Tips, Tools, Techniques, and Resources You Can Use in Your Patient Safety and Quality Improvement Initiatives

 

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Patient Safety Tip of the Week 

 

 

July 7, 2020 

Another Patient Found Dead in a Stairwell

 

 

Missing person found dead in stairwell. That’s a headline we’ve certainly heard many times in the past. The most recent one was slightly different in that this was not a patient in an acute care facility. But it does raise important points about what to do when a patient goes missing.

 

The 62-year-old man was a veteran living in a residential facility run by an independent not-for-profit company in a space it leases in a section of a building on a VA hospital campus (Romine 2020, Estes 2020, Cohan 2020, CBS Boston 2020). He was last seen at the facility on May 8 and had been reported missing on May 13. He was found dead in a stairwell on the campus of the adjacent VA hospital on June 12. The stairwell was only 60 feet from the room in which he resided, and he was found wearing the same clothing he had on the day he went missing. The cause of death has not yet been published, but early reports say foul play was not considered to have been a factor.

 

The residential facility did a search of its grounds once it was recognized the resident was missing. It also notified both the local town police department and the VA police responsible for the rest of the VA campus. Reports state that the agreement with the VA had some sort of wording that prevented the residential facility from searching any of the other VA property, including the stairwell where the resident was eventually found, though this restriction was disputed by the VA. The stairwell was an emergency-exit stairwell from a VA campus building. The VA campus has been described as a “sprawling 177-acre VA site, which resembles a college campus” and the local police and the VA police force apparently share jurisdiction for emergencies on the campus (Estes 2020).

 

It’s not clear from the reports whether the resident ended up in the stairwell by exiting the door that led to the stairwell, though the co-resident who found his body did apparently exit via that door into the stairwell.

 

Despite the finger-pointing about who was responsible for what, there are valuable lessons here. Many acute care hospitals have on their campus other facilities, like skilled nursing facilities or assisted living facilities. In addition, some acute care hospitals have on their campus privately managed areas that rent space (eg. a private MRI program or a physician-owned outpatient practice or a privately-run parking garage). In all such arrangements, there must be good communication, shared responsibility, and coordination of effort any time a patient or resident or even a visitor goes missing.

 

This topic was in the headlines several years ago after a patient was found dead 17 days after going missing at a San Francisco hospital in 2013 (see our October 15, 2013 Patient Safety Tip of the Week “Missing Patients” and our December 2013 What’s New in the Patient Safety World column “Lessons from the SFGH Missing Patient Incident”). But we had first addressed the issue in our July 28, 2009 Patient Safety Tip of the Week “Wandering, Elopements, and Missing Patients” and most recently in our April 7, 2015 Patient Safety Tip of the Week “Missing Patients and Death”.

 

In the latter column we discussed multiple incidents and cases of missing patients and noted several themes recur:

• Someone often sees them but does not recognize they are wandering
• No system to help other staff identify patients who have been labeled at risk
• Automatic locking doors may prevent re-access to the unit
• No coordinated response
• Overreliance on “Security” to find them
• Taking too long to issue a “missing patient code”
• No assessments for wandering risk

 

And all types of facilities need to develop policies and procedures for:

1)     doing an assessment for risk of wandering or elopement

2)     implementing risk reduction strategies for those patients at risk

3)     performing a prompt and thorough search when a patient is missing

 

It was noted above that residents of this facility were free to come and go. But we would expect that such a facility would have sign out/sign in logs (with planned destinations) to help them keep track of the residents. Having such a log should have led to earlier recognition that the resident had gone missing. When we said above “taking too long to issue a missing person code”, we were usually talking about minutes or hours, not days or a month. But even in this case, had the facility noted the resident had not returned overnight, initiating a search conceivably might have found him while still alive.

 

But the next most critical elements are what you do upon recognizing a patient has gone missing. When a patient is discovered to be missing a brief search of the local unit should be done. If the patient is not found immediately, the “code” for a missing patient should be issued. That is called to the hospital operator and announced over PA system. While most hospitals still use arcane codes for various emergencies, many are moving to “plain language” codes for these alerts. In the case of a missing patient a “plain language” code with the description of the missing patient has the additional advantage that visitors and other patients in the hospital might identify the missing patient. Some facilities use an alternative system to alert staff to missing patients. They may use text messages sent out in a “blast” fashion to computer terminals and staff smartphones, the equivalent of the well-known “Amber alert” when a child in the community goes missing. This sort of system can have the advantage of including a description of the patient and perhaps a photograph (that’s one of the many benefits of having digital patient photographs in your electronic health rccord). But the disadvantages of the “blast” system are that it may take longer to implement, and you lose the chance that a visitor or other patient might identify the missing patient.

 

Once the “code” is announced or the alert otherwise issued, there must be a coordinated effort to search for him/her. The facility should have a “grid search” where every area of the hospital and surrounding grounds has a designated person to search it. A central command post is set up, with a map having a predefined grid, and staff call in to that post once they have searched their sector. In addition, most facilities and campuses like this have closed-circuit TV (CCTV) monitoring of exits and other portions of the grounds. Someone must be assigned to look at those surveillance tapes, attempting to go back as far as the time the patient/resident was last seen. That might include CCTV feeds from areas such as parking ramps. Yes, these searches are resource intensive, both in terms of personnel needed and time needed. That highlights the point above about overreliance on “Security”. There is a tendency for everyone to think that ii is the job of the security force or police force to look for missing persons. When you are concerned about the health and safety of a patient or resident, it’s actually everyone’s concern. A well-coordinated “grid” search, where each square is assigned to one individual, can usually be performed expediently and with minimal distraction from their other responsibilities.

 

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” (or whatever code name you use for missing patients) is called (and don’t forget to include the police in your planning process).

 

And, of course, we invoke our old mantra “Never ass-u-me” because it will make an ass out of you and me. In this case, it sounds like several parties each “assumed” the other party had searched the implicated stairwell.

 

Doors. Several aspects of doors may be relevant. Most emergency-exit doors are self-locking. So, when someone exits through them, they cannot re-enter via that door. That was likely a factor in the death discussed in our December 2013 What’s New in the Patient Safety World column “Lessons from the SFGH Missing Patient Incident”. We even once got a cellphone call from a physician who responded to a cardiac arrest and got locked in a stairwell and could not get back into any unit! Also consider that there are times when your locked doors will be automatically unlocked (eg. fire alarms) creating an opportunity for a wandering patient to leave the unit.

 

Door alarms are only as good as the system you have in place to respond to a door alarm being triggered. It is unclear whether the door alarm in this facility was operational or not. The co-resident who found the deceased resident did exit via the emergency-exit  door to that stairwell. Did an alarm trigger when he opened that door? Did anyone respond to that alarm if it did occur? And how often do you check to see if the door alarms are in working order?

 

In our June 16, 2020 Patient Safety Tip of the Week “Tracking Technologies” we also discussed motion-sensitive surveillance cameras. Some motion-sensitive surveillance cameras can distinguish humans from other causes of motion and send an alert to a smart phone or other notification device. They can be placed, for example, in a stairwell that a patient might utilize to abscond from a secure unit. In addition to providing the real-time alert, they also typically store video of an event for a specified time period. That may be important in the search for a patient found missing.

 

And, speaking of alarms, there are other alarm issues pertinent to missing patients. Review of the death of a patient who wandered out of a San Diego hospital several years ago (Luke 2014) illustrates several problems related to reliance on alarms. First, the patient’s bed alarm never sounded. Then, once staff realized the patient was missing, they tried unsuccessfully to page Security and then tried to contact Security by pushing a panic button twice, also with no response. When state inspectors investigated, they found that the panic button had been broken for 8 days. In fact, they found the hospital failed to routinely test the buttons and failed to repair them when broken and that one out of every four panic buttons at the hospital didn’t work.

 

In our February 4, 2014 Patient Safety Tip of the Week “But What If the Battery Runs Low?” we described the following scenario: You implemented a “panic button” system to protect your behavioral health workers from assaults by patients on your locked behavioral health unit. The worker is in a situation where she fears potential harm from a patient and presses the panic button. However, the battery in the panic button is dead. Fortunately, other staff were within audible range of her shouts for help and responded before she was assaulted. The lesson is that any alarm or alert system, regardless of whether it is battery-operated or otherwise, needs frequent testing to ensure it is in working order.

 

Stairwells. In the current case, the man was found in the stairwell of part of the building that apparently had been closed off to stop the spread of the coronavirus (CBS Boston 2020). It’s not just wandering patients or patients seeking to elope that use stairwells. In our December 2012 What's New in the Patient Safety World column “Just Went to Have a Smoke” we mentioned a Denzel Washington movie “Flight”. In one scene there are 3 hospital inpatients who happen to come to the same hospital stairwell to smoke. One is a trauma patient, another an oncology patient, and the other a substance abuse patient recovering from an overdose. We wondered how often that scene might actually take place. To our amazement the same week a study came out in the Archives of Internal Medicine (Regan 2012) that answered our question! The answer: 18.4% of patients who smoke will smoke at some time during their inpatient hospitalization! That study was several years ago but we still continue to see smokers who get hospitalized and sneak off to smoke. Stairwells are often the most accessible locations to try to smoke.

 

In our April 7, 2015 Patient Safety Tip of the Week “Missing Patients and Death” we also mentioned that construction sites are particularly vulnerable for a few reasons. First, you often have outside workers there who are not thinking about patient safety. So, they may leave doors unlocked. Second, construction sites have lots of opportunities for someone to injure themselves. So, make sure you pay close attention to any sites at your facility with ongoing construction.

 

And don’t forget the risk of losing a patient to wandering or elopement during patient transports. One of the items we recommend including in your “Ticket to Ride” checklist/communication tool for transports (eg to Radiology) is information about wandering risk.

 

One of the recurrent themes we noted earlier is that someone often sees the patient but does not recognize they are wandering. Another case illustrates yet another common problem – staff may unwittingly facilitate the patient leaving the facility. Wandering patients or patients desiring to elope from behavioral health units often follow staff out of doors that are usually locked. A 65 y.o. man with a neurological condition and confusion was on an understaffed ward (Brooke 2017). He wandered off the ward and out of the hospital, only to be found many days later dead in a wooded area several miles from the hospital. Cause of death was presumed hypothermia. He had gotten out of the hospital by following a staff worker through a secure door and was let through further locked doors by a nurse who assumed he had previously been allowed through.

 

Many hospitals use color-coded wristbands (or color-coded hospital gowns) to identify patients at risk of wandering. That is generally a good idea. For example, in the case above, it might have alerted the staff member not to allow the patient to exit the door. The problem is that there is still no widely accepted standard for such color-coding. An orange wristband might signify wandering risk at one facility, but might signify something totally different at another facility. That can be problematic when staff work at more than one facility.

 

Our June 16, 2020 Patient Safety Tip of the Week “Tracking Technologies” discussed a whole host of potential technologies that can be used to track patient movements and location. These include devices that are based on RFID, GPS, Bluetooth, WiFi, infrared and other technologies. We’re not sure how applicable these are to the type of residential facility involved in the current case. But if you are a facility dealing with patients with delirium, dementia or other cognitive impairment who might be at risk for wandering, use of such tracking devices makes a lot of sense.

 

We’ve previously emphasized that technology will always be only part of the response to missing patients. It should never be the sole modality relied upon. A VA analysis suggests GPS beats RFID in most scenarios (VA 2013). But the specific technology chosen will likely differ from facility to facility and may depend upon the need to integrate with other technology needs. For example, though GPS probably would be best for locating patients who have left the facility or hospital grounds, some hospitals may prefer RFID because they are using an RFID system for inventory tracking. Bluetooth would have limited applicability because of limited range. Many of you probably already use low-power Bluetooth for tracking items like your keys (or maybe your TV remote!). But in the context of missing patients Bluetooth applications would most likely only be of use in alerting staff when a patient leaves the Bluetooth receiving area (about the size of a typical inpatient floor). Similarly, the bracelets used in newborns to prevent abduction can alert staff when a patient leaves the unit but are of little help in locating a patient once they have already left the unit.

 

Ironically, the VA had one of the earliest Real Time Location Systems (RTLS) but implementation of that system was cost-prohibitive and replete with errors and mismanagement, having been deployed without adequate oversite and without required security controls testing (VA OIG 2017).

 

Communication. In many of our prior columns on missing patients, we have stressed the importance of communication, both internally and externally. We recommend that the family or next of kin or significant other of the missing patient be notified as soon as possible and be kept up to date on the status of the search. Such communication is important, not only in the name of transparency, but also because the missing patient may contact those family members. Those family members may also have suggestions about where the patient might go. Multiple other communications issues were discussed in our December 2013 What’s New in the Patient Safety World column “Lessons from the SFGH Missing Patient Incident”.

 

 

We refer you back to our Patient Safety Tips of the Week for April 7, 2015 “Missing Patients and Death” and July 28, 2009 “Wandering, Elopements, and Missing Patients” for good discussion of assessment of patients for wandering risk, ways to reduce the risk of wandering, and staff education and drills. In those columns we also noted that it’s always a good time for facilities to say “could that happen here?” and do a thorough review of your policies and procedures for missing patient incidents, including making sure you do appropriate drills for such incidents. You probably will be unable to prevent every potential wandering patient or elopement. When one does occur, do a debriefing session as soon as possible to identify potential missed clues and other useful lessons. Then do a formal RCA (root cause analysis) within a short timeframe. There are always valuable lessons learned that hopefully can prevent other similar incidents in the future. But even if you’ve not already had a patient go missing it’s good to do a FMEA (failure mode and effects analysis) to determine your potential vulnerabilities. And make sure you do drills, with thorough critiques and debriefings following the drills. When you do your FMEA, consider also what happens to locking doors when a fire alarm goes off. You might even consider doing your missing patient drill immediately following a fire drill.

 

 

See our previous columns on wandering, eloping, and missing patients:

 

• July 28, 2009 “Wandering, Elopements, and Missing Patients”
• December 2012 “Just Went to Have a Smoke”
• April 2, 2013 “Absconding from Behavioral Health Services”
• October 15, 2013 “Missing Patients”
• December 2013 “Lessons from the SFGH Missing Patient Incident”
• April 7, 2015 “Missing Patients and Death”
• October 6, 2015 “Suicide and Other Violent Inpatient Deaths”
• April 12, 2016 “Falls from Hospital Windows”
• September 18, 2018 “More on Hospital Suicides”
• January 22, 2019 “Wandering Patients”
• June 16, 2020 “Tracking Technologies”

 

 

 

References:

 

 

Romine T. Veteran missing for a month found dead in stairwell at VA hospital. CNN 2020; June 16, 2020
https://www.cnn.com/2020/06/16/us/missing-veteran-found-dead-hospital/index.html

 

 

Estes A. A veteran died 20 yards from his room on the Bedford VA campus. No one noticed for five weeks. Congressional delegation demands federal investigation of Tim White's tragic death. Boston Globe 2020; June 18, 2020

https://www.bostonglobe.com/2020/06/18/metro/veteran-died-20-yards-his-room-bedford-va-campus-no-one-noticed-five-weeks/

 

 

Cohan A. Man found dead in stairwell at Bedford VA Hospital campus a month after he went missing. Had been reported missing on May 13. Boston Herald 2020; June 13, 2020

https://www.bostonherald.com/2020/06/13/man-found-dead-in-stairwell-at-bedford-va-hospital-campus-a-month-after-he-went-missing/

 

 

CBS Boston. Baker: Death Of Man At Bedford VA Hospital ‘A Terrible Tragedy’. CBS Boston 2020; June 15, 2020

https://boston.cbslocal.com/2020/06/15/charlie-baker-va-hospital-missing-man-death/

 

 

Luke S. Broken Bed Alarm Blamed for Walkaway Patient's Death. Thomas Vera died after he became disoriented and walked away from his hospital room at UCSD Medical Center in May 2013. NBC San Diego 2014  Published September 15, 2014, Updated on September 16, 2014

https://www.nbcsandiego.com/news/local/broken-bed-alarm-allowed-patient-to-walk-from-hospital-die-report/93024/

 

 

Regan S, Viana JC, Reyen M, Rigotti NA. Prevalence and Predictors of Smoking by Inpatients During a Hospital Stay. Arch Intern Med 2012; ():1-5, Published online ahead of print November 5, 2012

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1389239

 

 

Brooke C. Coroner blasts hospital staff after patient with degenerative brain condition escapes by wandering through secure unit and climbing over a wall before later being found dead. Daily Mail 2017; updated February 7, 2017

http://www.dailymail.co.uk/news/article-2549371/Coroner-blasts-hospital-staff-psychiatric-patient-escapes-secure-baby-unit-dead.html

 

 

VA. VISN 8 Patient Safety Center of Inquiry, Tampa. Wandering and Missing Incidents in Persons with Dementia. Updated: October 24, 2013

https://www.visn8.va.gov/patientsafetycenter/wandering/

 

 

VA Office of Inspector General. Department of Veterans Affairs. Review of Alleged Mismanagement of the Real Time Location System Project. VA 2017; December 19, 2017

https://www.va.gov/oig/pubs/VAOIG-15-05447-383.pdf

 

 

 

Print “Another Patient Found Dead in a Stairwell”

 





July 14, 2020 

A Thesis on Intrahospital Transports

 

 

Intrahospital transports can be very hazardous for patients (see our many columns on the issue listed at the end of today’s column). They are especially risky for critical care patients. Many of those transports are to the Radiology Suite or the MRI suite, areas we’ve also previously identified as being at high risk for patient safety issues. Lina Bergman, a PhD critical care nurse in Sweden, recently did a thesis on the hazards of intrahospital transports that adds to our understanding of the risks of these transports (Bergman 2020).

 

For the thesis, she and her research team analyzed almost 500 intrahospital transports of patients from 2 ICU’s in a Swedish hospital, one a general/trauma ICU (18 beds) and the other a neurological ICU (8 beds). A typical transport team consisted of a minimum of 2 individuals but might have as many as 5 or more. A researcher or research assistant did observations during intrahospital transports and also performed semi-structured interviews with both intensive care staff (nurses and physicians) and patients.

 

She utilized a conceptual model based on the 5 components of the SEIPS (Systems Engineering Initiative for Patient Safety) model:

• Teamwork
• Transport-related tasks
• Tools and technologies
• Environment
• Organization

 

An item set was developed that, after several iterations, had a total 55 items among the 5 dimensions: teamwork (16), transport-related tasks (9), tools and technologies (12), environment (9), organization (9).

 

A total of 51 intrahospital transports over a 6-week period constituted the data sample. 62% of the transports were for CT scans. 80% of transported patients were on mechanical ventilation, 61% were receiving continuous sedation, and 51% were on vasopressors.

 

A total of 365 patient safety hazards were identified during these 51 intrahospital transports, with a median of 7 hazards per transport. Broken down by category:

• Tools and technology (34%)
• Task hazards (23%)
• Team hazards (17%)
• Organizational hazards (13%)
• Environmental hazards (13%)

 

Examples of ineffective teamwork included loss of information between team members or tasks not being performed as intended. Examples of task hazards included interruptions and distractions during preparation for transport that resulted in skipped safety checks or prolonged preparation times. Examples of tools and technologies hazards included equipment errors, such as disconnection of tubes or lines, Problems with equipment and workplace design often led to workarounds.

 

Classifying by type of event found increased risk of harm (n=204), minor hazards (n=81), no harm (n-21), and observable adverse events (n-3).

 

Themes were grouped into 2 main categories:

1. Organizational, environmental, and technical requirements
2. Knowledge, skills, and competences needed

 

In the first category, poor equipment design and lack of technical solutions often resulted in hazards that led to equipment errors and equipment-related mishaps. Poor workplace design, both at the ICU and destination sites (and sites between) provided obstacles that had to be navigated around. Staff felt that the same equipment used in the ICU should be used during the transports. Moreover, poor overall hospital design was a significant contributing factor. For example, staff often felt that hospitals should have been designed such that radiology would be located near the ICU and avoiding the need for elevator transport.

 

In the second category, staff noted that knowledge and experience in performing transport-related functions and individual skills to anticipate and predict safety scenarios were important. Moreover, they recognized that the “collective competence of the transport team” was especially important. Only a third of interviewees said they used a checklist during the intrahospital transports, but 64% of these found use of the checklists helpful.

 

When the researchers assessed the opinions of nurses and physicians, they found a pattern we have seen previously – nurses wanted more interprofessional collaboration, whereas physicians were satisfied with the current status.

 

The researchers also interviewed patients and found they, in general, were very satisfied with the transports and trusted their caregivers. The healthcare professionals, on the other hand, found the transports to be demanding and sometimes unsafe.

 

The Bergman thesis does include a 24-item scale that can be used for evaluation of intrahospital transports of ICU patients. It can serve as a good quality improvement tool.

 

Bergman provides several practical recommendations for intrahospital transports, based on the research observations:

• Triage should be performed prior to the intrahospital transports, with assessment of competences of staff.
• Team roles and responsibilities should be standardized at the local ICU.
• Critically ill patients should be accompanied by at least 3 healthcare professionals, 2 of whom are nurses qualified in intensive care.
• A “team timeout” should be performed prior to departure from the ICU and, if needed, during the transport.
• Communication techniques, such as closed-loop communication) should be used during transports.
• When handoffs occur, use of a standardized format (such as SBAR) should be used.
• Other ICU duties should be handed over prior to preparing the patient for transport.
• Interruptions and distractions should be avoided during the preparation phase.
• A checklist for intrahospital transport to support task performance should be developed and implemented.
• Transport equipment should be easy to use and facilitate task performance.
• The transport team should be available to monitor the patient throught the transport.
• Continuous maintenance of equipment should minimize technical errors.
• Workplace design at both the ICU and destinations should be improved to minimize workarounds.
• Hospital settings should be planned or rebuilt to shorten transport routes (preferably with hallways reserved for staff).
• Transport routes should be mapped and displayed.
• Local maintenance should minimize environmental disturbances.
• Local guidelines for intrahospital transport should be developed.
• Staff education and training should address both technical and non-technical skills.
• Adequate staff and resources should be provided.

 

We really like her idea of a “team timeout” prior to departure from the ICU. We are a big fan of “huddles”. This is an opportunity not only to say “Do we have everything we need?” and go over the “Ticket to Ride” checklist, but also to say “Are there any things we might anticipate?”. That’s also a good time to ask “Have we communicated with the receiving unit?”. Hospital personnel on the receiving end also be familiar with the transport equipment and status of the patient. That brings us to another thing we’d emphasize: the need for an appropriate handoff prior to and following the transport. Let’s say you are transporting a critically ill patient to the Radiology suite for a CT scan. You should discuss with the radiology nurse or radiology staff whether your patient is on oxygen, being ventilated, whether the patient will need sedation for the procedure, what sorts of medications are running in various lines, etc. and discuss what events might be anticipated.

 

The Bergman thesis broke down the 365 safety hazards into 5 categories but did not provide individual description of each hazard. But you can go back to our October 22, 2013 Patient Safety Tip of the Week “How Safe Is Your Radiology Suite?” for a comprehensive discussion of all the things that can go wrong when a patient is sent to the radiology suite. That column and several others demonstrate a wide variety of hazards you might encounter during an intrahospital transport. We also refer you back to our August 25, 2015 Patient Safety Tip of the Week “Checklist for Intrahospital Transport” for discussion about the many factors contributing to incidents related to intrahospital transports. These include equipment failures, oxygenation issues, battery/power issues, and things like attention to patient hydration. And don’t forget the problems that arise when sending diabetic patients off for substantial periods of time (what to do with their insulin, planning for meals, etc.).

 

In our August 25, 2015 Patient Safety Tip of the Week “Checklist for Intrahospital Transport” we noted problems maintaining adequate oxygenation are particularly a problem during transport of patients (within or outside of facilities). The Pennsylvania Patient Safety Authority highlighted this issue in a Patient Safety Advisory in 2005 “Continuity of Oxygen Therapy During Intrahospital Transport” (PPSA 2005b). They reviewed numerous reports to the Pennsylvania Patient Safety Reporting System (PA-PSRS) and looked at failure modes in the many steps involved in maintaining adequate oxygen therapy during transport. They noted that oxygen therapy has been reported to be interrupted in as many as 55% of transports. Failure modes identified included: failure to treat with oxygen when ordered, failure to initiate flow from the oxygen source, failure to connect the oxygen tubing to the source, failure to place the oxygen delivery device on the patient, and failure to anticipate the oxygen demand and provide an adequate supply throughout the transport. Battery power failure (see our February 4, 2014 Patient Safety Tip of the Week “But What If the Battery Runs Low?”) is a potential risk. Not only do portable ventilators run on battery power but monitors and infusion pumps and possibly other equipment may also run on batteries.

 

In our March 13, 2012 Patient Safety Tip of the Week “Medical Emergency Team Calls to Radiology” we noted  a series of articles by Lora K. Ott and colleagues (Ott 2012, Ott 2011a, Ott 2011b) that looked at medical emergency team/rapid response team calls to the radiology suite and analyzed patient factors related to those calls. The percentages in the papers differ, presumably because the time frames for each were different, but the most recent paper appears to account for all the cases over a two-year time period so we’ll use those statistics. The majority of the calls (60%) were for patients not from the ICU’s and for almost half they occurred on the patient’s first day in the hospital. The authors speculate that this could be due to several reasons: (1) ICU patients are recognized to be more at risk and are more likely to be accompanied to radiology by nursing staff (2) the subtler evolving signs of clinical deterioration may not have been appreciated in the patients from the general units who are not as closely monitored. The majority had a Charlson comorbidity index equal to or greater than 4 and about a third each had nasal cannula oxygen, dyspnea, or tachycardia.

 

The nature of the events in the radiology suite were primarily cardiac in 41%, respiratory in 29%, and neurological in 25% and most required a higher level of care after the event. 44% of the calls involved patients undergoing CT scan and 22% MRI scanning. That should not be surprising, given our many prior articles on safety issues in the radiology suite. During either procedure the patient is relatively isolated from monitoring staff for periods of time. In addition, sedation may be used to facilitate completion of some of those studies. Dislodging of catheters, tubes and lines during transfer to the CT/MRI platforms could also play a role. Also, the nature of the underlying condition necessitating the CT or MRI scan may also predispose these patients to the types of deterioration seen. In one of the earlier papers (Ott 2011b) neurological causes of deterioration were more frequent so it’s not surprising that many of these would have occurred during CT or MRI.

