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October 3, 2017
Respiratory Compromise: One Size Does Not Fit All
One of the prime strategies in patient safety is simplification. We always try to come up with solutions for prevention or intervention that are simple and can be applied across multiple settings and patient populations. But sometimes such “one size fits all” approaches are not appropriate.
One recently challenged example is the approach to monitoring for respiratory compromise in hospitalized patients. Because so many of our prior columns have focused on monitoring those at risk for opioid-induced respiratory depression (such as those patients likely to have obstructive sleep apnea), we have often focused on use of capnography for monitoring. But the National Association for the Medical Direction of Respiratory Care (NAMDRC) recently organized a workshop with representation from many national societies to address the unmet needs of respiratory compromise from a clinical practice perspective. At that workshop distinct subsets of respiratory compromise, characterized by the pathophysiological mechanisms they had in common, were identified that present similar opportunities for early detection and useful intervention to prevent respiratory failure (Morris 2017). The subtypes were:
The basic premise is that classification of acutely ill respiratory patients into one or more of these categories may help in selecting the screening and monitoring strategies that are most appropriate for the patient's particular pathophysiology.
Respiratory Compromise Due to Impaired Control of Breathing
This subgroup includes patients with dysfunction due to central nervous system injury, pharmacologic/toxic depressants, metabolic disorders, and sleep-associated breathing disorders. It also includes patients with neuromuscular weakness and sleep-disordered breathing.
Because inappropriate somnolence and markedly decreased breathing effort may represent early signs of respiratory compromise in this subgroup, patients at risk for respiratory compromise due to impaired control of breathing should undergo careful physical examination at regular intervals.
The authors note that monitoring of blood oxygenation is fairly routine but caution that changes in oxygenation are often the fairly abrupt end sequelae of compromised control of breathing. Therefore other monitoring options are appropriate for this subset of respiratory compromise, including continuous measurement of blood pressure, electrocardiogram, transcutaneous PCO2 estimation, and end-tidal capnometry.
They also note promising tools such as airflow measurement by a thermistor, to monitor the depth and frequency of breathing, and actigraphy to provide an indication of a patient’s general activity as a surrogate for the level of consciousness. They also note that periodic arterial blood gas measurements may provide unequivocal evidence of hypercarbia and hypoxemia. They also note the utility of clinical scales to measure consciousness, sedation, delirium, pain, and risk for sleep apnea. We’ve often discussed the RASS (Richmond Agitation-Sedation Scale) or the POSS (Pasero Opioid-Induced Sedation Scale) as useful tools. We’ve also stressed that in patients with sleep-disordered breathing, simply assessing their level of arousal, oxygen saturation or end-tidal CO2 when awake is inadequate. It’s important to observe their respiratory patterns when sleeping.
Respiratory Compromise Due to Impaired Airway Protection
Inability to properly swallow and effectively cough may lead to respiratory compromise due to impaired control of the upper airway. Such impairments are commonly seen in patients with stroke or neuromuscular disorders such as myasthenia gravis, Guillain-Barre syndrome, ALS, and various myopathies but may also occur in multiple sclerosis, Parkinson’s disease, and other CNS disorders. These predispose to aspiration and aspiration pneumonitis. The authors stress the many physical signs of aspiration or aspiration pneumonitis in the article.
Most of you are aware of the need to assess swallowing before attempting to feed stroke patients orally. But many forget to do similar assessment in patients with other neurological conditions. Repeated evaluations of the level of consciousness and the ability to chew, seal the lips, and swallow are recommended. Importantly, the authors note that transient episodes of respiratory status deterioration, even if they are brief and self-limited, may be warning signs of subsequent respiratory failure. They also note the importance of input from observation by family members, who may notice more subtle changes in level of arousal or respiratory drive.
Respiratory Compromise Due to Parenchymal Lung Disease
The authors discuss the many ways that parenchymal lung disease may impact physiological functions and result in respiratory compromise. This subgroup includes not only patients with pre-existing lung diseases but also patients who develop pneumonia or have a systemic inflammatory response. They note that tools like the lung injury prediction score may help identify patients at risk for development of ARDS. Common signs to watch for are hypoxemia and tachypnea and, again, changes in mental status may be clues.
Patients in this subgroup should be monitored continuously for changes in breathing frequency and for decreases in pulse oximetry or oxygen saturation. The authors caution that administration of supplemental oxygen may mask the hypoxemic effects of parenchymal lung disease. Therefore, this type of respiratory compromise is best monitored longitudinally by considering the increases in oxygen supplementation required to maintain adequate oxygenation.
Respiratory Compromise Due to Increased Airway Resistance
This subgroup includes not only patients with asthma and COPD but also those with increased airway resistance due to edema, laryngospasm, stenosis, or collapse of floppy tracheal segments.
A patient’s past history may be helpful. Severity of a patient’s prior exacerbations may be an important clue to identify respiratory compromise in patients with an acute asthma episode and previous ICU admissions and mechanical ventilation episodes are important predictors of respiratory failure in patients hospitalized with asthma. The situation in COPD is more complicated, since it depends upon the severity of the COPD and factors such as whether the patient has had hypercapnic episodes in the past.
Proper monitoring of ventilatory effort will allow earlier recognition of respiratory compromise due to increased airway resistance before the patient manifests deteriorations in gas exchange. Monitoring in this subgroup includes frequent heart rate, breathing frequency, and blood pressure measurement. While continuous oximetry and capnography may be useful, the authors emphasize the pitfalls of each. For example, pulse oximetry will not detect carbon dioxide retention, and can lead to a false sense of security, particularly when supplemental oxygen is being delivered. And capnography measurement may not be straightforward in patients with obstruction to air flow.
The authors note that clinical scales to quantify dyspnea can be followed over time to help detect respiratory compromise when progression of severity is gradual but that subjective scales may be of little value when impairment of cognitive function has occurred.
Respiratory Compromise Due to Hydrostatic Pulmonary Edema
Pulmonary edema is diagnosed on the basis of clinical, radiographic, and laboratory findings. Respiratory compromise from hydrostatic pulmonary edema is identified when oxygen saturation decreases, when FIO2 requirements increase, or when the breathing frequency and overall appearance suggest increased effort of breathing.
Monitoring longitudinally is important to identify the trajectory of the condition. Measurement of breathing frequency, oxygen saturation, FIO2 requirements longitudinally are used to detect escalating severity. Surveillance of ventilatory patterns, the effort required to sustain breathing, and estimation of extravascular lung water currently require frequent subjective evaluations.
Respiratory Compromise Due to Right-Ventricular Failure
Right ventricular failure may occur in pulmonary embolism, pulmonary arterial hypertension, and other causes. Pulmonary edema is characteristically absent in respiratory compromise due to right-ventricular dysfunction, However, the authors stress that, because the right ventricle is much less equipped than the left ventricle to increase its work load, this type of respiratory compromise entails the risk of rapid deterioration and catastrophic cardiac decompensation.
While continuous monitoring of breathing frequency and oxygen saturation may be helpful, the authors stress that hypoxemia from pulmonary vascular diseases may respond well to supplemental oxygen therapy, even as hemodynamics deteriorate. The principal danger is progressive right-ventricular failure so echocardiography and serologic tests of cardiac strain and damage should be checked periodically. Continuous electrocardiogram monitoring may detect new T-wave inversions in the
precordial leads, an ominous sign of right-ventricular worsening.
Overall, we found this article very enlightening. It really makes you understand you can’t just hook up patients to pulse oximetry and capnography and expect to identify all patients with deteriorating respiratory conditions. It really makes you understand that “one size does not fit all”.
Other Patient Safety Tips of the Week pertaining to respiratory issues:
References:
Morris TA, Gay PC, MacIntyre NR, et al. Respiratory Compromise as a New Paradigm for the Care of Vulnerable Hospitalized Patients. Respiratory Care 2017; 62(4): 497-512
http://rc.rcjournal.com/content/62/4/497
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October 10, 2017
More on Torsade de Pointes
Torsade de pointes is a relatively uncommon cause of sudden unexpected death but one that is potentially preventable (see our June 29, 2010 Patient Safety Tip of the Week “Torsade de Pointes: Are Your Patients At Risk?”). It is a form of ventricular tachycardia, often fatal, in which the QRS complexes become “twisted” (changing in amplitude and morphology) but is best known for its occurrence in patients with long QT intervals. Though cases of the long QT interval syndrome (LQTS) may be congenital, many are acquired and due to a variety of drugs that we prescribe. The syndrome is more common in females and many have a genetic predisposition. And there are a number of reasons why this syndrome is more likely to both occur and result in death in hospitalized patients. Hospitalized patients have a whole host of other factors that may help precipitate malignant arrhythmias in vulnerable patients. They tend to have underlying heart disease, electrolyte abnormalities (eg. hypokalemia, hypomagnesemia, hypocalcemia), renal or hepatic impairment, and bradycardia, all of which may be precipitating factors. More importantly they may have the sorts of conditions for which we prescribe the drugs that are primarily responsible for prolonging the QT interval (eg. haloperidol, antiarrhythmic agents, etc.). And many of those drugs are given intravenously and in high doses in the hospital as compared to the outpatient arena. Rapid intravenous infusion of such drugs may be more likely to precipitate Torsade de Pointes than slow infusion.
The drugs most commonly associated with Torsade de Pointes are haloperidol, methadone, thioridazine, amiodarone, quinidine, sotalol, procainamide, erythromycin, azithromycin, the antihistamine terfenadine and certain antifungals. For a full list of drugs that commonly cause prolongation of the QT interval and may lead to Torsade de Pointes, go to the CredibleMeds® website. That site provides frequent updates when new information becomes available about drugs that may prolong the QT interval.
But one matter of real concern is prolongation of the QT interval by combinations of drugs.
The FDA (FDA 2016) issued a warning last year about the commonly used anti-diarrheal loperamide (Imodium and numerous OTC formulations) as a possible cause of unexplained cardiac events including QT interval prolongation, Torsades de Pointes or other ventricular arrhythmias, syncope, and cardiac arrest. Apparently, the majority of reported serious heart problems occurred in individuals who were intentionally misusing and abusing high doses of loperamide in attempts to self-treat opioid withdrawal symptoms or to achieve a feeling of euphoria. “In cases of abuse, individuals often use other drugs together with loperamide in attempts to increase its absorption and penetration across the blood-brain barrier, inhibit loperamide metabolism, and enhance its euphoric effects.” The FDA lists the following drugs (noting the list is incomplete) as commonly interacting with loperamide: cimetidine, ranitidine, clarithromycin, erythromycin, gemfibrozil, quinidine, quinine, ritonavir, itraconazole and ketoconazole.
The latter two drugs are antifungal agents in the azole category. Researchers at Duke University School of Medicine recently presented at IDWeek 2017 data about interaction in patients receiving azole antifungals and amiodarone, a commonly used anti-arrhythmic drug (Cook 2017). Senior author PharmD Melissa Johnson presented results of a study of inpatients who were given systemic azoles (fluconazole, voriconazole, posaconazole, itraconazole) and amiodarone concomitantly. Of 252 patients with EKG results there was a mean maximal change in QTc of +32.4ms from baseline from 471.6 ms at baseline (monotherapy) to 504.0 ms (concomitant therapy). The commonly used danger parameter of QTc≥500ms was seen in 25.4% of patients at baseline and a follow-up QTc ≥500ms was seen in 48.8% of patients. Though no cardiac events were apparent in relation to concomitant azole-amiodarone therapy in the study, Dr. Johnson noted that more studies are needed to better understand the safety of azoles given in the context of other QTc prolonging drugs.
Another study (Lorberbaum 2016) used data mining and laboratory investigation to uncover some potential QT interval-prolonging drug-drug interactions (QT-DDIs). They found both direct and indirect signals in the adverse event reports that the combination of ceftriaxone (a cephalosporin antibiotic) and lansoprazole (a proton-pump inhibitor) will prolong the QT interval.
The major risk factors for Torsade de Pointes are potentially modifiable. Since the electrolyte disturbances may be corrected and medications may be switched there is significant opportunity to reduce the risk of torsade de pointes when prolonged QTc intervals are recognized early. But it’s pretty clear that it is beyond the capacity of the human brain to remember not only all the individual drugs that may prolong the QT interval but also all the drug-drug combinations that increase the risk. Add to that a general unawareness of the risks for Torsade de Pointes. So we really need to rely upon technology to help us. Clinical decision support systems (CDSS) are the logical answer. We discussed these in our Patient Safety Tips of the Week for April 9, 2013 “Mayo Clinic System Alerts for QT Interval Prolongation”and June 10, 2014 “Another Clinical Decision Support Tool to Avoid Torsade de Pointes”.
In our April 9, 2013 Patient Safety Tip of the Week “Mayo Clinic System Alerts for QT Interval Prolongation” we discussed one such CDSS tool that had been implemented at the Mayo Clinic (Haugaa 2013). In November 2010 the Mayo Clinic developed and implemented a system-wide QT alert system, called the pro-QTc system (see the prior column or the Haugaa article itself for details of the pro-QTc formula and scoring system). With some variation based on factors such as heart rate, a corrected QT interval (QTc) 500 msec or greater would trigger a notification alert to the ordering physician as a “semi-urgent finding” with a link to a Mayo website with guidance on management of such cases. They sent alerts to clinicians regarding about 2% of patients. For the population as a whole the QTc was a significant predictor of mortality. For each 10 msec increment in QTc there as a 13% increase in mortality, independent of age and sex. The pro-QTc score was also a significant predictor of death and did so in a “dose-dependent” manner (i.e. each one-point increment in the pro-QTc score further increased mortality by a factor of 17%). On multivariable analysis only the number of QT-prolonging medications and electrolyte abnormalities were significant independent predictors of death. This again emphasizes the importance of recognizing drug combinations that may contribute to QT prolongation.
Then in our June 10, 2014 Patient Safety Tip of the Week “Another Clinical Decision Support Tool to Avoid Torsade de Pointes” we discussed another study which demonstrated that use of CDSS and computerized alerts can reduce the risk of QT interval prolongation (Tisdale 2014). One of the most important considerations is developing a system in which the risk of alert fatigue is minimized. We know from multiple studies done in the past that physicians override over 90% of computer alerts during CPOE (computerized physician order entry). To minimize the risk of alert fatigue and still accomplish your goal of reducing the risk to patients it is important to (1) deliver the alert to the right person (2) deliver alerts only for the most potentially serious events and (3) provide alternative options for the physician’s response.
They system developed and implemented by Tisdale and colleagues did all three. First, the alerts first went to the pharmacist, who would then evaluate the situation and decide whether discussion with and recommendations for the physician were appropriate. Second, the thresholds to trigger the alerts were set at levels expected to minimize alert fatigue. And, third, the pharmacist responding to the alert would present the physician with some options for actions.
Their system would trigger an alert when the QTc interval was >500 ms or there was an increase in QTc of ≥60 ms from baseline. Their system also identified through the electronic medical record multiple other conditions or laboratory results that identified patients at higher risk for QT interval prolongation.
After implementation of the CDSS system the found a significant reduction in the risk of QT prolongation (odds ratio 0.65). In addition, they found a significant reduction in the prescription of non-cardiac drugs known to prolong the QT interval (especially fluoroquinolone antibiotics and intravenous haloperidol). Overall, 82% of alerts were overridden. That still compares favorably to the frequency with which other alerts are overridden. Most of the overrides were for cardiac drugs (eg. amiodarone or other anti-arrythmic drugs). The authors point out that overriding the computer alert did not mean that nothing was done. For example, even though the order for the drug may have been overridden the pharmacist and physician may have modified some other risk factor (eg. corrected an electrolyte disturbance or stopped another medication) or increased the frequency of QTc surveillance.
So what should your hospital or healthcare organization should be doing? We recommend the following:
Torsade de pointes is a relatively uncommon cause of sudden unexpected death but one that is potentially preventable. Being aware of the risk factors and having systems that identify when potentially dangerous drugs are being given to at-risk patients may potentially save lives.
Some of our prior columns on QT interval prolongation and Torsade de Pointes:
June 29, 2010 “Torsade de Pointes: Are Your Patients At Risk?”
February 5, 2013 “Antidepressants and QT Interval Prolongation”
April 9, 2013 “Mayo Clinic System Alerts for QT Interval Prolongation”
June 10, 2014 “Another Clinical Decision Support Tool to Avoid Torsade de Pointes”
April 2015 “Anesthesia and QTc Prolongation”
References:
CredibleMeds® website
FDA (US Food and Drug Administration). FDA Drug Safety Communication: FDA warns about serious heart problems with high doses of the antidiarrheal medicine loperamide (Imodium), including from abuse and misuse. FDA Safety Announcement June 7, 2016
http://www.fda.gov/Drugs/DrugSafety/ucm504617.htm
Lorberbaum T. Sampson KJ, Chang JB, et al. Coupling Data Mining and Laboratory Experiments to Discover Drug Interactions Causing QT Prolongation. J Am Coll Cardiol 2016; 68(16): 1756-1764
http://content.onlinejacc.org/article.aspx?articleID=2565914
Cook K, Sraubol T, Bova K, et al. QTc Prolongation in Patients Receiving Triazoles and Amiodarone. IDWeek 2017 Poster 173
As discussed in:
Han DH. QTc Prolongation With Concomitant Amiodarone, Azoles Examined. MPR 2017; October 6, 2017
Haugaa KH, Bos JM, Tarrell RF, et al. Institution-Wide QT Alert System Identifies Patients With a High Risk of Mortality. Mayo Clin Proc 2013; 88(4): 315-325
http://download.journals.elsevierhealth.com/pdfs/journals/0025-6196/PIIS0025619613000712.pdf
Tisdale JE, Jaynes HA, Kingery J, et al. Effectiveness of a Clinical Decision Support System for Reducing the Risk of QT Interval Prolongation in Hospitalized Patients. Circulation: Cardiovascular Quality and Outcomes 2014; published online before print May 6, 2014
http://circoutcomes.ahajournals.org/content/early/2014/05/06/CIRCOUTCOMES.113.000651.abstract
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October 17, 2017
Progress on Alarm Management
Among our numerous columns on alarm fatigue and alarm management issues, two columns were aimed at helping hospitals meet Joint Commission’s national patient safety goal on alarm safety (see our Patient Safety Tips of the Week July 2, 2013 “Issues in Alarm Management” and August 16, 2016 “How Is Your Alarm Management Initiative Going?”). Hopefully, all of you have your alarm management programs up and running and reducing unnecessary alarms without increasing adverse patient events.
So how are other hospitals doing? The whole Spring 2017 issue of Biomedical Instrumentation & Technology was dedicated to articles on clinical alarm management (Biomedical Instrumentation & Technology 2017).
One of the articles described one hospital’s program to reduce nonactionable alarms in a medical intensive care and stepdown unit at Yale New Haven Hospital (De Vaux 2017). De Vaux and colleagues used data collected by observational methods to identify PVCs as the most frequent cause of nonactionable alarms contributing to alarm fatigue. The alarm management team implemented changes to the default settings for PVC alarms to "off". The number of audible alarms after the intervention decreased from 210 to 48, a 77% reduction in audible alarms. Moreover, there was a decrease in nonactionable alarms to six from the original 122 in the pre-intervention period. The group also found that the percentage of customized alarms increased during the study period. All this occurred with no adverse patient events related to the changes reported in the event reporting system or by clinical staff during the post-intervention observational period.
We are also happy to see that their team decided to default the parameter for continuous QTc monitoring to "on" to allow for early identification of QTc prolongation and the associated risk of the life-threatening arrhythmia torsade de pointes, in keeping with the spirit of our October 10, 2017 Patient Safety Tip of the Week “More on Torsade de Pointes”.
