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July 12, 2016
Forget Brexit - Brits Bash the RCA!
The Brexit vote garnered the world’s attention last month, making a surprising attack on tradition. But another British attack on tradition targeted the root cause analysis (RCA). Peerally and colleagues (Peerally 2016) actually did a nice review of many of the pitfalls involved in RCA’s, most of which we agree with. We’ve actually addressed most of them in our prior columns on RCA’s, most recently in our July 14, 2015 Patient Safety Tip of the Week “NPSF’s RCA2 Guidelines”.
We’ve always had a strong conviction that the RCA (root cause analysis) is probably the most important learning tool that an organization with a good culture of safety has at its disposal. We encourage organizations to do RCA’s not just on events with bad patient outcomes but on any event that had the potential to induce harm (near-misses).
We’ll try to comment on each of the points raised in the Peerally paper. One of the criticisms offered by Peerally et al. is that the RCA team is often not expert in doing RCA’s. They point out that in the airline industry the RCA is typically done by a very expert team. When there is an aircraft crash (or other significant transportation incident) in the US, the NTSB (National Transportation Safety Board) dispenses a team to investigate the incident. The NTSB keeps “go teams” that are ready to travel to the site of the incident within hours so the investigation may begin expediently.
Given the large number of events that could and should benefit from performance of an RCA (we recommend RCA’s not only for incidents resulting in patient harm but also in most near misses) it is not practical to think an NTSB-like “go team” could be dispensed to investigate every such incident. Perhaps a larger multi-hospital system might be able to do this and it’s even conceivable that a PSO (Patient Safety Organization) might be able to have an “RCA go team” ready to send to contracted healthcare organizations. A hospital can (and should) always develop a “core” RCA group and ensure they get formal training on RCA (and other) techniques and tools. But there is something to be said for having a truly independent body or group be able to investigate incidents without having the biases that are inherent in most RCA’s (see section below on biases and the “political hijack”).
But another real need in healthcare is making sure that everyone in the organization understands what an RCA is all about and takes seriously that its main goal is to prevent similar events from occurring in the future. All too often those invited to participate in or provide information to the RCA team are frightened and fearful the RCA is an “inquisition”. Physicians, in particular, have historically been reluctant to even speak to the RCA team for fear that their “testimony” will be “discoverable” in litigation. That’s especially a problem in the United States compared to other less litiginous countries. So it is incumbent upon the organization’s leadership and the RCA “core” team to appropriately educate everyone to the RCA process in general and to orient them to the process if they are called upon to participate in an RCA.
Peerally et al. also criticize the somewhat arbitrary timelines and techniques “mandated” by some regulatory bodies for RCA’s. They note that such requirements often lead to more focus on putting together a document than actually preventing future similar events. That’s probably a legitimate criticism. They note as an example the practice of asking “the 5 why’s”. We also often see organizations struggling to address all the components and questions in the widely used VA Root Cause Analysis Tools (VA 2015), to the point they appear more concerned about their document than their solutions. Don’t get us wrong – the VA RCA Tools are very helpful in getting RCA teams to consider potential contributing factors and root causes related to Rules, Safeguards, Environment, Equipment, Information Technology, Fatigue and Scheduling, Training, and Communication. But organizations should use those categories as reminders of where they may find root causes and contributing factors.
Timelines are a mixed bag. Peerally and colleagues note these often result in “a compromise between depth of data and accuracy of the investigation”. Most regulatory bodies mandate RCA’s be completed within specific arbitrary timelines (typically 30-45 days). Timing of the initial RCA meeting is important. It should be held within 24-72 hours of the event. That helps ensure that events are accurately recalled by witnesses and should allow enough time for scheduling interviews and other activities. In our July 24, 2007 Patient Safety Tip of the Week “Serious Incident Response Checklist” we discussed the many other things that need to be done immediately after serious events. That column included a link to our Serious Event Response Checklist, which includes things like sequestering involved equipment, identification of witnesses, disclosure to patient or family, notification of regulatory bodies and Board if necessary, and others.
Prompt performance of the RCA is critical not only for ensuring accurate recall of events but also for taking those steps needed immediately to prevent similar occurrences. While most thorough RCA’s can and should be completed within 30-45 days, those arbitrary timelines fail to take into account some of the bureaucratic lags in our healthcare organizational hierarchies. Those timelines may be sufficient to have the RCA go through your hospital Quality Improvement/Patient Safety Committee and up to your Board. However, due to the complexities of scheduling, the RCA may not be discussed at clinical and support departmental meetings, committees such as your Pharmacy and Therapeutics Committee or OR Committee, and your Medical Executive Committee within those timelines. Sometimes important considerations are raised at those meetings that lead to changes in the RCA actions. And, as discussed below, it is critical that RCA action plans are disseminated to all those who must take actions and appropriate buy-in from all parties be obtained. Therefore, while an RCA may be submitted to your regulatory body within the 30-45 day timeframe, you must ensure that you review it again after those other committees and departments have discussed it, and revise and amend the RCA as necessary.
Peerally et al. highlight the challenges of getting unbiased information and the “political hijack”. By the latter they mean that areas of focus are often influenced by “interpersonal relationships, hierarchical tensions, and partisan interests” (essentially, some areas are underemphasized to avoid stepping on toes). They also note that some root causes may be edited out when solutions appear to be too difficult to achieve.
The next criticism by Peerally and colleagues, one with which we strongly agree, is that solutions and action plans are poorly designed or implemented. In our March 27, 2012 Patient Safety Tip of the Week “Action Plan Strength in RCA’s” we noted prior studies in the VA system (Hughes 2006) which analyzed action items from RCA’s and found that 30% were not implemented and another 25% were only partially implemented. Stronger action items were more likely to be implemented. Actions that were assigned to specific departments or people were more likely to be implemented than those assigned to general areas. And they found that the patient safety manager plays a critical role in RCA action implementation.
In our March 27, 2012 Patient Safety Tip of the Week “Action Plan Strength in RCA’s” we emphasized the importance of tracking whether recommended action steps were implemented following an RCA, whether they were effective, and whether there were any unintended consequences. All too often action steps never get implemented at all or consist solely of “weak” action steps and organizations are then surprised when a similar adverse event occurs in the future. Moreover, even the most well intentioned and well planned action steps sometimes lead to consequences that were never anticipated. We typically see weak actions like education and training or policy changes as the sole actions undertaken rather than strong actions like constraints and forcing functions. We discussed strength of actions in our March 27, 2012 Patient Safety Tip of the Week “Action Plan Strength in RCA’s”. In that column we included an analogy to the effectiveness of signs and tools used to try to get drivers to slow down in construction zones on highways. We put them together in pictures with RCA action items and now incorporate them in our webinar presentations on doing good RCA’s. Click here to see them. Remember: images are more likely to be remembered than words!
One of the biggest issues we see in hospitals related to RCA’s is failure to follow up and close the feedback loop. In fact, probably the majority of hospitals lack formal procedures for ensuring the corrective actions recommended in an RCA are actually carried out (or barriers to their implementation identified and alternative steps taken). In our March 30, 2010 Patient Safety Tip of the Week “Publicly Released RCA’s: Everyone Learns from Them” we discussed an incident at a hospital in which a similar incident had occurred several years prior. After the first incident an extensive root cause analysis was done and multiple recommendations were made, including key recommendations that should have prevented the second incident. But all those recommendations had never been fully implemented. Importantly, the recommendations were communicated back to those individuals deemed to be in the “need to know” but not widely disseminated to middle for front line management nor to front line staff.
We recommend you keep a list or table of such identified action items from all your RCA’s to discuss at your monthly patient safety committee or performance improvement committee meetings. Action items should remain on that list until they have been implemented or completed. Only that sort of rigorous discipline will ensure that you did what you said you were going to do, i.e. that you “closed the loop”. And don’t forget you need to monitor your implemented actions for unanticipated and unintended consequences. For example, you might take the strong action of removing a drug from a particular setting, only to realize later that there were circumstances where that drug was needed in that setting.
From our perspective the major failure in the patient safety movement in the US has been our failure to share lessons learned. Peerally and colleagues also lament a lack of dissemination of lessons learned and lack of aggregation of similar events. Ironically, the example Peerally and colleagues used to illustrate lessons not learned was implantation of incorrect intraocular lenses. In several of our columns (most recently in our May 17, 2016 Patient Safety Tip of the Week “Patient Safety Issues in Cataract Surgery”) we’ve described that very issue as one that led us over 20 years ago to develop one of the earliest surgical timeout protocols that served as a model for subsequent state and national timeout protocols. In those columns we describe how cases of incorrect intraocular lens (IOL) implantation occurred singly (or occasionally multiply) in many hospitals yet those cases and their contributing factors were never shared widely. The same concept, of course, was seen with cases of fatal overdoses from inadvertent injection of concentrated potassium chloride. Those typically occurred as single isolated events in many hospitals and it was only years later that the widespread occurrence of this unfortunate incident was appreciated and steps taken to remove concentrated potassium chloride from floor stocks.
Even in organizations capable of wider dissemination of lessons learned there is a tendency to wait until several cases have been aggregated before sharing those lessons. But some isolated solitary cases also need to be shared because the circumstances leading to those cases is very likely replicated at multiple other venues. Such an example is another ophthalmological incident with the inadvertent use of methylene blue dye instead of trypan blue (see our prior columns of May 20, 2014 “Ophthalmology: Blue Dye Mixup” and September 2014 “Another Blue Dye Eye Mixup”). When we discussed the first case, we said “we can’t believe this is the first time this has happened”. Then, shortly thereafter a second case was reported. In fact, the second case anteceded the first. Perhaps with better dissemination of lessons learned the subsequent case might have been avoided.
In reality, such failure to share is a societal problem. The various legal and public relations consequences of sharing lessons and aggregating similar cases have been among the biggest barriers to implementation of sound patient safety practices.
The “problem of many hands” described by Peerally and colleagues is that incidents with adverse patient outcomes typically have many contributing factors and no one individual or action is responsible entirely for the adverse outcome or the potential solutions. Often those “actors” are even outside direct control of the organization (for example, manufacturers and suppliers) and hospitals may have little ability to inform changes there.
Perhaps the toughest nut to crack is the complicated issue of blame. The beauty of the RCA is that it stresses identification and remediation of system defects that are generally more amenable than human behaviors. And it is clear that system defects may put individuals at risk of committing human errors that then result in adverse patient outcomes. One key tenet of the National Patient Safety Foundation’s RCA2 Guidelines is that it only addresses system issues and should not address or focus on individual performance (see our July 14, 2015 Patient Safety Tip of the Week “NPSF’s RCA2 Guidelines”). In fact, NPSF recommends that all organizations should define “blameworthy” events and actions that fall outside the purview of the safety system and define how and under what circumstances they will be handled separately. Of course, we would emphasize that system issues that lead to or facilitate improper individual performance must be addressed under the RCA2 process. For example, workarounds are (often) improper individual actions that almost always have a system issue that led to their use. Another example is “normalization of deviance” where the culture of the system led to acceptance of a certain deviation from proper practice as being “normal” and allowed that deviation to be performed by many individuals.
Peerally and colleagues acknowledge that a “no-blame” approach is not always possible or appropriate and may impede thorough incident investigation and we often see failure to place blame when placing blame may be appropriate. They note that most of us have adopted the “Just Culture” approach but that tools such as algorithms and decision tools (eg. the “culpability tree”) have flaws of their own. (Also, don’t forget that in parallel to your RCA process you need to ensure your organization has a means to address the “second victim” or healthcare workers involved in such incidents. See also our December 17, 2013 Patient Safety Tip of the Week “The Second Victim” and we expect to do another column on the “second victim” soon.)
Lastly, they admit we all have problems figuring out how to fit patients and families into the RCA process. Our many columns on critical incident response and disclosure and apology (see list of prior columns below) have emphasized how after disclosure and apology we need to keep patients and families in the loop as we complete our RCA’s and implement actions to prevent similar events in the future. But few of us have figured out how to actually include patients or their families in the actual RCA process. Often patients and families have unique perspectives and observations that healthcare workers have not seen (or have been unwilling to admit!). More and more research is demonstrating that patients and families impacted by adverse events are highly motivated to help ensure similar events don’t occur to other patients. While we don’t have the perfect solution to inclusion of patients and families on the RCA team, we do recommend that as part of the disclosure and apology process we also appeal to them “we need your help in determining exactly what happened and how we can prevent similar events”. We’ve also stressed the need to avoid intimidation when such interactions with patients and families occur (see our June 22, 2010 Patient Safety Tip of the Week “Disclosure and Apology: How to Do It”). Don’t hold such meetings in a formal Board Room or have 1-2 family members sitting across a table full of individuals dressed in suits or white coats. You must keep the meeting as cordial as possible, expressing your sincere apology and sincere desire to get their perspectives on the events and give them plenty of time to ask questions and present their observations and concerns.
See our July 14, 2015 Patient Safety Tip of the Week “NPSF’s RCA2 Guidelines” for many other recommendations to include in your RCA process.
So we’re not really bashing the Brits for bashing the RCA. We’re basically acknowledging problems with the RCA that we’ve been discussing all along and hope that this conversation may lead to improvement in our ability to actually implement useful changes after untoward events or near misses.
Some of our prior columns on RCA’s, FMEA’s, response to serious incidents, etc:
July 24, 2007 “Serious Incident Response Checklist”
March 30, 2010 “Publicly Released RCA’s: Everyone Learns from Them”
March 27, 2012 “Action Plan Strength in RCA’s”
March 2014 “FMEA to Avoid Breastmilk Mixups”
July 14, 2015 “NPSF’s RCA2 Guidelines”
Some of our prior columns on Disclosure & Apology:
July 24, 2007 “Serious Incident Response Checklist”
June 16, 2009 “Disclosing Errors That Affect Multiple Patients”
June 22, 2010 “Disclosure and Apology: How to Do It”
September 2010 “Followup to Our Disclosure and Apology Tip of the Week”
November 2010 “IHI: Respectful Management of Serious Clinical Adverse Events”
April 2012 “Error Disclosure by Surgeons”
June 2012 “Oregon Adverse Event Disclosure Guide”
Other very valuable resources on disclosure and apology:
References:
Peerally MF, Carr S, Waring J, Dixon-Woods M. The problem with root cause analysis. BMJ Qual Saf 2016; Published Online First 23 June 2016
http://qualitysafety.bmj.com/content/early/2016/06/23/bmjqs-2016-005511.short?g=w_qs_ahead_tab
VA (Veteran’s Administration). VA National Center for Patient Safety. Root Cause Analysis Tools. REV.02.26.2015
http://www.patientsafety.va.gov/docs/joe/rca_tools_2_15.pdf
Serious Incident Response Checklist.
docs/Serious_Event_Response_Checklist.htm
Hughes D. Root Cause Analysis: Bridging the Gap Between Ideas and Execution. VA NCPS Topics in Patient Safety TIPS 2006; 6(5): 1,4 Nov/Dec 2006
http://www.patientsafety.va.gov/docs/TIPS/TIPS_NovDec06.pdf#page=1
Weak vs. Strong Responses to an RCA (Power Point presentation).
docs/RCA_strong_vs_weak_responses.ppt
NPSF (National Patient Safety Foundation) RCA2. Improving Root Cause Analyses and Actions to Prevent Harm. NPSF 2015
http://c.ymcdn.com/sites/www.npsf.org/resource/resmgr/PDF/RCA2_first-online-pub_061615.pdf
Print “Forget Brexit – Brits Bash the RCA!”