 

In one of the articles (Ott 2011b) peak time for such events was between 10 AM and noon. The authors ascribe this interesting temporal trend as most likely reflecting detection on morning rounds of symptoms and signs necessitating the diagnostic studies.

 

One of the most comprehensive review of incidents related to intrahospital transport came from the Australian Incident Monitoring Study in Critical Care, reported by researchers from Australia and Johns Hopkins (Beckmann 2004). They found 191 incidents related to intrahospital transport from 37 Australian ICU’s between 1993 and 1999. Roughly a third (31%) of the incidents had serious adverse outcomes, with major physiological derangement in 15%, physical/psychological injury in 4%, death in 2%, and prolonged hospital stay in 4%. In addition, patient/family dissatisfaction occurred in 7%. The site to which the transport occurred was evenly split between the Radiology suite and the OR, with some transports to the ward, ER, or other sites.

 

They were able to categorize the incidents as equipment-related in 39% and related to patient/staff management issues in 61%. Overall, they identified 900 contributing factors, 46% of which were system factors and 54% human-based factors. Equipment related issues included problems with oxygen, battery/power supply, ventilators, monitors, drug delivery systems, etc. But, similar to the Bergman study, they also included things like problems with the hospital elevators. The patient/staff management issues mostly had to do with communication issues, airway management, vascular line management, monitoring, and positioning and set-up of equipment.

 

They did find a number of factors that seemed to prevent or limit harm to patients in the incidents. These included “rechecking equipment”, “rechecking the patient”, “prior experience”, “use of the correct protocol”, and “skilled assistance”.  These mitigating factors led the researchers to recommend potential use of checklists, protocols/guidelines for transport, and specific training for transport or use of specialized transport teams. They also stress the importance of adequate monitoring of the patient throughout. Some of the potential checklist items to include relate to oxygen supply, battery life, lines and tubes, and capability of transferring patient between bed, stretcher and table. Preparation must include not only getting the patient and equipment ready but also liaising with the staff at the destination department.

 

The Beckmann study also demonstrates the value of having incident reporting that allows such drill-down and tracking of intrahospital transport incidents. That, in fact, is a metric we think should be part of an ICU quality and performance improvement program.

 

Our March 31, 2020 Patient Safety Tip of the Week “Intrahospital Transport Issues in Children” looked at adverse events during intrahospital transport of critically ill children and highlighted a study by Haydar et al. (Haydar 2019). Respiratory and airway events were the most common type of adverse event. Hypothermia was common in infants. They also found instances of emergent tracheostomy, pneumothorax, and cardiac arrest. One transport-associated death was reported.

 

One hazard we had not commented upon often enough in intrahospital transports is hypothermia. We did discuss the risk of hypothermia in interhospital transfers (see our October 30, 2018 Patient Safety Tip of the Week “Interhospital Transfers”). In our January 7, 2020 Patient Safety Tip of the Week “Even More Concerns About MRI Safety” we discussed a study that showed most children who undergo MRI while under anesthesia experience hypothermia at some point during the procedure (Cronin 2019). Children, particularly infants, are especially prone to hypothermia. Nevertheless, you should consider the possibility that your patient might develop hypothermia during a transport, particularly one that might be prolonged, and take appropriate steps to keep the patient warm.

 

Apparently only about a third of transports in the Bergman study used checklists. Planning for and implementing transports is greatly facilitated by use of the “Ticket to Ride” checklist. The original “Ticket to Ride” checklist was developed to ensure that patients being transported had adequate oxygen supplies, since some studies showed that over half of patients transported to sites like the radiology suite ran out of oxygen. But the “Ticket to Ride” checklist has been expanded to include many other considerations for events that might happen during and after a transport (see our many columns on “Ticket to Ride” listed below).

 

A “Ticket to Ride” checklist for a patient returning to a med/surg unit from the OR or PACU must include not only items pertinent to the procedure and recovery that just took place, but must also consider issues from before the surgery or procedure. For example, were certain medications withheld prior to the surgery? Do they need to be restarted? Is there physiologic monitoring that needs to be restarted?

 

In our August 25, 2015 Patient Safety Tip of the Week “Checklist for Intrahospital Transport” we discussed a checklist for intrahospital transport of critically ill patients developed by clinical researchers in the Netherlands (Brunsveld-Reinders 2015). When they prospectively monitored transports, they found that in 26% of 503 transports to Radiology one or more incidents occurred.

 

We refer you to the Netherlands study itself (Brunsveld-Reinders 2015) to actually see the checklist they created for intrahospital transports. The article also addresses transport team composition (which may vary depending upon whether the patient is ventilated or on pressors or inotropes) and education/training needs for members of the transport team. The equipment check prior to transport includes not only status of the oxygen supply and battery/power supplies but also considerations such as hydration before studies using radiographic contrast or whether equipment is MRI-compatible (eg. non-ferromagnetic materials, long enough IV lines, etc.) if the patient is going for an MRI. Medication and fluid status must be addressed prior to transport. And it is crucial that communication take place with the receiving department to ensure they are ready to accept the patient and whether any items such as informed consent are available. One often-overlooked item is ensuring that the transport route is clear and functional. We’ve seen unsafe transports take place because no one realized an elevator was out of service. They provide considerations for during transport, such as attention to equipment, monitoring, and medications/IV’s. And post-transport they focus on ensuring proper equipment and line/tubing connections, resumption of feeding if applicable, turning on the humidifier on the ventilator, etc. They also stress the importance of reporting any incidents or events that may have happened during the transport.

 

The Netherlands checklist took an average of 4.5 minutes per phase (range 3 to 10 minutes). It was generally well accepted and one of the key factors in that was its integration with their electronic medical record.

 

A good “Ticket to Ride” type checklist for intrahospital transport should cover all three phases of transport: pre-transport, during-transport, and post-transport (Jarden 2010, Brunsveld-Reinders 2015). One question to include on the post-transport section of a “Ticket to Ride” checklist is “Are there any medications or monitoring that need to be restarted on this patient?”.

 

“Ticket to Ride” checklists also should be customized to reflect both patient-related factors and factors related to the destination or nature of the procedure the patient is being transported for. For example, on an ICU patient transport you probably don’t need items for wandering risk or suicide risk that you would want on transporting a confused patient from a med/surg unit or a depressed patient on a behavioral health unit. And, while we recommend at item about risk of hypothermia for most patients, that item is extremely important to include on infants and young children. And your checklist would differ for a patient going to Radiology for simple radiographs compared to a patient who might need sedation for a CT scan or MRI scan.

 

One extremely important question is missing in the Bergman thesis: how many of the transports were indicated in the first place? Every time we do a root cause analysis (RCA) on an intrahospital transport that had an adverse event, the first question we ask is “Was the transport indicated?”. Not uncommonly, we find that the indications for the test or procedure for which the transport was undertaken were “iffy” at best. One set of statistics we like to cite is that by Beckmann et al. (Beckmann 2004). They note that studies suggest care plans were changed for patients after such transports in only 24-39% of cases. So, one really needs to consider how likely the imaging study (or other procedure the patient may be going for) is really likely to change patient management.

 

In our August 25, 2015 Patient Safety Tip of the Week “Checklist for Intrahospital Transport” we discussed “the 5 W’s” of intrahospital transport (Day 2010). The first “W” is “Why” or “Why does the patient need to leave the ICU for the procedure?”. Important questions to ask here are “Are there bedside alternatives for the procedure? And “Is the patient’s condition stable?”. If the patient is considered unstable, the next questions are “Is the transport for a lifesaving intervention?” and “Is the transport to a diagnostic test pivotal to decision for emergent plan?”. Day’s second “W” is “Who”. This included both who is the patient and who will be caring for the patient and, importantly, will a handoff be required? The third “W” is “What” and refers to equipment, airway, ventilator support, circulatory support, and special considerations (eg. spine stability, intracranial pressure monitors, etc.). Under the fourth “W” for “When” Day discusses considerations about coordinating with the timing of the test or procedure (eg. fasting or withholding anticoagulants for procedures), renal protective protocols for contrast-using procedures, and collaborating with other healthcare providers. The last “W” is for “Where” which includes details about the route to be taken, issues regarding MRI safety if going for MRI, etc.

 

The majority of transports of ICU patients in the Bergman thesis were for CT scans. Our many columns on patient safety in the Radiology Suite or the MRI Suite (see lists below) stress that the incidents there are not usually related to the imaging study itself. Rather, these are patients with complex medical conditions, often unstable, who have multiple monitoring needs and may have multiple lines and tubes and are receiving multiple medications, oxygen, or other therapies. Given that so many ICU patient transports are for CT scanning, some hospitals have considered use of portable CT scans for this population. In our September 16, 2008 Patient Safety Tip of the Week “More on Radiology as a High Risk Area” we noted a study from the Cleveland Clinic that demonstrated the cost effectiveness of having a dedicated portable CT scanner to scan ICU patients.

 

It’s worth reiterating many of the points in our August 25, 2015 Patient Safety Tip of the Week “Checklist for Intrahospital Transport”. Most of the literature on the risks associated with intrahospital transport have dealt with critically ill patients. While incidents do occur during intrahospital transport of non-ICU patients, those from ICU’s are the most vulnerable. The percentage of ICU patients needing such intrahospital transfer probably depends on a host of factors, such as nature of the patient population, imaging capabilities, etc. One study ((Van Velsen 2011) noted that about a third of ICU patients required intrahospital transports. The literature also suggests that the risk of incidents and adverse events during transports is also related to the time duration of the transport. Hence, events such as CT scanning tend to be associated with more incidents because they require more time (PPSA 2005). We’ll also bet that the percentage of incidents related to transports to the MRI suite has been increasing as MRI scanning has superseded CT scanning for so many conditions.

 

The overall rate of incidents during intrahospital transports is difficult to glean from the literature. In our September 16, 2008 Patient Safety Tip of the Week “More on Radiology as a High Risk Area” we noted studies from the 1980’s and 1990’s that showed rates of transport incidents as high as 70%. A paper by Smith et al (Smith 1990) noted adverse events during 34% of all ICU transports but transport of ICU patients to the CT suite was associated with a 71% incidence of adverse events. Those high rates of transport incidents have probably diminished somewhat. Some authors had previously noted an incidence of 3.7% (Van Velsen 2011) but when they prospectively monitored transports (Brunsveld-Reinders 2015) they found that in 26% of 503 transports to Radiology one or more incidents occurred.

 

Another study (Parmentier-Decrucq 2013) found that 45.8% of 262 intrahospital transports were associated with adverse events. In 16.8% of all intrahospital transports the adverse event was considered serious for the patient. Risk factors were ventilation with positive end-expiratory pressure >6 cmH2O, sedation before transport, and fluid loading for intrahospital transports. Treatment modification before transport was also a risk factor identified.

 

Intrahospital transports have 3 phases: before, during, and after. Unfortunately, the “after” phase is often either neglected or poorly managed. A recent case presentation in the AORN Journal (AORN 2020) illustrates the latter. A 4 y.o. boy underwent intestinal surgery under general anesthesia. The procedure was uneventful, he was extubated in the OR, and sent to the PACU. Continuous pulse oximetry was ordered for 24 hours because of his age and long duration of surgery. Once stable in the PACU, he was transferred to the inpatient unit. Pulse oximetry was disconnected during the transport, which took about 10 minutes. Apparently, the only communication from the transporter was that the patient was now in a room. The receiving nurse had been told the procedure was uneventful and the patient stable, so she did not perform an evaluation right away. A few minutes later, she placed him on pulse oximetry and realized that he was markedly hypoxic. Oxygen was administered immediately but he became bradycardic and hypotensive and went into cardiac arrest. He was resuscitated but left with significant neurological damage as a result of hypoxic brain injury.

 

The discussion centered on several key issues. Obviously, communication issues were critical. Pulse oximetry was discontinued during the transport and was presumed to be started on arrival at the med/surg unit. Knowledge and skills clearly played a role as well.

The transporter stated that although he thought the patient was having difficulty breathing during the transport, he did not voice his concern because he had been assured the boy was stable and was not confident in his own judgment. That reluctance to speak up also is a reflection on the safety culture of the hospital. And it illustrates another key component of intrahospital transfers – the patient must be assessed before and after the transport. And it notes that use of non-medical personnel for transports is still fairly widespread.

 

 

Intrahospital transports, whether involving critical care patients or others, need to be undertaken with considerable planning, communication, and teamwork. You need to ensure that you have systems in place to ensure the safety of the patients and tools like the “Ticket to Ride” checklists may facilitate safe transports. And don’t forget there are 3 phases to intrahospital transports – before, during, and after the transport.

 

 

 

Some of our prior columns on intrahospital transports and the “Ticket to Ride” concept:

• April 8, 2008               “Oxygen as a Medication”
• November 18, 2008    “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
• August 11, 2009         “The Radiology Suite…Again!”
• March 13, 2012           “Medical Emergency Team Calls to Radiology”
• August 25, 2015         “Checklist for Intrahospital Transport”
• September 1, 2015      “Smarter Checklists”
• November 2016          “Oxygen Tank Monitoring”
• February 2018             “Oxygen Cylinders Back in the News”
• May 22, 2018              “Hazardous Intrahospital Transport”
• October 30, 2018        “Interhospital Transfers”
• March 31, 2020           “Intrahospital Transport Issues in Children”
• June 23, 2020              “Telemetry Incidents”

 

Some of our prior columns on patient safety issues in the radiology suite:

• October 16, 2007        “Radiology as a Site at High-Risk for Medication Errors”
• February 19, 2008       “MRI Safety”
• September 16, 2008    “More on Radiology as a High Risk Area”
• October 7, 2008          “Lessons from Falls....from Rehab Medicine”
• October 2008              “Preventing Infection in MRI”

• March 17, 2009           “More on MRI Safety”
• March 2009                 “Risk of Burns during MRI Scans from Transdermal Drug Patches”

• August 11, 2009         “The Radiology Suite…Again!”
• January 2010               “Falls in the Radiology Suite”
• August 2010               “Sedation Costs for Pediatric MRI”
• January 25, 2011         “Procedural Sedation in Children”

• February 1, 2011         “MRI Safety Audit”
• October 25, 2011        “Renewed Focus on MRI Safety”
• March 13, 2012           “Medical Emergency Team Calls to Radiology”
• August 2012               “Newest MRI Hazard: Ingested Magnets”
• October 22, 2013        “How Safe Is Your Radiology Suite?”
• February 25, 2014       “Joint Commission Revised Diagnostic Imaging Requirements”
• July 2014                    “New MRI Risks: for Staff!”
• July 1, 2014                “Interruptions and Radiologists”
• November 2014          “More Radiologist Interruptions”
• October 21, 2014        “The Fire Department and Your Hospital”
• June 23, 2015              “Again! Mistaking Antiseptic Solution for Radiographic Contrast”
• August 25, 2015         “Checklist for Intrahospital Transport”
• March 22, 2016           “Radiology Communication Errors May Surprise You”
• August 2016                “Guideline Update for Pediatric Sedation”
• October 2016              “MRI Safety: There’s an App for That!”
• January 17, ,2017        “Pediatric MRI Safety”
• August 8, 2017           “Sedation for Pediatric MRI Rising”
• November 14, 2017    “Tracking C. diff to a CT Scanner”
• March 2018                 “MRI Death a Reminder of Dangers”
• March 2018                 “Cardiac Devices Safe During MRI But Spinners!?”
• April 2018                   “Radiologists Get Fatigued, Too”
• May 2018                    “Cost of Interrupting a Radiologist”
• November 2018          “OMG! Not My iPhone!”
• December 11, 2018     “Another NMBA Accident”
• April 2, 2019               “Unexpected Events During MRI”
• September 2019          “New MRI Hazard: Magnetic Eyelashes”
• October 15, 2019        “Lots More on MRI Safety”
• November 5, 2019      “A Near-Fatal MRI Incident”
• November 12, 2019    “Patient Photographs Again Help Radiologists”
• November 26, 2019    “Pennsylvania Law on Notifying Patients of Test Results”
• January 7, 2010           “Even More Concerns About MRI Safety”

 

Some of our prior columns on patient safety issues related to MRI:

• February 19, 2008 “MRI Safety”

• March 17, 2009 “More on MRI Safety”
• October 2008  “Preventing Infection in MRI”
• March 2009 “Risk of Burns during MRI Scans from Transdermal Drug Patches”
• January 25, 2011 “Procedural Sedation in Children”
• February 1, 2011 “MRI Safety Audit”
• October 25, 2011 “Renewed Focus on MRI Safety”
• August 2012 “Newest MRI Hazard: Ingested Magnets”
• October 22, 2013 “How Safe Is Your Radiology Suite?”
• October 21, 2014 “The Fire Department and Your Hospital”
• August 25, 2015 “Checklist for Intrahospital Transport”
• August 2016 “Guideline Update for Pediatric Sedation”
• October 2016 “MRI Safety: There’s an App for That!”
• January 17, 2017 “Pediatric MRI Safety”
• August 8, 2017 “Sedation for Pediatric MRI Rising”
• March 2018 “MRI Death a Reminder of Dangers”
• March 2018 “Cardiac Devices Safe During MRI But Spinners!?”
• November 2018 “OMG! Not My iPhone!”
• April 2, 2019 “Unexpected Events During MRI”
• September 2019 “New MRI Hazard: Magnetic Eyelashes”
• October 15, 2019 “Lots More on MRI Safety”
• November 5, 2019 “A Near-Fatal MRI Incident”
• November 2019 “ECRI Institute’s Top 10 Health Technology Hazards for 2020”
• January 7, 2010 “Even More Concerns About MRI Safety”
• March 2020 “Airway Emergencies in the MRI Suite”

 

 

References:

 

 

Bergman L, Patient safety during intrahospital transports in intensive care: Hazards, experiences and future measurements. (Thesis, Gothenburg University). BrandFactory 2020; Gothenburg, Sweden (2020)

https://gupea.ub.gu.se/handle/2077/63248

 

 

Pennsylvania Patient Safety Authority. Patient Safety Advisory. Is CT a High-Risk Area for Patient Transport? PA PSRS Patient Saf Advis 2005; 2(3): 11-12

http://patientsafety.pa.gov/ADVISORIES/Pages/200509_11.aspx

 

 

Ott LK, Pinsky MR, Hoffman LA, et al. Medical emergency team calls in the radiology department: patient characteristics and outcomes. BMJ Qual Saf 2012; published online ahead of print March 2, 2012

http://qualitysafety.bmj.com/content/early/2012/03/01/bmjqs-2011-000423.short?g=w_qshc_ahead_tab

 

 

Ott LK, Hoffman LA, Hravnak M. Intrahospital Transport to the Radiology Department: Risk for Adverse Events, Nursing Surveillance, Utilization of a MET, and Practice Implications. Journal of Radiology Nursing 2011; 30(2): 49-54

http://www.radiologynursing.org/article/S1546-0843%2811%2900038-1/abstract

 

 

Ott LK, Hravnak M, Clark S, Amesur NB. Patients’ Instability, Emergency Response, and Outcomes in the Radiology Department.

Am J Crit Care November 2011; 20(6): 461-469

http://ajcc.aacnjournals.org/content/20/6/461

 

 

Beckmann U, Gillies DM, Berenholtz SM, Wu AW, Pronovost P. Incidents relating to the intra-hospital transfer of critically ill patients: An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care. Intensive Care Medicine 2004; 30(8): 1579-1585
https://link.springer.com/article/10.1007/s00134-004-2177-9

 

 

Haydar B, Baetzel A, Elliott A, et al. Adverse Events During Intrahospital Transport of Critically Ill Children. A Systematic Review. Anesthesia & Analgesia 2019; Published ahead of print December 16, 2019

https://journals.lww.com/anesthesia-analgesia/Abstract/publishahead/Adverse_Events_During_Intrahospital_Transport_of.95857.aspx

 

 

Cronin JA, Shen ., Rana S, et al. Association Between Magnetic Resonance Imaging in Anesthetized Children and Hypothermia. Pediatric Quality & Safety 2019, 4(4): e181

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6708655/

 

 

Brunsveld-Reinders AH, Arbous M, Kuiper SG, de Jonge E. A comprehensive method to develop a checklist to increase safety of intra-hospital transport of critically ill patients. Critical Care 2015; 19: 214 (7 May 2015)

http://www.ccforum.com/content/19/1/214

 

 

Jarden RJ, Quirke S. Improving safety and documentation in intrahospital transport: development of an intrahospital transport tool for critically ill patients. Intensive Crit Care Nurs 2010; 26: 101-107

http://www.intensivecriticalcarenursing.com/action/showAbstract?pii=S0964-3397%2809%2900126-8&journalCode=YICCN

 

 

Day D. Keeping Patients Safe During Intrahospital Transport. Crit Care Nurse 2010; 30: 18-32

http://ccn.aacnjournals.org/content/30/4/18.full

 

 

Van Velzen C, Brunsveld-Reinders AH, Arbous MS. Incidents related to intrahospital transport of patients in the ICU. Critical Care 2011; 15(Suppl 1): P535

http://www.ccforum.com/content/15/S1/P535

 

 

Smith I, Fleming S, Cernaianu A. Mishaps during transport from the intensive care unit. Critical Care Medicine. 1990; 18(3):278-281

http://www.ccmjournal.com/pt/re/ccm/abstract.00003246-199003000-00006.htm;jsessionid=LTPGG1QpccT2RZ3RjFNl8g2QmdKQ2GjPp6vyvtxZP7ZBlRQJ66pl!-2013963969!181195629!8091!-1?index=1&database=ppvovft&results=1&count=10&searchid=1&nav=search

 

 

Parmentier-Decrucq E, Poissy J, Favory R, et al. Adverse events during intrahospital transport of critically ill patients: incidence and risk factors. Ann Intensive Care 2013; 3: 10

https://annalsofintensivecare.springeropen.com/articles/10.1186/2110-5820-3-10#citeas

(Parmentier-Decrucq 2013)

 

 

AORN (Association of periOperative Registered Nurses). Anonymous. Adverse event during intrahospital transport: The official voice of perioperative nursing the official voice of perioperative nursing. AORN Journal 2020; 111(5): 577-579

https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13013

 

 

 

Print “A Thesis on Intrahospital Transports”

 





July 21, 2020 

Is This Patient Allergic to Penicillin?

 

 

We haven’t given much attention to the issue of penicillin allergy in our patient safety columns. Penicillin, of course, is one of our oldest antibiotics and has been widely used since the 1950’s. Its analogs and second and third generation cousins have been used to treat millions of infections as well as serving as prophylactic agents to prevent infection in surgery and other procedures. In patients who cannot receive penicillins we often have to resort to other antibiotics, leading to antibiotic resistance to those other antibiotics. In addition, use of many of those other antibiotics may lead to unwanted consequences such as C. diff infection. So, good antibiotic stewardship needs to focus not just on antibiotic use, per se, but also on how the issue of penicillin allergy might be impacting antibiotic use.

 

We have discussed problems with the electronic health record (EHR) that may either lead to inappropriate administration of a penicillin in a patient who is allergic to it, or in the opposite direction, avoiding penicillins in a patient who is not really allergic to them. Our January 2013 What's New in the Patient Safety World column “More IT Unintended Consequences” gave an example of a patient who was allergic to penicillin developing anaphylaxis after being given ampicillin. The information about the allergy had been entered into part of the EHR that was not linked to the allergy portion of the pharmacy computer system that would have triggered an alert if the allergy had been recognized. On the other hand, our July 2020 What's New in the Patient Safety World column “Patient Requests for EHR Corrections” noted a scenario where your own electronic health record (EHR) says you are allergic to penicillin buy you are not, in fact, allergic to penicillin. Yet, you might at some time in the future be denied appropriate use of penicillins or other antibiotics cross-reacting with penicillin.

 

So, why is it so important to know whether your patient has a true penicillin allergy? Probably the best example is the patient about to undergo surgery. A study published in Clinical Infectious Disease looked at surgical site infections (SSI’s) in over 9000 surgical procedures and found that patients giving a history of penicillin allergy had 50% increased odds of SSI (Blumenthal 2018). Reason: they received second-line perioperative antibiotics. They were administered less cefazolin (12% vs 92%) and more clindamycin (49% vs 3%), vancomycin (35% vs 3%), and gentamicin (24% vs 3%) compared with those without a reported penicillin allergy. The authors conclude that clarification of penicillin allergies as part of routine preoperative care may decrease SSI risk.

 

Some hospitals now include penicillin allergy tesitng as part of their preoperative patient optimization. In our April 7, 2020 Patient Safety Tip of the Week “From Preoperative Assessment to Preoperative Optimization” Aronson and colleagues (Aronson 2020) detailed how they established a comprehensive preoperative assessment and management program to optimize patients for surgery at Duke University Hospital and School of Medicine. Their multidisciplinary group implemented a Preoperative Anesthesia and Surgical Screening (PASS) Clinic to screen patients and to more proactively and efficiently manage modifiable risks at the time a patient’s surgical candidacy is first considered. One of their specific optimization programs was a preoperative penicillin allergy testing clinic,

 

Interestingly, Kimberly Blumenthal, M.D., author of the study noted previously, says “But just because you were told you had a penicillin allergy, or had one in the past, does not mean you have one now. People with a penicillin allergy history have their allergy disproved with allergy testing more than 90% of the time.” (Blumenthal 2019). So, confirming or ruling out a penicillin allergy through allergy testing could justify the risk, or potentially avert it by allowing use of beta-lactams. The first step is skin testing for penicillin allergy. Anyone with a positive skin test to penicillin — usually itching, redness, and swelling at the site of the skin prick — is allergic and should avoid penicillin. People who have no reaction to the skin test can then safely undergo the amoxicillin challenge. In that test, the allergist gives the person amoxicillin and observes signs and symptoms for at least one hour. This is done under medical supervision.

 

In a recent AORN Journal interview, it was noted that beta lactams, the group of antibiotics related to penicillin, are the most widely used antibiotics to prevent surgical site infections (Sunshine 2020). The author interviews Valeria Fabre, MD, associate medical director of the Antimicrobial Stewardship Program and at The Johns Hopkins Hospital. Dr. Fabre begins by noting the statistic from the Blumenthal study mentioned above. She goes on to note that most people who have a penicillin allergy label are actually not allergic and that, with an appropriate protocol in place, these patients can safely receive that beta-lactam antibiotic at the time of surgery. Sometimes, intolerance of an antibiotic may be erroneously labelled and allergy. For example, isolated diarrhea or headache after an antibiotic more likely represents intolerance and not a true allergy.

