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July 12, 2022
Radiologists Racked by Interruptions
Just as interruptions and distractions can be problematic for any clinician, they can also impact radiologists (see our Patient Safety Tip of the Week for July 1, 2014 “Interruptions and Radiologists” and our What's New in the Patient Safety World columns for November 2014 “More Radiologist Interruptions” and May 2018 “Cost of Interrupting a Radiologist”). If a radiologist gets interrupted while interpreting an imaging study, he/she may forget a point they were intending to make in a report. Or they may have to go back to square one and begin review of the imaging study as a brand new one. If interrupted while dictating a report, they may have to go back to the beginning to be sure they have included all the necessary information.
Unfortunately, “radiology rounds” have largely become a thing of the past. In the “old days” our team of attendings, residents and students would finish rounding on patients and then head down to the radiology suite. There we would meet with a radiologist and review the images of our patients that were all hanging on the radiology “boards?”. So, it was a time the radiologist set aside from interpreting images and dictating reports. Today, with images on PACS systems, clinicians are likely to view images on their patients remotely. When they have questions, they contact the radiologist by phone (or other method). This results in the radiologist having more frequent interruptions and incursions on their workflow.
In our July 1, 2014 Patient Safety Tip of the Week “Interruptions and Radiologists” we took a look at the impact of interruptions and distractions on the workflow of radiologists. A study (Yu 2014) found that during a typical 8PM to 8AM overnight shift there was an average of 72 telephone calls, with a median call duration 57 seconds, and the average time spent on the phone was 108 minutes. The median interval from the start of one telephone call to the start of the next ranged from 3 to 10 minutes, depending on the time of day. There was also a correlation between volume of phone calls and the volume of CT scans being done (volume of other imaging studies was not measured as part of this study). That study did not include any measure of image interpretation accuracy or disparities between interpretations by the on-call radiologist and any subsequent interpretations.
In our What's New in the Patient Safety World column for November 2014 “More Radiologist Interruptions” we noted another study found a relationship between telephone calls to radiology residents on-call and discrepancies on reports (Balint 2014). There was a statistically significant increase in the average number of phone calls in the 1 hour preceding the generation of a discrepant preliminary report. The authors suggest that one additional phone call during the hour preceding the generation of a discrepant preliminary report resulted in a 12% increased likelihood of a resident error.
Recently, Shah and colleagues (Shah 2022) studied the workflow and impact of interruptions on pediatric radiologists at a large academic free-standing pediatric tertiary care facility with level 1 trauma. They found that total interruption time nearly equaled the total time interpreting studies for radiologists!
A business process improvement team was consulted to observe the activity of academic pediatric radiologists in the general, neuroradiology, and body reading rooms during daytime, evening, weekday, and weekend shifts. Activities were broken down into interpretation time (time spent reviewing and dictating studies), active interruptions (disruptions in interpretation initiated by the radiologist), and passive interruptions (disruptions in reading studies not initiated by the radiologist).
Three reading rooms were studied. The main reading room was responsible for interpreting the bulk of the radiographs and all inpatient ultrasound exams. It is situated close to the emergency department and is considered the “central hub” of the department. The neuroradiology reading room was responsible for all head, neck, and spine cross sectional imaging including CT and MRI scans. The body reading room was responsible for all cross-sectional non-neuro exams including musculoskeletal, cardiac, abdomen, and pelvic exams. Each reading area typically has 2 radiologists and up to 3 trainees, which may include medical students, residents, and fellows. Each reading area has its own workflow and resources. The main reading room had a dedicated reading room assistant who answers and triages incoming phone calls before notifying the radiologist.
Overall, radiologists spent 53% of their time interpreting studies, 18% on passive interruptions, and 29% on active interruptions, though the numbers varied by reading room type. Interruptions also varied by time of day with peaks during mid-morning and midafternoon times, corresponding with increased hospital-wide consultation of radiology. A majority of the interruptions were related to patient care.
Approximately 50% of non-interpretive time involved in-person conversations or consults (51% with colleagues, 17% with trainees, 16% with clinicians, and 14% with technologists). Other examples of non-interpretive activities included: calling a clinician, talking to a technologist, teaching a trainee, speaking with a colleague, signing paper orders, protocoling studies, responding to emails, administrative work, and technology issues. Phone calls represented 16% of non-interpretive time, of which 67% were incoming calls. Administrative work, including e-mail, comprised 13% of all non-interpretive time.
The longest time period recorded without an interruption was 20 minutes. Perhaps most importantly, 85% of the time an interruption came within 3 minutes of beginning an interpretation. 90% of interruptions lasted less than 3 minutes or less and 70% lasted 1 minute or less.
Interruptions clearly decreased efficiency and increased report interpretation times for all modalities studied. Interruptions not only cost the radiologist whatever time it took to address the interruption, but also cost additional total time to finalize the report dictation. Duplication of work occurred, as radiologists often needed to start again from the beginning when interpreting imaging studies.
There, of course, are “bad” interruptions and “good” interruptions. An interruption during which a radiologist conveys important information to a clinician is a “good” interruption. But, are there better ways to convey that information without interrupting the workflow of the radiologist? Shah and colleagues have some useful recommendations. They redesigned the central radiology reading room, combining the neuroradiology and body radiology reading rooms with sound barriers and strategic placement of a reading room assistant at the entrance to triage phone calls and direct visitors to the appropriate location. The reading room assistant hours were expanded to 24/7 and training was improved to assure consistency. Standardized phone call intake forms helped radiologists filter out non-urgent requests that could wait until an interpretative task was completed.
Asynchronous communication can help reduce radiologist interruptions and improve their workflow. Rather than having to respond to every individual phone call, some questions may be posed by text message or email and the corresponding responses made in between times when the radiologist is interpreting an imaging study or dictating a report. Fewer interruptions also mean the radiology reports can be posted on the PACS system or in the electronic medical record more promptly, further reducing the need for some interruptions. (Keep in mind the dangers of texting noted in our several columns listed below. However, most of those cautions apply to the issue of texting orders.)
Shah and colleagues implemented text-based communication through the EMR and phone-based application for more efficient communication with other departments and clinicians. A new PACS with worklist orchestrator and department-wide text-based communication is planned for the future.
They also addressed interruptions from radiology technologists. Imaging protocols were improved and standardized to minimize phone calls from technologists while assuring high quality image acquisition. Technologist training was also increased to allow for more independence and fewer instances of interrupting the radiologist.
And they modified trainee rotation schedules to assure that no more than one trainee would be with a radiologist at a time.
We suspect that an audit of interruptions for radiologists in most hospitals would reveal similar findings. The study by Shah and colleagues should give you some ideas to jump start a program of minimizing those interruptions and improving workflow and productivity of your radiologists.
Prior Patient Safety Tips of the Week dealing with interruptions and distractions:
See our other Patient Safety Tip of the Week columns dealing with texting:
Some of our prior columns on patient safety issues in the radiology suite:
References:
Yu J-P, Kansagra AP, Morgan J. The Radiologist's Workflow Environment: Evaluation of Disruptors and Potential Implications. JACR 2014; published online April 26, 2014
http://www.jacr.org/article/S1546-1440%2813%2900850-8/pdf
Balint BJ, Steenburg SD, Lin H, et al. Do Telephone Call Interruptions Have an Impact on Radiology Resident Diagnostic Accuracy? Academic Radiology 2014; published online September 30, 2014
http://www.academicradiology.org/article/S1076-6332%2814%2900307-9/abstract
Shah SH, Atweh LA, Thompson CA, et al. Workflow interruptions and effect on study interpretation efficiency. Current Problems in Diagnostic Radiology 2022; Published online 27 June 2022
https://www.sciencedirect.com/science/article/abs/pii/S0363018822000871?via%3Dihub
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July 19, 2022
Sucked Out of the Plane at 17,000 Feet
Our regular readers know we like to use aviation analogies to make points about safety in healthcare (see list of prior columns below). We are giving a course on “Why Accidents Happen” and one of our examples is well worth telling here. The following comes from the book “Inviting Disaster” by James R. Chiles and 2 videos “Blow Out”, a short version and a long version.
On June 10, 1990 British Airways Flight 111 left Birmingham, England on a flight to Malaga, Spain with 87 passengers and crew aboard. As the aircraft climbed out, the captain and copilot unbuckled their chest straps but left their lap belts loosely fastened. Then, at 17,000 feet, the windscreen pulled loose and flew up and over the nose, snapped off a radio antenna and fell free. A force of 5500 pounds pulled the captain out of his seatbelt and launched him headfirst into the window frame. His legs and feet were lodged in the console but he was now mostly outside the plane in zero degree temperature and windspeed 396 miles per hour. Hypothermia was very likely to kill him even if he did not fall out completely.
The cockpit and cabin filled with fog (the decompression takes water vapor out of the air) and wind whistled through the cockpit at 350+ mph. The copilot could not hear anything else and could not communicate with air traffic control. The captain’s legs and feet, still lodged in the console, were actually causing the plane to increase speed. A downed cabin door also contributed to lack of access to controls. The copilot knew he must descend to lower altitude, so passengers and crew do not suffer from lack of oxygen. He must descend blindly over Heathrow airspace, one of the busiest in the world, thus risking a mid-air crash.