July 19, 2016
Infants and Wrong Site Surgery
A mother was dumbfounded when nurses brought her newborn back from what she thought was a routine physical examination and instead was listening to instructions about aftercare for her newborn’s frenulectomy (CBS News 2016). The newborn had no reason to have a frenulectomy. Apparently a pediatrician had mistaken this newborn for another newborn who was to have the frenulectomy.
No details about the events leading to that misidentification error are available. The newborn, of course, could not communicate to staff that he did not need a frenulectomy. Was there an appropriate consent in the chart? Certainly, the hospital should have had in place Universal Protocol or its equivalent to ensure correct patient and procedure. The reports don’t mention where the procedure was done. Sometimes minor procedures don’t require an operating room and are simply done in a procedure room. However, even bedside procedures should have an appropriate timeout to ensure correct patient, correct procedure, and correct laterality (see our June 6, 2011 Patient Safety Tip of the Week “Timeouts Outside the OR”).
We’ve done multiple columns on misidentification errors in newborns and infants. See our Patient Safety Tips of the Week for November 17, 2009 “Switched Babies”,
September 4, 2012 “More Infant Abductions”, December 11, 2012 “Breastfeeding Mixup Again”, April 8, 2014 “FMEA to Avoid Breastmilk Mixups” and our August 2015 What's New in the Patient Safety World column “Newborn Name Confusion”.
So just how frequent are newborn misidentification errors? The Pennsylvania Patient Safety Authority recently published an advisory on patient identification issues in newborns (Wallace 2016). They found 1234 such misidentification errors in newborns over a 2 year period, an average of almost 2 misidentification errors in Pennsylvania hospitals and birthing centers per day. That may even be an underestimate since many misidentification errors impact 2 patients (for example, one patient gets a medication intended for someone else and the other patient does not get his/her intended medication) and the reports to the PPSA may have each only included 1 patient.
The good news from the PPSA report, though, is that very few of the misidentification errors actually reached the patient and caused harm. Of the 1234 reports, harm occurred in only 5 cases and was serious in only one. The majority of errors were intercepted by interventions like double checks, barcoding, ID tags, etc.
In our Patient Safety Tips of the Week November 17, 2009 “Switched Babies” and December 11, 2012 “Breastfeeding Mixup Again” we noted that one of the risk factors for these mixups are similar sounding names. Similar names are always an issue when it comes to wrong patient events but neonates may be even more at risk. In our May 20, 2008 Patient Safety Tip of the Week “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?” we noted you would be surprised to see how often patients with the same or very similar names may be hospitalized at the same time. Shojania (2003) described a near-miss related to patients having the same last name and noted that a survey on his medical service over a 3-month period showed patients with the same last names on 28% of the days. The problem is even more significant on neonatal units, where multiple births often lead to many patients with the same last name being hospitalized at the same time and medical record numbers being similar except for one digit. Gray et al (2006) found multiple patients with the same last names on 34% of all NICU days during a full calendar year, and similar sounding names on 9.7% of days. When similar-appearing medical records numbers were also included, not a single day occurred where there was no risk for patient misidentification. Both these studies were on relatively small services so one can anticipate that the risks of similar names is much higher when the entire hospitalized patient population is in the database.
So it is common for newborns to have similar last names, similar dates of birth, and even similar medical record numbers (since most hospitals assign medical record numbers sequentially). The inability of the newborn to participate in the identification verification process is another obvious contributing factor. And, though we’re trying to not sound politically incorrect, newborns look alike! Keep in mind that a mother who just delivered may have seen her newborn for only a short time and her cognition might be clouded by medications received during or after the labor and delivery. So even a mom might have difficulty identifying her own newborn.
Our June 26, 2012 Patient Safety Tip of the Week “Using Patient Photos to Reduce CPOE Errors”) highlighted an intervention developed by Children’s Hospital of Colorado (Hyman 2012) in which a patient verification prompt accompanied by photos of the patient reduced the frequency of wrong patient order entry errors. That may be helpful for older children and adults but, frankly, is not of much benefit in neonates.
In our August 2015 What's New in the Patient Safety World column “Newborn Name Confusion” we noted researchers have applied the retract-and-reorder or RAR tool to assess the impact of a change in naming conventions for newborns (Adelman 2015). Hospitals need to create a name for each newborn promptly on delivery because the families often have not yet decided on a name for their baby. Most hospitals have used the nonspecific convention “Baby Boy” Jones or “Baby Girl” Jones. A suggested alternative uses a more specific naming convention. It uses the first name of the mother. For example, it might be “Wendysgirl Jones”. Montefiore Medical Center switched to this new naming convention in its 2 NICU’s in July 2013 and the RAR tool was used to measure the impact on wrong patient errors. Wrong patient error rates measured in the one year after implementation of the new more specific naming protocol were 36% fewer than in the year prior to implementation. For reasons not immediately clear, error rates were reduced even more for orders placed by housestaff (52% reduction) and orders placed on male patients (61% reduction).
Switch to the more specific neonatal naming convention was simple and effective and done without significant financial or labor cost and done with technology already present in most NICU’s. Though the Montefiore study was not blinded and was potentially subject to the Hawthorne effect, the more specific naming convention is very promising. Validation at other NICU’s would be the next logical step before adopting this convention in a more widespread fashion.
The authors note that they only studied the impact on order entry. They point out that mixing up names is also a potentially serious for reading imaging studies or pathology specimens, giving blood products, and may also be a factor in breastmilk mixups. So the potential for this new naming convention to avert wrong patient errors is substantial.
In the PPSA advisory (Wallace 2016) misidentification errors were most commonly related to procedures, treatment, or tests (80%). Another 8.3% were medication errors. Some errors were related to identification bands missing (eg. might be taped on the bassinet rather than infant) but others were related to having the wrong identification band. Sometimes the errors were related to labeling errors on blood or urine specimens or on breastmilk. The PPSA advisory on misidentification errors in newborns noted breastfeeding the wrong infant or breast milk administration mishaps were also common. We’ve addressed those in our Patient Safety Tips of the Week November 17, 2009 “Switched Babies” and December 11, 2012 “Breastfeeding Mixup Again” and April 8, 2014 “FMEA to Avoid Breastmilk Mixups”. We refer you to those columns for details. If your organization does obstetrics and cares for newborns or young infants, we highly recommend you do your own FMEA (failure mode and effects analysis) to assess your risk for breastmilk mixups. We suspect you will be very surprised at the potential vulnerabilities you identify.
The PPSA advisory offers recommendations for risk reduction strategies to reduce labeling errors, registration issues, documentation practices, and issues related to identification bands and band design. In addition to the baby naming convention we noted above, the PPSA advisory also suggests daily huddles to acknowledge and discuss newborns with similar names, and try not to place newborns with similar names in the same location where possible. They also suggest using some visual flag (like a star, or “stop” sign, or color-coding) to visually alert workers that a newborn with a similar name may be present in the unit. (How many of you even do a daily printout, by unit, of patients so you can flag instances where patients have similar names?) Use of technologies that assist correct identification (barcoding, radiofrequency ID, etc.) should be used and might also reduce labeling errors. One important point is having bedside label printers to generate labels for specimens at the point of care (so phlebotomists and others don’t arrive at the bedside with a slew of pre-printed labels from which they might select the wrong one).
In several of our columns, most recently in our January 19, 2016 Patient Safety Tip of the Week “Patient Identification in the Spotlight” we’ve discussed many of the reasons that CPOE (computerized physician order entry) may lead to wrong patient errors. That column also includes some of the tools that have been adapted to CPOE to reduce the risk of those errors.
Another issue related to infant identification is infant abductions from hospitals. Think you are not at risk for infant abductions at your facility? Watch this man attempt to abduct an infant in a shopping bag (Urbanski 2015). See our Patient Safety Tips of the Week for December 20, 2011 “Infant Abduction” and September 4, 2012 “More Infant Abductions” for details about how infant abductions occur and ways to identify your vulnerabilities to these. In those we’ve described some of the characteristic scenarios by which infant abductions occur. Another infant abduction in Canada two years ago also illustrates a rather typical scenario seen (Schwartz 2014). And the excellent NCMEC resources for healthcare professionals includes descriptions of typical abductors and scenarios.
Also timely is this month’s ECRI Institute’s PSO Monthly Brief, which has an article on faulty infant security systems. It has descriptions of several scenarios in which infant alarms will not work properly and other vulnerabilities. It has good recommendations on what you should be doing to ensure your system is functioning properly, including daily testing and regular drills. We've discussed infant abduction drills in several of our prior columns and even recommend you consider doing one coincident with a fire alarm drill to make sure your system does not become disabled during such events. Note that the monthly brief is one of several free newsletters provided by ECRI Institute. You are missing out if you don’t subscribe to any of these very valuable free resources. You can subscribe at: https://www.ecri.org/Pages/eNews.aspx.
Doing drills is important. But you need to do them the right way. In our December 20, 2011 Patient Safety Tip of the Week “Infant Abduction” we noted that the hospital at which an abduction occurred had done 4 such “Code Pink” drills in the two prior years and that in each of those drills the “abductor” had been able to exit the facility. So when you do drills you need to be sure your observer/evaluators know what to look for. Then you need to be sure you follow up on items that need correction. The NCMEC resources for healthcare professionals includes a good drill critique form with a list of items to evaluate during drills and provides a good bibliography to other resources about doing drills. One item you would evaluate is whether during the “Code Pink” appropriate people were stopped and interrogated or prevented from exiting. Even though NCMEC has developed a profile of a typical abductor, we would caution against “profiling” during a Code Pink and recommend every person be considered a potential abductor. Also, given our comments about doors during fire alerts you might even consider doing a “Code Pink” drill immediately following a fire alert drill.
So see our Patient Safety Tips of the Week for December 20, 2011 “Infant Abduction” and September 4, 2012 “More Infant Abductions” and the NCMEC resources for healthcare professionals to see what you should be doing to protect against infant abductions from your facilities. But we also highly recommend those facilities taking care of newborns and children do a FMEA (failure mode and effects analysis) to assess their potential vulnerabilities to infant abductions. Doing a FMEA gets you to always consider “what if…?” scenarios to help you identify areas of vulnerability.
The whole point of a FMEA is to identify areas where unexpected circumstances might occur that could breach your safe processes.
Newborns can’t fend for themselves very well from a medical standpoint. We can’t afford to also expose them to a host of threats from a variety of other sources.
Some of our prior columns related to identification issues in newborns:
November 17, 2009 “Switched Babies”,
December 20, 2011 “Infant Abduction”
September 4, 2012 “More Infant Abductions”.
December 11, 2012 “Breastfeeding Mixup Again”.
April 8, 2014 “FMEA to Avoid Breastmilk Mixups”
August 2015 “Newborn Name Confusion”
January 19, 2016 “Patient Identification in the Spotlight”
Some of our prior columns related to wrong-site surgery:
September 23, 2008 “Checklists and Wrong Site Surgery”
June 5, 2007 “Patient Safety in Ambulatory Surgery”
July 2007 “Pennsylvania PSA: Preventing Wrong-Site 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”
August 2011 “New Wrong-Site Surgery Resources”
December 2011 “Novel Technique to Prevent Wrong Level Spine Surgery”
October 30, 2012 “Surgical Scheduling Errors”
January 2013 “How Frequent are Surgical Never Events?”
January 1, 2013 “Don’t Throw Away Those View Boxes Yet”
August 27, 2013 “Lessons on Wrong-Site Surgery”
September 10, 2013 “Informed Consent and Wrong-Site Surgery”
July 2014 “Wrong-Sided Thoracenteses”
May 17, 2016 “Patient Safety Issues in Cataract Surgery”
References:
CBS News. Mix-up leads to surgical procedure on wrong baby. CBS News February 5, 2016
http://www.cbsnews.com/news/mix-up-leads-to-surgical-procedure-on-wrong-baby/
Wallace SC. Newborns Pose Unique Identification Challenges. Pa Patient Saf Advis 2016; 13(2): 42-49
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2016/jun;13(2)/Pages/42.aspx
Shojania KG. AHRQ Web M&M Case and Commentary. Patient Mix-Up. February 2003
http://www.webmm.ahrq.gov/case.aspx?caseID=1&searchStr=shojania
Gray JE, Suresh G, Ursprung R, et al. Patient Misidentification in the Neonatal Intensive Care Unit: Quantification of Risk. Pediatrics 2006; 117: e43-e47
http://pediatrics.aappublications.org/cgi/reprint/117/1/e43
Hyman D, Laire M, Redmond D, Kaplan DW. The Use of Patient Pictures and Verification Screens to Reduce Computerized Provider Order Entry Errors. Pediatrics 2012; 130: 1-9 Published online June 4, 2012 (10.1542/peds.2011-2984)
http://pediatrics.aappublications.org/content/early/2012/05/29/peds.2011-2984.abstract
Adelman J, Aschner J, Schechter C, et al. Use of Temporary Names for Newborns and Associated Risks. Pediatrics 2015; Published online July 13, 2015
http://pediatrics.aappublications.org/content/early/2015/07/08/peds.2015-0007.full.pdf+html
Urbanski D. When You Realize Who’s Inside the Bag He’s Trying to Sneak Out of a Hospital, You Will Be One Step Ahead of the Staffers. The Blaze 2015; March 12, 2015
Schwartz D. Baby Victoria abduction: What hospitals can do to boost security. Educating nurses, moms most important safety measure, expert says after Trois-Rivières incident. CBC News 2014; Posted: May 28, 2014
NCMEC (National Center for Missing & Exploited Children). For health care professionals: Guidelines on prevention of and response to infant abductions. 10th edition. 2014
http://www.missingkids.com/en_US/publications/NC05.pdf
ECRI Institute PSO. Babies and Buzzers: Faulty Infant Security Systems. ECRI Institute's PSO Monthly Brief 2016; July 2016
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July 26, 2016
Confirmed: Keep Your OR Doors Closed
In several of our columns we’ve warned that long surgical duration has the potential to increase surgery-related infections and that excessive OR traffic and opening of OR doors is likely a major factor.
In our March 10, 2009 Patient Safety Tip of the Week “Prolonged Surgical Duration and Time Awareness” we noted a study (Lynch 2009) that suggested increased foot traffic may be factor related to prolonged procedures that increases the likelihood of surgical site infections.
Then in our January 2010 What's New in the Patient Safety World column “Operative Duration and Infection” we discussed another study (Proctor et al 2010) that looked at a large database of general surgical procedures and demonstrated a linear relationship between duration of surgery and infectious complications. This relationship persisted even after adjustment for a variety of other risk factors for perioperative infections. The unadjusted infectious complication rate increased by 2.5% per half hour. Hospital length of stay (LOS) also increased geometrically by 6% per half hour. We again speculated that increased foot traffic may be another factor related to prolonged procedures that increases the likelihood of surgical site infections as suggested by Lynch et al.
And our December 30, 2014 Patient Safety Tip of the Week “Data Accumulates on Impact of Long Surgical Duration” cited several other studies in which surgical infections were one of several complications related to prolonged surgery.
