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July 11, 2017
The 12-Hour Shift Takes More Hits
We’ve discussed the pros and cons of the 12-hour nursing shift in many columns. On the “pro” side the only real theoretical advantage is fewer handoffs. However, also on the “pro” side is that many nurses do like the flexibility of work hours and having more time to spend with family or other activities. And many nurse administrators like the flexibility of scheduling.
But on the “con” side there are many more arguments. The most salient ones are the impact of fatigue on patient care and the personal health of nurses.
Now a new study comes out of the RN4CAST study, which has provided many good lessons learned in the past. Ball and colleagues (Ball 2017a) used survey data from the RN4CAST study to correlate measures of nurse-reported quality with shift duration. They found the odds of poor quality care were 1.64 times higher for nurses working ≥12 hours. And rate of “care left undone” (our Patient Safety Tips of the Week for November 26, 2013 “Missed Care: New Opportunities?” and May 9, 2017 “Missed Nursing Care and Mortality Risk”) was 1.13 times higher for nurses working ≥12 hours. In addition, job dissatisfaction was higher the longer the shift length, with nurses more than 50% more likely to report job dissatisfaction when working 12-hour shifts compared to 8-hour shifts.
The care left undone finding is particularly bothersome. In our May 9, 2017 Patient Safety Tip of the Week “Missed Nursing Care and Mortality Risk” we noted a striking finding in a previous study by Ball (Ball 2017b) that a 10% increase in the amount of care left undone by nurses was associated with a 16% increase in mortality. While that study focused more on overall nurse staffing levels and care left undone, the current Ball study suggests that care left undone is a significant problem with 12-hour shifts and one might assume that same effect on mortality rates might apply.
A systematic review of the relationship between shift length and nurse errors (Clendon 2015) found that the risk of making an error appears higher among nurses working 12 hour or longer on a single shift in acute care hospitals. Though some of the smaller studies included in that systematic review did not show such an association, 6 studies that made up 89% of the total sample size showed a strong relationship between errors and 12 hour or longer shifts.
In our October 2014 What’s New in the Patient Safety World column “Another Rap on the 12-Hour Nursing Shift” we discussed another study from the RN4CAST Consortium (Griffiths 2014) which showed nurses working shifts of 12 hours or more were more likely to perceive poor or failing patient safety, poor or fair quality of care, and more care activities being left undone. Working overtime, regardless of shift length, was also associated with nurses’ perception of poor or failing patient safety, poor or fair quality of care, and more care activities being left undone.
Multiple studies, discussed in our prior columns, have described the negative effects of 12-hour shifts on nurse health, well-being, and job satisfaction. In our September 29, 2015 Patient Safety Tip of the Week “More on the 12-Hour Nursing Shift” we noted another RN4CAST study that provides insight into the impact of 12-hour shifts on nurse well-being (Dall’Ora 2015). Those researchers found that, while all shift lengths greater than 8 hours were associated with more nurse adverse outcomes, nurses working shifts ≥12 h were more likely to experience burnout, have emotional exhaustion, depersonalization, and low personal accomplishment. Moreover, they were more likely to have job dissatisfaction, dissatisfaction with work schedule flexibility, and report intention to leave their job due to dissatisfaction. Nurses working shifts of 12 hours or more were 40% more likely to report job dissatisfaction and 29% more likely to report their intention to leave their job due to dissatisfaction.
Another yet unpublished study from the RN4Cast study apparently shows that nurses are more likely to call in sick and miss work after a 12-hour shift (Merrifield 2017).
One of the problems with studies on shift duration and any sort of outcome is that there may be a difference between scheduled 12-hour shifts and unscheduled (i.e. overtime) ones or between circumstances where nurses choose to work 12-hour shifts vs. those where the extra hours are mandated. Note that the term “mandated” overtime is used loosely. Even when overtime cannot be truly “mandated”, most nurses feel obligated to work overtime when unexpected absences lead to nurse shortages on an upcoming shift.
Ball and colleagues note that a key issue of 12-hour shifts is that “it depends on how it’s done”. They acknowledge that future research should focus on how 12-hour shifts might be optimized to minimize the potential risks.
While evidence continues to accumulate regarding the downside of 12-hour shifts, we don’t expect them to disappear entirely any time soon. In several of our columns we have talked about interventions like the use of power naps to reduce the likelihood of fatigue.
But other issues remain. For example, we’ve said that a “pro” for 12-hour shifts is fewer handoffs. But are handoffs well done after 12-hour shifts? Do we allow enough time to do adequate handoffs between those 12-hour shifts? Moreover, there is probably less time available for educational activities when 12-hour shifts are being used. And we don’t know how 12-hour shifts impact team building or social support issues.
Meanwhile, an experiment in the opposite direction – reducing the hours in the workday – met with mixed findings. In Gothenburg, Sweden, an “old persons home” looked at the impact of a 6-hour workday (Greenfield 2017, Heath 2017). While the outcomes on nurses’ health and sick leave were largely positive, the cost was considered to be too high. The study ended after 23 months when funding ran out. So it is not clear how sustainable any savings on healthcare expenses might be.
Nurses working six hours took 4.7 percent fewer sick days and fewer work absences than when they worked eight-hour days. Nurses in the control group (working eight hour days) actually increased the number of sick days during the trial by 62.5 percent. Nurses working six hours overall were more active, less sick, less stressed and had less back and neck pain than nurses working eight-hour shifts.
The home had to hire 17 additional staff to cover the shifts, increasing the payroll by about 22%. Theoretically, if the savings on sick leave are sustainable and if job satisfaction translates to reduced turnover, the increased costs might be offset in the long run. But we’ll probably never find out, since the study has been terminated.
However, outcomes regarding patient health and patient safety have not been reported. While (anecdotally) nurses spent more time with patients, we’ve not seen any data on patient outcomes. Of course, one concern with the shorter workday is that the number of handoffs is higher, increasing the chance for communication errors.
So don’t expect a shift to 6-hour workdays any time soon!
We hope that you’ll go back to some of our prior columns on the 12-hour shift that highlight the important contributions of researchers like Geiger-Brown, Stimpfel, Trinkoff, and others.
Our previous columns on the 12-hour nursing shift:
November 9, 2010 “12-Hour Nursing Shifts and Patient Safety”
February 2011 “Update on 12-hour Nursing Shifts”
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”
September 29, 2015 “More on the 12-Hour Nursing Shift”
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”
September 6, 2016 “Napping Debate Rekindled”
April 18, 2017 “Alarm Response and Nurse Shift Duration”
References:
RN4CAST Study.
Ball J, Day T, Murrells T, et al. Cross-sectional examination of the association between shift length and hospital nurses job satisfaction and nurse reported quality measures. BMC Nursing 2017; 16: 26
https://bmcnurs.biomedcentral.com/articles/10.1186/s12912-017-0221-7#CR25
Ball JE. Nurse Staffing Levels, Care Left Undone, & Patient Mortality in Acute Hospitals. Karolinska Institutet; Stockholm 2017
Clendon J, Gibbons V. 12 h shifts and rates of error among nurses: a systematic review. Int J Nurs Stud 2015; 52(7): 1231-1242
http://www.sciencedirect.com/science/article/pii/S0020748915000735
Griffiths P, Dall’Ora C, Simon M, et al. Nurses' Shift Length and Overtime Working in 12 European Countries: The Association With Perceived Quality of Care and Patient Safety. Medical Care 2014; published online September 15, 2014
Dall’Ora C, Griffiths P, Ball J, Simon M, Aiken LH. Association of 12 h shifts and nurses’ job satisfaction, burnout and intention to leave: findings from a cross-sectional study of 12 European countries. BMJ Open 2015, 5: doi:10.1136/bmjopen-2015-008331, published 23 August 2015
http://bmjopen.bmj.com/content/5/9/e008331.full.pdf+html
Merrifield N. Nurses more likely to be absent from work after 12-hour shifts, study finds. Nursing Times 2017; 11 April, 2017
Greenfield R. How the Six-Hour Workday Actually Saves Money. A Swedish experiment may have missed the bigger picture of how shorter days can mean long-term profit. Bloomberg.com 2017; April 17, 2017
https://www.bloomberg.com/news/articles/2017-04-17/how-the-six-hour-workday-actually-saves-money
Heath T. A six-hour workday could make you happier, healthier and more productive. Washington Post 2017; April 21, 2017
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July 18, 2017
Another Hazard from Alcohol-Based Hand Gels
Along with soap and water, alcohol-based hand gels are a key component of our hand hygiene programs. But occasionally we have seen unexpected consequences from these.
In our April 2013 What's New in the Patient Safety World column “Reminder: Hand Sanitizers Are Flammable” we noted a very unusual hospital fire injuring a young girl in Oregon (Budnick 2013). It was suspected that an alcohol-based hand sanitizer from a wall-mounted dispenser was the key fuel in this fire. The fire began on the shirt of an 11 y.o. girl, who suffered third degree burns over multiple parts of her body. The report of the fire marshal who investigated the fire determined through discovery and analysis of circumstantial evidence and elimination of other ignition sources that static electricity had likely been the ignition source. The girl had apparently been scuffing her feet and rubbing her bed linens in attempt to create sparks on her sheets. The fuel source was determined to be an alcohol-based hand sanitizer, which the girl had apparently spread on her bedside table and shirt. The alcohol content of the hand sanitizer was 50-70%. In addition, there was olive oil on the girl’s shirt and hair. This apparently had been used to remove glue from EEG electrodes that had been used for monitoring. It was noted that some olive oil dripped on her shirt while it was combed through her hair and that the girl also wiped her hands on her shirt after touching her hair. The fire marshal tested the hypothesis regarding the oil and hand sanitizer on her shirt and the ignition source and confirmed burn patterns that matched those in the actual case. Notably, he determined that ignition source would not have been adequate to ignite just the olive oil without the presence of the hand sanitizer.
Those who are familiar with surgical fires know that the alcohol-based skin preps used in the OR are commonly identified as the fuel in surgical fires. But that was the first time we’d heard of the hand sanitizers found in most hospital rooms as a potential fuel. But they certainly have the same types of volatile alcohols in high concentrations that we see in the surgical skin preps that have been associated with surgical fires. This fire did not even require an oxygen-rich environment. But static electricity is ubiquitous and the fumes from the alcohol-based hand sanitizer obviously were enough to generate this fire.
But, beside fires, there are other potential unexpected consequences from hand sanitizers. Now a report from the UK describes another unintended consequence of alcohol-based hand sanitizers: a patient death from drinking substantial amounts of an alcohol-based hand gel (75% ethyl alcohol concentration). Though the case apparently occurred in 2015, it just began to receive attention this year. The 76 y.o. patient apparently had dementia and was confused and drank large amounts of the sanitizer, which was at the end of his bed (Burke 2017). The amount of alcohol in his blood was six times the legal limit (Wooler 2017).
In response to the UK incident, some hospitals have introduced lockable wall mounted dispensers and issued staff with personal mini bottles of hand wash (Coggan 2017).
This is not the first time ingestion of hand gel for its alcohol content has been problematic in the UK. Previously there were reports of patients and visitors drinking hand gel from public areas of hospitals. A number of hospitals in the north of England have removed hand gel from public areas because some patients and visitors were drinking it for its alcoholic content (Barbour 2012).
Gormley and colleagues described a case of coma due to ingestion of an ethanol-based hand sanitizer in a medical inpatient in the US (Gormley 2012). The teenage patient complained of dizziness and then became comatose on the sixth day of a hospitalization. After the patient was admitted to the ICU, a nurse from the patient’s floor found an empty 500 mL bottle of hand sanitizer in the patient’s wastebasket, covered with a towel. Another clue to the underlying etiology was in serum osmolarity (alcohol is highly osmotic and is included in most formulas for calculating osmolarity but is usually assumed to be zero). In this case, the calculated osmolarity was 304 mOsm/kg and measured osmolarity was 388 mOsm/kg. That led to measurement of serum ethanol level, which returned as 720 mg/dL when drawn more than 6 hours after onset of symptoms. He was treated with hemodialysis and, after regaining consciousness, admitted to infusing the hand sanitizer into his gastrostomy tube because he wanted to “get a buzz” though he denied any suicidal intent. He also admitted to several ingestions during the past year of other ethanol-based hand sanitizers, mouthwash and alcoholic beverages through his gastrostomy tube.
And after we began writing this column, an AHRQ WebM&M presented yet another case of a patient becoming unconscious from alcohol intoxication related to drinking hand sanitizer (Stewart 2017). The patient had a history of alcohol abuse and severe depression and had been hospitalized with pneumonia. When found unconscious, her blood alcohol level was 530 mg/dL. Several empty containers of alcoholic foam hand sanitizer were found and the patient later admitted drinking the sanitizer.
Poisoning from hand sanitizing solutions has been increasing recently. In Canada there have been deaths reported due to ingestion of such agents, which may also contain methanol which is even more toxic (CBC 2013). CDC recently reported on exposure of children aged ≤12 years in the US to hand sanitizers (Santos 2017), using data from the National Poison Data System (NPDS). From 2011 to 2014, a total of 70,669 hand sanitizer exposures in children aged ≤12 years were reported to NPDS, 92% of which were exposures to alcohol-based hand sanitizers. Exposures were somewhat less common during summer months and it was speculated that there might be greater access to hand sanitizers during the school year. The major route of exposure was ingestion and the majority of intentional exposures to alcohol hand sanitizers occurred in children aged 6–12 years. Alcohol hand sanitizer exposures were associated with worse outcomes than were nonalcohol hand sanitizer exposures. The CDC article points out that younger children have decreased liver glycogen stores, which increases their risk of developing hypoglycemia, and have various pharmacokinetic factors which make them more susceptible to developing toxicity from alcohol. The report concludes that caregivers and health care providers should be aware of the potential dangers associated with hand sanitizer ingestion and that children using alcohol hand sanitizers should be supervised and these products should be kept out of reach from children when not in use.
The fact that older children are more likely to be exposed suggests to the CDC authors that many such exposures are intentional. The above-mentioned Canadian report noted there are many online videos featuring teenagers ingesting hand sanitizers to get intoxicated (CBC 2013).
So what, if anything, should hospitals and other healthcare facilities do regarding this risk? First of all, remember that the overall risk:benefit ratio for alcholol-based sanitizers is overwhelmingly in favor of a net benefit. In so many of our columns on hand hygiene we’ve stressed the importance of ready availability of dispensers to promote compliance with hand hygiene. So no one would advocate widespread removal of these products from hospitals and clinics.
But there probably are a few things that might be done. First is a risk assessment for the patient. Patients who have a history of alcohol abuse or are at risk for alcohol withdrawal or are confused, delirious or demented might be considered at-risk for ingestion of the products. In such cases, it might be possible to utilize methods of dispensing only small amounts of alcohol-containing sanitizer.
The AHRQ article (Stewart 2017) cites as potential solutions dispensers that yield a small dose with a refractory period between doses or dispensers that alarm when used multiple times in a short period. But Stewart notes that these machines are likely to be expensive and thus impractical. As noted above, some UK hospitals have begun use of lockable wall mounted dispensers and issued staff with personal mini bottles of hand wash. Some hospitals are already using hand sanitizing systems that electronically capture the amounts dispensed in order to assess staff compliance with recommended hand hygiene practices. Most of those measure volumes dispensed over 24 hours or longer periods but theoretically they could be programmed to alarm if a certain amount is exceeded within a specified timeframe (keeping in mind that the same amount that would be appropriately dispensed for a healthcare rounding team in a patient room could be enough to seriously harm a patient who ingested that amount).