Next, a paper by Pelter and colleagues (Pelter 2017) discussed steps UCSF took to address alarm management. Their clinical alarm management (CALM) committee selected the patient safety manager, a masters-prepared nurse responsible for patient safety for all three campuses, to link together this diverse committee, which included clinical leaders, administrative leaders, and clinical staff. These included representatives from nursing, medicine, clinical engineering, biomedical engineering, information technology, risk management, respiratory therapy, and materials management.
Next an alarm inventory was conducted, with individual committee members scoring each piece of equipment on: potential for harm, clinical oversight required, current clinical oversight, use frequency per patient during hospitalization, and urgency. The scores were summed for each piece of equipment or device to produce an overall risk assessment score which was used by the consensus committee to prioritize alarms. The inventory also included assessment of alarm default settings and levels of alarm alerts.
Settings for arrhythmia and SpO2 alarms were changed in the adult intensive care units. Also, based upon literature review, they also standardized electrode management and took steps to ensure provision of fresh electrodes on all their units. Facility-wide education included examples of how alarm fatigue led to adverse patient events. The CALM Committee was established as the centralized governing and oversight committee for ensuring alarm safety. The Pelter article does not provide details on the outcomes but we previously discussed the UCSF experience (Drew 2014) in our August 16, 2016 Patient Safety Tip of the Week “How Is Your Alarm Management Initiative Going?”.
Several papers discussed the role of middleware in alarm management. One (Jaques 2017) addresses the questions you must ask (and answer!) in developing middleware as part of your alarm management system. This includes questions like:
The type of device selected to receive messages from the middleware is important since it impacts what type of data can be sent (eg. text only? waveforms? etc.). It also impacts how receipt of messages may be acknowledged and escalated. The article nicely addresses each of the questions above and even provides some real-life scenarios to demonstrate issues.
Zaleski and Venella (Zaleski 2017) looked at the role of middleware in monitoring of patients receiving opioids. They especially focused on smart alarms and noted several techniques and strategies that work to reduce false, or nonactionable, alarm signals, including:
They note that multiparameter physiologic monitors are critical components for continuous patient monitoring and data capture. Capnography and continuous pulse oximetry monitoring provide a sensitive and early indicator of OIRD (opioid-induced respiratory distress) as long as the appropriate clinical indications are detected and the associated smart alarm signals communicated to clinical staff. Capnography, which measures respiratory rate and exhaled end-tidal carbon dioxide and inhaled carbon dioxide, produces a waveform together with the instantaneous values of end-tidal carbon dioxide and trends in respiratory rate that are key indicators as to whether a patient is in respiratory failure or is trending towards respiratory failure,
Middleware retrieves episodic data from medical devices, translates it to a standard format, combines it with data from the patient health record and then uses methods for disseminating and distributing the data and the smart alarm signals to those who need to know in a timely fashion (eg. to dashboards or mobile devices). It is important, however, to ensure your system updates who the responsible parties are and how they receive the information. For example, in our February 9, 2016 Patient Safety Tip of the Week “It was just a matter of time…” we described a case where a critical alarm alert was sent to a party who was no longer responsible for the patient rather than to the responsible party, leading to a delay in response.
Zaleski and Venella emphasize the importance of teamwork and involving all stakeholders in design and management of the alarm system and really emphasize the value of clinical workflow in such systems.
Connie Clements Dills (Dills 2017) addressed managing mechanical ventilator alarms with middleware. Her Hospital for Special Care (HSC) in New Britain, CT, manages approximately 100 mechanically ventilated patients each day. They identified middleware as the best route in addressing the challenge of managing alarms from so many ventilators and other monitoring devices. The middleware works as an electronic monitoring system, which interfaces with medical devices and continuously collects data and monitors for breaches in set alarm parameter settings. It then alerts caregivers to potential life-threatening conditions. Middleware allows for customization of alarms and then sends notifications to a secondary device (e.g., a pager, smartphone, laptop, desktop computer, and/or electronic message board). Dills feels that middleware's most invaluable contribution to clinical care is the ability to distinguish between actionable and nonactionable alarm conditions.
Their alarm inventory found that HIP (high inspiratory pressure) alarms accounted for nearly one-third of all alarms and their second most frequently occurring alarm was HRR (high respiratory rate). Combined, these two alarms accounted for more than 50% of all ventilator alarms. Most of these alarms were nonactionable and precipitated by patient actions such as coughing, swallowing, attempting to speak, or repositioning. By using middleware, they filtered out those alarm conditions as a level one priority. But their interdisciplinary team identified other alarm conditions as critical to patient safety: patient disconnect, low exhaled minute volume (Low Ve), low inspiratory pressure (LIP), and no data. Respiratory therapists can also set "smart alarms" through the middleware to alert them to alarm conditions for patients whose clinical condition warrants a heightened level of concern.
They saw an immediate 80% reduction in the number of nonactionable ventilator alarms following implementation of the middleware. When an actionable alarm occurs, the respiratory therapist is notified via pager with a message indicating the patient's name, the room number, and the alarm condition and urgency. A secondary page alerts coworkers if the primary caregiver's response is delayed. They are now also in the process of monitoring response times.
Other articles in this dedicated supplement discuss AAMI’s work on addressing alarm standards (Moyer 2017), classification of alarms (Edworthy 2017), lessons on alarm management from other “process” industries (eg. chemicals, oil refining, oil and gas production, pulp and paper, pharmaceuticals, food and beverage, non-nuclear power generation) (Forrest 2017), and a good round table discussion about issues in alarm management. There is also a very thoughtful article on the difference between “monitoring” and “surveillance” (Giuliano 2017) which emphasizes the cognitive processes used by nurses, early warning systems, and rapid response team systems. Another article (Peters 2017) discusses use of the “influencer” model to promote change. There’s even a clever analogy comparing alarm management to a football game (Vanella 2017).
This whole supplement of Biomedical Instrumentation & Technology is well worth your reading. You’ll find many of the article contain valuable information that will help you with your alarm management system.
Prior Patient Safety Tips of the Week pertaining to alarm-related issues:
References:
Biomedical Instrumentation & Technology. Horizons Spring 2017 supplement. Clinical Alarms: Managing the Overload.
http://www.aami-bit.org/toc/bmit/51/s2
De Vaux L, Cooper D, Knudson K, et al. Reduction of Nonactionable Alarms in Medical Intensive Care. Biomedical Instrumentation & Technology: Clinical Alarms: Managing the Overload 2017; 51(s2): 58-61
http://www.aami-bit.org/doi/abs/10.2345/0899-8205-51.s2.58
Pelter MM, Stotts J, Spolini K, et al. Developing a Clinical Alarms Management Committee at an Academic Medical Center. Biomedical Instrumentation & Technology: Clinical Alarms: Managing the Overload 2017; 51(s2): 21-29
http://www.aami-bit.org/doi/abs/10.2345/0899-8205-51.s2.21
Drew BJ, Harris P, Zègre-Hemsey JK, et al. Insights into the Problem of Alarm Fatigue with Physiologic Monitor Devices: A Comprehensive Observational Study of Consecutive Intensive Care Unit Patients. PLOS One 2014; Published: October 22, 2014
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0110274
Jacques S. Factors that Affect Design of Secondary Alarm Notification Systems. Biomedical Instrumentation & Technology: Clinical Alarms: Managing the Overload 2017; 51(s2): 16-20
http://www.aami-bit.org/doi/abs/10.2345/0899-8205-51.s2.16
Zaleski J, Venella J. Using Middleware to Manage Smart Alarms for Patients Receiving Opioids. Biomedical Instrumentation & Technology: Clinical Alarms: Managing the Overload 2017; 51(s2): 44-49
http://www.aami-bit.org/doi/abs/10.2345/0899-8205-51.s2.44
Dills CC. Managing Mechanical Ventilator Alarms with Middleware. Biomedical Instrumentation & Technology: Clinical Alarms: Managing the Overload 2017; 51(s2): 62-65
http://www.aami-bit.org/doi/abs/10.2345/0899-8205-51.s2.62
Moyer J. AAMI Tackles Alarm Management Standards. Biomedical Instrumentation & Technology: Clinical Alarms: Managing the Overload 2017; 51(s2): 7
http://www.aami-bit.org/doi/abs/10.2345/0899-8205-51.s2.7
Edworthy JR, Schlesinger JJ, McNeer RR, et al. Classifying Alarms: Seeking Durability, Credibility, Consistency, and Simplicity. Biomedical Instrumentation & Technology: Clinical Alarms: Managing the Overload 2017; 51(s2): 50-57
http://www.aami-bit.org/doi/abs/10.2345/0899-8205-51.s2.50
Forrest S, Sands N. Alarm Management Lessons from the Process Industries. Biomedical Instrumentation & Technology: Clinical Alarms: Managing the Overload 2017; 51(s2): 30-33
http://www.aami-bit.org/doi/abs/10.2345/0899-8205-51.s2.30
Giuliano KK. Improving Patient Safety through the Use of Nursing Surveillance. Biomedical Instrumentation & Technology: Clinical Alarms: Managing the Overload 2017; 51(s2): 34-43
http://www.aami-bit.org/doi/abs/10.2345/0899-8205-51.s2.34
Peters K, Shields S. Using the Influencer Model to Improve Alarm Management Practices. Biomedical Instrumentation & Technology: Clinical Alarms: Managing the Overload 2017; 51(s2): 66-70
http://www.aami-bit.org/doi/abs/10.2345/0899-8205-51.s2.66
Venella J. Drawing Up a New Game Plan to Reduce Alarm Fatigue. Biomedical Instrumentation & Technology: Clinical Alarms: Managing the Overload 2017; 51(s2): 71-72
http://www.aami-bit.org/doi/abs/10.2345/0899-8205-51.s2.71
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October 24, 2017
Neurosurgery and Time of Day
We’ve done several columns highlighting the phenomenon that surgery done “after hours” may be associated with more complications than surgery done during normal daytime working hours (see the list of columns at the end of today’s column).
In our What's New in the Patient Safety World columns for September 2009 “After-Hours Surgery – Is There a Downside?” and October 2014 “What Time of Day Do You Want Your Surgery?” we discussed studies that showed for certain types of orthopedic surgery after hours there was an increased need for reoperations for removal of painful fracture hardware (Ricci 2009) and laparoscopic cholecystectomies done at night compared to daytime were associated with a higher conversion rate to open cholecystectomy (11% vs 6%) (Wu 2014). We also noted previous studies by Kelz and colleagues that showed increased morbidity in non-emergent surgical cases done “after hours”, one in the VA system (Kelz 2008) and another in a private hospital setting (Kelz 2009). And our January 2015 What's New in the Patient Safety World column “Emergency Surgery Also Very Costly” suggested, in addition to the human costs of after-hours surgery there may also be financial costs.
In our October 4, 2016 “More on After-Hours Surgery”, we noted Canadian researchers (WFSA 2016) showed that surgical mortality does vary by time of day and that, after adjustment for age and ASA scores, patients operated at night (11:30 PM-7:29 AM) were 2.17 times more likely to die within 30 days than those operating on during regular daytime working hours (7:30 AM-3:29 PM). Those operated on in the late day (3:30 PM-11:29 PM) were 1.43 times more likely to die than those operated on during regular daytime working hours.
Now add to those previous studies a new one which looked at neurosurgical procedures at the University of Michigan Health System (Linzey 2017). Noting that reported outcomes are worse at night for things like coronary angioplasty, orthopedic surgery, and colorectal surgery, Linzey and colleagues reviewed their own experience in neurosurgery. There was a higher percentage of more minor procedures late in the day. As you’d expect, complications were more frequent in those cases done as “emergent” and in those patients with more comorbidities (likelihood of complications increasing 10% for each comorbidity). But after adjusting for all patient and procedure characteristics, the odds of a complication were increased by more than 50% for start times between 21:01 and 07:00 (OR 1.53). The odds ratio was even higher when severe complications were considered (OR 1.61).
Linzey and colleagues have some thoughtful comments on why a “night effect” might not have been seen in some reported series of transplant surgery. They noted that transplant surgery is done by teams who are used to working together and who frequently perform surgery at night. Transplant teams are also less reliant on housestaff. And transplant teams are typically doing one type of surgery, compared to other specialties which may be performing multiple different types of surgery at night.
Why should “after hours” surgery be more prone to adverse outcomes than regularly scheduled elective surgery? There are many reasons aside from the fact that patients needing emergency and after hours surgery are generally sicker. Obviously, fatigue (for all members of the surgical team) may be a factor. But for surgery, in particular, the impact of time of day on teamwork is important. You are often operating with a team that is likely different from your daytime team. All members of that team (physicians, nurses, anesthesiologists, techs, etc.) may not have the same level of expertise or experience as your regular daytime team (because many hospitals have “seniority” policies, you may have less experienced personnel on your OR “on-call” teams) and the team dynamics between members is likely to be different. The post-surgery recovery unit is likely to be staffed much differently after-hours as well. The staff may be more likely to be unfamiliar with things like location of equipment. And some of the other hospital support services (eg. radiology, laboratory, sterile processing, etc.) may have lesser staffing after-hours. Just as importantly, many or all of the “on-call” staff that make up the after-hours surgical team have likely worked a full daytime shift that day so fatigue enters as a potential contributory factor. And there are always time pressures after hours as well. In addition, one of the most compelling reasons surgery is done at night rather than deferred to the next morning is the schedule of the surgeon or other physician for that next morning (either in surgery or the cath lab or his/her office). Because the surgeon does not want to disrupt that next day schedule, he/she often prefers to go ahead with the current case at night. Similarly, many hospitals run very tight OR schedules and adding a case from the previous night can disrupt the schedule of many other cases.
All of this, of course, needs to be balanced against the need to do truly emergent cases as soon as possible. In our August 15, 2017 Patient Safety Tip of the Week “Delayed Emergency Surgery and Mortality Risk” we noted a study (McIsaac 2017) showing that delays in performing emergent cases were associated with increased mortality (OR 1.56), increased length of stay (incident rate ratio 1.07), and higher total costs.
We highly recommend hospitals take a hard look at surgical cases done “after hours”. You need to look at the morbidity and mortality statistics of such cases. In particular, you need to determine which cases truly needed to be done after hours (emergency cases) and, perhaps more importantly, which ones could have and should have been done during “regular hours”. If the latter are significant, you need to consider system changes such as reserving some “regular hours” for such cases to be done the following morning. You may have to alter the scheduling of cases for individual surgeons as well. For example, perhaps the surgeon on-call tonight should not have elective cases scheduled tomorrow morning. That way, if a case comes in tonight that should be done tomorrow morning you will have both a “free” OR room and a “free” surgeon. And you would need to develop a list of criteria to help you triage cases into “regular” or “after-hours” time slots.
Some of our previous columns on “after-hours” surgery:
References:
Ricci WM, Gallagher B, Brandt A, Schwappach J, Tucker M, Leighton R. Is After-Hours Orthopaedic Surgery Associated with Adverse Outcomes? A Prospective Comparative Study. J Bone Joint Surg Am. 2009; 91: 2067-2072
Wu JX, Nguyen AT, de Virgilio C, et al. Can it wait until morning? A comparison of nighttime versus daytime cholecystectomy for acute cholecystitis. Amer J Surg 2014; published online first September 20, 2014
http://www.americanjournalofsurgery.com/article/S0002-9610%2814%2900438-3/abstract
Kelz, R.R., Freeman, K.M., Hosokawa, P.W. et al. Time of day is associated with postoperative morbidity: an analysis of the national surgical quality improvement program data. Annals of Surgery 2008; 247: 544–552
http://www.ncbi.nlm.nih.gov/pubmed/18376202?dopt=Abstract
Kelz RR, Tran TT, Hosokawa P, et al. Time-of-day effects on surgical outcomes in the private sector: a retrospective cohort study. J Am Coll Surg 2009; 209(4): 434-445.e2.
http://www.journalacs.org/article/S1072-7515%2809%2900507-9/abstract
WFSA (World Federation of Societies of Anaesthesiologists). Five-year study reveals patients operated on at night twice as likely to die as patients who have daytime operations. Science Daily 2016; August 29, 2016
Regarding:
Wang N, et al. Retrospective analysis of time of day of surgery and its 30 day in-hospital postoperative mortality rate at a single Canadian institution. Poster presentation 601. World Congress of Anaesthesiologists 2016
https://www.sciencedaily.com/releases/2016/08/160829192642.htm
Linzey JR, Burke JF, Sabbagh A, et al. The Effect of Surgical Start Time on Complications Associated With Neurological Surgeries. Neurosurgery 2017; Published online 13 October 2017
McIsaac DI, Abdulla K, Yang H, et al. Association of delay of urgent or emergency surgery with mortality and use of health care resources: a propensity score–matched observational cohort study. CMAJ 2017; 189: E905-E912 published online July 10, 2017
http://www.cmaj.ca/content/189/27/E905.full
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October 31, 2017
Target Drugs for Deprescribing
We’ve done numerous columns on the use of potentially inappropriate medications (PIM’s) in the elderly and the value of deprescribing (see list at the end of today’s column). Two populations particularly vulnerable to PIM’s are: (1) nursing home residents and (2) patients with dementia. Two recent studies examined PIM’s in these populations.
Dutch researchers looked at the impact of deprescribing in a nursing home population in a randomized trial (Wouters 2017). Potentially inappropriate medications (PIM’s) were identified using several tools we’ve often discussed: START (Screening Tool to Alert Doctors to Right Treatment), STOPP (Screening Tool of Older Persons' Potentially Inappropriate Prescriptions), and the Beers criteria.
Patients were assigned to intervention with their Multidisciplinary Multistep Medication Review (3MR) or to usual care. Components of the 3MR are:
More patients discontinued use of at least 1 PIM in the intervention group than the control group (39.1% vs. 29.5%) and clinical outcomes did not deteriorate between baseline and follow-up.
Another European study (Renom-Guiteras 2017) found that 60% of the patients with dementia had at least one PIM prescription and 26.4% at least two. The PIM therapeutic subgroups most frequently prescribed were psycholeptics (26% of all PIM prescriptions) and ‘drugs for acid-related disorders’ (21%). Prescription of two or more PIM’s was associated with higher chance of suffering from at least one fall-related injury and at least one episode of hospitalization in the time between baseline and follow-up. Risk factors for being prescribed two or more PIM’s were: age 80 years and older, living in institutional long-term care settings, having more comorbidities, and having more functional impairment.
Douglas Paauw, MD (Paauw 2017) recently discussed “11 Drugs You Should Seriously Consider Deprescribing”:
Paauw also co-authored a recent study on polypharmacy in primary care, focusing on medication side effects and drug interactions (Merel 2017). They discussed important side effects of several medications commonly prescribed in older adults (statins, proton pump inhibitors, trimethoprim-sulfamethoxazole and fluoroquinolone antibiotics, zolpidem, nonsteroidal antiinflammatory drugs, selective serotonin reuptake inhibitors, dipeptidyl peptidase 4 inhibitors). They also discussed important drug interactions with four agents or classes (statins, warfarin, factor Xa inhibitors, and calcium channel blockers).
These articles are important practical contributions to our understanding of polypharmacy and our potential to reduce use of PIM’s. Deprescribing, when done properly, can be a very valuable intervention to improve the lives of our elderly patients. We hope you’ll go back and review some of our previous articles on deprescribing.
Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:
Some of our past columns on deprescribing:
References:
Wouters H, Scheper J, Koning H, et al. Discontinuing Inappropriate Medication Use in Nursing Home Residents: A Cluster Randomized Controlled Trial. Ann Intern Med 2017; published online October 10, 2017
Renom-Guiteras A, Thürmann PA, Miralles TR, et al.Potentially inappropriate medication among people with dementia in eight European countries. Age and Ageing 2017; Published online 01 September 2017
Paauw DS. 11 Drugs You Should Seriously Consider Deprescribing. Medscape 2017; September 5, 2017
http://www.medscape.com/slideshow/deprescribing-6009041?src=wnl_edit_tpal&uac=14695HV
Merel SE, Paauw DS. Common Drug Side Effects and Drug-Drug Interactions in Elderly Adults in Primary Care. J Am Geriatr Soc 2017; 65(7): 1578-1585
http://onlinelibrary.wiley.com/doi/10.1111/jgs.14870/full
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November 7, 2017
Perioperative Neuropathies
A recent article in Anesthesiology News reminds us about the risk of nerve injuries during surgical procedures but also reminds us that not all perioperative neuropathies are related to patient positioning (Hardman 2017).
Hardman presents 3 cases of perioperative nerve injuries (PNI’s) but makes a good argument that patient positioning during surgery was not likely the cause in each of the 3 cases. In one patient, bilateral ulnar neuropathies were as likely to have occurred during a SICU or hospital ward stay. In a second case, the patient may have simply had progression of an underlying diabetic peripheral neuropathy. And the third case may have represented an inflammatory brachial plexopathy that happened to occur in the postoperative period.
Hardman does discuss the epidemiology of and risk factors for PNI’s. He cites studies showing estimates of PNI’s range from 0.037% to 0.5% of surgeries. PNI’s are more common in men but other risk factors include extremes of BMI and duration of hospitalization greater than 14 days. Kamal et al. (Kamel 2016) note that in addition to those risk factors, chronic hypertension, diabetes mellitus, tobacco use, neurosurgical procedures, orthopedic procedures, and prone position have all been associated with perioperative peripheral nerve injury.
In our September 29, 2009 Patient Safety Tip of the Week “Perioperative Peripheral Nerve Injuries” we discussed perioperative neuropathies related to pressure, stretch, and other mechanisms. We do know that the existence of some underlying polyneuropathies may render nerves more vulnerable to the effects of pressure or other trauma. It’s well known that entrapment neuropathies are more common in patients with underlying polyneuropathies. So a history of known polyneuropathy, such as a diabetic polyneuropathy, should clearly be considered as a risk factor for perioperative nerve injury. Patients with hypertrophic neuropathies, whether hereditary or acquired, are especially susceptible to the effects of compression.
Weight loss is another predisposing factor to some compressive neuropathies. Peroneal nerve injuries are particularly likely to occur in individuals who have lost the typical subcutaneous fat pad that protects the nerve near the head of the fibula. So it might be expected that cancer patients might be particularly susceptible because of weight loss and the frequent occurrence of polyneuropathy (either as a remote effect of cancer or a result of chemotherapy).
One of the potentially modifiable risk factors for perioperative nerve injuries that we have stressed is the duration of surgery. That is one of the reasons we recommend periodic “calling out” of the case duration time (see our columns on surgical case duration listed below). That way the surgical team can consider whether repositioning the patient is indicated (of course, there are other things to consider as the case duration becomes longer, such as the need for re-dosing prophylactic antibiotics or initiation of DVT prophylaxis). Hardman, in his current article, does appropriately point out that the literature is insufficient to evaluate the efficacy of periodic assessment of patient positioning. Nevertheless, such periodic evaluation is a common sense strategy. The 2011 ASA Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies states “The literature is insufficient to evaluate the efficacy of periodic assessment of patient position during a procedure in reducing the risk of upper extremity peripheral neuropathies” but goes on to say that 92% of the consultants and 97% of the ASA members agree that upper extremity position should be periodically assessed during procedures.
Strikingly, even the data from the medicolegal databases lacks information about total duration of anesthesia, duration a patient was in a certain position, etc. You don’t have to be a neurologist to know that positional changes may affect nerve function. All of you have experienced your arm or leg “falling asleep” when it is in a certain position too long. What do you do in response? You change position and maybe shake the limb around a little bit and the sensation returns in a few seconds. You can often then return it to the original position. It is amazing that the literature on perioperative nerve injuries does not even comment on the issue of periodic or intermittent repositioning of limbs.
There have been at least a few attempts at better understanding the relationship between positional changes and nerve damage. Kamel et al (Kamel 2006) retrospectively looked at patient undergoing spinal surgery who had intraoperative monitoring of somatosensory evoked potentials (SSEP’s). The amplitudes of SSEP’s are affected by multiple factors, such as mean arterial blood pressure, depth of anesthesia, manipulation of the spine, etc. but they may also be sensitive to ischemia, compression, stretching or other dysfunction of peripheral nerves or plexuses. In their study, they found that about 6% of changes in upper extremity SSEP’s during spine surgery responded to changes in position of the affected upper extremity. They were thus able to determine which body positions were more likely to be associated with such changes during spine surgery. The study did not include assessment of individual nerve function so information cannot be generalized to make recommendations for protection of specific peripheral nerves. But such methodology is promising and needs to be studied prospectively in a variety of surgical settings. Since patients under anesthesia cannot sense symptoms related to peripheral nerve dysfunction, SSEP’s do have promise at uncovering reversible changes during a variety of surgical procedures, not just spinal surgery.
Kamal and colleagues (Kamel 2016) also reported on intraoperative monitoring of SSEP’s during spine surgeries performed on adult patients in the prone surrender (“superman”) position. They identified that changes in intraoperative MAP (mean arterial pressure) were independent predictors associated with upper extremity position–related neurapraxia (the term we use to denote a temporary and reversible failure of conduction in the peripheral nerve) in the prone surrender position under general anesthesia. Specifically, the found that intraoperative MAP <55 mm Hg for a total duration of ≥5 minutes was an independent risk factor associated with a greater incidence of upper extremity position–related neurapraxia compared with a duration of <5 minutes with MAP <55 mm Hg. Compared with patients in their control group, patients in the case group had significantly longer duration of surgery. The mean onset time of position-related neurapraxia from the beginning of surgery was 283 minutes (range, 79–700 minutes).
Ideally, using techniques such as those used by Kamal et al to monitor somatosensory evoked potentials of multiple nerves during surgery could identify cases where stretching or compression of nerves is occurring and lead to at least temporary repositioning of the patient to minimize the risk of a PNI. However, it certainly would not be practical to do such monitoring on all surgical patients. However, using such techniques on a series of patients might well lead to recommendations about how frequently or at what intervals we might at least temporarily reposition patients.
We still wish we had some firmer recommendations for you in this significant patient safety issue. However, all we can say at this time is that you should attempt to identify patients at highest risk, try to minimize the total duration of anesthesia or the duration they are in certain positions, and use the ASA recommendations for position, padding, equipment, etc. A lot more needs to be done before we have any definitive recommendations.
Some of our prior columns on perioperative nerve injuries:
Our prior columns focusing on surgical case duration:
References:
Hardman D. Intraoperative Positioning-Related Nerve Injury, or a Case of Mistaken Identity?: 3 Selected Cases. Anesthesiology News 2017; October 13, 2017
Kamel I, Zhao H, Koch SA et al. The Use of Somatosensory Evoked Potentials to Determine the Relationship Between Intraoperative Arterial Blood Pressure and Intraoperative Upper Extremity Position–Related Neurapraxia in the Prone Surrender Position During Spine Surgery: A Retrospective Analysis. Anesthesia & Analgesia 2016; 122(5): 1423-1433
The American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies. Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies: An Updated Report by the American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies. Anesthesiology 2011; 114(4): 741-754
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1930729
Kamel IR, Drum ET, Koch SA, Whitten JA et al. The Use of Somatosensory Evoked Potentials to Determine the Relationship Between Patient Positioning and Impending Upper Extremity Nerve Injury During Spine Surgery: A Retrospective Analysis. Anesthesia & Analgesia 2006; 102(5): 1538-1542
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November 14, 2017
Tracking C. diff to a CT Scanner
We’ve previously noted that your CT or MRI scanner could be a source of infection to patients (see our October 22, 2013 Patient Safety Tip of the Week “How Safe Is Your Radiology Suite?”). And a recent study showed a CT scanner was a potential source for nosocomial transmission of C. difficile infections in a large university hospital (Murray 2017). Those authors found that passing through the CT scanner in the ED within 24 hours after a patient with C. difficile had been there was associated with increased risk of developing C. diff infection (CDI).
But the real story in the Murray study is not that the CT scanner was a source of nosocomial transmission but rather they manner in which they identified it as a source. They used their EHR (electronic health record) as a tool to identify potential sources!
They first identified patients who had proven C. diff infections and then tracked all the places within the hospital that they had been. Places or spaces were considered potentially contaminated for 24 hours after a patient with CDI visited them. All hospitalized patients who had not yet tested positive for CDI and passed through a space while it was potentially contaminated were considered exposed to C. difficile, while patients who occupied the same space at any other time served as the unexposed control group.
CDI-positive patients moved through a mean of 4.2 hospital locations, potentially contaminating those spaces. Being exposed to CDI in the CT scanner in the emergency department was significantly associated with the development of CDI (OR 2.5). That remained significant even after adjustment for covariates and in sensitivity analyses that extended the incubation period to 72 hours. There were no trends in other areas of the hospital that reached statistical significance. Once they identified this increased risk of nosocomial transmission they found that the cleaning practices for the scanner table of the CT scanner in the ED had not yet been updated to match the standardized methods applied in other radiology suites.
The study shows the value of the EHR in tracking patients in time and space can be leveraged as a tool in infection control and hospital epidemiology. Many don’t realize that the location and time stamps available in most EHR’s can be used to track patient movements within the hospital.
The study also serves as a reminder that the standards which apply to one area of the hospital (such as the radiology suite) should also apply to any components that may be housed in separate areas of the hospital.
To our mind, it also highlights another possibility: compared to patients already hospitalized, patients in the ED are less likely to be diagnosed with CDI or considered at risk for CDI. Hence, some of the precautions taken with patients with known or suspected CDI may not be taken when the patient first arrives at the ED.
Previous studies have shown that patients in rooms occupied by other patients with CDI are at increased risk for CDI (Echaiz 2014). Also patients in rooms previously occupied by patients who had received antibiotics were also at risk for CDI (Freedberg 2016). All these studies emphasize the role environmental surfaces may play in transmission of CDI.
Some of our prior columns on patient safety issues in the radiology suite:
References:
Murray SG, JWL, Croci R, et al. Using Spatial and Temporal Mapping to Identify Nosocomial Disease Transmission of Clostridium difficile. JAMA Intern Med 2017; Published online October 23, 2017
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2659323
Echaiz JF, Veras L, Zervos M, Dubberke E, Johnson L. Hospital roommates and development of health care-onset Clostridium difficile infection. Am J Infect Control 2014; 42(10): 1109-1111
http://www.ajicjournal.org/article/S0196-6553(14)00938-9/abstract
Freedberg DE, Salmasian H, Cohen B, et al. Receipt of Antibiotics in Hospitalized Patients and Risk for Clostridium difficile Infection in Subsequent Patients Who Occupy the Same Bed. JAMA Intern Med 2016; 176(12): 1801-1808
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2565687
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November 21, 2017
OSA, Oxygen, and Alarm Fatigue
We’ve done numerous columns on the dangers of oxygen supplementation in patients lacking hypoxemia. And we’ve often commented on the danger that supplemental oxygen may mask incipient respiratory depression in patients on opioids. Now, for the first time, a well-done study has demonstrated that use of supplemental oxygen in patients with OSA (obstructive sleep apnea) indeed may lead to elevated levels of CO2 postoperatively.
As we’ve seen so many times, researchers from the University of Toronto led by Frances Chung did this study on OSA patients undergoing surgery (Liao 2017). They randomized patients with documented OSA (apnea/hypopnea index greater than 5 per hour) to routinely receive supplemental oxygen (3L/minute via nasal prongs) or not. The group receiving supplemental oxygen did have higher average oxygen saturation and a lower average oxygen desaturation index and a decreased AHI when measured on postoperative night #3. However, though the average amount of time spent with pCO2 greater than 55 mm Hg did not differ between groups, 11.4% of patients receiving supplemental oxygen had CO2 levels exceeding 55 mm Hg on postoperative nights, most notably on the first postoperative night.
So the Liao study had somewhat mixed results. It clearly showed better oxygenation status and actual improvement in sleep disordered breathing parameters. The paper has a good discussion of the theoretical reasons oxygen would improve the latter. But it also highlights that a substantial minority of patients with OSA do develop some degree of respiratory depression postoperatively when receiving supplemental oxygen. The authors recommend additional monitoring of respiratory rate or pCO2 measured by transcutaneous CO2 monitor (Ptc CO2) , especially on postoperative night 1.
Yet another study from the University of Toronto group (Lam 2017) was a systematic review and meta-analysis of continuous pulse oximetry and continuous capnography monitoring of patients receiving opioids postoperatively. They concluded that use of continuous pulse oximetry on the surgical ward is associated with significant improvement in the detection of oxygen desaturation versus intermittent nursing spot-checks, and that there is a trend toward fewer ICU transfers with continuous pulse oximetry versus standard monitoring. The evidence on whether the detection of oxygen desaturation leads to less rescue team activation and mortality was inconclusive. They also concluded that capnography provides an early warning of postoperative respiratory depression before oxygen desaturation, especially when supplemental oxygen is administered.
So we have long been advocates of monitoring all patients receiving opioids with continuous pulse oximetry, respiratory rate, and capnography. Of course, the issue of alarm fatigue always rears its ugly head any time we are talking about continuous monitoring. The number of false alarms that may occur can be immense. A very elegant 2-part study done at Virtua Health System (VHS) in New Jersey used an algorithm from combined alarms to result in a significant reduction of alarms without sacrificing patient safety (Supe 2017). VHS sought to prioritize narcotic safety by implementing noninvasive capnography monitoring in 2013. But since most of their post-op patients on opioids were located on med/surg units, where continuous monitoring equipment was not as ubiquitous as in ICU’s, alarm fatigue became a potential barrier. So they first did a pilot study focused on remote monitoring of capnography alarm signals issued through middleware to telemetry technicians within three hospitals in their system. Various alarms were prioritized, based upon clinical importance and degree of urgency, and appeared color-coded on the remote telemetry dashboard. Their initial data collection showed that alarms for respiratory rate, heart rate, pulse oximetry, and end-tidal CO2 were far too frequent. An overall average across all patients of 182 alarms per hour was determined from the raw counts of the data. In some cases, as many as 427 alarms per hour were issued on a single patient corresponding to threshold breaches (principally) in low respiratory rate and low et CO2. They especially found that low etCO2 and both low and high respiratory rate alarm signals dominated. So they used this data to investigate ways in which to reduce alarm signals and provide only actionable notifications to appropriate clinical staff.
They also noted that two sensor devices, the end-tidal CO2 nasal cannula and the pulse oximeter, were very sensitive to patient movement and thus generated many false alarms. Another important observation was that some patients with OSA would not awaken to the audible alarms that occurred in their rooms while they were asleep (those in-room alarms were indeed intended to awaken the patient).
The data also noted distinctions between alarms resulting from breaches in thresholds for single alarms versus consecutive alarm breaches, also termed sustained alarm signals. The clinical team hypothesized that individual, self-correcting measurements (i.e., those that breached a threshold, then returned to normal range) should not be communicated. Rather, only those instances where measurements continuously trended below/above a specified threshold for a predefined period of time should be communicated. To validate the hypothesis that sustained alarm signal generation would considerably reduce the overall number of alarm signals issued, the data of the initial phase pilot were retrospectively evaluated against sustained delays of 30 seconds. Further clinical discussion and survey of the literature resulted in a decision to consider 30 seconds as the sustained alarm threshold. If measurements in any individual parameter were sustained at or below/above the threshold value for 30 seconds or longer, then an alarm signal would be issued on an individual parameter.
They next took into account how to handle alarms related to technical conditions (eg. nasal prongs off patient) and took the following questions into account as they designed the follow-up study to the original pilot study:
This resulted in a clinical trial to evaluate the use of alarm signals generated using sustained and combinatorial alarm rule conditions (defined as those for which multiple criteria must be met simultaneously before an alarm condition is signaled) over a period of 4 weeks at one hospital within the health system. 25 patients were enrolled in the study based on existing diagnoses of OSA or meeting the STOP-BANG criteria for OSA.
They found that patients were experiencing extended periods of single-parameter threshold breaches that were continuous or repetitive in nature. In most cases, these single-parameter alarm signals did not signify clinically meaningful events requiring intervention, as verified by research nursing staff. They also found that quantities of combinatorial alarm signals were significantly lower than the single-parameter sustained alarm signals.
As expected in this OSA population cohort, pulse oximetry and pulse rate alarm signals occurred far less often than either respiratory rate or end-tidal CO2 alarms. In addition, alarms related to low end-tidal CO2 were far more frequent than those related to high end-tidal CO2.
The use of combinational alarm rules was clearly of benefit, making the quantity of alarm signals much more manageable. One example was that, when SpO2 was removed from the combinatorial calculations, the number of alarm signals was large (>4,500) until sustained delay of 18 seconds was used, at which point the quantity of alarm signals decreased to 209. Another was that, by using hypopneic hypoventilation combinatorial alarm signals, there was more than a 98% reduction over 30-second sustained middleware-generated respiratory rate and end-tidal CO2 alarm signals.
During the study, seven patients were identified as requiring some form of intervention, four with true respiratory distress (one requiring administration of naloxone to reverse the effect of the opioid and placement on noninvasive ventilator support). These patients were discovered as a result of the sustained alarms, and combinatorial alarms were triggered for these patients as well.
Analyzing their data over several potential alarm delay periods, they noted a significant reduction in middleware-generated alarm signals occurred when the sustained delay was increased to 48 seconds, compared to the 30 second delay used clinically in this study. That should be a focus for future studies.
The authors conclude that combinatorial alarm signals based on multiparameter assessment reduced overall load better than individual-parameter sustained alarm signals and appeared to be more effective at identifying at-risk patients.
Their work also identified another key need: workflow needs to integrate clinical engineering into the alarm reporting infrastructure, so that technical alarms (e.g., low battery notifications) can be communicated to staff to ensure that technical intervention takes place in a timely manner.
This work is a great contribution to our understanding of both monitoring the post-op patient for opioid-induced respiratory depression and addressing the issue of alarm fatigue proactively. Is it a definitive study? No. The total patient population was small and females may have been overrepresented (17 women and 8 men, which may be somewhat unusual for an OSA population). But it is a great start and this work needs to be replicated in other venues and patient populations. Kudos to the folks at Virtua Health System for this contribution.
Since we are talking about OSA, it is worth mentioning two other recent studies contributing to the OSA literature. One was yet another meta-analysis done by the University of Toronto group evaluating postoperative complications associated with OSA patients undergoing cardiac surgery (Nagappa 2017). They found that, after cardiac surgery, MACCE’s (major adverse cardiac or cerebrovascular events) and newly documented POAF (postoperative atrial fibrillation) had 33.3% and 18.1% higher odds in OSA versus non-OSA patients, respectively. The majority of OSA patients were not treated with continuous positive airway pressure therapy.