A flight steward enters the cockpit and grabs hold of the captain’s legs. Another steward enters and moves the fallen cabin door, freeing up the controls. The copilot descends to a safe level and makes contact with air traffic control (ATC). He asks for emergency landing at Gatwick Airport, which he is familiar with. ATC suggests Southampton airport instead. The copilot is concerned because he thinks he needs at least a 2200 meter runway (because of full fuel load that cannot be dumped) and Southampton has only 1800 meter runway. ATC still says to go to Southampton anyway and it deploys emergency vehicles there.
Flight stewards took turns holding the captain’s legs, while the copilot reduced speed and altitude. Crew was certain the captain was already dead and, at one point, had to decide whether to let the captain go. The decision to keep holding on to him was based as much on risk factors to the plane (fear his body would damage wings or jet engine) as well as the remote chance they could save him.
The copilot managed a safe emergency landing on the short runway at Southampton 18 minutes later. There the captain was whisked off in an ambulance. In the ambulance his eyes began to open. He’s still miraculously alive!!! He suffered frostbite, cuts and bruises, and several broken bones but survived. Five months later he returned to pilot again.
That was the drama. You can watch both a short version and a long version of these events online.
But the lessons came after the successful landing.
The investigation began immediately. There was no evidence of structural damage to the fuselage and no glass shards or fragments were found, so a bird strike or collision with other object was excluded. The investigator reviewed logs and saw that recent maintenance had been done. So the investigation moved back to Birmingham, England.
At 3:00 AM that morning the plane had rolled into the maintenance facility at Birmingham, England for a windscreen replacement that needed to be finished by 6:30 AM so the aircraft could get a wash before starting the day’s flight to Malaga, Spain. Windscreens must be strong enough to resist tons of force from cabin pressure when the airplane is at high altitudes. A hard-working maintenance manager decided to take on the awkward job of replacing the sixty-pound slab of layered glass and plastic himself. He began the job at 3:00 AM. He had replaced aircraft windscreens six times before, but he still read through that part of the maintenance manual quickly. Then he gathered his tools, positioned a scaffold, and climbed up to unscrew ninety bolts from the rim of the windscreen. He had a new windscreen ready and he had the pile of original bolts, eighty-four of which he knew to be of size 7D and six of them a little longer. But some of the bolt heads had globs of dried paint on them and others had been scarred from the removal process. He refused to take the easy course of using as many of the old bolts as possible, replacing only the damaged ones. He wanted to replace them all.
He went to the storeroom with a sample of the bolts he needed. The 7D bolt bin had only a few on hand, far less than he needed. The man in charge of the storeroom told him he should be using 8D bolts for a windscreen replacement, anyway. He disregarded that comment, figuring that since 7D bolts had worked before, they would work again. (The proper bolt actually was the 8D.)
There was a standby parts depot located two miles away, so he drove there. Most of the bins weren’t marked, none were supervised, and the lighting in this part of the building was bad. He kept digging until he found a bin of bolts that, when he held one up in the gloom alongside his old 7D, looked to be the same. In fact, the ones he found were neither 7D’s nor the proper 8D’s. The eighty-four unmarked bolts he loaded up and took back with him to the hangar were size 8C. They were one-fortieth of an inch narrower in diameter than the 7D’s he wanted. When he was finished, of all ninety bolts, only six long bolts of the correct size actually held the windscreen fast.
So, what were the contributing factors in this case that we also often see in healthcare incidents? The lead investigator in this incident said that there were “something like 13” contributing factors to this accident and that correction or avoidance of any one of them would have prevented the accident. Sound familiar? In healthcare incidents we typically see such a cascade of events and contributing factors, avoidance of any one of which would have prevented the adverse outcome.
Fatigue may well have played a role. The maintenance work took place in the middle of the night, beginning at 3:00 AM and not finishing until near the end of the maintenance manager’s shift. Time pressures clearly played a role. This work had to be done so the flight could get washed at 6:30 AM prior to its early departure time. So, all the work had to be compressed into the period between 3:00 AM and 6:00 AM. In the airline industry (and most industries), “time is money”.
Work overload likely contributed as well. There were so many ongoing maintenance jobs that the manager had to do this job on his own. In addition, there were likely distractions, since the manager was in charge of all work being done and was concerned how all the other jobs were going, even while doing his own project.
Workarounds were a major contributor. People often take pride in their workarounds and may be considered “resourceful” Some workarounds are indeed “resourceful” and useful, but most are not and can be dangerous. In this case, the workaround was that the manager did not look at the parts catalog. He told the investigators, apparently with a sense of pride, that finding the correct bolts is “easier to do visually”. In fact, bypassing the parts catalog apparently had become the norm in this maintenance facility. We refer to that as “normalization of deviance”.
Assumptions played a big role. The manager matched up bolts to the ones he had removed. The old ones had been in place for 4 years, apparently without incident. He assumed that, if the old ones worked, the new ones will work.
And 2 of the common cognitive biases we so often see in healthcare incidents came into play here: confirmation bias and ignoring disconfirming evidence. The bolts looked like they were the same size as the ones he had removed. “I got 7D bolts out, I put 7D bolts back in”. There were at least 2 bits of disconfirming evidence. He ignored stockroom worker’s warning that those were not the correct bolts and he also ignored the fact that the bolts went in without the usual resistance you’d expect when putting them in.
Overconfidence (or hubris) also played a role. When asked why he ignored the storeroom clerk’s statement that those were the wrong bolts, the manager said “Well, I’m an engineer…”.
There were also environmental factors. The hangar was full and the plane was pushed up against a wall, making it difficult for the manager to work on the windscreen. The lighting in the auxiliary parts storeroom was poor, making identification of the bolts difficult.
And there was also a critical design flaw. The bolts on this aircraft windscreen went in from the outside. On newer models, the bolts go on the inside. If the bolts loosened at high altitude, the higher cabin pressure inside the plane would push the windscreen against the fuselage rather than having the windscreen blow out as it would on the old design.
And there was probably a latent factor: the old bolts were actually the wrong size!!! It’s incredible this accident had not occurred earlier. Perhaps those 6 long bolts had been originally located just strategically enough to prevent a blowout?
When we look at an incident, there is typically a “sharp” end. The root causes and other contributing factors at the “blunt” end add up and leave a human with “the smoking gun”. The lead investigator in this incident said “This investigation uncovered pressures in the hangar that caused an otherwise proficient engineer to make potentially lethal mistakes while being certain he was doing the right thing”.
Lastly, this incident was technically a “near miss” since the ultimate outcome for the pilot and the 87 passengers and crew was not physically detrimental. As in many healthcare incidents that are “near misses”, a little bit of luck is important. On the bad luck side, the pilot happened to be sitting on the side of the defective windscreen and had loosened his shoulder harness. On the good luck side, all were lucky the plane did not hit any other planes as they descended blindly through crowded airspace and that the runway was just long enough for a fully fueled plane to be able to stop. And the hypothermia the captain undoubtedly experienced as he lay outside the aircraft may well have protected his brain from the lack of oxygen he also undoubtedly experienced.
We know this is not a healthcare incident. But we hope you can all see the common root causes, latent factors, cognitive biases, and other contributing factors seen in this case are often present in our serious healthcare incidents. If you have time, the long version is quite dramatic and worth watching. It’s just over 51 minutes but you’ll be impressed by it.
This case is also a reminder that accidents often follow maintenance activities. Many high profile industrial disasters (Three Mile Island, Chernobyl, Bhopal, Piper Alpha) and many airline disasters occurred during maintenance procedures. Our August 7, 2007 Patient Safety Tip of the Week “Role of Maintenance in Incidents” discussed the book “Managing Maintenance Error” by James Reason and Alan Hobbs. Maintenance may be a factor in some healthcare incidents as well. Our March 5, 2007 Patient Safety Tip of the Week “Disabled Alarms” described a near-miss in which tape placed over an oxygen blender alarm on a ventilator during maintenance resulted in lack of a warning when the ventilator became disconnected from it oxygen source while in use on a patient.
See some of our previous columns that use aviation analogies for healthcare:
May 15, 2007 “Communication, Hearback and Other Lessons from Aviation”
August 7, 2007 “Role of Maintenance in Incidents”
August 28, 2007 “Lessons Learned from Transportation Accidents”
October 2, 2007 “Taking Off From the Wrong Runway”
May 19, 2009 “Learning from Tragedies”
May 26, 2009 “Learning from Tragedies. Part II”
January 2010 “Crew Resource Management Training Produces Sustained Results”
May 18, 2010 “Real Time Random Safety Audits”
April 5, 2011 “More Aviation Principles”
April 26, 2011 “Sleeping Air Traffic Controllers: What About Healthcare?”
