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October 2, 2018
Speaking Up About Disruptive Behavior
One of the biggest barriers to patient safety is a culture that discourages healthcare workers at all levels from speaking up. We’ve discussed disruptive behavior in multiple columns and noted how it has a negative impact on both staff morale and patient care. In our January 2011 What's New in the Patient Safety World column “No Improvement in Patient Safety: Why Not?”, we echoed the theme of John Nance’s book “Why Hospitals Should Fly” that we have failed to create a true culture of safety in healthcare.
Then in our March 29, 2011 Patient Safety Tip of the Week “The Silent Treatment: A Dose of Reality” we highlighted a study “The Silent Treatment. Why Safety Tools and Checklists Aren’t Enough to Save Lives” by AORN (Association of perioperative Registered Nurses) and the AACN (American Association of Critical-Care Nurses). They honed in on three “undiscussable” issues: dangerous shortcuts, incompetence, and disrespect. They found that 4 out of 5 nurses participating in the study admitted having concerns that one or more of these three “undiscussables” were potentially causing patient harm and that very often they did not discuss the issues with the party doing the undiscussable (who could be another nurse or a physician or other healthcare worker). In some cases they were more likely to bring the undiscussable to the attention of a supervisor. But even the nursing supervisors participating in the study admitted that they often did not confront the offending party or take appropriate action.
In that column we also highlighted a 2007 American College of Physician Executives (ACPE) Quality of Care Survey (Steiger 2007) that revealed numerous issues considered by physician executives to be obstacles to quality of care or patient safety. But in many of the cases the perceived obstacles were failure of the system as a whole to deal with incompetent, impaired or disruptive physicians. Below are some of the quotes from respondents to that survey:
Then in our July 2012 What's New in the Patient Safety World column “A Culture of Disrespect” we discussed Lucien Leape’s provocative concept that disrespectful behavior goes well beyond the classic “disruptive” behavior (the physician yelling and screaming, perhaps throwing things) and that some of the more passive forms of disrespect may have consequences that are even more detrimental.
And in our September 22, 2015 Patient Safety Tip of the Week “The Cost of Being Rude” we discussed several studies showing how physicians or nurses being rude to each other can impact patient care and patient safety.
The basic tenet of all these columns is that a culture which discourages people from speaking up allows perpetuation of undesirable behaviors that ultimately may lead to adverse patient events and to problems with staff morale, retention, and turnover.
Johns Hopkins Medicine addressed this issue head on. Following discovery of serious misconduct by a physician, the Hopkins medical system commissioned a study to assess why healthcare workers fail to speak up and then to implement a program to encourage “voice” (Dixon-Woods 2018). In the “diagnostic” phase, confidential interviews with both senior leaders and frontline staff were conducted by a group of independent researchers.
Two main themes emerged as reasons for reluctance to speak up:
The former was the result of a hierarchical culture “where territories and autonomies were often fiercely defended by powerful individuals and their allies”. They described the “untouchables”: individuals, usually senior physicians, who were able to engage in transgressive or disruptive conduct with impunity, often because of their positions of power or ability to generate revenue. (Hey! Didn’t we hear that in the quotes in that 2007 ACPE Quality of Care Survey we noted above?). The behavior of the “untouchables” created conflict-laden working environments that led to poor teamwork and difficulties in
staff retention. Gaps between policy and practice were created and there was “normalization of deviance”. We’ve discussed “normalization of deviance” in several of our columns. This is where the culture of the system has led to acceptance of a certain deviation from proper practice as being “normal” and allowed that deviation to be performed by many individuals. The deviation has been used so frequently without serious adverse consequences occurring that staff no longer consider it abnormal.
But just as important was the perception, by both frontline staff and senior leaders, that their concerns were not always taken seriously or that nothing happened when they spoke up.
The results of that “diagnostic” phase probably don’t surprise any of you. Such problems occur at the majority of healthcare organizations in this country, even at respected organizations like Johns Hopkins.