Meanwhile, a nice review on maternal obstructive sleep apnea and sleep disordered breathing (SDB) during pregnancy was also recently published (Pamidi 2017). It notes that prospective observational studies in which the investigators ascertained SDB by using complete polysomnography have shown a prevalence ranging from approximately 17% to 45% in the third trimester. Observational studies indicate that maternal SDB may be linked with the development of adverse pregnancy outcomes, such as gestational hypertension and gestational diabetes mellitus and possibly delivery of infants who are small for gestational age. However, the review notes that indications for screening for SDB during routine obstetric prenatal visits are still unclear, and little currently is known about whether treatment of SDB during pregnancy improves clinical outcomes for the mother and/or baby. Nice review, but lots of questions remain unanswered.
Other Patient Safety Tips of the Week pertaining to opioid-induced respiratory depression and PCA safety:
Our prior columns on obstructive sleep apnea in the perioperative period:
June 10, 2008 “Monitoring the Postoperative COPD Patient”
August 18, 2009 “Obstructive Sleep Apnea in the Perioperative Period”
August 17, 2010 “Preoperative Consultation – Time to Change”
July 2010 “Obstructive Sleep Apnea in the General Inpatient Population”
July 13, 2010 “Postoperative Opioid-Induced Respiratory Depression”
November 2010 “More on Preoperative Screening for Obstructive Sleep Apnea”
February 22, 2011 “Rethinking Alarms”
November 22, 2011 “Perioperative Management of Sleep Apnea Disappointing”
March 2012 “Postoperative Complications with Obstructive Sleep Apnea”
May 22, 2012 “Update on Preoperative Screening for Sleep Apnea”
February 12, 2013 “CDPH: Lessons Learned from PCA Incident”
February 19, 2013 “Practical Postoperative Pain Management”
March 26, 2013 “Failure to Recognize Sleep Apnea Before Surgery”
June 2013 “Anesthesia Choice for TJR in Sleep Apnea Patients”
September 24, 2013 “Perioperative Use of CPAP in OSA”
May 13, 2014 “Perioperative Sleep Apnea: Human and Financial Impact”
March 3, 2015 “Factors Related to Postoperative Respiratory Depression”
August 18, 2015 “Missing Obstructive Sleep Apnea”
June 7, 2016 “CPAP for Hospitalized Patients at High Risk for OSA”
October 11, 2016 “New Guideline on Preop Screening and Assessment for OSA”
Prior Patient Safety Tips of the Week pertaining to alarm-related issues:
References:
Liao P, Wong J, Singh M, et al. Postoperative Oxygen Therapy in Patients With OSA: A Randomized Controlled Trial. Chest 2017; 151: 597-611
http://journal.chestnet.org/article/S0012-3692(16)62594-1/fulltext
Lam T, Nagappa M, Wong J, et al. Continuous Pulse Oximetry and Capnography Monitoring for Postoperative Respiratory Depression and Adverse Events: A Systematic Review and Meta-analysis. Anesthesia & Analgesia 2017; Article Published Ahead of Print Post Author Corrections: October 19, 2017
Supe D, Baron L, Decker T, et al. Research: Continuous Surveillance of Sleep Apnea Patients in a Medical-Surgical Unit. Biomedical Instrumentation & Technology 2017; 51(3): 236-251
http://www.aami-bit.org/doi/full/10.2345/0899-8205-51.3.236
Nagappa M, Ho G, Patra J, et al. Postoperative Outcomes in Obstructive Sleep Apnea Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-Analysis of Comparative Studies. Anesthesia & Analgesia 2017; Article Published Ahead of Print Post Author Corrections: October 17, 2017
Pamidi S, Kimoff RJ. Maternal Sleep Apnea. Sleep-Disordered Breathing in PregnancySleep-Disordered Breathing in Pregnancy. Chest 2017; Article in Press October 21, 2017
http://journal.chestnet.org/article/S0012-3692(17)32906-9/fulltext
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November 28, 2017
More on Dental Sedation/
Anesthesia Safety
Lee and colleagues recently asked why we aren’t doing more to avoid tragedies related to dental sedation/anesthesia (Lee 2017). They described a case where a young patient with dental caries was sedated with Versed and nitrous oxide for dental work because he had behavioral issues. More Versed was required during the procedure and after the procedure was done the dentist left the child in recovery with a dental assistant. But when he returned with the boy's mother, the child was cyanotic. Rescue efforts failed and the boy was dead upon arrival at the hospital. Lee and colleagues call for more data and more research on the reasons for pediatric sedation deaths during dental procedures.
Actually, a considerable amount of data collection and analysis has been done recently, as noted in our March 28, 2017 Patient Safety Tip of the Week “More Issues with Dental Sedation/Anesthesia”, which we’ll reiterate later.
But very timely is an article from the California Dental Association (CDA 2017) in which Dr. Steven Yun, a board-certified M.D. anesthesiologist who specializes in dental office anesthesia, is interviewed about safe dental sedation in the office.
Dr. Yun notes 2 important trends in improving dental sedation safety: “There is now an emphasis on the team model, meaning that as an anesthesiologist I must recruit and activate each member of the treatment team to take an active role in patient safety. Dentists, dental assistants and the front-office staff must be recognized as important and valuable members of the care team when it comes to anesthesia patient safety.” He describes how he introduces himself to each member of the team and talks about their role(s), in a manner that promotes a culture in which team members feel empowered to speak up. He also reviews basic emergency procedures with the office, checks backup emergency equipment and completes a pre-anesthesia checklist before every procedure.
The second important trend is the use of checklists. Dr. Yun uses a Safety Checklist for Office-Based Procedural Sedation/Anesthesia downloaded from the American Dental Society of Anesthesiology. That checklist is similar to the Safe Surgery Checklist we’ve so often discussed and is customizable.
Another important point is that he provides his patients and their parents access to a variety of information about safety on his website and emphasizes the need to do this well in advance.
And then he provides several very practical recommendations:
The point about calling 911 first is very important. Dr. Yun emphasizes that one of the most common mistakes is waiting too long to seek emergency assistance. That was one of the root causes identified by the Texas Blue Ribbon Panel that we discussed in our March 28, 2017 Patient Safety Tip of the Week “More Issues with Dental Sedation/Anesthesia”.
We’ve also emphasized over and over that the only way to be prepared for rare emergencies, whether they are events related to dental sedation or hospital events like surgical fires, is to practice for them. Every member of the team needs to understand their role in such events. We also like the way he stresses that everyone, including front office staff, are critical to successfully handling sedation emergencies.
Periodic inspection (with a log) of all emergency equipment should be done regularly.
Of course, Dr. Yun is an anesthesiologist. We doubt that most dental practices are using an anesthesiologist. Much more often the dentist, who is also doing the dental work, is the one certified in dental sedation/anesthesia. That dual role is obviously problematic, regardless of how well we think we can multi-task.
Proper procedures and guidelines for pediatric sedation (Coté 2016) were discussed in our August 2016 What's New in the Patient Safety World column “Guideline Update for Pediatric Sedation”.
Our March 28, 2017 Patient Safety Tip of the Week “More Issues with Dental Sedation/Anesthesia” discussed the Texas blue ribbon panel (Texas SBDE 2017) recommendations that were made after analyzing multiple Texas cases with adverse events and reviewing the scientific literature, the above mentioned guidelines, and regulations in place in other states.
The panel’s review of incidents that had occurred in Texas included some of the following root causes and contributing factors:
The latter factor (long delays in calling 911 or otherwise activating the EMS) was the most common contributing factor identified, though it was not universal. The panel identified several root causes for such delays, including fear that such might lead to a regulatory investigation, considering the need for EMS as a personal failure, and lack of practice in crisis management.
One other factor suspected, but which was difficult to prove, was that in some cases the sedation provider may have left the dental operatory for a period of time, leaving the patient unobserved. Current rules in Texas require continuous presence of the sedation provider until the patient has reached a defined level of recovery.
The panel found that at least 2 major failures had occurred in all 6 major events and that no sedation related event would likely have occurred if all rules currently in place had been closely followed and failures avoided.
The Texas blue ribbon panel made several recommendations, including the following:
Other suggestions included encouraging or mandating a preoperative sedation checklist, clarifying what should be included in the preoperative evaluation, and what constitutes an acceptable sedation/anesthesia record.
They also had multiple administrative recommendations and suggestions that you can read in our prior column.
Texas already had a rule/regulation that at least one member of the assistant staff be present during nitrous oxide/oxygen inhalation sedation. The dental provider may delegate monitoring of nitrous oxide/oxygen inhalation sedation (once pharmacologic and vital sign stability has been established) to an assistant who is certified by the State Board of Dental Examiners (SBDE) to do so. Assisting staff must also be certified in BLS (Basic Life Support).
The updated American Academy of Pediatrics (AAP)/American Academy of Pediatric Dentistry (AAPD) “Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures” (Coté 2016) emphasizes the role of capnography in appropriate physiologic monitoring and continuous observation by personnel not directly involved with the procedure to facilitate accurate and rapid diagnosis of complications and initiation of appropriate rescue interventions. We were glad to see the Texas blue ribbon panel recommendation for use of capnography.
The updated AAP/AAPD guideline has specific recommendations for when the intended level of sedation is minimal, moderate, deep or general sedation. One critical point that should be of particular concern for dental practices, is that use of moderate or deeper sedation shall include the provision of a person, in addition to the practitioner, whose responsibility is to monitor appropriate physiologic parameters and to assist in any supportive or resuscitation measures. While that individual might also be responsible for assisting with interruptible patient-related tasks of short duration, such as holding an instrument or troubleshooting equipment, the primary role of that individual is monitoring the patient. For deep sedation the sole role of the support individual is to monitor the patient. In either case that individual should be trained in and capable of providing advanced airway skills (eg, PALS) and shall have specific assignments in the event of an emergency and current knowledge of the emergency cart/kit inventory.
Monitoring is critical and should include the level of patient’s ability to communicate (where assessable), heart rate, respiratory rate, blood pressure, oxygen saturation, and expired carbon dioxide values (via capnography) should be recorded, at minimum, every 10 minutes in a time-based record. The guideline stresses use of capnography but acknowledges that it may not be able to be used in some procedures around the face, including many dental procedures.
The guideline also discusses selection of drugs and the importance of knowledge about the duration of action of the drugs used. It also discusses the needs for the emergency cart/kit and backup emergency services access and availability. There is also a good section on discharge issues, including what should be monitored by families after discharge.
One important item we could not find in either Texas’ current regulations or the recommendations made by the panel is a statement about patient restraints or immobilization devices. You’ll recall that several of the events we described in our March 15, 2016 Patient Safety Tip of the Week “Dental Patient Safety” involved use of a pediatric restraint called a “papoose” that may have contributed to the adverse outcomes. The updated AAP/AAPD guideline has a good discussion about the use of immobilization devices, such as the “papoose” boards. Such must be applied in such a way as to avoid airway obstruction or chest restriction and the child’s head position and respiratory excursions should be checked frequently to ensure airway patency. If an immobilization device is used, a hand or foot should be kept exposed, and the child should never be left unattended.
We do like the Safety Checklist for Office-Based Procedural Sedation/Anesthesia downloaded from the American Dental Society of Anesthesiology. It has sections for room setup, pre-procedure issues, postop recovery, and record keeping. But we also wonder how often dental practices do pre-procedure huddles (briefings) and post-procedure debriefings. Those offer the opportunity to both plan for contingencies and analyze things that might have been done better.
We certainly concur with Lee and colleagues that deaths and other adverse events related to dental sedation/anesthesia should be avoidable. There are already some excellent guidelines and recommendations available. The question is how often dental practices comply with those guidelines and recommendations.
Sedation/anesthesia probably allows dental and oral surgery procedures needed by many young children. But it is not something that dental practices or parents of young children should approach cavalierly. Guidelines like those outlined today need to be adhered to closely and a high level of vigilance incorporated into such dental practices.
Some of our previous columns on dental patient safety issues:
March 15, 2016 “Dental Patient Safety”
August 2016 “Guideline Update for Pediatric Sedation”
March 28, 2017 “More Issues with Dental Sedation/Anesthesia”
August 8, 2017 “Sedation for Pediatric MRI Rising”
References:
Lee H, Milgrom P, Huebner CE, et al. Ethics Rounds: Death After Pediatric Dental Anesthesia: An Avoidable Tragedy? Pediatrics 2017, e20172370
CDA (California Dental Association). Dental anesthesia safety: Say something if you see something. CDA News/Events 11/09/2017
ADSA (American Dental Society of Anesthesiology). Safety Checklist for Office-Based Procedural Sedation/Anesthesia.
https://irp-cdn.multiscreensite.com/f37fe5b3/files/uploaded/ADSAChecklistFINAL%20copy.pdf
Coté CJ, Wilson S, American Academy of Pediatrics, American Academy of Pediatric Dentistry. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics 2016; 138(1): e2016121
http://pediatrics.aappublications.org/content/138/1/e20161212
State Board of Dental Examiners (Texas). Report to the Texas Sunset Advisory Commission by the Blue Ribbon Panel on Dental Anesthesia/Sedation Safety. January 4, 2017
https://lintvkxan.files.wordpress.com/2017/01/anesthesia-recommendations-final-report.pdf
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December 5, 2017
Massachusetts Initiative on Cataract Surgery
Cataract surgery is generally considered to be one of the safest surgical procedures. We have, however, identified problems related to cataract surgery over the years (see the full list at the end of today’s column). A year ago we discussed the findings of a report from Massachusetts’ Betsy Lehman Center for Patient Safety regarding patient safety issues in cataract surgery (see our May 17, 2016 Patient Safety Tip of the Week “Patient Safety Issues in Cataract Surgery”).
Now two reports have been published regarding the adverse events (AE’s) in cataract surgery from the Betsy Lehman Center study, with a focus on the anesthesia-related issues (Roberto 2017, Nanji 2017).
The first report (Roberto 2017) described the reports of 37 AE’s reported to state agencies in Massachusetts involving cataract surgery from 2011 to 2015. Wrong intraocular lens (N = 15, 41%) involved selecting a lens intended for a different patient, and was the most frequent AE. We’ve discussed this issue in several of our prior columns.
Next most frequent were complications from needle-based eye blocks (N = 10, 27%), which included 5 globe perforations (serious reportable events or SRE’s) and 5 non-SRE major incidents, such as retrobulbar hematoma. There were also 3 cases of wrong side eye blocks and one case of wrong side surgery. Other AE’s included retained object/tissue (2 cases) and 3 cases of suspected toxic anterior segment syndrome. The authors discuss possible mechanisms for the permanent visual loss related to the needle-based blocks. The authors also queried the Anesthesia Incident Reporting System, the CRICO Comparative Benchmarking System, and the Anesthesia Closed Claims Database and identified other adverse events. They conclude that there is likely underreporting of adverse events in all these data sources but that the types of injuries identified should be a signal for investigation into ways to avoid these adverse events. In particular, they note that reporting from ASC’s (ambulatory surgery centers) has been less robust than from hospitals, That is a concern since there has been a massive shift in cataract surgery from hospital-based outpatient surgery to ASC’s (Stagg 2017).
The companion paper (Nanji 2017) delved into details of the Massachusetts cases with adverse events and a panel of experts identified 2 principal categories of contributing factors: systems failures and choice of anesthesia technique. Systems failures included inadequate safety protocols (48.7% of contributing factors), communication challenges (18.4%), insufficient provider training (17.1%), and lack of standardization (15.8%). Choice of anesthesia technique involved the increased relative risk of needle-based eye blocks.
Among the inadequate safety protocols they identified inadequate timeout protocols (40.5%) and poor adherence to time-outs (37.8%) as major contributing factors. Failure to include a second provider in the time out, incomplete time outs, and time outs separated in time from the procedure were specific deviations noted. Improper lens storage was cited in 13.5% of incidents and failure to use at least 2 independent sources of lens verification was also identified as a contributing factor. One facility reported that they bring lenses for all scheduled patients into the operating room at the start of the day.
The authors also identified high case volumes and time pressures as significant contributing factors. These often led to workarounds for time outs, complacency with time outs, and distractions by concurrent activities leading to lack of active participation in time outs. They also mention the literature notes changes in surgical schedules may contribute.
All these are very familiar to us. Over 20 years ago we investigated our first case of wrong lens implantation. A high number of cases were scheduled at an ASC for one ophthalmologist, who brought into the OR all his outpatient records for patients scheduled that day plus all the lenses expected to be used that day. When one patient complained he had wanted to be first case of the day, staff changed the OR schedule and inserted that patient earlier than originally scheduled. As a result, two consecutive patients each received the wrong lens implants before the situation was recognized. That was the case that led us to develop a comprehensive time out process that served as a template for New York State’s first time out policy and eventually Joint Commission’s Universal Protocol.
Having multiple patient records in the room and having multiple lenses in the room simply increased the odds of mistakes considerably. Verification of the correct lens (using primary source verification) also needs to be a formal part of the time out process. Because cataract surgery typically is done on an ambulatory basis, some factors come into play. There is typically no “hospital” medical record with details available and much of the vital information is in the physician office notes, which have not become part of the facility medical records. Failure to ensure that a history & physical are in the chart prior to the start of the case also is a missed opportunity to identify discrepancies that may lead to wrong patient or wrong eye or wrong lens events.
Nanji and colleagues also identified communication issues as the second major contributing factor. Many involved staff miscommunication during lens time outs but others were miscommunications with patients (a cited example was when the wrong patient responded when the nurse called for the next patient). But written communication breakdowns were also an issue, often related to poor handwriting. And, as we so often see in serious incident investigations, failure of staff to speak up and hesitancy to voice concerns in high-turnover rooms was involved in 28.6% of the communications challenges identified.
The third most common contributing factor identified was insufficient training. Inadequate orientation and training and use of temporary staff or locum tenens staff contributed in some cases. Inadequate training on the administration of eye blocks was cited as a factor in the 5 cases of globe perforation in the Massachusetts series. The authors note that less than one fourth of anesthesiology residency programs offer ophthalmic anesthesia training.
The fourth contributing category identified was lack of standardization across and even within facilities. Things that have not been standardized across sites include: lens ordering forms, site marking techniques, and even variations in lens packaging.
Choice of anesthesia technique was a major focus of the Nanji paper. Over 40% of the adverse events in the Massachuesetts series involved eye blocks. They note that none of the AEs involved topical anesthesia, sub-Tenon’s block, or general anesthesia. Importantly, the anesthesiologist with 5 reported globe perforations was a contracted provider working his second day at the facility. His privileges had been granted based upon information provided by a credentialing service. The expert panel suspected that inadequate credentialing and insufficient orientation to unfamiliar equipment and lack of knowledge/experience or improper technique contributed as well as the inherent risks associated with the type of anesthesia used. The Nanji paper goes into detail about the types of anesthesia technique (including an appendix describing each in detail) and the great variation with which each is used across facilities and providers.
The panel identified 6 key strategies to help prevent AE’s in cataract surgery:
To these we would add our own further recommendations (these and others are described in our May 17, 2016 Patient Safety Tip of the Week “Patient Safety Issues in Cataract Surgery”):
The two papers resulting from Massachusetts’ Betsy Lehman Center for Patient Safety investigation are important contributions to our understanding of factors contributing to adverse events in cataract surgery. While cataract surgery remains one of the safest procedures done today, the findings indicate we can do more to make it even safer.