 

Medical records often just include penicillin or one of its relatives under “allergy” without clarification of what the supposed allergic reaction was. In many cases, it was not a true allergy. Dr. Fabre recommends that some simple questions may help differentiate true allergies from other reactions:

• What was the reaction?
• How did it look (if a rash)?
• When did it happen (i.e. at what age)?
• How soon after the antibiotic was given?
• What other antibiotics has the patient had since the reaction?”

 

She notes what we are most concerned about is the risk of anaphylaxis in a patient with a true penicillin allergy. This needs to be differentiated from a previous reaction that is actually at low risk for anaphylaxis. She gives a great example regarding a rash occurring after administration of a penicillin. She notes that the most common reaction to penicillin or penicillin-related antibiotics is a skin rash that appears usually after two or three days of taking the antibiotic. It’s a diffuse rash that may appear over several areas of the body, feels rough to touch, and is usually red. It’s called a delayed rash and, though it can be very impressive, it is a benign rash. If the patient takes the same antibiotic, it may not happen again. That’s not a rash that will transform into anaphylaxis. It’s very important to distinguish that type of delayed rash from an immediate reaction, which usually occurs within a couple of hours after antibiotic administration. This type of rash is hives and can be associated with anaphylaxis. She again emphasizes that after 10 years, 8 out of 10 patients who had a true penicillin allergy will overcome that allergy. Most people think or fear that if they had an allergy it’s a lifelong situation—and that’s not the case.

 

Fabre states that, if the patient is having an elective surgery, there’s time to assess the patient and determine if the patient can have the recommended beta-lactam for surgical prophylaxis.

 

She further notes that understanding responses to previous antibiotics may also be helpful. For example, if a patient is allergic to penicillin, there is a 95% chance of being allergic to amoxicillin too. Why? Because those two antibiotics are very similar. But a patient allergic to penicillin is highly unlikely to have a reaction to a third-or a fourth-generation cephalosporin. Knowing that a patient tolerated a cephalosporin in the past can be very helpful.

 

Some hospitals will have an allergy clinic where they can perform a skin test to confirm the presence or absence of the allergy. Other hospitals will do a test challenge, in which the patient takes a smaller dose of the antibiotic and is observed for reactions. These protocols can be driven by pharmacy, nursing, allergy, physicians, and advanced practitioners based on local experience. Antibiotic recommendations for patients with true contraindications should be developed by a multidisciplinary team, including antibiotic stewardship, infectious diseases or hospital epidemiology and infection prevention, anesthesia, and surgery to ensure appropriate alternatives based on local epidemiology.

 

Fabre notes that Johns Hopkins has an antimicrobial stewardship toolkit that includes a section on penicillin allergy:

 

There are, of course, costs and delays associated with the need for penicillin allergy testing prior to surgery. Recently, Australian researchers developed a clinical decision rule to identify low-risk penicillin allergies that potentially do not require penicillin skin testing by a specialist (Trubiano 2020). They looked at 622 patients who had been allergy-tested to derive the clinical decision rule. Patients who reported a penicillin allergy underwent penicillin allergy testing using skin prick, intradermal, or patch testing and/or oral challenge (direct or after skin testing). The 4 features associated with a positive penicillin allergy test result on multivariable analysis were summarized in the mnemonic “PEN-FAST”: penicillin allergy five or fewer years ago, anaphylaxis or angioedema, severe cutaneous adverse reaction (SCAR), and treatment required for allergy episode. They assigned points for major and minor criteria: allergy event occurring 5 or fewer years ago (2 points), anaphylaxis/angioedema or SCAR (2 points), and treatment required for an allergy episode (1 point). For internal validation, a cutoff of less than 3 points for PEN-FAST was chosen to classify a low risk of penicillin allergy, for which only 17 of 460 patients (3.7%) had positive results of allergy testing, with a negative predictive value of 96.3%. External validation resulted in similar findings.

 

The authors conclude that PEN-FAST is a simple rule that accurately identified low-risk penicillin allergies that do not require formal allergy testing. The results suggest that a PEN-FAST score of less than 3, associated with a high negative predictive value, could be used by clinicians and antimicrobial stewardship programs to identify low-risk penicillin allergies at the point of care.

 

Think about the numbers here. For patients who have a “history” of penicillin allergy, which accounts for about 10% of patients undergoing surgery, there is a potential to reduce their risk of incurring a surgical site infection by up to 50% by doing penicillin allergy testing or assessment. There are very few interventions we do that can reduce SSI risk by 50%! We’re surprised more healthcare systems have not begun to incorporate formal penicillin allergy programs into their preoperative assessment programs.

 

Of course, it’s not just in the surgery patient for whom assessment of the risk for penicillin allergy exists. There are many other infections where treatment with penicillin or other beta-lactam antibiotic would be preferable to other antibiotics.

 

This also raises the question about how we use our EHR’s to document allergies. In some, someone simply enters the name of a drug into an allergy field. Better EHR’s would prompt for a description of what sort of reaction occurred to that drug. And it reminds us that we need to ensure that such information gets updated in any other IT systems that may not be fully interoperable. Each healthcare organization or practice should also have protocols for who and how EHR data for allergies can be amended so that an inappropriate designation of an allergy does not get perpetuated.

 

Recent comprehensive reviews of penicillin allergy have appeared in the New England Journal of Medicine (Castells 2020) and JAMA (Shenoy 2019).

 

The Castells review concludes that, in contemporary clinical practice, more than 90% of patients labeled as allergic to penicillin can safely receive the drug. They note that, on average, 8 to 15% of unselected international patients are labeled as allergic to penicillin, meaning that many patients labeled as allergic to penicillin could safely receive it.

 

The Shenoy review notes that the goals of antimicrobial stewardship are undermined when reported allergy to penicillin leads to the use of broad-spectrum antibiotics that increase the risk for antimicrobial resistance, including increased risk of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus, or the risk of developing Clostridium difficile infection. The authors suggest that direct amoxicillin challenge is appropriate for patients with low-risk allergy histories and moderate-risk patients can be evaluated with penicillin skin testing, which carries a negative predictive value that exceeds 95% and approaches 100% when combined with amoxicillin challenge.

 

 

References:

 

 

Blumenthal KG, Ryan EE, Li Y, et al. The impact of a reported penicillin allergy on surgical site infection risk. Clin Infect Dis 2018; 66(3): 329-336

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5850334/

 

 

Aronson S, Murray S, Martin G, et al. Roadmap for transforming preoperative assessment to preoperative optimization. Anesth Analg 2020; 130: 811-819

https://journals.lww.com/anesthesia-analgesia/Abstract/2020/04000/Roadmap_for_Transforming_Preoperative_Assessment.4.aspx

 

 

Blumenthal K. Do you really have a penicillin allergy? Harvard Health Blog 2019; February 26, 2019

https://www.health.harvard.edu/blog/do-you-really-have-a-penicillin-allergy-2019022616017

 

 

Sunshine WL. Perioperative Antibiotics and Infection Prevention: Demystifying Penicillin Allergies. AORN Journal 2020; 111(5): 491-493 First published: 28 April 2020

https://aornjournal.onlinelibrary.wiley.com/doi/10.10-2/aorn.13016

 

 

Trubiano JA, Vogrin S, Chua KYL, et al. Development and Validation of a Penicillin Allergy Clinical Decision Rule. JAMA Intern Med 2020; Published online March 16, 2020

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2762878

 

 

Johns Hopkins Medicine. Toolkit to Enhance Nursing and Antibiotic Stewardship Partnership.

https://www.hopkinsmedicine.org/antimicrobial-stewardship/nursing-toolkit/index.html

 

 

Castells M, Khan DA, Phillips EJ, et al. Penicillin Allergy. N Engl J Med 2019; 381: 2338-2351

https://www.nejm.org/doi/full/10.1056/NEJMra1807761

 

 

Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and management of penicillin allergy: a review. JAMA 2019; 321(2): 188-199

https://jamanetwork.com/journals/jama/article-abstract/2720732

 

 

 

Print “Is This Patient Allergic to Penicillin?”

 





July 28, 2020 

Electrosurgical Safety

 

 

Electrosurgery and electrocautery are handy processes in the OR and are used in a variety of surgical procedures. Yet, complications related to electrosurgery are not uncommon. In our many columns on surgical fires and the “fire triangle” we’ve noted that electrosurgical devices are the heat source in over 90% of cases. And, electrosurgical devices are also one of the most common causes of iatrogenic burns. And, in our June 12, 2102 Patient Safety Tip of the Week “Lessons Learned from the CDPH: Retained Foreign Bodies” we noted that cautery tips are also one of the most common surgical items inadvertently retained. Some studies have also identified hemorrhage and mechanical failure as adverse consequences of electrosurgery. Some may produce electromagnetic interference that might interfere with implanted medical devices. Lastly, these devices are primary causes of surgical smoke, which may have deleterious effects on those present in the OR.

 

Though we usually lump electrocautery and electrosurgery together, they are technically not the same thing (Mir 2017). In electrocautery, current does not pass through the patient, whereas in electrosurgery there is passage of high frequency alternating electrical current through living tissue to achieve varying degrees of tissue destruction. Also, electrosurgery produces electromagnetic interference and, thus, can interfere with implanted medical devices. But, for the rest of today’s column, we’ll continue lump electrocautery and electrosurgery together.

 

Overbey et al (Overbey 2015) searched the FDA's Manufacturer and User Facility Device Experience (MAUDE) database for surgical energy-based device injuries and deaths reported over a 20 year period. They analyzed 178 deaths and 3,553 injuries. The most common complications were: thermal burns (63%), hemorrhage (17%), mechanical failure of device (12%), and fire (8%). While most events were identified intraoperatively, 9% were identified postoperatively and 9% after discharge. Thermal injury was the most common reason for death (39% of the 178 deaths). Mechanisms for thermal injury were direct application (30%), dispersive electrode burn (29%), and insulation failure (14%). Regarding surgical fires, they were most common with monopolar “Bovie”, especially when they were used in head and neck operations.

 

Burns and thermal injuries. Thermal burns are obviously the most frequent complication of electrocautery and electrosurgery, but there are several mechanisms for such thermal injuries. Our September 5, 2017 Patient Safety Tip of the Week “Another Iatrogenic Burn” discussed in detail thermal burns related to electrosurgery or electrocautery. We began with a case reported by the California Department of Public Health (CDPH 2017) in which a patient undergoing bilateral knee replacement surgery suffered a full-thickness thermal injury, related to an electrocautery device that had been set down on the patient without holstering it. See that column for details of the case.

 

Mundinger et al. (Mundinger 2007) noted that intraoperative electrocautery burns can be divided into at least 4 categories:

1. direct contact burns resulting from inappropriate operator use of the active electrode
2. burns at the grounding electrode site due to improper attachment or placement
3. burns resulting from electrode heating of pooled solutions
4. burns occurring outside the operative field as a result of circuits generated between the active electrode and an alternate grounding source

Of course, the fifth category would be burns resulting from surgical fires triggered by electrosurgical devices in an oxygen-rich environment.

 

The above CDPH case is an example of a direct contact burn related to failure to holster the electrocautery device and subsequent contact with a patient’s skin. Burns more commonly can develop related to current flow when monopolar electrocautery devices are used. Saaiq et al. (Saaiq 2012) reported on 3 cases of full-thickness deep burns related to the grounding pad of electrocautery systems. All 3 of their cases involved use of monopolar cautery and improper placement of the grounding electrode. The authors note that when the grounding pad is misapplied and loose, this may cause heat generation and sparking at the contact site, without providing an appropriate exit for the current to pass safely through the circuit. Saaiq et al. had the following recommendations:

• The surgeon himself should have a proactive attitude and personally ensure that the grounding pad is adequately applied with firm contact to the skin over an adequate surface area
• Preferably it should be secured to the skin with a crepe bandage
• An area of at least 70 cm² of firm skin-pad contact should be ensured
• Special care should be exercised to re-check the position of the pad if the patient’s position is changed intraoperatively
• One may employ the newer grounding pads with adhesive properties that firmly attach them to skin
• The diathermy machine’s active alarm system will also help to limit the extent of the resultant burn injury
• If a bipolar cautery is employed the risk of grounding pad burns can be eliminated altogether

 

The authors also note that the electrical current can also run between the active electrode and an alternate grounding source. They note the case described by Mundinger et al. (Mundinger 2007) in which a patient had the grounding pad on her lateral thigh but burns occurred on her forehead related to titanium plates previously implanted in her skull. Mundinger et al. also noted that burns resulting from aberrant circuits have been reported at sites of electrocardiographic lead placement, temperature probe insertion, uninsulated surgical table contact with the patient, intra-arterial line placement, motor-evoked potential monitoring electrode placement, and electroencephalogram electrode placement. That’s pretty scary! How many people would even consider the potential impact of remote hardware in or on a patient’s body?

 

Mundinger et al. note that similar burns at sites of contact remote from the operative field and the normal grounding pad may occur on areas of uninsulated surgical table contacting the patient, electrocardiographic leads, temperature probe insertion sites, and sites of placement of various other monitoring devices.

 

While many thermal injuries from electrosurgery occur on the surface or in the direct visual field of the operator, don’t lose sight of the fact that thermal injuries related to electrocautery devices can also occur internally during surgery. Such are well known to structures such as bowel and ureters. Such injuries are often not recognized during the procedure and result in tissue necrosis and delayed manifestations of symptoms. In fact, most electrothermal injuries to the bowel (approximately75%) are unrecognized at the time of occurrence (Alkatout 2012). The result of an unrecognized bowel injury is usually serious, often leading to long-term complications. Alkatout et al. note that small bowel, especially the ileum, is most frequently involved, and the injury may not cause clear cut or rapid symptoms or abnormal laboratory values. Generally speaking, symptoms of bowel perforation following electrothermal injury are usually seen 4 to 10 days after the procedure.

 

Kaya et al. (Kaya 2016) also described iatrogenic burns related to electrocautery devices. The authors discussed the differences between the two types of electrocautery, namely “unipolar” (or “monopolar”) and “bipolar,”. They made the following recommendations:

• The patient should be examined for any metal implants, and any jewelry should be removed.
• The plates to be used must be of suitable size for the surface area and must fully contact the patient’s skin surface.
• The plate must be placed close to the surgery site, on a smooth, hairless, clean, dry, and well-vascularized muscle.
• The plate must be properly placed on the patient before the surgery and should be regularly checked in long-lasting procedures, and measures such as cold compression should be taken in case of temperature increase.
• Cut and burn settings of the cautery are of further importance. Cut and burn settings of the cautery device should be verified prior to the procedure by both the surgeon and the OR team.
• Necessary information should be given to the healthcare staff about the installation and connections of the equipment, proper placement of the cautery plate, monitoring of the plate during the procedure, and aspects that need the attention of the user.

 

A 2018 FDA communication with recommendations to reduce surgical fires also had several good recommendations related to electrosurgical devices in general (FDA 2018). It recommended all instruments should be inspected for evidence of insulation failure (device, wires, and connections) prior to use. Those with defects should not be used. It noted that monopolar energy use can directly result in unintended patient burns from capacitive coupling and intra-operative insulation failure. So, it had specific recommendations if a monopolar electrosurgical units (ESU) is used:

• Do not activate when near or in contact with other instruments.
• Use a return electrode monitoring system.
• Tips of cautery instruments should be kept clean and free of char and tissue.
• When not in use, place ignition sources, such as ESU’s, electrocautery devices, fiber-optic illumination light sources and lasers in a designated area away from the patient (e.g., in a holster or a safety cover) and not directly on the patient or surgical drapes.

 

Insulation failure. Another common issue with electrosurgical devices is insulation failure. Small amounts of current can leak through tiny breaks and minute cracks in the instrument's shaft (Bilski 2020). Then, current can stray from the intended energy path, causing small electrical burns to non-targeted tissue and cause thermal injury. Such defects have been found in up to 20% of laparoscopic instruments and up to 50% of instruments used during robotic surgery. Disposable instruments have a lower incidence of insulation failure compared with reusable instruments (Alkatout 2012). The distal third of laparoscopic instruments is the most common site of insulation failure. Obviously, meticulous inspection of electrosurgical instruments should be undertaken before every use. The instruments should also be tested before use.

 

Surgical smoke is a concern any time electrosurgery is used. The smoke generated during electrosurgical procedures can potentially contain viruses (such as HPV), bacteria, cancer cells, hazardous chemicals, and other fine, particulate matter. In the COVID-19 pandemic era, we’d also be concerned that coronavirus might also be aerosolized in surgical smoke, though it is not yet known whether that happens (AORN 2020a). It's recommended you use smoke evacuation systems and fit-tested surgical N95 masks during procedures in which electrosurgery is used. The AORN Go Clear Award Program (AORN 2020b) has numerous resources and recommendations about surgical smoke generated by electrosurgery devices and any other type of device.

 

Surgical fires. We’ve, of course, discussed electrosurgical devices extensively in our many columns on surgical fires (see list below). They are the heat source in over 90% of surgical fires. The most important intervention needed is good communication between the surgeon and the anesthesiologist. The surgeon must announce in advance his/her intent to use the electrocautery/electrosurgery device so that the anesthesiologist can temporarily halt the flow of oxygen while a heat source is about to be used. Similarly, good communication with nursing staff is important to ensure that any alcohol-based skin disinfectant has had adequate time to dry before use of the electrosurgical device.

 

Electromagnetic interference. Lastly, we mentioned that some electrosurgical devices produce electromagnetic interference and, thus, can interfere with implanted medical devices. It is always wise to know what implantable medical devices your patient may have and whether use of your electrosurgical device might interfere with that.

 

 

There are a variety of simple tools out there to remind you of safe electrosurgical practices. Jaisa Olasky, M.D., offered the following 10 tips for safer electrosurgery (Olasky 2018):

• Always use the lowest power setting possible to get the effect you want
• Understand the true functions of cut and coag
• Understand that technique is as important as choosing the right settings
• Understand proper placement for dispersive electrodes
• Choose the right instrument for the case
• Beware of insulation failures
• Beware that injuries can happen outside the field of vision
• Make sure everyone knows where the foot pedal is
• Take smoke evacuation seriously
• Understand the fire triangle

 

Similarly, Alkatout et al. (Alkatout 2012) had this list of safety measures for prevention of electrosurgical complications:

• Inspect insulation carefully
• Use the lowest possible power setting
• Use a low-voltage waveform (cut)
• Use brief intermittent activation
• Do not activate in open circuit
• Do not activate in close proximity or direct contact withanother instrument
• Use bipolar electrosurgery when appropriate
• Select an all metal cannula system as the safest choice
• Utilize available technology (tissue response generator,active electrode monitoring) to eliminate concerns aboutinsulation failure and capacitive coupling

 

There are also several safety checklists for electrosurgery available (ECRI 2020, 3M 2020, Bovie 2019). These are very practical. The 3M checklist also has a nice list of “do’s and don’ts”.

 

 

 

Our prior columns on iatrogenic burns:

• March 2009 “Risk of Burns during MRI Scans from Transdermal Drug Patches”
• June 1, 2010 “Iatrogenic Burns”
• October 5, 2010 “More Iatrogenic Burns”
• December 23, 2014 “Iatrogenic Burns in the News Again”
• March 2015 “Another Source of Iatrogenic Burns”
• September 5, 2017 “Another Iatrogenic Burn”
• June 5, 2018 “Pennsylvania Patient Safety Authority on Iatrogenic Burns”

 

 

Our prior columns on surgical fires:

 

• December 4, 2007       “Surgical Fires”
• April 29, 2008             “ASA Practice Advisory on Operating Room Fires”
• November 2009          “ECRI: Update to Surgical Fire Prevention”
• January 2011               “Surgical Fires Not Just in High-Risk Cases”
• March 2011                 “APSF Fire Safety Video”
• November 2011          “FDA Initiative on Preventing Surgical Fires”
• December 13, 2011     “Surgical Fires Again”
• April 24, 2012             “Fire Hazard of Skin Preps Oxygen”
• April 2013                  “Reminder: Hand Sanitizers Are Flammable”
• June 25, 2013              “Update on Surgical Fires”
• October 1, 2013          “Fuels and Oxygen in OR Fires”
• August 12, 2014         “Surgical Fires Back in the News”
• December 16, 2014     “More on Each Element of the Surgical Fire Triad”
• December 2015           “Unique Ignition Sources in Surgical/OR Fires”
• January 10, 2017         “The 26-ml Applicator Strikes Again!”
• January 9, 2018           “More on Fire Risk from Surgical Preps”
• June 2018                    “ISMP on Fire Risk from Skin Preps”
• July 2018                    “FDA on Surgical Fires”
• September 11, 2018    “Lessons from a Surgical Fire”
• May 7, 2019                “Simulation Training for OR Fires”
• July 2019                    “Surgical Fire – A New Risk Factor”

 

 

References:

 

 

Mir MR, Shou-en Sun G, Wang CM. Electrocautery. Medscape 2017; Dec 14, 2017

https://emedicine.medscape.com/article/2111163-overview

 

 

Overbey DM, Townsend NT, Chapman BC, et al. Surgical Energy-Based Device Injuries and Fatalities Reported to the Food and Drug Administration. J Am Coll Surg 2015; 221(1): 197-205.e1

https://www.journalacs.org/article/S1072-7515(15)00236-7/fulltext

 

 

CDPH (California Department of Public Health). Complaint Intake Number CA00397790; August 31, 2017

https://www.cdph.ca.gov/Programs/CHCQ/LCP/CDPH%20Document%20Library/Hospital%20Administrative%20Penalties/Riverside/2017-2567LomaLindaUnivMC.pdf

 

 

Mundinger GS, Rozen SM, Carson B et al. Full-thickness fore-head burn over indwelling titanium hardware resulting from an aberrant intraoperative electrocautery circuit. Eplasty 2007; 8: 1-7 Published December 4, 2007

http://www.eplasty.com/index.php?option=com_content&view=article&id=72&catid=145:volume-08-eplasty-2008

 

 

Saaiq M, Zaib S, Ahmad S. Electrocautery burns: experience with three cases and review of literature. Ann Burns Fire Disasters 2012; 25(4): 203-206. Published online 2012 Dec 31

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3664530/pdf/Ann-Burns-and-Fire-Disasters-25-203.pdf

 

 

Alkatout, I., Schollmeyer, T., Hawaldar, N. A., Sharma, N., & Mettler, L. (2012). Principles and safety measures of electrosurgery in laparoscopy. JSLS : Journal of the Society of Laparoendoscopic Surgeons 2012; 16(1): 130-139

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3407433/pdf/jls130.pdf

 

 

Kaya B, Çelik B, Çerkez C, et al. Iatrogenic Burns. Turkish Journal of Plastic Surgery 2016; 24(1): 35-38

http://www.turkjplastsurg.org/sayilar/1/buyuk/35-381.pdf

 

 

FDA (US Food and Drug Administration). Recommendations to Reduce Surgical Fires and Related Patient Injury: FDA Safety Communication. FDA 2018; May 29, 2018

https://www.fda.gov/medical-devices/safety-communications/recommendations-reduce-surgical-fires-and-related-patient-injury-fda-safety-communication

 

 

Bilski J. Electrosurgery Safety Essentials. A back-to-basics approach is more critical than ever for your surgeons, staff and patients. Outpatient Surgery Magazine 2020; XXI(4): April 2020

http://www.outpatientsurgery.net/surgical-services/electrosurgery/electrosurgery-safety-essentials--04-20

 

 

AORN. (Association of periOperative Registered Nurses). Smoke and COVID-19 FAQs. AORN 2020

https://aorn.org/education/facility-solutions/aorn-awards/aorn-go-clear-award/faq

 

 

AORN. (Association of periOperative Registered Nurses). AORN Go Clear Award Program. Accessed July 2020

https://aorn.org/goclear

 

 

Olasky J. 10 Tips for Safer Electrosurgery. Use these guidelines to keep both patients and staff safe. Outpatient Surgery Magazine 2018; September 2018

http://www.outpatientsurgery.net/_media/pop/print-article?id=15529

 

 

ECRI Institute. Electrosurgery Checklist. ECRI 2020

http://www.mdsr.ecri.org/summary/detail.aspx?doc_id=8271

 

 

3M Healthcare. Electrosurgical Procedure Safety Checklist. Accessed July 2020

https://multimedia.3m.com/mws/media/343115O/electrosurgical-procedure-safety-checklist-with-dos-and-donts.pdf

 

 

Bovie. 9 Safety Precautions for Electrosurgery. Bovie 2019

http://www.boviemedical.com/2015/10/05/9-safety-precautions-for-electrosurgery/

 

 

 

Print “Electrosurgical Safety”

 





August 4, 2020 

Intravenous Issues

 

 

For some time we had been planning a column on issues related to various intravenous issues. A recent safety bulletin from ISMP Canada prompted us to do that column now.

 

ISMP Canada (ISMP Canada 2020) analyzed over 1500 incidents related to intravenous issues and found several underlying themes:

• Handling and logistic challenges
• Administration errors
• Issues related to IV devices, supplies, or other equipment

 

Handling and logistic challenges included subthemes: inappropriate timing, incompatibilities, incorrect labelling, and improper storage/expired product. Subthemes under administration errors included: wrong patient, wrong drug, wrong dose, wrong route, and wrong rate. Issues related to IV devices, supplies, or other equipment included pump programming issues, clamps, tubing, ­filters, and syringes. Also included were other issues, such as problems with batteries, printers, pump malfunction, and turning on/off.

 

While the majority of errors occurred during the administration stage of medication use (56.7%), errors also occurred during order entry/transcription (20.1%), and dispensing/delivery (14.5%). One in 10 incidents resulted in patient harm. The top 5 drugs in incidents causing patient harm were morphine, heparin, hydromorphone, piperacillin/tazobactam, and vancomycin.

 

Labeling issues often led to miscommunication. Calculations or instructions on the labels sometimes led to confusion with pump programming. For example, drug concentration or infusion rates on the MAR or on the infusion bag label often did not align with the pump programming units or sequence. One example was that calculation instructions for a pharmacy technician on the label were misread as programming information for the nurse.