Then in our November 24, 2015 Patient Safety Tip of the Week “Door Opening and Foot Traffic in the OR” we discussed a study from Johns Hopkins that formally studied how often OR doors are opened during joint arthroplasty surgeries and the impact on OR air flow (Mears 2015). The researchers measured how often and for how long OR doors were opened during 191 hip and knee arthroplasty procedures. They also measured air pressures in the OR and adjacent corridors. They found that, on average, OR doors were open 9.5 minutes per case and the average time between door openings was 2.5 minutes. As you’d expect the number and duration of door openings correlated with the length of surgery. In 77 of the 191 cases positive pressure within the OR was defeated. The implications are obvious. While they found only one surgical infection in the 191 cases, the effects of the door opening on OR pressure and air flow theoretically would predispose to surgical infections. OR’s have positive pressure to avoid flow of air and airborne pathogens from nonsterile adjacent areas.
Now a new study has actually demonstrated that a program to reduce unnecessary door openings may reduce surgery-related infections (Camus 2016). A Canadian hospital did a manual count of door openings during total joint replacement operations and revision procedures. They counted between 42 and 70 door openings per operation from incision time to joint capsule closure time. Operations averaged 75 minutes. Reasons for entering and exiting the OR during operations included retrieving charts, instruments, or equipment, and taking a break.
Next their CUSP (Comprehensive Unit-Based Program) team brainstormed and came up with key changes, including stopping all traffic in and out of the OR between total joint capsule opening and closure, communicating by phone, and increasing the use of templates to identify implant size prior to each operation. They also put a sign on the OR door reminding staff to minimize traffic and asking them to record why they are entering the OR during an operation. Subsequent traffic audits taken every six months indicated an amazing reduction in OR traffic from between 42 and 70 door openings to 3.2 door openings per case. They felt this intervention may have contributed to a decrease in orthopedic SSIs from 2.8 percent to 2.1 percent. The Canadian team is expanding its program to multiple other services and other hospitals in their multi-hospital system.
We’ve previously suggested two “nudges” that could reduce OR door openings: (1) using a sign akin to the “On Air” signs recording studios use to indicate a procedure is in progress and (2) requiring those opening and closing the OR doors to record the reason for their action. It appears that those were two of the interventions used in their program. Also we’ve discussed in numerous columns how use of presurgical “huddles” or briefings and postsurgical debriefings may help identify issues that can lead to reduction in surgical duration and unnecessary OR traffic (see our December 30, 2014 Patient Safety Tip of the Week “Data Accumulates on Impact of Long Surgical Duration”).
The Canadian study only reported the impact on surgical infections. But we’re willing to bet that their efforts reduced not only door openings but likely significantly reduced surgical durations. That, in turn, likely reduced several other unwanted complications seen with prolonged surgery, not to mention the economic benefits to the hospital from improved efficiencies.
Of course, we’d like to see validation of their study at other sites. We don’t know if every hospital can achieve the remarkable reduction in OR door openings reported by the Canadian researchers but it’s certainly worth your while to emulate their efforts.
Our prior columns focusing on surgical case duration:
References:
Lynch RJ, Englesbe MJ, Sturm L, et al. Measurement of Foot Traffic in the Operating Room: Implications for Infection Control. American Journal of Medical Quality 2009; 24: 45-52
http://ajm.sagepub.com/content/24/1/45.abstract
Procter LD, Davenport DL, Bernard AC, Zwischenberger JB. General Surgical Operative Duration Is Associated with Increased Risk-Adjusted Infectious Complication Rates and Length of Hospital Stay, Journal of the Amercican College of Surgeons 2010; 210: 60-65
http://www.journalacs.org/article/S1072-7515%2809%2901411-2/abstract
Mears SC, Blanding R, Belkoff SM. Door Opening Affects Operating Room Pressure During Joint Arthroplasty. Orthopedics 2015; 38(11): e991-e994
Camus S. Operating Room Traffic Monitoring Improves Patient Safety. Abstract session presentation at the 2016 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) Conference. July 18, 2016 as reported in ACS (American College of Surgeons). Minimizing Operating Room Traffic May Improve Patient Safety by Lowering Rates of Surgical Site Infections. ACS Press Release July 18, 2016
https://www.facs.org/media/press-releases/restricted/ssi
Print “Confirmed: Keep Your OR Doors Closed”
August 2, 2016
Drugs in the Elderly: The Goldilocks Story
In our numerous columns on inappropriate prescribing in the elderly (see full list below) we’ve usually emphasized that the elderly are all too often prescribed not only inappropriate drugs but also too many drugs (polypharmacy). But in our January 28, 2014 Patient Safety Tip of the Week “Is Polypharmacy Always Bad?” we discussed a study by Payne and colleagues (Payne 2014) which pointed out that most previous studies linking polypharmacy to unplanned hospitalizations have had certain flaws. They then performed a retrospective analysis of patients in Scotland to further study the relationship between medications and hospitalizations. Though it was a retrospective analysis rather than a randomized controlled trial, their findings were interesting. Yes, they confirmed that there is a strong correlation overall between the number of drugs taken and the risk of unplanned hospital admission. Patients taking 4-6 medications were more than twice as likely to have an unplanned admission than those taking 1-3 medications. And those taking 10 or more medications were 6 times more likely to be admitted than those taking 1-3 medications. But when they factored in comorbidities they found that the strength of the association between number of medications and unplanned admissions was greatly reduced as the number of comorbidities increased. In fact, for the patients with the most comorbidities (6 or more conditions) there was no difference in the risk of unplanned admission between those taking 4-6 medications vs. those taking 1-3 medications. Even for those taking 10 or more medications the risk was only moderately increased (OR 1.5). They explained their results by noting that many studies on polypharmacy have ignored one very important factor that seems counterintuitive: underprescribing! That is, patients on multiple medications may not be taking a medication that is very important for at least one of their underlying conditions. Of course, it may not be truly underprescribing. Rather it may reflect poor compliance, a phenomenon we tend to see increase with the number of medications prescribed.
Now a new study from Belgium attempts to answer this question as to whether the elderly are prescribed too many or too few drugs (Wauters 2016). Researchers applied the STOPP and START criteria (see our June 21, 2011 Patient Safety Tip of the Week “STOPP Using Beers’ List?”) to a cohort of community-dwelling adults, aged 80 and older (mean age 84.4). The mean number of medications prescribed was 5 (surprisingly few by US standards). But they found that polypharmacy, underuse, and misuse were high (all around 60%) and that underuse and misuse often coexisted. In only 9% of this population was there no overuse, underuse or misuse. After adjustment for number of medications and misused medications, there was an increased risk of mortality and hospitalization for every additional underused medication. Associations with misuse were less clear. Their main finding was that every additional underused medication was associated with a relative increase in mortality rate of 36%, and in hospitalization rate of 26% after 18 months, independent of the number of medications taken, and of the number of misused medications.
The authors of both the Payne and Wauters studies therefore caution against the use of “polypharmacy” per se as a quality indicator because it may be misleading. Measures of inappropriate prescribing (eg. Beers’ list, STOPP list) are likely to be better quality metrics than using total number of medications. In our June 21, 2011 Patient Safety Tip of the Week “STOPP Using Beers’ List?” we noted the STOPP criteria identified potentially avoidable ADE’s impacting on hospitalization over twice as often as did Beers’ criteria.
We’ve done multiple columns on Beers’ list, the STOPP list, and inappropriate prescribing in the elderly (see the list at the end of today’s column). We are also strong advocates of regular reviews of a patient’s medications (medication therapy management or MTM). See our May 7, 2013 Patient Safety Tip of the Week “Drug Errors in the Home” for details on MTM. We’ve mentioned multiple times that when we do such reviews on high-risk patients we almost always come away with medication lists that are 1-2 medications shorter (because of therapeutic duplication or medications no longer needed). Several of our columns also deal with how to “deprescribe”. But the work described in the Payne and Wauters studies would suggest we need to add another column to our MTM sheets – one for evidence-based medications that are missing for a condition the patient has!
In our hospitals we’ve already added such a column to our discharge checklists and this has helped hospitals improve their compliance with quality metrics for a variety of P4P programs. But we probably have not kept up to date on our similar MTM lists on the outpatient side.
So is polypharmacy always bad? In analogy to the Goldilocks fairytale, is our prescribing in the elderly too many, too few, or just right? What we really need to strive for is “eupharmacy” or, as Goldilocks would have said “just right”.
Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:
References:
Payne RA, Abel GA, Avery AJ, et al. Is polypharmacy always hazardous? A retrospective cohort analysis using linked electronic health records from primary and secondary care. British Journal of Clinical Pharmacology 2014; 15 January 2014
http://onlinelibrary.wiley.com/doi/10.1111/bcp.12292/pdf
Wauters M, Elseviers M, Vaes B, et al. Too many, too few, or too unsafe? Impact of inappropriate prescribing on mortality, and hospitalisation in a cohort of community-dwelling oldest old. British Journal of Clinical Pharmacology 2016; published online 18 July 2016
http://onlinelibrary.wiley.com/doi/10.1111/bcp.13055/abstract
Print “Drugs in the Elderly: The Goldilocks Story”
August 9, 2016
More on the "Second Victim"
Back in the early 1990’s as we began dealing with investigations on serious events we recognized that those healthcare workers involved in serious events, either directly or indirectly, often had difficulty coping in the aftermath of such events. Albert Wu, M.D., is generally recognized as coining the term “second victim” to describe such individuals and their plight (Wu 2000). But while we recognized the issue of the second victim in those early days of patient safety, we didn’t really know how to best help them. We often simply made available to them professional assistance (employee assistance programs or psychological counselling). Over the years, helping the “second victim” has evolved considerably and such referral for professional help is not a good firstline strategy and may even be counterproductive.
In our December 17, 2013 Patient Safety Tip of the Week “The Second Victim” we described some of the excellent work done in developing “second victim” programs by Wu and colleagues at Johns Hopkins and by Susan Scott and colleagues at the University of Missouri. Scott et al. (Scott 2009) interviewed 31 second victims (10 physicians, 11 nurses, 10 other) involved in serious events and identified 6 stages that constitute the natural history of second victims. They found that, regardless of the gender or profession or years of experience of the healthcare worker, the second victim phenomenon is a life-altering experience with long-term impact. Both psychological symptoms and physical symptoms were common in second victims. Intensity varied and was often influenced by factors such as the relationship the provider had with the patient or family or the age of the patient being similar to that of a provider’s family member. External stimuli (eg. same location, similar name, similar diagnosis) often triggered thoughts about the incident. But they found that “second victims” typically went through the following 6 stages:
See our December 17, 2013 Patient Safety Tip of the Week “The Second Victim” or the original study by Scott and colleagues (Scott 2009) for details about those 6 stages. Their work has since been further expanded. The March/April 2015 issue of Patient Safety & Quality Healthcare has an article on the “second victim” that every healthcare organization needs to read. That article (Hirschinger 2015) summarizes lessons learned over 5 years of the University of Missouri program providing clinician support in such cases. The program they built has 3 tiers. The first tier is immediate “emotional first aid” from colleagues and/or supervisors. In the second tier, trained peers monitor the colleagues for “second victim responses” and provide support in both one-on-one sessions (“caring moments”) and group debriefings. The third tier is access to professional services beyond the capabilities of the trained peers. The system relies heavily on the use of trained peers who have volunteered to participate. The paper nicely describes what they look for, how they use services, team design, safety culture development, and lessons learned (both from peers and insights from the “second victims” themselves). It discusses how real-time support is used and how to identify when interventions are necessary (because many “second victims” do not actively seek support).
There have been multiple other publications related to the “second victim” in the past two years. Two new “second victim” programs have recently launched in Maryland (Pitts 2015). These actually resulted from the work done by Albert Wu, M.D., who is generally recognized as coining the term “second victim” (Wu 2000) and was developed by the Maryland Patient Safety Center and Johns Hopkins’ Armstrong Institute for Patient Safety and Quality. The program has rolled out at Greater Baltimore Medical Center and will soon be launched at the University of Maryland Medical Center. Each facility assembles a team of about two dozen peer responders (physicians, nurses, administrators and others) who get comprehensive training using case studies and videos. They brainstorm possible scenarios and act out scenarios. Effective listening is the most critical skill for team members.
In our December 17, 2013 Patient Safety Tip of the Week “The Second Victim” we discussed many of the symptoms experienced by healthcare workers following a serious incident in which they were involved. One recent study from Belgium reveals the personal and professional tolls taken on second victims (Van Gerven 2016). The study looked at responses from a sample of almost 6000 physicians and nurses at Belgium acute and psychiatric hospitals. 9% of participants reported having been personally involved in a patient safety incident in the preceding 6 months. Compared to those who had not been involved in an incident, those who were involved in an incident (the “second victims”) were found to be at a greater risk of burnout, more prone to problematic medication use and to greater work-home interference, and to more turnover intentions. Moreover, they found that incidents resulting in harm to a patient predicted problematic medication use, risk of burnout, and work-home interference. There were some differences between physicians and nurses. Patient safety incidents were more likely to be related to problematic medication use in physicians and more excess alcohol consumption in nurses. And the relationship between actual patient harm and work-home interference and turnover intentions was stronger in respondents from psychiatric hospitals. The authors note that the occurrence of these personal and professional adverse consequences following a patient safety incident might put these physicians and nurses at risk for future patient safety incidents as well, highlighting the importance of implementing programs to help “second victims”.
Another recent study compared emotions and coping mechanisms between the UK and US (Harrison 2015). Though the authors had suspected differences such as the litigation climate might impact these, they found little evidence of such a difference. Interestingly, they also found little difference between emotional responses and severity of the incident. Overall, a third of respondents reported that either their work performance or personal life suffered at least moderately following an incident. As expected, negative emotional responses were more common than positive ones. While many had strained relationships with colleagues, 56% actually valued their relationships with colleagues more following the incident. And the vast majority (84%) noted they paid more attention to safety issues following the incident. As in many other studies, differences between physicians and nurses were noted. Nurses had more of the following emotions: upset, worried, distressed, scared, and nervous. Coping strategies included “approach” strategies (eg. discussing the error with colleagues or superiors) and “reappraisal” and learning from mistakes. Just over half of the respondents were aware of organizational support services and 49% expressed willingness to access them. However, many noted feelings of shame and fears over confidentiality as barriers to using such services. Importantly, many expressed that support from a trusted existing resource (such as a peer) was preferable to a formal service.
Perception of the level of institutional support available after a patient safety event was also an important issue in another recent study. Joesten and colleagues surveyed healthcare workers at a large community teaching hospital (Joesten 2015), using one of several tools available from MITSS (Medically Induced Trauma Support Services), a non-profit organization whose mission is to support healing and restore hope to patients, families, and clinicians impacted by medical errors and adverse medical events. Of a convenience sample of 365 individuals, 73% answered that they had been directly involved in a patient safety event within the past 3 years. However, over half of those did not answer any of the items on the survey, leaving 120 evaluable surveys. Most of the respondents were female nurses, practicing a median 16 years. Symptoms of the “second victim” phenomenon were present in many respondents. But, notably, a significant proportion of respondents were unaware of services available to them (including guidance from a disclosure support team member, personal legal advice and support, opportunity to take time out from clinical duties, and access to counseling). Those that were aware of available services generally found them to be useful. Interestngly, 64% of respondents agreed they experienced support from their clinical colleagues but only 38% noted support from managers or chairmen. Also notable was that 60% disagreed that they could report a patient safety event without fear of retribution. This study highlights two things. First, it’s not enough to just have services available. You need to make everyone aware of the program and its usefulness. Second, it again emphasizes how “culture” trumps everything else. In a culture where fear of retribution is widespread, it is difficult to implement even programs designed to help the frontline healthcare worker.
