were missing informed consent forms when they presented to the preoperative area. This required nurses to contact the attending surgeon or resident to perform the informed consent. It led to delays in case start times in 14% of cases. Moreover, often the individual responding to the nurse request was a resident, who was pulled away from other patient care responsibilities or teaching rounds and typically spent less time performing the consent than expected. Residents typically spent less time obtaining informed consent in all locations and the vast majority spent only 5 minutes or less when obtaining it in the preoperative area. And, to top it off, the majority of attending surgeons were not satisfied with the performance of the residents on informed consent and felt that patients preferred being asked for their consent by an attending surgeon. The paper has an excellent discussion on the dilemma of doing informed consent appropriately yet also ensuring that residents learn how to do it. Based on their findings they are implementing 3 things to improve the informed consent process:
1) Creating a centralized single streamlined electronic process to be used by all attending surgeons to ensure that all consents obtained in clinics reliably make it to the medical record
2) Standardize the consent forms for commonly performed procedures
3) Include specific educational initiatives for surgical residents on informed consent
Yes, the above 3 descriptions all come from teaching hospitals but problems with availability and accuracy of informed consents occur even in non-teaching hospitals. It is extremely common even in community or rural hospitals for surgeons to obtain the informed consent in the preoperative area. Our June 5, 2007 Patient Safety Tip of the Week “Patient Safety in Ambulatory Surgery” noted that ambulatory surgery is particularly vulnerable to missing documents because those documents are usually in the surgeon’s office rather than at the hospital. That is why you need to be firm in your requirement for such documents before cases are scheduled. And, yes, we still continue to encounter some surgeons who look at the document as some sort of regulatory requirement foisted upon them!
The preoperative area is not the appropriate place for the informed consent process to take place. Proper informed consent requires the physician or practitioner provide the patient with details of the procedure, the potential benefits and potential harms, and the alternatives (including what might happen with the alternative of doing nothing). That discussion takes time and there must be adequate opportunity for the patient (and any surrogate) to ask questions. The pressures in the preoperative area cause considerable truncation of the informed consent process. Moreover, once a patient has committed to coming to the hospital or ASC for a procedure, they are very unlikely to say no. So the more appropriate place for the informed consent to be performed is the physician’s office, clinic, or inpatient bedside if the patient is already admitted.
We strongly recommend that you not schedule surgery until you (the hospital or ASC) have in hand copies of the H&P, the booking form, the consent form, and imaging studies. While you might provide a tentative date and time for surgery you must have a “drop dead” date on which you will cancel that tentatively scheduled slot if you have not received these items. Things like the H&P may need updating to meet regulatory time frames but you should have available at least the H&P from the office at the time the case was originally scheduled.
Having the consent form ahead of time will help in the preoperative verification process. It should prompt the surgeon to address the issues well before the day of the procedure and allow preoperative personnel to spot discrepancies long before the day of surgery so they can be resolved. The study from Hopkins also would suggest that, in addition to helping prevent wrong-site surgery, you will also likely improve OR efficiency and throughput.
We also like the recommendation in the paper by Mallett et al. (Mallett 2012) to include on the informed consent form a legend (right, left, and bilateral) next to where the practitioner writes the name of the procedure to be performed. Our October 30, 2012 Patient Safety Tip of the Week “Surgical Scheduling Errors” has many recommendations about scheduling and booking. In that column we also mentioned a paper by Wu and colleagues (Wu 2012) that did a qualitative and quantitative analysis of errors occurring during the surgical booking/scheduling process and identified not only patient safety issues but also analyzed the costs associated with the delays such errors end up causing. The Wu paper noted the Minnesota Alliance for Patient Safety sample booking form that contains a section which must be filled out by the physician performing the surgery (i.e. that cannot be delegated to staff). Though that is a booking form it also utilizes the visual cue to force the physician to verify laterality of the procedure. The Minnesota Alliance for Patient Safety has several other valuable resources as part of its Surgery Scheduling and Verification Pilot Project. These include algorithms for scheduling for either the hospital or ambulatory surgery center and for the clinic or physician office, and verification checklists for both sites.