 

Delays or miscommunication related to transport or portering of medication were also contributing factors

 

One very important theme that we’ve heard before from both ISMP Canada and ISMP US is over-reliance on technology, such as smart pump and bar-code technology (see our Patient Safety Tips of the Week for August 23, 2016 “ISMP Canada: Automation Bias and Automation Complacency” and June 11, 2019 “ISMP’s Grissinger on Overreliance on Technology”). The found that failure to perform an independent double check before IV medication administration (to verify and document the patient’s name, the drug and its concentration, the prescribed infusion rate, the line attachments and labels), was a key contributing factor in many of these incidents. We’ve discussed the pros and cons of double checks in many columns (listed below) but clearly there is a role for double checks, which should be done in a truly independent fashion, in medication safety.

 

One very interesting finding was the role of unfamiliarity with devices. That was especially a problem when inexperienced or relief staff were used. With infusion pumps, that may be related to the wide variety of pumps available on the market. The user interfaces might not be familiar to such staff. Programming sequences might differ or the metrics preprogrammed into the pumps might differ. Another problem with infusion pumps was that drug libraries or rates were sometimes incomplete. Our several prior columns on infusion pump problems are listed below.

 

Accessories were sometimes problematic. For example, a filter might be missing or correct tubing might not be available. Some items the ISMP Canada includes under “accessories” are not surprising to us, but others are surprising. One is pump failure due to inadequate maintenance and/or battery charge. Not surprising, given our February 4, 2014 Patient Safety Tip of the Week “But What If the Battery Runs Low?”. But they also identified one we had never thought about - printer-related issues, such as low ink levels resulting in illegible reports.

 

Problems with misidentification of IV lines continues to be a problem. ISMP Canada noted improper labelling of the IV line and transposition of IV lines after temporary disconnection as contributing factors. Our many columns on hazards of intrahospital transports, especially to the radiology suite, have emphasized the latter issue. Your “Ticket to Ride” checklist for intrahospital transports should highlight the need for accurate reconnection of any IV lines. So many of our patients today have multiple IV lines, so it is easy to mix them up. In addition to proper labeling of lines, many hospitals have used colored tags to help identify lines and their proper connections. One very interesting concept in the works is use of fiber optics to light up IV lines to facilitate correct identification (Vega 2019).

 

ISMP’s Michael Cohen (Cohen 2018) published an important article in 2018 about avoiding some common pitfalls in developing plans to reduce the likelihood of a recurrent incident. It happened to highlight cases of IV line transposition, in which a hospital suffered an IV line transposition accident, implemented what they thought was a solution, only to suffer a second similar accident within a few months.

 

In the index case, the patient “was receiving continuous IV infusions of octreotide and norepinephrine. Both infusions had been compounded by the pharmacy in 250-mL bags, so they were similar in size, and both were placed in brown overwraps to protect the medications from light, making them similar in appearance. They also had similar-looking pharmacy-applied labels on the overwraps. When the volume in both infusions was nearing completion, new infusion bags were hung simultaneously but were interchanged in error. The octreotide bag was spiked with the IV administration set that was loaded into the infusion pump programmed for norepinephrine, and the norepinephrine bag was spiked with the IV administration set that was loaded into the infusion pump programmed for octreotide. As a result, the patient received an overdose of norepinephrine and a subtherapeutic dose of octreotide.”

 

The hospital implemented what it felt were logical interventions to prevent a recurrence:

• Label all infusion lines between the pump and the infusion bag so the label is visible during bag changes
• Trace all infusion lines from the patient, through the pump, and to the medication to verify the correct route of administration, pump, and line prior to starting an infusion or changing the bag
• Use the existing barcode point-of-care (BPOC) system to scan each infusion at the bedside prior to set-up and administration (previous practice had been to “pre-scan” the infusions upon receipt from the pharmacy).

 

But, within a few months, a second very similar incident occurred despite those interventions. A cardiac patient was receiving continuous IV infusions of norepinephrine and EPINEPHrine. When new infusion bags were needed for both vasopressors after a procedure in the cardiac catheterization lab, a nurse (who was not involved in the prior event) inadvertently switched the 2 medications while replacing the bags. The IV lines had been labeled. However, the labels had been placed between the patient and the pump, not between the pump and infusion bag as required by the new policy. Because the labels were below the pumps, and the nurse had not traced the IV lines from the patient to the medication per policy, the nurse did not even notice the labels on the tubing. Like the previous error, both medications were similar in appearance, having been compounded by the pharmacy in 250-mL bags, placed in light-protective overwraps, and labeled with similar-looking pharmacy-applied labels.

 

Cohen pointed out that hospital relied too much on a process prone to human error (i.e. it stressed nurse vigilance as the primary action). That action plan also included a component (the barcoding piece) that would not be expected to have any effect on preventing a recurrent event. While such bedside barcoding is good practice to ensure the medication and the patient are correct, it does not prevent attaching the wrong medication to the wrong IV tubing. Perhaps most importantly, the hospital failed to address what was, arguably, the most important contributing factor: the IV bags were the same size and were wrapped in the same style overwrap, and labeled with similar-looking pharmacy-applied labels.

 

You should read the Cohen article for an excellent discussion on proper design and implementation of action steps following an untoward incident. We’ve just included it here because of its relevance to the issue of intravenous mistakes.

 

Kuitunen and colleagues did a series of articles earlier this year on hospital intravenous medication errors. In the first (Kuitunen 2020a) they did a systematic review of the literature on causes of such errors. Pretty much as you’d expect, they found systemic errors in all phases of the medication use process (prescribing, preparation, administration, dispensing and storage, and treatment monitoring. Administration, prescribing, and preparation were the process phases most prone to systemic errors. Leading causes were insufficient actions to secure safe use of high-alert medications, lack of knowledge of the drug, calculation tasks, failure in double-checking procedures, and confusion between look-alike, sound-alike medications.

 

In the follow up article (Kuitunen 2020b) they looked at systemic defenses to prevent intravenous medication errors. In the literature they found features of closed-loop medication management systems appeared in 61% of the studies, with smart pumps being the defense most widely studied (24%). However, in general, the evidence quality of the included articles was limited and few were of high quality. Of the systemic defenses identified, 52% were related to administration, 18% prescribing, 13% preparation, 4% monitoring, and 2% dispensing.

 

Computerized orders and decision support systems were found to contribute toward safe dispensing, administration, and treatment monitoring by preventing errors related to interpretation of orders, calculation tasks, and follow-up. Other systemic defenses included prefilled syringes and color-coded systems, which were found to reduce errors in high-risk environments and situations, such as operating rooms and resuscitation.

 

The authors caution that, although smart infusion pumps were the systemic defense most widely studied, their effectiveness in preventing medication error remains unclear. They emphasize that the key component of smart pumps is the drug library containing predefined parameters for the drug type, strength, and dosing limits of specific drugs. They point out that “Soft” limits and alerts can be overridden by clinicians. Other problems include insufficient compliance in drug library use. Opportunities for improvement they cite include use of hard limits and integrating smart pumps with other systemic defenses, such as barcode readers and computerized physician order entry (CPOE), and real-time clinical data (e.g., glucose control and respiratory monitoring). They have a nice table that outlines error prevention components for each of the phases of the medication use system. Kuitunen and colleagues suggest that prevention of errors throughout the IV medication process requires integrating smart pumps into closed-loop medication management systems, such as electronic patient records, clinical pharmacist review of orders, automated compounding systems, barcode verification at the bedside, and real-time clinical monitoring data.

 

Flushing IV lines is always fraught with the risk that you might inadvertently use a dangerous solution to flush with. Most of you remember the series of disastrous incidents where high concentration heparin was used to flush lines (see our What's New in the Patient Safety World columns for December 2007 “1000-fold Heparin Overdoses Back in the News Again” and May 2008 “UK NPSA Alert on Heparin Flushes” and our July 15, 2008 Patient Safety Tip of the Week “Heparin Flushes.....Again!”). In our January 2020 What's New in the Patient Safety World column “ISMP Canada: Change Management to Prevent Recurrences” we discussed ISMP Canada’s simple, but practical, article on change management (ISMP Canada 2019). They described the steps taken by a hospital in response to two fatal pediatric incidents involving concentrated potassium solutions. One of those incidents involved the inadvertent use of concentrated potassium phosphate solution to flush an intravenous line.

 

One category of errors is the inadvertent intravenous administration of medications or substances that were intended for use via another route. The corollary is inappropriate administration in another route of a medication or substance that was intended to be administered intravenously. Each is usually met with disastrous consequences. We’ve done several columns on vincristine administered intrathecally rather than intravenously:

    December 2016 “Standardize 4 Safety and Just Bag It!”

    June 2017 “Just Bag It Campaign Success Story”

    January 2018 “Eliminating Vincristine Administration Events”

    June 12, 2018 “Adverse Events in Cancer Patients”

The Just Bag It! campaign calls for health care professionals to always dilute vincristine in a 50ml mini-IV drip bag and never in a syringe to minimize the risk of such incidents. We’ve also done columns on inadvertent spinal injection of tranexamic acid (see our Patient Safety Tips of the Week for June 4, 2019 “Medication Errors in the OR – Part 3” and July 9, 2019 “Spinal Injection of Tranexamic Acid”).

 

And it is not just drugs intended for spinal use that might get injected intravenously. A recent AHRQ Web M&M described cases where solutions intended for bladder irrigation were instead hooked up to patients’ intravenous lines (Bohringer 2020). It is recommended that irrigation fluids should be clearly labelled as “For Irrigation Only” and the label should be made in a bright noticeable color. “This label should also be large and ideally cover about a third of the size of the fluid bag. The label should be attached to the bag of fluid as soon as an additive has been injected because this additive now has effectively converted the bag of intravenous fluids into an irrigation solution. Irrigation solutions should not be stored in the same location as intravenous fluids once they have been prepared. Consideration should be given for irrigation solutions to be prepared in pharmacy and appropriately labelled there.”

 

Intravenous fluids and irrigation fluids should ideally not be suspended together from the same IV pole. Intravenous and irrigation fluid bags should always be spiked with their respective tubing right after they are hung on the pole. It should be easy to visually distinguish the irrigation tubing from the IV tubing. Irrigation specific tubing and connectors should be employed whenever available. Designating a pole for exclusive use with irrigation fluid also has been described as a useful strategy to prevent this type of error.1 Hanging bags of fluid from poles when they are not connected to any tubing is bad practice and should be avoided.

 

Bohringer also encourages industry to develop bags and tubing of different colors for irrigation solutions in the same way that they have developed yellow tubing to clearly distinguish epidural infusion lines from intravenous lines.

Most intravenous medications are administered via infusion, but some are administered by a “push” or bolus. ISMP in 2015 issued “Safe Practice Guidelines for Adult IV Push Medications” (ISMP 2015). But those guidelines are not always adhered to. A follow up survey in 2018 (ISMP 2018) showed numerous risky practices associated with the administration of IV push medications continued. These included the withdrawal of medications from prefilled syringes or cartridges, unnecessary dilution of IV push medications, and nurse preparation or manipulation of IV push medications at the bedside. Although the 2018 survey showed a reduction in some of these unsafe practices, many practitioners still reported using prefilled syringes or cartridges as vials, diluting IV push medications despite their availability in a ready-to-administer form, unsafe labeling practices, and preparing IV medications at the bedside. These were not always just due to human error alone. Other factors contributing to them included Some of these unsafe practices appear to be associated with ongoing drug shortages, system vulnerabilities, and/or teaching strategies that perpetuate these practices.

 

Withdrawing medications from a prefilled syringe (or cartridge) and transferring into another syringe to administer some or all of an IV push medication dose is considered an unsafe practice. Yet 66% of respondents reported withdrawing medications from a prefilled syringe (or cartridge) and transferring into another syringe to administer some or all of an IV push medication dose, and 16% do this more than half of the time they encounter a prefilled syringe.

 

As many as 1 in every 5 participants still reported in 2018 that they sometimes, often, or always dilute medications provided in multiple-dose vials (21%) or manufacturer’s prefilled syringes (16%), another practice considered unsafe. Opioids, anxiolytics/antipsychotics, and antiemetics were the most frequently diluted medications. Such dilution was often carried out using a prefilled saline flush syringe and seldom was that included on the label of the final product.

 

Labeling was another issue. Only half the participants always label IV push medications that are self-prepared away from the patient’s bedside. This sometimes results in a nurse carrying multiple unlabeled syringes at one time.

 

Training plays a role in perpetuation of some unsafe practices. Most respondents were taught how to administer IV push medications earlier in their career or current position, often being told to dilute the IV push medications.

 

The rate of administration of a drug may be very important from a safety perspective. But that rate is not always provided on the patient’s medication administration record or electronic health record. Some respondents said they need to look up the rate of administration in drug references (41%), in facility-specific guidelines (40%), or remember the rate from previous administrations (41%), and 18% said they administer all IV push medications over 2 to 5 minutes, so they don’t need to look up or know the specific rate of administration for each drug. To control how fast they are administering IV push medications, 82% use a clock, watch, phone, or other timing device. To administer the dose over the desired timeframe, 38% stated that they give small incremental doses frequently, whereas 30% said they just apply constant pressure on the plunger. In our March 2017 What's New in the Patient Safety World column “Loading Doses Again” we discussed how the recommended rates of administration of loading doses of phenytoin or fosphenytoin are often not adhered to, resulting in adverse cardiac effects.

 

Lastly, there is one type of chemotherapy adverse event we consider unforgivable. That is when a chemotherapy drug intended to be infused over several days gets infused much more rapidly (see our Patient Safety Tips of the Week for September 11, 2007 “Root Cause Analysis of Chemotherapy Overdose”, April 6, 2010 “Cancer Chemotherapy Accidents”, September 15, 2015 “Another Possible Good Use of a Checklist”, and June 12, 2018 “Adverse Events in Cancer Patients”). In those columns on home infusion chemotherapy we noted no one seems to be asking “what is the highest dose that a patient could tolerate in one day (or less) if there was inadvertent administration of the whole infusion?”. A safety culture would design the protocol with sublethal dosages that would protect the patient in the event of “what can go wrong will go wrong”. It also would not put the healthcare workers at the “sharp end” in a situation none of us would want to be in. Why would you ever expose a patient to the risk of a fatal overdose just for the sake of convenience of the patient, healthcare professional or payer?

 

 

Some of our other columns on medication errors:

 

December 2007           “1000-fold Heparin Overdoses Back in the News Again”

May 2008                    “UK NPSA Alert on Heparin Flushes”

July 15, 2008              “Heparin Flushes.....Again!”

March 24, 2009           “Medication Errors in the OR”

May 20, 2014              “Ophthalmology: Blue Dye Mixup”

September 2014          “Another Blue Dye Eye Mixup”

November 3, 2015      “Medication Errors in the OR - Part 2”

December 1, 2015       “TALLman Lettering: Does It Work?”

May 2016                    “Name Confusion in the Pharmacy”

May 24, 2016              “Texting Orders – Is It Really Safe?”

July 2016                    “ISMP Updates TALLman Lettering List”

August 23, 2016         “ISMP Canada: Automation Bias and Automation Complacency”

December 2016           “Standardize 4 Safety and Just Bag It!”

March 2017                 “Loading Doses Again”

March 2017                 “Yes! Another Voice for Medication e-Discontinuation!”

June 2017                    “Just Bag It Campaign Success Story”

August 2017               “Medication Errors Outside of Healthcare Facilities”

September 2017          “Safe Medication Use in the ICU”

January 2018               “Eliminating Vincristine Administration Events”

February 2018             “10 Years on the Wrong Medication”

May 8, 2018                “Heparin Overdose”

August 28, 2018         “Thought You Discontinued That Medication? Think Again”

September 2018          “ISMP Updates List of High-Alert Medications”

December 4, 2018       “Don’t Use Syringes for Topical Products”

December 11, 2018     “Another NMBA Accident”

December 18, 2018     “Great Recommendations for e-Prescribing”

January 1, 2019           “More on Automated Dispensing Cabinet (ADC) Safety”

February 5, 2019         “Flaws in Our Medication Safety Technologies”

February 12, 2019       “From Tragedy to Travesty of Justice”

March 5, 2019             “Infusion Pump Problems”

April 2019                   “ISMP on Designing Effective Warnings”

June 11, 2019              “ISMP’s Grissinger on Overreliance on Technology”

July 9, 2019                “Spinal Injection of Tranexamic Acid”

August 2019               “Including Indications for Medications: We Are Failing”

August 6, 2019           “Repeat Adverse Drug Events”

November 19, 2019    “An Astonishing Gap in Medication Safety”

February 4, 2020         “Drugs and Chronic Kidney Disease”

May 2020                    “PPSA on IV Vancomycin Safety”

June 16, 2020              “Tracking Technologies”

July 2020                    “Medication Dosage Miscalculations”

July 21, 2020              “Is This Patient Allergic to Penicillin?”

 

 

Some of our prior columns on medication errors in the OR:

 

March 24, 2009           “Medication Errors in the OR”

May 20, 2014              “Ophthalmology: Blue Dye Mixup”

September 2014          “Another Blue Dye Eye Mixup”

November 3, 2015      “Medication Errors in the OR - Part 2”

June 4, 2019                “Medication Errors in the OR – Part 3”

July 9, 2019                “Spinal Injection of Tranexamic Acid”

June 9, 2020                “Perioperative Medication Safety”

June 16, 2020              “Tracking Technologies”

 

 

Our prior columns related to infusion pump issues:

• May 2010 “FDA's Infusion Pump Safety Initiative”
• April 27, 2010 “Infusion Pump Safety”
• August 2016 “Home Infusion Therapy Pitfalls”
• March 5, 2019 “Infusion Pump Problems”
• March 2020 “ISMP Smart Infusion Pump Guidelines”

 

Some of our other columns on double checks:

 

January 2010               “ISMP Article on Double Checks”

October 26, 2010        “Confirming Medications During Anesthesia”

October 16, 2012        “What is the Evidence on Double Checks?”

December 9, 2014       “More Trouble with NMBA’s”

April 19, 2016             “Independent Double Checks and Oral Chemotherapy”

December 11, 2018     “Another NMBA Accident”

March 5, 2019             “Infusion Pump Problems”

August 27, 2019         “Double Check on Double Checks”

 

Some of our prior columns on vincristine administered intrathecally rather than intravenously:

 

December 2016           “Standardize 4 Safety and Just Bag It!”

June 2017                    “Just Bag It Campaign Success Story”

January 2018               “Eliminating Vincristine Administration Events”

June 12, 2018              “Adverse Events in Cancer Patients”

 

 

Some of our prior columns on medications administered intravenously rather than spinally or spinally rather than intravenously:

 

April 2010                   “RCA: Epidural Solution Infused Intravenously”

December 2016           “Standardize 4 Safety and Just Bag It!”

June 2017                    “Just Bag It Campaign Success Story”

January 2018               “Eliminating Vincristine Administration Events”

June 12, 2018              “Adverse Events in Cancer Patients”

July 9, 2019                “Spinal Injection of Tranexamic Acid”

 

 

 

 

References:

 

 

ISMP Canada. Intravenous Medication Safety: A Multi-Incident Analysis. ISMP Canada Safety Bulletin 2020; 20(7):  1-4 July 16, 2020

https://www.ismp-canada.org/download/safetyBulletins/2020/ISMPCSB2020-i7-IVMedsAnalysis.pdf

 

 

Vega M. This Healthcare Startup Lights Up IV Lines to Cut Out Human Error. Hypepotamus.com 2019; April 8, 2019

https://hypepotamus.com/companies/lightengale/

 

 

Cohen MR. Common Missteps with Medication Safety: Rolling a Single Dice, Ineffective Strategies, and Unexecuted Action Plans. Hospital Pharmacy 2018, 53(1): 25-28

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5805021/pdf/10.1177_0018578717747445.pdf

 

 

Kuitunen S, Niittynen I, Airaksinen M, Holmström A-R. Systemic Causes of In-Hospital Intravenous Medication Errors. A Systematic Review. Journal of Patient Safety 2020; Publish Ahead of Print January 31, 2020

https://journals.lww.com/journalpatientsafety/Abstract/publishahead/Systemic_Causes_of_In_Hospital_Intravenous.99231.aspx

 

 

Kuitunen SK, Niittynen I, Airaksinen M, Holmström A-R. Systemic Defenses to Prevent Intravenous Medication Errors in Hospitals, Journal of Patient Safety 2020;: Publish Ahead of Print March 14, 2020

https://journals.lww.com/journalpatientsafety/Abstract/9000/Systemic_Defenses_to_Prevent_Intravenous.99194.aspx

 

 

ISMP Canada. Change Management in Response to Preventable Tragedies. ISMP Canada Safety Bulletin 2019; 19(10): 1-5 December 12, 2019

https://www.ismp-canada.org/download/safetyBulletins/2019/ISMPCSB2019-i10-ChangeManagement.pdf

 

 

Bohringer C. Is that solution for IV or irrigation?: Fluid administration errors in the operating room. AHRQ PSNet WebM&M 2020; March 2020

https://psnet.ahrq.gov/web-mm/solution-iv-or-irrigation-fluid-administration-errors-operating-room

 

 

ISMP (Institute for Safe Medication Practices). ISMP Safe Practice Guidelines for Adult IV Push Medications; ISMP 2015

https://www.ismp.org/guidelines/iv-push

 

 

 

ISMP (Institute for Safe Medication Practices). Part I: Survey Results Show Unsafe Practices Persist with IV Push Medications. ISMP Medication Safety Alert! Acute Care Edition 2018; 23(22): November 1, 2018

https://www.ismp.org/resources/part-i-survey-results-show-unsafe-practices-persist-iv-push-medications

 

 

 

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August 11, 2020 

Above-Door Alarms to Prevent Suicides

 

 

In our September 3, 2019 Patient Safety Tip of the Week “Lessons from an Inpatient Suicide” we discussed an unfortunate suicide in which a patient used as an anchor the top of a corridor door to hang himself (OIG 2019), We noted that case was particularly ironic, because it occurred at a VA hospital. The VA system has produced so many valuable resources on suicide prevention that we now use in hospitals world-wide.

 

We summarized lessons learned from that case:

• Use a tool like the VA Mental Health Environment of Care Checklist (MHEOCC) to guide your environment of care rounds on your behavioral health units.
• Make sure all relevant staff are appropriately trained on the MHEOCC.
• Strongly consider use of over-the-door alarms on your corridor doors on behavioral health units.
• Make sure your responsible staff understand their role in your 15-minute (or other designated interval) observations and that they are not multi-tasking during those responsibilities. Audit compliance with these protocols.
• When your security cameras malfunction for any reason, make sure the reasons for such malfunctions are promptly addressed and corrected.
• Your leadership needs to take an active role in oversight of your inpatient behavioral health units.

 

Subsequently, VA researchers undertook a study of all VA medical centers having behavioral health units. Mills et al. (Mills 2020) searched VHA databases for reports of suicide deaths and attempts on inpatient mental health units from January 2008 (when VHA began using over-the-door alarms) to June 2019.

 

Of 389 suicide attempt and suicide death events, 179 (46.0%) were due to hanging, including 6 deaths. Of those 179 reports of hanging, 127 (71.0%) used doors as the anchor point, including 4 of the deaths.

 

Of the 127 RCA and safety reports of hanging on a door, 44 (34.6%) cases involved an over-the-door alarm. And in every case involving an over-the-door alarm, the patient did not die. In 2 cases the patients were contemplating hanging but did not because they were aware of the over-the-door alarms. In 2 other cases the alarm did not go off.

 

The authors conclude that, though the association is not proof, the findings suggest that many deaths were likely averted by over-the-door alarms.

 

Perhaps just as importantly, there were lessons learned from those alarms that failed to go off. They illustrate the importance of testing and checking the alarms on a regular basis, and of continuing regular rounds and checks on the unit even with the alarms. Note that some over-the-door alarms apparently are capable of triggering an alert when the alarm needs maintenance. We’d still recommend manually checking those alarms regularly.

 

The data reviewed by Mills and colleagues also included information about the materials used as lanyards/nooses for the attempted hangings. Sheets as the lanyard material to form the noose in 69.3% of the reports and clothing or pajamas in 19.6%. The authors admit it would be difficult to eliminate all the lanyard material on a mental health unit as patients will have some type of bedding and pajamas or other clothes. But they do describe anti-ligature bedding that uses a one-piece bed cover that is too thick to use as a lanyard for hanging. They suggest that, coupled with the use of over-the-door alarms help to mitigate the risk of a suicide death by hanging.

 

Two of the root causes identified in the RCA’s of all the cases were:

• access to anchor points
• lack of visibility of patients in private areas.

The authors note that over-the-door alarm technology helps eliminate these hazards by removing a reliable anchor point, and alerting staff to patient attempts when out of view.

 

Environmental hazards are root causes or contributing factors in most suicide attempts. You’ll, of course, recognize the lead author Peter Mills as the architect of the widely used VA Mental Health Environment of Care Checklist (MHEOCC) that we’ve discussed in many of our columns. That checklist is available online on the VA Patient Safety website, as is an excellent video narrated by Peter Mills, MD. In our February 14, 2017 Patient Safety Tip of the Week “Yet More Jumps from Hospital Windows” we mentioned 2 publications (Watts 2016, Mills 2016) showing sustained results from implementation of the Mental Health Environment of Care Checklist (MHEOCC). The checklist and program became mandated at all VA hospitals in 2007. Inpatient suicide rates in VA hospitals dropped from 4.2 per 100,000 admissions to 0.74 per 100,000 admissions from 2000 to 2015. The reduction in suicides coincided with introduction of the MHEOCC and has been sustained since implementation in 2007. The authors stress that the physical changes brought about by the MHEOCC likely have a bigger impact on inpatient suicide reduction than the numerous other interventions used.

 

While you probably should install over-the-door alarms on all doors in your behavioral health units, keep in mind there are other situations in which that is not practical:

• the suicidal patient who must be housed on a non-behavioral health unit because of concomitant medical problems
• the behavioral health patient who is on an intrahospital transport (for example, to radiology)

We’ve certainly seen attempted suicides by hanging on general med/surg units or in bathrooms in the Radiology suite. In fact, most of our columns on hospital suicides address suicides in those non-behavioral health parts of hospitals.