In an editorial, Edrees and Federico (Edrees 2015) note that although these and other studies have been useful in further understanding the problem of second victims in healthcare, future studies should focus on organizational culture and the willingness of second victims to access support services after an unanticipated adverse event. They also call for studies that focus on identifying and mitigating institutional barriers for supporting second victims.
Most studies on the “second victim” have chronicled the negative symptoms and experiences a healthcare worker suffers after a serious event. But a recent study (Plews-Ogan 2016) looked at factors associated not just with “coping” after a medical error but with growing and achieving positive outcomes. The authors interviewed 61 physicians who had made a serious medical error. The study was likely biased towards those who had positive outcomes since they were recruited via advertisement and word of mouth. Nevertheless, the findings offer significant insight into factors that help such physicians have positive outcomes. They identified eight themes reflecting what helped physician “wisdom exemplars” cope positively:
Talking about it is a strategy always noted in studies about second victims. However, the interesting insight from this study was that it was crucial that the person they talked to did not downplay the seriousness of the error. They note that there is a “tendency of well-intentioned colleagues to minimize, dissolve, deny or attempt to solve the error, which they did not find helpful.” They noted they needed to share both the medical aspects of the error and the emotional ones. They also found that in talking others often shared their own mistakes, letting the physician understand they were not alone.
We’ve discussed disclosure and apology in multiple columns (see full list below). Physicians who had positive outcomes were more likely to have disclosed the error to patients or their families and apologized. This helped patients and families understand the physician cared. There was even one instance where the disclosure and apology was met with anger by the patient but the physician went back a second time to apologize and the patient said “I know you care about me…I forgive you”.
Foregiveness from the patient/family was often the result of disclosure and apology but some noted it was also a struggle to forgive themselves without lowering their standards or “letting themselves off the hook”. Several noted how the moral context (eg. spirituality or professionalism) helped them to do the right thing, citing how discussions with mentors or even a medical student helped them do the right thing.
Dealing with imperfection was a key theme but those with positive outcomes realized they could be “imperfect but good” physicians.
The last three themes are related. Those with positive outcomes often strived to learn about and become experts about the knowledge or technical deficiencies involved. They also participated in figuring out what happened and fixing it, preventing similar events, and teaching others about it.
The study has important implications for organizations. We need to train physicians to provide peer support in the proper way, serving as “an ear” that listens and does not try to minimize the seriousness of the event(s). Also noted was that many of the responding physicians noted they had never been trained on how to do disclosure and apology so we need to do a better job of preparing physicians for that. And changing our culture to recognize we are not perfect needs to start in medical school and extend throughout our careers.
As we have evolved in patient safety toward full disclosure and apology when adverse events occur (see our many columns on disclosure and apology listed below) there has been a lag in preparing clinicians to participate in such activity. Carolyn Clancy, in an editorial on how we should approach second victims (Clancy 2012), noted how the evolving practice of disclosure and apology might be a means of alleviating the emotional trauma of both the first and second victims of patient safety events. A recent study of how surgeons address adverse clinical events with their patients and/or patient families is most telling (Elwy 2016). Elwy and colleagues surveyed surgeons in the Veterans Affairs medical system about their experiences in disclosing adverse events. Most of the respondents to the survey used 5 of 8 recommended disclosure items:
But use of the other 3 recommended disclosure items was less frequent:
They found that surgeons who reported they were less likely to discuss preventability of the adverse event, those who stated the event was very or extremely serious, or who reported difficult communication experiences were more negatively affected by disclosure than others. Those surgeons with more negative attitudes about disclosure at baseline reported more anxiety about patients’ surgical outcomes or events following disclosure. The study clearly highlights the need for training for disclosure and apology and development of skillsets to use for such. Logically, it might be anticipated that development of those skills might reduce the negative experiences with disclosure and apology on the part of surgeons and perhaps be a first step in aiding the “second victims”, too.
In all our years in both clinical medicine and patient safety we’ve always found that personal stories are much more compelling than any study. We noted several such personal stories in our December 17, 2013 Patient Safety Tip of the Week “The Second Victim”. But we can’t do it any better than the story by Sarah Kliff in Vox earlier this year (Kliff 2016). She tells the tragic story of Kim Hiatt, an experienced and compassionate nurse who struggled after a medical error and ultimately took her own life. This emphasizes the plight of the second victim and how our systems often fail to identify the needs of the second victim and provide the right kinds of support to our colleagues and coworkers in their greatest time of need. We can’t just sit back and wait for them to ask for help. We need proactive programs in place that anticipate the stages a “second victim” will go through and be there at the right time for them with the skills needed to help them cope and not only mitigate the negative effects but also grow and achieve positive outcomes. It takes a strong organizational commitment to develop programs like those in Maryland and Missouri but some day each one of us could be a “second victim” and need such a program.
Some of our prior columns on Disclosure & Apology:
July 24, 2007 “Serious Incident Response Checklist”
June 16, 2009 “Disclosing Errors That Affect Multiple Patients”
June 22, 2010 “Disclosure and Apology: How to Do It”
September 2010 “Followup to Our Disclosure and Apology Tip of the Week”
November 2010 “IHI: Respectful Management of Serious Clinical Adverse Events”
April 2012 “Error Disclosure by Surgeons”
June 2012 “Oregon Adverse Event Disclosure Guide”
December 17, 2013 “The Second Victim”
July 14, 2015 “NPSF’s RCA2 Guidelines”
June 2016 “Disclosure and Apology: The CANDOR Toolkit”
Other very valuable resources on disclosure and apology:
References:
Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ 2000; 320: 726–727
Scott SD, Hirschinger LE, Cox KR, et al. The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care 2009; 18(5): 325-330
http://qualitysafety.bmj.com/content/18/5/325.full?sid=495da4c7-557e-45ec-a01e-54538e9ebc1f
Hirschinger LE, Scott SD, Hahn-Cover K. Clinician Support: Five Years of Lessons Learned. Patient Safety & Quality Healthcare 2015; March/April 2015. Published 03 April 2015
http://psqh.com/march-april-2015/clinician-support-five-years-of-lessons-learned
Pitts J. Program helps caregivers under stress after errors. The Baltimore Sun 2015; June 21, 2015
Van Gerven E, Vander Elst T, Vandenbroeck S, et al. Increased risk of burnout for physicians and nurses involved in a patient safety incident. Med Care 2016; [Epub ahead of print] May 20, 2016
Harrison R, Lawton R, Perlo J, et al. Emotion and Coping in the Aftermath of Medical Error: A Cross-Country Exploration. Journal of Patient Safety 2015; 11(1): 28-35
Joesten L, Cipparrone N, Okuno-Jones S, DuBose ER. Assessing the Perceived Level of Institutional Support for the Second Victim after a Patient Safety Event. Journal of Patient Safety 2015; 11(2): 73-78
MITSS (Medically Induced Trauma Support Services)
http://www.mitsstools.org/index.html
Edrees H, Federico F. Supporting clinicians after medical error. (Editorial). BMJ 2015; 350: h1982 (Published 15 April 2015)
http://www.bmj.com/content/350/bmj.h1982
Plews-Ogan M, May N, Owens J, et al. Wisdom in Medicine: What Helps Physicians After a Medical Error? Acad Med 2016; 91(2): 233-241
Clancy CM. Alleviating “Second Victim” Syndrome: How We Should Handle Patient Harm. Journal of Nursing Care Quality 2012; 27(1): 1-5, January/March 2012
Elwy R, Itani KMF, Bokhour BG, et al. Surgeons’ Disclosures of Clinical Adverse Events. JAMA Surg 2016; Published online July 20, 2016
http://archsurg.jamanetwork.com/article.aspx?articleid=2534133
Kliff S. Fatal mistakes. Doctors and nurses make thousands of deadly errors every year. They are reprimanded. Do they also deserve support? Vox 2016; March 15, 2016
http://www.vox.com/2016/3/15/11157552/medical-errors-stories-mistakes
Print “More on the Second Victim”
August 16, 2016
How Is Your Alarm Management Initiative Going?
By now your organization should be well on its way in implementation of an alarm management initiative to meet The Joint Commission’s NPSG on Alarm Management (see our August 2013 What's New in the Patient Safety World column “Joint Commission Formalizes 2014 NPSG on Alarm Management”). As of January 1, 2016 in phase 2 of that NPSG The Joint Commission expects hospitals will have established and implemented policies and procedures for managing clinical alarms and have done appropriate staff education.
Our July 2, 2013 Patient Safety Tip of the Week “Issues in Alarm Management” discussed in detail the issue of alarm fatigue and provided recommendations on how you should put together an alarm management program with attention to several very relevant issues. But now we also have the benefit of many valuable lessons learned as organizations have grappled with implementation of alarm management programs.
One issue that many hospitals have struggled with in phase 1 of the NPSG on Alarm Management was inventorying and data collection about alarms. While hospitals with the most up-to-date technology systems and large IT departments have used IT analysts to look at virtually all alarms over a period of time, smaller hospitals and those with fewer resources may have chosen to use a sampling strategy rather total strategy. But one problem frequently noted is that often one or two patients have accounted for a disproportionate number of alarms. So in cases where sampling is used you may need to include a way of dealing with such outliers in both your baseline data and your ongoing data collection. For example, you might consider dropping from your statistics those patients with alarm frequencies greater than 2 standard deviations beyond the mean. We’re sure there will be some statistician out there who will rail at this but let’s be practical – we’re not publishing the data in a peer reviewed journal! We’re using it as the key measure in our performance improvement activities. That doesn’t mean you ignore the outliers (because their alarms are still requiring your staff to respond) but the outliers may require different approaches, such as customizing alarm settings for individual patients.
Many hospitals were surprised during their alarm inventory to find they had more than one alarm doing basically the same thing! For example, such duplicate alarms may have included separate alarms for bradycardia and low heart rate or tachycardia and high heart rate (Sendelbach 2015). And the built-in default values for those alarms may have actually been different!
After you did an inventory of you alarms you categorized and prioritized them. Some categorized alarms as clinical vs. technical. But all should have identified which alarms pointed to actionable conditions and then determined how and how urgently those alarms needed to be attended to. Most have identified low priority alarms but many found they had alarms which triggered for conditions for which they never took action. The best examples are alarms for PVC couplets or bigeminy. Since almost no one takes an action when couplets or bigeminy occur, there is little reason to keep such alarms active in your systems.
An outstanding example of doing an alarm inventory with categorization and prioritization comes from researchers at UCSF (Drew 2014). Over a 31-day study period in 5 adult intensive care units with 461 patients they found an audible alarm burden of 187/bed/day. 88.8% of the 12,671 annotated arrhythmia alarms were false positives. Conditions causing excessive alarms included inappropriate alarm settings, persistent atrial fibrillation, and non-actionable events such as PVC's and brief spikes in ST segments. Low amplitude QRS complexes in some but not all available ECG leads caused undercounting heart rate and false arrhythmia alarms. Wide QRS complexes due to bundle branch block or ventricular pacemaker rhythm caused false alarms. 93% of the 168 true ventricular tachycardia alarms were not sustained long enough to warrant treatment.
Alarms for PVC’s were the most frequent nonactionable type of alarm. Even though guidelines do not recommend intervention for isolated PVC’s, clinicians were apparently concerned about the potential for torsade de pointes in patients with prolonged QTc intervals so PVC alarms were not disabled (see our prior columns on torsade de pointes listed at the end of today’s column for potential solutions to that issue). Atrial fibrillation alarms would repeat in patients with persistent atrial fibrillation. And in one patient with atrial fibrillation and a ventricular response rate of 130-135 per minute the high heart rate alarm would fire because the hospital default threshold was 130 per minute (resulting in an average of 211 alarms per hour!). They also noted that accelerated ventricular rhythms and non-sustained ventricular tachycardia (lasting less than 30 seconds) were not considered “actionable”. True positive ventricular tachycardia alarms (where intervention was required) were relatively infrequent. Sometimes an artifact mimicking a ventricular arrhythmia might appear in one lead and trigger an alarm even though other leads showed a different rhythm (other leads may not have been visible on monitors). Notably, 91% of asystole or pause false alarms had visible QRS complexes in other leads that could have been detected had multiple leads been used. Apnea or respiratory rate alarms occurred, on average, 79 alarms/bed/day. Many of these were false alarms where the waveform looked flat in patients who were known to be breathing adequately.
The Drew article ends with some good recommendations for hospitals (especially regarding the need for customizing alarms and avoiding nonactionable alarms) and for vendors/manufacturers (eg. integrating multiple ECG leads into monitors, messaging when alarms continue when atrial fibrillation is persistent) and others.
The other area in which much success has been achieved is reducing the amount of unnecessary telemetry. In our July 2, 2013 Patient Safety Tip of the Week “Issues in Alarm Management” we noted that telemetry is one technology we often see overutilized in many hospitals, which may contribute to alarm fatigue. When we discuss alarm management strategies with hospitals one of the first areas of focus we recommend is telemetry, particularly that occurring outside ICU’s. 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.
In our October 2014 What's New in the Patient Safety World column “Alarm Fatigue: Reducing Unnecessary Telemetry Monitoring” we cited a study at Christiana Care Health System that successfully implemented a system that significantly reduced unnecessary non-ICU telemetry and achieved substantial financial savings while not adversely impacting patient safety (Dressler 2014). A multidisciplinary team designed the program and ensured appropriate training of impacted departments. The key component was hardwiring the AHA guidelines into their electronic ordering system. Providers were now required to choose an indication from a list, each of which included a duration based upon the AHA guidelines. In addition, they removed telemetry orders from order sets for conditions where monitoring was not supported by the AHA guidelines. Also, guidelines were established for automatic discontinuation of telemetry monitoring.
After implementation there was a 70% reduction in the mean daily number of patients being monitored by telemetry. The mean weekly number of telemetry orders dropped 43% and the mean duration of telemetry dropped by 47%. They assessed for potential impact on patient safety and found no worsening of mortality, code blues, or rapid response team activations. Their mean daily cost for non-ICU telemetry decreased from $18,971 to $5,772, with a projected annual savings of $4.8 million. Undoubtedly, this also had a beneficial effect on the phenomenon of alarm fatigue, though they had no specific measure of the latter. This excellent work by Christiana Care Health System demonstrates that such a focus on unnecessary telemetry monitoring can lead to significant financial savings without sacrificing patient safety and likely reducing alarm fatigue.
Do you implement an entire “bundle” of interventions in one fell swoop or do you add interventions sequentially? One hospital system took the latter approach and piloted interventions before taking them system-wide and, by sequencing the interventions, was able to determine the relative impact attributable to each intervention (Turmell 2016). Their program reduced alarms up to 30% and they estimated it had the potential to save $136,500 and 841 hours of registered nurses' time per year. No patient harm occurred during the 2-year project and, though it could not be directly measured, there was a perception of reduced alarm fatigue. There were 5 individual components to their program. Daily electrode changes reduced alarms 33% and reduced “artifact” alarms 26%. Eliminating nonactionable and duplicate alarms and adjustment of thresholds reduced alarms 36-84% (the unit with the lesser reduction having one patient accounting for the majority of alarms). As we’d expect, appropriate use of telemetry (using the AHA/ACC guidelines) identified an average of 15 patients per day who could potentially have telemetry monitoring removed (with actual removal occurring in an average of 6 patients per day). Interestingly, they found their initiative on customization of alarms actually increased alarms! So they did not roll that intervention out to the rest of the system. But that customization relied heavily on technology so even though they “turned off” that setting, they still proceeded with education of nursing staff about customization of alarms. Turmell and colleagues emphasize that this is not a “one and done” type of project but rather that there is a need for continued evaluation, particularly for adjusting default alarm settings.