What about psychiatric patients? A review of intentional ingestions of ethanol-containing hand sanitizers (Gormley 2012) noted that many published case reports describe intentional ingestions that frequently occurred in the emergency department or psychiatric wards, with goals of intoxication or suicide.
What about those psychiatric patients admitted to medical or surgical services? We’ve done numerous columns on the risk of suicide on med/surg units and other non-behavioral health units. When you have to house a potentially suicidal patient or patient with significant psychiatric conditions on a medical or surgical unit, you need to perform a thorough environmental risk assessment. While hanging or jumping out of windows are probably the most common ways such patients may attempt suicide on those units, exposure to chemicals or other hazardous materials is another risk. And what hazard could be closer than the hand sanitizer dispenser in the patient’s room? Since the availability of such dispensers on such units is important for infection control purposes, this might be one situation where the type of “alarming” dispenser mentioned by Stewart might be appropriate.
What about pediatric patients? From the recent CDC report it is clear that children are at highest risk for exposure to hand sanitizers and we’d expect hospitalized children are also likely at high risk.
What about using non-alcohol-based sanitizers? These are less potentially risky than alcohol-based ones but they are also less effective from an infection control standpoint. So don’t expect any significant move away from the alcohol-based hand sanitizers. However, if you have a unit that has a historically low prevalence of infections (eg. a behavioral health unit), these might be an option.
We admit that none of these proposed solutions is ideal. The response in the UK to the case noted above indicates that product redesign may be necessary but is also looking for expert input into potential solutions.
While efforts to prevent ingestion of hand-sanitizers may be suboptimal currently, it is equally important to have early recognition of the resultant intoxication so that adequate support can be provided. Management includes the usual supportive care we’d provide any obtunded or comatose patient. But some patients may require dialysis to avoid end organ damage. Therefore, a high level of suspicion is needed if you find a patient obtunded or comatose. As noted above, serum osmolarity may be a clue. If there is a disparity between the calculated osmolarity and the measured one, get a serum ethanol level. Obviously, when we are confronted with a patient with altered level of consciousness and a picture compatible with a “metabolic encephalopathy” we consider intoxications as potential etiologies. But we often forget about that possibility in patients who develop this clinical picture after admission to the hospital. So when there is no obvious other “metabolic” derangement as a likely explanation for the patient’s clinical status, get a toxicology screen. But while you are waiting for that tox screen to come back from the lab, don’t forget a simple inexpensive step: “Search the trash!”. Look in the trash receptacles in the patient’s room or any other locations he/she may have recently been.
Lastly, don’t forget that the dangers to the “at-risk” patient extend beyond the patient’s room. They can easily find hand sanitizer dispensers when you send them to the radiology suite or multiple other areas of the hospital. You might, therefore, even consider adding a warning on your “Ticket to Ride” for intra-hospital transports.
Spreading awareness of the risks associated with alcohol-based hand sanitizers, regardless of how infrequent, is an important first step. However, we need evidence for strategies that mitigate the risks yet help maintain the critical role in infection control that these sanitizers provide. Please send us your comments about any steps you’ve taken at your facilities or other logical interventions that might be undertaken.
References:
Budnick N. Portland hospital fire investigated; hand sanitizer link suspected in girl's injuries. The Oregonian February 18, 2013
http://www.oregonlive.com/health/index.ssf/2013/02/portland_hospital_fire_investi.html
State of Oregon. Office of the Fire Marshal. Fire and Life Safety Supplemental Investigation Report. February 5, 2013
http://media.oregonlive.com/health_impact/other/OHSU%20Feb%2002%20Report%20Final.pdf
Burke D. NHS warned over 'future deaths' after dementia patient, 76, dies after drinking hand sanitiser in hospital. Daily Mail (UK) 2017; 3 June 2017
Wooler S. OAP OD’s On Hand Gel. Elderly dementia patient dies from alcohol poisoning after downing a bottle of hospital hand sanitizer. The Sun (UK) 2017; 3 June 2017
https://www.thesun.co.uk/living/3712643/elderly-dementia-patient-dies-from-alcohol-poisoning/
Coggan A. Keogh unveils safety steps after patient dies from drinking alcohol gel. Health Service Journal 2017; 8 June 2017
Barbour S. Patients 'drinking alcohol hand gel'. BBC News 2012; 19 Nov 2012
http://www.bbc.com/news/av/health-20404541/patients-drinking-alcohol-hand-gel
Gormley NJ, Bronstein AC, Rasimas JJ, et al. The Rising Incidence of Intentional Ingestion of Ethanol-Containing Hand Sanitizers. Crit Care Med. 2012; 40(1): 290-294
Stewart S. Cases & Commentaries. AHRQ WebM&M. The Hidden Harms of Hand Sanitizer. Published July 2017
https://psnet.ahrq.gov/webmm/case/415
CBC. Hand sanitizer ingestion linked to 2 Ontario deaths. Bodico brand contained toxic ingredient methanol. CBC News 2013; Posted: Oct 25, 2013
http://www.cbc.ca/news/canada/toronto/hand-sanitizer-ingestion-linked-to-2-ontario-deaths-1.2252046
Santos C, Kieszak S, Wang A, et al. Reported adverse health effects in children from ingestion of alcohol-based hand sanitizers - United States, 2011-2014. MMWR Morbidity Mortality Weekly Report 2017; 66(8): 223-226
https://www.cdc.gov/mmwr/volumes/66/wr/mm6608a5.htm
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July 25, 2017
Can We Influence the "Weekend Effect"?
In our many columns on the “weekend effect” or the “after hours effect” we have stressed that there is probably a combination of patient-related and system-related factors contributing (see, for example, our What's New in the Patient Safety World columns for November 2013 “The Weekend Effect: Not One Simple Answer” and June 2016 “Weekend Effect Challenged”). It’s a complex interaction and it’s difficult to determine the relative contribution of each of those two factors.
A new study adds an interesting twist to that complex interaction: the method of patient arrival may play a role! Most previous studies on the weekend effect have used administrative data to perform risk adjustments and estimate patient severity of illness. These may not adequately measure severity of illness. Now, Anselmi and colleagues (Anselmi 2017) used arrival at the emergency department by ambulance as a proxy for greater severity of illness to analyze mortality and its variation by day and time of the week.
In their analysis, when using conventional risk-adjustment methods, there appeared to be a higher risk of mortality following emergency admission to hospital at nights and on weekends. However, after accounting for mode of arrival at hospital, this pattern changed substantially, with no increased risk of mortality following admission at night or for any period of the weekend apart from Sunday daytime.
The authors conclude that risk-adjustment based on inpatient administrative data probably does not adequately account for illness severity and that the elevated mortality at weekends and at night probably reflects a higher proportion of more severely ill patients arriving by ambulance at these times.
Another recent study (Walker 2017) used laboratory data to improve risk adjustment and severity of illness. After adjusting for multiple confounders including demographics, comorbidities, and admission characteristics, incorporating non-linearity and interactions, they then considered the effect of adjusting for 15 common hematology and biochemistry test results or proxies for hospital workload. Adjustment for test results explained 33% of the excess mortality associated with emergency admission on Saturdays compared with Wednesdays, 52% on Sundays, and 87% on public holidays after adjustment for standard patient characteristics. Excess mortality was predominantly restricted to admissions between 1100 h and 1500 h on weekend days. They also found that no hospital workload measure was independently associated with mortality. But the latter measures (total admissions, total net hospital occupancy [admissions minus discharges], and percentage of bed occupancy based on inpatient duration) did not include actual staffing information. Those authors concluded that the weekend effect arises from patient-level differences at admission rather than reduced hospital staffing or services.
That said, we probably cannot do much about the patient-related factors contributing to the “weekend effect” or “after hours effect”. But we can certainly do more to mitigate some of the system-related factors contributing to them.
In our February 23, 2016 Patient Safety Tip of the Week “Weekend Effect Solutions?” we cited a study which suggested that specific hospital resources might be used to overcome the “weekend effect” seen in urgent general surgical procedures (Kothari 2015). Researchers identified emergent/urgent surgeries (appendectomies, cholecystectomies, and hernia repairs) in the HCUP database for Florida from 2007 to 2011 and used as a surrogate for the weekend effect an extended median length of stay on the weekend compared to weekdays. They identified 17 out of 166 hospitals that did not exhibit the “weekend effect” and looked to see how these hospitals differed from the others. Patient level factors like socioeconomic status did affect the occurrence of the weekend effect but hospital characteristics had more important associations with the weekend effect. They found that hospitals not having the weekend effect were more likely to have higher nurse-to-patient ratios, full adoption of electronic medical records, home health programs, pain management programs, and inpatient physical rehabilitation. The authors hypothesize that the improvement in the weekend effect at some hospitals is a result of “the ability of the identified components of perioperative infrastructure to assist patients with increased discharge needs, improve transitional care, and ensure care continuity from the week to the weekend”.
The study, of course, was limited by its use of administrative data and use of a proxy for the weekend effect. Also, the nurse staffing ratios were averages and did not specify whether such differed on weekends. Also questioned is why 3 procedures that typically have very low mortalities were chosen. Also, these are associations and may not play a causal role. But are they plausible contributory factors? They certainly could be. Previous work shows that the weekend effect is complex and involves both patient-related factors and quality of care factors (see our November 2013 What's New in the Patient Safety World column “The Weekend Effect: Not One Simple Answer”).
In a recent followup study Kothari and colleagues (Kothari 2017) identified components of electronic health record systems that were associated with less pronounced weekend effect in patients undergoing urgent general surgical procedures. Weekend effect was 33% less likely in those hospitals with electronic operating room scheduling compared with hospitals using paper-based scheduling. In addition, weekend effect was 35% less likely in those hospitals having electronic bed-management systems.
In our many previous columns on the weekend effect or after-hours effect we have pointed out how hospitals differ during these more vulnerable times. Staffing patterns (both in terms of volume and experience) are the most obvious difference but there are many others as well. Many diagnostic tests are not as readily available during these times. Physician and consultant availability may be different and cross-coverage by physicians who lack detailed knowledge about individual patients is common. You also see more verbal orders, which of course are error-prone, at night and on weekends.
We’ve often said the use of the simple nurse:patient staffing ratio on weekends may be misleading. That is because there is often a significant difference in nurse workload on weekends. We’ve described the tremendous increase in nurse responsibilities on weekends due to lack of other staff (no clerical staff, delayed imaging, physicians not on site) that add additional responsibilities to their jobs. Our December 15, 2009 Patient Safety Tip of the Week “The Weekend Effect” discussed how adding non-clinical administrative tasks to already overburdened nursing staff on weekends may be detrimental to patient care. Just do rounds on one of your med/surg floors or ICU’s on a weekend. You’ll see nurses answering phones all day long, causing interruptions in some attention-critical nursing activities. Calls from radiology and the lab that might go directly to physicians now often go first to the nurse on the floor, who then has to try to track down the physician. They end up filing lab and radiology reports or faxing medication orders down to pharmacy, activities often done by clerical staff during daytime hours. Even in those facilities that have CPOE, nurses off-hours often end up entering those orders into the computer because the physicians are off-site and are phoning in verbal orders. You’ll also see nurses giving directions to the increased numbers of visitors typically seen on weekends. They may even end up doing some housekeeping chores and delivering food trays. All of these interruptions and distractions obviously interfere with nurses’ ability to attend to their clinically important tasks (see our Patient Safety Tips of the Week for August 25, 2009 “Interruptions, Distractions, Inattention…Oops!” and May 4, 2010 “More on the Impact of Interruptions”). We thus think that simply addressing nurse:patient staffing ratios without addressing nurse workload issues may be short-sighted.
It is clear we have not yet achieved the desired state in which our systems of hospital care are equivalent 24 hours a day, 7 days a week. Add to this the increase in acuity or severity for patient requiring weekend or after-hours admission and it is not surprising that we see less desirable outcomes in those situations.
Some of our previous columns on the “weekend effect”:
References:
Anselmi L, Meacock R, Kristensen SR, et al. Arrival by ambulance explains variation in mortality by time of admission: retrospective study of admissions to hospital following emergency department attendance in England. BMJ Qual Saf 2017; 26(8): 613-621
http://qualitysafety.bmj.com/content/26/8/613
Kothari AN, Zapf MAC, Blackwell RH, et al. Components of Hospital Perioperative Infrastructure Can Overcome the Weekend Effect in Urgent General Surgery Procedures. Annals of Surgery 2015; 262(4): 683-691, October 2015
Kothari AN, Brownlee SA, Blackwell RH. Association Between Elements of Electronic Health Record Systems and the Weekend Effect in Urgent General Surgery (Research Letter). JAMA Surgery 2017; Published online March 29, 2017
http://jamanetwork.com/journals/jamasurgery/article-abstract/2613701
Walker AS, Mason A, Quan TP, et al. Mortality risks associated with emergency admissions during weekends and public holidays: an analysis of electronic health records. The Lancet 2017; published online May 9, 2017
http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(17)30782-1.pdf
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August 1, 2017
Progress on Wrong Patient Orders
As early as 2008 we were concerned that wrong-patient errors might be more frequent as we began implementing CPOE systems (see our Patient Safety Tip of the Week for May 20, 2008 “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?”) and we’ve done multiple subsequent columns on errors in patient identification. We outlined the many factors contributing to wrong-patient orders in that column and in our Patient Safety Tips of the Week for July 17, 2012 “More on Wrong-Patient CPOE” and January 19, 2016 “Patient Identification in the Spotlight”.
In the latter columns we noted some of the tools developed by Adelman and colleagues to minimize the chances of such occurring (Adelman 2013). The intervention tools they developed were simple yet elegant. The “ID-verify alert” was triggered by opening an order entry screen and prompted the physician with the patient name, gender and age and the physician was required to acknowledge that was the correct patient before being allowed to proceed with order entry. The “ID-reentry function” prevents the provider from accessing the order entry screen until he/she re-enters the patient’s initials, gender and age. These interventions were piloted in a randomized fashion. While the “ID-verify alert” reduced errors by 16%, the “ID-reentry function” reduced them by 41%.
And, of course, not all solutions are high tech. In our August 2015 What's New in the Patient Safety World column “Newborn Name Confusion” we discussed another study by Adelman and colleagues in which they applied their “retract and reorder” (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.
Now a new study in NICU patients has demonstrated that these interventions, applied serially, have indeed had a positive impact on reducing wrong-patient errors (Adelman 2017a). At baseline, wrong-patient orders were more frequent in NICU than in non-NICU pediatric units (117.2 vs 74.9 per 100,000 orders, respectively). Over a 7-year study period there was a substantial reduction in the error rate. After implementation of the ID reentry intervention, errors in the NICU were reduced to 60.2 per 100,000. The combined ID reentry and distinct naming interventions yielded an additional decrease to 45.6 per 100,000 (a 61.1% reduction from baseline).
The study confirms this combination of hi-tech and low-tech interventions has had a dramatic impact on wrong-patient errors. Congratulations to Adelman and colleagues, who have been pioneers in the charge to reduce such errors.
We should also mention here yet another recent contribution by Adelman and colleagues regarding wrong-patient errors. We’ve always contended that one of the biggest risk factors for wrong-patient orders is having medical records of more than one patient open at a time. Adelman and colleagues (Adelman 2017b) recently found in a survey of 167 inpatient and outpatient facilities using EHR systems designed to open multiple records at once, 44.3% were configured to allow ≥3 records open at once (unrestricted), 38.3% allowed only 1 record open (restricted), and 17.4% allowed 2 records open (hedged). Hence, there is yet no consensus on how to best address this issue.