 

We don’t know if any of the over-the-door alarms are “portable” and might be moved to non-behavioral health units as needed. But we have previously recommended that general hospitals which often have to house potentially suicidal patients on their non-behavioral health units consider dedicating one or two rooms to have special design similar to rooms on behavioral health units. That could easily include ligature-resistant doors and over-the-door alarms.

 

 

Some of our prior columns on preventing hospital suicides:

 

• January 6, 2009 “Preventing Inpatient Suicides”
• February 9, 2010 “More on Preventing Inpatient Suicides”
• March 16, 2010 “A Patient Safety Scavenger Hunt”
• December 2010 “Joint Commission Sentinel Event Alert on Suicide Risk Outside Psych Units”
• September 27, 2011 “The Canadian Suicide Risk Assessment Guide”
• December 2011 “Columbia Suicide Severity Rating Scale”
• July 2012 “VA Checklist Reduces Suicide Risk”
• August 2013 “Suicide Attempts on Med/Surg Units”
• August 25, 2015 “Checklist for Intrahospital Transport”
• October 6, 2015 “Suicide and Other Violent Inpatient Deaths”
• March 2016 “TJC Sentinel Event Alert on Preventing Suicide”
• April 12, 2016 “Falls from Hospital Windows”
• February 14, 2017 “Yet More Jumps from Hospital Windows”
• August 29, 2017 “Suicide in the Bathroom”
• December 12, 2017 “Joint Commission on Suicide Prevention”
• July 10, 2018 “Another Jump from a Hospital Window”
• September 18, 2018 “More on Hospital Suicides”
• January 22, 2019 “Wandering Patients”
• January 29, 2019 “National Patient Safety Goal for Suicide Prevention”
• July 30, 2019 “Lessons from Hospital Suicide Attempts”

• September 3, 2019 “Lessons from an Inpatient Suicide”

 

 

 

References:

 

 

OIG (Office of Inspector General). Department of Veterans Affairs. VHA (Veterans Health Administration). Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center Florida. Healthcare Inspection Report #19-07429-195; August 22, 2019

https://www.va.gov/oig/pubs/VAOIG-19-07429-195.pdf

 

 

Mills PD, Soncrant C, Bender J, Gunnar W. Impact of over-the-door alarms: Root cause analysis review of suicide attempts and deaths on veterans health administration mental health units. General Hospital Psychiatry 2020; 64: 41-45

https://www.sciencedirect.com/science/article/abs/pii/S0163834320300219

 

 

Mental Health Environment of Care Checklist (VA)

http://www.patientsafety.va.gov/docs/MHEOCCed092016508.xlsx

video

http://www.patientsafety.va.gov/professionals/onthejob/mentalhealth.asp

 

 

Watts BV, Shiner B, Young-Xu Y, Mills PD. Sustained Effectiveness of the Mental Health Environment of Care Checklist to Decrease Inpatient Suicide. Psychiatric Services 2016; Published Online Ahead of Print: November 15, 2016

http://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201600080

 

 

Mills PD. Use of the Mental Health Environment of Care Checklist to Reduce the Rate of Inpatient Suicide in VHA. TIPS (Topics in Patient Safety) 2016; 16(3):  3-4 July/August/September 2016

http://www.patientsafety.va.gov/professionals/publications/newsletter.asp

 

 

 

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August 18, 2020 

More Caution on Double Checks

 

 

One of our most popular columns has been our October 16, 2012 Patient Safety Tip of the Week “What is the Evidence on Double Checks?”. In that column and several subsequent ones (listed below) we pointed out the lack of high-quality studies addressing the efficacy of double checks, though we continue to recommend them in certain circumstances, with the caveat that they are not infallible.

 

In our August 27, 2019 Patient Safety Tip of the Week “Double Check on Double Checks” we discussed a systematic review of studies evaluating evidence of the effectiveness of double checking to reduce medication administration errors (Koyama 2020). Those authors again cited the paucity of high-quality evidence and concluded that there is insufficient evidence that double versus single checking of medication administration is associated with lower rates of medication administration errors or reduced harm. They called for higher-quality studies to determine if, and in what context (eg, drug type, setting), double checking produces sufficient benefits in patient safety to warrant the considerable resources required.

 

Now another new study raises questions about how double checks are actually done in practice and what their real impact is on medication errors. Westbrook and colleagues (Westbrook 2020) published results of direct observation of 298 nurses administering 5140 medication doses to 1523 patients in a pediatric hospital. Details of administrations and double-checking were recorded by independent observers in real time. For each dose administration, observers recorded whether nurses performed a truly independent double check, or one that was “primed” by the other nurse, or one that was incomplete, or no double-check.

 

Processes at this pediatric hospital were somewhat unusual in that hospital policy required independent double-checking by registered nurses (RN’s) for all medication administrations except for a select group. 69.3% of all medication administrations required double-checking according to hospital policy. Time taken (for the checking nurse alone) to double-check averaged 6.4 minutes (7.9 minutes for IV and 5.5 min for non-IV administrations).

 

The researchers found no association between double-checking and the occurrence of a medication administration error (OR 0.89) or the potential severity of MAE’s (OR 0.86). For double-checked administrations the error rate was 72/100 administrations and for those not double-checked 71/100.

 

For those medication administrations where double-checking was mandated, observations were:

• independently double-checked (1.0%)
• primed double-checked (92.5%)
• incomplete or no double-check (6.5%)

 

For those medications for which double-checking was optional (such as topical creams, vitamins, oral antibiotics, inhaled medications), nurses did double checks in 26.4%. However, in only 1.7% was an independent double-check performed.

 

Essentially what they found was that mandatory double-checking conferred no additional

safety benefit compared with single-checking. Nurses were highly compliant but almost never did truly independent double-checks. Instead, most double checks resulted from priming. (A “primed” double check is one in which a nurse shares information which may influence the checking nurse).

 

Interestingly, for those medication administrations where double-checking was optional but used, there was a significantly lower odds of the occurrence of a medication administration error (OR 0.71) and MAE severity (OR 0.75).

 

Westbrook and colleagues do discuss some of the factors that render double-checking potentially ineffective, including diffusion of responsibility, ritualization, deference to those with higher authority, false reassurance, and rushing the process.

 

Reduction or diffusion of responsibility refers to the complacency that tends to occur when someone feels that someone else will catch any mistakes that they made. We know from other industries that the error rate when a supervisor checks someone else’s work may be 10% or higher, though that usually does not involve truly independent double checks. More of a diffusion of responsibility today is deferring to technology (“the computer says it’s ok so it must be ok”). Somewhat related to this concept is one of the most common cognitive biases, confirmation bias, in which we accept a response or evidence as confirming our assessment even in the presence of disconfirming evidence.

 

Westbrook et al. go on to discuss the costs of double-checking, in both human and financial terms. They do note, appropriately, that medications for pediatric patients are often more complex than for adults, especially since dosing may be based upon patient weights (or other parameters, like age or body surface area). However, many of these same considerations would apply to certain adult populations, like an oncology ward.

 

Our biggest problem with this study is that double checks were mandated for such a high percentage of their medication administrations. We know few hospitals (or other healthcare venues) where double checks are so widely mandated. That certainly is a factor that probably leads to reducing the importance of the double check in the minds of many healthcare professionals. It likely tends to make the double-check perfunctory in many cases. We usually recommend double checks be required only for a few high-alert medications or situations where the probability of error is very high, such as those involving calculations.

 

In our July 2020 What's New in the Patient Safety World column “Medication Dosage Miscalculations” we discussed typical human error rates for a variety of industries. Error rates in simply “doing arithmetic wrongly” range from 0.01 to 0.03. That’s why having a second person independently perform a calculation can be valuable.

 

In our August 27, 2019 Patient Safety Tip of the Week “Double Check on Double Checks” we cited ISMP’s practical article on double checks (ISMP 2019a). Though it acknowledges the paucity of high-quality evidence on double checks, it summarizes findings from many of the observational studies that have demonstrated a benefit from correctly performed double checks. ISMP remains an advocate of truly independent double checks in special circumstances. Notably, it does not recommend them for all high alert medications. It cites the time-consuming nature of independent double checks as a downside.

 

ISMP suggests your decision about which processes should require an independent double check should be based upon analysis of 4 key considerations:

1. Processes and medications that pose the greatest risk of harm if an error occurs (e.g., intravenous [IV]/epidural opioids, IV insulin, IV heparin, IV chemotherapy)
2. The primary reason for the independent double check (what you are trying to catch) and what specifically needs to be verified to achieve that goal
3. Whether an independent double check is the best strategy to detect a specific risk or prevent a specific error
4. How the independent double check fits in with other risk-reduction strategies that might address the same or a similar safety concern

 

ISMP notes you might use findings from hazard and event analysis, or a FMEA (Failure mode and effects analysis) to help inform your decisions about what processes should require double checks. We’ve noted in our several columns on accidents with NMBA’s (neuromuscular blocking agents) that, if you store these in an automated dispensing cabinet, you need a way of verifying that the patient is intubated and ventilated (or that the NMBA is being used to facilitate intubation and ventilation) before dispensing the NMBA from the ADC. But we’ve also recommended that a second qualified healthcare professional verify that dispensing of the NMBA from the ADC is correct. But you need to be wary that the second person is truly acting independently and not simply ”signing off” complacently. How many times have you seen a transfusion reaction occur after two individuals supposedly “verified” the unit of blood was correct for that patient?

 

ISMP notes that bedside barcode verification may be more reliable than double checks for getting the correct patient, medication, and dose. But that independent double check at the bedside may be a better strategy for avoiding infusion pump programming errors and line confusion errors.

 

ISMP has always stressed that the double check needs to be a truly independent double check. That means that two qualified healthcare professionals need to assess the question(s) separately and only compare their conclusions after each has completed their assessments.

 

One study (Douglass 2018) randomized emergency department nurses into single- and double-check groups in exercises on a simulated patient. Errors were intentionally introduced into the simulation, including weight-based dosage errors and wrong medication vial errors. In the single-check group, 9% of nurses detected the weight-based dosage error compared with 33% of nurses in the double-check group (odds ratio 5.0) Fifty-four percent of nurses in the single-check group detected the wrong vial error compared with 100% of nurses in the double-check group (odds ratio 19.9). Overall, the researchers found that use of a double check increased certain error detection rates in some circumstances, but not others. Both techniques missed many errors. In some cases, the second nurse actually dissuaded the first nurse from acting on the error. In cases in which the second nurse dissuaded the first confused nurse and the error was missed, the second nurse tended to be older and more experienced (so likely “deference to authority”). They also noted in several cases that the second nurse rushed the first nurse. That study was conducted in a relatively controlled environment. One could imagine that such “rushing” might be more prevalent in high intensity environments like the ER, OR, or ICU.

 

The authors did note that use of a double check may promote cooperation between the 2 nurses to detect an error. They found that, in regard to the first nurse, the double-check condition may have made him/her more comfortable engaging the second nurse in analyzing the confusing weight-based order. If the first nurse was confused, he/she always involved the second nurse during the double-check condition. In contrast, in the single-check condition, the first nurse would often dismiss concerns without involving the other nurse.

 

In our April 14, 2020 Patient Safety Tip of the Week “Patient Safety Tidbits for the COVID-19 Pandemic” we noted the potential hazards of performing a double check in the COVID-19 era. ISMP (ISMP 2020a) recently addressed the need to balance the benefits of double checks versus the risks of exposure and the need to conserve personal protective equipment (PPE) when doing double checks in the COVID-19 environment. They found that most organizations are establishing ways to conduct critical parts of independent double checks without entering a patient’s room. For example, a hard stop in EHR’s requiring dual documentation of verification before proceeding now reflects only those components of the check that can be accomplished outside the patient’s room. They also describe how some hospitals became innovative. Where infusion pumps remain in the patient’s room, the nurse who enters the room takes a picture of the pump screen using a mobile phone device left in the room, and sends the picture to a nurse outside the room via a secure messaging system. This allows most components of the independent double check to occur.

 

In our March 2020 What's New in the Patient Safety World column “ISMP Smart Infusion Pump Guidelines” we noted that ISMP’s Smart Infusion Pump Guidelines (ISMP 2020b) recommend performance of double checks at certain points in the clinical workflow. When starting selected facility-defined high-alert medication infusions and at additional facility-defined steps (e.g., change of shift/handoffs, change in the rate/dose of infusion, change in bag/bottle/syringe) require that a double check be performed and documented to verify the following before starting the infusion:

• Patient
• Patient weight used for weight-based medications
• Drug/solution
• Drug concentration
• Dose-rate of continuous infusions, dose and rate of intermittent infusions
• Channel selection
• Line attachment

 

ISMP notes that technology (eg. barcoding) is the preferred method for double checking most of these items but use of a second practitioner is necessary to perform and document an independent double check for line attachment.

 

Double checks may also be important when other medication safety techniques are not available. In our November 19, 2019 Patient Safety Tip of the Week “An Astonishing Gap in Medication Safety” we discussed several incidents in which community vaccination programs inadvertently gave dangerous medications to recipients rather than the intended vaccines. We noted that one of our most important medication safety tools we use in the hospital setting  – barcoding – was not available in most of those cases. Given that there was no barcoding as a layer of defense, we suggested falling back on an old technique – the independent double check. Perhaps in settings lacking barcoding it may make sense to have a second person confirm the vaccine/medication being given. In at least one of the incidents there was only one healthcare professional present. In hospitals, having a second set of eyes is useful even if independent double checks are not being used. Typically, a pharmacist prepares and dispenses the medication and then a nurse checks it before administering it. In the vaccine incident there was only one person preparing and administering the vaccine.

 

In our January 1, 2019 Patient Safety Tip of the Week “More on Automated Dispensing Cabinet (ADC) Safety” we also recommended that independent double checks should be required for ADC overrides. Failure to incorporate double checks into the ADC override process was an important contributing factor in some of the serious accidents involving neuromuscular blocking agents (NMBA’s). But you need to be wary that the second person is truly acting independently and not simply ”signing off” complacently.

 

In our August 4, 2020 Patient Safety Tip of the Week “Intravenous Issues” we discussed ISMP Canada’s (ISMP Canada 2020) analysis of over 1500 incidents related to intravenous issues. One very important theme they found was over-reliance on technology, such as smart pump and bar-code technology (see our Patient Safety Tips of the Week for August 23, 2016 “ISMP Canada: Automation Bias and Automation Complacency” and June 11, 2019 “ISMP’s Grissinger on Overreliance on Technology”). They found that failure to perform an independent double check before IV medication administration (to verify and document the patient’s name, the drug and its concentration, the prescribed infusion rate, the line attachments and labels), was a key contributing factor in many of these incidents.

 

The “primed” double check prevalent in the Westbrook study clearly differs from the truly independent double check which we are usually referring to. Pfeiffer et al. point out that the definition of double checks is varied in much of the literature (Pfeiffer 2020) and offer a framework for future research on double checks. ISMP also pointed out the lack of standardization of terms in the literature.

 

Despite our concerns about the applicability of the Westbrook study to other hospitals, the study is important in several regards:

• It is one of the few studies that shows what actually happens in the “real world”
• It tells us that we need to do further research to demonstrate where double checks might actually reduce medication errors
• It provides an estimate of “cost” of performing double checks

 

Lastly, we always take the opportunity to revive what seems to be a forgotten form of double check in the era of computerized medicine, the “mental” double check. When we talk about double checks, we are usually talking about two separate individuals independently checking something. The mental double check simply involves one person employing a separate cognitive process to double check. Or, it may be a nurse or pharmacist doing a quick mental double check of an order from a physician. In the “old days”, when a nurse looked at an order for a medication, he/she would do a quick mental calculation of the ordered dose and decide if the result fell into a reasonable range (this would be considered a “plausibility check” in the Pfeiffer framework). In the era of CPOE and e-prescribing, it’s often assumed that whatever the computer says is correct and the step of “mental double checking” seems to be a lost art.

 

We agree with several points made by ISMP (ISMP 2019b) after recent publication of studies that seemingly downplay the effectiveness of double checks:

• Use double checks selectively and judiciously
• Make sure your double checks are truly independent double checks
• Avoid sole reliance on double checks
• Conduct a cognitive review of the medication
• Standardize the process and provide education and tools on how to perform double checks

 

Every time we come away from doing a column on double checks, we have great feelings of ambivalence. The lack of a solid evidence base remains disconcerting. We lament that the process of double checking is flawed and may lead to a false sense of security. But we hold out hope that, if double checks are limited to just a few very critical circumstances and are done in a truly independent fashion, we might see fewer errors.

 

 

Some of our other columns on double checks:

 

January 2010               “ISMP Article on Double Checks”

October 26, 2010        “Confirming Medications During Anesthesia”

October 16, 2012        “What is the Evidence on Double Checks?”

December 9, 2014       “More Trouble with NMBA’s”

April 19, 2016             “Independent Double Checks and Oral Chemotherapy”

December 11, 2018     “Another NMBA Accident”

January 1, 2019           “More on Automated Dispensing Cabinet (ADC) Safety”

March 5, 2019             “Infusion Pump Problems”

August 27, 2019         “Double Check on Double Checks”

November 19, 2019    “An Astonishing Gap in Medication Safety”

April 14, 2020             “Patient Safety Tidbits for the COVID-19 Pandemic”

March 2020                 “ISMP Smart Infusion Pump Guidelines”

August 4, 2020           “Intravenous Issues”

 

 

References:

 

 

Koyama AK, Maddox CS, Li L, et al. Effectiveness of double checking to reduce medication administration errors: a systematic review. BMJ Quality & Safety 2020; 29: 595-603

https://qualitysafety.bmj.com/content/29/7/595

 

 

Westbrook JI, Li L, Raban MZ, et al Associations between double-checking and medication administration errors: a direct observational study of paediatric inpatients. BMJ Quality & Safety Published Online First: 07 August 2020

https://qualitysafety.bmj.com/content/early/2020/08/06/bmjqs-2020-011473

 

 

Douglass AM, Elder J, Watson R , et al. A randomized controlled trial on the effect of a double check on the detection of medication errors. Ann Emerg Med 2018: 71(1): 74-82.e1

https://www.sciencedirect.com/science/article/abs/pii/S0196064417303189

 

 

ISMP (Institute for Safe Medication Practices). Independent Double Checks: Worth the Effort if Used Judiciously and Properly. ISMP Medication Safety Alert! Acute Care Edition 2019. June 6, 2019

https://www.ismp.org/resources/independent-double-checks-worth-effort-if-used-judiciously-and-properly

 

 

ISMP (Institute for Safe Medication Practices). Suspending independent double checks. ISMP Medication Safety Alert! Acute Care Edition 2020; Special Edition 25(7): 1-2 April 9, 2020

https://www.ismp.org/acute-care/special-edition-medication-safety-alert-april-9-2020

 

 

ISMP (Institute for Safe Medication Practices). Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps. ISMP 2020; February 10, 2020

https://www.ismp.org/guidelines/safe-implementation-and-use-smart-pumps

 

 

ISMP Canada. Intravenous Medication Safety: A Multi-Incident Analysis. ISMP Canada Safety Bulletin 2020; 20(7):  1-4 July 16, 2020

https://www.ismp-canada.org/download/safetyBulletins/2020/ISMPCSB2020-i7-IVMedsAnalysis.pdf

 

 

Pfeiffer Y, Zimmerman C, Schwappach DLB. What are we doing when we double check? BMJ Quality & Safety 2020; Published Online First: 18 February 2020

https://qualitysafety.bmj.com/content/early/2020/02/18/bmjqs-2019-009680

 

 

ISMP (Institute for Safe Medication Practices). Published Review of Independent Double Checks Shouldn’t Dissuade Providers from Using Them Judiciously. ISMP Medication Safety Alert! Acute Care Edition 2020; September 26, 2019

https://www.ismp.org/resources/published-review-independent-double-checks-shouldnt-dissuade-providers-using-them

 

 

 

 

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August 25, 2020 

The Off-Hours Effect in Radiology

 

 

We’ve done multiple columns on “the weekend effect” and “the after hours effect”, in which patient outcomes tend to be worse than for those during “normal” daytime hours. And, we’ve done even more columns on the impact of fatigue or derangements of normal circadian cycles on performance.

 

Physicians, nurses, and really all healthcare workers tend to have drop-offs in performance when fatigued. In our April 2018 What's New in the Patient Safety World column “Radiologists Get Fatigued, Too” we highlighted a study looking at the effect of overnight shifts on performance of radiologists (Hanna 2018). The researchers used a tool for measuring fatigue and advance eye tracking technology to assess the performance of radiologists (both attendings and residents).

 

During each session, radiologists viewed 20 bone radiographs consisting of normal and abnormal findings. The Swedish Occupational Fatigue Inventory results demonstrated worsening in all five variables (lack of energy, physical exertion, physical discomfort, lack of motivation, and sleepiness) after overnight shifts. Not surprisingly, participants demonstrated worse diagnostic performance in the fatigued versus not-fatigued state. Viewing time per case was significantly prolonged when the radiologists were fatigued. Mean total fixations generated during the search increased by 60% during fatigued sessions. Mean time to first fixate on bone fractures increased by 34% during fatigued sessions. Moreover, dwell times associated with true- and false-positive decisions increased, whereas those with false negatives decreased. Effects of fatigue were more pronounced in residents.

 

The authors concluded that further research is needed to address and reverse the impact of such fatigue-related changes. They speculate that environmental changes (eg. lighting) and activity changes (eg. periodic breaks, moving around, etc.) might help mitigate the adverse effects of fatigue on performance.

 

There have actually been several studies on the impact of fatigue on radiologist performance, but most have focused primarily on radiology residents. Now a new study has looked at the performance of radiology fellows who have completed full radiology residencies (all of whom successfully completed the American Board of Radiology board certification following their fellowship year), comparing CT scan reading error rates during daytime or night shifts (Patel 2020).

 

Fellows working off-hours interpreted in-patient and emergency department examinations. The following day, attending radiologists read the studies that had been interpreted by the fellows. All fellows had at least 11 hours off prior to any off-hours assignment, and fellows took no more than 5 consecutive off-hours assignments before having at least 48 hours off work.

 

During the study period, off-hour day assignments on weekends and holidays were from 7:00 AM to 5:59 PM; the off-hour night assignments on weekends, holidays, and Fridays were from 6:00 PM to 6:59 AM. Off-hour night assignments on Monday to Thursday were from 8:00 PM to 6:59 AM.

 

Over 10,000 body CT studies were interpreted by 32 radiology fellows. Nighttime studies had error rates of 3%, compared to 2% for daytime studies, and 69% of the radiology fellows had higher error rates for night cases. Moreover, there were significantly more errors during the last half of night assignments (3.7%) compared with the first half (2.5%).

 

Diagnostic error rates were also lower in the first half of the day assignment from 7:00 AM to 11:59 AM compared with the second half from 12:00 PM to 5:59 PM (1.1% vs. 2.6%), but that difference was not statistically significant. Though not statistically significant, we would tend not to ignore that trend. In our May 3, 2011 Patient Safety Tip of the Week “It’s All in the Timing” we noted that detection rates for polyps or adenomas during colonoscopy fell off during colonoscopies done later in a shift. And in our June 2019 What's New in the Patient Safety World column “More on the Time of Day” we noted your chance of getting an influenza vaccination or one of several preventive screening procedures also falls off when you are seen late in the day.

 

The authors state: “The error rate was higher despite lower work intensity during night assignments and despite having work schedules exceeding Accreditation Council for Graduate Medical Education guidelines to promote rest. The error rate was highest during the latter half of night assignments. These findings have implications for patient care and quality assurance efforts, and for designing processes to deliver the highest quality of care at lowest cost.”

 

Of course, there may be factors other than fatigue that contribute to more errors occurring toward the end of the night shift (or toward the end of the day shift). It may be that the attention of the healthcare professional is directed toward what will happen once the shift has ended. While the Patel paper notes that all the fellows had at least 11 hours off prior to their off-hour shifts, it does not state whether they sometimes had to work during the day following the off-hour shift. Or it might be that the radiologist is rushed to finish up all work before the shift ends (eg. making sure that all dictations were done). It might even be that the time required for a safe “handoff” at the end of a shift leads to rushing the interpretation of the imaging study.

 

There is also one area in which we would like to have seen more data. The fellows often worked multiple consecutive night shifts (as many as five consecutive night shifts). In several of our columns we’ve discussed data that shows the number of performance errors in other industries increases with each consecutive night shift. For example, our November 9, 2010 Patient Safety Tip of the Week “12-Hour Nursing Shifts and Patient Safety” cited a study on shift workers in fields other than healthcare (Folkard 2003) which showed that the risk of incidents increased each consecutive day worked. For example, on average for night shifts risk was 6% higher on the second night, 17% higher on the third night, and 36% higher on the fourth night (for morning/day shifts the corresponding risks were 2%, 7% and 17%). It would have been very interesting to see in the current Patel study whether the radiology fellows made more errors on the fourth or fifth consecutive “off-hours” shift compared to the first or second.

 

Patel et al. note that dtouble reading is an established strategy used to mitigate radiology errors. But they go on to discuss of the downsides of double reading. One of those is ensuring that the result of the second reading gets back to the appropriate clinician at a time when intervention can be done. Both a patient and an emergency physician may have left the emergency department long before the result of that second reading is posted, potentially leading to “falling through the cracks”. Therefore, it is important to encourage real-time readings. They also discuss more demand for more in-house attending radiologist coverage. But we suspect those attendings would also likely be subject to the very same factors that led to more errors in all these studies.

 

There is another option: teleradiology. We once worked with a small, rural hospital that had a unique relationship with a radiology group. The group consisted of mostly top-notch Israeli radiologists, all licensed in the US and appropriately credentialed at the hospital. There was always one radiologist on-site at the US hospital during daytime hours. But at night the readings were done via teleradiology by one of the radiologists in Israel, where it was “daytime”. Clinicians at the US hospital still had the opportunity to talk with the remote radiologist and go over the imaging studies over the phone. Many hospitals in the US do use similar “nighthawk” services. With telemedicine, in general, now opening up in the COVID-19 era, it is conceivable that much radiology that is “night-time” in one location could be “daytime” in another.