On the other hand, Sendelbach and colleagues took a “bundled” approach to alarm management in a medical coronary care unit (Sendelbach 2015). They prioritized their alarms as “life-threatening”, “serious”, or “advisory” based upon what was likely to happen to the patient if the alarm were not immediately attended to. Note that, in attempt to reduce the noise created by alarms, some of the alarms in the “advisory” category now are sent via their mobile communication device system rather than continuing as audible alarms for everyone to hear. Individual program components were similar to those in the Turmell study and included: elimination of duplicate alarms, adjusting default alarm settings, customization of alarms based on individual needs, daily changes of ECG electrodes, standardized skin preparation, and use of disposable ECG leads. Overall, this “bundled” approach led to an 80-90% reduction in alarms in their CCU (from a mean of 28.5 alarms per patient per day down to 3.29 alarms per patient per day)! This basically preserved all the alarms for life-threatening events and eliminated most of the alarms that were of lower priority. Moreover, their improvement was sustained over time. As in the Turmell study, ongoing evaluation is important. They found that the use of disposable ECG leads did not reduce alarms so that component was dropped.
One intervention they found to be ineffective was decreasing the alarm threshold on pulse oximetry from 90% to 88% (an intervention found to be successful and safe in the literature). So it is important to remember that what works one place or setting may not work at another.
The above studies and, in fact, the bulk of studies on alarm management have focused on intensive care settings. On the other hand, a significant quality improvement project aimed at reducing alarms on general med/surg units actually preceded announcement of The Joint Commission’s NPSG on Alarm Management. Whalen and colleagues at Boston Medical Center began their performance improvement project in 2008 and expanded upon it in 2011 (Whalen 2014). They did the usual data mining of alarms but one crucial thing they did was direct observation of nurses’ responses to various alarms. That observation not only determined how nurses responded to the alarms but also demonstrated that those responses affected the staff’s ability to respond to other important alarms.
The focus was on self-resetting alarms (audible alarms capable of self-resetting once alarm conditions are no longer met) that contribute significantly to excess audible alarms and the phenomena of clinical alarm fatigue. For the QI project they set default heart rate limits to a lower limit of 45 and upper limit of 130 per minute. They also added an audible alert for atrial fibrillation (raising its status from a message alarm to a patient status arrhythmia advisory alarm). They did this to help better identify paroxysmal episodes of AF. However, nurses had the ability to reassign it to the nonaudible message alarm for patients with chronic AF. For the study, if a crisis alarm sounded nurses would respond immediately to the patient but they also had the opportunity to reset the default settings to better reflect the patients’ baseline heart rate and rhythm. A few other interventions occurred during the study (order sets were redesigned, short runs of V tach were moved from audible status to message status, and daily ECG lead changes were begun).
Following implementation there was an overall 89% reduction in total mean weekly audible alarms was achieved on the pilot unit, without requirement for additional resources or technology. The largest contribution to the reduction in alarm frequency was a 93% reduction in bradycardia, tachycardia, and heart rate parameter limit alarms. There were no adverse events related to missed cardiac monitoring events, and the incidence of code blues decreased by 50%. The maximum decibel level of noise on the pilot unit improved and both staff and patient satisfaction improved. The authors speculated that the improved patient satisfaction reflected not only the reduction in noise level but also that the nursing staff now had more time to spend with patients.
Moving lower priority alarms from audible status to messaging status can go a long way to reduce alarm fatigue and excessive noise in a variety of settings. Just keep in mind that things can still go wrong. See our February 9, 2016 Patient Safety Tip of the Week “It was just a matter of time…” for such an example.
One interesting approach on setting alarm thresholds was recently taken by a children’s hospital. Most thresholds are set via very arbitrary methods. But researchers at Stanford (Goel 2016) analyzed the heart and respiratory rate data from 16 months of Packard Children’s records and calculated the 5th and 95th percentiles for the measures, cutoffs chosen as reasonable thresholds for abnormally low or high values. They broke the data down by age range and, to avoid having the results skewed by critically ill children, excluded data from patients who spent time in the intensive care units. There were 55.6% fewer out-of-range measurements using data-driven vital sign limits. Safety evaluation of data-driven limits suggests they are as safe as those currently used. The authors suggest that implementation of these parameters in physiologic monitors may mitigate alarm fatigue. It will be most interesting to see if these findings can be replicated in adult and other settings. It would add a degree of rationality to setting alarm thresholds.
Not mentioned in any of the above studies and resources is the need to ensure you have chosen the correct monitoring parameter. We’ve done numerous columns about the limitations of pulse oximetry in patients on opioids and the need to use capnography to identify respiratory depression early. We’ve even noted how in patients with obstructive sleep apnea (OSA) you may hear audible pulse oximetry alarms when the patient’s oxygenation desaturates. By the time a nurse or respiratory therapist responds, the patient may have awakened and now is breathing normally and has a normal oxygen saturation. Often the alarm is written off as a false alarm. Such contributes to both excessive noise and alarm fatigue yet allows the patient to be in a very vulnerable status.
We refer you back to our July 2, 2013 Patient Safety Tip of the Week “Issues in Alarm Management” for suggestions on how to approach your alarm management and links to some useful resources. Another great resource is Clinical Alarm Management Compendium from the AAMI Foundation (AAMI 2015). Many of you may have participated in the series of webinars on alarm management put on by AAMI in 2015. And, of course, ECRI Institute’s Alarm Safety Resources is another valuable resource. And, by the way, Joint Commission Resources does make available a complimentary self-assessment process can help you maintain alarm safety in your organization. This is worth your while to help you prepare for your next Joint Commission survey.
Prior Patient Safety Tips of the Week pertaining to alarm-related issues:
Some of our prior columns on QT interval prolongation and Torsade de Pointes:
June 29, 2010 “Torsade de Pointes: Are Your Patients At Risk?”
February 5, 2013 “Antidepressants and QT Interval Prolongation”
April 9, 2013 “Mayo Clinic System Alerts for QT Interval Prolongation”
June 10, 2014 “Another Clinical Decision Support Tool to Avoid Torsade de Pointes”
April 2015 “Anesthesia and QTc Prolongation”
References:
Drew BJ, Harris P, Zègre-Hemsey JK, et al. Insights into the Problem of Alarm Fatigue with Physiologic Monitor Devices: A Comprehensive Observational Study of Consecutive Intensive Care Unit Patients. PLOS One 2014; Published: October 22, 2014
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0110274
Dressler R, Dryer MM, Coletti C, et al. Altering Overuse of Cardiac Telemetry in Non–Intensive Care Unit Settings by Hardwiring the Use of American Heart Association Guidelines. (Research Letter). JAMA Intern Med 2014; published online first September 22, 2014
http://archinte.jamanetwork.com/article.aspx?articleid=1906998
Turmell JW, Coke L, Catinella R, et al. Alarm Fatigue: Use of an Evidence-Based Alarm Management Strategy. Journal of Nursing Care Quality 2016; Published Ahead-of-Print Post Author Corrections: August 05, 2016
Sendelbach S, Wahl S, Anthony A, Shotts P. Stop the noise: a quality improvement project to decrease electrocardiographic nuisance alarms. Crit Care Nurse 2015; 35(4): 15-22
http://ccn.aacnjournals.org/content/35/4/15.full.pdf+html?sid=4608795f-d440-4837-862f-275acc1c69a6
Whalen DA, Covelle PM, Piepenbrink JC, et al. Novel Approach to Cardiac Alarm Management on Telemetry Units. Journal of Cardiovascular Nursing 2016; 29(5): E13-E22, September/October 2014
Goel VV, Poole SF, Longhurst CA, et al. Safety analysis of proposed data-driven physiologic alarm parameters for hospitalized children. J Hosp Med 2016; First published: 14 July 2016
http://onlinelibrary.wiley.com/doi/10.1002/jhm.2635/abstract
AAMI Foundation. Clinical Alarm Management Compendium. AAMI Foundation 2015
http://www.aami.org/productspublications/pressreleasedetail.aspx?ItemNumber=2905
ECRI Institute. Alarm Safety Resources.
https://www.ecri.org/resource-center/Pages/Alarms.aspx
Joint Commission Resources. CLINICAL ALARM SYSTEMS SAFETY REVIEW (self-assessment process for alarm management). April 9, 2016
https://www.facebook.com/jointcommissionresources/posts/10150617581234970
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August 23, 2016
ISMP Canada: Automation Bias and Automation Complacency
“It must be right, the computer said so.” Unfortunately, that concept has become very ingrained into our thinking and we see more and more adverse events related to over-reliance on technology. We love technology and think it is one of the most important tools in our armamentarium to help prevent medical errors and adverse patient outcomes. Yet we end up every year writing several columns on the unintended consequences of technology (see the list of those columns at the end of today’s column).
This month, ISMP Canada published a safety bulletin on over-reliance on technology (ISMP Canada 2016). They first described a patient incident and then focused on two very important and related concepts: automation bias and automation complacency.
The incident occurred in a patient admitted with new onset seizures. An order for phenytoin was handwritten using the brand name Dilantin. A hospital pharmacy staff member, who was relatively new to the clinical area, entered the first 3 letters “DIL” into the pharmacy IT system. The staff member was then interrupted and, when the task was resumed, diltiazem 300 mg was ordered instead of Dilantin 300 mg. Back on the clinical unit the handwritten order had correctly been transcribed by a nurse into the MAR. Later, when another nurse obtained the evening’s medications for the patient from the ADC (automated dispensing cabinet), he/she noted a discrepancy between the MAR and the ADC display but accepted the information on the ADC display as being correct. The diltiazem was erroneously administered and the patient developed significant hypotension and bradycardia.
Another example of over-reliance on technology that we give in several of our presentations is a near-miss involving insulin. A physician, from a specialty not used to ordering insulin, did medication reconciliation and mistook the “U-100” formulation of insulin listed on records accompanying the patient to be a dose of 100 units of insulin. The physician entered a dose of 100 units of regular insulin into the CPOE system. The pharmacy system did not have dose range limits for insulin and there was no prompt for special review by the pharmacist. The nurse who received the syringe with 100 units of regular insulin was somewhat surprised by the relatively high dose but barcoded the patient’s wrist band ID and the medication and looked at the electronic MAR, all of which indicated correct patient, correct medication, correct dose. So the medication was administered. Fortunately, because the nurse had an “uneasy feeling” she went back and checked the patient’s records and found that he had been on 10 units of regular insulin prior to admission. She drew a stat blood glucose level and administered D50W and potentially serious harm was prevented. In the old days, of course, a nurse would have immediately checked the records and the orders and spoken to the ordering physician before administering such a high dose of insulin. But, here, our tendency to believe that the technology is always correct biased the nurse toward first administering the insulin then checking further rather than checking further before administering it.
The first type of error in the ISMP Canada example is one we have encountered since the very first computers came out: the cursor error (also known variously as the mouseclick error, drop-down list error, picklist error, stylus error, or juxtaposition error depending upon the setting and device being used). We’ve all done it – you have a list of choices and you think you touched one choice yet your cursor or stylus actually hit the choice above or below the one you wanted. Usually we look to see what was chosen but, as in the ISMP Canada example, we may get distracted and not notice our erroneous choice (Yes, your email might get sent to someone you didn’t want it to go to!).
But the gist of the ISMP Canada article is not the error of choosing the wrong medication from a drop-down list. Rather, it is about our tendency to over-rely on technology and assume the technology is correct. They discuss two interrelated concepts: automation bias and automation complacency. Automation bias is “the tendency to favor or give greater credence to information derived from an automated decision-making system…and to ignore a manual (non-automated) source of information that provides contradictory information”. Examples are accepting the information on the ADC display rather than the handwritten MAR in the ISMP Canada example, or the acceptance of the barcoding system rather than the “gut feeling” in our insulin example. The closely related “automation complacency” refers to “monitoring of an automated process less frequently or with less vigilance than optimal because of a low degree of suspicion of error and a strong belief in the accuracy of the technology”. Both ignore the fact that the technology is only as good as the data that gets input.
ISMP Canada notes 3 factors contribute to automation bias and automation complacency: (1) our tendency to select the pathway with the least cognitive effort, (2) our perception that the analytic capability of automated aids is superior to humans, and (3) we often “shed” our responsibility when an automated system is performing the same function.
(Note that similar factors may contribute to the complacency we often see in double check systems as we’ve described in our October 16, 2012 Patient Safety Tip of the Week “What is the Evidence on Double Checks?”.)
The ISMP Canada article goes on to discuss the conflicting evidence as to the effect training and experience might have on automation bias and automation complacency. Some studies suggest that inexperience predisposes to such errors whereas other studies suggest increased familiarity with a technology may lead to desensitization and habituation.
ISMP Canada recommends training about automated systems both at orientation and on an ongoing basis, including discussion of limitations of such systems and any gaps or previous errors identified. It also suggests allowing trainees to experience automation failures during training. Further, a proactive risk assessment (eg. FMEA or failure mode and effects analysis) or a staged implementation should be used with new technologies to help identify unanticipated vulnerabilities. Input from end-users should be sought up front and feedback should be sought after implementation. They also have recommendations about avoiding interruptions during double checks, having standardized ways to address identified medication discrepancies, and the importance of comparing the ADC display with the MAR when selecting a medication from the ADC.
Note that there are other issues in the ISMP Canada incident that are important. One is failure to include an indication for the drug being ordered. A good system (whether manual or computerized) should require an indication. That gives everyone the opportunity to say “wait a minute, diltiazem is not used for treating seizures”. (But keep in mind that the indication may not be known for many medications taken prior to admission and continued during hospitalization.)
And the insulin example illustrates problematic medication reconciliation and lack of manual and electronic review of dosages for a high alert medication. One excellent patient safety intervention for high-risk drugs is setting dose range limits on your CPOE or pharmacy IT systems. This is very valuable in preventing, for example, overdoses of chemotherapy agents. For insulin, it is much more difficult than it sounds. That is because the dosages of insulin used are so variable across patients. Particularly at a large hospital treating lots of complex patients it might not be surprising for a nurse to have administered 100 units of insulin to a patient. But it is still worth looking at your data and saying “we’ve seldom used a dose of insulin exceeding x units” and then adding an alert that helps physicians, pharmacists or nurses question orders for large doses of insulin.
In aviation safety a term often encountered is “automation surprise”. That refers to the fact that many complex computerized aviation systems may have the aircraft flying in a mode that is relatively masked to the pilot. For example, an aircraft may be flying under autopilot and if the autopilot disengages the pilot may not immediately be aware of several important flight parameters. There are numerous instances in the NTSB files about automation surprises contributing to aviation crashes. You, yourself, may have experienced an “automation surprise” when your motor vehicle sped up as you were approaching the rear of another vehicle because you forgot your car was on cruise control.