Some CPOE systems might be able to prevent you from having two patient records open at the same time but some CPOE systems still have limited integration with other systems, such as a radiology PACS system. It is not uncommon for a physician to look at information on that other system while trying to input orders into the CPOE system. Since they are two different systems, it is possible to be looking at two different patients in the two systems. You therefore need to ensure that when the physician moves between these two systems the same patient must be visible on each system. That means you need to develop a way to launch the other application and port the patient identification information to the other application. We concur with Adelman and colleagues that this is an issue demanding consensus and there is a need for more clearcut guidelines.
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”
July 19, 2016 “Infants and Wrong Site Surgery”
Some of our prior columns related to patient identification issues:
May 20, 2008 “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?”
July 17, 2012 “More on Wrong-Patient CPOE”
June 26, 2012 “Using Patient Photos to Reduce CPOE Errors”
April 30, 2013 “Photographic Identification to Prevent Errors”
August 2015 “Newborn Name Confusion”
January 12, 2016 “New Resources on Improving Safety of Healthcare IT”
January 19, 2016 “Patient Identification in the Spotlight”
References:
Adelman JS, Kalkut GE, Schechter CB, et al. Understanding and preventing wrong-patient electronic orders: a randomized controlled trial. J Am Med Inform Assoc 2013; 20(2): 305-310 Published online 29 June 2012
http://jamia.oxfordjournals.org/content/20/2/305
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
Adelman JS, Aschner JL, Schechter CB, et al. Evaluating Serial Strategies for Preventing Wrong-Patient Orders in the NICU. Pediatrics 2017; 139(5): e20162863
Adelman JS, Berger MA, Rai A, et al. A national survey assessing the number of records allowed open in electronic health records at hospitals and ambulatory sites. JAMIA 2017; published online 17 April 2017
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August 8, 2017
Sedation for Pediatric MRI Rising
In our January 2017 What's New in the Patient Safety World column “Still Too Many CT Scans for Pediatric Appendicitis” we cited a presentation at the 2016 RSNA meeting that showed the use of MRI scanning in pediatric patients has been increasing in the emergency department at a major New York City hospital (Hulkower 2016). We suspect that is a trend we’d see at many hospitals across the country. The reasons for more MRI scans are mostly due to the increased availability of MRI, the campaigns to reduce the use of ionizing radiation, particularly in children, such as the Imaging Gently® campaign, and the fact that some diagnoses are more readily found on MRI than on CT scan. In the Hulkower study the increase in MRI was primarily driven by neurological imaging and there was a corresponding decrease in the use of CT scanning.
But how about MRI utilization in accountable care organizations? A recent study in an accountable care organization caring for children actually had relatively flat MRI utilization from 2009 to 2014 (Uffman 2017). However, they did encounter a somewhat bothersome trend: the percentage of pediatric MRI’s requiring patient sedation or general anesthesia increased from 21% to 28% of encounters over 2011 to 2014. The increase was shared across 1- to 6-year-old, 7- to 12-year-old, and 12- to 18-year-old subgroups. The authors also noted that the increasing need for anesthesia could not be attributed to secular trends in patient demographics or types of examinations ordered.
The need for sedation or general anesthesia in pediatric patients undergoing MRI scanning has cost, workflow, and patient safety considerations.
In the Uffman study, paid cost data were available for outpatient MRIs, and MRIs with sedation accounted for an increasing share of these costs (from 22% in 2011 to 33% in 2014). That posed a challenge to ACO cost containment. Costs related to sedation are a concern not only for ACO’s but for hospitals as well. In our August 2010 What's New in the Patient Safety World column “Sedation Costs for Pediatric MRI” we discussed a study (Vanderby 2010) that addressed the financial impact of sedation for MRI scanning in pediatrics. They analyzed the workflow, personnel, and costs involved in MRI scanning of children at Hospital for Sick Children in Toronto, Ontario. They found that the average time spent in the MRI suite was 2 hours and 21 minutes for children scanned awake, 3 hours 38 minutes for those sedated, and 4 hours 7 minutes for those anesthetized. Corresponding average costs (in Canadian dollars) were $54.68, $177.27, and $522.73 respectively. The Toronto group used their analysis to significantly redesign workflow and scheduling. This article has a good discussion about those workflow and personnel issues and has some good lessons learned that you may apply in your organization. To their recommendations we would again add that strong consideration needs to be given to the appropriateness of the MRI scan, in light of the patient safety and cost issues involved.
Use of sedation is probably the most serious issue in pediatric MRI safety. The Uffman study does not discuss any actual incident data or potential safety issues associated with pediatric sedation. In our January 17, 2017 Patient Safety Tip of the Week “Pediatric MRI Safety” we noted a study that showed that the prevalence of safety reports in MRI performed in children is increased relative to previously published data on adults (Jaimes Cobos 2016). The researchers found the rate of such reports was 0.53%, compared to a 0.35% rate of incident reporting for adults at the same hospital (Mansouri 2016). Jaimes Cobos and colleagues found that younger children had higher rates of safety reports: newborns (1.1%), infants (1.1%), and young children (0.9%). Children below the age of 6 years, inpatients, and use of sedation or general anesthesia were all factors associated with higher safety report rates.
Our August 2016 What's New in the Patient Safety World column “Guideline Update for Pediatric Sedation” discussed the updated American Academy of Pediatrics (AAP)/American Academy of Pediatric Dentistry (AAPD) “Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures” (Coté 2016). We refer you to our prior column and the updated guideline itself for all the details needed in performing safe sedation in pediatric patients for any procedure. But the guideline has an excellent section on sedation in the MRI suite, which is a very restricted environment and has needs for special equipment and monitoring techniques as we have discussed in our numerous columns on patient safety issues in the radiology and MRI suites. It notes that MRI-compatible pulse oximeters and capnographs capable of continuous function during scanning should be used in any sedated or restrained pediatric patient. Appropriate precautions must be taken to avoid thermal injuries. For example, the practitioner is cautioned to avoid coiling of all wires (oximeter, ECG) and to place the oximeter probe as far from the magnetic coil as possible to diminish the possibility of injury. It notes that ECG monitoring during MRI has been associated with thermal injury and that special MRI-compatible ECG pads are essential to allow safe monitoring. If sedation is achieved by using an infusion pump, then either an MRI-compatible pump is required or the pump must be situated outside of the room with long infusion tubing so as to maintain infusion accuracy. All equipment must be MRI compatible, including items such as laryngoscope blades and handles, oxygen tanks, and any ancillary equipment. In addition, all individuals, including parents, must be screened for ferromagnetic materials, phones, pagers, pens, credit cards, watches, surgical implants, pacemakers, etc, before entry into the MRI suite.
We’d also like to reiterate a few points from the American Society of Anesthesiologists Practice Advisory on Anesthetic Care for Magnetic Resonance Imaging (ASA 2015). It states that the anesthesiologist needs to develop a plan for implementing anesthesia care before each individual case. Such a plan should be done in collaboration with other personnel who will be involved in the care of the patient, including the MRI technician, radiologist, radiology nurse, other clinical personnel accompanying the patient and even the facility biomedical engineer. In addition to the anesthetic plan, preparation includes a plan for optimal positioning of equipment and personnel in the MRI suite during the procedure. We refer you to that guideline for details. The anesthesiologist should also prepare a plan for rapidly summoning additional personnel in the event of an emergency.
We suggested a few additions to this otherwise excellent ASA practice advisory. First is the importance of determining up front whether the MRI is truly indicated, whether the potential benefits of performing the MRI outweigh the potential risks, and whether alternative safer imaging modalities might suffice. In many of the incidents we’ve seen occurring in ICU patients transported to the MRI suite or radiology suite, we’ve been surprised at how often the scan being done was really of marginal value.
Second is the need for a huddle/timeout before the procedure is performed. We should approach doing MRI on these critically ill patients in the same manner in which we approach patients going to the OR. A “huddle” or whatever else you’d like to call a pre-procedure briefing is very important in such cases. Not only do you need to know you have all the equipment needed, but you also need to know everyone’s role and have contingency plans for emergencies. This is where you ensure all parties know what to do if there is a fire or if there is a cardiopulmonary arrest or a “quench”. You discuss what location you will need to move the patient to in such events. You discuss the availability and location of equipment and medications you may need. You discuss the line of sight required and where the monitoring equipment will be deployed. You may need to discuss also how you will communicate (with both staff and patient) given the high noise levels associated with MRI scanning. You should probably even discuss the potential impact of the lighting levels in the various zones (and fact that you may not be able to wear your ferromagnetic glasses in Zones III and IV).
Third, really related to the above, is use of a checklist. To remember all the needs for the procedure (which vary be individual patient) and the contingencies you have to plan for is really too much to expect for any individual or group of individuals. That’s where the simple checklist comes in: it helps you to remember details you might otherwise overlook.
Fourth, you need to practice for emergencies. We wonder how many MRI facilities, particularly hospital-based ones, actually simulate an emergency during MRI scanning.
Lastly, don’t forget that the trend toward more pediatric MRI patients needing sedation or general anesthesia has workflow issues for the MRI suites as well. A recent review on unexpected events during MRI (all patients, not just pediatrics) focused more on issues impacting workflow than on actual patient safety events (Sadigh 2017). The authors found that unanticipated events occurred in 16.7% of all scans. Of those, 10.4% were labeled non-contrast-related patient events and 11.9% of those were related to the need for sedation or general anesthesia.
The authors found that the rate of overall unanticipated events was significantly higher in university-affiliated sites than at community-affiliated sites (18% vs. 5%), in scans performed in the mixed outpatient/inpatient settings than those strictly outpatient settings (22.3% vs. 12.6%), and in scans performed during weekends/holidays than on business days (21.5% vs. 16.2%). The higher weekend/holiday rate was largely driven by patient events unrelated to contrast, which include the need for sedation or general anesthesia.
Note that the Hulkower study noted above (Hulkower 2016) also had some workflow implications. They found the highest pediatric MRI volume was during the evening and early nighttime hours with peak volume occurring during the 10 PM hour when 8.2% of MRI exams were performed. That suggested the need for deployment of additional resources at certain times and need for availability of radiologists, particularly those with expertise in neurological MRI, to read the MRI scans.
We again refer you to the study that analyzed the workflow, personnel, and costs involved in MRI scanning of children at Hospital for Sick Children in Toronto, Ontario (Vanderby 2010). This article has a good discussion about those workflow and personnel issues and has some good lessons learned that you may apply in your organization.
Note also that a new scale for pediatric sedation has recently been developed and validated (Cravero 2017). The Pediatric Sedation State Scale (PSSS), developed by American Academy of Pediatrics and American Society of Anesthesiologists, is intended to specifically meet the needs of pediatric procedural sedation providers to measure effectiveness and quality of care. But it may be difficult to implement while patients are undergoing MRI scanning. The six sedation states defined are:
In particular, assessment of facial expression may not be possible during MRI scanning. Maybe future MRI design might incorporate video facial imaging!
Some of our prior columns on patient safety issues related to MRI:
Some of our previous columns on pediatric sedation issues:
References:
Hulkower M, Taragin B, Davoudzadeh R, et al. Pediatric MRI in the Emergency Department Over Five Years: An Analysis of Usage and Trends. Program SSQ17-06. Radiological Society of North America 2016 Scientific Assembly and Annual Meeting, November 27 - December 2, 2016, Chicago IL
http://archive.rsna.org/2016/16005757.html
Imaging Gently® Campaign
Uffman JC, Tumin D, Raman V, et al. MRI Utilization and the Associated Use of Sedation and Anesthesia in a Pediatric ACO. J Am Coll Radiol 2017; 14(7): 924-930
http://www.jacr.org/article/S1546-1440(17)30121-7/fulltext
Vanderby SA, Babyn PS, Carter MW, et al. Effect of Anesthesia and Sedation on Pediatric MR Imaging Patient Flow. Radiology 2010; 256(1): 229-237
http://pubs.rsna.org/doi/full/10.1148/radiol.10091124
Jaimes Cobos C, Murcia D, Miguel K, et al. Identification of Quality Improvement Areas in Pediatric MRI from Analysis of Patient Safety Reports. Radiological Society of North America 2016 Scientific Assembly and Annual Meeting, November 27 - December 2, 2016, Chicago IL
http://archive.rsna.org/2016/16006085.html
Mansouri M, Aran S, Harvey HB, et al. Rates of safety incident reporting in MRI in a large academic medical center. Journal of Magnetic Resonance Imaging 2016. 43(4): 998-1007
http://onlinelibrary.wiley.com/doi/10.1002/jmri.25055/full
Coté CJ, Wilson S, American Academy of Pediatrics, American Academy of Pediatric Dentistry. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics 2016; 138(1): e2016121
http://pediatrics.aappublications.org/content/138/1/e20161212
ASA (American Society of Anesthesiologists). Practice Advisory on Anesthetic Care for Magnetic Resonance Imaging: An Updated Report by the American Society of Anesthesiologists Task Force on Anesthetic Care for Magnetic Resonance Imaging. Anesthesiology 2015; 122(3): 495-520
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2091587&resultClick=3
Sadigh G, Applegate KE, Saindane AM. Prevalence of Unanticipated Events Associated With MRI Examinations: A Benchmark for MRI Quality, Safety, and Patient Experience. J Am Coll Rad 2017; 14(6): 765-772 Published online: March 26, 2017
Cravero JP, Askins N, Sriswasdi P, et al. Validation of the Pediatric Sedation State Scale. Pediatrics 2017; 139(5): e20162897
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August 15, 2017
Delayed Emergency Surgery and Mortality Risk
It’s well known that delays in performing surgery for hip fracture increase patient morbidity and mortality. But the relationship has been less well defined for other types of emergency surgery. Now Canadian researchers have published a new study that sheds light on the impact of delays for all types of emergency non-cardiac surgery (McIsaac 2017). McIsaac and colleagues at Ottawa Hospital analyzed cases where surgery for emergency cases was delayed compared to those performed without delay. They found that 18.6% of over 15,000 emergency cases between January 2012 and October 2014 experienced a delay. They found that in-hospital mortality in delayed cases was 4.9% compared to 3.2% in those without delay. They then did matching based on propensity scores in attempt to account for confounding variables other than delays. That adjusted analysis revealed that delays were significantly associated with mortality (OR 1.56), increased length of stay (incident rate ratio 1.07), and higher total costs (incident rate ratio 1.06). The number needed to harm for mortality was 60.
Moreover, they found that system issues dominated the reasons for delay (accounting for over 86% of cases with documented reasons for delay). They found that availability of personnel was a common reason for delays. That unavailability was most often for the surgeon but occasionally also involved anesthesiologists or nurses. Availability of physical resources (operating room, post-anesthesia recovery unit, equipment) was also a common reason for delays. And many cases had multiple reasons for delay. Many cases were bumped by higher priority cases. Patient-specific reasons for delay were less common but usually involved medically complex or decompensated patients who needed stabilization prior to surgery.
You need to read the McIsaac article to understand the way they defined delays and how they classified degree of urgency. But suffice it to say that they determined an expected wait time for surgery for each type of surgery and its classified degree of urgency. They then found another very interesting trend. As wait time increased up to 1.1 multiples of the accepted wait-time window the odds of mortality increased. But for wait times beyond 1.1 multiples, the odds of mortality actually decreased. They thus postulated there may be two distinct subgroups of patients: those that truly need emergent surgery and those that have a survivorship bias.