Some of our previous patient safety columns involving ophthalmology issues:
June 5, 2007 “Patient Safety in Ambulatory Surgery”
March 11, 2008 “Lessons from Ophthalmology”
June 8, 2010 “Surgical Safety Checklist for Cataract Surgery”
June 2012 “Tailored Timeouts for Ophthalmologists”
May 20, 2014 “Ophthalmology: Blue Dye Mixup”
September 2014 “Another Blue Dye Eye Mixup”
May 17, 2016 “Patient Safety Issues in Cataract Surgery”
References:
Nanji KC, Roberto SA, Morley MG, Bayes J. Preventing Adverse Events in Cataract Surgery: Recommendations From a Massachusetts Expert Panel. Anesthesia & Analgesia 2017; Published Ahead-of-Print Post Author Corrections: October 04, 2017
Roberto SA, Bayes J, Karner PE, et al. Patient Harm in Cataract Surgery: A Series of Adverse Events in Massachusetts. Anesthesia & Analgesia 2017; Published Ahead-of-Print Post Author Corrections: October 05, 2017
Stagg BC, Talwar N, Mattox C, et al. Trends in Use of Ambulatory Surgery Centers for Cataract Surgery in the United States, 2001-2014. JAMA Ophthalmol 2017; Published online November 22, 2017
https://jamanetwork.com/journals/jamaophthalmology/article-abstract/2664081
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December 12, 2017
Joint Commission on Suicide Prevention
We’ve done many columns on the issue of suicide in hospitals (see the full list at the end of today’s column). A recent issue of Joint Commission Online (TJC 2017) had a perspective on safeguards to prevent suicide in a variety of healthcare settings. It summarized recommendations from 3 expert panels that reviewed interventions to prevent suicide in several different healthcare settings, with a heavy focus on making the environment safe.
You’ll see that the recommendations rely heavily on many of the points from the VA’s Mental Health Environment of Care Checklist, which we’ve discussed in so many columns (most recently in our August 29, 2017 Patient Safety Tip of the Week “Suicide in the Bathroom”). 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.
Particular attention was paid to potential ligature-related risks. They present in an appendix some statistics about use of ligature points for suicide attempts on corridor doors, drop ceilings, and toilet seats. Recommendations are made for inpatient psychiatric units, general acute inpatient settings, and emergency departments.
Recommendations for Inpatient Psychiatric Units
Inpatient psychiatric units, in both psychiatric hospitals and general/acute care settings, must be ligature-resistant in the following areas:
In inpatient psychiatric units, in both psychiatric hospitals and general/acute care settings, the doors between patient rooms and hallways must contain ligature-resistant hardware which includes, but may not be limited to, hinges, handles, and locking mechanisms.
But the recommendations note that nursing stations with an unobstructed view (so that a patient attempt at self-harm at the nursing station would be easily seen and interrupted) do not need to be ligature-resistant and will not be cited for ligature risks. Areas behind self-closing/self-locking doors would also be considered exempt.
In inpatient psychiatric units, in both psychiatric hospitals and general/acute care settings, the transition zone between patient rooms and patient bathrooms must be ligature-free or ligature-resistant. They note that this may be accomplished with mechanical or behavioral solutions. Mechanical solutions include removing the bathroom door, placing an alarm on the door to prevent inappropriate use, and using a special door designed to prevent using the top to support a ligature (for example, an angled upper edge or breakaway magnetic hinges). A behavioral solution would be denying access to the bathroom unless staff is present; this still requires having the profile of the door be ligature-resistant in the closed arrangement. Our August 29, 2017 Patient Safety Tip of the Week “Suicide in the Bathroom” discussed these issues in detail. The Joint Commission document does note that in some states modifications or removal of doors are not allowed due to privacy concerns.
The panel discussed whether standard toilet seats (with a hinged seat and lid) posed significant ligature/suicide risk but concluded that traditional toilet seats are as safe as toilets without movable seats and covers, offer patients more comfort, and are less stigmatizing.
Corridor doors remain problematic. Several panelists reported that they were aware of cases in which a patient slipped a ligature between the corridor door and the door frame and/or hinges and committed suicide. And there are several mechanical devices available to decrease the risk of the top of a door being used to fix a ligature (eg. laser beams, pressure-sensing plates, and monitoring cameras) but the efficacy of such devices is unproven. So the panel does not recommend mandatory installation of such devices. Rather, they recommend organizations should note such doors on their environmental risk assessments and describe their mitigation strategies, such as appropriate rounding and monitoring by staff, requiring that doors be left open during certain hours, and so on.
In inpatient psychiatric units, in both psychiatric hospitals and general/acute care settings, patient rooms and bathrooms must have a solid ceiling and that a drop ceiling is not an acceptable alternative because patients might climb up to the drop ceiling, remove a panel, and gain access to ligature risk points in the space above the drop ceiling. They do allow drop ceilings in hallways and common patient care areas as long as all aspects of the hallway are fully visible to staff and there are no objects that patients could easily use to climb up to the drop ceiling. But for areas that are not fully visible to staff or where patients could easily move objects to access the area above the drop ceiling there should be a risk assessment and an appropriate mitigation plan. Mitigation strategies might include gluing the tiles in place, using tile retention clips, installing motion sensors above the ceiling to sense tampering, or using another comparable harm-resistive arrangement.
Importantly, the document recognizes that some patients in psychiatric units may have medical needs that necessitates use of beds or equipment that may present ligature risks. In such cases, the medical needs and the patients’ risk for suicide should be carefully assessed and balanced. In such cases, there must be appropriate mitigation plans and safety precautions in place.
Recommendations for General Acute Inpatient Settings
Joint Commission recognizes that, because of the medical needs of patients on med/surg units, it is impossible to make their environment truly ligature-resistant. Therefore. the general medical/surgical inpatient setting does not need to meet the same standards as an inpatient psychiatric unit to be a ligature-resistant environment. Instead, while it is still incumbent to remove all objects that pose a risk for self-harm without adversely affecting the ability to deliver medical care, Joint Commission focuses on human/behavioral solutions to prevent suicides on these units. These would include mitigating strategies such as:
Organizations should have policies, procedures, training, and monitoring systems in place to ensure these are done reliably. That would include training staff and testing them for competency on how they would address the situation of a patient with serious suicidal ideation and 1:1 monitoring of patients with serious suicidal ideation.
It would also include conducting risk assessments for objects that could pose a risk for self-harm and identifying those objects that should be routinely removed from the immediate vicinity of patients with suicidal ideation. And plans for monitoring visitors would be required.
Monitoring bathroom use and protocols for having qualified staff accompany patients on intrahospital transport would also be necessary. We are a bit troubled that the recommendations did not specifically address one area we always focus on: the bathrooms in the radiology suite (or other hospital area to which psychiatric patients might occasionally be transported). Virtually every time we visit a hospital we find a bathroom in such areas that has multiple potential ligature points and which can be locked from the inside. While it may not be feasible to make those bathrooms ligature-free, the staff accompanying the potentially suicidal patient must have ready access to the keys in the event the patient locked him/herself in the bathroom.
Recommendations for Emergency Departments
Like the med/surg units, emergency departments do not need to meet the same standards as an inpatient psychiatric unit to be a ligature-resistant environment.
But Joint Commission recommends two main strategies to keep patients with serious suicide ideation safe in emergency departments:
Once again, organizations should have policies, procedures, training, and monitoring systems in place to ensure these are done reliably. A defined policy for “demonstrably reliable monitoring” could include 1:1 continuous monitoring, observations allowing for 360-degree viewing, or continuously monitored video) but monitoring must be linked to the provision of immediate intervention by qualified staff member when needed.
Other interventions should include:
Staff must be trained and tested for competency on how they would address a situation with a patient with serious suicidal ideation.
Suicide should be a “never event” for patients in the hospital and every hospital, not just those with inpatient psychiatric units, must be prepared to do everything possible to prevent such events. We encourage you to read our other columns on this issue.
Some of our prior columns on preventing hospital suicides:
References:
TJC (The Joint Commission). November 2017 Perspectives Preview: Special Report: Suicide Prevention in Health Care Settings. Recommendations Regarding Environmental Hazards for Providers and Surveyors. Joint Commission Online 2017; October 25, 2017
Mental Health Environment of Care Checklist (VA)
http://www.patientsafety.va.gov/docs/MHEOCCed092016508.xlsx
http://www.patientsafety.va.gov/professionals/onthejob/mentalhealth.asp
Watts BV, Shiner B, Young-Xu Y, Mills PD. Sustained Effectiveness of the Mental Health Environment of Care Checklist to Decrease Inpatient Suicide. Psychiatric Services 2016; Published Online Ahead of Print: November 15, 2016
http://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201600080
Mills PD. Use of the Mental Health Environment of Care Checklist to Reduce the Rate of Inpatient Suicide in VHA. TIPS (Topics in Patient Safety) 2016; 16(3): 3-4 July/August/September 2016
http://www.patientsafety.va.gov/professionals/publications/newsletter.asp
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December 19, 2017
More on Overlapping Surgery
Lots has transpired since Boston Globe first published its investigative report (Abelson 2015) that ignited the controversy on double-booked surgery and the subsequent review by the Senate Finance Committee (Senate Finance Committee 2016). It didn’t take long for everyone to agree that concurrent surgery (where critical parts of two surgeries might be taking place simultaneously) should be banned but we’ve been left with the debate about “overlapping” surgery. But details both about the frequency of overlapping surgery and its safety were largely lacking when the controversy first appeared.
In the 6 months since our last column on overlapping surgery quite a bit has happened. There has been a flurry of publications on the experience with overlapping vs. non-overlapping surgery, mostly at single institutions.
Analysis of a large series of neurosurgical cases at Emory University Hospital failed to demonstrate an association between overlapping surgery (OS) and complications, such as mortality, morbidity, or worsened functional status (Howard 2017). The Emory study was a well-done retrospective analysis that used propensity score weighting to adjust for differences between the cohorts receiving non-overlapping surgery (NOS) or overlapping surgery (OS). The researchers also divided OS cases into 2 subgroups: (1) overlapping in-room time (OS-R) where the preparation stage for the second patient occurred simultaneously with the emergence phase of surgery for the first patient and (2) overlapping skin-to-skin time (OS-StS).
After propensity score weighting regression analysis failed to demonstrate any statistically significant difference between either form of OS and NOS for mortality, overall or severe morbidity, ICU LOS, overall LOS, discharge location, functional status at discharge or within the 90-day global period, unexpected readmission within 30 days, or unplanned return to the OR or procedure room.
After use of propensity score weighting to adjust, the only differences between the NOS and OS groups were in-room and skin-to-skin operating times and presence of a fellow. Median surgical times were significantly longer for patients in the OS cohort vs the nonoverlapping surgery cohort (in-room time, 219 vs 188 minutes; skin-to-skin time, 141 vs 113 minutes). Longer in-room time (but not skin-to-skin time) was associated with morbidity, but not mortality or followup functional status.
A retrospective review of over 1000 consecutive nonemergent neurosurgical procedures (Guan 2017) also failed to demonstrate an association between OS and complications, such as mortality, morbidity, or worsened functional status. The overall complication rate was not significantly higher for overlapping cases than for nonoverlapping cases (26.3% vs 26.9%), nor was the rate of serious complications (14.7% vs 11.8%).
Another study of over 7000 neurosurgical patients in an urban academic hospital found no difference between overlapping surgery and non-overlapping surgery for length of stay, estimated blood loss, discharge location, 30-day mortality, 30-day readmission, return to operating room, acute respiratory failure, and severe sepsis (Zygourakis 2017a). Procedure times, however, were longer in patients with overlapping surgery (214 vs 172 min). And a study of over 2000 spine surgeries at UCSF (Zygourakis 2017b) found equivalent rates of 30-day mortality, readmission, return to the operating room, estimated blood loss, length of stay, and total hospital cost but overlapping surgeries had longer procedure times (estimate = 26.17) and lower rates of discharge to home (odds ratio 0.65).
We previously reported in our December 13, 2016 Patient Safety Tip of the Week “More on Double-Booked Surgery” the retrospective review comparing overlapping surgery with non-overlapping surgery at the Mayo Clinic (Hyder 2017). Over 10,000 cases of overlapping surgery were matched to a similar number of non-overlapping surgeries. Adjusted odds ratio for inpatient mortality was greater for non-overlapping procedures (adjusted odds ratio, OR = 2.14 vs overlapping procedures) and length of stay and morbidity were no different. And in our May 2017 What's New in the Patient Safety World column “The Concurrent Surgery Debate Continues” we noted an abstract presented at the 2017 American Association of Neurological Surgeons (AANS) Annual Meeting (Bohl 2017, Melville 2017) which found better, not worse, outcomes with overlapping surgery. The better outcome measures included hospital length of stay, return to the operating room, and disposition status. Procedure length, however, was longer in the overlapping cases.
And in our November 29, 2016 Patient Safety Tip of the Week “Doubling Down on Double-Booked Surgery” we highlighted the study done by Zhang and colleagues at UCSF comparing overlapping cases with non-overlapping cases for a variety of orthopedic surgical procedures performed in an academic ambulatory surgery setting (Zhang 2016). The latter found no difference in patient operating room time, procedure time, and 30-day complication rates between overlapping and non-overlapping surgery.
And the MGH, after the original Boston Globe Spotlight story, did its own review of concurrent/overlapping surgery and concluded there were no adverse effects from this practice (see our November 10, 2015 Patient Safety Tip of the Week “Weighing in on Double-Booked Surgery”).
Finally, one study we have been citing for the past year has now been published in full form in a peer reviewed journal (Ravi 2017). Researchers looked at two cohorts in Ontario, Canada: hip fracture patients and patients undergoing total hip replacement. They identified overlapping surgery from administrative data as surgery in which the surgeon was involved in two cases with an overlap as greater than 30 minutes of simultaneous operating room time (and <3 hours to exclude outliers), They matched overlapping and nonoverlapping hip fractures by patient age, patient sex, surgical procedure (for the hip fracture cohort), primary surgeon, and hospital. Followup period was 1 year, considerably longer than most of the US studies. Primary outcomes were the occurrence of an infection, revision, or dislocation within a year. Those were selected because they are the most likely to result from technical errors, which in turn may occur during unsupervised portions of the procedure. Other outcomes of interest were duration of surgery and death within 90 days After matching, overlapping hip fracture procedures had a statistically significant greater risk for a complication (hazard ratio 1.85), as did overlapping THA procedures (hazard ratio 1.79). Moreover, for the overlapping hip fracture operations, increasing duration of operative overlap was associated with increasing risk for complications (adjusted odds ratio, 1.07 per 10-minute increase in overlap). For hip fracture patients the complications in the overlapping group were primarily infections and revisions (the THA population was underpowered to comment on individual complications).
Zhang (Zhang 2017), in an editorial accompanying the Ravi study, discussed possible reasons that the results of the Ravi study differed from the study they had done (Zhang 2016). The Zhang study patients had a variety of outpatient procedures performed on an ambulatory basis and were generally healthy patients, compared to the patient cohort in the Ravi study which was older and likely had many more comorbidities. The Ravi study also had the opportunity to identify complications occurring beyond 30 days and those that might have been identified at other hospitals. Another strength of the Ravi study was that the Ontario administrative data recorded the time the patient entered and exited the operating room. Zhang also questioned whether there were differences in the surgical teams (eg. the percentage of cases with residents or fellows) and whether some of the Ravi cohort cases actualliy have been examples of concurrent rather than overlapping surgery.
One huge difference between the Ravi study and the US studies is in the relative percentages of cases done as overlapping cases. Whereas rates of 70% or higher may apply to orthopedic cases in the US, only 2.5% of hip fracture procedures and 3% of THAs were performed overlapping with another procedure in the Ontario cohorts.
So, to summarize, we now have at least 8 retrospective cohort studies supporting the safety of overlapping surgery and a single one noting an increased risk of complications with overlapping surgery.
But there is a basic problem with all these studies. Untoward events related to overlapping surgery, particularly serious ones, are not common. In fact, the vast majority of overlapping surgeries are accomplished without any problems. The serious events therefore get “buried” or “diluted out” in any large series. The only real way to determine whether overlapping surgery caused or contributed to such events is to perform root cause analysis of all cases with adverse events, a time- and resource-intensive process. A second problem is that, even in those studies that used propensity score adjustments to minimize bias, there is likely an element of selection bias. There is really no way from administrative data or even chart review to fully understand why non-overlapping surgery was chosen over overlapping surgery or vice versa.
Those of us involved in patient safety have all undoubtedly seen instances in which overlapping surgery was a contributing factor to or root cause of an adverse event. And just because the population-based studies seem to show a relative safety of overlapping surgery, it does not mean we don’t need to pay attention to the dangers. Wrong-site surgery and retained surgical items are also relatively rare events. Yet we strive to prevent all such cases of those. Why should events related to overlapping surgery be treated differently?
The one thing that is reassuriong from these studies is that, with the exception of the Ontario study, there does not seem to be an increased rate of surgical site infections in cases of overlapping surgery. That is somewhat surprising to us, given that virtually all the studies have shown that procedure durations are longer in overlapping surgery. We’ve actually done several columns on prolonged surgical duration (see list at the end of today’s column) and you’ve heard us often use the statistic that infection rates increase by 2.5% for every half hour of surgery (Procter 2010). Many of the above studies showed mean surgical durations on the order of 30 minutes longer in overlapping cases. Thus, we would have predicted we’d see increased infection rates in such cases. But note that those are mean durations. Quite likely there are many cases with prolonged durations of, say, 10 minutes and then other cases with more prolonged durations that raise the mean. Perhaps the latter ones are associated with increased infection rates. That cannot be determined from the currently published studies. It is interesting that in the Canadian study the complication rate did increase incrementally as the duration of overlap increased.
Views of overlapping surgery are largely in the eye of the beholder. A survey of otolaryngologists (Cognetti 2017) found 40.4% of respondents reported performing some form of multiple-room surgery (subspecialists were more likely than general otolaryngologists to do multi-room surgery). Most believed that regulations disallowing multiple-room surgery would result in an increase in late starts (73.5%), an increase in the time to schedule surgery (84.5%), a detriment to residency training (63.1%), and no improvement in patient safety (60%.). The authors conclude that policy changes that restrict multiple-room surgery must consider a potential unintended negative impact on patient care and access.
The perspective of the patient was noted in our May 2017 What's New in the Patient Safety World column “The Concurrent Surgery Debate Continues”. A survey (Kent 2017) looked at knowledge of overlapping surgery, expectations on disclosure during the informed consent process, and their willingness to participate in such a procedure. That survey found that only 3.9% of respondents had any knowledge of the practice of overlapping surgery. Interestingly, though the majority of respondents were not supportive of the practice, 31% supported or strongly supported this practice. But 94.7% believed that the attending surgeon should inform them in advance of overlapping surgery and 95.6% would want definition of the critical components of the operation. And 91.5% felt that the surgeon should document what portion of the operation he or she was present for.
Our own perspective remains that we would not want to consent to overlapping surgery without very specific conditions. Here are the issues we’ve described in our original and subsequent columns on overlapping surgery:
The “Critical Part of the Surgery”
Hospitals must develop lists of which surgical procedures might be appropriate for overlapping surgery and those for which it is never appropriate. Once those lists are developed they must address the issue of definition of “the critical portion of the surgery” . That remains a huge gray zone. Historically that definition has largely been left up to the individual surgeon and there is likely wide variability in such definitions.
Yes, there are times during surgery that complications, emergencies, and unexpected circumstances are more likely to occur. Yet anyone who has spent any time in OR’s or analyzing perioperative adverse events will attest to the fact that those occurrences may pop up at the most unexpected times.