 

In an editorial accompanying the Patel study, Bruno (Bruno 2020) notes that many academic centers have already been using in-house radiology attendings along with residents, so that all interpretations are final in real-time. He also notes that many medical centers and hospitals are relying on “nighthawk” services, akin to the teleradiology services we allude to above. Bruno notes that the key take-home message of the Patel study is that even attending-level radiologists are prone to more errors when working a night shift.

 

Regardless of which solutions might be put in place, it is important that hospitals and medical centers actually measure error rates to ensure that their solutions actually achieved the desired effects.

 

 

Some of our previous columns on the “weekend effect”:

• February 26, 2008     “Nightmares….The Hospital at Night”
• December 15, 2009   “The Weekend Effect”
• July 20, 2010             “More on the Weekend Effect/After-Hours Effect”
• October 2008            “Hospital at Night Project”
• September 2009        “After-Hours Surgery – Is There a Downside?”
• December 21, 2010   “More Bad News About Off-Hours Care”
• June 2011                  “Another Study on Dangers of Weekend Admissions”
• September 2011        “Add COPD to Perilous Weekends”
• August 2012              “More on the Weekend Effect”
• June 2013                  “Oh No! Not Fridays Too!”
• November 2013        “The Weekend Effect: Not One Simple Answer”
• August 2014              “The Weekend Effect in Pediatric Surgery”
• October 2014            “What Time of Day Do You Want Your Surgery?”
• December 2014         “Another Procedure to Avoid Late in the Day or on Weekends”
• January 2015             “Emergency Surgery Also Very Costly”
• May 2015                  “HAC’s and the Weekend Effect”
• August 2015              “More Stats on the Weekend Effect”
• September 2015        “Surgery Previous Night Does Not Impact Attending Surgeon Next Day”
• February 23, 2016     “Weekend Effect Solutions?”
• June 2016                  “Weekend Effect Challenged”
• October 4, 2016        “More on After-Hours Surgery”
• July 25, 2017             “Can We Influence the “Weekend Effect”?”
• August 15, 2017        “Delayed Emergency Surgery and Mortality Risk”

 

 

Some of our previous columns on “after-hours” surgery:

• September 2009        “After-Hours Surgery – Is There a Downside?”
• October 2014            “What Time of Day Do You Want Your Surgery?”
• January 2015             “Emergency Surgery Also Very Costly”
• September 2015        “Surgery Previous Night Does Not Impact Attending Surgeon Next Day”
• October 4, 2016        “More on After-Hours Surgery”
• August 15, 2017        “Delayed Emergency Surgery and Mortality Risk”
• October 24, 2017      “Neurosurgery and Time of Day”
• December 2019         “Surgeon On-Call Shifts”

 

 

Some of our other columns on the role of fatigue in Patient Safety:

 

November 9, 2010      “12-Hour Nursing Shifts and Patient Safety”

April 26, 2011             “Sleeping Air Traffic Controllers: What About Healthcare?”

February 2011             “Update on 12-hour Nursing Shifts”

September 2011          “Shiftwork and Patient Safety

November 2011          “Restricted Housestaff Work Hours and Patient Handoffs”

January 2012               “Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety

January 3, 2012           “Unintended Consequences of Restricted Housestaff Hours”

June 2012                    “June 2012 Surgeon Fatigue”

November 2012          “The Mid-Day Nap”

November 13, 2012    “The 12-Hour Nursing Shift: More Downsides”

July 29, 2014              “The 12-Hour Nursing Shift: Debate Continues”

October 2014              “Another Rap on the 12-Hour Nursing Shift”

December 2, 2014       “ANA Position Statement on Nurse Fatigue”

August 2015               “Surgical Resident Duty Reform and Postoperative Outcomes”

September 2015          “Surgery Previous Night Does Not Impact Attending Surgeon Next Day”

September 29, 2015    “More on the 12-Hour Nursing Shift”

September 6, 2016      “Napping Debate Rekindled”

April 18, 2017             “Alarm Response and Nurse Shift Duration”

July 11, 2017              “The 12-Hour Shift Takes More Hits”

February 13, 2018       “Interruptions in the ED”

April 2018                   “Radiologists Get Fatigued, Too”

August 2018               “Burnout and Medical Errors”

September 4, 2018      “The 12-Hour Nursing Shift: Another Nail in the Coffin”

August 2020               “New Twist on Resident Work Hours and Patient Safety”

 

 

 

References:

 

 

Hanna TN, Zygmont ME, Peterson R, et al. The effects of fatigue from overnight

shifts on radiology search patterns and diagnostic performance. J Am Coll Radiol 2018; 15(12): 1709-1716

https://www.jacr.org/article/S1546-1440(17)31661-7/fulltext

 

 

Patel AG, Pizzitola VJ, Johnson CD, et al. Radiologists Make More Errors Interpreting Off-Hours Body CT Studies during Overnight Assignments as Compared with Daytime Assignments. Radiology 2020; Published Online: Aug 18 2020

https://pubs.rsna.org/doi/10.1148/radiol.2020201558

 

 

Folkard S, Tucker P. Shift work, safety and productivity. Occupational Medicine 2003; 53: 95-101

http://occmed.oxfordjournals.org/content/53/2/95.full.pdf+html?sid=a10ee101-4552-4258-8490-8a6d91a2b925

 

 

Bruno MA. Radiology Errors across the Diurnal Cycle. Radiology 2020; Published Online: Aug 18 2020

https://pubs.rsna.org/doi/full/10.1148/radiol.2020202902

 

 

 

 

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September 1, 2020 

NY State and Nurse Staffing Issue

 

 

Several of this month’s What's New in the Patient Safety World columns raised the issue of nurse:patient staffing issues and nurse workload. We discussed state legislative efforts to improve nurse staffing ratios in our October 2018 What's New in the Patient Safety World column “Nurse Staffing Legislative Efforts”. There, we specifically discussed proposed legislation in Massachusetts, which eventually failed.

 

Now New York State has reintroduced proposed legislation to improve nursing staffing ratios in hospitals. The Safe Staffing For Quality Care Act would mandate the nurse-to-patient ratio at 1-to-1 for trauma emergency care and advanced labor stages, 1:2 for intensive care, post-anesthesia care and early labor, 1:3 for emergency department, pediatrics, step-down and telemetry, newborn and intermediate care nursery, 1:4 for medical-surgical and acute care psychiatric, 1:5 for rehabilitation and subacute units, and 1:6 for well baby units. Nursing homes would be required to provide 0.75 hours of RN care, 1.3 hours of LPN care, and 2.8 hours of CNA care to each resident per 24-hour day, 7 days a week. Since the care hours do not need to be given continuously, there is some room for flexibility for nurse scheduling.

 

The proposed legislation does have one improvement over previous proposals. Most previous proposals dealt with average nurse:patient ratios. The current proposal sets the ratios based upon the maximum number of patients assigned to any licensed nurse at all times during a shift rather than an average. Hospitals would be prohibited from exceeding these ratios and assigning more patients to each nurse. Hospitals could assign fewer patients to each RN, as needed, based on patient acuity and necessary level of nursing care. Importantly, the proposal would require that nurses assigned to each unit have demonstrated competence in that specific clinical area and receive an orientation for that clinical practice. Assistive personnel would not count toward the RN-to-patient ratios.

 

The New York State Department of Health (NYSDOH) just released a report on nursing staffing issues that it had been mandated to study. The report does not provide support for the proposed legislative mandate for specific nurse:patient ratios. Its rationale is based primarily on 3 points:

• The evidence base is mixed when it comes to demonstrating that mandated nurse staffing levels improve quality and patient safety. It notes that in California, which is currently the only state with such a mandate, there was no correlation with patient outcomes.
• The cost of meeting the mandate would be prohibitive. It cites a Cornell University study that estimates filling the required workforce need would cost an additional $1.8 to $2.4 billion dollars for hospitals and between $1.9 and $2.3 billion dollars for nursing homes. This reflects an increase in nurse wage costs of between 40 and 53 percent for hospitals, and between 79 and 96 percent for nursing homes.
• There is already a nursing shortage that will persist through at least the next decade.

 

NYSDOH says that, instead of a minimum staffing mandate, there is “a need for a comprehensive approach to ensure that New York State has a highly trained, skilled nursing workforce that will continue to meet the needs of patients and residents in a safe work environment”. It suggests a workforce development approach should include strategies to ensure:

• nursing continues to be an attractive career;
• enough capacity exists to educate and train the workforce of the future;
• nurses have training opportunities to advance their careers;
• programs exist to support work-life balance for nurses;
• a safe work environment that minimizes the stressors that nurses experience;
• New York State has the necessary data to conduct nurse workforce research that informs future workforce planning; and
• State workforce policy provides flexibility to allow providers to align workforce capacity with patient and resident needs in a dynamic, continually evolving delivery system.

 

Those of us who have spent most of our professional careers in hospitals recognize the impact that nursing understaffing has on patient safety and patient outcomes, in addition to the negative impact it has not only on nursing morale but also on all healthcare workers’ morale and on patient satisfaction. But the issue is much more complex than simple nurse:patient ratios.

 

We’ve often cited the work of Linda Aiken and colleagues, who have demonstrated that patient outcomes are better with stronger nurse:patient ratios and higher educational levels of nursing staffing. They found that each additional patient per nurse was associated with a 7% increase in the likelihood of dying within 30 days of admission and a 7% increase in the odds of failure-to-rescue (Aiken 2002), and a 10% increase in the proportion of nurses holding a bachelor's degree was associated with a 5% decrease in the likelihood of patients dying within 30 days of admission and the odds of failure to rescue for surgical patients (Aiken 2003).

 

A more recent study in the UK (Griffiths 2018) looked at in-hospital mortality in relation to nursing staffing, comparing those with staffing levels above to those below the mean staffing level. They found the hazard of death was increased by 3% for every day a patient experienced RN staffing below the ward mean. Each additional hour of RN care available over the first 5 days of a patient’s stay was associated with 3% reduction in the hazard of death. And, days where admissions per RN exceeded 125% of the ward mean were associated with an increased hazard of death (aHR 1.05). Although low nursing assistant staffing was associated with increases in mortality, high nursing assistant staffing was also associated with increased mortality.

 

The NYSDOH report seems to rely heavily on a Massachusetts study assessing the impact of a Massachusetts law, which required a 1:1 or 2:1 patient-to-nurse staffing ratio in intensive care units were published (Law 2018). The researchers compared staffing levels and mortality and certain patient complications between Massachusetts ICU’s and out-of-state ICU’s. There actually were only modest increases in ICU nurse staffing ratios in Massachusetts (from 1.38 patients per nurse before implementation to 1.28 patients per nurse after) and those staffing increases were largely mirrored in other states that did not have the mandate. Massachusetts ICU nurse staffing regulations were not associated with changes in hospital mortality within Massachusetts or when compared with changes in hospital mortality in other states. Complications and DNR orders also remained on either staffing levels or patient outcomes. We discussed that study in our February 2019 What's New in the Patient Safety World column “Nurse Staffing, Workload, Missed Care, Mortality” and noted we might have predicted that, because the ICU’s are already staffed at high levels, we would not see much change.

 

The NYSDOH report also focused heavily on the experience of California, which is the only state that has already mandated minimum nursing staffing ratios. NYSDOH notes that numerous studies have explored the impact of the California nurse-to-patient staffing ratios but that results are mixed. Some studies found higher levels of nurse staffing were associated with improved patient outcomes such as lower mortality rates and reduced falls, hospital-acquired infections and pressure ulcers, but other studies showed weaker relationships or no relationship at all, potentially due to differences in methodology.

 

Yet the NYSDOH report acknowledges “There is a growing body of literature related to the topic of nurse staffing levels and their impact on patient safety and outcomes, quality of care, nurse and patient satisfaction, and overall cost of care. Research in this area is important because of concerns including 1) poorer outcomes mean increased costs, 2) poorer nurse satisfaction and retention result in higher turnover, leading to increased costs for recruitment and retention, and 3) providers with higher nurse staffing ratios have a lower chance of being penalized for medical errors and adverse patient events than providers with lower staffing levels.”

 

We fully support legislation that improves nursing staffing. But the issue is more complex than simple nurse:patient ratios. Those ratios do not take into account actual nurse workload nor do they take into account the fatigue factor that may accompany long work shifts or forced overtime. One factor that comes into play in those conditions is the concept of “missed nursing care” or “care left undone” (see our Patient Safety Tips of the Week for November 26, 2013 “Missed Care: New Opportunities?” and May 9, 2017 “Missed Nursing Care and Mortality Risk”). We discussed the issue of nursing workload in detail in our Patient Safety Tips of the Week for March 6, 2018 “Nurse Workload and Mortality” and May 29, 2018 “More on Nursing Workload and Patient Safety”. In those columns we discussed the issue of how to best measure workload and match nursing staffing levels to that workload.

 

The NYSDOH report does acknowledge that reductions in non-licensed staff (aides/techs in hospitals, administrative staff/unit secretaries, therapists, etc.) may inadvertently increase nurse workloads with tasks that formerly were delegated. That is a point we frequently make in our columns on the “weekend effect”. But reduction in those other jobs has already impacted nursing workload beyond the weekend.

 

Another factor not noted in the NYSDOH report is the impact of the electronic medical record (EMR). Studies on the time efficiency of the EMR for nurses have had mixed results. Many show improved time efficiency, though a few show reduced time efficiency. But these studies have primarily focused on documentation time. They don’t take into account any additional indirect workload on nurses dealing with other problems created by the EMR. Nurses often have to deal with problems physicians or other healthcare professionals are having with the EMR and that does not show up in studies on nurse time efficiency related to the EMR.

 

The NYSDOH report also notes that the use of agency nurses to meet nurse:patient ratios is potentially problematic. It notes such could potentially have consequences for quality of care since relationships may not be built between agency nurses and permanent staff and patients. However, as noted above, the legislative proposal would require that nurses assigned to each unit have demonstrated competence in that specific clinical area and receive an orientation for that clinical practice. So you would not be able to simply plug in an agency nurse to meet a mandated ratio.

 

One of our other concerns is that one of the unintended consequences of mandated minimum nursing staffing ratios will be forcing nurses to work overtime. While many states, New York included, have banned “mandatory” overtime, that simply means a nurse cannot be forced to work beyond his/her scheduled shift. But often unwanted overtime is not “mandated” but more subtle pressures can be put to bear on the nurse to do that overtime (eg. “We really need you”).

 

Regarding level of nursing staffing, it should be noted that New York State enacted the “BSN in 10” law, which went into effect this past June. It requires that nurses obtain a baccalaureate degree or higher in nursing (a Bachelor of Science in Nursing [BSN], a Master of Science in Nursing [MSN], or a doctoral level degree) within ten years of receiving their initial RN license, or risk having their license suspended. Nurses currently practicing, as well as those currently enrolled in a nursing program at the time of enactment, are not subject to the requirement. The BSN in 10 law is laudable. However, we wonder what impact it is likely to have on the likely worsening shortage of nursing personnel in the next decade.

 

And as the NYSDOH report was being prepared, COVID-19 hit. NYSDOH did include an “update” on COVID-19 in its report and a “snapshot” of its impact on peak nursing needs. However, it appears primarily focused on what the cost implications would be if the proposed nurse:patient staffing rations were in place. Lasatar et al. (Lasater 2020), in an article titled “Chronic hospital nurse understaffing meets COVID-19” were actually collecting survey data in New York and Illinois (the other state apparently considering mandating minimum nursing staffing levels) just prior to the first COVID-19 wave. They found that over half the nurses in both states experienced high burnout. Half gave their hospitals unfavorable safety grades and two-thirds would not definitely recommend their hospitals. One-third of patients rated their hospitals less than excellent

and would not definitely recommend it to others. After adjusting for confounding factors, each additional patient per nurse increased odds of nurses and per cent of patients giving unfavorable reports; ORs ranged from 1.15 to 1.52 for nurses on medical-surgical units and from 1.32 to 3.63 for nurses on intensive care units. Their conclusion was that hospital nurses were already burned out and already working in understaffed conditions in the weeks prior to the first wave of COVID-19.

 

A Royal College of Nursing survey in the UK during the COVID-19 pandemic received almost 42,000 responses and highlighted that nursing staff continued to go above and beyond, while working under the pressures of staff shortages, longer hours and often working above their pay grade (Ford 2020). We don’t doubt that the same likely occurred in the US.

 

The current COVID-19 pandemic certainly has impacted the issue, but in two separate ways (AP 2020). On the one hand, the pandemic accentuated the shortage of nursing staff and lack of flexibility in staffing. On the other hand, COVID-19 has had a devastating impact on hospital finances, making now a very inopportune time to be considering any mandate that would substantially increase hospital expenses. The latter fact will likely doom passage of the proposed legislation in the near future.

 

NYSDOH did have discussion with multiple stakeholders, both those supporting the legislation (such as nurses’ organizations) and those opposing it (such as hospitals). The same two sides did battle in Massachusetts when it was considering a similar proposal (see our October 2018 What's New in the Patient Safety World column “Nurse Staffing Legislative Efforts”).

 

Interestingly, both the Cornell report and the NYSDOH report focus on the additional costs that would be incurred if the proposed legislation passed. We did not see in either report any estimation of potential costs saved by improvements in care provided. Admittedly, those cost savings are difficult to quantitate. But neither even acknowledged that there would be savings to offset increased expenses.

 

Looks to us that “the deck is stacked” at least for the time being. With hospitals bleeding due to the COVID-19 pandemic, it is highly unlikely that we’ll see much needed reform on nursing staffing. But this issue won’t die and we’ll be discussing it again in future years.

 

 

Some of our other columns on nursing workload and missed nursing care/care left undone:

 

November 26, 2013    “Missed Care: New Opportunities?”

May 9, 2017                “Missed Nursing Care and Mortality Risk”

March 6, 2018             “Nurse Workload and Mortality”

May 29, 2018              “More on Nursing Workload and Patient Safety”

October 2018               “Nurse Staffing Legislative Efforts”

February 2019             “Nurse Staffing, Workload, Missed Care, Mortality”

July 2019                    “HAI’s and Nurse Staffing”

 

 

Our previous columns on the 12-hour nursing shift:

 

November 9, 2010      “12-Hour Nursing Shifts and Patient Safety”

February 2011             “Update on 12-hour Nursing Shifts”

November 13, 2012    “The 12-Hour Nursing Shift: More Downsides”

July 29, 2014              “The 12-Hour Nursing Shift: Debate Continues”

October 2014              “Another Rap on the 12-Hour Nursing Shift”

December 2, 2014       “ANA Position Statement on Nurse Fatigue”

September 29, 2015    “More on the 12-Hour Nursing Shift”

July 11, 2017              “The 12-Hour Shift Takes More Hits”

May 29, 2018              “More on Nursing Workload and Patient Safety”

September 4, 2018      “The 12-Hour Nursing Shift: Another Nail in the Coffin”

 

 

References:

 

 

NYSDOH (New York State Department of Health). Study of Nurse Caregiver Minimum Staffing Levels and Other Staffing Enhancement Strategies and Patient Quality Improvement Initiatives. NYSDOH 2020; August 2020

https://health.ny.gov/press/reports/docs/2020-08_staffing_report.pdf

 

 

Aiken LH, Clarke SP, Sloane DM, et al. Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. JAMA 2002; 288(16): 1987-1993

https://jamanetwork.com/journals/jama/fullarticle/195438

 

 

Aiken LH, Clarke SP, Cheung RB, et al. Educational levels of hospital nurses and surgical patient mortality. JAMA 2003; 290(12): 1617-1623

https://jamanetwork.com/journals/jama/fullarticle/197345?resultClick=1

 

 

Law AC, Stevens JP, Hohmann S, Walkey AJ. Patient Outcomes After the Introduction of Statewide ICU Nurse Staffing Regulations. Critical Care Medicine 2018; 46(10): 1563-1569  

https://journals.lww.com/ccmjournal/Abstract/2018/10000/Patient_Outcomes_After_the_Introduction_of.2.aspx

 

 

Griffiths P, Maruotti A, Recio Saucedo A, et al. on behalf of the Missed Care Study Group. Nurse staffing, nursing assistants and hospital mortality: retrospective longitudinal cohort study. BMJ Qual Saf 2018; Published Online First: 04 December 2018

https://qualitysafety.bmj.com/content/early/2018/11/25/bmjqs-2018-008043

 

 

Lasater KB, Aiken LH, Sloane DM, et al. Chronic hospital nurse understaffing meets COVID-19: an observational study. BMJ Quality & Safety 2020; Published Online First: 18 August 2020

https://qualitysafety.bmj.com/content/early/2020/08/13/bmjqs-2020-011512

 

 

Ford M. Nurses warn of worse staffing levels and rise in stress amid Covid-19. Nursing Times 2020; 21 August, 2020

https://www.nursingtimes.net/news/workforce/nurses-warn-of-worse-staffing-levels-and-rise-in-stress-amid-covid-19-21-08-2020/?eea=MlNsWUgxTldNRlhYS2czS2VuanpNd2FsQ284aG9UYlg5M1o2Umc4ZExuaUtsSERCTTcvV0Rkd1RBK2MzdWpYag==&n_hash=1137&mkt_tok=eyJpIjoiWkdJME16TmxNR0U0WkRrNCIsInQiOiI1dHd2eVQ2dTdrcjNWK0dBckE2akhYSVVpRUFWUlZoUFdtVGdzQ0w1eTR6clhMY3crZit6WWVITDVNTTN3YStNMkltUGRcL0srUGlSYUZwNXdmdzdiUThGWUJQV1hcL2NCQ2lvU3Azb01cL3NUU2lRbHlUZ1ZlcWZWQVBhT3FWanVpMyJ9

 

 

 

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September 8, 2020 

Follow Up on Tests Pending at Discharge

 

 

In our many columns on test results “slipping through the cracks” there is one particular scenario we always caution about. That pertains to the patient who is discharged from the hospital or from the emergency department when the official result of one or more tests is “pending”. Every hospital must have in place a mechanism to ensure that the “clinician who needs to know” will follow up on that test result and take appropriate action based upon that test result.

 

We’ve previously discussed the emergency department as one area prone to failure to follow up, particularly for radiology studies and lab tests. Callen et al. (Callen 2010) noted that studies have reported rates of failure to follow-up laboratory tests for ED patients range from 3% for microbiology tests to 75% for pregnancy tests and that 6% of cervical spine injury might be missed.

 

The reason for the ED visit may also be important. Trauma patients get lots of studies, particularly imaging studies, that are likely to have incidental findings. Sich et al. (Sich 2018) found that trauma patients had a rate of incidental findings of 70%, of which 36% were clinically relevant.

 

There are several factors that make “slipping through the cracks” more likely in the emergency department. The clinician who initially ordered the test may have already ended his/her shift, yet the official report may be sent to that clinician. Worse yet, that clinician may not be scheduled to be in the hospital again for some time (and maybe not even at all). In some cases, the official report may come hours after the patient is discharged or the following day. But sometimes several days may elapse.

 

Add to that another problem we often see: the primary care physician is often never notified that his/her patient had an emergency department visit and, thus, is unaware of any test results that are pending. Hospital IT systems do not, in general, do a good job of ensuring that the correct PCP is in the system. Patients may change PCP’s and the hospital IT system may never be informed.

 

Responsibility to ensure closing the loop is the responsibility of the ordering physician, the radiologist/imager (or lab for lab test results), the physician primarily responsible for management of the patient, and the patient him/herself.

 

A new study reported in the Annals of Emergency Medicine (Mikhaeil 2020) addresses this issue as it pertains to patients seen in the ED. It gives two examples of common problematic occurrences:

• The incidental pulmonary nodule discovered when the radiologist does the official report on a chest X-ray done for other purpose
• The urine or blood culture which shows an organism that is resistant to the antibiotic the patient was sent home on

 

The Mikhaeil study was a systematic review of the literature on this topic. They found primarily four types of processes used to address test results pending at discharge:

• nurse or clerical staff contacting patients
• physician-driven processes
• engaging patients themselves in the follow-up process
• collaborative efforts between ED practitioners and clinical pharmacists

 

Nurses or clerical staff contacting patients used a variety of methods. Phone contact, followed up with a letter if phone contact was unsuccessful, was the most commonly used method. Some used certified letters. They gave examples where these efforts resulted in an increased percentage of patients with successful follow-up, from 8.1% before to 57% after the new processes were implemented. The time to patient follow-up also decreased from 20.1 hours to 7.1 hours.

 

Physician-led follow up included systems led by either emergency department physicians or radiologists. We previously have recommended that the clinical director of the emergency department, or his/her surrogate, could review cases the next day to determine which patients needed follow up. Note that computer systems can help identify such cases by using the timestamps on the reports and the timestamp showing when the patient was discharged (these are helpful but not infallible). The study by Callen et al. (Callen 2010) also suggested online “endorsement” of test results could be an important intervention. If you had such a system in place, the physician reviewing cases the following day could simply search for test results lacking a physician “endorsement”.

 

Mikhaeil et al. describe the Callen study as the only one where dedicated administrative shifts for emergency physicians were used to follow up on test results pending at discharge. The other studies involved radiologists doing the follow ups. We’ve done several columns highlighting the responsibility of the radiologist to follow up on any report that has significant unexpected findings. Systems must be in place to facilitate that. But we’ve also pointed out the barriers and resulting frustrations for the radiologist who is attempting to do that follow up. They would usually want to discuss the findings first with a responsible clinician rather than calling a patient blindly. But the clinician who ordered the study may no longer be available and it may not be clear to the radiologist what clinician will be following the patient after discharge from the ED.

 

Mikhaeil et al. note that the process led by radiologists allowed 59% of patients to be notified of their incidental findings and given appropriate follow-up instructions, compared with the 7% before implementation.

 

Patient engagement. We also always recommend that patient discharge instructions include comment about any test results pending and encourage them to contact their physician if they have not heard those results within a reasonable amount of time. We emphasize “no news is not good news” and they should never assume the test result was normal. The Mikhaeil systematic review found some studies with unique ways in which patients were engaged in the process. One of those studies was by Huppert et al. (Huppert 2012), who were studying a population of adolescents and young adults seen in the ED with possible STI’s (sexually transmitted infections). Those test results typically take several days to come back after ED discharge. In those who test positive, follow up is important not only to ensure they receive the correct treatment, but also to receive counselling on partner treatment and safer sex practices.