A key point of the McIsaac article and the accompanying editorial (Urbach 2017) is that in allocating human and financial resources for the OR, we need to take a strong look at downstream costs. While fixing some of the system issues leading to surgery delays may be expensive, there may well be cost offsets in the long run (due to reduced length of stay and other costs).
At first blush, these findings might seem to contradict a point we made in our several columns on “after-hours” surgery (see the list below). In those columns we’ve discussed the multiple factors that may lead to less desirable outcomes when surgery is performed after-hours and in some of those columns we’ve intimated that many cases may be more safely performed the following morning rather than at night.
But the McIsaac study was not a study of time of day surgery was done. Rather, it looked at delays any time of day. And many of the system factors identified by McIsaac and colleagues leading to delays are also the same ones we’ve identified in after-hours cases.
So the conclusions by McIsaac et al. are not really contradictory to those in our prior columns. We are in agreement that there are multiple system issues that interfere with optimal care when emergent cases are either delayed or done after-hours. Attention to correcting those factors may lead to better outcomes.
In our October 4, 2016 Patient Safety Tip of the Week “More on After-Hours Surgery” we discussed why “after hours” surgery might be more prone to adverse outcomes than regularly scheduled elective surgery. There are many reasons aside from the fact that patients needing emergency and after hours surgery are generally sicker. For surgery, in particular, the impact of time of day on teamwork is important. You are often operating with a team that is likely different from your daytime team. All members of that team (physicians, nurses, anesthesiologists, techs, etc.) may not have the same level of expertise or experience as your regular daytime team (because many hospitals have “seniority” policies, you may have less experienced personnel on your OR “on-call” teams) and the team dynamics between members is likely to be different. The post-surgery recovery unit is likely to be staffed much differently after-hours as well. The staff may be more likely to be unfamiliar with things like location of equipment. And some of the other hospital support services (eg. radiology, laboratory, sterile processing, etc.) may have lesser staffing after-hours. Just as importantly, many or all of the “on-call” staff that make up the after-hours surgical team have likely worked a full daytime shift that day so fatigue enters as a potential contributory factor. And there are always time pressures after hours as well. In addition, one of the most compelling reasons surgery is done at night rather than deferred to the next morning is the schedule of the surgeon or other physician for that next morning (either in surgery or the cath lab or his/her office). Because the surgeon does not want to disrupt that next day schedule, he/she often prefers to go ahead with the current case at night. Similarly, many hospitals run very tight OR schedules and adding a case from the previous night can disrupt the schedule of many other cases.
The Urbach editorial (Urbach 2017) suggests that use of team-based surgical care models may be one way to address some of the system-level barriers to timely emergency surgery. Working in such teams may allow cross-coverage so that delays due to a single surgeon being occupied elsewhere are minimized. Obviously such models are best implemented at academic medical centers or larger urban hospitals and are more difficult to implement at rural or smaller community hospitals.
We highly recommend hospitals take a hard look at surgical cases done “after hours” and all your cases of “emergency” surgery. You need to look at the morbidity and mortality statistics of such cases. You need to identify factors contributing to delays in such cases and you need to determine which cases truly needed to be done after hours and, perhaps more importantly, which ones could have and should have been done during “regular hours”. If the latter are significant, you need to consider system changes such as reserving some “regular hours” for such cases to be done the following morning. You may have to alter the scheduling of cases for individual surgeons as well. For example, perhaps the surgeon on-call tonight should not have elective cases scheduled tomorrow morning. That way, if a case comes in tonight that should be done tomorrow morning you will have both a “free” OR room and a “free” surgeon. And you would need to develop a list of criteria to help you triage cases into “regular” or “after-hours” time slots.
The study by McIsaac et al. suggests that investment in personnel and system issues that may lead to delays in surgery are likely to be offset by downstream savings (in reduced length of stay and other costs).
Some of our previous columns on the “after-hours” surgery:
References:
McIsaac DI, Abdulla K, Yang H, et al. Association of delay of urgent or emergency surgery with mortality and use of health care resources: a propensity score–matched observational cohort study. CMAJ 2017; 189: E905-E912 published online July 10, 2017
http://www.cmaj.ca/content/189/27/E905.full
Urbach DR. Delivering timely surgery in Canadian hospitals. CMAJ 2017; 189: E903-E904
http://www.cmaj.ca/content/189/27/E903.full
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August 22, 2017
OR to ICU Handoff Success
Handoffs are critical points in transitions of care at multiple levels. The complexities of the handoff are no better illustrated than in the perioperative handoff. We know that, in a variety of settings, formalizing handoffs with checklists or other structured tools and processes leads to better transitions and fewer unwanted events.
Clinicians and researchers at the Oregon Health & Science University (OHSU) recently reported on outcomes following implementation of a structured process for handoffs between their intraoperative cardiac surgery team and the ICU team (Hall 2017). After implementation of a comprehensive, multidisciplinary, structured handoff process they found a significant reduction in preventable patient complications.
A team of intraoperative nurses, critical care nurses, anesthesiologists, intensivists, and cardiac surgeons convened to analyze transfer of care from the intraoperative team to the ICU team. Each subgroup identified specific barriers to continuous excellent care and identified steps that might circumvent those barriers.
A scripted handover template was a key to the success of the program. Though the templates did use information from clinical information systems, the focus was on the scripted verbal handoff process. As we noted in our January 29, 2013 Patient Safety Tip of the Week “A Flurry of Activity on Handoffs”, the handoff involves 2 key components: (1) transfer of information and (2) transfer of responsibility. The OHSU structured tool emphasized both. They also adopted a key philosophy we employ in developing checklists or other structured tools – don’t clutter your tool with unimportant information. Similarly, all good handoffs are two-way communication vehicles in which the receiving parties have the opportunity to ask questions and get clarification. Importantly, use of “hear-back” is important and verbal acknowledgement using closed-loop communication of the formal transfer of care was crucial. They provide as an example “My patient is now your patient.”.
They used the well-known SBAR (Situation, Background, Assessment, Recommendations) format for each handoff tool that was tailored for specific team members. They provide an example template for the handoff from the anesthesia provider to the critical care team.
They measured both total complications and preventable complications before and after the implementation of the structured handoff. Total complications were not different after the implementation but preventable complications were statistically significantly different after the implementation (adjusted odds ratio 0.35). Interestingly, younger patients seemed to benefit more that older patients. The authors attributed this to fewer comorbidities and shorter periods of vulnerability in the younger patients.
Anesthesiologist transfer of care time was measured and was less than 2 minutes longer after the new process was implemented and did not likely disrupt OR flow. The study did not include measures of adherence to the handoff process or overall satisfaction with the process, though they noted they anecdotally observed overall satisfaction of surgical, nursing, anesthesiology, and ICU team members.
There were probably several keys to success of the OHSU project:
Having a solid structured process and tools for handoffs is important in ensuring safety and efficacy of transitions in any industry, particularly in healthcare. The OHSU program is another example of how adding such structure leads to improvement in outcomes. The OHSU team is to be commended for its excellent work in this regard.
So make sure you add structure to your handoffs, whether in perioperative or other venues. But don’t lose sight of the critical success factors noted above. Sometimes the making of the tools and processes is as important as the final result.
Some of our other columns on the perioperative handoff:
December 2011 “AORN Perioperative Handoff Toolkit”
March 2012 “More on Perioperative Handoffs”
August 2012 “Review of Postoperative Handoffs”
February 11, 2014 “Another Perioperative Handoff Tool: SWITCH”
March 2014 “The “Reverse” Perioperative Handoff: ICU to OR”
January 6, 2015 “Yet Another Handoff: The Intraoperative Handoff”
Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:
May 15, 2007 “Communication, Hearback and Other Lessons from Aviation”
May 22, 2007 “More on TeamSTEPPS™”
August 28, 2007 “Lessons Learned from Transportation Accidents”
December 11, 2007 “Communication…Communication…Communication”
February 26, 2008 “Nightmares….The Hospital at Night”
September 30, 2008 “Hot Topic: Handoffs”
November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
December 2008 “Another Good Paper on Handoffs”.
June 30, 2009 “iSoBAR: Australian Clinical Handoffs/Handovers”
April 25, 2009 “Interruptions, Distractions, Inattention…Oops!”
April 13, 2010 “Update on Handoffs”
July 12, 2011 “Psst! Pass it on…How a kid’s game can mold good handoffs”
July 19, 2011 “Communication Across Professions”
November 2011 “Restricted Housestaff Work Hours and Patient Handoffs”
December 2011 “AORN Perioperative Handoff Toolkit”
February 14, 2012 “Handoffs – More Than Battle of the Mnemonics”
March 2012 “More on Perioperative Handoffs”
June 2012 “I-PASS Results and Resources Now Available”
August 2012 “New Joint Commission Tools for Improving Handoffs”
August 2012 “Review of Postoperative Handoffs”
January 29, 2013 “A Flurry of Activity on Handoffs”
December 10, 2013 “Better Handoffs, Better Results”
February 11, 2014 “Another Perioperative Handoff Tool: SWITCH”
March 2014 “The “Reverse” Perioperative Handoff: ICU to OR”
September 9, 2014 “The Handback”
December 2014 “I-PASS Passes the Test”
January 6, 2015 “Yet Another Handoff: The Intraoperative Handoff”
March 2017 “Adding Structure to Multidisciplinary Rounds”
References:
Hall M, Robertson J, Merkel MM, et al. A Structured Transfer of Care Process Reduces Perioperative Complications in Cardiac Surgery Patients. Anesthesia & Analgesia 2017; 125(2): 477-482
Sample handoff template from the OHSU article.
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August 29, 2017
Suicide in the Bathroom
We had been waiting to write a column about suicide risk in bathrooms on behavioral health units after 2 such cases in a recent batch of CDPH case reports. Now a third such case reminded us that this risk continues and there are lessons learned that might help prevent suicide in other hospitals.
The first case (CDPH 2016a) was a 17 y.o. patient admitted voicing suicidal intent. Because of continued suicidal ideation her observation was moved from every 15 minutes to every 5 minutes. When the patient was showering, the nurse who was monitoring her was called away for an emergency (unruly patient) to give medications in that other emergency. The patient was left unattended in the shower. There was a handoff to a MHW who responded “within minutes” but the patient was the found in the shower with the shower hose wrapped around her neck. CPR was unsuccessful and she died.
The bathroom had been equipped with a hand-held shower head and flexible metal hose that was intended to be compatible with the Americans with Disabilities Act (ADA). But this patient had no disabilities that would have merited use of that special shower apparatus and it should have been removed from that bathroom after use by someone who may have needed it. It was only intended for use under the supervision of facility staff and, when not in use, was supposed to be removed and stored in a secure location.
The hospital’s policy was that patients should be visually checked at least every 30 seconds while showering.
It was felt that the need to remove the special shower head had not been adequately conveyed to all staff. So in addition to staff training, they also developed a sign in/out log for that shower head.
The case also provides a good example of how another emergency may lead to distractions that allow an incident to occur. We’ve previously mentioned how distractions like fire alarms may lead to other incidents, such as patient elopements.
The second case (CDPH 2016b), at the same hospital as above, involved a male patient admitted after an overdose attempt. Because of suicidal ideation he was originally on 1:1 observation but was then changed to every 5 minute observation. On the day of the incident he was showering “for quite a while”. A mental health worker (MHW) heard the water stop and went to check on the patient. But the patient angrily yelled that he was getting dressed and needed more time. The MHW felt intimidated and left to give him more privacy. When she returned to check on him, she found him hanging with clothing from bathroom doorknob, pulseless and not breathing. He was resuscitated and transferred to another facility.
The plan of correction included an inservice on how to deal with intimidating patients, including role playing to demonstrate various scenarios. Staff were also educated on guidelines for shower use and what clothing can be taken into shower. The facility also installed anti-ligature door knobs on all patient bathrooms and showers. They also developed a reassessment for suicide risk tool.
We find it somewhat surprising that neither the facility nor the CDPH investigator mentioned the influence of gender issues in monitoring patients taking showers. We would have presumed most facilities would have a same-sex person monitor for patients in the shower. Perhaps that was one factor that allowed for the female MHW to be intimidated by the male patient in this case.
The third case (Fisher 2017) was described in an inquest in Alberta, Canada. The 49 y.o. male patient with a history of bipolar illness and major depressive illness was brought to the hospital by police after family stated he had wanted to cut his own head off. Though the patient himself denied any suicidal ideation, he was admitted involuntarily to a behavioral health unit. Though his mood and judgment were described as good, it was noted he was vague at times and jumped from one topic to another. No hallucinations were noted. Staff noted the discrepancy between the history provided by family and by the patient. Few or no concerns were noted during the patient’s stay and he was mostly on observation every 30 minutes. On the day following admission he was noted to be on the telephone at about 21:50 and then appeared to be upset following the phone call. At 22:30 he was noted by the nursing attendant (who was doing observation rounds while the nurse who would usually do the observation rounds was on break) to be sleeping and breathing normally (observation done from about 10 feet away). He was found at 23:00 hanging by a bedsheet from his bathroom door. He was temporarily revived but subsequently died.
He was not in one of the seclusion rooms on the behavioral health unit that had video cameras. The light in his room was off, though the light in the bathroom was on when he was found. The room did have a large window facing the nursing station but the curtains were closed.
The inquest noted that it had been recommended in a number of past Inquiries regarding psychiatric units, that all rooms in all psychiatric facilities be monitored by video cameras but this has not been undertaken by the hospital. The current inquest recommended that all units within the psychiatric unit in this hospital, whether the rooms are seclusion rooms or not, should be monitored by video cameras, with a rationale that the safety of the patients is more important than the privacy issues that might be argued.
The evidence also noted the patient had tied his bed sheet to a hanger on the inside of the bathroom door. It was recommended that all mechanisms attached to bathroom doors in the psychiatric units be removed.
There was also testimony that patients become aware of the specific times that patient observations are carried out and that the patients should not be able to predict exactly when the patient observations will be carried out so it was recommended that nursing staff and security staff who carry out patient observations not utilize exactly the same routine for checking the patients, while still being within reasonable compliance with the ordered frequency of observation.
Previous medical records were not readily available to the treating psychiatrist. These apparently would have shown a series of suicidal attempts and threats dating back 10 years, including two earlier stays at the hospital that year, including one only two weeks before his last admission (Lo 2017). Conceivably, those records might have led to assignment of a higher suicide risk category and potentially increasing the frequency of observation or moving the patient to one of the rooms that had video monitoring capability.
A number of other issues were also identified in the inquest (lack of prompt inquiry, failure to sequester video recordings from the nursing station, lack of prompt access to prior medical records, issues surrounding patient use of phones, and requirement that any informal notes made by security personnel doing observation rounding be made part of the formal patient record).
These 3 cases illustrate some dilemmas and tradeoffs. The tradeoff between privacy and safety is an obvious one. The Canadian case raises the question of video monitoring in patient rooms. But a real dilemma is the privacy/safety tradeoff when patients are showering or using the bathroom.
The other tradeoff was the issue of having an ADA-compliant hand-held showerhead vs. the threat such could be used for hanging. The intervention (a sign in/out log for that shower head/hose) implemented by the hospital in first case (CDPH 2016a) is a good step but it still requires someone to remember to return the shower head/hose promptly to its secure site. In this day and age where RFID and Bluetooth technologies are readily available one could envision sending timed alerts to prompt removal of that item from patient bathrooms.