Many may define the critical portion as everything except skin closure, the latter being delegated to residents, fellows or surgical assistants. But even for all you who would delegate skin closure as “routine, not requiring special expertise” what would you do in the following real-life scenarios if the primary surgeon is now in another room doing a “critical” part of that second surgery:
Ideally, definitions of the “critical part” of each procedure would be defined by specialty societies but that has yet to happen. Rather than allowing individual surgeons to define the “critical part” many have relied upon the clinical department chairs to establish the definitions. But Mello and Livingston, in their perspective on “The Evolving Story of Overlapping Surgery” (Mello 2017), take the view that the individual clinical departments have an innate conflict of interest and should not be the ones to establish what constitutes the “critical part” of procedures. Rather, lacking guidance from specialty societies, they call for multidisciplinary hospital committees to make those determinations. We’ve come around to agreeing with that point of view.
While we personally would not want our surgeon to leave during any part of our own surgery, we would describe the “critical part” of the surgery as “from the pre-op huddle through the final surgical ‘count” and examination of all tools and materials removed from the surgical site”. Essentially that would just leave the skin closure as the only portion of the surgery for which the attending surgeon would not be present. While that might better ensure our own safety, note that it would probably still result in the surgeon failing to participate in the post-surgery debriefing. Such absence might result in failure to identify factors that might prevent an adverse event to subsequent patients. Note that this definition would also imply that the second case is also not started until the surgeon has participated in the pre-op huddle for that second case.
It’s interesting that we often hear surgeons say “we’re there for all but the skin closure”. Yet the studies noted above typically showed a mean difference in case duration on the order of 30 minutes between overlapping and non-overlapping cases. We find it doubtful that a resident or fellow or surgical assistant would take 30 minutes longer to close the skin than the attending surgeon would. So we suspect that most surgeons are defining their “critical part” as considerably less than “all but skin closure”.
Timeouts
Any policy for overlapping surgery must include specific reference to the timeout process. The attending surgeon should be an active participant in the initial timeout in every case he/she is responsible for. Moreover, when the attending surgeon switches from one case to another there must be an additional timeout, just like there must always be additional timeouts when other surgeons may come in for part of a case or when there is any other change in medical personnel. This should apply even when the attending surgeon was an active participant in the original timeout because events may have occurred in the interim during his/her absence.
Post-Procedure Debriefing
We recall a case in which a surgeon encountered a problem with a piece of equipment during a non-overlapping case. The nurse commented “Oh, Dr. Jones had a problem with that on Monday.” The surgeon asked “Why wasn’t it flagged during the post-surgical debriefing?”. The nurse responded “We didn’t have a debriefing because Dr. Jones had already left for his other (overlapping) case.”.
If the attending surgeon leaves one OR prior to completion of the case he/she is obviously not going to participate in the post-op debriefing. Thus, in at least half the double-booked cases the key individual (attending surgeon) is not part of the debriefing. We consider the debriefing to be a very important patient safety tool (see list of our prior columns on debriefings listed at the end of today’s column).
In debriefings you are basically asking “What went well?”, “What didn’t go well?” and “What could we do better next time?”. You’ll often identify the need to fix broken equipment or ensure the availability of appropriate backup instruments. Sometimes it’s something simple like tray set-ups or equipment set-ups that interfered with the surgeon’s movements during the procedure. And you need to be sure that someone follows up on issues identified and communicates back to the group when they are fixed. Also, make sure you identify at the debriefing any problems you had with team communication during the procedure.
Absence of the attending surgeon from such debriefings (or lack of presence of that surgeon from substantial portions of the entire surgery) obviously is a missed opportunity to improve future care.
The debriefing is also an opportunity for the attending surgeon to discuss issues with the resident or fellow who may have been a major participant or even the primary surgeon in the case.
Ironically, in the above-mentioned anecdote any complication would be ascribed to the non-overlapping case even though the root cause was the overlapping case from the prior day!
The Pre-op “Huddle”
Just as many cases of overlapping surgery lack a post-surgery debriefing, many of the second (or subsequent) cases lack participation of the surgeon in a pre-op “huddle” or briefing. These are times when the surgeon, anesthesiologist, and circulating nurse get together and discuss the upcoming case, making sure all needed equipment or implants are available and discussing potential events or contingencies. It is conceivable that such huddles could be held for multiple cases prior to the first case (assuming all parties for each case are available at that time) but, in our experience, such huddles are more informative when done immediately prior to a case and confined to one specific case at a time. If the case will be an overlapping case, the identity of the backup surgeon should be clarified during both the pre-op huddle and the timeout.
Duration of surgery
The original Boston Globe report cited anesthesiologists complaining that patients often had to wait, while still under anesthesia, for considerable periods while their attending surgeon was elsewhere. The Globe cites an e-mail noting that such waits for the attending surgeon while the patient is under anesthesia may sometimes be as long as 2 hours.
We’ve done several columns discussing the complications that may occur as the duration of a surgical procedure increases (see list of our prior columns on surgical duration listed at the end of today’s column). Our March 10, 2009 Patient Safety Tip of the Week “Prolonged Surgical Duration and Time Awareness” discussed time unawareness during many surgeries. In addition to the potential impact on infectious complications, we noted that there are other potential patient safety issues related to prolonged surgical duration such as DVT, decubiti, hypothermia, fluid/electrolyte shifts, pulmonary complications, nerve compression, compartment syndromes, and rhabdomyolysis. Long-duration cases also increase the likelihood of personnel changes that increase the chance of retained foreign objects or retained surgical items (see our August 19, 2014 Patient Safety Tip of the Week “Some More Lessons Learned on Retained Surgical Items”). And the fatigue factor comes into play with longer cases, increasing the likelihood of a variety of other errors.
But the biggest risk is for surgical site infections. Surgical case duration is one of the few modifiable risk factors for surgical infections. A number of studies in the past have demonstrated an association between perioperative infection and the duration of the surgical procedure. In our January 2010 What’s New in the Patient Safety World column “Operative Duration and Infection” we noted a study (Proctor et al 2010) which found the infectious complication rate increased by 2.5% per half hour and hospital length of stay (LOS) also increased geometrically by 6% per half hour.
Other Infection Control Issues
We’ve done several columns on the potential adverse effects of OR foot traffic and unnecessary opening and closing of OR doors (see list at the end of today’s column). But overlapping surgery raises one other concern: compliance with appropriate sterile techniques. We would anticipate that any surgeon leaving an OR must remove gloves, gown, masks and any other protective gear, then perform appropriate hand hygiene and don entirely new gear before entering the next OR. Knowing habits of some surgeons (and others) in multiple OR environments, we are willing to bet that workarounds are common and shortcuts taken.
Definition of “Immediately Available”
When overlapping surgery is performed, there should be designation of a backup surgeon who will be “immediately available” to intervene if the original attending surgeon is doing other surgery. Defining “immediately available”, as anticipated, has been controversial. There has been wide variation in the timeframes and locations in the policies of respondent hospitals. The American College of Surgeons guidance (ACS 2016) states the surgeon should be “reachable through a paging system or other electronic means, and able to return immediately to the operating room.” The ACS did not define a timeframe for response. But this doesn’t mean someone who might be seeing patients in his/her office or clinic 3 floors away. (In fact, we suggest that you might as part of your quality management program occasionally try to get hold of that covering physician and see how long it actually takes for him/her to get to the OR.) In addition, this backup surgeon must be fully aware of his/her responsibilities and should have some knowledge of the case he is “covering”. He/she also obviously needs to be credentialed/privileged for the procedure that he/she is covering.
Multitasking
We physicians often take pride in our ability to multitask. Such pride is probably misplaced. Any human activity that requires attention to two different scenarios is prone to error. Some will argue that the two surgeries involved are typically quite similar in nature. That actually makes it much more likely that details from one case may be transposed to the other case. For example, in orthopedic surgery it might be very easy to mistakenly call for an implant of a specific size (or other characteristic) that was appropriate for the “other” patient but not this patient.
The educational/training mandate
A surgical “perspective” in the Annals of Surgery (Beasley 2015) defended the practice of overlapping surgery in the name of training: “The incremental acquisition of surgical competence during training is critically important to maintaining a surgical workforce.” No one can argue with that statement. However, incremental delegation of procedures to residents and fellows and provision of incremental responsibility should not require that the attending surgeon be absent from the room.
The Ethical Issue(s)
And then there is the ethical issue (which is really the most important issue). The biggest revelation in the Boston Globe report was that the patient was usually unaware that their attending surgeon might not be present for their entire surgery. It’s one thing to tell a patient during informed consent that residents and fellows and others will be involved in their surgery and may perform substantial portions of the surgery. But failure to tell them that their attending surgeon may be in a totally different room doing surgery on another patient is a huge ethical breach. Quite frankly, no patient in their right mind should agree to have a major surgical procedure knowing that the attending surgeon, in whom they have placed their trust, will not be in the OR for the duration of their surgery.
Informed consent must be transparent and presented in a manner that allows patients to understand the potential ramifications of their surgeon being in another room during any portion of their surgery. A recent viewpoint on informed consent in concurrent surgery (Langerman 2016) points out the “information asymmetry” involved, where “surgeons know much and our patients know little about what will happen during their operation.” Patients may not understand the implications of potentially spending extra time under anesthesia in the event their surgeon is delayed in responding to something in their case because he/she is doing surgery on another patient. Most patients in academic centers understand that physicians in training will actively participate in the surgery and likely improve the quality of their overall care. But they also likely expect that their primary surgeon will be present to oversee all aspects of their surgery. Dr. James Rickert, in an informative Health Affairs Blog (Rickert 2016), also suspects that in discussing overlapping surgery “Euphemisms, incomplete information, and oblique discussions will be the norm.” It is clear that this discussion must take place at a time when the patient would have adequate time to digest the information, ask questions, and be able to cancel the surgery if desired. So having the discussion on the day of surgery is a no-go. Some of the hospitals included a specific time period, such as “at least 24 hours prior to the surgery”, but many left the wording vague such as “sufficiently prior to” surgery. In a 2016 editorial Healy (Healy 2016) recommended surgeons “do the right thing” and obtain specific informed consent at least 2 weeks prior to the operation. This consent should include a specific description of what the attending surgeon will and will not do.
We are pleased to see that many, if not most, hospitals have adopted policies in which patients must be told of overlapping surgery during informed consent. Good examples are the Seattle area hospitals that have developed such policies (Q13 News 2017). A sample consent form from one of those hsopitals even includes reference to the designated attending surgeon who might serve as a backup.
There may be a second ethical issue as well. What would you do if a surgeon on your staff declines to do a patient’s surgery if that patient does not consent to overlapping surgery? What if the surgeon’s response is “You should find another surgeon or another hospital.”? We think it would be unethical for a surgeon to refuse to perform surgery on a patient who refuses to consent to overlapping surgery. It may be appropriate to let a patient know his/her surgery may not be able to be scheduled as soon if it is not overlapping. But to refuse to do the surgery as a nonoverlapping case would be unethical. We feel that including specific wording to that effect in the informed consent document or the educational materials provided to the patient should be part of every hospital’s policy on overlapping surgery. And hospitals obviously need to make it clear to their staff that such refusal would not be tolerated.
Who Should Be Allowed to Perform Overlapping Surgery?
Hospitals obviously need to determine which types of surgery should never be allowed to be double-booked. But one issue that has not received attention in the literature is which surgeons should be allowed to perform overlapping surgery and how that question relates to credentialing an privileging. One might consider requiring demonstration of proficiency for new surgeons in the credentialing and privileging process before double-booking is allowed. But at the other end of the spectrum, the older surgeon whose surgical skills are still good but whose ability to multitask may be starting to deteriorate (you all know this surgeon but no one is willing to speak up), is a much more difficult situation. What objective criteria would you use to tell that surgeon he/she can still do surgery but can no longer double-book?
Monitoring Overlapping Surgery
Perhaps the strongest recommendations in the Senate committee report (Senate Finance Committee 2016) deal with ensuring compliance with policies. The report stresses that developing policies on overlapping surgery are an important first step but that training all staff to ensure they understand the policies and then overseeing that the policies are adhered to are critical steps. They liked language similar to that used by some hospitals:
They also liked language used by some hospitals to describe roles played by others staff in ensuring compliance with the policies:
Monitoring surgeon location and tracking the critical portions of the surgical procedures is also considered important in the Senate committee report. Many hospital policies simply used the CMS billing requirement that the surgeon document in the medical record that he/she was present for the critical portion(s) of the surgery. We previously noted the Massachusetts Board of Registration in Medicine proposal requiring that surgeon presence or absence in the room at various times be documented. We like the latter idea. We actually have proposed hospitals record entry and exit of all OR personnel in attempt to reduce opening and closing of OR doors (which may predispose to infections) as described in our July 26, 2016 Patient Safety Tip of the Week “Confirmed: Keep Your OR Doors Closed”.
In our November 29, 2016 Patient Safety Tip of the Week “Doubling Down on Double-Booked Surgery” we also suggested that you might as part of your quality management program occasionally try to get hold of that “backup” physician and see how long it actually takes for him/her to get to the OR.
Our Take
From all the above you can see that we are not big fans of overlapping surgery. Quite frankly, we’d like to see it disappear completely. However, we are pragmatic and realize it is probably not going away soon. One point worth noting form a recent comment and reply on overlapping surgery (Hyder 2017b, Livingston 2017) is that we agree with Hyder et al. that “the safety of overlapping surgery and its success in improving access to surgical care are highly local phenomena”. There are some organizations that do a better job than others.
We hope that you’ll heed the concerns and recommendations from today’s column and our previous columns listed below. We’ve also set up our “Overlapping Surgery Checklist” to help you plan for safe implementation if your organization does allow overlapping surgery.
See our previous columns on double-booked, concurrent, or overlapping surgery:
And our “Overlapping Surgery Checklist”
See our prior columns on huddles, briefings, and debriefings:
Our prior columns focusing on surgical case duration:
References:
Abelson J, Saltzman J, Kowalcyzk L, Allen S. Clash in the Name of Care. Boston Globe October 26, 2015
http://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/
Senate Finance Committee. Concurrent and Overlapping Surgeries: Additional Measures Warranted. A Senate Finance Committee Staff Report 2016; December 6, 2016
http://www.finance.senate.gov/imo/media/doc/Concurrent%20Surgeries%20Report%20Final.pdf
Howard BM, Holland CM, Mehta CC, et al. Association of Overlapping Surgery With Patient Outcomes in a Large Series of Neurosurgical Cases. JAMA Surg 2017; Published online November 8, 2017
https://jamanetwork.com/journals/jamasurgery/fullarticle/2661297
Guan J, Brock AA, Karsy M, et al. Managing overlapping surgery: an analysis of 1018
neurosurgical and spine cases. Journal of Neurosurgery 2017; 127(5): 1096-1104
http://thejns.org/doi/full/10.3171/2016.8.JNS161226
Zygourakis CC, Keefe M, Lee J, et al. Comparison of patient outcomes in 3725 overlapping vs 3633 nonoverlapping neurosurgical procedures using a single institution’s clinical and administrative database. Neurosurgery 2017; 80(2): 257-268
https://academic.oup.com/neurosurgery/article-abstract/80/2/257/2884534?redirectedFrom=fulltext
Zygourakis CC, Sizdahkhani S, Keefe M, et al. Comparison of Patient Outcomes and Cost of Overlapping Versus Nonoverlapping Spine Surgery. World Neurosurgery 2017; 100: 658-664.e8
http://www.worldneurosurgery.org/article/S1878-8750(17)30087-6/fulltext
Bohl M. Overlapping Surgeries are not Associated with Worse Patient Outcomes: Retrospective Multivariate Analysis of 14,872 Neurosurgical Cases Performed at a Single Institutiion. American Association of Neurological Surgeons (AANS) 2017 Annual Meeting. Abstract 917. Presented April 26, 2017
http://www.aans.org/flippingbook/QuickPlanner/index.html#100/z
and summarized in:
Melville NA. Outcomes Better, Not Worse, in Overlapping Neurosurgeries. Medscape Medical News 2017; April 28, 2017
http://www.medscape.com/viewarticle/879253
Hyder JA, Hanson KT, Storlie CB, et al. Safety of Overlapping Surgery at a High-volume Referral Center. Annals of Surgery 2017; 265(4): 639-644
Zhang AL, Sing DC, Dang DY, et al. Overlapping Surgery in the Ambulatory Orthopaedic Setting. J Bone Joint Surg Am 2016; 98 (22): 1859-1867
Ravi B, Pincus D, Wasserstein D, et al. Association of Overlapping Surgery With Increased Risk for Complications Following Hip SurgeryA Population-Based, Matched Cohort Study. JAMA Intern Med 2017; Published online December 4, 2017
Zhang AL. Overlapping Surgery—Perspectives From the Other Side of the Table. JAMA Intern Med 2017; Published online December 4, 2017
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2663753
Procter LD, Davenport DL, Bernard AC, Zwischenberger JB. General Surgical Operative Duration Is Associated with Increased Risk-Adjusted Infectious Complication Rates and Length of Hospital Stay, Journal of the Amercican College of Surgeons 2010; 210: 60-65
http://www.journalacs.org/article/S1072-7515%2809%2901411-2/abstract
Cognetti DM, Nussenbaum B, Brenner MJ, et al. Current State of Overlapping, Concurrent, and Multiple-Room Surgery in Otolaryngology: A National Survey. Otolaryngology-Head and Neck Surgery 2017; First Published August 8, 2017
http://journals.sagepub.com/doi/full/10.1177/0194599817723897
Kent M, Whyte R, Fleishman A, et al. Public Perceptions of Overlapping Surgery. Journal of the American College of Surgeons 2017; Published online: February 11, 2017
http://www.journalacs.org/article/S1072-7515(17)30163-1/fulltext
Mello MM, Livingston EH. The Evolving Story of Overlapping Surgery.JAMA 2017; Published online June 28, 2017
http://jamanetwork.com/journals/jama/fullarticle/2636711
ACS (American College of Surgeons). Statements on Principles. Revised April 12, 2016
https://www.facs.org/about-acs/statements/stonprin
Beasley GM, Pappas TN, Kirk AD. Procedure Delegation by Attending Surgeons Performing Concurrent Operations in Academic Medical Centers: Balancing Safety and Efficiency. Annals of Surgery 2015; 261(6): 1044-1045
Langerman A. Concurrent Surgery and Informed Consent. JAMA Surg 2016; 151(7): 601-602
http://archsurg.jamanetwork.com/article.aspx?articleid=2504500
Rickert J. A Patient-Centered Solution To Simultaneous Surgery. Health Affairs Blog 2016; June 14, 2016
http://healthaffairs.org/blog/2016/06/14/a-patient-centered-solution-to-simultaneous-surgery/
Healy WL. Overlapping Surgery: Do the Right Thing. Commentary on an article by Alan L. Zhang, MD, et al.: “Overlapping Surgery in the Ambulatory Orthopaedic Setting”. J Bone Joint Surg Am 2016; 98 (22): e101
Q13 News Staff. Seattle hospitals begin informing patients about overlapping surgeries.
Q13 Fox 2017; June 8, 2017
http://q13fox.com/2017/06/08/seattle-hospitals-begin-informing-patients-about-overlapping-surgeries/
Hyder JA, Habermann EB, Cima RR. Length of Stay After Overlapping Surgery
JAMA 2017; 318(21): 2140
https://jamanetwork.com/journals/jama/article-abstract/2664991
says their study really did not show longer length of stay with OS
also “The safety of OS and its success in improving access to surgical care are highly local phenomena. A summary of the literature should acknowledge that a global estmate of safety or efficiency, averaged across dozens of institutions, is meaningless.”
Livingston EH, Mello MM. Length of Stay After Overlapping Surgery—Reply
JAMA 2017; 318(21): 2140-2141
https://jamanetwork.com/journals/jama/article-abstract/2664995
Our own “Overlapping Surgery Checklist”.
http://www.patientsafetysolutions.com/docs/Overlapping_Surgery_Checklist.htm
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Barcoding Better? Not So Fast!