May 8, 2012 “Importance of Non-Technical Skills in Healthcare”
March 5, 2013 “Underutilized Safety Tools: The Observational Audit”
April 16, 2013 “Distracted While Texting”
May 2013 “BBC Horizon 2013: How to Avoid Mistakes in Surgery”
August 20, 2013 “Lessons from Canadian Analysis of Medical Air Transport Cases”
December 17, 2013 “The Second Victim”
January 7, 2014 “Lessons from the Asiana Flight 214 Crash”
January 5, 2016 “Lessons from AirAsia Flight QZ8501 Crash”
October 23, 2018 “Lessons From Yet Another Aviation Incident”
References:
Chiles JR.. Inviting Disaster. HarperCollins. Kindle Edition. 2008
Blowout (short version). British Airways Flight 5390; October 22, 2016
https://www.youtube.com/watch?v=pOcm6E10anI
Blow Out (full episode). The Captain That Got Stuck Outside Of The Plane! Mayday: Air Disaster; September 10, 2021
https://www.youtube.com/watch?v=7xfaDr0nhoQ
Reason J, Hobbs A. Managing Maintenance Error. Aldershot, England: Ashgate Publishing Limited, 2003
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July 26, 2022
More Risks in the Radiology Suite
You’ve seen our multiple columns describing the radiology suite as being high-risk for patient safety events. In our October 22, 2013 Patient Safety Tip of the Week “How Safe Is Your Radiology Suite” and the other columns listed below we’ve discussed the multitude of safety issues seen in radiology suites that have little to do with radiology per se. That’s because sick patients with multiple medical problems and vulnerabilities are being taken to the radiology suite and staying there, sometimes for prolonged periods. The events include things like falls, medication errors, patient mixups, IV connection errors, running out of oxygen, conscious sedation incidents, suicides, and others.
But sometimes factors related to the imaging procedure may also contribute to patient safety events. Sanchez et al. (Sanchez 2022) recently discussed cases of 2 patients given IV sedation to facilitate MRI scans. In one, a 43-year-old woman with acute neurological symptoms and signs was given lorazepam 2 mg intravenously (IV) as premedication to reduce agitation after a first attempt at doing the MRI was unsuccessful. The MRI was again unsuccessful, despite anxiolysis. After returning to the medical unit, flumazenil 0.2 mg was given due to somnolence, with subsequent improvement in mental status.
In the second case, a 71-year-old man with a possible epidural abscess following a bout of sepsis was sent for an MRI scan. He was unable to tolerate the scan due to back pain, so hydromorphone 0.5 mg IV was administered. Because of continued restlessness, additional doses of lorazepam 1 mg IV and hydromorphone 0.4 mg IV were ordered. After the patient received a 3rd dose of lorazepam 1mg IV, he became obtunded, hypotensive, and developed respiratory depression with oxygen saturation around 60%. The rapid response team was called, and naloxone and flumazenil were administered. The patient was placed on bilevel positive airway pressure (BiPAP) and given a fluid bolus before being transported to the intensive care unit (ICU), where he was emergently intubated. The patient remained intubated for several days due to severe acute respiratory distress syndrome (ARDS), which was attributed to aspiration while in the MRI machine.
Sanchez et al. provide a nice discussion of the risks of minimal-to-moderate sedation for imaging procedures, especially in high-risk patients, when multiple medication doses are required, and when monitoring is limited or inadequate (e.g., inside an MRI machine). They highlight the need for risk assessment prior to administering such drugs and consideration of patient-specific risk factors for respiratory depression. They stress such risk factors for oversedation as obesity, hepatic, renal, and lung disease; substance use disorder, and obstructive sleep apnea. They recommend looking for higher American Society of Anesthesia (ASA) physical status classification and checking a STOP-BANG score to help identify patients who might have unrecognized obstructive sleep apnea. In addition, they note that lower BMI values are associated with higher plasma concentrations of fentanyl or midazolam, two commonly used medications for diagnostic imaging sedation. They also suggest assessing the patient for potential aspiration risk and considering NPO (nothing by mouth) orders prior to diagnostic imaging procedures with sedation.
They caution against “dose-stacking” of medications (administering medications multiple times and/or from various routes before each dose reaches its peak therapeutic effect).
Monitoring is very important. Because of variability and risk for oversedation, patients must be assessed before and after each dose or medication administration. They note that consistent sedation assessments are important throughout the duration of action of the medication(s) administered. They emphasize “Continuous electronic monitoring is indicated for moderate levels of sedation or higher and should be considered for high-risk patients receiving opioids and/or benzodiazepines.”
They also stress an important point that is often overlooked – sedation might be avoided all together in many patients. They discuss non-pharmacologic techniques that can be used to minimize anxiety, agitation, and claustrophobia prior to such imaging studies. These include positioning issues, use of movie goggles, mirrors, 2-way communications, call buttons, and even fragrance administration.
Nice, practical discussion of a problem we continue to see all too often in patients undergoing imaging studies.
Some of our prior columns on patient safety issues in the radiology suite:
Some of our prior columns on patient safety issues related to MRI:
References:
Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. AHRQ PSNet Web M&M July 8, 2022
https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging
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August 16, 2022
Perioperative Brain Health
For years, we’ve proposed that the 3 most important elements of a preoperative evaluation are assessment for (1) delirium risk, (2) frailty, and (3) obstructive sleep apnea. And we’ve done numerous columns, listed below, on the prevention and management of delirium and perioperative cognitive issues. So, we were quite delighted when the American Society of Anesthesiologists launched its Perioperative Brain Health Initiative in 2015.
This month, Vacas et al. published an excellent review on perioperative brain health in the older adult in Anesthesia & Analgesia (Vacas 2022). They categorize perioperative neurocognitive disorders (PND’s) according to the ASA Nomenclature Consensus Working Group:
They note that POD is the most common surgical complication in older adults and is defined as an acute fluctuating state of confusion, inattention, and level of consciousness that occurs within the first 7 days after surgery. Incidence of POD depends on the study methodology, patient population, and surgical procedure, but generally ranges from 5% to 65%. And new or worsening long-term cognitive dysfunction occurs in >10% of noncardiac surgical patients >60 years of age and has been reported in up to 50% of patients, depending on existing comorbidities or type of surgery. And, of course, PND’s are associated with prolonged hospital stays, other complications (like falls), functional decline, increased risk of institutionalization, death, and dementia, and increased health care costs.
They begin with the preoperative risk assessment, which includes consideration of both predisposing factors and precipitating factors. While you can’t modify risk factors such as age, there are some risk factors that can be modified or potentially optimized. These include frailty, polypharmacy, sleep, pain, vision and/or hearing impairment, diabetes, infection, neuropsychiatric conditions, and poor nutrition.
They have a nice discussion of the various neurocognitive screening tools, including estimated administration times. They note that the Mini-Cog, the Mini-Mental State Examination (MMSE), or the Montreal Cognitive Assessment (MoCA) are fast and applicable to the preoperative setting. But even the simple clock drawing exercise, which takes less than 2 minutes, can be a useful screening tool. They also recommend screening for frailty, using tools such as the Frailty Index, Clinical Frailty Scale, Risk Analysis Index, or ASA Frailty Toolkit.
Preoperative interventions include education on lifestyle modifications and possibly neurocognitive rehabilitation. The Neurobics randomized clinical trial showed that an electronic, tablet-based preoperative cognitive exercise targeting memory, speed, attention, flexibility, and problem-solving functions reduced the incidence of postoperative delirium from 23.0% to 14.4% (Humeidan 2021). They also noted that incorporation of elements from the Hospital Elder Life Program (HELP), which we have discussed so often, may be part of a preoperative program.
Perhaps the most important preop intervention is a focus on medications, including those medications known to be risk factors for delirium (such as benzodiazepines) and other potentially inappropriate medications (PIM’s) from Beers Criteria List. They also recommend identifying sleep disturbances, such as obstructive sleep apnea (note: they’ve hit our 3 most important points: delirium risk, frailty, and OSA!).
Lastly, they recommend involvement of a physician with expertise in geriatric medicine throughout the perioperative period.
The risk of perioperative neurocognitive disorders should be discussed with older patients and their families as part of the informed consent process.
During the intraoperative period, it does not appear that the type of anesthesia is a significant contributor to PND. And studies of EEG-guided hypnotic administration have yielded conflicting results on the occurrence of post-op delirium or PND. It makes sense to avoid hypotension during surgery, though evidence of the impact of intraoperative hypotension on delirium is soft. Though some studies have found no association, a recent retrospective study found an association between intraoperative hypotension, particularly duration of hypotension, and delirium occurrence (Vlessides 2022).
We’ve already discussed in many columns the post-operative interventions we do to reduce the likelihood of delirium or manage delirium that has already occurred.
We should avoid medications that commonly induce delirium, especially anticholinergic drugs, sedative/hypnotics, diphenhydramine, and benzodiazepines. Some pain medications may contribute to delirium, but so does inadequate pain control. Most recommend use of non-opioid analgesics where possible.