Note also that in the first 2 cases the hospital’s policy was that patients should be visually checked at least every 30 seconds while showering. The first two cases demonstrate that may not be practical in many cases (in one case the unrelated emergency took the observer away from the patient and in the other case the patient’s vociferous complaints led to non-compliance with the 30 second policy).
Perhaps the more important lesson is the need to eliminate items in the environment that can be used for suicide. Many of those issues are addressed in the VA’s Mental Health Environment of Care Checklist (MHEOCC), which we’ve discussed now in several columns (our Patient Safety Tips of the Week for January 6, 2009 “Preventing Inpatient Suicides” and February 9, 2010 Patient Safety Tip of the Week “More on Preventing Inpatient Suicides” and our July 2012 What's New in the Patient Safety World column “VA Checklist Reduces Suicide Risk”). That checklist is available online on the VA Patient Safety website.
One very pertinent question asked in the MHEOCC is “Are doors that are within rooms and that open to other in-room areas such as bath/shower/toilet areas (i.e., not corridor doors) designed to eliminate anchor points?”. But keep in mind that almost any type of solid door might be used as an anchor even if it lacks latches, hooks, or other obvious loopable items. One could still conceivably loop bedsheets or clothing over the top of a solid door even if it has a “sloped” surface. Therefore, the MHEOCC recommends soft break-away doors for bathrooms and showers.
In our February 14, 2017 Patient Safety Tip of the Week “Yet More Jumps from Hospital Windows” we mentioned 2 publications (Watts 2016, Mills 2016) showing sustained results from implementation of the Mental Health Environment of Care Checklist (MHEOCC). The checklist and program became mandated at all VA hospitals in 2007. Inpatient suicide rates in VA hospitals dropped from 4.2 per 100,000 admissions to 0.74 per 100,000 admissions from 2000 to 2015. The reduction in suicides coincided with introduction of the MHEOCC and has been sustained since implementation in 2007. The authors stress that the physical changes brought about by the MHEOCC likely have a bigger impact on inpatient suicide reduction than the numerous other interventions used.
The MHEOCC is an excellent tool for identifying and abating environmental factors that might facilitate inpatient suicide. But don’t forget the risk of suicide in bathrooms not on behavioral health units. In several of our columns on suicide outside of behavioral health units we’ve noted that the potentially suicidal patient on an intrahospital transport, such as a trip to the radiology suite, may lock him/herself in a bathroom in that suite and there are a number of loopable items in those bathrooms. You’ll recall that in our March 16, 2010 Patient Safety Tip of the Week “A Patient Safety Scavenger Hunt” we included the items below as ones to search for in your patient safety scavenger hunt:
So what should facilities do to minimize the risk of suicide in the bathroom or shower? We’d recommend at least the following:
Some of our prior columns on preventing hospital suicides:
References:
CDPH (California Department of Public Health). Complaint Intake Number CA00307558; 2016
CDPH (California Department of Public Health). Complaint Intake Number CA00313278; 2016
Fisher FC. Report to the Minister of Justice and Solicitor General. Public Fatality Inquiry. Province of Alberta (Canada); May 29, 2017
https://justice.alberta.ca/programs_services/fatality/Documents/fatality-report-piche.pdf
Lo T. Psych ward video cameras could save lives, suggests report after hospital bathroom suicide of Glenn Piche. CBC News 2017; August 21, 2017
http://www.cbc.ca/news/canada/calgary/glenn-piche-fatality-inquiry-cameras-1.4255998
Mental Health Environment of Care Checklist (VA)
http://www.patientsafety.va.gov/docs/MHEOCCed092016508.xlsx
http://www.patientsafety.va.gov/professionals/onthejob/mentalhealth.asp
Watts BV, Shiner B, Young-Xu Y, Mills PD. Sustained Effectiveness of the Mental Health Environment of Care Checklist to Decrease Inpatient Suicide. Psychiatric Services 2016; Published Online Ahead of Print: November 15, 2016
http://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201600080
Mills PD. Use of the Mental Health Environment of Care Checklist to Reduce the Rate of Inpatient Suicide in VHA. TIPS (Topics in Patient Safety) 2016; 16(3): 3-4 July/August/September 2016
http://www.patientsafety.va.gov/professionals/publications/newsletter.asp
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September 5, 2017
Another Iatrogenic Burn
It’s been over two years since our last column on iatrogenic burns (aside from surgical fires). In our original column on iatrogenic burns (June 1, 2010 Patient Safety Tip of the Week “Iatrogenic Burns”) we described burns from recently autoclaved instruments, warm compresses, MRI interactions with coiled electrodes or metallic transdermal drug patches or various other foreign bodies, thermal blankets, warming bottles, microwaved objects, alcohol or other substances put on skin, and radiation overdoses.
Then in our October 5, 2010 Patient Safety Tip of the Week “More Iatrogenic Burns” we focused on the issue of inadequate cooling of flash-sterilized items and risks associated with dental handpieces. And in our December 23, 2014 Patient Safety Tip of the Week “Iatrogenic Burns in the News Again” we focused on burns related to warming blankets and the practice of “hosing” or “free-hosing”. Our March 2015 What's New in the Patient Safety World column “Another Source of Iatrogenic Burns” discussed an unusual case of a burn related to halogen lights in the OR. And several of our columns on surgical fires have mentioned other light sources as heat producers.
The most recent release of Statements of Deficiency/Plans of Correction by the CDPH (California Department of Public Health) included a case of an iatrogenic burn. In that case (CDPH 2017) a patient underwent bilateral knee replacement surgery. Left calf blistering was noted post-op that evolved into a full-thickness thermal injury, requiring extensive wound treatments, and it was related to the electrocautery device that had been set down on the patient without holstering it. The bi-polar cautery device handpiece was part of the Aquamantys System. Interview with one of the OR techs indicated that when he entered the OR room he "saw more steam than usual" and saw the electrocautery device under the patient’s leg. He yelled “Stop” and removed the device.
The facility’s plan of correction included re-training to the Operating Room staff on the proper use of the equipment. Training included the proper placement of the wand when not in use and maintaining the alarm volume at an audible setting. The manufacturer at the time apparently did not have an attachment holder for the wand so the facility designed its own mechanism for placement of the wand when not in use.
In some of our previous columns on iatrogenic burns we’ve noted other pieces of hot equipment, such as recently flash sterilized instruments that had not adequately cooled, inadvertently placed on the drapes over a patient have led to burns.
While we have often discussed the role of electrocautery devices in creating surgical fires in oxygen-rich environments (see our numerous columns on surgical fires listed below), Mundinger et al. (Mundinger 2007) noted that intraoperative electrocautery burns can be divided into at least 4 other categories:
The current CDPH case is an example of a direct contact burn related to failure to holster the electrocautery device and subsequent contact with a patient’s skin. Burns more commonly can develop related to current flow when monopolar electrocautery devices are used. Saaiq et al. (Saaiq 2012) reported on 3 cases of full-thickness deep burns related to the grounding pad of electrocautery systems. All 3 of their cases involved use of monopolar cautery and improper placement of the grounding electrode. The authors note that when the grounding pad is misapplied and loose, this may cause heat generation and sparking at the contact site, without providing an appropriate exit for the current to pass safely through the circuit. Saaiq et al. had the following recommendations:
The authors also note that the electrical current can also run between the active electrode and an alternate grounding source. They note the case described by Mundinger et al. (Mundinger 2007) in which a patient had the grounding pad on her lateral thigh but burns occurred on her forehead related to titanium plates previously implanted in her skull. Mundinger et al. also noted that burns resulting from aberrant circuits have been reported at sites of electrocardiographic lead placement, temperature probe insertion, uninsulated surgical table contact with the patient, intra-arterial line placement, motor-evoked potential monitoring electrode placement, and electroencephalogram electrode placement. That’s pretty scary! How many people would even consider the potential impact of remote hardware in or on a patient’s body?
Mundinger et al. note that similar burns at sites of contact remote from the operative field and the normal grounding pad may occur on areas of uninsulated surgical table contacting the patient, electrocardiographic leads, temperature probe insertion sites, and sites of placement of various other monitoring devices.
Of 6 iatrogenic burns described by Kaya et al. (Kaya 2016), 3 were related to electrocautery devices. The authors discussed the differences between the two types of electrocautery, namely “unipolar” (or “monopolar”) and “bipolar,”. They made the following recommendations:
And don’t lose sight of the fact that thermal injuries related to electrocautery devices can also occur internally during surgery. Such are well known to structures such as bowel and ureters. Such injuries are often not recognized and result in tissue necrosis and delayed manifestations of symptoms.
Another unusual cause of iatrogenic burns is related to sue of operating microscopes. Choudhry et al. (Choudhry 2013) reported on a patient who experienced a burn from an operating microscope during surgery for a brachial plexus birth palsy, did a literature review, and made recommendations on how to avoid such injuries.
Lopez and colleagues (Lopez 2016) reported a burn related to an operating microscope in a 1 year old girl who underwent surgery for a lumbosacral lipoma with associated cord tethering consistent with a diagnosis of lipomyelomeningocele. Lopez and colleagues did a systematic literature review and found that all the clinical cases of iatrogenic microscope burns presented in the literature have involved the use of a xenon-based operating room microscope. Thirteen out of the 15 cases in the literature involved a microscope which is equipped with a xenon light source and 14 out of the 15 cases involved operating microscopes illuminating at 100% intensity. Twelve of the 15 reported cases occurred during otolaryngology procedures. Furthermore, the cases reported in the literature were highly variable in length of procedure ranging from 15 min to over 180 min. Most of the iatrogenic burns resulted in second degree burns with few receiving further surgical management, such as skin grafting.
They then did a search of FDA’s MAUDE database and found a total of 60 unique cases of iatrogenic burns associated with operating microscopes reported to the FDA from 2004 to 2013. A disproportionate large number of iatrogenic burns occurred during neurosurgical and otolaryngology procedures compared to other surgical specialties. They found that 25% of cases occurred in procedures that lasted more than 3 h but two cases reported skin burns after procedures that lasted less than 30 min. Approximately a quarter of the cases reported using 100% illumination intensity while only one case reported using less than 50% illumination intensity.
The majority of the reported cases in the literature occurred either in the elderly or the very young. To explain why such events were more frequent during neurosurgical or otolaryngology procedures, they speculated that the sites operated on might be particularly vulnerable to burns due to a thin dermis or minimal underlying adipose tissue such as the ears, scalp, or the mid-back. They also speculated that certain medications (eg. steroids, local anesthetics with or without epinephrine) might predispose to burns. And they note that hyperpigmentation or darker skin may be a risk factor, perhaps due to increased light absorption from the skin. They mention that even pigmentation from the skin disinfectant used might predispose to such burns.
Lopez and colleagues recommended the following best practices to minimize the risk of thermal injuries during procedures using the microscope:
Pabari et al. (Pabari 2007) also noted 2 cases of unusual burns in the OR. One burn of skin on arm during orthopedic surgery related to alcohol skin preparation. Details were not provided. One would wonder whether this might have also been related to mono-polar cautery as we’ve described above. The other case involved a scalding injury to the perineum related to leak of water heated to 80 degrees C during a hydrothermal ablation of the uterus.
In our June 1, 2010 Patient Safety Tip of the Week “Iatrogenic Burns” we noted there are really 3 key conditions that predispose patients to burns. They are either insensitive to pain/temperature, unresponsive, or unable to communicate. There may be some additional predisposing factors, too, like poor tissue perfusion and impaired ability for the vasculature to help dissipate heat from the skin. And, of course, you need a heat source.
Patients who are obtunded or comatose or who are under anesthesia may not perceive heat or pain or be able to respond even if they could feel it. Patients who cannot communicate (infants, patients with aphasia, patients isolated in MRI suites, etc.) may perceive pain and temperature but may not be able to alert caregivers. And some patient cannot feel heat/pain because of local or regional anesthetic or certain neurological disorders (diabetic neuropathy, some other neuropathies, congenital insensitivity to pain, spinal cord problems, syringomyelia, certain CNS lesions, etc.).
But even patients with normal sensation may get burns under certain circumstances. Has the following ever occurred to you? You test the water temperature before you step into the shower and it feels too hot. You turn the hot water knob down (or turn the cold water knob up) and the water temperature is comfortable enough for you to begin showering. After a few minutes you increase the water temperature. The increased warmth may, in fact, feel good. But when you finish your shower you notice your skin is much redder than you usually experience. What happened? This was adaptation to heat (adaptation probably occurs at both the peripheral receptor level and a central level). You were no longer bothered by water at the same temperature that frightened you at the start. Yet that hot water was capable of burning your skin. The same sort of adaptation takes place to cold (ever dive in a 65 degree lake? You shout out “It’s freezing!” but after about a minute it becomes more tolerable).
So the point is this: even moderate heat applied for a long duration is capable of producing burns and patients may be surprisingly unaware that the burn is occurring. The potential damage to skin (or other organs) is a function of both temperature and duration.
So what should you do in your organization to minimize the risks of iatrogenic burns?
A point worth reiterating is the fact that burns result not just from the temperature of the heat source but also the duration. In several of our columns on the impact of surgical case duration we’ve recommended all OR’s have in place a system where the duration of surgery is formally announced to all participants at regular intervals. That may provide a clue that certain actions may be needed (eg. give a second dose of prophylactic antibiotics, reposition the patient to avoid pressure ulcers or pressure neuropathies, consider intraoperative DVT prophylaxis). Perhaps, given today’s warnings about burns related to electrocautery systems or operating microscopes, you might also add checking the grounding pad site or microscope field to such actions.
While burns due to surgical fires are also clearly iatrogenic, we have separated those out in our discussions about iatrogenic burns.
Our prior columns on iatrogenic burns:
Our prior columns on surgical fires:
References:
CDPH (California Department of Public Health). Complaint Intake Number CA00397790; August 31, 2017
Mundinger GS, Rozen SM, Carson B et al. Full-thickness fore-head burn over indwelling titanium hardware resulting from an aberrant intraoperative electrocautery circuit. Eplasty 2007; 8: 1-7 Published December 4, 2007
Saaiq M, Zaib S, Ahmad S. Electrocautery burns: experience with three cases and review of literature. Ann Burns Fire Disasters 2012; 25(4): 203-206. Published online 2012 Dec 31
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3664530/pdf/Ann-Burns-and-Fire-Disasters-25-203.pdf
Kaya B, Çelik B, Çerkez C, et al. Iatrogenic Burns. Turkish Journal of Plastic Surgery 2016; 24(1): 35-38
http://www.turkjplastsurg.org/sayilar/1/buyuk/35-381.pdf
Choudhry IK, Kyriakedes J, Foad MB. Iatrogenic Burn Caused by an Operating Microscope: Case Report. J Hand Surg 2013; 38(3): 545-547
http://www.jhandsurg.org/article/S0363-5023(12)01714-5/abstract
Lopez J, Soni A, Calva D, et al. Iatrogenic surgical microscope skin burns: A systematic review of the literature and case report. Burns 2016; 42(4): e74-e80
http://www.burnsjournal.com/article/S0305-4179(15)00240-5/fulltext
Pabari AJ, Gilbert PM, Dheansa BS, et al. Iatrogenic burn injury, patient safety in the operating room. Burns 2007; 33(1, Supplement): S41
http://www.burnsjournal.com/article/S0305-4179(06)00414-1/abstract
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September 12, 2017
Can You Hear Me Now?