So what do you do about them? Hopkins took a 4-step approach:
The results of the interviews were shared in multiple venues, not only in departmental or unit meetings but also in “town hall” type meetings that were well attended. Simply discussing the issues led to a perception that openness was now encouraged and staff began to come forward and speak up just as a result of those meetings. They then built upon an existing program, “Safe at Hopkins”, which focused on disruptive, bullying, or violent behavior and sought to intervene early. With strong support from upper levels at both the hospitals and medical school and university in the form of a Physician Executive Oversight Committee, interventions included graduated steps that would escalate if the unwanted behaviors continued.
In addition, leaders (for example, department directors) were provided with training and tools regarding voice opportunities, including how to deal with reported concerns and identifying and investigating disruptive behaviors. This included a 30-minute e-learning module followed by a two-hour interactive simulation workshop which leaders practiced having difficult conversations. Department directors often appreciated that the details collected in the “Safe at Hopkins” program provided “cover” and helped them in dealing with those difficult conversations with physicians with whom they were intervening.
Kudos to Johns Hopkins Medicine and the outside researchers/consultants who recognized this problem, delved into the causes, and implemented the program to address those causes. Being able to “speak up” without fear of retribution and knowing that your concerns will be addressed and lead to positive change are critical to having a culture of safety.
Some of our prior columns on the impact of “bad behavior” of healthcare workers:
January 2011 “No Improvement in Patient Safety: Why Not?”
March 29, 2011 “The Silent Treatment: A Dose of Reality”
July 2012 “A Culture of Disrespect”
July 2013 “"Bad Apples" Back In?”
July 7, 2015 “Medical Staff Risk Issues”
September 22, 2015 “The Cost of Being Rude”
April 2017 “Relation of Complaints about Physicians to Outcomes”
Some of our prior columns related to the “culture of safety”:
April 2009 “New Patient Safety Culture Assessments”
June 2, 2009 “Why Hospitals Should Fly...John Nance Nails It!”
January 2011 “No Improvement in Patient Safety: Why Not?”
March 2011 “Michigan ICU Collaborative Wins Big”).
March 29, 2011 “The Silent Treatment: A Dose of Reality”
May 24, 2011 “Hand Hygiene Resources”
March 2012 “Human Factors and Operating Room Safety”
July 2012 “A Culture of Disrespect”
July 2013 “"Bad Apples" Back In?”
July 22, 2014 “More on Operating Room Briefings and Debriefings”
October 7, 2014 “Our Take on Patient Safety Walk Rounds”
July 7, 2015 “Medical Staff Risk Issues”
September 22, 2015 “The Cost of Being Rude”
May 2016 “ECRI Institute’s Top Ten Patient Safety Concerns for 2016”
June 28, 2016 “Culture of Safety and Catheter-Associated Infections”
April 2017 “Relation of Complaints about Physicians to Outcomes”
April 2017 “Joint Commission Sentinel Event Alert on Safety Culture”
References:
AACN/AORN/VitalSmarts. The Silent Treatment. Why Safety Tools and Checklists Aren’t Enough to Save Lives. 2011
http://www.silenttreatmentstudy.com/
Steiger B. Doctors Say Many Obstacles Block Paths to Patient Safety. The Physician Executive 2007; 6-14 May • June 2007
http://net.acpe.org/MembersOnly/pejournal/2007/May_June/Steiger.pdf
Dixon-Woods M, Campbell A, Martin G, et al. Improving Employee Voice About Transgressive or Disruptive Behavior: A Case Study. Academic Medicine 2018; Published Ahead of Print September 11, 2018
Print “Speaking Up About Disruptive Behavior”
October 9, 2018
More on Lab Specimen Mixups
A report in the news earlier this year (Moore 2018) rekindled our interest in the issue of specimen mixups. A patient underwent a prostatectomy on the basis of a biopsy that showed an invasive, aggressive cancer. But it turned out that the removed prostate was healthy. The biopsy results that showed the cancer belonged to another patient. There had been a mixup. And this had occurred despite the fact that the patient, at the urologist’s suggestion, had a DNA swab taken at the same time he had the biopsy. That should have made it nearly impossible to mix up test results among patients. But that’s exactly what happened.