You should do your own simple audit of availability of the informed consent document when the patient arrives in your preoperative area. You will probably find some issues that make you vulnerable not only to wrong-site surgeries but also day-to-day OR inefficiencies.
Some of our prior columns related to wrong-site surgery:
Patient Safety Tip of the Week columns:
September 23, 2008 “Checklists and Wrong Site Surgery”
June 5, 2007 “Patient Safety in Ambulatory Surgery”
March 11, 2008 “Lessons from Ophthalmology”
July 1, 2008 “WHO’s New Surgical Safety Checklist”
January 20, 2009 “The WHO Surgical Safety Checklist Delivers the Outcomes”
September 14, 2010 “Wrong-Site Craniotomy: Lessons Learned”
November 25, 2008 “Wrong-Site Neurosurgery”
January 19, 2010 “Timeouts and Safe Surgery”
June 8, 2010 “Surgical Safety Checklist for Cataract Surgery”
December 6, 2010 “More Tips to Prevent Wrong-Site Surgery”
June 6, 2011 “Timeouts Outside the OR”
October 30, 2012 “Surgical Scheduling Errors”
January 1, 2013 “Don’t Throw Away Those View Boxes Yet”
August 27, 2013 “Lessons on Wrong-Site Surgery”
What’s New in the Patient Safety World columns:
July 2007 “Pennsylvania PSA: Preventing Wrong-Site Surgery”
August 2011 “New Wrong-Site Surgery Resources”
December 2011 “Novel Technique to Prevent Wrong Level Spine Surgery”
January 2013 “How Frequent are Surgical Never Events?”
References:
Tallents P, Mushtaq I. Independent Review Report. Investigation into the removal of the wrong kidney from patient XY. Our Lady’s Children’s Hospital, Crumlin
1st September 2008
http://www.stateclaims.ie/ClinicalIndemnityScheme/publications/2009/OLHSC.pdf
Mallett R, Conroy M, Saslaw LZ, Moffatt-Bruce S. Preventing Wrong Site, Procedure, and Patient Events Using a Common Cause Analysis. American Journal of Medical Quality 2012; 27: 21-29
http://ajm.sagepub.com/content/27/1/21.full.pdf+html
Garonzik-Wang JM, Brat G, Salazar JH, et al. Missing Consent Forms in the Preoperative Area. A Single-Center Assessment of the Scope of the Problem and Its Downstream Effects. JAMA Surg 2013; published online before print July 10, 2013
http://archsurg.jamanetwork.com/article.aspx?articleid=1710508
Wu RL, Aufses AH. Characteristics and costs of surgical scheduling errors. Am J Surg 2012; 204(4): 468-473, October 2012
http://www.americanjournalofsurgery.com/article/S0002-9610%2812%2900191-2/abstract
Minnesota Alliance for Patient Safety. Surgery Scheduling and Verification Pilot Project.
http://www.mnpatientsafety.org/OurWork/PastWork/SurgerySchedulingandVerificationProject.aspx
sample OR scheduling form
Print “Informed Consent and Wrong-Site Surgery”
September 17, 2013
First MEWS, Now PEWS
We’ve done numerous columns on the need to recognize clinical deterioration earlier in patients and the potential usefulness of early warning scores such as MEWS (the Modified Early Warning Score). See the columns listed at the end of today’s column for links to those discussions on MEWS and early deterioration.
MEWS and all its modifications have been developed and validated for adult populations. So you’d expect that similar early warning scores or systems might be developed for pediatric populations. Indeed, PEWS (Pediatric Early Warning Scores) have been developed and evaluated in several settings. Like their adult counterparts, PEWS use clinical and physiological parameters that are routinely monitored in the care of pediatric patients.