 

First, they assigned a single nurse practitioner (NP) to handle all STI follow-ups. Then they tried to ensure they had a confidential phone number in the EMR for each patient by issuing a prompt in the EMR for the clinician to update that phone number. Then, they developed the “patient activation card”.  Each business-sized card read: “Our goal is to keep you healthy! You had tests performed on (date). Your results should be back in about 3-4 days. Tell your doctor or nurse today what number we should call to reach you. We will contact you in a few days if your results are positive. You may also call Rachael at 513-xxx-xxxx to get your test results. Please call between 9 AM and 5 PM”. The nurse practitioner was also given a dedicated cell phone to receive these calls.

 

These interventions improved the proportion of patients they were able to reach for follow up from 45% to 65%. Moreover, they achieved a decrease in patients lost to follow up from a baseline of 40% to a postintervention result of 24%.

 

In the Mikhaeil study’s last category, the “collaborative” methods were used to ensure the correct antibiotic was being used in those patients for whom cultures were done and antibiotics prescribed. Clinical pharmacists would review all microbiology results and confer with the emergency physician about potential antimicrobial changes. After that discussion, a nurse or a pharmacist would contact the patient with the recommendations.

 

We’ve always recommended that hospital discharge summaries should always have a section for “test results pending” and a phone conversation with the clinician assuming care after discharge should specifically include discussion of test results pending. Similarly, any ED summary intended to be sent to the PCP or other clinician responsible for post-discharge care should also include a specific section for “test results pending”.

 

The study by Sich et al. (Sich 2018) was particularly enlightening, and applied to trauma patients who were admitted or discharged from the emergency department. Because of the high rate of failure to follow up on incidental findings, they developed an intervention with 2 key changes. First, radiologists were asked to report as a clinically relevant finding any incidental finding with the potential for requiring follow-up or need for clinical correlation. If a clinically relevant incidental finding (CRIF) was identified, radiologists would provide high and low risk follow up modalities and time intervals for each CRIF. Radiologists would report CRIF’s in the impression/summary of their report for easy identification in addition to the body of the dictation.

 

Secondly, the electronic trauma history and physical examination was modified to include a required section for incidental findings. Trauma providers were asked to report CRIF’s at the conclusion of the trauma evaluation prior to admission or discharge from the emergency room and then required to document it in a new section of the electronic H&P. When this field was populated in the trauma H&P, it created a follow-up visit order automatically with the PCP. This order was then pulled into the discharge instructions automatically with other required follow-up visits.

 

Rates of follow up recommendation and disclosure to patients were 22% and 27%, respectively, before their intervention. After their intervention, rates of follow up recommendation and disclosure to patients were 68% and 85%, respectively.

 

In their systematic review, Mikhaeil et al. found 5 features in quality improvement studies that improve the likelihood of successful follow-up for test results pending at discharge:

• dedicating staff to quality assurance processes
• giving staff time off from clinical duties
• integrating the process into the electronic medical record
• encouraging collaboration between disciplines and departments
• enabling patient engagement

 

Dedicating staff or giving clinicians “off” time to carry out these processes, of course, costs money. But, we’ll be the first to point out that a single malpractice case avoided by doing this more than makes up for the additional expense incurred. We’ve always favored assigning someone to check the day following ED visits for any test results that came in after the patient left the ED (or have still not yet come in). Using IT to help identify those tests that need follow up is also important. Responsibility for closing the loop belongs to the hospital and its ED, the ordering physician, the discharging physician, the radiologist/imager (or lab for lab test results), the physician primarily responsible for management of the patient, and the patient him/herself.

 

 

See also our other columns on communicating significant results:

• May 1, 2007 “The Missed Cancer”
  
• February 12, 2008 “More on Tracking Test Results”
• October 13, 2009 “Slipping Through the Cracks”
• July 2009 “Failure to Inform Patients of Clinically Significant Outpatient Test Results”
• March 9, 2010 “Communication of Urgent or Unexpected Radiology Findings”
• March 1, 2011 “Tests Pending at Discharge”
• August 21, 2012 “More on Missed Followup of Tests in Hospital”
• October 2, 2012 “Test Results: Everyone’s Worst Nightmare”
• March 12, 2013 “More on Communicating Test Results”
• October 2013 “New AHRQ Toolkit: Improving Your Office Testing Process”
• January 2014 “Email Alerts for Pending Test Results”
• July 2015 “Technology to Avoid Delays in Follow-up of Significant Results”
• November 17, 2015 “Patient Perspectives on Communication of Test Results”
• December 20, 2016 “End-of-Rotation Transitions and Mortality”
• September 2018 “ECRI Institute Partnership: Closing the Loop”
• September 24, 2019 “EHR-related Malpractice Claims”
• November 26, 2019 “Pennsylvania Law on Notifying Patients of Test Results”
• January 2020 “The Joint Commission on Closing the Loop”

 

 

References:

 

 

Callen J, Georgiou A, Prgomet M, et al. A qualitative analysis of emergency department physicians’ practices and perceptions in relation to test result follow-up. Stud Health Technol Inform 2010; 160(pt 2): 1241-1245

http://ebooks.iospress.nl/publication/13642

 

 

Sich N, Rogers A, Bertozzi D, et al. Filling the void: a low-cost, high-yield approach to addressing incidental findings in trauma patients. Surgery 2018; 163:657-660

https://www.sciencedirect.com/science/article/abs/pii/S0039606017306918

 

 

Mikhaeil JS, Jalali H, Orchanian-Cheff A, Chartier LB. Quality Assurance Processes Ensuring Appropriate Follow-up of Test Results Pending at Discharge in Emergency Departments: A Systematic Review. Annals of Emergency Medicne 2020; Published online: August 25, 2020

https://www.annemergmed.com/article/S0196-0644(20)30590-4/fulltext

 

 

Huppert JS, Reed JL, Munafo JK, et al. Improving notification of sexually transmitted infections: a quality improvement project and planned experiment. Pediatrics 2012; 130(2): e415-e422

https://pediatrics.aappublications.org/content/130/2/e415

 

 

 

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September 15, 2020 

An Eerily Familiar Incident

 

 

In our April 2, 2007 Patient Safety Tip of the Week “More Alarm Issues” we described a catastrophic case with numerous lessons learned. A patient with asthma arrived mid-morning at an emergency room with status asthmaticus. Treatment was begun but the patient required intubation and mechanical ventilation. He was stabilized and the ICU was called to admit the patient. The ICU had no empty beds but told the ER that they expected a bed to open up shortly. The ER said the patient could stay on a ventilator in an ER room until that bed was ready. Respiratory Therapy evaluated the patient and hooked the patient up to a dual power-source portable ventilator. That was felt to be ideal for this patient because it could be used either with typical AC current in the ER or use its built-in battery during transport.

 

A call to the ICU after an hour still found no available ICU bed. The ER now started getting busier, but the patient remained stable on the portable ventilator. Unbeknownst to all, the circuit breaker on the AC wall source had tripped, so the portable ventilator was running on battery power. After 5 hours in the ER, the portable ventilator exhausted its battery power and ceased functioning. The patient had a respiratory and then cardiac arrest.

 

Investigation revealed that no staff had heard any alarms on the EKG monitor even though it was likely the patient would have developed tachycardia and/or bradycardia after the ventilator had ceased functioning. The alarm volume, in fact, had been turned down to a level barely audible even by those in the immediate room. The room was immediately adjacent to the nursing and secretarial work area and staff had turned down the alarm volume because it distracted them from work.

 

When the hospital team conducting the RCA investigation came to the ER to re-enact the events, they found that the volume on the same alarms had been turned down again. A similar visit done with the health department a week later again found the alarm volume turned down.

 

Avoiding the snap reaction to take punitive action against the staff member who had initially turned down the alarm volume, it became very clear that the root cause was a flawed design to the ER plus a serious problem with the “culture” in the ER. That design of the ER led to the practice of turning down the alarm volume. One wonders how many ER’s, ICU’s, etc. suffer from this same type of design flaw that promotes such an unsafe practice. I’m always amazed when a hospital administrator proudly states “we designed this unit to have full visual contact of all patients”, only to find that the very proximity led to this practice of lowering alarm volumes. A second root cause was the development of a “culture” in the ER that tolerated manipulation of the alarms as an unsafe workaround.

 

Another root cause was in the design of the portable ventilator. How was one to know that it was functioning on battery power rather than AC power from the wall outlet? In fact, it did have an indicator light to flag which power source was being utilized. However, that indicator light was located on the back of the unit and not readily visible to staff in the room.

 

The case is also a good example of how technological “safety” advances may not actually reduce accidents, much like maritime radar simply encouraged ships to go faster. In this case, the “ideal” dual power-source ventilator fostered a false sense of security.

 

Lastly, the bottleneck caused by bed unavailability in the ICU was yet another root cause that led to implementation of a better system for triage of ICU beds.

 

A very unfortunate case but it illustrates multiple points that one often sees in cases with adverse outcomes (cascade of errors, latent errors, violations, unsafe workarounds, communication breakdowns, misuse of alarm systems, multiple design flaws, safety “culture” issues, bottlenecks and patient flow issues, and technological advances with unintended consequences).

 

Fast forward to 2020. A recent Anesthesia Patient Safety Foundation (APSF) case report (Levin 2020) sounds eerily similar to that incident. During the COVID-19 crisis, a patient with respiratory failure was housed in a windowless negative pressure room in a telemetry unit that had been converted to a temporary COVID-19 ICU. Because of the concomitant ventilator shortage, an anesthesia machine ventilator was used to ventilate the patient. On the tenth hospital day an audible alarm sounded at the central station and the patient’s SpO2 was noted to be 45%. Staff responding to the alarm found that multiple things controlled by electricity in the room were not working. The anesthesia ventilator itself was not working and its workstation control screen was dark. The AC power indicator light was off. However, the physiologic monitor, which had a separate battery backup system, was on and functioning. The patient was removed from that ventilator and manually bagged, with prompt return to baseline oxygen saturation levels.

 

The anesthesia machine ventilator was then connected into a different electrical outlet. The AC power indicator light came on and the machine rebooted. Staff performed the usual pre-use checks and reconnected the patient to the ventilator.

 

Investigation confirmed that the power supply to the anesthesia machine had been lost due to a tripped circuit breaker, just as in our earlier case. Review of the service log revealed an AC power loss and appropriate cutover to the backup battery. Several alarm messages had been displayed on the workstation screen beginning 28 minutes after the AC power loss progressing from “Battery Low”, “Battery V Low” to “Battery V VERY LOW” and, after 1 hour 43 minutes, to “Battery Empty.” The system shut down after 1 hour 52 minutes. Thus, the anesthesia machine had functioned fully as it was designed to work. It was also likely that use of several electrical appliances in the room may have led to the circuit breaker tripping.

 

During normal use of an anesthesia workstation, “a qualified anesthesia provider is in constant attendance, able to view the screens, hear audible alarms, and make adjustments as necessary”. The APSF/ASA Guidance on use of such workstations as ventilators elsewhere includes the recommendation that “An anesthesia professional needs to be immediately available for consultation, and to ‘round’ on these anesthesia machines at least every hour.”

 

Fortunately, the patient in the Levin case did not suffer the dire consequences seen in our earlier case. But the similarities between the two cases are striking. In each case, the tripping of the circuit breaker went unnoticed and staff were unaware that the ventilator was running on battery backup power. While each device did have an indicator that it was on battery backup power, that indicator was either in a position not readily visible or the screen with the warning was not observed because no one was in the room. Multiple root causes were involved in both cases. Unforeseen circumstances led to the use of the surrogate ventilator in both cases (the COVID-19 pandemic in the Levin case, and the ICU backup on our first case). Staff unfamiliarity with the devices may have played a role in each case. Poor design of the working area contributed in both.

 

The Levin study notes that many conventional ventilators used in ICU’s today also have battery backup systems, some of which only last an hour and that the same problem could have occurred with a conventional ventilator. They also note that some of those ventilators lack the remote monitoring capability that was critical in alerting staff in the current case.

 

Our recommendations from lessons learned in these 2 cases:

• Be aware that any time you use equipment that is unfamiliar to staff, errors will be more likely. Extra vigilance is required.
• Similarly, makeshift environments that are unfamiliar to staff may also be more prone to unexpected events.
• All equipment that has a “backup” (battery) electrical system should have a readily visible tag that states “This system has a battery backup that is expected to last ___.” “It was last checked on _____ and battery capacity was at ___%. You need to be aware that the primary electrical source could be interrupted without your awareness.” It should also indicate how you would be notified if the unit switched to battery backup power.
• Battery capacity should be checked immediately before the equipment is deployed to patient use.
• There must be a way in which the staff become aware that the unit is on battery backup power (that must include audible as well as visual alerts).
• The machine then must be deployed in a manner that they will be alerted when the battery runs out.
• Do an inventory to see which of your devices have battery backups.
• You need a system for regular battery checks on all equipment that runs on batteries (our February 4, 2014 Patient Safety Tip of the Week “But What If the Battery Runs Low?”).
• Don’t purchase a machine that lacks a readily visible way to alert staff the machine is on battery power (don’t put the indicator light on the back of the machine!!!).
• For equipment like ventilators, don’t use an outlet that is also being used by multiple other devices.
• Whenever possible, put your monitoring devices/alarms on an outlet separate from the one the ventilator is on.

 

Our bet is that these are not the only cases out there where failure to recognize equipment is running on battery backup led to disasters or near misses. The potential contributing factors are likely present in many hospitals.

 

 

 

References:

 

 

Levin MA, Burnett G, Villar J, et al. Anesthesia Machine as an ICU Ventilator-A Near Miss. APSF (Anesthesia Patient Safety Foundation) 2020; September 4, 2020

https://www.apsf.org/article/anesthesia-machine-as-an-icu-ventilator-a-near-miss/

 

 

 

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September 22, 2020 

VA RCA's: Suicide Risks Vary by Site

 

 

Much of the good work analyzing suicides and attempted suicides in hospitals has come from the VA hospital system. Several of our recent columns highlighted lessons learned in that system and almost all of our previous columns on suicide, listed below, have reference to something from the VA system.

 

Mills et al. (Mills 2020) recently published findings from 847 root cause analyses (RCA’s) of suicides and suicide attempts in the VA system. These included events on mental health units, inpatient medical units, emergency departments, outpatient clinics, community living centers, or on the hospital grounds.

 

The most striking finding is that the mode used for attempting suicide varied considerably by location, and that has implications for what you should be doing to prevent suicides.

 

Hanging accounted for 38.1% of the attempts and 70.9% of the deaths on mental health units, but also accounted for 25.9% of the attempts and 50.0% of the deaths on medical units. Hanging accounted for lesser percentages of attempts in emergency departments (19.6%). and community living centers (22.9%), though these did often result in death.

 

Cutting with a sharp object accounted for relatively equal percentages of attempts on mental health units (24.6), medical units (22.4%), and emergency departments (22.4%), but more so in community living centers (39.6%). However, cutting resulted in no deaths.

 

Overdose accounted for 54.5% of the deaths in residential units and all the deaths in emergency departments. Strangulation accounted for roughly equal percentages of attempts on mental health units (20.9%), medical units (15.3%), and emergency departments (29.0%), but accounted for very few deaths. Gunshot accounted for 59.1% of the deaths on hospital grounds (outside of inpatient or clinic area) and all the deaths in outpatient clinics. Jumping from high places was more common on hospital grounds.

 

And, as you’d expect, the root causes contributing to suicides and suicide attempts also varied by location. The paper has a nice table summarizing root causes by site, with some specific examples.

 

Mills et al., therefore, suggest strategies to prevent suicides should be tailored to the location. The authors note that the methods used in attempted suicides may be largely a function of what opportunities are available to the patients. For example, on mental health units and medical units, where environments are more controlled and observed, hanging and cutting are the most common means available.

 

On mental health units you need to eliminate all anchor points that can be used for hanging (and use above-door alarms as discussed in our August 11, 2020 Patient Safety Tip of the Week “Above-Door Alarms to Prevent Suicides”). All other lethal means, such as drugs, plastic bags (that can be used for asphyxiation) and sharps should be removed off the unit. Ligature-resistant hardware should be used in all places. You should be using the VA Mental Health Environment of Care Checklist (MHEOCC) that we’ve discussed in many of our columns. That checklist is available online on the VA Patient Safety website. Lights and electrical outlets should be modified so they cannot be used for self-harm. Doing regular environmental safety rounds is a good idea. And, given the root causes found in their RCA’s, attention to assessment and treatment are critical.

 

In the emergency department, overdoses were the only method of suicide resulting in death. These usually involved drugs or medication brought into the emergency department by the patient and used in the bathroom when not under supervision. So, in the emergency department, careful assessment of patients for suicide risk coupled with one-to-one observation of at-risk patients is most important. They stress that includes observation in the bathroom. And, though they note lack of an evidence base for efficacy, contraband searches make a lot of sense.

 

The authors noted that jumping was seen more on hospital grounds than on inpatient units and that most jumping events did not result in death. We’ve done several columns on jumping from windows and have noted some common patterns and themes. Many such incidents occur when patients are housed on non-psychiatric units or general medical floors. The typical patient is a young or middle-aged male, but occasionally elderly patients or females have also jumped through or out of windows. The patient is often admitted for an attempted suicide but, again, not always. Typically, he/she is confused or hallucinating. It’s not just patients with known psychiatric disorders or a history of suicide attempt that are at risk. Patients with brain injuries or delirium are at risk, particularly those who have demonstrated a tendency to wander or have verbalized their intent to “get out of here” or “go home”. And the incidents have commonly occurred while patients are already on 1:1 continuous observation and the observer is actually in the room. However, the “sitter” has often been inadequately trained in dealing with such patients. Hospital beds are often used as “launch pads”. Objects in the room, such as a chair or piece of medical equipment, are often used to break the glass in the window.

 

Bathrooms are a frequent location for suicide attempts (see our August 29, 2017 Patient Safety Tip of the Week “Suicide in the Bathroom”). While you can make structural changes to all bathrooms on your mental health units, it is not feasible to do so in all other bathrooms. Nevertheless, we recommend you look at modifications in “high-risk” bathrooms (for example, those in the ED or radiology suite or in medical unit rooms in which you most often house suicidal patients). In several columns we’ve also noted that the suicide occurred while the observer was waiting outside the bathroom or shower. We pondered whether the “modesty” factor or “gender” factor may have played a role and suggest that use of same-sex observers might make sense when suicidal patients need to be observed in those locations.

 

The authors acknowledge that on medical units it is not possible to eliminate all dangerous items because many are need for provision of medical care. They note the importance of one-to-one observation and that the observer needs to be both aware of the suicide risk and properly trained to deal with such patients. They again stress the importance of continuing observation in the bathroom.

 

In several of our own columns we have recommended hospitals which often have a need to house such patients on medical units make one or two rooms safer in that regard. For example, such “dedicated” rooms might have the type of windows installed on behavioral health units that are not breakable or subject to manipulation. They might also have doors with anti-ligature features and above-the-door alarms. On a general medical unit, a suicidal patient also has more easy access not only to medications but also to things like cleaning agents that might be in unlocked locations. And we echo Mills’ point about the importance of having observers that have been appropriately trained in handling such patients.

 

And, of course, don’t forget our frequent warnings about the dangers during intrahospital transports. We’ve noted cases where patients are taken to the Radiology suite for an imaging study and go into a bathroom there and hang themselves. We recommend one of the items on your “Ticket to Ride” intrahospital transport checklist should be related to suicide risk.

 

We’ll also add that you always need to be aware of dangers just outside your units as well. There have been cases where patients have used fire alarms to sneak off locked units, then jump off rooftops in adjacent areas. Therefore, it is important that you check all your stairwells and make sure doors to areas like rooftops are locked.

 

Ironically, the GAO (Government Accounting Office) recently issued a report criticizing the VA for its experience with on-campus suicides (GAO 2020). The report acknowledges that the VA has made suicide prevention a priority and noted the several interventions it has implemented. However, it found that identification of all suicides was incomplete and inaccurate. Specifically, the GAO identified four cases of undercounting (deaths that should have been reported as an on-campus veteran suicide but were not) and 10 cases of overcounting (deaths that were reported as on-campus veteran suicides but should not have been). It also found that no RCA’s were done on several on-campus suicides which the VA responded did not meet the written criteria for RCA’s because the individuals had not received recent psychiatric care within the VA system. We don’t think the GAO report should detract from the good programs the VA has implemented and the useful lessons learned it has disseminated outside the VA system. The report does have some nice photos of the above-door alarms that we discussed both today and in our August 11, 2020 Patient Safety Tip of the Week “Above-Door Alarms to Prevent Suicides” and photos of some of the barriers they have installed to prevent jumping from high places.

 

 

Some of our prior columns on preventing hospital suicides:

 

• January 6, 2009 “Preventing Inpatient Suicides”
• February 9, 2010 “More on Preventing Inpatient Suicides”
• March 16, 2010 “A Patient Safety Scavenger Hunt”
• December 2010 “Joint Commission Sentinel Event Alert on Suicide Risk Outside Psych Units”
• September 27, 2011 “The Canadian Suicide Risk Assessment Guide”
• December 2011 “Columbia Suicide Severity Rating Scale”
• July 2012 “VA Checklist Reduces Suicide Risk”
• August 2013 “Suicide Attempts on Med/Surg Units”
• August 25, 2015 “Checklist for Intrahospital Transport”
• October 6, 2015 “Suicide and Other Violent Inpatient Deaths”
• March 2016 “TJC Sentinel Event Alert on Preventing Suicide”
• April 12, 2016 “Falls from Hospital Windows”
• February 14, 2017 “Yet More Jumps from Hospital Windows”
• August 29, 2017 “Suicide in the Bathroom”
• December 12, 2017 “Joint Commission on Suicide Prevention”
• July 10, 2018 “Another Jump from a Hospital Window”
• September 18, 2018 “More on Hospital Suicides”
• January 22, 2019 “Wandering Patients”
• January 29, 2019 “National Patient Safety Goal for Suicide Prevention”
• July 30, 2019 “Lessons from Hospital Suicide Attempts”
• September 3, 2019 “Lessons from an Inpatient Suicide”
• August 11, 2020 “Above-Door Alarms to Prevent Suicides”

 

 

Some of our past columns on issues related to behavioral health:

 

• January 6, 2009 “Preventing Inpatient Suicides”
• September 22, 2009 “Psychotropic Drugs and Falls in the SNF”
• February 9, 2010 “More on Preventing Inpatient Suicides”
• March 16, 2010 “A Patient Safety Scavenger Hunt”
• October 2010 “Antipsychotic Drugs and Venous Thrombembolism”
• December 2010 “Joint Commission Sentinel Event Alert on Suicide Risk Outside Psych Units”
• September 27, 2011 “The Canadian Suicide Risk Assessment Guide”
• December 2011 “Columbia Suicide Severity Rating Scale”
• July 2012 “VA Checklist Reduces Suicide Risk”
• August 2013 “Suicide Attempts on Med/Surg Units”
• January 15, 2013 “Falls on Inpatient Psychiatry”
• April 2, 2013 “Absconding from Behavioral Health Services”
• August 25, 2015 “Checklist for Intrahospital Transport”
• October 6, 2015 “Suicide and Other Violent Inpatient Deaths”
• March 2016 “TJC Sentinel Event Alert on Preventing Suicide”
• April 12, 2016 “Falls from Hospital Windows”
• May 10, 2016 “Medical Problems in Behavioral Heatlth”
• February 14, 2017 “Yet More Jumps from Hospital Windows”
• March 14, 2017 “More on Falls on Inpatient Psychiatry”
• August 29, 2017 “Suicide in the Bathroom”
• December 12, 2017 “Joint Commission on Suicide Prevention”
• February 6, 2018 “Adverse Events in Inpatient Psychiatry”
• July 10, 2018 “Another Jump from a Hospital Window”
• September 18, 2018 “More on Hospital Suicides”
• January 22, 2019 “Wandering Patients”
• January 29, 2019 “National Patient Safety Goal for Suicide Prevention”
• July 30, 2019 “Lessons from Hospital Suicide Attempts”
• September 3, 2019 “Lessons from an Inpatient Suicide”
• February 2020 “DVT and Behavioral Health”
• March 2020 “Risk Factor for Preventable Harm: Psychiatric Diagnosis”
• August 11, 2020 “Above-Door Alarms to Prevent Suicides”

 

 

References:

 

 

Mills PD, Soncrant C, Gunnar W. Retrospective analysis of reported suicide deaths and attempts on veterans health administration campuses and inpatient units. BMJ Quality & Safety 2020; Published Online First: 20 August 2020

https://qualitysafety.bmj.com/content/early/2020/08/19/bmjqs-2020-011312

 

 

Mental Health Environment of Care Checklist (VA)

http://www.patientsafety.va.gov/docs/MHEOCCed092016508.xlsx

video

http://www.patientsafety.va.gov/professionals/onthejob/mentalhealth.asp

 

 

GAO (Government Accounting Office). Veteran Suicide: VA Needs Accurate Data and Comprehensive Analyses to Better Understand On-Campus Suicides. GAO-20-664: GAO (Government Accounting Office) 2020; September 9, 2020

https://www.gao.gov/assets/710/709243.pdf

 

 

 

Print “VA RCA’s: Suicide Risks Vary by Site”

 





September 29, 2020 

ISHAPED for Nursing Handoffs

 

 

We’ve covered just about every type of handoff in healthcare in our previous columns (see the full list below) and touched upon almost every one of the mnemonics for those handoffs. But one we have never discussed is ISHAPED.

 

ISHAPED stands for Introduction, Story, History, Assessment, Plan, Error-Prevention, and Dialogue. It is a format that has been used in shift-to-shift nursing handoffs at the bedside. At Seattle Children’s Hospital shift-to-shift handoffs were not considered to be problematic but anecdotal concerns had been raised regarding handoffs between departments (intensive care to acute care, emergency department to acute care, etc.). A prior systematic review (Ong 2011) had also found that exposure of handoffs at patient transfers presented challenges that are not experienced in inter-shift handoffs. So, clinicians and researchers at Seattle Children’s Hospital (Stimpson 2020) implemented a modified ISHAPED (m-ISHAPED) tool to align the content shared and the expectations for interdepartmental handoffs. Their quality improvement team and relevant stakeholders studied multiple handoff tools and ultimately chose ISHAPED as the one to use for interdepartmental handoffs.