We’ve done several columns on lost surgical specimens or misidentification of surgical samples. In our March 24, 2015 Patient Safety Tip of the Week “Specimen Issues in Prostate Cancer” some of the estimates of switched or contaminated prostate biopsy specimens ranged from 1% to 2.5%. But those were largely estimates. A more realistic estimate comes from a recent clinical trial, the Reduction by Dutasteride of Prostate Cancer Events (REDUCE) prostate cancer risk reduction study. After three cases of biopsy sample misidentification were discovered in the first 2 years of that study, all protocol-mandated biopsy samples were DNA tested to verify biopsy identity (Marberger 2011). A total of 11,235 primary study biopsy samples were DNA identity tested. The results found that 27 biopsies were confirmed to be mismatched to the patient for whom they were originally submitted. In the first two years of the study, 0.4% of biopsies (n = 26) were found to be mismatched. After a rigorous improvement process, only a single biopsy was mismatched in the following two years.
The authors suggest some key strategies to address biopsy identification errors in clinical trials but several of them are pertinent to any setting:
We’ve talked about doing DNA identity testing in several of our prior columns listed below and noted that there are some pathologists and urologists who have suggested such should be routine for all patients undergoing prostate biopsy. Note that a proposed bill, the Prostate Cancer Misdiagnosis Elimination Act of 2017, calls for Medicare to reimburse labs $200 for DNA testing that compares and matches the patient's biopsy tissue with cells from the inside the cheek that are taken with a cotton swab to ensure both came from the same person (Mulcahy 2017). To our knowledge that bill has not yet progressed through Congress.
An analysis of closed pathology claims (Akland 2018) is very revealing. The majority of the claims were related to misreads, but in 38% of the claims there were systems issues that contributed. As we’ve seen with most “lab” errors, the majority occur in the pre-analytic phase. Specimen loss/mix-ups accounted for 78% of the systems issues. The other 22% involved specimen contamination (eg. floaters, carry-over artifacts and cross-contamination).
Errors may occur related to the handling practices of the submitting physician by his/her staff, But they may also occur within the lab related to transport and receiving the specimen, or related to accessioning and slide identification. Examples of errors include mislabeling, misidentification, sorting, routing and pour-off (decanting) errors.
Carolyn Akland provides several illustrative case descriptions and then offers the following excellent recommendations pertinent to labeling and identification issues:
We strongly encourage you to read Akland’s analysis since she also has excellent recommendations regarding communication issues, using all available clinical information when rendering interpretations, avoiding interruptions and distractions, how to deal with and communicate amended reports, and others.
Lippi and colleagues (Lippi 2017a) recently published an article on patient and sample identification in the lab. They identified the following causes of identification errors in medical laboratory:
Homonymy, of course, refers to names sounding alike. They note that in one hospital district in Texas, 2488 patients were named Maria Garcia, and 231 of these (9.3%) also shared the same date of birth (Lippi 2017a)!
They note that Joint Commission’s National Patient Safety Goal NPSG.01.01.01 mandates that at least two patient identifiers should be used when collecting blood samples and other specimens for clinical testing, or when providing other treatments and procedures. Notably, the room number or physical location of the patient should not be used as identifiers, whereas containers used for blood and other specimens should be labeled in the presence of the patient.
Lippi et al. point out an important distinction between handling of blood samples compared to surgical specimens. Whereas we’ve emphasized you should not pre-label containers for biopsies or surgical specimens, they recommend the practice for blood samples should be pre-labelling of tubes. There apparently have been discrepancies in the recommendations amongst the several specialty organizations covering laboratories, but evidence apparently suggests that post-collection labeling of tubes carries a higher risk of identification errors (Lippi 2011).
Lippi et al. (Lippi 2017a) note that conventional or two-dimensional (2D) barcoded wristbands are indeed the most used approach for patient identification around the globe. But they go on to discuss the roles of technological solutions to the identification process, radio-frequency identification (RFID) tags, infrared (IR)-based patient tracking, wireless networks, patient smart cards and biometric technologies, each of which has its own advantages and limitations. They also talk about future developments, including an automated device based on four cameras which photographs the outside of a sample tube and then recognizes discrepancies between patient identity in the lab information system versus that on the blood tube label by means of optical character recognition (OCR). Another is a recently developed chip-size passive RFID tag also offers a locating capability and read range that are comparable to an active tag, but in a form factor and price that would allow to attach the tags to disposable labels.