Multimodal interventions, such as those included in the Hospital Elder Life Program (HELP), are important. These include return of the patient’s visual and hearing aids, early mobilization, and resumption of a normal diet, and attempts to create a more normal sleep/waking cycle. See our March 16, 2021 Patient Safety Tip of the Week “Sleep Program Successfully Reduces Delirium” for several sleep-promoting programs that have been used in prevention and management of delirium.
Vacas et al. also acknowledge the importance of early family engagement and social support. We always recommend families bring in familiar objects from home (like their clock radio).
Though the anesthesiologist may no longer be involved directly in the patient’s care, Vacas et al. remind us that we must be vigilant for the occurrence of delirium or any form of PND. That would include frequent use of screening tools like the Confusion Assessment Method (CAM), Confusion Assessment Method for the ICU (CAM-ICU), and others.
The Vacas article goes on to discuss future directions for research on perioperative neurocognitive disorders. This article is a nice summary of the current state of affairs for perioperative neurocognitive disorders. We hope that you’ll also go back to some of our many columns on prevention and management of delirium listed below.
Note that there are some newer ancillary studies touted to be predictors of delirium, such as EEG (Kronemyer 2022), ocular-based screenings (Anesthesiology News 2020), and measurement of preoperative plasma concentrations of Tau-PT217 and Tau-PT181 (Liang 2022), but these are not yet ready for widespread adoption.
Some of our prior columns on delirium assessment and management:
References:
ASA (American Society of Anesthesiologists). Perioperative Brain Health Initiative
https://www.asahq.org/brainhealthinitiative
Vacas S. Canales C, Deiner SG, et al. Perioperative Brain Health in the Older Adult: A Patient Safety Imperative, Anesthesia & Analgesia 2022; 135(2): 316-328
Humeidan ML, Reyes JC, Mavarez-Martinez A, et al. Effect of cognitive prehabilitation on the incidence of postoperative delirium among older adults undergoing major noncardiac surgery: the Neurobics randomized clinical trial. JAMA Surg 2021;156:148–156
https://jamanetwork.com/journals/jamasurgery/fullarticle/2772853
Vlessides M. Post-op Delirium Linked to Intra-op Arterial Hypotension. Anesthesiology News 2022; February 8, 2022
Kronemyer B. Post-op Delirium Detected With Peri-op EEG Monitoring Of Older Patients. Anesthesiology News 2022; April 13, 2022
Liang F, Baldyga K, Quan Q, et al. Preoperative Plasma Tau-PT217 and Tau-PT181 Are Associated With Postoperative Delirium, Annals of Surgery 2022; July 6, 2022
Anesthesiology News. ‘60-Second Abstracts’: A Novel Pre-op Method for Identifying Post-op Cognitive Delirium. Anesthesiology News 2020; December 22, 2020
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August 23, 2022
Yes, There is a Proper Way to Assess Orthostatic Hypotension
Year after year we have seen cases of falls or syncope in which the potential role of orthostatic hypotension has been inadequately assessed. Even when orthostatic hypotension is considered as a potential contributory factor, we often see that it is excluded because the correct assessment was never performed. The proper technique for checking orthostatic signs is as follows:
First, have the patient lie supine for at least 5 minutes prior to beginning measurements. One should then measure both the blood pressure and pulse of the patient in the supine position. Then, after telling the patient what you will be doing and asking him to tell you about symptoms such as dizziness or graying out of vision that might occur when upright, one stands the patient upright (being sure you can safely lie him down if they do become symptomatic!). The pulse should be measured first on standing since what the heart rate does in response to orthostatic hypotension may provide clues to the etiology of the orthostatic hypotension. The blood pressure is then recorded. If there is a drop in blood pressure, one should keep the patient upright (unless symptomatic) and record the blood pressure and pulse again at 1-2 minutes intervals until it has stabilized.
Why do all this? We ran an autonomic nervous system lab for many years and saw many patients with symptomatic orthostatic hypotension. The reason for having the patient lie supine for a significant period prior to first BP determination is that patients with some neurological disorders, such as Multiple System Atrophy, will have supine hypertension in addition to orthostatic hypotension. The magnitude of their blood pressure drop will be much greater when going from supine to standing rather than sitting to standing. The reason for checking the pulse immediately on standing may provide clues to the etiology of any orthostatic hypotension. If the autonomic nervous system is intact, you should see a prompt increase in heart rate that plateaus and then stabilizes. That pattern might be seen in patients whose orthostatic hypotension is caused by dehydration, hypovolemia, some drugs, and other conditions. On the other hand, the lack of such compensatory tachycardia might be seen in patients with impaired autonomic nervous systems, such as those with diabetic polyneuropathy.
So, why is this a patient safety issue? The best time to determine the primary cause of a fall or factors contributing to a fall is immediately following a fall or syncopal episode. We always recommend assessment for orthostatic hypotension at the time of the event. But you may also proactively identify orthostatic hypotension as a risk factor for falls and take steps to reduce that risk.
A recent study (Juraschek 2022) sheds light on the importance of proper assessment for orthostatic hypotension. The Study to Understand Fall Reduction and Vitamin D in You (STURDY) was a randomized trial of vitamin D3 supplementation and fall in community-based adults aged ≥70 years at high risk of falls. Participants had blood pressure measurements going both from sitting-to-standing and supine-to-standing.
Mean BP increased 3.5 mmHg from sitting to standing but decreased with supine to standing (mean change: −3.7 mmHg). Orthostatic hypotension (defined in this study as a drop in systolic or diastolic BP of at least 20 or 10 mmHg) was detected in 2.1% of seated versus 15.0% of supine assessments (P < 0.001). While supine and seated OH were not associated with falls (HR1.55 vs 0.69), supine systolic OH was associated with higher fall risk (HR 1.77). Supine OH was associated with self-reported fainting, blacking out, seeing spots and room spinning in the prior month, while sitting OH was not associated with any symptoms They authors conclude that supine OH was more frequent, associated with orthostatic symptoms, and potentially more predictive of falls than seated OH.
Measuring the supine to standing BP and P thus is important in the elderly population (or other population you might consider at risk for falls). If you find significant orthostatic hypotension you may need to take steps to reduce the magnitude of the BP drop or at least advise the patient about the risks of rapidly going from supine to standing.
Doing a proper orthostatic assessment immediately in a patient with syncope or unexplained fall is also important because some of the conditions causing it may be transitory. For example, micturition syncope has often been described in young, otherwise healthy, military recruits. After a night of alcohol consumption, they get vasodilation and diuresis (alcohol inhibits their antidiuretic hormone), lay down to sleep, then arise and urinate in the standing position. The drop in blood pressure from standing is exaggerated by a reduction in sympathetic tone from emptying the bladder and the patient faints. By later that day the patient may no longer have orthostatic hypotension and you will have missed an important diagnostic finding if you did not check for orthostatic hypotension shortly after the syncope of fall.
Some of our prior columns stressing orthostatic hypotension and falls:
References:
Juraschek SP, Appel LJ, Mitchell CM, et al. Comparison of supine and seated orthostatic hypotension assessments and their association with falls and orthostatic symptoms. J Am Ger Soc 2022; 70(8): 2310-2319 First Published: 22 April 2022
https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17804
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August 30, 2022
Stunning Lab Vulnerability
We’ve done many columns on misdiagnoses due to laboratory errors. Most have dealt with issues such as incorrect specimen labeling or lost specimens. But in several columns, we noted misdiagnoses due to contamination of tissue specimen slides with tissue from a specimen from another patient. In our January 22, 2013 Patient Safety Tip of the Week “You Don’t Know What You Don’t Know” we discussed the possibility that you might have a biopsy specimen which was either not yours or was yours but also had some tissue from another patient on the slide(s). Such errors are known as occult specimen provenance complications (SPC’s). In that Tip we noted a study providing an estimate of how often such SPC’s occur (Pfeifer 2013). They examined about 13,000 prostate biopsy specimens from a wide variety of urology practices and pathology laboratories using a DNA identification technology. They found the frequency of occult type 1 errors (a complete transposition between patients) was 0.26% and type 2 errors (contamination of the patient’s tissue with 1 or more unrelated patients) was 0.67%. Overall, the mean frequency of SPCs across practice settings was 0.22% for type 1 errors and 1.69% for type 2 errors.
Our March 24, 2015 Patient Safety Tip of the Week “Specimen Issues in Prostate Cancer” noted a study (Wojno 2015) that estimated the potential economic impact of such errors.
The July 2022 issue of the American Journal of Clinical Pathology contained a study that really opened our eyes to the issue of specimen contamination. Carll et al. (Carll 2022) noted that, after some laboratory changes due to hospital construction, some cases were found to be affected by “carryovers” (contaminants that are incorporated into the paraffin block). They note that incorporation into a block makes identification of a contaminant more difficult, as the contaminant will often be present in multiple cut levels and typically lack the artifactual morphologic features that characterize “floaters” (the more common type of contaminant that occurs when thin-cut tissue sections transfer to inappropriate slides).
Fortunately, the pathologists at this hospital were able to identify the contamination and no patients were impacted. But the occurrence led to an investigation to determine the underlying causes.