Most recently, the utility of PEWS in identifying children in the emergency department who are in need of ICU care was demonstrated (Seiger 2013). The researchers evaluated ten different PEWS in a prospective cohort of almost 18,000 children aged <16 years who had presented to the ED of a university hospital in The Netherlands. Most of the PEWS involved scoring systems where individual components were summed into an overall PEWS score. Others were triggering systems where a single parameter might flag the patient as being at risk.
They found that most PEWS systems were pretty good at predicting which children needed ICU care but only fair for predicting the need for hospitalization. In general, the PEWS that used summated scores were better than the triggering systems. None of the tools was great. Those that had high sensitivities had low specificities and vice versa. PEWS scoring systems that were most suited for the emergency department were the one developed by Duncan et al. (Duncan 2006) and its modification by Parshuram et al. (Parshuram 2011).
One limitation of the study was that substantial amounts of data were missing (eg. vital signs) and had to be imputed into the scoring tools. However, even with this limitation, it appears there may be utility in use of such PEWS tools at least in helping clinicians decide whether ICU admission might be advisable. It will be interesting to see if these results can be replicated in other pediatric emergency settings. Note also that the authors do not advise using PEWS systems or scores as the sole triaging tools when prioritizing children in the ED for evaluation.
This is not the first study to demonstrate the utility of PEWS in the emergency room setting. Another study presented as a poster at the 2013 Critical Care Congress of the Society of Critical Care Medicine (An 2012) had also shown PEWS was valuable in predicting which children in the emergency department were likely to be admitted to the pediatric ICU.
PEWS systems have been demonstrated to be useful in other settings as well. Akre and colleagues (Akre 2010) retrospectively calculated PEWS scores in children on medical and surgical units at a Children’s Hospital (excluding ICU and stepdown units) who had either activation of a rapid response team or a code event. 85.5% of the children having such events had a critical PEWS score in the 24 hours prior to the event. And the median time from the first critical PEWS score to the event was almost 12 hours. This suggests that use of PEWS could identify pediatric inpatients at risk for deterioration much earlier and lead to interventions that might help avoid codes and RRT events. They used the PEWS scoring and color-coded algorithm developed by Monaghan (Monaghan 2005).
Similarly, a group in Norway (Solevåg 2013) recently demonstrated in a department of pediatric and adolescent medicine that the modified Brighton PEWS could be used to identify patients with severe illnesses and surrogate markers of cardio-respiratory compromise.
Parshuram et al. (Parshuram 2011) demonstrated that implementation of a modified PEWS system in a community hospital was associated with fewer late transfers to tertiary pediatric centers, fewer serious clinical deterioration events, and fewer stat calls to pediatricians. In addition, there was no change to pediatrician workload and staff noted decreased apprehension when calling the physician.
Our September 11, 2012 Patient Safety Tip of the Week “In Search of the Ideal Early Warning Score” summarizes many of the issues associated with development and use of early warning tools in adults. It describes the NEWS (National Early Warning Score) being rolled out in the UK and has links to the NEWS resources downloadable from the Royal College of Physicians website, which are quite useful. It also has links to a color-coded clinical observation chart to record and view all the variables and the total score. For examples of a color-coded scoring chart for PEWS, see the article by Akre et al. (Akre 2010).
Some of our other columns on MEWS or recognition of clinical deterioration:
References:
Seiger N, Maconochie I, Oostenbrink R, Moll HA. Validity of Different Pediatric Early Warning Scores in the Emergency Department. Pediatrics 2013; Published online September 9, 2013 (10.1542/peds.2012-3594)
http://pediatrics.aappublications.org/content/early/2013/09/04/peds.2012-3594.abstract
Duncan H, Hutchison J, Parshuram CS. The pediatric early warning system score: A severity of illness score to predict urgent medical need in hospitalized children.