When we first started this column the title was intended to be “Translation Barriers and Patient Outcomes”. But as we progressed we realized that not only are language barriers problematic for patient outcomes and safety, but hearing impairment that interferes with effective communication is equally problematic.
The original article by Squires et al. (Squires 2017) found that for limited English proficiency patients, only 20% of home health visits were language concordant. The study suggests that home health care services may not be meeting the demand for language services, perhaps predisposing to suboptimal patient outcomes.
Then another recent study (Karliner 2017) sought to determine if increasing access to professional interpreters improves hospital outcomes for older patients with limited English proficiency (LEP). Karliner and colleagues explored the impact of a dual-handset interpreter telephone at every bedside on a medicine floor of an academic hospital. They found a significant decrease in observed 30-day readmission rates for the LEP group during the 8-month intervention period compared with 18 months preintervention, 17.8% vs. 13.4%. The improved readmission outcome for the LEP group was not maintained during the subsequent postintervention period when the telephones became less accessible. There was no significant intervention impact on length of stay but the intervention proved to be cost-effective. After accounting for interpreter services costs, the estimated 119 readmissions averted during the intervention period were associated with estimated monthly hospital expenditure savings of $161,404.
A previous study (Nápoles 2015) had shown that inaccurate language interpretation in medical encounters is common and more frequent when untrained interpreters are used compared to professionals in-person or via videoconferencing.
Hospitals, of course, must provide interpretation services to meet Joint Commission (and other regulatory body) requirements. But also included in those requirements are the need to provide similar services for the deaf or hearing impaired patient. It was shortly after the above articles that we saw that a federal appeals court has paved the way for patients to sue a hospital for not taking steps to assure they understood what was happening to them when they got medical treatment (Musgrave 2017). “In the lawsuit, patients described how scared and confused they were when doctors and nurses used gestures or passed notes to them to explain medical procedures. The medical professionals apparently resorted to such methods because of the failure of a video system the hospital uses to communicate with the deaf. Instead of hiring sign language interpreters to come to the hospital, the hospital uses a service where interpreters at remote locations are beamed onto a TV screen. But, patients said, the image is often blurry. Or, they said, the screen goes blank. Sometimes medical professionals didn’t know how to operate it.”
Hospitals must provide signing services for the deaf and, just like language interpreters, those who sign need to be trained to deal with medical terms and concepts. But the problem goes well beyond those with significant hearing loss. Even minor degrees of hearing loss may impair communication between healthcare professionals and patients.
The problem was really emphasized by a recent article in JAMA Otolaryngology-Head & Neck Surgery (Cudmore 2017). Cudmore and colleagues conducted semi-structured interviews on 100 adults age 60 and older. Of the 100, 57 reported having some degree of hearing loss. 43 of the 100 reported mishearing a physician or nurse in a primary care or hospital setting (this did not vary by age group). They identified several themes (in order of frequency): general mishearing, consultation content, physician-patient or nurse-patient communication breakdown, hospital setting, use of language, selective deafness.
Some patients especially noted problems with similar sounding words. Others complained that the physician or nurse did not look at them while talking (we’ll bet some of these patients were lip reading) and others complained the healthcare professional spoke too fast or in too low a volume.
The accompanying editorial (Weinreich 2017) notes patients with hearing loss are missing instructions, missing diagnoses, and missing medication information. Weinreich notes that, in addition to physicians speaking too quickly or quietly, background noise may cause patients to miss messages. She notes we need to know when our patients have hearing loss and change how we communicate with hearing loss patients. She notes we need to:
Last of all, don’t assume that what is heard is actually understood. A recent article (Ginsberg 2017) noted an anecdote that was recently shared with the CreakyJoints community: a patient was diagnosed with rheumatoid arthritis and prescribed methotrexate. The doctor told her that she "can't" get pregnant while taking methotrexate. The patient apparently took her doctor literally and grew lax in her contraceptive use, simply because she was following his orders. Obviously, the physician meant "you shouldn't get pregnant," not "you can't get pregnant." (because methotrexate may cause birth defects, as well as other problems). That emphasizes the concepts of “hear back” and “teach back” which we have stressed in our columns on health literacy and numeracy. (“Hear back” is obviously also critical in communication between healthcare professionals).
So if you are a hospital or similar medical facility, make sure you use professional interpreters and signers and meet or exceed the requirements of the regulatory bodies. In all healthcare settings you need to assess whether your patients have hearing impairment (some of us won’t admit it!). Use some of the techniques noted above in the Cudmore and Weinreich articles. And, perhaps most importantly, use hear back and teach back to make sure your patients truly understand what you are trying to communicate to them.
Some of our other columns on health literacy and numeracy:
June 2012 “Parents' Math Ability Matters”
May 7, 2013 “Drug Errors in the Home”
November 2014 “Out-of-Hospital Pediatric Medication Errors”
January 13, 2015 “More on Numeracy”
August 2017 “More on Pediatric Dosing Errors”
References:
Squires A, Peng TR, Barrón-Vaya Y, Feldman P. An Exploratory Analysis of Patient-Provider Language-Concordant Home Health Care Visit Patterns. Home Health Care Management & Practice 2017; First Published March 9, 2017
http://journals.sagepub.com/doi/abs/10.1177/1084822317696706?journalCode=hhcb
Karliner LS, Pérez-Stable EJ, Gregorich SE. Convenient Access to Professional Interpreters in the Hospital Decreases Readmission Rates and Estimated Hospital Expenditures for Patients With Limited English Proficiency. Medical Care 2017; 55(3): 199-206, March 2017
Nápoles AM, Santoyo-Olsson J, Karliner LS, Gregorich SE, Pérez-Stable EJ. Inaccurate Language Interpretation and Its Clinical Significance in the Medical Encounters of Spanish-speaking Latinos. Medical Care 2015; 53(11): 940-947
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4610127/
Musgrave J. Deaf patients get go-ahead to sue Boynton’s Bethesda hospital. Palm Beach Post 2017; May 3, 2017
Cudmore V, Henn P, O’Tuathaigh CMP, et al. Age-Related Hearing Loss and Communication Breakdown in the Clinical Setting. JAMA Otolaryngol Head Neck Surg 2017; Published online August 24, 2017
http://jamanetwork.com/journals/jamaotolaryngology/article-abstract/2649281
Weinreich HM. Hearing Loss and Patient-Physician CommunicationThe Role of an Otolaryngologist. JAMA Otolaryngol Head Neck Surg 2017; Published online August 24, 2017
http://jamanetwork.com/journals/jamaotolaryngology/article-abstract/2649280
Ginsberg S. Say What? Dangers of Miscommunicating. When miscommunication means life or death. MedPage Today News 2017; June 11, 2017
http://www.medpagetoday.com/rheumatology/generalrheumatology/65928
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Adverse Drug Events After Hospitalization
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Opioid-Induced Respiratory Depression Costly in Fiscal as Well as Human Terms
October 19, 2021
COVID-19 Vaccine/ Flu Vaccine Mixups
October 12, 2021
FDA Approval of Concussion Tool – Why Not a Fatigue Detection Tool?
October 5, 2021
September 28, 2021
Barcoding Better? Not So Fast!
September 21, 2021
Repeat CT in Anticoagulated Patients After Minor Head Trauma Not Cost-Effective
September 14, 2021
September 7, 2021
The Vanderbilt Tragedy Gets Uglier
August 31, 2021
The Community Pharmacy and Patient Safety
August 24, 2021
More Home Infusion Safety Issues
August 17, 2021
Tip of the Week on Vacation
August 10, 2021
Tip of the Week on Vacation
August 3, 2021
Obstetric Patients More At-Risk for Wrong Patient Orders
July 27, 2021
July 20, 2021
FDA Warning: Magnets in Consumer Electronics May Affect Medical Devices
July 13, 2021
The Skinny on Rapid Response Teams
July 6, 2021
Tip of the Week on Vacation
June 29, 2021
June 22, 2021
Remotely Monitoring Suicidal Patients in Non-Behavioral Health Areas
June 15, 2021
What’s Happened to Your Patient Safety Walk Rounds?
June 8, 2021
Cut OR Traffic to Cut Surgical Site Infections
June 1, 2021
Stronger Magnets, More MRI Safety Concerns
May 25, 2021
Yes, Radiologists Have Handoffs, Too
May 18, 2021
Medical Overuse Is Not Just An Economic Problem
May 11, 2021
How Are Alerts in Ambulatory CPOE Doing?
May 4, 2021
More 10x Dose Errors in Pediatrics
April 27, 2021
Errors Common During Thrombolysis for Acute Ischemic Stroke
April 20, 2021
Taser “Slip and Capture Error” Again!
April 13, 2021
Incidental Findings – What’s Your Strategy?
April 6, 2021
March 30, 2021
Need for Better Antibiotic Stewardship
March 23, 2021
Nursing Staffing and Sepsis Outcomes
March 16, 2021
Sleep Program Successfully Reduces Delirium
March 9, 2021
Update: Disclosure and Apology: How to Do It
March 2, 2021
Barriers to Timely Catheter Removal
February 23, 2021
February 16, 2021
New Methods for QTc Monitoring
February 9, 2021
February 2, 2021
MGH Protocols Reduce Risk of Self-Harm in ED
January 26, 2021
This Freezer Accident May Cost Lives
January 19, 2021
Technology to Identify Fatigue?
January 12, 2021
January 5, 2021
Dilaudid/HYDROmorphone Still Problematic
December 29, 2019
Tip of the Week on Vacation
December 22, 2019
Tip of the Week on Vacation
December 15, 2020
Our Perennial Pre-Holiday Warning: “Be Careful Out There!”
December 8, 2020
Maternal Mortality: Looking in All the Wrong Places?
December 1, 2020
An Early Warning System and Response System That Work
November 24, 2020
November 17, 2020
A Picture Is Worth a Thousand Words
November 10, 2020
November 3, 2020
Reminder: Infant Abduction Risk
October 27, 2020
Conflicting Studies on Technology to Reduce RSI’s
October 20, 2020
More on Post-operative Risks for Patients with OSA
October 13, 2020
October 6, 2020
Successfully Reducing Opioid-Related Adverse Events
September 29, 2020
September 22, 2020
VA RCA’s: Suicide Risks Vary by Site
September 15, 2020
September 8, 2020
Follow Up on Tests Pending at Discharge
September 1, 2020
NY State and Nurse Staffing Issues
August 25, 2020
The Off-Hours Effect in Radiology
August 18, 2020
August 11, 2020
Above-Door Alarms to Prevent Suicides
August 4, 2020
July 28, 2020
July 21, 2020
Is This Patient Allergic to Penicillin?
July 14, 2020
A Thesis on Intrahospital Transports
July 7, 2020
Another Patient Found Dead in a Stairwell
June 30, 2020
What Happens after Hospitalization?
June 23, 2020
June 16, 2020
June 9, 2020
Perioperative Medication Safety
June 2, 2020
May 26, 2020
May 19, 2020
Reminder on Telephone or Verbal Orders
May 12, 2020
May 5, 2020
COVID-19 and the Dental Office
April 28, 2020
April 21, 2020
Parenteral Nutrition Safety Issues
April 14, 2020
Patient Safety Tidbits for the COVID-19 Pandemic
April 7, 2020
From Preoperative Assessment to Preoperative Optimization
March 31, 2020
Intrahospital Transport Issues in Children
March 24, 2020
Mayo Clinic: How to Get Photos in Your EMR
March 17, 2020
March 10, 2020
Medication Harm in the Elderly
March 3, 2020
Opportunities to Reduce Unnecessary Contact Precautions
February 25, 2020
More on Perioperative Gabapentinoids
February 18, 2020
February 11, 2020
February 4, 2020
Drugs and Chronic Kidney Disease
January 28, 2020
January 21, 2020
Disruptive Behavior and Patient Safety: Cause or Effect?
January 14, 2020
January 7, 2020
Even More Concerns About MRI Safety
December 31, 2019
Tip of the Week on Vacation
December 14, 2019
Tip of the Week on Vacation
December 17, 2019
December 10, 2019
December 3, 2019
Overlapping Surgery Back in the News
November 26, 2019
Pennsylvania Law on Notifying Patients of Test Results
November 19, 2019
An Astonishing Gap in Medication Safety
November 12, 2019
Patient Photographs Again Help Radiologists
November 5, 2019
October 29, 2019
Tip of the Week on Vacation
October 22, 2019
Tip of the Week on Vacation
October 15, 2019
October 8, 2019
October 1, 2019
Electronic Medication Reconciliation: Glass Half Full or Half Empty?
September 24, 2019
EHR-related Malpractice Claims
September 17, 2019
American College of Surgeons Geriatric Surgery Verification Program
September 10, 2019
Joint Commission Naming Standard Leaves a Gap
September 3, 2019
Lessons from an Inpatient Suicide
August 27, 2019
August 20, 2019
Yet Another (Not So) Unusual RSI
August 13, 2019
Betsy Lehman Center Report on Medical Error
August 6, 2019
July 30, 2019
Lessons from Hospital Suicide Attempts
July 23, 2019
Order Sets Can Nudge the Right Way or the Wrong Way
July 16, 2019
July 9, 2019
Spinal Injection of Tranexamic Acid
July 2, 2019
Tip of the Week on Vacation
June 25, 2019
June 18, 2019
June 11, 2019
ISMP’s Grissinger on Overreliance on Technology
June 4, 2019
Medication Errors in the OR – Part 3
May 28, 2019
May 21, 2019
Mixed Message on Number of Open EMR Records
May 14, 2019
Wrong-Site Surgery and Difficult-to-Mark Sites
May 7, 2019
Simulation Training for OR Fires
April 30, 2019
Reducing Unnecessary Urine Cultures
April 23, 2019
In and Out the Door and Other OR Flow Disruptions
April 16, 2019
AACN Practice Alert on Alarm Management
April 9, 2019
Handoffs for Every Occasion
April 2, 2019
Unexpected Events During MRI
March 26, 2019
March 19, 2019
March 12, 2019
Update on Overlapping Surgery
March 5, 2019
Infusion Pump Problems
February 26, 2019
Vascular Access Device Dislodgements
February 19, 2019
Focus on Pediatric Patient Safety
February 12, 2019
From Tragedy to Travesty of Justice
February 12, 2019
2 ER Drug Studies: Reassurances and Reservations
February 5, 2019
Flaws in Our Medication Safety Technologies
January 29, 2018
National Patient Safety Goal for Suicide Prevention
January 22, 2019
Wandering Patients
January 15, 2019
Another Plus for Prehabilitation
January 8, 2019
Maternal Mortality in the Spotlight
January 1, 2019
More on Automated Dispensing Cabinet (ADC) Safety
December 25, 2018
Happy Holidays!