Carryovers indicate contamination at or before the point of tissue embedding and have usually been attributed to either the grossing bench or the embedding station. But they were able to rule out contamination at the bench or embedding station. They suspected that the contamination may have occurred during tissue transport through a pneumatic tube system that had been required during the recent hospital construction.
So, they did an interesting experiment to assess that possibility. Cassettes of friable donor tissue were mixed with cassettes of spongy recipient tissue in formalin-filled containers and agitated by shipment via pneumatic tube. The tissue cassettes were processed, embedded as blocks, and cut as usual. Liquid samples were prepared from the submission containers as well as from workstation submission containers and histology tissue processor waste.
They found a high rate of contamination (14.9%) under these artificial conditions. Friable donor tissue, including urothelium and colorectal adenocarcinoma, and placental villi were common contaminants, and fluid from submission containers showed viable tumor cells and fragments.
This study implicates liquid transport media as a possible avenue of contamination during submission and transportation of tissue cassettes for histologic processing. Attention should be given to the friability of submitted tissue and physical agitation of the cassettes in transit. Such contaminants may be present in the fluid in tissue submission bins and in tissue processor fluid.
That finding certainly has practical implications. They concluded that agitation of fluid sloshing back and forth between and through cassettes during transport presumably can dislodge small fragments of friable tissue that may subsequently get trapped within tissue submitted in other cassettes. While few labs probably still transport specimens via pneumatic tubes, presumably any method of transport that has significant agitation could produce similar contamination. They note that couriers using carts or motor vehicles to transport specimens may produce some degree of physical agitation that could be similar to that produced by the pneumatic tube transport.
The authors encourage anatomic pathology labs to review their submission and transportation protocols to identify possible sources of tissue contamination and to improve quality and safety outcomes.
In an editorial accompanying the Carll study, Zarbo (Zarbo 2022) discusses the numerous steps in which contamination of pathology specimens might occur and concludes “it is safe to conclude that tissue contamination occurs daily, everywhere surgical pathology is practiced, despite good intention, written procedures, staff education, competency assessments, and regulatory requirements crafted to promote safety.” He says it is imperative that pathologists be ever suspicious and adopt the “trust but verify” approach to microscopic diagnosis. He notes that when the observations don’t seem to be compatible with the clinical context, we can stop and verify a suspected tissue misidentity with molecular DNA fingerprinting of even tiny amounts of tissue in doubt. But he acknowledges that an unsuspected contaminant that appears to make sense in the microscopic context of the case creates a dangerous problem.
In one of our earliest columns on lab errors (see our October 9, 2007 Patient Safety Tip of the Week “Errors in the Laboratory“) we noted a paper (Suba 2007) that suggested we consider the “DNA timeout” akin to the surgical timeout where we ask the question “Is this the correct diagnosis for the correct patient?” before doing an invasive procedure.
Zarbo laments that” the open and communal systems, numerous manual touches, and reused tools requiring voluntary and imprecise manual wiping to clean between patients are not a sound basis to guarantee a process that is free from contamination.” He concludes that it is time for a radical redesign of the processes involved.
Some of our other columns on errors related to laboratory studies:
References:
Pfeifer JD, Liu J. Rate of Occult Specimen Provenance Complications in Routine Clinical Practice. Am J Clin Path 2013; 139: 93-100
https://academic.oup.com/ajcp/article/139/1/93/1766518
Wojno K, Hornberger J, Schellhammer P, et al. The Clinical and Economic Implications of Specimen Provenance Complications in Diagnostic Prostate Biopsies. Journal of Urology 2015; Published online: November 13, 2014
https://www.auajournals.org/article/S0022-5347%2814%2904864-2/abstract
Carll T, Fuja C, Antic T, et al. Tissue Contamination During Transportation of Formalin-Fixed, Paraffin-Embedded Blocks. American Journal of Clinical Pathology 2022; 158(1): 96-104
https://academic.oup.com/ajcp/article-abstract/158/1/96/6534995?redirectedFrom=fulltext&login=false
Zarbo RJ. The Unsafe Archaic Processes of Tissue Pathology: Manifesto for Change. American Journal of Clinical Pathology 2022; 158(1): 4-7
https://academic.oup.com/ajcp/article-abstract/158/1/4/6540054?redirectedFrom=fulltext&login=false
Suba EJ, Pfeifer JD, Raab SS. Patient Identification Error Among Prostate Needle Core Biopsy Specimens—Are We Ready for a DNA Time-Out? J Urol 2007; 178(4): 1245-1248
https://www.auajournals.org/article/S0022-5347%2807%2901423-1/abstract
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September 6, 2022
AORN and Others on Retained Surgical Items
Cynthia Saver authored 3 articles on retained surgical items in a recent issue of AORN Journal. The first (Saver 2022a) was an overview on the challenges that contribute to RSI’s as a persistent problem. She notes that 609 respondents to a recent AORN survey identified the top 4 obstacles to preventing RSI’s at their facilities:
While surgical sponges remain the most frequent source of RSI’s, survey respondents also noted that packing materials and needles are the next most frequent known RSI’s. And, while the OR is still the most frequent location where RSI’s happen, they are also occurring in other areas, such as labor and delivery and procedure rooms (eg, endoscopy units).
In the second article (Saver 2022b) she addresses the human factors contributing to RSI’s. She begins by summarizing results of a study published on Mayo Clinic’s incredible performance improvement regarding RSI’s over a 10-year period (Cima 2022). Between January 2009 and December 2019, the RSI rate improved from 1 per 5500 operations to 1 per 26,704 operations, a 486% performance improvement! (Note that Cima et al. found that retained surgical sponges remained the most frequent RSI despite use of sponge-counting technology.) Saver points out that a large part of that organization’s success can be attributed to addressing human factors issues related to RSI’s, which personnel identified as:
Saver points out how “normalization of deviance” often slips into organizations and can be a factor contributing to RSI’s. Because counting is a routine, it gets pushed down the priority list by busy clinicians. It becomes easier for them to cut corners and, when nothing happens (RSI’s are not common occurrences), there is no motivation to return to the “correct” way. Thus, the deviation from the desired standard becomes “normalized” as a new, unofficial standard.
Savor notes that productivity pressures may contribute to RSI’s.
But she also notes that complacency, because RSI’s are still relatively rare, is a contributing factor.
Interestingly, she notes how social pressures may come into play. Nurses may feel ostracized and experience incivility when they try to follow safety procedures exactly. She also notes that all the training a new nurse gets during orientation may fall by the wayside when their subsequent mentors do something different.
Saver also notes that inattentional blindness may be a contributory factor. An example she gives is when RN circulators and surgical techs count needles at the end of a procedure, they expect a used needle to be present in each sequential space of the needle counter and may overlook an empty space. She notes that environmental factors, such as noise level and the physical layout of the OR, can contribute to RSI’s, including increasing staff members’ inattentional blindness.
Saver has a good discussion on the culture of safety, communication, and team dynamics, stressing “Everyone has to respect other people’s roles” and the importance of speaking up. We cannot overemphasize the importance of speaking up when anyone feels something is amiss. A recent review on preventing RSI’s (Weston 2022) had an excellent example of using the ARCC approach (ask a question; make a request; voice a concern; and if all else fails, seek help from the chain of command). Weston gives the following scenario: when performing the final count during an abdominal hysterectomy, the RN circulator notes that a sponge is missing and observes that the surgeon and resident are having a personal conversation while closing the abdomen. She uses ARCC to speak up and addresses the issue as follows.
Note the similarity of the ARCC approach to another example of escalating assertive communication we often recommend: the CUSS tool.
C “I’m concerned and need clarification”
U “I am uncomfortable and don’t understand”
S “I’m seriously worried here”
S “Stop”
Saver has a good discussion of the work environment, including fatigue and impact of overtime and long shifts. And, of course, the impact of distractions in the work environment is critical.
Timing the count appropriately is one way to help avoid distractions. Ensuring that the surgeons are ready for the count is important. Timing is also important when completing the initial count before the beginning of surgery.
Process standardization helps avoid deviation. Checklists may help. She notes the Johns Hopkins checklist of 14 steps to follow when there is a discrepancy or when a portion of a device breaks off and needs to be retrieved (The Johns Hopkins Hospital Unintentional Retained Foreign Object [URFO] Procedure Checklist).
Saver notes that setting expectations is a key part of standardization. Examples:
Saver’s third article (Saver 2022c) focuses on developing a program to prevent RSI’s. It’s really a refresher course on doing almost any performance improvement project. She notes three key recommendations in the AORN “Guideline for prevention of unintentionally retained surgical items”:
A multidisciplinary team must involve the key stakeholders, including clinical leaders, frontline staff, supply chain personnel, and others such as radiology technologists and radiologists. Support from organization executives is critical. Developing policies and procedures and standardization is an important function of the multidisciplinary team.