Journal of Critical Care 2006; 21(3): 271-278 September 2006
http://www.jccjournal.org/article/S0883-9441%2806%2900088-8/abstract
Parshuram CS, Bayliss A, Reimer J, et al. Implementing the Bedside Paediatric Early Warning System in a community hospital: A prospective observational study. Paediatr Child Health. 2011; 16(3): e18–e22.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3077313/?report=classic
Solevåg AL, Eggen EH, Schröder J, Nakstad B. Use of a Modified Pediatric Early Warning Score in a Department of Pediatric and Adolescent Medicine. PLoS ONE 2013; 8(8): e72534. doi:10.1371/journal.pone.0072534 published 26 Aug 2013
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0072534
An E, Mink R. Abstract (poster) 744: Efficacy of the Pediatric Early Warning Score (Pews) in Predicting Placement of A Pediatric Placement to the Ward or Picu. Critical Care Medicine 2012; 40(12): 1-328, December 2012
Akre M, Finkelstein M, Erickson M, et al. Sensitivity of the Pediatric Early Warning Score to Identify Patient Deterioration. Pediatrics 2010; 125:4 e763-e769; published ahead of print March 22, 2010, doi:10.1542/peds.2009-0338
Monaghan A. Detecting and managing deterioration in children. Paediatr Nurs 2005;
17(1): 32–35
Royal College of Physicians (UK). National Early Warning Score (NEWS). Standardising the assessment of acute-illness severity in the NHS. July 2012
http://www.rcplondon.ac.uk/resources/national-early-warning-score-news
Royal College of Physicians. National Early Warning Score (NEWS): Standardising the assessment of acuteillness severity in the NHS. Report of a working party. London: RCP, 2012
color coded chart
Observation chart for the National Early Warning Score (NEWS)
National Early Warning Score (NEWS)
The scoring system
The National Early Warning Score (NEWS) thresholds and triggers
Clinical response to NEWS triggers
Print “First MEWS, Now PEWS”
September 24, 2013
Perioperative use of CPAP in OSA
We’ve long recognized the risks associated with obstructive sleep apnea (OSA) in patients undergoing surgery (see the list of prior columns at the end of today’s column). Many, if not most, patients with OSA are undiagnosed before their surgery. We’ve discussed that use of excellent tools, such as the STOP-Bang questionnaire, to screen patients preoperatively for OSA risk may be valuable but these remain underutilized.
However, we also lamented in our November 22, 2011 Patient Safety Tip of the Week “Perioperative Management of Sleep Apnea Disappointing” that there has been a striking lack of evidence that interventions for OSA in the perioperative period actually have a beneficial effect. But we expressed hope that ongoing research would soon demonstrate some positive results. Indeed, we finally have such evidence from a randomized controlled trial (RCT). The research group in Toronto headed by Frances Chung, which has done much of the seminal research on OSA in the perioperative period, has just published results of a randomized controlled trial of auto-titrated continuous positive airway pressure (APAP) in the perioperative period for patients with moderate to severe OSA not previously on CPAP who underwent surgery (Liao 2013).
The intervention group received APAP for 2-3 preoperative and 5 postoperative nights. The control group received usual care. In the APAP group the apnea hypopnea index (AHI) decreased from a baseline of 30.1 events per night to 3.0 events per night on postoperative night 3. In the control group the AHI increased from a baseline of 30.4 events per night to 31.9 events per night on postoperative night 3. Also, compared to the control group, patients in the APAP group had significantly less oxygen desaturation postoperatively. The study was underpowered to demonstrate any impact on complications or other patient outcomes.
The study did, however, demonstrate many of the barriers to interventions with APAP or conventional CPAP in these patients perioperatively. Compliance with APAP for all observed nights in the study group was only 45%. Moreover, the mean usage time for APAP was 2.4 to 4.6 hours per night with over half the patients using it less than 4 hours per night. Major reasons for noncompliance were generalized discomfort and nausea/vomiting.
The study did have some limitations. It was not double blinded and that may have introduced some bias. In fact, more patients in the APAP group received supplemental oxygen (which may have affected the oxygen saturation outcomes but not the AHI outcomes). In addition to the relatively poor APAP compliance noted above, there was also a high dropout rate. However, the beneficial impact of APAP on the apnea hypopnea index held up even on intent-to-treat analysis.