December 18, 2018
Great Recommendations for e-Prescribing
December 11, 2018
December 4, 2018
Don’t Use Syringes for Topical Products
November 27, 2018
November 20, 2018
November 13, 2018
Antipsychotics Fail in ICU Delirium
November 6, 2018
More on Promoting Sleep in Inpatients
October 30, 2018
October 23, 2018
Lessons From Yet Another Aviation Incident
October 16, 2018
October 9, 2018
October 2, 2018
Speaking Up About Disruptive Behavior
September 25, 2018
Foley Follies
September 18, 2018
September 11, 2018
September 4, 2018
The 12-Hour Nursing Shift: Another Nail in the Coffin
August 28, 2018
Thought You Discontinued That Medication? Think Again
August 21, 2018
Delayed CT Scan in the Anticoagulated Patient
August 14, 2018
ISMP Canada’s Updated “Do Not Use” Abbreviation List
August 7, 2018
Tip of the Week on Vacation
July 31, 2018
Surgery and the Opioid-Tolerant Patient
July 24, 2018
More on Speech Recognition Software Errors
July 17, 2018
OSA Screening in Stroke Patients
July 10, 2018
Another Jump from a Hospital Window
July 3, 2018
Tip of the Week on Vacation
June 26, 2018
Infection Related to Colonoscopy
June 19, 2018
June 12, 2018
Adverse Events in Cancer Patients
June 5, 2018
Pennsylvania Patient Safety Authority on Iatrogenic Burns
May 29, 2018
More on Nursing Workload and Patient Safety
May 22, 2018
Hazardous Intrahospital Transport
May 15, 2018
May 8, 2018
May 1, 2018
April 24, 2018
April 17, 2018
More on Tests Pending at Discharge
April 10, 2018
Prepping the Geriatric Patient for Surgery
April 3, 2018
March 27, 2018
March 20, 2018
Minnesota Highlights Lost Tissue Samples
March 13, 2018
March 6, 2018
February 27, 2018
Update on Patient Safety Walk Rounds
February 20, 2018
February 13, 2018
February 6, 2018
Adverse Events in Inpatient Psychiatry
January 30, 2018
January 23, 2018
Unintentional Hypothermia Back in Focus
January 16, 2018
January 9, 2018
More on Fire Risk from Surgical Preps
January 2, 2018
Preventing Perioperative Nerve Injuries
December 26, 2017
Tip of the Week on Vacation
December 19, 2017
December 12, 2017
Joint Commission on Suicide Prevention
December 5, 2017
Massachusetts Initiative on Cataract Surgery
November 28, 2017
More on Dental Sedation/Anesthesia Safety
November 21, 2017
OSA, Oxygen, and Alarm Fatigue
November 14, 2017
Tracking C. diff to a CT Scanner
November 7, 2017
Perioperative Neuropathies
October 31, 2017
Target Drugs for Deprescribing
October 24, 2017
Neurosurgery and Time of Day
October 17, 2017
Progress on Alarm Management
October 10, 2017
More on Torsade de Pointes
October 3, 2017
Respiratory Compromise: One Size Does Not Fit All
September 26, 2017
Tip of the Week on Vacation
September 19, 2017
Tip of the Week on Vacation
September 12, 2017
Can You Hear Me Now?
September 5, 2017
Another Iatrogenic Burn
August 29, 2017
Suicide in the Bathroom
August 22, 2017
August 15, 2017
Delayed Emergency Surgery and Mortality Risk
August 8, 2017
Sedation for Pediatric MRI Rising
August 1, 2017
Progress on Wrong Patient Orders
July 25, 2017
Can We Influence the “Weekend Effect”?
July 18, 2017
Another Hazard from Alcohol-Based Hand Gels
July 11, 2017
The 12-Hour Shift Takes More Hits
July 4, 2017
Tip of the Week on Vacation
June 27, 2017
June 20, 2017
June 13, 2017
June 6, 2017
NYS Mandate for Sepsis Protocol Works
May 30, 2017
Errors in Pre-Populated Medication Lists
May 23, 2017
May 16, 2017
Are Surgeons Finally Ready to Screen for Frailty?
May 9, 2017
Missed Nursing Care and Mortality Risk
May 2, 2017
Anatomy of a Wrong Procedure
April 25, 2017
April 18, 2017
Alarm Response and Nurse Shift Duration
April 11, 2017
Interruptions: The Ones We Forget About
April 4, 2017
Deprescribing in Long-Term Care
March 28, 2017
More Issues with Dental Sedation/Anesthesia
March 21, 2017
Success at Preventing Delirium
March 14, 2017
More on Falls on Inpatient Psychiatry
March 7, 2017
February 28, 2017
February 21, 2017
Yet More Jumps from Hospital Windows
February 14, 2017
February 7, 2017
January 31, 2017
More Issues in Pediatric Safety
January 24, 2017
Dexmedetomidine to Prevent Postoperative Delirium
January 17, 2017
January 10, 2017
The 26-ml Applicator Strikes Again!
January 3, 2017
What’s Happening to “I’m Sorry”?
December 27, 2016
Tip of the Week on Vacation
December 20, 2016
End-of-Rotation Transitions and Mortality
December 13, 2016
More on Double-Booked Surgery
December 6, 2016
Postoperative Pulmonary Complications
November 29, 2016
Doubling Down on Double-Booked Surgery
November 22, 2016
Leapfrog, Picklists, and Healthcare IT Vulnerabilities
November 15, 2016
November 8, 2016
Managing Distractions and Interruptions
November 1, 2016
CMS Emergency Preparedness Rule
October 25, 2016
Desmopressin Back in the Spotlight
October 18, 2016
Yet More Questions on Contact Precautions
October 11, 2016
New Guideline on Preop Screening and Assessment for OSA
October 4, 2016
September 27, 2016
September 20, 2016
Downloadable ABCDEF Bundle Toolkits for Delirium
September 13, 2016
Vanderbilt’s Electronic Procedural Timeout
September 6, 2016
August 30, 2016
Can You Really Limit Interruptions?
August 23, 2016
ISMP Canada: Automation Bias and Automation Complacency
August 16, 2016
How Is Your Alarm Management Initiative Going?
August 9, 2016
August 2, 2016
Drugs in the Elderly: The Goldilocks Story
July 26, 2016
Confirmed: Keep Your OR Doors Closed
July 19, 2016
Infants and Wrong Site Surgery
July 12, 2016
Forget Brexit – Brits Bash the RCA!
July 5, 2016
Tip of the Week on Vacation
June 28, 2016
Culture of Safety and Catheter-Associated Infections
June 21, 2016
Methotrexate Errors in Australia
June 14, 2016
Nursing Monitoring of Patients on Opioids
June 7, 2016
CPAP for Hospitalized Patients at High Risk for OSA
May 31, 2016
More Frailty Measures That Predict Surgical Outcomes
May 24, 2016
Texting Orders – Is It Really Safe?
May 17, 2016
Patient Safety Issues in Cataract Surgery
May 10, 2016
Medical Problems in Behavioral Health
May 3, 2016
Clinical Decision Support Malfunction
April 26, 2016
Lots More on Preventing Readmissions But Where's the Beef?
April 19, 2016
Independent Double Checks and Oral Chemotherapy
April 12, 2016
April 5, 2016
Workarounds Overriding Safety
March 29, 2016
March 22, 2016
Radiology Communication Errors May Surprise You
March 15, 2016
March 8, 2016
Tip of the Week on Vacation
March 1, 2016
February 23, 2016
February 16, 2016
February 9, 2016
February 2, 2016
January 26, 2016
More on Frailty and Surgical Morbidity and Mortality
January 19, 2016
Patient Identification in the Spotlight
January 12, 2016
New Resources on Improving Safety of Healthcare IT
January 5, 2016
Lessons from AirAsia Flight QZ8501 Crash
December 29, 2015
More Medical Helicopter Hazards
December 22, 2015
The Alberta Abbreviation Safety Toolkit
December 15, 2015
Vital Sign Monitoring at Night
December 8, 2015
Danger of Inaccurate Weights in Stroke Care
December 1, 2015
TALLman Lettering: Does It Work?
November 24, 2015
Door Opening and Foot Traffic in the OR
November 17, 2015
Patient Perspectives on Communication of Test Results
November 10, 2015
Weighing in on Double-Booked Surgery
November 3, 2015
Medication Errors in the OR - Part 2
October 27, 2015
Sentinel Event Alert on Falls and View from Across the Pond
October 20, 2015
Updated Beers List
October 13, 2015
Dilaudid Dangers #3
October 6, 2015
Suicide and Other Violent Inpatient Deaths
September 29, 2015
More on the 12-Hour Nursing Shift
September 22, 2015
The Cost of Being Rude
September 15, 2015
Another Possible Good Use of a Checklist
September 8, 2015
TREWScore for Early Recognition of Sepsis
September 1, 2015
August 25, 2015
Checklist for Intrahospital Transport
August 18, 2015
Missing Obstructive Sleep Apnea
August 11, 2015
New Oxygen Guidelines: Thoracic Society of Australia and NZ
August 4, 2015
Tip of the Week on Vacation
July 28, 2015
July 21, 2015
Avoiding Distractions in the OR
July 14, 2015
July 7, 2015
June 30, 2015
What Are Appropriate Indications for Urinary Catheters?
June 23, 2015
Again! Mistaking Antiseptic Solution for Radiographic Contrast
June 16, 2015
June 9, 2015
Add This to Your Fall Risk Assessment
June 2, 2015
May 26, 2015
May 19, 2015
May 12, 2015
More on Delays for In-Hospital Stroke
May 5, 2015
Errors with Oral Oncology Drugs
April 28, 2015
April 21, 2015
April 14, 2015
Using Insulin Safely in the Hospital
April 7, 2015
March 31, 2015
Clinical Decision Support for Pneumonia
March 24, 2015
Specimen Issues in Prostate Cancer
March 17, 2015
March 10, 2015
FDA Warning Label on Insulin Pens: Is It Enough?
March 3, 2015
Factors Related to Postoperative Respiratory Depression
February 24, 2015
More Risks with Long-Acting Opioids
February 17, 2015
Functional Impairment and Hospital Readmission, Surgical Outcomes
February 10, 2015
The Anticholinergic Burden and Dementia
February 3, 2015
CMS Hopes to Reduce Antipsychotics in Dementia
January 27, 2015
The Golden Hour for Stroke Thrombolysis
January 20, 2015
He Didn’t Wash His Hands After What!
January 13, 2015
January 6, 2015
Yet Another Handoff: The Intraoperative Handoff
December 30, 2014
Data Accumulates on Impact of Long Surgical Duration
December 23, 2014
Iatrogenic Burns in the News Again
December 16, 2014
More on Each Element of the Surgical Fire Triad
December 9, 2014
December 2, 2014
ANA Position Statement on Nurse Fatigue
November 25, 2014
Misdiagnosis Due to Lab Error
November 18, 2014
Handwashing Fades at End of Shift, ?Smartwatch to the Rescue
November 11, 2014
Early Detection of Clinical Deterioration
November 4, 2014
Progress on Fall Prevention
October 28, 2014
RF Systems for Retained Surgical Items
October 21, 2014
The Fire Department and Your Hospital
October 14, 2014
October 7, 2014
Our Take on Patient Safety Walk Rounds
September 30, 2014
More on Deprescribing
September 23, 2014
Stroke Thrombolysis: Need to Focus on Imaging-to-Needle Time
September 16, 2014
Focus on Home Care
September 9, 2014
The Handback
September 2, 2014
Frailty and the Trauma Patient
August 26, 2014
Surgeons’ Perception of Intraoperative Time
August 19, 2014
Some More Lessons Learned on Retained Surgical Items
August 12, 2014
Surgical Fires Back in the News
August 5, 2014
Tip of the Week on Vacation
July 29, 2014
The 12-Hour Nursing Shift: Debate Continues
July 22, 2014
More on Operating Room Briefings and Debriefings
July 15, 2014
Barriers to Success of Early Warning Systems
July 8, 2014
Update: Minor Head Trauma in the Anticoagulated Patient
July 1, 2014
Interruptions and Radiologists
June 24, 2014
Lessons from the General Motors Recall Analysis
June 17, 2014
SO2S Confirms Routine Oxygen of No Benefit in Stroke
June 10, 2014
Another Clinical Decision Support Tool to Avoid Torsade de Pointes
June 3, 2014
More on the Risk of Sedative/Hypnotics
May 27, 2014
A Gap in ePrescribing: Stopping Medications
May 20, 2014
May 13, 2014
Perioperative Sleep Apnea: Human and Financial Impact
May 6, 2014
Monitoring for Opioid-induced Sedation and Respiratory Depression
April 29, 2014
More on the Unintended Consequences of Contact Isolation
April 22, 2014
Impact of Resident Workhour Restrictions
April 15, 2014
Specimen Identification Mixups
April 8, 2014
FMEA to Avoid Breastmilk Mixups
April 1, 2014
Expensive Aspects of Sepsis Protocol Debunked
March 25, 2014
March 18, 2014
Systems Approach Improving Stroke Care
March 11, 2014
We Miss the Graphic Flowchart!
March 4, 2014
Evidence-Based Prescribing and Deprescribing in the Elderly
February 25, 2014
Joint Commission Revised Diagnostic Imaging Requirements
February 18, 2014
February 11, 2014
Another Perioperative Handoff Tool: SWITCH
February 4, 2014
But What If the Battery Runs Low?
January 28, 2014
Is Polypharmacy Always Bad?
January 21, 2014
January 14, 2014
Diagnostic Error: Salient Distracting Features
January 7, 2014
Lessons From the Asiana Flight 214 Crash
December 24-31, 2013
Tip of the Week on Vacation
December 17, 2013
December 10, 2013
Better Handoffs, Better Results
December 3, 2013
Reducing Harm from Falls on Inpatient Psychiatry
November 26, 2013
Missed Care: New Opportunities?
November 19, 2013
Can We Improve Dilaudid/HYDROmorphone Safety?
November 12, 2013
More on Inappropriate Meds in the Elderly
November 5, 2013
Joint Commission Sentinel Event Alert: Unintended Retained Foreign Objects
October 29, 2013
PAD: The Pain, Agitation, and Delirium Care Bundle
October 22, 2013
How Safe Is Your Radiology Suite?
October 15, 2013
October 8, 2013
October 1, 2013
Fuels and Oxygen in OR Fires
September 24, 2013
Perioperative Use of CPAP in OSA
September 17, 2013
September 10, 2013
Informed Consent and Wrong-Site Surgery
September 3, 2013
Predicting Perioperative Complications: Slow and Simple
August 27 2013
Lessons on Wrong-Site Surgery
August 20 2013
Lessons from Canadian Analysis of Medical Air Transport Cases
August 13 2013
August 6, 2013
July 9-30, 2013
Tip of the Week on Vacation
July 2, 2013
June 25, 2013
June 18, 2013
DVT Prevention in Stoke – CLOTS 3
June 11, 2013
June 4, 2013
May 28, 2013
The Neglected Medications: IV Fluids
May 21, 2013
May 14, 2013
Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)
May 7, 2013
April 30, 2013
Photographic Identification to Prevent Errors
April 23, 2013
Plethora of Medication Safety Studies
April 16, 2013
April 9, 2013
Mayo Clinic System Alerts for QT Interval Prolongation
April 2, 2013
Absconding from Behavioral Health Services
March 26, 2013
Failure to Recognize Sleep Apnea Before Surgery
March 19, 2013
Dealing with the Violent Patient in the Emergency Department
March 12, 2013
More on Communicating Test Results
March 5, 2013
Underutilized Safety Tools: The Observational Audit
February 26, 2013
Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?
February 19, 2013
Practical Postoperative Pain Management
February 12, 2013
CDPH: Lessons Learned from PCA Incident
February 5, 2013
Antidepressants and QT Interval Prolongation
January 29, 2013
A Flurry of Activity on Handoffs
January 22, 2013
You Don’t Know What You Don’t Know
January 15, 2013
January 8, 2013
More Lessons Learned on Retained Surgical Items
January 1, 2013
Don’t Throw Away Those View Boxes Yet
December 25, 2012
Tip of the Week on Vacation
December 18, 2012
Unintended Consequences of the CAUTI Measure?