Saver mentions use of tools to help prevent RSI’s, including checklists, posters, count sheets, whiteboards, needle counters, sponge-counting bags, and adjunct technology for detection of items. However, as in virtually all other resources on RSI’s, it’s important to recognize that technology is an adjunct and does not replace the need for the manual count. The detection technologies are pretty good at detecting “soft goods” RSI’s but don’t pick up the “sharp” items that have been becoming increasingly more important.
Johns Hopkins uses a nice poster to remind the nurses, surgeons, anesthesia personnel, and radiology techs of their individual roles in preventing RSI’s.
Saver has a good discussion on educational efforts. Standardization may be important. For example, it is recommended that counts should be performed in the same order each time—surgical sponges first, needles second, miscellaneous items third. She also notes that efficient organization of items on the sterile back table and Mayo stand can promote accurate counting.
Another, often overlooked, item is acknowledging when a situation is high risk, such as when team members are not accustomed to working together.
Saver further emphasizes the importance of sharing data, not only of actual RSI’s but also any near-misses. RCA’s (root cause analyses) should be done on any RSI or near-miss. Also, don’t wait for an RSI or near-miss to occur – do periodic audits to help ensure adherence to policies and procedures.
Kaplan et al. (Kaplan 2022) recently reported on a quality improvement project at several New York State hospitals. TeamSTEPPS® training was provided to all perioperative staff at each site, and use of RF detection became required in all procedures. After the interventions, the incidence of RSI’s decreased from 11.66 to 5.80 events per 100,000 operations. The frequency of RSI’s involving RF-detectable items decreased from 5.21 to 1.35 events per 100,000 operations but the difference in RSI’s involving non-RF-detectable surgical items was not statistically significant. This is reassuring that use of technology does reduce retention of RF-detectable items but again points out that items in the ”sharps” category (as opposed to soft goods) have remained problematic. We’re sorry to see the authors concluded that the benefit of TeamSTEPPS® training alone may not result in a reduction of RSI’s. We’ve always been strong advocates of TeamSTEPPS® training, particularly since it helps build team cooperation and communication and improves the culture of safety. Two of the organizations mentioned in Saver’s articles, Johns Hopkins Hospital and MedStar Health, both stressed the importance of TeamSTEPPS® in their programs.
The articles by Cima et al. and Kaplan et al. should serve to show organizations that significant reduction of RSI’s is possible. Those articles plus the excellent ones from AORN should provide a sound basis for those hospitals and surgical facilities that are still struggling with RSI’s.
In addition to the AORN guideline and our many prior columns on RSI’s/RFO’s listed below, there are many good resources available to help prevent these. NoThing Left Behind® (NoThing Left Behind®) is the preeminent resource. Others include AORN (AORN 2022b), the American College of Surgeons (ACS 2016), The Joint Commission (TJC 2017, TJC 2013), Pennsylvania Patient Safety Authority (Wallace 2017). Verna Gibbs, founder and director of NoThing Left Behind®, also has provided some great tips for surgeons, nurses, and all OR staff for avoiding RSI’s (Gibbs 2019). And Victoria Steelman, author of so many publications on RSI’s, and her colleagues have also published recent articles on RSI’s (Steelman 2018, Steelman 2019, Steelman 2019b).
Our prior columns on retained surgical items/retained foreign objects (RSI’s/RFO’s):
References:
Saver C. Retained Surgical Items: Overview of a Persistent Problem in Health Care
AORN Journal 2022; 116(2): 111-115 First Published:26 July 2022
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13747
Saver C. Addressing the Role of Human Factors in the Retention of Surgical Items. AORN Journal 2022; 116(2): 118-125 First Published:26 July 2022
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13748
Cima RR, Bearden BA, Kollengode A, et al. Avoiding retained surgical items at an academic medical center: sustainability of a surgical quality improvement project. Am J Med Qual 2022; 37 (3): 236-245 Published online November 19, 2021
Weston M, Chiodo C. Preventing Retained Surgical Items. AORN Journal 2022; 115(6): 569-575 First Published:26 May 2022
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13697
Saver C. Developing a Program for Sustained Prevention of Retained Surgical Items. AORN Journal 2022; 116(2): 127-132 First Published:26 July 2022
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13749
The Johns Hopkins Hospital Unintentional Retained Foreign Object (URFO) Procedure Checklist
AORN. Guideline for prevention of unintentionally retained surgical items. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2022: 827-894
https://aornguidelines.org/guidelines/content?sectionid=173723395&view=book
The Johns Hopkins Hospital. Preventing URFO…know your responsibility! (Poster)
Kaplan HJ, Spiera ZC, Feldman DL, et al. J Am Coll Surg. 2022; 235(3): 494-499
AORN (Association of periOperative Registered Nurses). Guideline Quick View: Retained Surgical Items. AORN Journal 2022; 15(2): 197-202 First Published:27 January 2022
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13632
AORN (Association of periOperative Registered Nurses). Retained Surgical Items (resources). AORN 2022; Accessed February 23, 2022
NoThing Left Behind®: A National Surgical Patient Safety Project to Prevent Retained Surgical Items
ACS (American College of Surgeons). Revised statement on the prevention of unintentionally retained surgical items after surgery. October 1, 2016
TJC (The Joint Commission). New Sentinel Event Alert video: Preventing Unintended Retained Foreign Objects. Joint Commission Online 2017; October 25, 2017
TJC (The Joint Commission). Sentinel Event Alert. Preventing unintended retained foreign objects. Issue 51 October 17, 2013
http://www.pwrnewmedia.com/2013/joint_commission/urfo/downloads/SEA_51_URFOs.pdf
Wallace SC. PPSA (Pennsylvania Patient Safety Authority). Retained Surgical Items: Events and Guidelines Revisited. Pennsylvania Patient Safety Advisory 2017; 14(1): 27-35
http://patientsafety.pa.gov/ADVISORIES/Pages/201703_RSI.aspx
Gibbs V. 5 Keys to Preventing Retained Surgical Items. Use these strategies so there's nothing left behind. Outpatient Surgery 2019; XX(4): April 2019
Steelman, V.M., Shaw, C., Shine, L. et al. Retained surgical sponges: a descriptive study of 319 occurrences and contributing factors from 2012 to 2017. Patient Saf Surg 2018; 12, 20
https://pssjournal.biomedcentral.com/articles/10.1186/s13037-018-0166-0#citeas
Steelman VM, Schaapveld AG, Storm HE, et al. The Effect of Radiofrequency Technology on Time Spent Searching for Surgical Sponges and Associated Costs. AORN Journal 2019; 109(6): 718-727
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12698
Steelman VM. Retained Surgical Items: Evidence Review and Recommendations for Prevention. AORN Journal 2019; 110(1): 92-96
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12740
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September 13, 2022
Smart Socks and Robots for Fall Prevention?
Fall prevention in both the hospital setting and the community is an important patient safety endeavor. Many have felt that technology would provide the solutions we are desperately looking for. But, to date, technology has failed to make much of an impact. Bed/chair pressure sensors, designed to alarm when a patient attempts to get out of bed or out of a chair, were widely touted as a fall prevention intervenion. But randomized, controlled trials of bed/chair pressure sensors (Shorr 2012, Sahota 2014) failed to demonstrate a reduction in patient falls. In fact, a systematic review and meta-analysis of clinical trials of in-hospital use of sensors for prevention of falls (Cortes 2021) actually found an increase of 19% in falls among elderly patients who are users of sensors located in their bed, bed-chair, or chair.
Bed pressure sensors have even had some unintended consequences. In our June 19, 2007 Patient Safety Tip of the Week “Unintended Consequences of Technological Solutions” we gave an example where a hospital purchased a new bed pressure alarm system intended to alert staff when a patient attempted to get out of bed. It turned out that on some units there were not enough electrical outlets for both the new bed alarms and the nurse call buttons. So, a decision was made in some cases to swap out these two devices. You can guess what happened: nursing staff responded to the “out-of-bed” alarm only to find the patient lying on the floor with an injury because he tried to get out of bed after no one responded when he pushed the nurse call button!
Enter the newest technologies…“Smart socks” and robots!
Moore et al. (Moore 2022) published results of a prospective study of smart socks to prevent falls in hospitalized patients. The smart socks contain pressure sensors which detect when a patient is trying to stand up. The system also uses a wireless connection to a monitoring device at the nurses’ station, and Smart Badge notification devices worn by the nurses. When the Smart Socks detect an attempt to stand up, the 3 closest nurses to the alarming room receive an alert through their badge. Once a nurse with a badge then enters the patient’s room, the alert is automatically deactivated. If none of the 3 nurses enter the room within the first 60 seconds, then it will escalate to the next 3 closest. At a total of 90 seconds, the system proceeds to an “all call” and alerts all Smart Badges logged on to the alarming unit. If staff are getting a patient out of bed for therapy, or a bathroom visit, or any other activity, the alarms can be suspended via an in-room tablet before getting the patient out of bed.
We really like that alarm concept. In our many columns on alarm fatigue and alarm management, we have stressed the importance of alerting only those with a “need to know” but having an escalation capability in case no one heeds the alarm promptly. And, clearly, this alarm is a “good” alarm in that it is “actionable”, unlike so many other alarms that do not lead to any actions, and has a very low “false alarm” rate.