September 21, 2021
Repeat CT in Anticoagulated Patients After Minor Head Trauma Not Cost-Effective
September 14, 2021
September 7, 2021
The Vanderbilt Tragedy Gets Uglier
August 31, 2021
The Community Pharmacy and Patient Safety
August 24, 2021
More Home Infusion Safety Issues
August 17, 2021
Tip of the Week on Vacation
August 10, 2021
Tip of the Week on Vacation
August 3, 2021
Obstetric Patients More At-Risk for Wrong Patient Orders
July 27, 2021
July 20, 2021
FDA Warning: Magnets in Consumer Electronics May Affect Medical Devices
July 13, 2021
The Skinny on Rapid Response Teams
July 6, 2021
Tip of the Week on Vacation
June 29, 2021
June 22, 2021
Remotely Monitoring Suicidal Patients in Non-Behavioral Health Areas
June 15, 2021
What’s Happened to Your Patient Safety Walk Rounds?
June 8, 2021
Cut OR Traffic to Cut Surgical Site Infections
June 1, 2021
Stronger Magnets, More MRI Safety Concerns
May 25, 2021
Yes, Radiologists Have Handoffs, Too
May 18, 2021
Medical Overuse Is Not Just An Economic Problem
May 11, 2021
How Are Alerts in Ambulatory CPOE Doing?
May 4, 2021
More 10x Dose Errors in Pediatrics
April 27, 2021
Errors Common During Thrombolysis for Acute Ischemic Stroke
April 20, 2021
Taser “Slip and Capture Error” Again!
April 13, 2021
Incidental Findings – What’s Your Strategy?
April 6, 2021
March 30, 2021
Need for Better Antibiotic Stewardship
March 23, 2021
Nursing Staffing and Sepsis Outcomes
March 16, 2021
Sleep Program Successfully Reduces Delirium
March 9, 2021
Update: Disclosure and Apology: How to Do It
March 2, 2021
Barriers to Timely Catheter Removal
February 23, 2021
February 16, 2021
New Methods for QTc Monitoring
February 9, 2021
February 2, 2021
MGH Protocols Reduce Risk of Self-Harm in ED
January 26, 2021
This Freezer Accident May Cost Lives
January 19, 2021
Technology to Identify Fatigue?
January 12, 2021
January 5, 2021
Dilaudid/HYDROmorphone Still Problematic
December 29, 2019
Tip of the Week on Vacation
December 22, 2019
Tip of the Week on Vacation
December 15, 2020
Our Perennial Pre-Holiday Warning: “Be Careful Out There!”
December 8, 2020
Maternal Mortality: Looking in All the Wrong Places?
December 1, 2020
An Early Warning System and Response System That Work
November 24, 2020
November 17, 2020
A Picture Is Worth a Thousand Words
November 10, 2020
November 3, 2020
Reminder: Infant Abduction Risk
October 27, 2020
Conflicting Studies on Technology to Reduce RSI’s
October 20, 2020
More on Post-operative Risks for Patients with OSA
October 13, 2020
October 6, 2020
Successfully Reducing Opioid-Related Adverse Events
September 29, 2020
September 22, 2020
VA RCA’s: Suicide Risks Vary by Site
September 15, 2020
September 8, 2020
Follow Up on Tests Pending at Discharge
September 1, 2020
NY State and Nurse Staffing Issues
August 25, 2020
The Off-Hours Effect in Radiology
August 18, 2020
August 11, 2020
Above-Door Alarms to Prevent Suicides
August 4, 2020
July 28, 2020
July 21, 2020
Is This Patient Allergic to Penicillin?
July 14, 2020
A Thesis on Intrahospital Transports
July 7, 2020
Another Patient Found Dead in a Stairwell
June 30, 2020
What Happens after Hospitalization?
June 23, 2020
June 16, 2020
June 9, 2020
Perioperative Medication Safety
June 2, 2020
May 26, 2020
May 19, 2020
Reminder on Telephone or Verbal Orders
May 12, 2020
May 5, 2020
COVID-19 and the Dental Office
April 28, 2020
April 21, 2020
Parenteral Nutrition Safety Issues
April 14, 2020
Patient Safety Tidbits for the COVID-19 Pandemic
April 7, 2020
From Preoperative Assessment to Preoperative Optimization
March 31, 2020
Intrahospital Transport Issues in Children
March 24, 2020
Mayo Clinic: How to Get Photos in Your EMR
March 17, 2020
March 10, 2020
Medication Harm in the Elderly
March 3, 2020
Opportunities to Reduce Unnecessary Contact Precautions
February 25, 2020
More on Perioperative Gabapentinoids
February 18, 2020
February 11, 2020
February 4, 2020
Drugs and Chronic Kidney Disease
January 28, 2020
January 21, 2020
Disruptive Behavior and Patient Safety: Cause or Effect?
January 14, 2020
January 7, 2020
Even More Concerns About MRI Safety
December 31, 2019
Tip of the Week on Vacation
December 14, 2019
Tip of the Week on Vacation
December 17, 2019
December 10, 2019
December 3, 2019
Overlapping Surgery Back in the News
November 26, 2019
Pennsylvania Law on Notifying Patients of Test Results
November 19, 2019
An Astonishing Gap in Medication Safety
November 12, 2019
Patient Photographs Again Help Radiologists
November 5, 2019
October 29, 2019
Tip of the Week on Vacation
October 22, 2019
Tip of the Week on Vacation
October 15, 2019
October 8, 2019
October 1, 2019
Electronic Medication Reconciliation: Glass Half Full or Half Empty?
September 24, 2019
EHR-related Malpractice Claims
September 17, 2019
American College of Surgeons Geriatric Surgery Verification Program
September 10, 2019
Joint Commission Naming Standard Leaves a Gap
September 3, 2019
Lessons from an Inpatient Suicide
August 27, 2019
August 20, 2019
Yet Another (Not So) Unusual RSI
August 13, 2019
Betsy Lehman Center Report on Medical Error
August 6, 2019
July 30, 2019
Lessons from Hospital Suicide Attempts
July 23, 2019
Order Sets Can Nudge the Right Way or the Wrong Way
July 16, 2019
July 9, 2019
Spinal Injection of Tranexamic Acid
July 2, 2019
Tip of the Week on Vacation
June 25, 2019
June 18, 2019
June 11, 2019
ISMP’s Grissinger on Overreliance on Technology
June 4, 2019
Medication Errors in the OR – Part 3
May 28, 2019
May 21, 2019
Mixed Message on Number of Open EMR Records
May 14, 2019
Wrong-Site Surgery and Difficult-to-Mark Sites
May 7, 2019
Simulation Training for OR Fires
April 30, 2019
Reducing Unnecessary Urine Cultures
April 23, 2019
In and Out the Door and Other OR Flow Disruptions
April 16, 2019
AACN Practice Alert on Alarm Management
April 9, 2019
Handoffs for Every Occasion
April 2, 2019
Unexpected Events During MRI
March 26, 2019
March 19, 2019
March 12, 2019
Update on Overlapping Surgery
March 5, 2019
Infusion Pump Problems
February 26, 2019
Vascular Access Device Dislodgements
February 19, 2019
Focus on Pediatric Patient Safety
February 12, 2019
From Tragedy to Travesty of Justice
February 12, 2019
2 ER Drug Studies: Reassurances and Reservations
February 5, 2019
Flaws in Our Medication Safety Technologies
January 29, 2018
National Patient Safety Goal for Suicide Prevention
January 22, 2019
Wandering Patients
January 15, 2019
Another Plus for Prehabilitation
January 8, 2019
Maternal Mortality in the Spotlight
January 1, 2019
More on Automated Dispensing Cabinet (ADC) Safety
December 25, 2018
Happy Holidays!
December 18, 2018
Great Recommendations for e-Prescribing
December 11, 2018
December 4, 2018
Don’t Use Syringes for Topical Products
November 27, 2018
November 20, 2018
November 13, 2018
Antipsychotics Fail in ICU Delirium
November 6, 2018
More on Promoting Sleep in Inpatients
October 30, 2018
October 23, 2018
Lessons From Yet Another Aviation Incident
October 16, 2018
October 9, 2018
October 2, 2018
Speaking Up About Disruptive Behavior
September 25, 2018
Foley Follies
September 18, 2018
September 11, 2018
September 4, 2018
The 12-Hour Nursing Shift: Another Nail in the Coffin
August 28, 2018
Thought You Discontinued That Medication? Think Again
August 21, 2018
Delayed CT Scan in the Anticoagulated Patient
August 14, 2018
ISMP Canada’s Updated “Do Not Use” Abbreviation List
August 7, 2018
Tip of the Week on Vacation
July 31, 2018
Surgery and the Opioid-Tolerant Patient
July 24, 2018
More on Speech Recognition Software Errors
July 17, 2018
OSA Screening in Stroke Patients
July 10, 2018
Another Jump from a Hospital Window
July 3, 2018
Tip of the Week on Vacation
June 26, 2018
Infection Related to Colonoscopy
June 19, 2018
June 12, 2018
Adverse Events in Cancer Patients
June 5, 2018
Pennsylvania Patient Safety Authority on Iatrogenic Burns
May 29, 2018
More on Nursing Workload and Patient Safety
May 22, 2018
Hazardous Intrahospital Transport
May 15, 2018
May 8, 2018
May 1, 2018
April 24, 2018
April 17, 2018
More on Tests Pending at Discharge
April 10, 2018
Prepping the Geriatric Patient for Surgery
April 3, 2018
March 27, 2018
March 20, 2018
Minnesota Highlights Lost Tissue Samples
March 13, 2018
March 6, 2018
February 27, 2018
Update on Patient Safety Walk Rounds
February 20, 2018
February 13, 2018
February 6, 2018
Adverse Events in Inpatient Psychiatry
January 30, 2018
January 23, 2018
Unintentional Hypothermia Back in Focus
January 16, 2018
January 9, 2018
More on Fire Risk from Surgical Preps
January 2, 2018
Preventing Perioperative Nerve Injuries
December 26, 2017
Tip of the Week on Vacation
December 19, 2017
December 12, 2017
Joint Commission on Suicide Prevention
December 5, 2017
Massachusetts Initiative on Cataract Surgery
November 28, 2017
More on Dental Sedation/Anesthesia Safety
November 21, 2017
OSA, Oxygen, and Alarm Fatigue
November 14, 2017
Tracking C. diff to a CT Scanner
November 7, 2017
Perioperative Neuropathies
October 31, 2017
Target Drugs for Deprescribing
October 24, 2017
Neurosurgery and Time of Day
October 17, 2017
Progress on Alarm Management
October 10, 2017
More on Torsade de Pointes
October 3, 2017
Respiratory Compromise: One Size Does Not Fit All
September 26, 2017
Tip of the Week on Vacation
September 19, 2017
Tip of the Week on Vacation
September 12, 2017
Can You Hear Me Now?
September 5, 2017
Another Iatrogenic Burn
August 29, 2017
Suicide in the Bathroom
August 22, 2017
August 15, 2017
Delayed Emergency Surgery and Mortality Risk
August 8, 2017
Sedation for Pediatric MRI Rising
August 1, 2017
Progress on Wrong Patient Orders
July 25, 2017
Can We Influence the “Weekend Effect”?
July 18, 2017
Another Hazard from Alcohol-Based Hand Gels
July 11, 2017
The 12-Hour Shift Takes More Hits
July 4, 2017
Tip of the Week on Vacation
June 27, 2017
June 20, 2017
June 13, 2017
June 6, 2017
NYS Mandate for Sepsis Protocol Works
May 30, 2017
Errors in Pre-Populated Medication Lists
May 23, 2017
May 16, 2017
Are Surgeons Finally Ready to Screen for Frailty?
May 9, 2017
Missed Nursing Care and Mortality Risk
May 2, 2017
Anatomy of a Wrong Procedure
April 25, 2017
April 18, 2017
Alarm Response and Nurse Shift Duration
April 11, 2017
Interruptions: The Ones We Forget About
April 4, 2017
Deprescribing in Long-Term Care
March 28, 2017
More Issues with Dental Sedation/Anesthesia
March 21, 2017
Success at Preventing Delirium
March 14, 2017
More on Falls on Inpatient Psychiatry
March 7, 2017
February 28, 2017
February 21, 2017
Yet More Jumps from Hospital Windows
February 14, 2017
February 7, 2017
January 31, 2017
More Issues in Pediatric Safety
January 24, 2017
Dexmedetomidine to Prevent Postoperative Delirium
January 17, 2017
January 10, 2017
The 26-ml Applicator Strikes Again!
January 3, 2017
What’s Happening to “I’m Sorry”?
December 27, 2016
Tip of the Week on Vacation
December 20, 2016
End-of-Rotation Transitions and Mortality
December 13, 2016
More on Double-Booked Surgery
December 6, 2016
Postoperative Pulmonary Complications
November 29, 2016
Doubling Down on Double-Booked Surgery
November 22, 2016
Leapfrog, Picklists, and Healthcare IT Vulnerabilities
November 15, 2016
November 8, 2016
Managing Distractions and Interruptions
November 1, 2016
CMS Emergency Preparedness Rule
October 25, 2016
Desmopressin Back in the Spotlight
October 18, 2016
Yet More Questions on Contact Precautions
October 11, 2016
New Guideline on Preop Screening and Assessment for OSA
October 4, 2016
September 27, 2016
September 20, 2016
Downloadable ABCDEF Bundle Toolkits for Delirium
September 13, 2016
Vanderbilt’s Electronic Procedural Timeout
September 6, 2016
August 30, 2016
Can You Really Limit Interruptions?
August 23, 2016
ISMP Canada: Automation Bias and Automation Complacency
August 16, 2016
How Is Your Alarm Management Initiative Going?
August 9, 2016
August 2, 2016
Drugs in the Elderly: The Goldilocks Story
July 26, 2016
Confirmed: Keep Your OR Doors Closed
July 19, 2016
Infants and Wrong Site Surgery
July 12, 2016
Forget Brexit – Brits Bash the RCA!
July 5, 2016
Tip of the Week on Vacation
June 28, 2016
Culture of Safety and Catheter-Associated Infections
June 21, 2016
Methotrexate Errors in Australia
June 14, 2016
Nursing Monitoring of Patients on Opioids
June 7, 2016
CPAP for Hospitalized Patients at High Risk for OSA
May 31, 2016
More Frailty Measures That Predict Surgical Outcomes
May 24, 2016
Texting Orders – Is It Really Safe?
May 17, 2016
Patient Safety Issues in Cataract Surgery
May 10, 2016
Medical Problems in Behavioral Health
May 3, 2016
Clinical Decision Support Malfunction
April 26, 2016
Lots More on Preventing Readmissions But Where's the Beef?
April 19, 2016
Independent Double Checks and Oral Chemotherapy
April 12, 2016
April 5, 2016
Workarounds Overriding Safety
March 29, 2016
March 22, 2016
Radiology Communication Errors May Surprise You
March 15, 2016
March 8, 2016
Tip of the Week on Vacation
March 1, 2016
February 23, 2016
February 16, 2016
February 9, 2016
February 2, 2016
January 26, 2016
More on Frailty and Surgical Morbidity and Mortality
January 19, 2016
Patient Identification in the Spotlight
January 12, 2016
New Resources on Improving Safety of Healthcare IT
January 5, 2016
Lessons from AirAsia Flight QZ8501 Crash
December 29, 2015
More Medical Helicopter Hazards
December 22, 2015
The Alberta Abbreviation Safety Toolkit
December 15, 2015
Vital Sign Monitoring at Night
December 8, 2015
Danger of Inaccurate Weights in Stroke Care
December 1, 2015
TALLman Lettering: Does It Work?
November 24, 2015
Door Opening and Foot Traffic in the OR
November 17, 2015
Patient Perspectives on Communication of Test Results
November 10, 2015
Weighing in on Double-Booked Surgery
November 3, 2015
Medication Errors in the OR - Part 2
October 27, 2015
Sentinel Event Alert on Falls and View from Across the Pond
October 20, 2015
Updated Beers List
October 13, 2015
Dilaudid Dangers #3
October 6, 2015
Suicide and Other Violent Inpatient Deaths
September 29, 2015
More on the 12-Hour Nursing Shift
September 22, 2015
The Cost of Being Rude
September 15, 2015
Another Possible Good Use of a Checklist
September 8, 2015
TREWScore for Early Recognition of Sepsis
September 1, 2015
August 25, 2015
Checklist for Intrahospital Transport
August 18, 2015
Missing Obstructive Sleep Apnea
August 11, 2015
New Oxygen Guidelines: Thoracic Society of Australia and NZ
August 4, 2015
Tip of the Week on Vacation
July 28, 2015
July 21, 2015
Avoiding Distractions in the OR
July 14, 2015
July 7, 2015
June 30, 2015
What Are Appropriate Indications for Urinary Catheters?
June 23, 2015
Again! Mistaking Antiseptic Solution for Radiographic Contrast
June 16, 2015
June 9, 2015
Add This to Your Fall Risk Assessment
June 2, 2015
May 26, 2015
May 19, 2015
May 12, 2015
More on Delays for In-Hospital Stroke
May 5, 2015
Errors with Oral Oncology Drugs
April 28, 2015
April 21, 2015
April 14, 2015
Using Insulin Safely in the Hospital
April 7, 2015
March 31, 2015
Clinical Decision Support for Pneumonia
March 24, 2015
Specimen Issues in Prostate Cancer
March 17, 2015
March 10, 2015
FDA Warning Label on Insulin Pens: Is It Enough?
March 3, 2015
Factors Related to Postoperative Respiratory Depression
February 24, 2015
More Risks with Long-Acting Opioids
February 17, 2015
Functional Impairment and Hospital Readmission, Surgical Outcomes
February 10, 2015
The Anticholinergic Burden and Dementia
February 3, 2015
CMS Hopes to Reduce Antipsychotics in Dementia
January 27, 2015
The Golden Hour for Stroke Thrombolysis
January 20, 2015
He Didn’t Wash His Hands After What!
January 13, 2015
January 6, 2015
Yet Another Handoff: The Intraoperative Handoff
December 30, 2014
Data Accumulates on Impact of Long Surgical Duration
December 23, 2014
Iatrogenic Burns in the News Again
December 16, 2014
More on Each Element of the Surgical Fire Triad
December 9, 2014
December 2, 2014
ANA Position Statement on Nurse Fatigue
November 25, 2014
Misdiagnosis Due to Lab Error
November 18, 2014
Handwashing Fades at End of Shift, ?Smartwatch to the Rescue
November 11, 2014
Early Detection of Clinical Deterioration
November 4, 2014
Progress on Fall Prevention
October 28, 2014
RF Systems for Retained Surgical Items
October 21, 2014
The Fire Department and Your Hospital
October 14, 2014
October 7, 2014
Our Take on Patient Safety Walk Rounds
September 30, 2014
More on Deprescribing
September 23, 2014
Stroke Thrombolysis: Need to Focus on Imaging-to-Needle Time
September 16, 2014
Focus on Home Care
September 9, 2014
The Handback
September 2, 2014
Frailty and the Trauma Patient
August 26, 2014
Surgeons’ Perception of Intraoperative Time
August 19, 2014
Some More Lessons Learned on Retained Surgical Items
August 12, 2014
Surgical Fires Back in the News
August 5, 2014
Tip of the Week on Vacation
July 29, 2014
The 12-Hour Nursing Shift: Debate Continues
July 22, 2014
More on Operating Room Briefings and Debriefings
July 15, 2014
Barriers to Success of Early Warning Systems
July 8, 2014
Update: Minor Head Trauma in the Anticoagulated Patient
July 1, 2014
Interruptions and Radiologists
June 24, 2014
Lessons from the General Motors Recall Analysis
June 17, 2014
SO2S Confirms Routine Oxygen of No Benefit in Stroke
June 10, 2014
Another Clinical Decision Support Tool to Avoid Torsade de Pointes
June 3, 2014
More on the Risk of Sedative/Hypnotics
May 27, 2014
A Gap in ePrescribing: Stopping Medications
May 20, 2014
May 13, 2014
Perioperative Sleep Apnea: Human and Financial Impact
May 6, 2014
Monitoring for Opioid-induced Sedation and Respiratory Depression
April 29, 2014
More on the Unintended Consequences of Contact Isolation
April 22, 2014
Impact of Resident Workhour Restrictions
April 15, 2014
Specimen Identification Mixups
April 8, 2014
FMEA to Avoid Breastmilk Mixups
April 1, 2014
Expensive Aspects of Sepsis Protocol Debunked
March 25, 2014
March 18, 2014
Systems Approach Improving Stroke Care
March 11, 2014
We Miss the Graphic Flowchart!