 

The original ISHAPED tool was developed by the Inova Health System (Friesen 2013). The original ISHAPED tool from Inova Health is available on the IHI (Institute for Healthcare Improvement) website. Because the original tool was intended for shift-to-shift bedside handoffs, the Seattle Children’s team modified it for interdepartmental handoffs and pediatric patients. The resultant m-ISHAPE Form is available on the web: http://links.lww.com/JNCQ/A671.

 

Their implementation plan included 4 key elements:

1. Creation of a job aid, intended to be used as a reference at the time of handoff
2. Creation of an education plan that leveraged preexisting annual nurse education time. The education consisted of a short didactic section, a video demonstrating the process in action, and time for the nurses to practice using it with short scenarios;
3. Creation of a superuser support plan for the first week of go-live. Nurses who were involved in the project received additional training to support the new practice change;
4. K-card audit and coaching, which included realtime coaching, and collection of feedback from the nurses.

 

They then implemented the new interdepartmental handoff process and the m-ISHAPED tool across the ED, acute care units (medical, surgical, and oncology), ICUs (pediatric,

cardiac, and neonatal), rehabilitation unit, postanesthesia care unit (PACU), inpatient psychiatric unit, and ambulatory infusion area.

 

Audits revealed the process was widely adhered to and the tool used correctly 82.6% of the time. Handoff failures were identified as having incorrect or missing information or resulting in a delay, omission, or delivery of inappropriate care. The rate of handoff failures fell from 6.84 per 100 patient days pre-implementation to 1.57 per 100 patient days post-implementation (P < .001). Nurse satisfaction with the handoff process improved from 81.1% pre-implementation to 90.6% post-implementation (P < .001).

 

The authors note that some nursing units and departments have begun using the tool for shift-to-shift handoffs as well.

 

We note that the tool conveys a tremendous amount of information. Hence, some of the important considerations for any handoff apply, such as allowing ample time, doing the handoff in a quiet environment devoid of interruptions and distractions, and allowing the receiver to ask questions and seek clarification. Importantly, the tool emphasizes the use of “repeat-back”. When Inova originally developed ISHAPED they also identified multiple best practices for handoffs, including use of face-to-face communication, use of written documentation, and importance of read-back. They also emphasized that handoffs involve not only the transfer of information but also the unambiguous transfer of responsibility.

 

So go ahead and add ISHAPED as one more option to choose from when you are looking at improving your handoffs, particularly your interdepartmental handoffs.

 

 

Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:

 

May 15, 2007              “Communication, Hearback and Other Lessons from Aviation”

May 22, 2007              “More on TeamSTEPPS™”

August 28, 2007         “Lessons Learned from Transportation Accidents”

December 11, 2007     “Communication…Communication…Communication”

February 26, 2008       “Nightmares….The Hospital at Night”

September 30, 2008     “Hot Topic: Handoffs”

November 18, 2008     “Ticket to Ride: Checklist, Form, or Decision Scorecard?”

December 2008            “Another Good Paper on Handoffs”.

June 30, 2009               “iSoBAR: Australian Clinical Handoffs/Handovers”

April 25, 2009             “Interruptions, Distractions, Inattention…Oops!”

April 13, 2010             “Update on Handoffs”

July 12, 2011              “Psst! Pass it on…How a kid’s game can mold good handoffs”

July 19, 2011              “Communication Across Professions”

November 2011           “Restricted Housestaff Work Hours and Patient Handoffs”

December 2011            “AORN Perioperative Handoff Toolkit”

February 14, 2012       “Handoffs – More Than Battle of the Mnemonics”

March 2012                 “More on Perioperative Handoffs”

June 2012                    “I-PASS Results and Resources Now Available”

August 2012               “New Joint Commission Tools for Improving Handoffs”

August 2012                “Review of Postoperative Handoffs”

January 29, 2013         “A Flurry of Activity on Handoffs”

December 10, 2013     “Better Handoffs, Better Results”

February 11, 2014       “Another Perioperative Handoff Tool: SWITCH”

March 2014                  “The “Reverse” Perioperative Handoff: ICU to OR”

September 9, 2014      “The Handback”

December 2014            “I-PASS Passes the Test”

January 6, 2015            “Yet Another Handoff: The Intraoperative Handoff”

March 2017                 “Adding Structure to Multidisciplinary Rounds”

August 22, 2017         “OR to ICU Handoff Success”

October 2017              “Joint Commission Sentinel Event Alert on Handoffs”

October 30, 2018        “Interhospital Transfers”

April 9, 2019               “Handoffs for Every Occasion”

November 2019          “I-PASS Delivers Again”

August 2020               “New Twist on Resident Work Hours and Patient Safety”

 

 

Some of our prior columns on intrahospital transports and the “Ticket to Ride” concept:

• April 8, 2008               “Oxygen as a Medication”
• November 18, 2008    “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
• August 11, 2009         “The Radiology Suite…Again!”
• March 13, 2012           “Medical Emergency Team Calls to Radiology”
• August 25, 2015         “Checklist for Intrahospital Transport”
• September 1, 2015      “Smarter Checklists”
• November 2016          “Oxygen Tank Monitoring”
• February 2018             “Oxygen Cylinders Back in the News”
• May 22, 2018              “Hazardous Intrahospital Transport”
• October 30, 2018        “Interhospital Transfers”
• March 31, 2020           “Intrahospital Transport Issues in Children”
• June 23, 2020              “Telemetry Incidents”
• July 14, 2020              “A Thesis on Intrahospital Transports”
• August 4, 2020           “Intravenous Issues”

 

 

References:

 

 

Ong MS, Coiera E. A systematic review of failures in handoff communication during intrahospital transfers. Jt Comm J Qual Patient Saf 2011; 37(6): 274-284

https://www.jointcommissionjournal.com/article/S1553-7250(11)37035-3/fulltext

 

 

Stimpson M, Carlin K, Ridling D, Implementation of the m-ISHAPED Tool for Nursing Interdepartmental Handoffs, Journal of Nursing Care Quality 2020; 35(4): 329-335

https://journals.lww.com/jncqjournal/Abstract/2020/10000/Implementation_of_the_m_ISHAPED_Tool_for_Nursing.8.aspx

 

 

Friesen MA, Herbst A, Turner JW, Speroni KG, Robinson J. Developing a patient-centered ISHAPED handoff with patient/family and parent advisory councils. J Nurs Care Qual 2013; 28(3): 208-216

https://journals.lww.com/jncqjournal/Abstract/2013/07000/Developing_a_Patient_Centered_ISHAPED_Handoff_With.3.aspx

 

 

Inova Health System. ISHAPED Patient-Centered Approach to Nurse Shift Change Bedside Report. IHI (Institute for Healthcare Improvement). 2012; Accessed September 2, 2020

http://www.ihi.org/resources/Pages/Tools/ISHAPEDPatientCenteredNurseShiftChangeBedsideReport.aspx

 

 

m-ISHAPE Form. Seattle Childrens’ Hospital.

http://links.lww.com/JNCQ/A671

 

 

 

Print “ISHAPED for Nursing Handoffs”

 







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August 6, 2019

Repeat Adverse Drug Events

July 30, 2019

Lessons from Hospital Suicide Attempts

July 23, 2019

Order Sets Can Nudge the Right Way or the Wrong Way

July 16, 2019

Avoiding PICC’s in CKD

July 9, 2019

Spinal Injection of Tranexamic Acid

July 2, 2019

Tip of the Week on Vacation

June 25, 2019

Found Dead in a Bed – Part 2

June 18, 2019

Found Dead in a Bed

June 11, 2019

ISMP’s Grissinger on Overreliance on Technology

June 4, 2019

Medication Errors in the OR – Part 3

May 28, 2019

The Older Physician

May 21, 2019

Mixed Message on Number of Open EMR Records

May 14, 2019

Wrong-Site Surgery and Difficult-to-Mark Sites

May 7, 2019

Simulation Training for OR Fires

April 30, 2019

Reducing Unnecessary Urine Cultures

April 23, 2019

In and Out the Door and Other OR Flow Disruptions

April 16, 2019

AACN Practice Alert on Alarm Management

April 9, 2019

Handoffs for Every Occasion

April 2, 2019

Unexpected Events During MRI

March 26, 2019

Patient Misidentification

March 19, 2019

Updated Beers Criteria

March 12, 2019

Update on Overlapping Surgery

March 5, 2019

Infusion Pump Problems

February 26, 2019

Vascular Access Device Dislodgements

February 19, 2019

Focus on Pediatric Patient Safety

February 12, 2019

From Tragedy to Travesty of Justice

February 12, 2019

2 ER Drug Studies: Reassurances and Reservations

February 5, 2019

Flaws in Our Medication Safety Technologies

January 29, 2018

National Patient Safety Goal for Suicide Prevention

January 22, 2019

Wandering Patients

January 15, 2019

Another Plus for Prehabilitation

January 8, 2019

Maternal Mortality in the Spotlight

January 1, 2019

More on Automated Dispensing Cabinet (ADC) Safety

December 25, 2018

Happy Holidays!

December 18, 2018

Great Recommendations for e-Prescribing

December 11, 2018

Another NMBA Accident

December 4, 2018

Don’t Use Syringes for Topical Products

November 27, 2018

Focus on Deprescribing

November 20, 2018

Checklist Implementation

November 13, 2018

Antipsychotics Fail in ICU Delirium

November 6, 2018

More on Promoting Sleep in Inpatients

October 30, 2018

Interhospital Transfers

October 23, 2018

Lessons From Yet Another Aviation Incident

October 16, 2018

Burnout

October 9, 2018

More on Lab Specimen Mixups

October 2, 2018

Speaking Up About Disruptive Behavior

September 25, 2018

Foley Follies

September 18, 2018

More on Hospital Suicides

September 11, 2018

Lessons from a Surgical Fire

September 4, 2018

The 12-Hour Nursing Shift: Another Nail in the Coffin

August 28, 2018

Thought You Discontinued That Medication? Think Again

August 21, 2018

Delayed CT Scan in the Anticoagulated Patient

August 14, 2018

ISMP Canada’s Updated “Do Not Use” Abbreviation List

August 7, 2018 

Tip of the Week on Vacation

July 31, 2018

Surgery and the Opioid-Tolerant Patient

July 24, 2018

More on Speech Recognition Software Errors

July 17, 2018

OSA Screening in Stroke Patients

July 10, 2018

Another Jump from a Hospital Window

July 3, 2018

Tip of the Week on Vacation

June 26, 2018

Infection Related to Colonoscopy

June 19, 2018

More EHR-Related Problems

June 12, 2018

Adverse Events in Cancer Patients

June 5, 2018

Pennsylvania Patient Safety Authority on Iatrogenic Burns

May 29, 2018

More on Nursing Workload and Patient Safety

May 22, 2018

Hazardous Intrahospital Transport

May 15, 2018

Helping Inpatients Sleep

May 8, 2018

Heparin Overdose

May 1, 2018

Refrigerator Alarms

April 24, 2018

Review on Hourly Rounding

April 17, 2018

More on Tests Pending at Discharge

April 10, 2018

Prepping the Geriatric Patient for Surgery

April 3, 2018

Cost of a CAUTI

March 27, 2018

PICC Use Persists

March 20, 2018

Minnesota Highlights Lost Tissue Samples

March 13, 2018

Intercepting Errors

March 6, 2018

Nurse Workload and Mortality

February 27, 2018

Update on Patient Safety Walk Rounds

February 20, 2018

Delirium and Falls

February 13, 2018

Interruptions in the ED

February 6, 2018

Adverse Events in Inpatient Psychiatry

January 30, 2018

Texting Errors Revealed

January 23, 2018

Unintentional Hypothermia Back in Focus

January 16, 2018

Just the Fax, Ma’am

January 9, 2018

More on Fire Risk from Surgical Preps

January 2, 2018

Preventing Perioperative Nerve Injuries

December 26, 2017

Tip of the Week on Vacation

December 19, 2017

More on Overlapping Surgery

December 12, 2017

Joint Commission on Suicide Prevention

December 5, 2017

Massachusetts Initiative on Cataract Surgery

November 28, 2017

More on Dental Sedation/Anesthesia Safety

November 21, 2017

OSA, Oxygen, and Alarm Fatigue

November 14, 2017

Tracking C. diff to a CT Scanner

November 7, 2017

Perioperative Neuropathies

October 31, 2017

Target Drugs for Deprescribing

October 24, 2017

Neurosurgery and Time of Day

October 17, 2017

Progress on Alarm Management

October 10, 2017

More on Torsade de Pointes

October 3, 2017

Respiratory Compromise: One Size Does Not Fit All

September 26, 2017

Tip of the Week on Vacation

September 19, 2017

Tip of the Week on Vacation

September 12, 2017

Can You Hear Me Now?

September 5, 2017

Another Iatrogenic Burn

August 29, 2017

Suicide in the Bathroom

August 22, 2017

OR to ICU Handoff Success

August 15, 2017

Delayed Emergency Surgery and Mortality Risk

August 8, 2017

Sedation for Pediatric MRI Rising

August 1, 2017

Progress on Wrong Patient Orders

July 25, 2017

Can We Influence the “Weekend Effect”?

July 18, 2017

Another Hazard from Alcohol-Based Hand Gels

July 11, 2017

The 12-Hour Shift Takes More Hits

July 4, 2017

Tip of the Week on Vacation

June 27, 2017

Texting – We Told You So!

June 20, 2017

Dilaudid Dangers #4

June 13, 2017

Layering Up

June 6, 2017

NYS Mandate for Sepsis Protocol Works

May 30, 2017

Errors in Pre-Populated Medication Lists

May 23, 2017

Trolling the RCA

May 16, 2017

Are Surgeons Finally Ready to Screen for Frailty?

May 9, 2017

Missed Nursing Care and Mortality Risk

May 2, 2017

Anatomy of a Wrong Procedure

April 25, 2017

Dialysis and Alarm Fatigue

April 18, 2017

Alarm Response and Nurse Shift Duration

April 11, 2017

Interruptions: The Ones We Forget About

April 4, 2017

Deprescribing in Long-Term Care

March 28, 2017

More Issues with Dental Sedation/Anesthesia

March 21, 2017

Success at Preventing Delirium

March 14, 2017

More on Falls on Inpatient Psychiatry

March 7, 2017

Nested Interruptions

February 28, 2017

The Copy and Paste ETTO

February 21, 2017

Yet More Jumps from Hospital Windows

February 14, 2017

Alarm Fatigue in the ED

February 7, 2017

Maternal Safety Bundles

January 31, 2017

More Issues in Pediatric Safety

January 24, 2017

Dexmedetomidine to Prevent Postoperative Delirium

January 17, 2017

Pediatric MRI Safety

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

Surgical Specimen Mishaps

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

More on After-Hours Surgery

September 27, 2016

Lab Errors Costly

September 20, 2016

Downloadable ABCDEF Bundle Toolkits for Delirium

September 13, 2016

Vanderbilt’s Electronic Procedural Timeout

September 6, 2016

Napping Debate Rekindled

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

More on the Second Victim

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

Falls from Hospital Windows

April 5, 2016

Workarounds Overriding Safety

March 29, 2016

Inappropriate Lab Testing

March 22, 2016

Radiology Communication Errors May Surprise You

March 15, 2016

Dental Patient Safety

March 8, 2016

Tip of the Week on Vacation

March 1, 2016

Colonoscopy Complications

February 23, 2016

Weekend Effect Solutions?

February 16, 2016

Fall Prevention Failing?

February 9, 2016

It was just a matter of time…

February 2, 2016

Success Against Sepsis

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

Smarter Checklists

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

Not All Falls Are the Same

July 21, 2015

Avoiding Distractions in the OR

July 14, 2015

NPSF’s RCA2 Guidelines

July 7, 2015

Medical Staff Risk Issues

June 30, 2015

What Are Appropriate Indications for Urinary Catheters?

June 23, 2015

Again! Mistaking Antiseptic Solution for Radiographic Contrast

June 16, 2015

Updates on Delirium

June 9, 2015

Add This to Your Fall Risk Assessment

June 2, 2015

Reminders of Dilaudid Dangers

May 26, 2015

How Safe is the Lab You Use?

May 19, 2015

Dueling Chlorhexidine Studies

May 12, 2015

More on Delays for In-Hospital Stroke

May 5, 2015

Errors with Oral Oncology Drugs

April 28, 2015

Failure to Escalate

April 21, 2015

Slip and Capture Errors

April 14, 2015

Using Insulin Safely in the Hospital

April 7, 2015

Missing Patients and Death

March 31, 2015

Clinical Decision Support for Pneumonia

March 24, 2015

Specimen Issues in Prostate Cancer

March 17, 2015

Distractions in the OR

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

More on Numeracy

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

More Trouble with NMBA’s

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

Antibiotic Stewardship

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

Ophthalmology: Blue Dye Mixup

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

Melatonin and Delirium

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

Nudged, But Who Nudged Who?

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

The PICC Myth

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

The Second Victim

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

Missing Patients

October 8, 2013

EMR Problems in the ED

October 1, 2013

Fuels and Oxygen in OR Fires

September 24, 2013

Perioperative Use of CPAP in OSA

September 17, 2013

First MEWS, Now PEWS

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

Adverse Events in Home Care

August 6, 2013

Let Me Sleep!

July 9-30, 2013

Tip of the Week on Vacation

July 2, 2013

Issues in Alarm Management

June 25, 2013

Update on Surgical Fires

June 18, 2013

DVT Prevention in Stoke – CLOTS 3

June 11, 2013

Amphotericin Mixups Continue

June 4, 2013

Reducing Unnecessary CT Scans

May 28, 2013

The Neglected Medications: IV Fluids

May 21, 2013

Perioperative Distractions

May 14, 2013

Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)

May 7, 2013

Drug Errors in the Home

April 30, 2013

Photographic Identification to Prevent Errors

April 23, 2013

Plethora of Medication Safety Studies

April 16, 2013

Distracted While Texting

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

Falls on Inpatient Psychiatry

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

Breastfeeding Mixup Again

December 4, 2012

Unintentional Perioperative Hypothermia: A New Twist

November 27, 2012

Dealing with Distractions

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

Surgical Scheduling Errors

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

Insulin Pump Safety

September 11, 2012

In Search of the Ideal Early Warning Score

September 4, 2012

More Infant Abductions

August 28, 2012

New Care Model Copes with Interruptions Better

August 21, 2012

More on Missed Followup of Tests in Hospital

August 14, 2012

Gait Speed: A New Vital Sign?

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

More on Wrong-Patient CPOE

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

Diagnostic Error Chapter 3

May 8, 2012

Importance of Nontechnical Skills in Healthcare

May 1, 2012

More LEAN Successes

April 24, 2012

Fire Hazard of Skin Preps Oxygen

April 17, 2012

10x Dose Errors in Pediatrics

April 10, 2012

Error Disclosure by Surgeons

April 3, 2012

New Risk for Postoperative Delirium: Obstructive Sleep Apnea

March 27, 2012

Action Plan Strength in RCAs

March 20, 2012

Adverse Events Related to Psychotropic Medications

March 13, 2012

Medical Emergency Team Calls to Radiology

March 6, 2012

Lab Error

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

Medication Safety in the OR

January 24, 2012

Patient Safety in Ambulatory Care

January 17, 2012

Delirium and Contact Isolation

January 10, 2012

Verbal Orders

January 3, 2012

Unintended Consequences of Restricted Housestaff Hours

December 20, 2011

Infant Abduction

December 13, 2011

Surgical Fires Again

December 6, 2011

Why You Need to Beware of Oxygen Therapy

November 29, 2011

More on Diagnostic Error

November 22, 2011

Perioperative Management of Sleep Apnea Disappointing

November 15, 2011

Rethinking Colonoscopy

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

Renewed Focus on MRI Safety

October 18, 2011

High-Risk Surgical Patients

October 11, 2011

LEAN in the Lab

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

More Tips on PCA Safety

August 30, 2011

Unintentional Discontinuation of Medications After Hospitalization

August 23, 2011

Catheter Misconnections Back in the News

August 16, 2011

Crisis Checklists for the OR

August 9, 2011

Frailty and the Surgical Patient

August 2, 2011

Hazards of e-Prescribing

July 26, 2011

Hourly Rounding

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

STOPP Using Beers List?

June 14, 2011

Failure to Follow Up

June 6, 2011

Timeouts Outside the OR

May 31, 2011

Book Review Human Factors and Team Psychology in a High Stakes Environment

May 24, 2011

Hand Hygiene Resources

May 17, 2011

Opioid-Induced Respiratory Depression Again!

May 10, 2011

Preventing Preventable Readmissions: Not As Easy As It Sounds

May 3, 2011

Its All in the Timing

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

More Aviation Principles

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

Early Warnings for Sepsis

March 8, 2011

Yes, Physicians Get Interrupted Too!

March 1, 2011

Tests Pending at Discharge

February 22, 2011

Rethinking Alarms

February 15, 2011

Controversies in VTE Prophylaxis

February 8, 2011

Inducing Too Early

February 1, 2011

MRI Safety Audit

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

Safer Use of PCA

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

Lost Lab Specimens

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

Slowing Down in the OR

October 5, 2010

More Iatrogenic Burns

September 28, 2010

Diagnostic Error

September 21, 2010

Dilaudid Dangers

September 14, 2010

Wrong-Site Craniotomy: Lessons Learned

September 7, 2010

Patient Safety in Ob/Gyn Settings

August 31, 2010

Postoperative Delirium

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

Iatrogenic Burns

May 25, 2010

Propofol Issues

May 18, 2010

Real-Time Random Safety Audits

May 11, 2010

Delayed Diagnosis of Cancer

May 4, 2010

More on the Impact of Interruptions

April 27, 2010

Infusion Pump Safety

April 20, 2010

HITs Limited Impact on Quality To Date

April 13, 2010

Update on Handoffs

April 6, 2010

Cancer Chemotherapy Accidents

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

The Hazards of Radiation

January 26, 2010

Preventing Postoperative Delirium

January 19, 2010

Timeouts and Safe Surgery

January 12, 2010

Patient Photos in Patient Safety

January 5, 2010

Hows Your Hand Hygiene?

December 29, 2009

Recognizing Deteriorating Patients

December 22, 2009

Falls on Toileting Activities

December 15, 2009

The Weekend Effect

December 8, 2009

Prescribing Errors

December 1, 2009

Patient Safety Doesnt End at Discharge

November 24, 2009

Another Rough Month for Healthcare IT

November 17, 2009

Switched Babies

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

Slipping Through the Cracks

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

The Radiology SuiteAgain!

August 4, 2009

Faulty Fall Risk Assessments?

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

More on Delirium in the ICU

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

Learning from Tragedies

May 12, 2009

Errors With PCA Pumps

May 5, 2009

Adverse Drug Events in the ICU

April 28, 2009

Ticket Home and Other Tools to Facilitate Discharge

April 21, 2009

Still Futzing with Foleys?

April 14, 2009

More on Rehospitalization After Discharge

April 7, 2009

Project RED

March 31, 2009

Screening Patients for Risk of Delirium

March 24, 2009

Medication Errors in the OR

March 17, 2009

More on MRI Safety

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

Lab Errors in the News

January 6, 2009

Preventing Inpatient Suicides

December 30, 2008

Unintended Consequences: Is Medication Reconciliation Next?

December 23, 2008

Why Safety Alerts Often Fail

December 16, 2008

Joint Commission Sentinel Event Alert on Hazards of Healthcare IT

December 9, 2008

Huddles in Healthcare

December 2, 2008

Playing without the ballthe art of communication in healthcare

November 25, 2008

Wrong-Site Neurosurgery

November 18, 2008

Ticket to Ride: Checklist, Form, or Decision Scorecard?

November 11, 2008

Probiotics and VAP Prevention

November 4, 2008

Beta Blockers Take More Hits

October 28, 2008

More on Computerized Trigger Tools

October 21, 2008

Preventing Delirium

October 14, 2008

Managing Delirium

October 7, 2008

Lessons from Falls....from Rehab Medicine

September 30, 2008

Hot Topic: Handoffs

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

Updates on VAP Prevention

August 26, 2008

Pattern Recognition and CPOE

August 19, 2008

Arterial Line Issues

August 12, 2008

Jerome Groopmans How Doctors Think

August 5, 2008

Tip of the Week on Vacation

July 29, 2008

Heparin-Induced Thrombocytopenia

July 22, 2008

Lots New in the Anticoagulation Literature

July 15, 2008

Heparin Flushes.....Again!

July 8, 2008

Medical Helicopter Crashes

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

Computerizing Trigger Tools

April 8, 2008

Oxygen as a Medication

April 1, 2008

Pennsylvania PSAs FMEA on Telemetry Alarm Interventions

March 25, 2008

More on MRSA

March 18, 2008

Is Desmopressin on Your List of Hi-Alert Medications?

March 11, 2008

Lessons from Ophthalmology

March 4, 2008

Housestaff Awareness of Risks for Hazards of Hospitalization

February 26, 2008

Nightmares.The Hospital at Night

February 19, 2008

MRI Safety

February 12, 2008

More on Tracking Test Results

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

Fall Prevention

December 25, 2007

Happy Holidays

December 18, 2007

Bed Rails

December 11, 2007

CommunicationCommunicationCommunication

December 4, 2007

Surgical Fires

November 27,2007

More on Rapid Response Teams

November 20, 2007

New Evidence Questions Perioperative Beta Blocker Use

November 13, 2007

AHRQ's Free Patient Safety Tools DVD

November 6, 2007

Don Norman Does It Again!

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

Errors in the Laboratory

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

Workarounds as a Safety Issue

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

Tip of the Week on Vacation

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

More on TeamSTEPPS

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

The Missed Cancer

April 23, 2007

Predictable Errors

April 16, 2007

Falls with Injury

April 9, 2007

Make Your Surgical Timeouts More Useful

April 2, 2007

More Alarm Issues

March 26, 2007

Alarms Should Point to the Problem

March 19, 2007

Put that machine back the way you found it!

March 12, 2007

10x Overdoses

March 5, 2007

Disabled Alarms

February 26, 2007

Unintended Consequences