The study took place in neurological and neurosurgical based units at a major academic health center. Patients 18 years or older who were determined to be at risk for falls were eligible. During 13 months of data collection on 569 enrolled patients (mean age of 59.5 years), zero falls happened. That calculated to a fall rate of 0 falls per 1000 patient-days compared to a historical rate of 4 falls per 1000 patient-days at the study site that was observed in the general patient population that consisted of both patients with and without fall risk.
They also monitored nurse response times. During the study period, 5010 alarms were associated with the Smart Socks system. Only 11 of these were reported to be false alarms, so 99.8% of the alarms were true patient standing events. Median nurse response time to each alarm was 24 seconds, with a range of 1 second to nearly 10 minutes.
Despite the impressive results of this study, we still consider the conclusions to be preliminary. This was not a randomized, controlled trial. Comparison with historical controls is always subject to bias from unrecognized confounding factors. (Note also that the historical fall rate was on a population that also included some patients not at risk of falls.) Also, when the study began, a sample size of 2500 patients was estimated provide at least 70% power to detect a 25% reduction in the fall rate. But, largely because of the COVID-19 pandemic, they enrolled only 569 patients. Also, the fact that patients in the study were hospitalized for a median of 2 days suggests to us that few would have been a very high risk for falls.
In prior work with the smart socks system in patients at high risk for falls, Baker et al. (Baker 2021) reported on 567 patients in a single-arm clinical trial and 949 patients in an observational study in med-surg units at two hospitals. In the clinical trial, fall rate was reduced from 4 to 0 per 1,000 patient-days (p < 0.01). In the observational study, fall rate was reduced from 4 to 1.3 per 1,000 patient-days (p < 0.05).
Obviously, the next step before smart socks technology gets widely adopted would be for a true randomized, controlled trial. Remember, the bed/chair pressure alarms were also heralded early on as “the next best thing” in fall prevention. But they fizzled out when randomized, controlled clinical trials were done. But the smart socks system, with its unique alarm distribution pattern, certainly sounds exciting.
And, after we had already begun writing today’s column, there was a report about a robot that can predict and catch seniors before they fall (Verma 2022). This robot, developed in Singapore, looks like a motorized wheelchair, with guard rails that come up to a person’s hip and are outfitted with sensors to judge when a person begins to go off balance. Users are strapped into a harness. When they are starting to tip, the robot engages to keep them from falling.
The robot has only been tested in small numbers of patients, who suffered from strokes, traumatic brain injuries and spinal cord injuries. The developer is working on 2 models, an at-home model (estimated cost $3000-4000) and a hospital version with a camera and multiple sensors (estimated cost about $20,000). Obviously, more testing is needed and then the robot would have to go through the regulatory approval process, but developers are targeting potential availability in two years. This device obviously is targeted at a different population than the population for the smart socks.
Our success at reducing falls seems to have plateaued in recent years. It’s nice to see some new potential interventions on the horizon.
Some of our prior columns related to falls:
References:
Shorr RI, Chandler AM, Mion LC, et al. Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: a cluster randomized trial. Ann Intern Med 2012; 157(10): 692-699
https://www.acpjournals.org/doi/10.7326/0003-4819-157-10-201211200-00005
Sahota O, Drummond A, Kendrick D, et al. REFINE (Reducing Falls in In-patieNt Elderly) using bed and bedside chair pressure sensors linked to radio-pagers in acute hospital. Age Ageing 2014; 43(2): 247-253
https://academic.oup.com/ageing/article/43/2/247/10785
Cortes OL, Pineros H, Aya PA, et al. Systematic review and meta-analysis of clinical trials: In-hospital use of sensors for prevention of falls. Medicine (Baltimore) 2021; 100(41): e27467
Moore T, Kline D, Palettas M, et al. Fall Prevention with the Smart Socks System Reduces Hospital Fall Rates. Journal of Nursing Care Quality 2022; Published online August 19, 2022
Baker PA, Roderick MW, Baker CJ. PUP® (Patient Is Up) Smart Sock technology prevents falls among hospital patients with high fall risk in a clinical trial and observational study. J Gerontol Nurs 2021; 47(10): 37-43
https://journals.healio.com/doi/10.3928/00989134-20210908-06
Verma P. This robot catches grandma before she falls. Washington Post 2022; September 10, 2022
https://www.washingtonpost.com/technology/2022/09/10/fall-prevention-robot/
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September 20, 2022
More on Missing Patients
Our interest in missing patients was rekindled recently after a report that in two days two patients managed to leave the emergency department of an Illinois hospital and go missing (Graham 2022, NBC5 2022, Borcia 2022). A 35-year-old patient was found safely and returned to the hospital, but a 61-year-old patient was found drowned in a nearby pond.
According to the news releases, the 61-year-old patient was being treated in the emergency department and left on foot before she was discharged. “There were concerns about the person’s mental state and sheriff’s deputies immediately attempted to locate her” according to the Sheriff’s Deputy. The sheriff’s canine “Duke” led deputies to a retention pond on the hospital property. A sheriff’s drone was deployed, and the drone pilot spotted the woman unresponsive in the water. Fire personnel were called to the scene and recovered the woman. They attempted resuscitation but she was pronounced deceased. Further details on these cases are not available.
Even without further details, there are several lessons learned here that need to be shared. First, while we often think about inpatient units and behavioral health units as sites most often impacted by wandering patients or patient elopements, the current incidents highlight the vulnerability of the emergency department.
Second, there were some new tools used in the above incident. We love the concept of using a drone in the search for a missing patient. While initial searches are typically focused on areas inside the hospital, the outside hospital grounds merit attention as well. Particularly if your facility is located near a serious potential hazard like a pond or other significant body of water, a highway, a busy road, railroad tracks, or a bridge, a drone could provide a rapid look at such areas. A drone could obviously also provide a flyover of the roof(s) of your facility or nearby parking garage. Just as we establish a search grid within the hospital and assign specific individuals to search each segment of the grid, someone capable of piloting the drone (most likely someone in your security department) should immediately be tasked with flying the drone over any of these high-risk areas outside the facility. This, of course, presumes that it is both legal and safe to fly a drone in your area.
The search dog in the above incident used the scent of the patient to lead the search crew to the retention pond, where the victim had died. We don’t know whether the scent given to the dog was from something in the hospital or something the family brought from home.
Early notification of the family is essential, not only from a transparency viewpoint, but also because they can help in the search and may be able to suggest areas that the patient might try to reach.
Fortunately, most eloping or wandering patients are found unharmed. But an incident like the one above is a reminder that there can be fatal outcomes in such cases. Healthcare facilities need to have plans in place so that an alert can be sent out as soon as a patient is found to be missing and a formal search be initiated promptly. Drills for missing patients (or abducted infants) need to be practiced at least annually and should also include your local law enforcement personnel.
If you identify a patient with confusion, dementia, hallucinations or frank psychosis in the ED, you should consider implementing a tracking technology to help in the case that they might wander or elope. We discussed various tracking devices in our June 16, 2020 Patient Safety Tip of the Week “Tracking Technologies”. But not all are ideal for tracking the wandering or eloped patient. The various Bluetooth or RFID devices could track patients within the facility but do not have the sort of range you’d need to find a patient outside the facility. GPS tracking devices would be the ideal solution, though these might be expensive. Other options would be those trackers that are located by nearby smartphones (such as Apple’s Air Tags, which use the wide network of iPhone users locate the device).
While a code for a missing patient should be announced over a PA system, some facilities have been reluctant to include a physical description of the missing patient over the air. In such cases, the PA announcement can be supplemented with a blast text message to all staff that includes a physical description of the patient (and even a photo of the patient if one is available in the EMR, with the caveat that the patient’s appearance may have changed since that photo was put in the EMR).
Our July 28, 2009 Patient Safety Tip of the Week “Wandering, Elopements, and Missing Patients” described what should be done when a patient is missing:
“The response to a missing patient is critical. It must be rapid, well-planned, and thorough to find the patient before he/she suffers any harm. Some facilities have chosen to merge their infant abduction policy with the elopement or missing patient policy since the procedures may be very similar. But be careful – you don’t want your staff searching for a newborn by mistake when they should be looking for a wandering geriatric patient.
Staff on the unit need to be notified as soon as a patient is missing. A very brief head count of patients and look in rooms on a unit is typically done but this should last no more than a couple minutes. At that point the hospital phone operator should be notified and “code yellow” (or whatever name you use at your facility) should be announced over the public address system. It should be announced with a brief description of the missing patient (age, sex, race, unit, etc.). Exits from the building need to be immediately locked (some doors may be locked from a central location) or manned by designated staff members. No one should be allowed to leave the building(s). The operator may notify visitors over the PA system that they are under no danger but need to avoid going near exits for the time being. Key assigned staff should immediately go to a designated “command center” from which they will direct the response. Each unit (clinical and nonclinical) will have a specific predetermined area they must search in a systematic fashion. The command center must have an overlay grid of the buildings and surrounding areas and be able to mark off areas on the grid that have been searched. The search teams must have keys to their search areas since sometimes patients lock themselves into rooms inadvertently.