March 4, 2014
Evidence-Based Prescribing and Deprescribing in the Elderly
February 25, 2014
Joint Commission Revised Diagnostic Imaging Requirements
February 18, 2014
February 11, 2014
Another Perioperative Handoff Tool: SWITCH
February 4, 2014
But What If the Battery Runs Low?
January 28, 2014
Is Polypharmacy Always Bad?
January 21, 2014
January 14, 2014
Diagnostic Error: Salient Distracting Features
January 7, 2014
Lessons From the Asiana Flight 214 Crash
December 24-31, 2013
Tip of the Week on Vacation
December 17, 2013
December 10, 2013
Better Handoffs, Better Results
December 3, 2013
Reducing Harm from Falls on Inpatient Psychiatry
November 26, 2013
Missed Care: New Opportunities?
November 19, 2013
Can We Improve Dilaudid/HYDROmorphone Safety?
November 12, 2013
More on Inappropriate Meds in the Elderly
November 5, 2013
Joint Commission Sentinel Event Alert: Unintended Retained Foreign Objects
October 29, 2013
PAD: The Pain, Agitation, and Delirium Care Bundle
October 22, 2013
How Safe Is Your Radiology Suite?
October 15, 2013
October 8, 2013
October 1, 2013
Fuels and Oxygen in OR Fires
September 24, 2013
Perioperative Use of CPAP in OSA
September 17, 2013
September 10, 2013
Informed Consent and Wrong-Site Surgery
September 3, 2013
Predicting Perioperative Complications: Slow and Simple
August 27 2013
Lessons on Wrong-Site Surgery
August 20 2013
Lessons from Canadian Analysis of Medical Air Transport Cases
August 13 2013
August 6, 2013
July 9-30, 2013
Tip of the Week on Vacation
July 2, 2013
June 25, 2013
June 18, 2013
DVT Prevention in Stoke – CLOTS 3
June 11, 2013
June 4, 2013
May 28, 2013
The Neglected Medications: IV Fluids
May 21, 2013
May 14, 2013
Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)
May 7, 2013
April 30, 2013
Photographic Identification to Prevent Errors
April 23, 2013
Plethora of Medication Safety Studies
April 16, 2013
April 9, 2013
Mayo Clinic System Alerts for QT Interval Prolongation
April 2, 2013
Absconding from Behavioral Health Services
March 26, 2013
Failure to Recognize Sleep Apnea Before Surgery
March 19, 2013
Dealing with the Violent Patient in the Emergency Department
March 12, 2013
More on Communicating Test Results
March 5, 2013
Underutilized Safety Tools: The Observational Audit
February 26, 2013
Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?
February 19, 2013
Practical Postoperative Pain Management
February 12, 2013
CDPH: Lessons Learned from PCA Incident
February 5, 2013
Antidepressants and QT Interval Prolongation
January 29, 2013
A Flurry of Activity on Handoffs
January 22, 2013
You Don’t Know What You Don’t Know
January 15, 2013
January 8, 2013
More Lessons Learned on Retained Surgical Items
January 1, 2013
Don’t Throw Away Those View Boxes Yet
December 25, 2012
Tip of the Week on Vacation
December 18, 2012
Unintended Consequences of the CAUTI Measure?
December 11, 2012
December 4, 2012
Unintentional Perioperative Hypothermia: A New Twist
November 27, 2012
November 20, 2012
Update on Perioperative Management of Obstructive Sleep Apnea
November 13, 2012
The 12-Hour Nursing Shift: More Downsides
November 6, 2012
Using LEAN to Improve Stroke Care
October 30, 2012
October 23, 2012
Latent Factors Lurking in the OR
October 16, 2012
What is the Evidence on Double Checks?
October 9, 2012
Call for Focus on Diagnostic Errors
October 2, 2012
Test Results: Everyone’s Worst Nightmare
September 25, 2012
Preoperative Assessment for Geriatric Patients
September 18, 2012
September 11, 2012
In Search of the Ideal Early Warning Score
September 4, 2012
August 28, 2012
New Care Model Copes with Interruptions Better
August 21, 2012
More on Missed Followup of Tests in Hospital
August 14, 2012
August 7, 2012
Cognition, Post-Op Delirium, and Post-Op Outcomes
July 31, 2012
Surgical Case Duration and Miscommunications
July 24, 2012
FDA and Extended-Release/Long-Acting Opioids
July 17, 2012
July 10, 2012
Tip of the Week on Vacation
July 3, 2012
Recycling an Old Column: Dilaudid Dangers
June 26, 2012
Using Patient Photos to Reduce CPOE Errors
June 19, 2012
More Problems with Faxed Orders
June 12, 2012
Lessons Learned from the CDPH: Retained Foreign Bodies
June 5, 2012
Minor Head Trauma in the Anticoagulated Patient
May 29, 2012
Falls, Fractures, and Fatalities
May 22, 2012
Update on Preoperative Screening for Sleep Apnea
May 15, 2012
May 8, 2012
Importance of Nontechnical Skills in Healthcare
May 1, 2012
April 24, 2012
Fire Hazard of Skin Preps Oxygen
April 17, 2012
April 10, 2012
April 3, 2012
New Risk for Postoperative Delirium: Obstructive Sleep Apnea
March 27, 2012
March 20, 2012
Adverse Events Related to Psychotropic Medications
March 13, 2012
Medical Emergency Team Calls to Radiology
March 6, 2012
February 28, 2012
AACN Practice Alert on Delirium in Critical Care
February 21, 2012
Improving PCA Safety with Capnography
February 14, 2012
Handoffs More Than Battle of the Mnemonics
February 7, 2012
Another Neuromuscular Blocking Agent Incident
January 31, 2012
January 24, 2012
Patient Safety in Ambulatory Care
January 17, 2012
Delirium and Contact Isolation
January 10, 2012
January 3, 2012
Unintended Consequences of Restricted Housestaff Hours
December 20, 2011
December 13, 2011
December 6, 2011
Why You Need to Beware of Oxygen Therapy
November 29, 2011
November 22, 2011
Perioperative Management of Sleep Apnea Disappointing
November 15, 2011
November 8, 2011
WHOs Multi-professional Patient Safety Curriculum Guide
November 1, 2011
So Whats the Big Deal About Inserting an NG Tube?
October 25, 2011
October 18, 2011
October 11, 2011
October 4, 2011
Radiology Report Errors and Speech Recognition Software
September 27, 2011
The Canadian Suicide Risk Assessment Guide
September 20, 2011
When Practice Changes the Evidence: The CKD Story
September 13, 2011
Do You Use Fentanyl Transdermal Patches Safely?
September 6, 2011
August 30, 2011
Unintentional Discontinuation of Medications After Hospitalization
August 23, 2011
Catheter Misconnections Back in the News
August 16, 2011
August 9, 2011
Frailty and the Surgical Patient
August 2, 2011
July 26, 2011
July 19, 2011
Communication Across Professions
July 12, 2011
Psst! Pass it onHow a kids game can mold good handoffs
July 5, 2011
Sidney Dekker: Patient Safety. A Human Factors Approach
June 28, 2011
Long-Acting and Extended-Release Opioid Dangers
June 21, 2011
June 14, 2011
June 6, 2011
May 31, 2011
Book Review Human Factors and Team Psychology in a High Stakes Environment
May 24, 2011
May 17, 2011
Opioid-Induced Respiratory Depression Again!
May 10, 2011
Preventing Preventable Readmissions: Not As Easy As It Sounds
May 3, 2011
April 26, 2011
Sleeping Air Traffic Controllers: What About Healthcare?
April 19, 2011
DVT Prophylaxis in Acute Stroke: Controversy Reappears
April 12, 2011
Medication Issues in the Ambulatory Setting
April 5, 2011
March 29, 2011
The Silent Treatment:A Dose of Reality
March 22, 2011
An EMR Feature Detrimental to Teamwork and Patient Safety
March 15, 2011
March 8, 2011
Yes, Physicians Get Interrupted Too!
March 1, 2011
February 22, 2011
February 15, 2011
Controversies in VTE Prophylaxis
February 8, 2011
February 1, 2011
January 25, 2011
Procedural Sedation in Children
January 18, 2011
More on Medication Errors in Long-Term Care
January 11, 2011
NPSA (UK) How to Guide: Five Steps to Safer Surgery
January 4, 2011
December 28, 2010
HAIs: Looking In All The Wrong Places
December 21, 2010
More Bad News About Off-Hours Care
December 14, 2010
NPSA (UK): Preventing Fatalities from Medication Loading Doses
December 6, 2010
More Tips to Prevent Wrong-Site Surgery
November 30, 2010
SURPASS: The Mother of All Checklists
November 23, 2010
Focus on Cumulative Radiation Exposure
November 16, 2010
November 9, 2010
12-Hour Nursing Shifts and Patient Safety
November 2, 2010
Insulin: Truly a High-Risk Medication
October 26, 2010
Confirming Medications During Anesthesia
October 19, 2010
Optimizing Medications in the Elderly
October 12, 2010
October 5, 2010
September 28, 2010
September 21, 2010
September 14, 2010
Wrong-Site Craniotomy: Lessons Learned
September 7, 2010
Patient Safety in Ob/Gyn Settings
August 31, 2010
August 24, 2010
The BP Oil Spill Analogies in Healthcare
August 17, 2010
Preoperative Consultation Time to Change
August 10, 2010
Its Not Always About The Evidence
August 3, 2010
Tip of the Week on Vacation
July 27, 2010
EMRs Still Have A Long Way To Go
July 20, 2010
More on the Weekend Effect/After-Hours Effect
July 13, 2010
Postoperative Opioid-Induced Respiratory Depression
July 6, 2010
Book Reviews: Pronovost and Gawande
June 29, 2010
Torsade de Pointes: Are Your Patients At Risk?
June 22, 2010
Disclosure and Apology: How to Do It
June 15, 2010
Dysphagia in the Stroke Patient: the Scottish Guideline
June 8, 2010
Surgical Safety Checklist for Cataract Surgery
June 1, 2010
May 25, 2010
May 18, 2010
Real-Time Random Safety Audits
May 11, 2010
May 4, 2010
More on the Impact of Interruptions
April 27, 2010
April 20, 2010
HITs Limited Impact on Quality To Date
April 13, 2010
April 6, 2010
March 30, 2010
Publicly Released RCAs: Everyone Learns from Them
March 23, 2010
ISMPs Guidelines for Standard Order Sets
March 16, 2010
A Patient Safety Scavenger Hunt
March 9, 2010
Communication of Urgent or Unexpected Radiology Findings
March 2, 2010
Alarm Sensitivity: Early Detection vs. Alarm Fatigue
February 23, 2010
Alarm Issues in the News Again
February 16, 2010
Spin/HypeKnowing It When You See It
February 9, 2010
More on Preventing Inpatient Suicides
February 2, 2010
January 26, 2010
Preventing Postoperative Delirium
January 19, 2010
January 12, 2010
Patient Photos in Patient Safety
January 5, 2010
December 29, 2009
Recognizing Deteriorating Patients
December 22, 2009
December 15, 2009
December 8, 2009
December 1, 2009
Patient Safety Doesnt End at Discharge
November 24, 2009
Another Rough Month for Healthcare IT
November 17, 2009
November 10, 2009
Conserving ResourcesBut Maintaining Patient Safety
November 3, 2009
Medication Safety: Frontline to the Rescue Again!
October 27, 2009
Co-Managing Patients: The Good, The Bad, and The Ugly
October 20, 2009
Radiology AgainBut This Time Its Really Radiology!
October 13, 2009
October 6, 2009
Oxygen Safety: More Lessons from the UK
September 29, 2009
Perioperative Peripheral Nerve Injuries
September 22, 2009
Psychotropic Drugs and Falls in the SNF
September 15, 2009
ETTOs: Efficiency-Thoroughness Trade-Offs
September 8, 2009
Barriers to Medication Reconciliation
September 1, 2009
The Real Root Causes of Medical Helicopter Crashes
August 25, 2009
Interruptions, Distractions, InattentionOops!
August 18, 2009
Obstructive Sleep Apnea in the Perioperative Period
August 11, 2009
August 4, 2009
July 28, 2009
Wandering, Elopements, and Missing Patients
July 21, 2009
Medication Errors in Long Term-Care
July 14, 2009
Is Your Do Not Use Abbreviations List Adequate?
July 7, 2009
Nudge: Small Changes, Big Impacts
June 30, 2009
iSoBAR: Australian Clinical Handoffs/Handovers
June 23, 2009
June 16, 2009
Disclosing Errors That Affect Multiple Patients
June 9, 2009
CDC Update to the Guideline for Prevention of CAUTI
June 2, 2009
Why Hospitals Should FlyJohn Nance Nails It!
May 26, 2009
Learning from Tragedies. Part II
May 19, 2009
May 12, 2009
May 5, 2009
Adverse Drug Events in the ICU
April 28, 2009
Ticket Home and Other Tools to Facilitate Discharge
April 21, 2009
April 14, 2009
More on Rehospitalization After Discharge
April 7, 2009
March 31, 2009
Screening Patients for Risk of Delirium
March 24, 2009
March 17, 2009
March 10, 2009
Prolonged Surgical Duration and Time Awareness
March 3, 2009
Overriding AlertsLike Surfin the Web
February 24, 2009
Discharge Planning: Finally Something That Works!
February 17, 2009
Reducing Risk of Overdose with Midazolam Injection
February 10, 2009
Sedation in the ICU: The Dexmedetomidine Study
February 3, 2009
NTSB Medical Helicopter Crash Reports: Missing the Big Picture
January 27, 2009
Oxygen Therapy: Everything You Wanted to Know and More!
January 20, 2009
The WHO Surgical Safety Checklist Delivers the Outcomes
January 13, 2009
January 6, 2009
December 30, 2008
Unintended Consequences: Is Medication Reconciliation Next?
December 23, 2008
December 16, 2008
Joint Commission Sentinel Event Alert on Hazards of Healthcare IT
December 9, 2008
December 2, 2008
Playing without the ballthe art of communication in healthcare
November 25, 2008
November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
November 11, 2008
November 4, 2008
October 28, 2008
More on Computerized Trigger Tools
October 21, 2008
October 14, 2008
October 7, 2008
Lessons from Falls....from Rehab Medicine
September 30, 2008
September 23, 2008
Checklists and Wrong Site Surgery
September 16, 2008
More on Radiology as a High Risk Area
September 9, 2008
Less is More.and Do You Really Need that Decimal?
September 2, 2008
August 26, 2008
August 19, 2008
August 12, 2008
Jerome Groopmans How Doctors Think
August 5, 2008
July 29, 2008
Heparin-Induced Thrombocytopenia
July 22, 2008
Lots New in the Anticoagulation Literature
July 15, 2008
July 8, 2008
July 1, 2008
WHOs New Surgical Safety Checklist
June 24, 2008
Urinary Catheter-Related UTIs: Bladder Bundles
June 17, 2008
Technology Workarounds Defeat Safety Intent
June 10, 2008
Monitoring the Postoperative COPD Patient
June 3, 2008
UK Advisory on Chest Tube Insertion
May27, 2008
If You Do RCAs or Design Healthcare ProcessesRead Gary Kleins Work
May20, 2008
CPOE Unintended Consequences Are Wrong Patient Errors More Common?
May13, 2008
Medication Reconciliation: Topical and Compounded Medications
May 6, 2008
Preoperative Screening for Obstructive Sleep Apnea
April 29, 2008
ASA Practice Advisory on Operating Room Fires
April 22, 2008
CMS Expanding List of No-Pay Hospital-Acquired Conditions
April 15, 2008
April 8, 2008
April 1, 2008
Pennsylvania PSAs FMEA on Telemetry Alarm Interventions
March 25, 2008
March 18, 2008
Is Desmopressin on Your List of Hi-Alert Medications?
March 11, 2008
March 4, 2008
Housestaff Awareness of Risks for Hazards of Hospitalization
February 26, 2008
Nightmares.The Hospital at Night
February 19, 2008
February 12, 2008
February 5, 2008
Reducing Errors in Obstetrical Care
January 29, 2008
Thoughts on the Recent Neonatal Nursery Fire
January 22, 2008
More on the Cost of Complications
January 15, 2008
Managing Dangerous Medications in the Elderly
January 8, 2008
Urinary Catheter-Associated Infections
January 1, 2008
December 25, 2007
December 18, 2007
December 11, 2007
CommunicationCommunicationCommunication
December 4, 2007
November 27,2007
November 20, 2007
New Evidence Questions Perioperative Beta Blocker Use
November 13, 2007
AHRQ's Free Patient Safety Tools DVD
November 6, 2007
October 30, 2007
Using IHIs Global Trigger Tool
October 23, 2007
Medication Reconciliation Tools
October 16, 2007
Radiology as a Site at High-Risk for Medication Errors
October 9, 2007
October 2, 2007
Taking Off From the Wrong Runway
September 25, 2007
Lessons from the National Football League
September 18, 2007
Wristbands: The Color-Coded Conundrum
September 11, 2007
Root Cause Analysis of Chemotherapy Overdose
September 4, 2007
August 28, 2007
Lessons Learned from Transportation Accidents
August 21, 2007
Costly Complications About To Become Costlier
August 14, 2007
More Medication-Related Issues in Ambulatory Surgery
August 7, 2007
Role of Maintenance in Incidents
July 31, 2007
Dangers of Neuromuscular Blocking Agents
July 24, 2007
Serious Incident Response Checklist
July 17, 2007
Falls in Patients on Coumadin or Other Anticoagulants
July 10, 2007
Catheter Connection Errors/Wrong Route Errors
July 3, 2007
June 26, 2007
Pneumonia in the Stroke Patient
June 19, 2007
Unintended Consequences of Technological Solutions
June 12, 2007
Medication-Related Issues in Ambulatory Surgery
June 5, 2007
Patient Safety in Ambulatory Surgery
May 29, 2007
Read Anything & Everything Written by Malcolm Gladwell!
May 22, 2007
May 15, 2007
Communication, Hearback and Other Lessons from Aviation
May 8, 2007
Doctor, when do I get this red rubber hose removed?
May 1, 2007
April 23, 2007
April 16, 2007
April 9, 2007
Make Your Surgical Timeouts More Useful
April 2, 2007
March 26, 2007
Alarms Should Point to the Problem
March 19, 2007
Put that machine back the way you found it!
March 12, 2007
March 5, 2007
February 26, 2007
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