This is really the first RCT to demonstrate the utility of APAP or CPAP in the perioperative period. Admittedly, the AHI and oxygen saturation parameters are somewhat surrogate measures in that we are really more interested in finding out if APAP/CPAP reduces perioperative complications or mortality. Answers to the latter would obviously require studies of much larger populations. Nevertheless, these results are quite compelling and suggest that similar interventions in patients with moderate to severe OSA undergoing surgery may be beneficial.
As per our prior columns, several studies have demonstrated that postoperative complications are increased in patients with OSA. A recent retrospective analysis of over 1 million patients in the National Inpatient Sample database showed that there was an increased independent association between sleep-disordered breathing and postoperative cardiopulmonary complications but there was no association with increased rate of hospital death (Mokhlesi 2013). The impact of sleep-disordered breathing on length of stay (LOS) and hospital costs varied considerably by type of surgery.
We strongly recommend that you incorporate screening for possible OSA into your preoperative evaluations and follow recommendations we’ve highlighted in our March 26, 2013 Patient Safety Tip of the Week “Failure to Recognize Sleep Apnea Before Surgery” and the other columns listed below. While we have always recommended continuation of CPAP postoperatively in patients already on CPAP, we now also finally have some evidence base for consideration of perioperative APAP/CPAP in patients with diagnosed OSA who have not previously been treated with CPAP. Note that there are some advantages to use of APAP over CPAP in this population. The pressure used may respond to changes in airway resistance that may be common in the postoperative period. In addition, the usual CPAP titration required after diagnosis of OSA might delay surgery. APAP could be used without that titration study.
Our prior columns on obstructive sleep apnea in the perioperative period:
Patient Safety Tips of the Week:
June 10, 2008 “Monitoring the Postoperative COPD Patient”
August 18, 2009 “Obstructive Sleep Apnea in the Perioperative Period”
August 17, 2010 “Preoperative Consultation – Time to Change”
July 13, 2010 “Postoperative Opioid-Induced Respiratory Depression”
February 22, 2011 “Rethinking Alarms”
November 22, 2011 “Perioperative Management of Sleep Apnea Disappointing”
May 22, 2012 “Update on Preoperative Screening for Sleep Apnea”
February 12, 2013 “CDPH: Lessons Learned from PCA Incident”
February 19, 2013 “Practical Postoperative Pain Management”
March 26, 2013 “Failure to Recognize Sleep Apnea Before Surgery”
What’s New in the Patient Safety World columns:
July 2010 “Obstructive Sleep Apnea in the General Inpatient Population”
November 2010 “More on Preoperative Screening for Obstructive Sleep Apnea”
March 2012 “Postoperative Complications with Obstructive Sleep Apnea”
June 2013 “Anesthesia Choice for TJR in Sleep Apnea Patients”
References:
Liao P, Luo Q, Elsaid H, et al. Perioperative Auto-titrated Continuous Positive Airway Pressure Treatment in Surgical Patients with Obstructive Sleep Apnea: A Randomized Controlled Trial. Anesthesiology 2013; 119(4): 837-847
Mokhlesi B, Hovda MD, Vekhter B, et al. Sleep-Disordered Breathing and Postoperative Outcomes After Elective Surgery: Analysis of the Nationwide Inpatient Sample. Chest 2013; 144(3): 903-914
http://journal.publications.chestnet.org/article.aspx?articleid=1672183
Print “Perioperative Use of CPAP in OSA”
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Cognitive Biases and Heuristics in the Delivery Room
November 9, 2021
November 2, 2021
Adverse Drug Events After Hospitalization
October 26, 2021
Opioid-Induced Respiratory Depression Costly in Fiscal as Well as Human Terms
October 19, 2021
COVID-19 Vaccine/ Flu Vaccine Mixups
October 12, 2021
FDA Approval of Concussion Tool – Why Not a Fatigue Detection Tool?
October 5, 2021
September 28, 2021
Barcoding Better? Not So Fast!
September 21, 2021
Repeat CT in Anticoagulated Patients After Minor Head Trauma Not Cost-Effective
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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