We also recommend early outdoor search since a patient can easily stray far from the building (or into automobile traffic) in a very short period of time. We also recommend that the local police department be notified immediately by the operator when the “code yellow” is called (don’t forget to include them in your planning process). Many facilities also use many security video cameras that are monitored centrally. Security staff may be able to scan those quickly to look for a patient exiting the building.
Someone on the unit from which the patient disappeared should be designated to send out a general email to all staff, describing the missing patient and including a photograph if one is present on the information system. The patient’s physician should be notified by the operator or staff on the patient unit. Someone needs to be designated to be in communication with the family as well.”
We also recommend you go back to our January 22, 2019 Patient Safety Tip of the Week “Wandering Patients” for many more details on what to do when a patient goes missing. In that column we also noted that Hattersley-Gray (Hattersley-Gray 2018) recommended placing some of the patient’s personal items and garments in a sealed plastic bag to help a search dog quickly identify the patient’s scent.
To facilitate the response to a missing patient, we recommend you have a readily available checklist that has all the steps you need to take and includes items such as the phone numbers of police and local agencies you must contact.
While most of those recommendations from those previous columns are still appropriate, our current comments about the use of drones, search dogs, early involvement of police and family, and consideration of tracking devices for high-risk patients should be added to those recommendations.
See our previous columns on wandering, eloping, and missing patients:
References:
Graham DT. Barrington-area hospital won't explain how 2 patients went missing in 2 days. Daily Herald 2022; July 22, 2022
NBC5. Two Patients Go Missing From Same Suburban Hospital, Investigation Underway. Two People Reported Missing From Suburban Hospital This Week, One Did Not Survive. NBCChicago.com 2022; Published July 20, 2022
Borcia S. Missing woman found dead in pond at Advocate Good Shepherd Hospital near Barrington. Lake and McHenry County Scanner 2022; July 19, 2022
Hattersley-Gray R. Responding to Elderly Patient Elopement and Wandering: Part 2. Campus Safety 2018; April 9, 2018
https://www.campussafetymagazine.com/news/elderly-patient-elopement-wandering/
Hattersley-Gray R. Preventing Elderly Patient Wandering and Elopement: Part 1. Campus Safety 2018; March 15, 2018
https://www.campussafetymagazine.com/hospital/elderly-patient-wandering-elopement/
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September 27, 2022
More Bad News for Gabapentin
We neurologists have used gabapentin for many years as a very useful anticonvulsant. But, over the past couple decades, gabapentin and gabapentinoids have been far more often used in management of pain. At the beginning, they were used primarily for neuropathic pain. But now we see them used for almost any sort of pain.
Over the past 5 years, we’ve seen more and more examples of the downside of gabapentinoids (see our prior columns listed below). There were several reports of increased risk of respiratory depression when gabapentinoids were used in conjunction with opioids.
In our February 25, 2020 Patient Safety Tip of the Week “More on Perioperative Gabapentinoids” we described 2 studies (Ohnuma 2019, Yan 2019) that showed gabapentinoids were associated with more post-operative respiratory depression and no significant reduction in opioid use. Also, a systematic review and meta-analysis on perioperative use of gabapentinoids (Verret 2019) found no clinically significant analgesic effect for the perioperative use of gabapentinoids, with low level of evidence, and an increased risk of adverse events with moderate level of evidence. The authors concluded that their results do not support the use of gabapentinoids for the management postoperative acute pain in adult patients.
Now another study has looked at perioperative gabapentin use among older patients undergoing major surgery. Park et al. (Park 2022) looked at almost 1 million patients aged 65 and older who underwent major surgery and were not on gabapentin prior to admission. The rate of perioperative gabapentin use was 12.3% in these patients. They used propensity score matching to reduce confounding when comparing events in those who received gabapentin compared to those who did not. Compared with nonusers, gabapentin users had increased risk of delirium (3.4% vs 2.6%), new antipsychotic use (0.8% vs 0.7%), and pneumonia (1.3% vs 1.2%). There was no significant difference in in-hospital death (0.3% vs 0.2%) between the groups. Risk of delirium among gabapentin users was greater in subgroups with high comorbidity burden than in those with low comorbidity burden.
The Park study and the two studies mentioned above were not randomized, controlled trials. Nevertheless, the evidence is growing that patients receiving perioperative gabapentinoids have an increased risk of complications, particularly postoperative opioid-related respiratory depression and delirium.
In the editorial accompanying the Park study, Bongiovanni et al. (Bongiovanni 2022) question whether the use of gabapentinoids as part of multimodal pain management is wise in older patients. They note that most studies showing a reduction in opioid use when gabapentinoids are used were done in patients of all ages. So, perhaps they are useful in younger patients undergoing surgery but should be used with caution in older patients. They also note that in the Park study 80% of gabapentin users received gabapentin on the day of surgery, suggesting that it was started prior to any patient report of pain. They suggest this might represent an opportunity to de-escalate gabapentin use for some patients.
One thing we were struck by was the low incidence of delirium in the Park study. 76.4% of the patients in that study had orthopedic surgery. Yet the incidence of delirium was only 3.4% and 2.6%, respectively, in the two groups. That incidence is far below what we’d expect in elderly patients undergoing major orthopedic surgery. The authors acknowledge that as well. They note that the claims-based algorithm used for delirium detection in this patient population had high specificity but low sensitivity. They further speculate that the delirium identification algorithm was better at identifying hyperactive delirium than hypoactive or normoactive delirium and that this might lead to their risk difference estimates even being underestimated.
Our January 2020 What's New in the Patient Safety World column “FDA Warning on Gabapentinoids” summarized some of our previous concerns about gabapentinoids and discussed a new warning on gabapentinoids from the FDA (FDA 2019). The FDA warns that “serious breathing difficulties may occur in patients using gabapentin (Neurontin, Gralise, Horizant) or pregabalin (Lyrica, Lyrica CR) who have respiratory risk factors. These include the use of opioid pain medicines and other drugs that depress the central nervous system, and conditions such as chronic obstructive pulmonary disease (COPD) that reduce lung function. The elderly are also at higher risk.”
The FDA notes that gabapentinoids are often being combined with CNS depressants (including opioids, anti-anxiety medicines, antidepressants, and antihistamines), which increases the risk of respiratory depression. It acknowledges that there is less evidence supporting the risk of serious breathing difficulties in healthy individuals taking gabapentinoids alone.
Note that the American Geriatrics Society Beers Criteria® now lists gabapentin as a potentially inappropriate medication (PIM) in the elderly because of its risk of sedation and respiratory depression, especially when used in combination with opioids.
We think it is pretty unlikely that a randomized, controlled trial of gabapentin or gabapentinoids will ever be done on elderly patients undergoing major surgery. But the evidence from the observational and cohort studies and meta-analyses certainly suggests that caution should be used in such patients, particularly when opioids are also used. We concur with Bongiovanni et al. that multimodal pain management pathways for older adults should be reconsidered, keeping in mind both pain reduction and complications.
Some of our prior columns on safety issues with gabapentinoids:
References:
Verret M, Lauzier F, Zarychanski R, et al. Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain: A Systematic Review and Meta-analysis. 2019 annual meeting of the American Society of Anesthesiologists (ASA; abstract A2096).
http://www.asaabstracts.com/strands/asaabstracts/abstract.htm?year=2019&index=18&absnum=1927
OhnumaT, Raghunathan K, Ellis A, et al. Abstract S-344 Effects of Acetaminophen, NSAID’s, Gabapentinoids and Their Combinations on the Day of Surgery in Total Hip and Knee Arthroplasties. Anesthesia & Analgesia 2019; 128(5): 741
https://iars.app.box.com/v/AM19AbstractSupplement
Yan R, Ohnuma T, Krishnamoorthy V, et al. Abstract S-353 Gabapentinoids on the Day of Colorectal Surgery Are Associated with Adverse Postoperative Respiratory Outcomes. Anesthesia & Analgesia 2019; 128(5): 760
https://iars.app.box.com/v/AM19AbstractSupplement
Park CM, Inouye SK, Marcantonio ER, et al. Perioperative Gabapentin Use and In-Hospital Adverse Clinical Events Among Older Adults After Major Surgery. JAMA Intern Med 2022; Published online September 19, 2022
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2796501
Bongiovanni T, Anderson TS, Marcum ZA. Perioperative Gabapentin Use in Older Adults: Revisiting Multimodal Pain Management. JAMA Intern Med 2022; Published online September 19, 2022
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2796503
FDA (US Food and Drug Administration). FDA warns about serious breathing problems with seizure and nerve pain medicines gabapentin (Neurontin, Gralise, Horizant) and pregabalin (Lyrica, Lyrica CR)When used with CNS depressants or in patients with lung problems. FDA 2019; 12-19-2019
https://www.fda.gov/media/133681/download
American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc 2019; 67: 674-694 First published: 29 January 2019
https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/jgs.15767
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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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