Reports to NASA’s Aviation Safety Reporting System also provide examples of how attention to autoflight can lead to loss of situational awareness (NASA 2013). In examples, awareness of the aircraft’s actual flight path seems to have been compromised by:
In our January 7, 2014 Patient Safety Tip of the Week “Lessons From the Asiana Flight 214 Crash” we noted that one of the major issues contributing to this crash was apparently overreliance on technology. The pilots apparently thought that the automatic throttle system was engaged, which should have increased engine thrust when the airplane speed fell below the recommended speed. However, that automatic throttle system was not engaged. Once the pilots recognized that their speed and altitude were too low and that the autothrottle had not automatically increased speed, they tried to initiate a “go round” (i.e. to abort the landing and fly around and try again) but it was too late. It’s pretty clear that sometimes pilots don’t understand what mode the computer systems are in. The FAA released a comprehensive study on the overreliance of pilots on automation and loss of situational awareness due to automation surprises (FAA 2013).
Healthcare is no different. We often use computer systems in which multiple “modes” are available and we may not recognize which mode the system is operating in. Also, in all our discussions about alarm issues we note that erroneous assumptions are often made that an alarm will trigger when anything serious happens.
The bottom line: we all likely have some degree of automation bias and automation complacency in both healthcare and our other daily activities. We still need to use common sense and never assume that the technology is flawless. In our June 2, 2009 Patient Safety Tip of the Week “Why Hospitals Should Fly…John Nance Nails It!” we noted that we all should really look at each thing we are doing in patient care and think “could what I am about to do harm this patient?”.
See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:
References:
ISMP Canada. Understanding Human Over-reliance on Technology. ISMP Canada Safety Bulletin 2016; 16(5): 1-4
https://www.ismp-canada.org/download/safetyBulletins/2016/ISMPCSB2016-05_technology.pdf
NASA. Autoflight Associated Loss of Situational Awareness. Callback 2013; 407: 1-2 December 2013
http://asrs.arc.nasa.gov/publications/callback/cb_407.html
FAA. Operational Use of Flight Path Management Systems. FAA September 5, 2013
http://media.nbcbayarea.com/documents/FAA_Final_Report_Recommendations+11-22-13.pdf
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August 30, 2016
Can You Really Limit Interruptions?
The impact of interruptions and distractions in facilitating human error and adverse events is well established. We’ve done multiple columns, listed below, on how interruptions and distractions affect nurses, physicians, pharmacists, clerical staff, and really all healthcare workers.
Strategies to reduce and minimize interruptions and distractions are thus important in potentially avoiding adverse patient events. But how successful are those strategies? There is limited literature on the efficacy of such strategies. But a recent study (Flynn 2016) assessed the impact of several strategies on reducing interruptions during medication administration. Flynn and colleagues have done an excellent job of summarizing the literature on interruptions and their impact on medication administration and chronicling those interventions which are evidence-based:
They piloted these interventions on two progressive cardiac care units (PCCU’s) and used a third PCCU as a control. They found that interruptions decreased significantly (from 23% to 4%) and medication errors decreased significantly (from 11% to 3%) in one PCCU after implementation of the evidence-based strategies. Total interruptions did not change on the second PCCU but avoidable interruptions decreased 83% and 53%, respectively, in the two intervention PCCU’s after implementation of the evidence-based strategies. Total interruptions actually increased in the third PCCU which served as the control.
Several problems related to the study design limit its ability to conclude that a reduction in interruptions translated to a reduction in medication errors. Most notable are the facts that (1) one of the 2 intervention units had a very low rate of medication errors at baseline and (2) there was a significant reduction in medication errors on the control unit. In addition, the study took place before barcoding was adopted at the hospital.
While those do limit their overall conclusions, there are some valuable lessons learned in this study. One is that potentially avoidable interruptions could, indeed, be reduced. Phone calls were a primary source of interruptions and these were clearly reduced. It took teamwork to ensure that the nurse passing meds had few interruptions. The unit secretary managed most of the communications with visitors and clerical requests from physicians or other healthcare workers. The charge nurse would address patient care issues with physicians and other healthcare workers. And hourly rounding activities were alternated so they coordinated with peak times for medication administration.
The nurse passing meds wore a yellow safety sash to designate “do not disturb” and cradled his/her phone to avoid phone interruptions. In addition, a colored magnetic icon appeared on the nurse assignment board so that all could see which nurse was passing meds and should not be disturbed. That magnetic icon would be removed when the nurse was finished passing meds and the charge nurse would update the nurse on any logged messages or other updates.
The most frequent source of interruptions was phone calls and there was a 48% reduction in interruptions from phone calls after the intervention. An important lesson learned was that of the interruptions due to unavailability of resources (the second most frequent cause of interruptions) the nurse having to stop and get water or a cup for the patient accounted for 85% of interruptions in this category. That sounds like a system issue with some relatively easy and inexpensive solutions! Most face-to-face interruptions were related to patient care issues. Interestingly, only 7% of interruptions were by physicians. And, although responses of patients and their families were “overwhelmingly positive” when told of the intervention, patient-related interruptions were no different before and after the intervention.
Another important lesson had to do with sustainability. Once funding for the initial pilot project ran out, practices tended to revert back to the old ways. Only when a new initiative took the evidence-based interventions to all nursing care units did practices improve again. In that broader implementation, the yellow safety sash was replaced simply with the barcoding scanner serving as the flag that the nurse was administering medications. Data were not provided on the hospital-wide impact of the broader intervention.
The Flynn article nicely outlines in table form with annotations the numerous studies in the literature on the impact of interruptions. That alone makes this article worth your time. But the article has the valuable lessons learned as noted above and has good descriptions of the communications strategies required to make the interventions successful.
Perhaps the one thing missing in this study (and it is no different from most other studies on interruptions) is that the medication error rate was the only patient outcome parameter measured. The total adverse event rate should also be reported in such studies to ensure that the intervention did not have unintended consequences on aspects of care other than medication safety.
Prior Patient Safety Tips of the Week dealing with interruptions and distractions:
References:
Flynn F, Evanish JQ, Fernald JM, et al. Progressive Care Nurses Improving Patient Safety by Limiting Interruptions During Medication Administration. Crit Care Nurse 2016; 36: 19-35
http://ccn.aacnjournals.org/content/36/4/19.full.pdf+html
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September 6, 2016
Napping Debate Rekindled
We’ve done numerous columns on the role of healthcare worker fatigue both on patient outcomes and worker personal health. One of the issues we’ve often discussed is the role of naps in mitigating these adverse effects of fatigue. Prior studies in nursing have revealed a strong correlation between lack of sleep and errors that have the potential to adversely affect patient care (Dorrian 2006). That Australian study concluded that less sleep may lead to the increased likelihood of making an error, and importantly, the decreased likelihood of catching someone else's error. Drowsiness, fatigue, and sleep deprivation also have an impact on personal health of nurses. The issue of nurses having accidents while driving home from work drowsy is fairly well known (Scott 2007, Dorrian 2006). While that applies to drowsiness after any shift, it is more prevalent after night shifts. Working while tired also predisposes to more needle sticks, stress levels, and other health issues.
Back in 2010 when we did our first column addressing the 12-hour nursing shift (see our November 9, 2010 Patient Safety Tip of the Week “12-Hour Nursing Shifts and Patient Safety”) we discussed the use of “power naps” that were part of the excellent 3-part series “Is It Time to Pull the Plug on 12-Hour Shifts?” by Geiger-Brown and Trinkoff (Geiger-Brown 2010). In our April 26, 2011 Patient Safety Tip of the Week “Sleeping Air Traffic Controllers: What About Healthcare?” we really delved into the issue of why naps, which are well accepted in other industries that operate in long shifts, are not more widely accepted in healthcare.
The issue of napping has been rekindled in a Medscape article following the unfortunate death of a Johns Hopkins nurse in an automobile accident following working a night shift (Stokowski 20016). The accident was likely due to drowsy driving.
Napping is an evidence-based intervention shown to reduce worker fatigue in a number of industries. The Joint Commission even refers to napping as a strategy in its Sentinel Event Alert on Healthcare Worker Fatigue and Patient Safety (TJC 2011) as discussed in our January 2012 What's New in the Patient Safety World column “Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety”.
In our April 26, 2011 Patient Safety Tip of the Week “Sleeping Air Traffic Controllers: What About Healthcare?” we discussed a study (Fallis 2011) that included focused interviews with 13 experienced nurses working the night shift in the emergency room or ICU setting in a community hospital in Canada. Ten of the 13 described themselves are “regular” nappers on the night shift (meaning that they often took brief naps on scheduled breaks if circumstances permitted). Three major themes evolved: the environmental scan, the impact of napping, and the consequences of not napping. The environmental scan was an analysis of all the variables taken into consideration in making a decision as to whether a nap was feasible. Those included things like how busy the unit was, what the mix of experienced vs. inexperienced nurses was, who was available for relieving them, and whether anyone was working a double shift. The impact of napping could be positive or negative. Most of the regular nappers noted a positive impact, such as awakening refreshed and able to think more clearly. But naps are not for everyone. One of the downsides of naps is occasionally awakening and temporarily feeling disoriented and slow to respond or the phenomenon of “sleep inertia”. Almost a quarter of the interviewees in the Fallis study mentioned this and it was the primary reason that several of them had become “non-nappers”. The consequences of not napping included slowed mental processes and “foggy thinking”. Nurses found themselves having to check things multiple times. They gave examples of missing arrhythmias on telemonitoring screens because of decreased vigilance. Many found the period between 4AM and 6AM to be most vulnerable. (Note that almost all studies on fatigue and sleepiness on the night shift do identify a roughly two-hour period where concentration abilities are at their worst but the exact time of that nadir differs from study to study).
Tiredness on the night shift is particularly problematic for a number of reasons. As noted by Gieger-Brown and colleagues (Geiger-Brown 2016) there is a normal low point in the circadian drive for wakefulness between 2AM and 6AM. Add to that several soporific factors on the night shift such as dim lighting, relative quiet, reduced patient activity and less overall activity.
But there is surprisingly scant high quality evidence on the impact of napping. A randomized controlled trial of naps on the night shift for both physicians and nurses working in the ER applied a battery of cognitive and performance tests to physicians (residents) and nurses who worked at least 3 consecutive night shifts in the ER were randomized to a nap group or a control no-nap group (Smith-Coggins 2006). The tests were administered at 4AM and 7:30AM and then a driving simulation was done at 8AM. Those in the nap group had fewer performance lapses at 7:30AM and took less time to insert an IV. They also reported less fatigue and sleepiness and more vigor. On the driving simulation they did not perform better overall than the non-nap group, though they showed less dangerous driving tendencies and fewer behavioral signs of tiredness during the simulation. Interestingly, in view of the comments about sleep inertia in the Fallis study mentioned above, those in the nap group performed more poorly on a memory test administered at 4AM (immediately after the nap). So this study strongly supports the concept of the restorative nap during the night shift even though actual impact on patient outcomes was not measured or assessed.
A systematic review on the effect of napping in night-shift workers in multiple industries done in 2014 (Ruggiero 2014) found such variability in study size and design that they had to do a “narrative” systematic review. Of the 13 relevant studies only one was a randomized controlled trial and 12 had quasi-experimental designs. Overall they found that planned naps during night shifts (or simulated night shifts) reduced nocturnal sleepiness and improved sleep-related performance deficits in a number of populations and settings.
A Canadian study reported the attitudes of 47 critical care nurse managers toward napping and this demonstrated numerous barriers to implementation of napping as a safety tool (Edwards 2013). While most were aware of the patient safety issues caused by nurse fatigue and also aware of the worker safety issues (eg. needle sticks, accidents driving home, etc.) they had numerous concerns about napping. Most respondents felt that their administrators would disapprove of napping and most stated their hospital lacked a formal policy on napping or were unaware of one. Many expressed concern that napping might create patient care coverage shortages or that coverage would be being provided by nurses who knew little about their patients. Others noted the lack of suitable facilities for napping. And many felt that patients or their families would look unfavorably upon nurses napping. Some also feared “sleep inertia”. The latter is a “groggy” feeling sometimes perceived when one wakes up from sleep. We discussed an article on sleep physiology (Amin 2012) in our November 2012 What's New in the Patient Safety World column “The Mid-Day Nap” which noted short naps are typically not associated with the phenomenon of “sleep inertia” that is often seen after one wakens from a long nap.
Another recent study from Geiger-Brown and colleagues highlights the barriers in implementing power nap programs for nurses (Geiger-Brown 2016). They had planned implementation of a night shift nurse napping program at 6 units in two hospitals. However, the implementation never got off the ground in 4 of the units and was waylaid in a 5th unit. Therefore, it was only actually fully implemented in one of the six units. Several barriers were encountered but the major one was that nurse managers did not buy in. They often never even presented the project to their staff nurses. Many were concerned about short staffing. One was concerned that nurses would not be available to respond to rapid response team calls. Lack of adequate space for napping was another concern. Interestingly, on some units nurses never took extended breaks at all, even though they may be working 12-hour shifts. But the one unit that implemented the napping program did so very successfully. Over the 3-month pilot project naps averaged 31 minutes and on over half the naps nurses noted actual sleep occurred. Nurses noted an average score of 6.1 (scale 1 to 9 with 9 being the most sleepy) on a sleepiness scale prior to napping (with 44% having scores between 7 and 9). After napping 56% of nurses felt “alert and refreshed” and sleep inertia was relatively rare. And, though not formally measured, many nurses noted that napping had eliminated drowsy driving on their way home after work.
Several key factors aided that successful implementation. The nursing director met with the supervisors and charge nurses prior to implementation and discussed potential barriers and concerns. Staff nurses were then engaged and had input. An appropriate space for napping that ensured complete privacy was provided. Nap breaks, with plans for patient care coverage for napping nurses, were planned at the beginning of each shift. Also important was that several of the nurses had experienced nap programs elsewhere, they already had a “buddy” system in place to cover patient care, and they had a high level of trust among each other.
Note that the program was continued on the one unit after the pilot study was completed and several other units expressed interest in implementing a napping program. Some also felt that other nurses now wanted to “float” to this unit after they heard about the napping program. The napping protocol was modified to include an additional 5 minutes before and after the 30 minutes of actual sleep time.
The optimal timing of naps remains unclear. The systematic review by Ruggiero and Redeker (Ruggiero 2014) noted that further studies are needed to determine the optimal timing of naps in order to minimize the possible hazards associated with sleep inertia.
So here are the key lessons learned for implementing a napping program:
Many nurses remain concerned about what their patients or patient families may think about nurses napping. To that we recommend you have a prepared script with which to respond if questioned. That script should mention the adverse impact of healthcare worker fatigue on patient care, that napping has been shown to be an effective means of reducing fatigue, that The Joint Commission actually recommends napping programs, and use the analogy of how the aviation industry sets work hour limits to reduce pilot fatigue and allows naps for pilots on long flights.
The time has come to break down the many barriers that have prevented implementation of napping programs. The safety of our patients and the personal safety and health of our nurses demands that we step up to the plate and address this important issue. It would be very helpful to have a study that shows both a reduction in patient safety events and worker health events after implementation of a program with an analysis of the financial savings that might be accrued from such a program. However, hospitals shouldn’t have to wait for such study to begin implementation of napping programs.