December 11, 2012
December 4, 2012
Unintentional Perioperative Hypothermia: A New Twist
November 27, 2012
November 20, 2012
Update on Perioperative Management of Obstructive Sleep Apnea
November 13, 2012
The 12-Hour Nursing Shift: More Downsides
November 6, 2012
Using LEAN to Improve Stroke Care
October 30, 2012
October 23, 2012
Latent Factors Lurking in the OR
October 16, 2012
What is the Evidence on Double Checks?
October 9, 2012
Call for Focus on Diagnostic Errors
October 2, 2012
Test Results: Everyone’s Worst Nightmare
September 25, 2012
Preoperative Assessment for Geriatric Patients
September 18, 2012
September 11, 2012
In Search of the Ideal Early Warning Score
September 4, 2012
August 28, 2012
New Care Model Copes with Interruptions Better
August 21, 2012
More on Missed Followup of Tests in Hospital
August 14, 2012
August 7, 2012
Cognition, Post-Op Delirium, and Post-Op Outcomes
July 31, 2012
Surgical Case Duration and Miscommunications
July 24, 2012
FDA and Extended-Release/Long-Acting Opioids
July 17, 2012
July 10, 2012
Tip of the Week on Vacation
July 3, 2012
Recycling an Old Column: Dilaudid Dangers
June 26, 2012
Using Patient Photos to Reduce CPOE Errors
June 19, 2012
More Problems with Faxed Orders
June 12, 2012
Lessons Learned from the CDPH: Retained Foreign Bodies
June 5, 2012
Minor Head Trauma in the Anticoagulated Patient
May 29, 2012
Falls, Fractures, and Fatalities
May 22, 2012
Update on Preoperative Screening for Sleep Apnea
May 15, 2012
May 8, 2012
Importance of Nontechnical Skills in Healthcare
May 1, 2012
April 24, 2012
Fire Hazard of Skin Preps Oxygen
April 17, 2012
April 10, 2012
April 3, 2012
New Risk for Postoperative Delirium: Obstructive Sleep Apnea
March 27, 2012
March 20, 2012
Adverse Events Related to Psychotropic Medications
March 13, 2012
Medical Emergency Team Calls to Radiology
March 6, 2012
February 28, 2012
AACN Practice Alert on Delirium in Critical Care
February 21, 2012
Improving PCA Safety with Capnography
February 14, 2012
Handoffs More Than Battle of the Mnemonics
February 7, 2012
Another Neuromuscular Blocking Agent Incident
January 31, 2012
January 24, 2012
Patient Safety in Ambulatory Care
January 17, 2012
Delirium and Contact Isolation
January 10, 2012
January 3, 2012
Unintended Consequences of Restricted Housestaff Hours
December 20, 2011
December 13, 2011
December 6, 2011
Why You Need to Beware of Oxygen Therapy
November 29, 2011
November 22, 2011
Perioperative Management of Sleep Apnea Disappointing
November 15, 2011
November 8, 2011
WHOs Multi-professional Patient Safety Curriculum Guide
November 1, 2011
So Whats the Big Deal About Inserting an NG Tube?
October 25, 2011
October 18, 2011
October 11, 2011
October 4, 2011
Radiology Report Errors and Speech Recognition Software
September 27, 2011
The Canadian Suicide Risk Assessment Guide
September 20, 2011
When Practice Changes the Evidence: The CKD Story
September 13, 2011
Do You Use Fentanyl Transdermal Patches Safely?
September 6, 2011
August 30, 2011
Unintentional Discontinuation of Medications After Hospitalization
August 23, 2011
Catheter Misconnections Back in the News
August 16, 2011
August 9, 2011
Frailty and the Surgical Patient
August 2, 2011
July 26, 2011
July 19, 2011
Communication Across Professions
July 12, 2011
Psst! Pass it onHow a kids game can mold good handoffs
July 5, 2011
Sidney Dekker: Patient Safety. A Human Factors Approach
June 28, 2011
Long-Acting and Extended-Release Opioid Dangers
June 21, 2011
June 14, 2011
June 6, 2011
May 31, 2011
Book Review Human Factors and Team Psychology in a High Stakes Environment
May 24, 2011
May 17, 2011
Opioid-Induced Respiratory Depression Again!
May 10, 2011
Preventing Preventable Readmissions: Not As Easy As It Sounds
May 3, 2011
April 26, 2011
Sleeping Air Traffic Controllers: What About Healthcare?
April 19, 2011
DVT Prophylaxis in Acute Stroke: Controversy Reappears
April 12, 2011
Medication Issues in the Ambulatory Setting
April 5, 2011
March 29, 2011
The Silent Treatment:A Dose of Reality
March 22, 2011
An EMR Feature Detrimental to Teamwork and Patient Safety
March 15, 2011
March 8, 2011
Yes, Physicians Get Interrupted Too!
March 1, 2011
February 22, 2011
February 15, 2011
Controversies in VTE Prophylaxis
February 8, 2011
February 1, 2011
January 25, 2011
Procedural Sedation in Children
January 18, 2011
More on Medication Errors in Long-Term Care
January 11, 2011
NPSA (UK) How to Guide: Five Steps to Safer Surgery
January 4, 2011
December 28, 2010
HAIs: Looking In All The Wrong Places
December 21, 2010
More Bad News About Off-Hours Care
December 14, 2010
NPSA (UK): Preventing Fatalities from Medication Loading Doses
December 6, 2010
More Tips to Prevent Wrong-Site Surgery
November 30, 2010
SURPASS: The Mother of All Checklists
November 23, 2010
Focus on Cumulative Radiation Exposure
November 16, 2010
November 9, 2010
12-Hour Nursing Shifts and Patient Safety
November 2, 2010
Insulin: Truly a High-Risk Medication
October 26, 2010
Confirming Medications During Anesthesia
October 19, 2010
Optimizing Medications in the Elderly
October 12, 2010
October 5, 2010
September 28, 2010
September 21, 2010
September 14, 2010
Wrong-Site Craniotomy: Lessons Learned
September 7, 2010
Patient Safety in Ob/Gyn Settings
August 31, 2010
August 24, 2010
The BP Oil Spill Analogies in Healthcare
August 17, 2010
Preoperative Consultation Time to Change
August 10, 2010
Its Not Always About The Evidence
August 3, 2010
Tip of the Week on Vacation
July 27, 2010
EMRs Still Have A Long Way To Go
July 20, 2010
More on the Weekend Effect/After-Hours Effect
July 13, 2010
Postoperative Opioid-Induced Respiratory Depression
July 6, 2010
Book Reviews: Pronovost and Gawande
June 29, 2010
Torsade de Pointes: Are Your Patients At Risk?
June 22, 2010
Disclosure and Apology: How to Do It
June 15, 2010
Dysphagia in the Stroke Patient: the Scottish Guideline
June 8, 2010
Surgical Safety Checklist for Cataract Surgery
June 1, 2010
May 25, 2010
May 18, 2010
Real-Time Random Safety Audits
May 11, 2010
May 4, 2010
More on the Impact of Interruptions
April 27, 2010
April 20, 2010
HITs Limited Impact on Quality To Date
April 13, 2010
April 6, 2010
March 30, 2010
Publicly Released RCAs: Everyone Learns from Them
March 23, 2010
ISMPs Guidelines for Standard Order Sets
March 16, 2010
A Patient Safety Scavenger Hunt
March 9, 2010
Communication of Urgent or Unexpected Radiology Findings
March 2, 2010
Alarm Sensitivity: Early Detection vs. Alarm Fatigue
February 23, 2010
Alarm Issues in the News Again
February 16, 2010
Spin/HypeKnowing It When You See It
February 9, 2010
More on Preventing Inpatient Suicides
February 2, 2010
January 26, 2010
Preventing Postoperative Delirium
January 19, 2010
January 12, 2010
Patient Photos in Patient Safety
January 5, 2010
December 29, 2009
Recognizing Deteriorating Patients
December 22, 2009
December 15, 2009
December 8, 2009
December 1, 2009
Patient Safety Doesnt End at Discharge
November 24, 2009
Another Rough Month for Healthcare IT
November 17, 2009
November 10, 2009
Conserving ResourcesBut Maintaining Patient Safety
November 3, 2009
Medication Safety: Frontline to the Rescue Again!
October 27, 2009
Co-Managing Patients: The Good, The Bad, and The Ugly
October 20, 2009
Radiology AgainBut This Time Its Really Radiology!
October 13, 2009
October 6, 2009
Oxygen Safety: More Lessons from the UK
September 29, 2009
Perioperative Peripheral Nerve Injuries
September 22, 2009
Psychotropic Drugs and Falls in the SNF
September 15, 2009
ETTOs: Efficiency-Thoroughness Trade-Offs
September 8, 2009
Barriers to Medication Reconciliation
September 1, 2009
The Real Root Causes of Medical Helicopter Crashes
August 25, 2009
Interruptions, Distractions, InattentionOops!
August 18, 2009
Obstructive Sleep Apnea in the Perioperative Period
August 11, 2009
August 4, 2009
July 28, 2009
Wandering, Elopements, and Missing Patients
July 21, 2009
Medication Errors in Long Term-Care
July 14, 2009
Is Your Do Not Use Abbreviations List Adequate?
July 7, 2009
Nudge: Small Changes, Big Impacts
June 30, 2009
iSoBAR: Australian Clinical Handoffs/Handovers
June 23, 2009
June 16, 2009
Disclosing Errors That Affect Multiple Patients
June 9, 2009
CDC Update to the Guideline for Prevention of CAUTI
June 2, 2009
Why Hospitals Should FlyJohn Nance Nails It!
May 26, 2009
Learning from Tragedies. Part II
May 19, 2009
May 12, 2009
May 5, 2009
Adverse Drug Events in the ICU
April 28, 2009
Ticket Home and Other Tools to Facilitate Discharge
April 21, 2009
April 14, 2009
More on Rehospitalization After Discharge
April 7, 2009
March 31, 2009
Screening Patients for Risk of Delirium
March 24, 2009
March 17, 2009
March 10, 2009
Prolonged Surgical Duration and Time Awareness
March 3, 2009
Overriding AlertsLike Surfin the Web
February 24, 2009
Discharge Planning: Finally Something That Works!
February 17, 2009
Reducing Risk of Overdose with Midazolam Injection
February 10, 2009
Sedation in the ICU: The Dexmedetomidine Study
February 3, 2009
NTSB Medical Helicopter Crash Reports: Missing the Big Picture
January 27, 2009
Oxygen Therapy: Everything You Wanted to Know and More!
January 20, 2009
The WHO Surgical Safety Checklist Delivers the Outcomes
January 13, 2009
January 6, 2009
December 30, 2008
Unintended Consequences: Is Medication Reconciliation Next?
December 23, 2008
December 16, 2008
Joint Commission Sentinel Event Alert on Hazards of Healthcare IT
December 9, 2008
December 2, 2008
Playing without the ballthe art of communication in healthcare
November 25, 2008
November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
November 11, 2008
November 4, 2008
October 28, 2008
More on Computerized Trigger Tools
October 21, 2008
October 14, 2008
October 7, 2008
Lessons from Falls....from Rehab Medicine
September 30, 2008
September 23, 2008
Checklists and Wrong Site Surgery
September 16, 2008
More on Radiology as a High Risk Area
September 9, 2008
Less is More.and Do You Really Need that Decimal?
September 2, 2008
August 26, 2008
August 19, 2008
August 12, 2008
Jerome Groopmans How Doctors Think
August 5, 2008
July 29, 2008
Heparin-Induced Thrombocytopenia
July 22, 2008
Lots New in the Anticoagulation Literature
July 15, 2008
July 8, 2008
July 1, 2008
WHOs New Surgical Safety Checklist
June 24, 2008
Urinary Catheter-Related UTIs: Bladder Bundles
June 17, 2008
Technology Workarounds Defeat Safety Intent
June 10, 2008
Monitoring the Postoperative COPD Patient
June 3, 2008
UK Advisory on Chest Tube Insertion
May27, 2008
If You Do RCAs or Design Healthcare ProcessesRead Gary Kleins Work
May20, 2008
CPOE Unintended Consequences Are Wrong Patient Errors More Common?
May13, 2008
Medication Reconciliation: Topical and Compounded Medications
May 6, 2008
Preoperative Screening for Obstructive Sleep Apnea
April 29, 2008
ASA Practice Advisory on Operating Room Fires
April 22, 2008
CMS Expanding List of No-Pay Hospital-Acquired Conditions
April 15, 2008
April 8, 2008
April 1, 2008
Pennsylvania PSAs FMEA on Telemetry Alarm Interventions
March 25, 2008
March 18, 2008
Is Desmopressin on Your List of Hi-Alert Medications?
March 11, 2008
March 4, 2008
Housestaff Awareness of Risks for Hazards of Hospitalization
February 26, 2008
Nightmares.The Hospital at Night
February 19, 2008
February 12, 2008
February 5, 2008
Reducing Errors in Obstetrical Care
January 29, 2008
Thoughts on the Recent Neonatal Nursery Fire
January 22, 2008
More on the Cost of Complications
January 15, 2008
Managing Dangerous Medications in the Elderly
January 8, 2008
Urinary Catheter-Associated Infections
January 1, 2008
December 25, 2007
December 18, 2007
December 11, 2007
CommunicationCommunicationCommunication
December 4, 2007
November 27,2007
November 20, 2007
New Evidence Questions Perioperative Beta Blocker Use
November 13, 2007
AHRQ's Free Patient Safety Tools DVD
November 6, 2007
October 30, 2007
Using IHIs Global Trigger Tool
October 23, 2007
Medication Reconciliation Tools
October 16, 2007
Radiology as a Site at High-Risk for Medication Errors
October 9, 2007
October 2, 2007
Taking Off From the Wrong Runway
September 25, 2007
Lessons from the National Football League
September 18, 2007
Wristbands: The Color-Coded Conundrum
September 11, 2007
Root Cause Analysis of Chemotherapy Overdose
September 4, 2007
August 28, 2007
Lessons Learned from Transportation Accidents
August 21, 2007
Costly Complications About To Become Costlier
August 14, 2007
More Medication-Related Issues in Ambulatory Surgery
August 7, 2007
Role of Maintenance in Incidents
July 31, 2007
Dangers of Neuromuscular Blocking Agents
July 24, 2007
Serious Incident Response Checklist
July 17, 2007
Falls in Patients on Coumadin or Other Anticoagulants
July 10, 2007
Catheter Connection Errors/Wrong Route Errors
July 3, 2007
June 26, 2007
Pneumonia in the Stroke Patient
June 19, 2007
Unintended Consequences of Technological Solutions
June 12, 2007
Medication-Related Issues in Ambulatory Surgery
June 5, 2007
Patient Safety in Ambulatory Surgery
May 29, 2007
Read Anything & Everything Written by Malcolm Gladwell!
May 22, 2007
May 15, 2007
Communication, Hearback and Other Lessons from Aviation
May 8, 2007
Doctor, when do I get this red rubber hose removed?
May 1, 2007
April 23, 2007
April 16, 2007
April 9, 2007
Make Your Surgical Timeouts More Useful
April 2, 2007
March 26, 2007
Alarms Should Point to the Problem
March 19, 2007
Put that machine back the way you found it!
March 12, 2007
March 5, 2007
February 26, 2007
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