Some of our other columns on the role of fatigue in Patient Safety:
November 9, 2010 “12-Hour Nursing Shifts and Patient Safety”
April 26, 2011 “Sleeping Air Traffic Controllers: What About Healthcare?”
February 2011 “Update on 12-hour Nursing Shifts”
September 2011 “Shiftwork and Patient Safety
November 2011 “Restricted Housestaff Work Hours and Patient Handoffs”
January 2012 “Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety
January 3, 2012 “Unintended Consequences of Restricted Housestaff Hours”
June 2012 “June 2012 Surgeon Fatigue”
November 2012 “The Mid-Day Nap”
November 13, 2012 “The 12-Hour Nursing Shift: More Downsides”
July 29, 2014 “The 12-Hour Nursing Shift: Debate Continues”
October 2014 “Another Rap on the 12-Hour Nursing Shift”
December 2, 2014 “ANA Position Statement on Nurse Fatigue”
August 2015 “Surgical Resident Duty Reform and Postoperative Outcomes”
September 2015 “Surgery Previous Night Does Not Impact Attending Surgeon Next Day”
References:
Dorrian J, Lamond N, van den Heuvel C, et al. A Pilot Study of the Safety Implications of Australian Nurses' Sleep and Work Hours. Chronobiology International 2006; 23(6): 1149–1163
http://informahealthcare.com/doi/abs/10.1080/07420520601059615
Scott LD, Hwang W-T, Rogers AE, et al. The Relationship between Nurse Work Schedules, Sleep Duration, and Drowsy Driving. Sleep 2007; 30(12): 1801-1807
http://www.journalsleep.org/ViewAbstract.aspx?pid=27018
Geiger-Brown J, Trinkoff AM. Is It Time to Pull the Plug on 12-Hour Shifts? Part 3. harm reduction strategies if keeping 12-Hour Shifts. Journal of Nursing Administration 2010; 40(9): 357-359, 2010 Sep
Stokowski LA. Should Night-Shift Nurses Nap at Work? Medscape Nurses Viewpoints 2016; August 05, 2016
http://www.medscape.com/viewarticle/866836
The Joint Commission. Sentinel Event Alert. Health care worker fatigue and patient safety. Issue #48. December 14, 2011
http://www.jointcommission.org/assets/1/18/SEA_48.pdf
Fallis, WM, McMillan DE, Edwards MP. Napping During Night Shift: Practices, Preferences, and Perceptions of Critical Care and Emergency Department Nurses
Crit Care Nurse March 31, 2011 vol. 31 no. 2 e1-e11
http://ccn.aacnjournals.org/content/31/2/e1.full
Geiger-Brown J, Sagherian K, Zhu S, et al. CE: Original research: napping on the night
shift: a two-hospital implementation project. Am J Nurs 2016; 116: 26-33
Smith-Coggins R, Howard SK, Mac DT, et al. Improving Alertness and Performance in Emergency Department Physicians and Nurses: The Use of Planned Naps. Ann Emerg Med 2006; 48: 596-604
http://www.annemergmed.com/article/S0196-0644%2806%2900239-3/abstract
Ruggiero JS, Redeker NS. Effects of napping on sleepiness and sleep-related performance deficits in night-shift workers: a systematic review. Biol Res Nurs 2014; 16: 134-142
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4079545/
Edwards MP, McMillan DE, Fallis WM. Napping during breaks on night shift: critical care nurse managers’ perceptions. Dynamics (now the Canadian Journal of Critical Care Nursing) 2013; 24(4): 30-35
http://chemshark.com/nursing/wp-content/uploads/2014/07/NursingNappingNightShift.pdf
Amin MM, Graber M, Ahmad K, et al. The Effects of a Mid-Day Nap on the Neurocognitive Performance of First-Year Medical Residents: A Controlled Interventional Pilot Study. Academic Medicine 2012; 87(10): 1428-1433, October 2012.
Print “Napping Debate Rekindled”
September 13, 2016
Vanderbilt's Electronic Procedural Timout
Checklists are marvelous tools to ensure completion of important tasks and improve quality and patient safety. But use of some checklists has not yet met with universal acceptance (see, for example, our May 2015 What’s New in the Patient Safety World column “The Great Checklist Debate” and our September 1, 2015 Patient Safety Tip of the Week “Smarter Checklists”).
Recently, Singer and colleagues did direct observation of over 200 surgical procedures at 10 South Carolina hospitals to evaluate checklist performance and surgeon buy-in (Singer 2016). Few teams completed most or all SSC items and teams more often completed items considered procedural “checks” than conversation “prompts.” In fact, in only 3% of cases was there full completion of checklists. Clinical leadership, communication, a summary measure of teamwork overall, and observers’ teamwork ratings positively related to overall checklist completion. Age of the patient and case duration also correlated with completion of more checklist items. Though shared clinical leadership, open communication, active coordination, and mutual respect were critical in prompting case-related conversations, they did not result in completing more procedural checks.
One of the most important uses of checklists in healthcare, of course, is that used for the surgical or procedural timeout. We use that to help verify we have the correct patient, are going to do the correct procedure, and do it on the correct side or site. Despite a focus on avoiding never events over the past 2 decades, cases of wrong patient, wrong site, wrong side surgery/procedures continue to occur. Universal Protocol and the surgical timeout in theory should prevent most such incidents. However, actual compliance with these is often suboptimal. We’ve previously discussed many of the issues in inadequate timeouts: failure to include all participants, failure to get “active” participation of members, failure to have all participants devote their sole attention to the timeout procedure, failure to consult primary documents, checkboxes for items not done checked as complete, checkboxes/documentation completed after the case, skipped items, poor patient safety culture, and many others.
Education and training have limited ability to improve compliance with the surgical/procedural timeout. We’ve been big fans of using forcing functions or constraints to improve compliance. Such interventions include things like preventing opening of the surgical trays or procedure kits until all the items on a timeout checklist have been completed.
Vanderbilt University Medical Center took a similar approach, with a unique twist, to improving their surgical/procedural timeouts – they created an electronic version of the timeout in which all steps need to be completed before a case can proceed (Rothman 2016). Basically, all their OR’s are equipped with large LCD screens that are the equivalent of electronic “white boards”. Their proprietary software system makes available all relevant clinical and administrative information. Projected on the displays before an incision is made is their item-by-item surgical/procedural timout. Their process is a forcing function in that documentation of the case cannot proceed until all items have been checked off as completed. The system currently has 13 questions but an abbreviated 3-question timeout is used for emergency cases.
Since implementation they have essentially had 100% compliance with timeouts and they have had no cases of wrong surgery. Given the rarity of wrong surgery overall, one cannot state with certainty that the system has prevented wrong surgery but this is a very sound system. It apparently has been well accepted and has been sustainable. It has been both time- and cost-efficient to implement.
Take time to read the Rothman article, which has samples of the displays used in their system. It looks easier than paper-based checklists and is something most hospitals and ambulatory surgery centers could easily implement.
In our many columns on use of checklists in healthcare (and other industries) we’ve emphasized a number of factors that are important for promoting their use. We’ve discussed in detail in our May 2015 What’s New in the Patient Safety World column “The Great Checklist Debate” and our September 1, 2015 Patient Safety Tip of the Week “Smarter Checklists” some factors that may contribute to a trend toward checklist fatigue. First and foremost is buy-in from those who will be using the checklists as tools. And buy-in requires that there be an appropriate culture of patient safety.
NASA (NASA 2014), which oversees the ASRS (Aviation Safety Reporting System) has noted that reports submitted to ASRS indicate that errors related to checklist usage generally fall into one of these five categories:
NASA also in a subsequent newsletter (NASA 2015) noted 5 important factors in appropriate use of checklists:
Note also we have in several previous columns noted a guidance from the UK Civil Aviation Authority that has some excellent recommendations about the design of emergency checklists used in aviation (UK Civil Aviation Authority 2006). Many of these design issues are equally applicable to healthcare checklists.
In our September 1, 2015 Patient Safety Tip of the Week “Smarter Checklists” we noted a study by Russ and colleagues (Russ 2015) that offered the following lessons for implementing change:
We hope that you will go back and read our September 1, 2015 Patient Safety Tip of the Week “Smarter Checklists”. In particular, pay attention to the interesting perspective by Eliot Grigg (Grigg 2015) on improving use of checklists and avoiding checklist fatigue and using technological capabilities to make the checklists more useable. While Grigg’s focus was on anesthesia-related checklists, we gave an example of how we could apply many of his principles to other healthcare checklists.
And, speaking about checklists, The Joint Commission has just put out “The Joint Commission Big Book of Checklists”. It contains lots of downloadable checklists for a variety of purposes and which you can customize for your own use.
Some of our prior columns on checklists:
Some of our prior columns related to wrong-site surgery:
September 23, 2008 “Checklists and Wrong Site Surgery”
June 5, 2007 “Patient Safety in Ambulatory Surgery”
July 2007 “Pennsylvania PSA: Preventing Wrong-Site 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”
August 2011 “New Wrong-Site Surgery Resources”
December 2011 “Novel Technique to Prevent Wrong Level Spine Surgery”
October 30, 2012 “Surgical Scheduling Errors”
January 2013 “How Frequent are Surgical Never Events?”
January 1, 2013 “Don’t Throw Away Those View Boxes Yet”
August 27, 2013 “Lessons on Wrong-Site Surgery”
September 10, 2013 “Informed Consent and Wrong-Site Surgery”
July 2014 “Wrong-Sided Thoracenteses”
May 17, 2016 “Patient Safety Issues in Cataract Surgery”
July 19, 2016 “Infants and Wrong Site Surgery”
References:
Singer SJ, Molina G, Li Z, et al. Relationship between operating room teamwork, contextual factors, and safety checklist performance. J Am Coll Surg 2016; Jul 25, 2016 [Epub ahead of print]
http://www.journalacs.org/article/S1072-7515(16)30685-8/abstract
Rothman BS, Shotwell MS, Beebe R, et al. Electronically Mediated Time-out Initiative to Reduce the Incidence of Wrong Surgery: An Interventional Observational Study. Anesthesiology 2016; 125(3): 484-494
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2528136&resultClick=3
NASA. Checklist Checkup. Callback 2014; 410: 1-2 March 2014
http://asrs.arc.nasa.gov/publications/callback/cb_410.html
NASA. A Checklist Checklist. Callback 2015; 428: 1-2 September 2015
http://asrs.arc.nasa.gov/publications/callback/cb_428.html
Civil Aviation Authority (UK). CAP 676: Guidance on the Design, Presentation and Use
of Emergency and Abnormal Checklists. 2006.
http://www.avhf.com/html/library/International_Pubs/CAA_CAP676.pdf
Russ SJ, Sevdalis N, Moorthy K, et al. A Qualitative Evaluation of the Barriers and Facilitators Toward Implementation of the WHO Surgical Safety Checklist Across Hospitals in England: Lessons From the “Surgical Checklist Implementation Project”. Annals of Surgery 2015; 261(1): 81-91
Grigg E. Smarter Clinical Checklists: How to Minimize Checklist Fatigue and Maximize Clinician Performance. Anesth Analg 215; 121(2): 57-573
TJC (The Joint Commission). The Joint Commission Big Book of Checklists. 2016
http://www.jcrinc.com/the-joint-commission-big-book-of-checklists/
Print “Vanderbilt’s Electronic Procedural Timeout”
September 20, 2016
Downloadable ABCDEF Bundle Toolkits for Delirium
Among our numerous columns on the management and prevention of delirium we have noted the “ABCDE Bundle” which focuses on prevention of two very common and very serious iatrogenic problems seen in our ICU’s: delirium and ICU-acquired weakness (see our What's New in the Patient Safety World columns for December 2010 “The ABCDE Bundle” and February 2013 “The ABCDE Bundle in Action”). Now the new acronym “ABCDEF” appropriately includes an additional “F” to convey the importance of family engagement. Thus, the ABCDEF acronym stands for:
The incidence of delirium in ICU’s may be as high as 80%, with highest rates in those mechanically ventilated and the elderly. Delirium is obviously a patient safety concern but also has a tremendous financial impact on hospitals because it may prolong both ICU and total hospital length of stay. Because patients who experience delirium are also at risk for cognitive dysfunction following acute hospitalization there are additional costs for post-hospital care. Therefore, multiple organizations have collaborated in implementing “bundles” of individual evidence-based interventions aimed at reducing and managing delirium and ICU weakness. Fortunately for those hospitals yet to implement the ABCDEF bundle, those hospitals that have implemented it have experienced numerous lessons learned and identified both success factors and barriers to implementation. And tools used in those implementations are now readily available to hospitals.
In our February 2013 What's New in the Patient Safety World column “The ABCDE Bundle in Action” we discussed a study (Balas 2013a , Balas 2014) that was a prospective, cohort, before-after study of the ABCDE bundle at a large, tertiary medical center, involving patients from multiple ICU’s. They found patients treated with the ABCDE bundle experience more days breathing without assistance and a shorter duration of ICU delirium. The odds of delirium were cut almost in half. Patients on the bundle were also more likely to be mobilized out of bed during their ICU stay. No significant differences were noted in self-extubation or reintubation rates. Balas and colleagues subsequently published an excellent paper on the lessons learned from that implementation, including both factors for success and barriers encountered (Balas 2013b).
One factor of importance is the perception as to whether implementation of ABCDEF will improve patient outcomes. Balas and colleagues found that only 29% of respondents surveyed after implementation thought it would improve patient outcomes at 4 months but this increased to over 50% by 8 months. Probably important in this regard is the culture of the units. Physicians, in particular, were slow to accept use of the bundle and the feeling “I already know what I’m doing” seemed to be an underlying theme.
Another theme was concern about doing spontaneous breathing trials (SBT’s) at night. Both respiratory therapists and nurses often felt that SBT’s and SAT’s (spontaneous awakening trials) should be deferred to daytime hours. (That concern may actually be a valid one in view of a just-published study (Gershengorn 2016) which showed that for patients mechanically ventilated more than 12 hours, those extubated overnight had higher reintubation rates and higher ICU and hospital mortality with no difference in length of stay. We’ll be discussing that study in an upcoming column. But the Balas study did not show higher reintubation rates.)
Concerns about workload were significant prior to implementation. Balas and colleagues found that support from administration and nursing leadership was needed to ensure both that staff had adequate time to undergo the required education/training sessions and to have adequate staffing available to provide all the components of the ABCDEF bundle.
They also identified issues in confidence to us the CAM-ICU tool to screen for delirium. This fluctuated during the implementation, though confidence in using the CAM-ICU tool increased by 8 months post-implementation.
Concerns about documentation needs were very high on the list of barriers. Staff wanted to make sure that documentation would be concise and available electronically and visible to all disciplines involved in the patient’s care. Fears that the documentation would just become another piece of unnecessary paperwork were common. They apparently had experienced lack of use of their institution’s daily goals sheets and feared that the ABCDEF documentation would suffer a similar fate.
Suggestions from participants for improvement of implementation included: continuing education (particularly since staff may have turnover), shorter, more readable policies, merging documentation with the EMR, adding to the daily rounding sheets, creating early mobilization teams, and creating a “unit champion” award. They also felt that the intensivist should always ensure the ABCDEF bundle was discussed on daily rounds.
Overall, factors they felt facilitated adoption of the ABCDEF bundle were: performance of daily interdisciplinary rounds, use of standardized delirium and sedation screening tools, and intense/sustained educational efforts. Significant barriers were inconsistent medical practice, reluctance to follow any protocol, workflow documentation-related concerns, and the fears about timing of SBT’s and SAT’s and their possible adverse consequences. Perhaps the two most important lessons were the need for adequate leadership/institutional support and the importance of interdisciplinary rounds and associated communication. Also, they identified the importance of having the educational sessions be done by clinical staff rather than the research team as a means of improving buy-in.
They also acknowledged differences in implementing the ABCDEF bundle compared to implementing the related PAD guidelines (see our October 29, 2013 Patient Safety Tip of the Week “PAD: The Pain, Agitation, and Delirium Care Bundle”).
Their experiences and those of others have now led to a proliferation of toolkits and other resources to support implementation of ABCDEF. The Society for Hospital Medicine is the latest of several organizations that have made available downloadable toolkits for implementation of the ABCDEF Bundle (SHM 2016). The Society for Critical Care Medicine has launched an ICU Liberation collaborative related to implementing the PAD guidelines via application of the ABCDEF bundle (SCCM 2015). Additional toolkits are available from the ICU Delirium and Cognitive Impairment Study Group (ICU Delirium and Cognitive Impairment Study Group 2013) and the American Association of Critical-Care Nurses (AACN 2016). Also available are a good video on implementing the bundle (Barnes-Daly 2015), an ABCDEF Bundle Action planning tool (NYSPFP 2016), and a set of slides on implementation from an IHI presentation (Masica 2014). These resources are comprehensive and include suggestions about building your teams, developing the educational materials (including handouts and slides), sample pocket reference cards, brochures for patients and families, scripts for communication, sample rounding tools, protocols for the components of the ABCDEF bundle, and measurement and tracking performance. Several also include tools dealing with change management, gap analysis and readiness assessment, and securing stakeholder buy-in. The SHM toolkit also has an excellent section on leveraging the EHR to help practice adoption.
Aside from ensuring there is a culture that recognizes the need to improve and is willing to change, two keys to implementation are (1) improving interdisciplinary care and (2) empowering nurses and respiratory therapists in the decision making process. Several studies have shown that weaning patients from mechanical ventilation can be successfully achieved by nurses and respiratory therapists using protocols, rather than relying solely on individual physician judgment. The standardization of care and use of standardized tools like the CAM‐ICU (Confusion Assessment Method for the Intensive Care Unit) and the RASS (Richmond Agitation‐Sedation Scale) are the easy parts. Communicating status of these parameters and the patient responses on SBT and SAT to all members of the interdisciplinary care team are the more difficult parts. Status of the ABCDEF bundle should be a formal part of interdisciplinary rounds and we recommend use of a checklist for interdisciplinary rounds to remind all of that need.
Pay attention to the timelines in some of the above resources. It will be easy for you to convince your senior management and nursing and medical leadership of both the human and financial business cases for implementing the ABCDEF bundle. But you will need more time to get buy-in from the key frontline clinical stakeholders. They must be part of the planning process. And remember, as in any change management program, if you don’t get a lot of upfront “noise”, your project will be doomed. You need to get all their concerns out on the table and deal with them before you get started. Regular feedback once you get started is also critical, both for completion of your implementation and especially for sustainability.
Some of our prior columns on delirium assessment and management:
References:
Balas M, Olsen K, Gannon D, et al. Safety And Efficacy Of The ABCDE Bundle In Critically-Ill Patients Receiving Mechanical Ventilation. Abstract at Society of Critical Care Medicine 42nd Critical Care Congress. Presented January 20, 2013. Crit Care Med 2012; 40(12) (Suppl.): 1
Balas MC, Vasilevskis EE, Olsen KM, et al: Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Crit Care Med 2014; 42: 1024-1036
Balas MC, Burke WJ, Gannon D, et al. Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: opportunities, challenges, and lessons learned for implementing the ICU Pain, Agitation, and Delirium Guidelines. Crit Care Med 2013; 41(9 Suppl 1): S116-127
Gershengorn HB, Scales DC, Kramer A, Wunsch H. Association between Overnight Extubations and Outcomes in the Intensive Care Unit. JAMA Intern Med 2016; Published Online First September 06, 2016
http://archinte.jamanetwork.com/article.aspx?articleid=2547203
SHM (Society for Hospital Medicine). Introduction | Delirium ABCDEF Bundle Program Implementation Toolkit Version 1.0. 2016
SCCM (Society for Critical Care Medicine). Helping Critically Ill Patients and Families Thrive through an ABCDEF Approach. SCCM 2015; 4 August 2015
Masica A, Smith S, Berryman C (Baylor Scott & White Health). Insights on Implementing a Bundle for ICU Delirium. IHI Presentation 2014
ICU Delirium and Cognitive Impairment Study Group. Delirium Prevention and Safety: Starting with the ABCDEF’s. 2013
http://www.icudelirium.org/medicalprofessionals.html
AACN (American Association of Critical-Care Nurses). Implementing the ABCDE Bundle at the Bedside. 2016
http://www.aacn.org/wd/practice/content/actionpak/withlinks-abcde-toolkit.pcms?menu=practice
Barnes-Daly MA, Barr J. Road Map for Implementing the New ABCDEF Bundle in Your ICU (YouTube video). May 18, 2015
https://www.youtube.com/watch?v=ZDDKkcb9xtQ
NYSPFP (New York State Partnership for Patients). ABCDEF Bundle Action Planning Tool. 2016
https://www.nyspfp.org/Materials/2016_NYSPFP_VAE_ABCDEF_Bundle.pdf
Print “Downloadable ABCDEF Bundle Toolkits for Delirium”
September 27, 2016
Lab Errors Costly
In our multiple columns on errors related to lab testing we’ve usually focused on the cost in human terms. But there is also a cost in financial terms. With results similar to prior studies, an ECRI Institute “Deep Dive” in 2014 (ECRI Institute 2014) showed 74% of lab errors occurred in the pre-analytic phase and 22% in the post-analytic phase. Only 4% occurred during the analytic phase.
A prior study (Green 2013) estimated that errors related to poor blood specimen quality and pre-analytical errors could represent as much as 0.23% to 1.2% of total hospital operating expenses. Extrapolated to an average 650-bed hospital the unnecessary expenditure could be $1.2 million per year. Costs include those related to patient management, redraws, lab investigations, collection consumables, and instrument downtime.
A new study (Atwaru 2016) has also quantified some of the costs related to lab errors, particularly those related to the pre-analytical phase where most lab errors occur. Atwaru and colleagues noted the most common errors in the pre-analytical phase were specimen labeling errors, improperly collected samples, wrong blood in tube, and missing specimens and subsequent redraws so they focused their cost analyses on these categories of pre-analytic errors.
Factoring in the time spent by various personnel when a specimen is missing, they found the average cost of a missing specimen that is found is $401.25 and that of a missing specimen not found $583.72. But when calculating the average costs times the frequency of such events they found the average cumulative costs over 3 months were $14,826.45 and $20,430.20 for those two categories respectively.
For an improperly collected specimen with request for stat retesting the average cost was $158.30 (cumulatively $2374.50 over 3 months). And for wrong blood in a tube the average cost was $562.65 (cumulatively $11,815.65 over 3 months).
These cost estimates do not even take into account the indirect costs that might be associated with unhappy customers impacted by the lab errors.
The authors note that addressing such errors involves a broad range of personnel (client services, clerical staff, sales staff, technical staff, quality improvement staff, and executive staff).
A study on pre-analytic errors (Kaushik 2014) categorized such errors in 3 phases:
We addressed specimen labeling errors in several previous columns (see our Patient Safety Tips of the Week for October 9, 2007 “Errors in the Laboratory“ and November 16, 2010 “Lost Lab Specimens”). Another recent study looked at specimen labeling errors in specimens drawn by nurses in two adult ICU’s (Martin 2015). The error rate prior to interventions was 1.31 errors per 1000 specimens. The intervention was two-fold: (1) one-on-one education for the nurses and (2) removal of an electronic option that allowed bypassing of the barcode safety function. After the intervention the error rate was reduced to 0.139 errors per 1000 specimens. Though the actual total numbers of errors were small (10 errors before and 1 error after the intervention) the reduction was statistically significant.
Note that workarounds that bypass barcoding are not uncommon. In our June 17, 2008 Patient Safety Tip of the Week “Technology Workarounds Defeat Safety Intent” we highlighted a study by Koppel and colleagues that found 15 types of workarounds and 31 types of causes for the workarounds in barcoding medication administration systems (Koppel 2008).
In our March 6, 2012 Patient Safety Tip of the Week ““Lab” Error” we suggested each hospital (or other healthcare facility) use a tracer methodology to determine which steps in their facility might be vulnerable to errors in the pre- and post-analytic steps. It’s worth repeating here the steps we’d recommend in doing a tracer on laboratory testing:
Step 1 Choose a Test to Trace
Where would you start? Which tests should you look at? One option would be to take a look at your highest volume tests, since statistically most errors in the loop would occur for these tests. However, you might also consider looking at tests you already know may be “abused” or of controversial value. Or you might look at tests for which errors would be likely to have the most serious patient consequences.
Step 2 Ordering the Test
After you choose a test on which to run a tracer, let’s start at the beginning: the ordering of the test by a clinician. Is the rationale for ordering the test clear from the medical record? Is it for diagnosis related to current patient symptoms? Is it for screening or risk factor management? Is it a necessary follow up to a prior abnormal test result? Is it for monitoring treatment (eg. serum drug levels) or assessing for treatment efficacy or side effects?
But there are other questions you should ask. Was there a prior result of that test that might have sufficed? Was that result known? Could it have been known? Was that result available on the hospital IT system or the regional RHIO? Did the provider attempt to see if a prior result was available?
If the rationale for the test is not obvious, also look to see if there were circumstances that “nudged” the provider to order the test. Was the test part of a “panel” or was ordering the test influenced by its appearance on a standardized order set or clinical protocol or the way the lab requisition was formatted (some commercial labs use the requisition form in a manner that tends to “market” certain tests).
Was the timing of the ordered test appropriate? For example, if the test was for a serum anticonvulsant level was the test likely ordered before a steady state level would have been achieved? Or if it is an HbA1C level has enough time elapsed since the change in management that the HbA1C level would reflect the overall glycemic status resulting from that change?
The patient interaction must be considered as well. Was the reason for the test discussed with the patient? Was special preparation for the test (eg. fasting) discussed with the patient? Most importantly, did the provider discuss with the patient how long it would be before the test results come back and how the result will be communicated with him/her (more on that on the post-analytic phase)?
Lastly, and most importantly, before ordering a test the clinician should ask him/herself, and discuss with the patient (1) what will we do if the test result is normal? (2) what will we do if it is abnormal as we expect it to be? (3) what will we do if it shows us something unexpected? For example, do you really need to order that C-reactive protein (CRP) in your patient who has multiple CAD risk factors and a high LDL who you are going to treat with statins regardless of the CRP result?
Keep in mind that some lab results may be “abnormal” by chance. If you have a 5% chance that a test result will fall outside the “normal range” statistically and you order a comprehensive metabolic profile of 18-20 tests you are very likely to have one test result that is “abnormal”. Interestingly, when we talk to lab directors we often get responses like “it is less expensive and more efficient for me to run the panel than the individual test”. That, however, fails to take into account the expense and inconveniences that will be generated following up on such an “abnormal” result.
Step 3 How was the test ordered?
Was it written out on a prescription form? Was a lab requisition used? Was CPOE used? Regardless of the method used, was the intent of the order clear? Were there handwriting issues? Inappropriate abbreviations used? Was it clear who was ordering the test? (Ever get a test report for a patient who was not your patient because the lab could not read the name of the actual ordering physician?)
Note that some errors in Steps 2 and 3 may be reduced by use of electronic laboratory utilization management systems. A recent study (Konger 2016) found that such a system effectively reduced unnecessary lab testing. Laboratory cost savings were estimated on the order of $150,000 annually for one hospital and no adverse effects on patient care were reported.
Step 4 Specimen Collection
Where, when and how was the specimen obtained? Were the appropriate patient identification procedures used prior to obtaining the specimen? Were the correct tubes or other containers used for collecting the specimen? Were they correctly labeled? Are all specimens labeled immediately and individually? How did they get to the lab (collected at the lab, sent by courier to the lab, transported from a hospital unit to the lab, etc.)? Do you have a system that actually tracks the specimen on its way to the lab? How do you know if a specimen never reached the lab? If the specimen and test were time-sensitive, did the specimen get to the lab within the appropriate time frame?
Again, see our Patient Safety Tips of the Week for October 9, 2007 “Errors in the Laboratory“ and November 16, 2010 “Lost Lab Specimens” for discussions on specimen identification, labeling, etc. Some best practices to help avoid patient misidentification and specimen labeling errors are use of barcoding, use of at least 2 patient identifiers, use of biometrics, and labeling the specimen containers immediately after specimen collection (for example, printing labels and affixing them right at the bedside when the specimen is obtained).
We also recommend you pay particular attention to sites doing point of care (POC) testing, whether in the office or at the bedside in the hospital. Our experience is that procedures for identification and labeling of specimens in those settings are more prone to “workarounds” and thus more errors.
Our March 6, 2012 Patient Safety Tip of the Week ““Lab” Error” also addressed the need to analyze your post-analytic steps. See that column and our numerous columns on communicating significant test results (listed below).
Some of our other columns on errors related to laboratory studies:
See also our other columns on communicating significant results:
References:
ECRI Institute. From the ECRI Institute PSO Deep Dive: An Examination of “Lab” Errors. ECRI Institute PSO Monthly Brief 2014; May 2014
https://www.ecri.org/EmailResources/PSO_Monthly_Brief/2014/PSO_Brief_May14.pdf
Green SF. The cost of poor blood specimen quality and errors in preanalytical processes. Clin Biochem 2013; 46(13): 1175-1179
http://www.sciencedirect.com/science/article/pii/S0009912013002786
Atwaru A, Duen M, Poczter H, Giugliano E. The Cost of Quality. Pathology and Lab Medicine 2016 American Society for Clinical Pathology (ASCP) Annual Meeting: Poster LP10. Presented September 14, 2016
http://www.planion.com/EvalCenter/ASCP/cache/ePosters/1cf3b52b-e3c8-43f2-a47f-f5499c48cd4c.html
Kaushik N, Green S. Pre-analytical errors: their impact and how to minimize them. MLO Online 2014; May 18, 2014
http://www.mlo-online.com/pre-analytical-errors-their-impact-and-how-to-minimize-them.php
Martin, H., Metcalfe, S. & Whichello, R. (June 2015). Specimen labeling errors: A retrospective study. Online Journal of Nursing Informatics (OJNI), 19 (2), Available at http://www.himss.org/ojni
http://www.himss.org/specimen-labeling-errors-retrospective-study
Koppel R, Wetterneck T, Telles JL, Karsh B-T. Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, And Threats To Patient Safety. JAMIA 2008; 15(4): 408-423 First published online 1 July 2008
http://jamia.oxfordjournals.org/content/15/4/408
Konger RL, Ndekwe P, Jones G, et al. Reduction in Unnecessary Clinical Laboratory Testing Through Utilization Management at a US Government Veterans Affairs Hospital. Am J Clin Path 2016; 145(3): 355-364 First published online: 18 February 2016
http://ajcp.oxfordjournals.org/content/145/3/355
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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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