In yet another paper by Lippi and colleagues (Lippi 2017b) note that the frequency of misidentification in vitro laboratory diagnostic testing may be relatively low compared to that of other laboratory errors (i.e., usually comprised between 0.01 and 0.1% of all specimens received). But up to 10–20% of these errors translate into harm for patients and may impact other human and economic resources.
They state the healthcare system should be re-engineered to act proactively to address this important problem. The advocate the widespread use of more than two unique patient identifiers, the accurate education and training of healthcare personnel, the delivery of more resources for patient safety (i.e., implementation of safer technological tools), and the use of customized solutions according to local organization and resources and, as above, after weighing advantages and drawbacks, labeling blood collection tubes before and not after venipuncture as a safer practice for safeguarding patient safety and optimizing phlebotomist's activity.
Some of our other columns on errors related to laboratory studies:
References:
Moore D. His doctor said it was cancer. It was not. But the lab mix-up news came too late. St. Louis Post-Dispatch 2018; February 11, 2018
Akland C. An Analysis of Pathology Closed Claims, SVMIC (State Volunteer Mutual Insurance Company) January, 2017
https://home.svmic.com/resources/newsletters/59/an-analysis-of-pathology-closed-claims
Marberger M, McConnell JD, Fowler I, et al. Biopsy Misidentification Identified by DNA Profiling in a Large Multicenter Trial. J Clin Oncol 2011; 29(13): 1744-1749
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3107764/
Mulcahy N. A Bill to 'Eliminate Prostate Cancer Misdiagnosis'. Medscape Medical News 2017; November 17, 2017
https://www.medscape.com/viewarticle/888840
Lippi G, Chiozza L, Mattiuzzi C, Plebani M. Patient and Sample Identification. Out of the Maze? J Med Biochem 2017; 36(2): 107-112
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5471642/
Lippi G, Sonntag O, Plebani M. Appropriate labelling of blood collection tubes: a step ahead towards patient's safety. Clin Chem Lab Med 2011; 49: 192-1923
https://www.degruyter.com/view/j/cclm.2011.49.issue-12/cclm.2011.736/cclm.2011.736.xml?format=INT
Lippi G, Mattiuzzi C, Bovo C, Favaloro EJ. Managing the patient identification crisis in healthcare and laboratory medicine. Clinical Biochemistry 2017; 50(10-11): 562-567
https://www.sciencedirect.com/science/article/pii/S0009912017300012?via%3Dihub
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October 16, 2018
Burnout
We just did a column on physician burnout and its impact on medical errors (see our August 2018 What's New in the Patient Safety World column “Burnout and Medical Errors”). We’ve also talked about nurse burnout in multiple columns on nurse workload and long nursing shifts. But since August there has been a deluge of publications on burnout, so here we go again.
Burnout, of course, occurs in all careers, not just healthcare ones. And we all know healthcare workers who show signs of burnout. But why are we talking about burnout in a patient safety column? The answer is simple: burnout affects patient care and patient safety.
That August 2018 What's New in the Patient Safety World column “Burnout and Medical Errors” highlighted a study (Tawfik 2018) which showed that physicians reporting symptoms of burnout were more than twice as likely to have reported a major medical error in the prior 3 months.
In addition to that study, there have been two recent systematic reviews and meta-analyses showing an association between physician burnout and patient safety issues. And physician burnout also made Becker’s Hospital Review’s “10 Top Patient Safety Issues for 2018” (Vaidya 2018).
The first systematic review (Panagioti 2018) analyzed 47 studies that met their inclusion criteria, accounting for over 42,000 physicians. Physician burnout was associated with an increased risk of patient safety incidents (OR, 1.96), poorer quality of care due to low professionalism (OR, 2.31), and reduced patient satisfaction (OR, 2.28). The links between burnout and low professionalism were larger in residents and early-career (≤5 years post residency) physicians compared with middle- and late-career physicians. Particularly in residents and early career physicians (≤5 years post residency), burnout was associated with close to four times increased risk for unprofessional behaviors. Overall, the depersonalization dimension had the most adverse association with quality and safety of patient care and patient satisfaction.
The second systematic review that focused on patient safety (Mossburg 2018) found that, of 22 studies meeting inclusion criteria, ten studies showed a relationship between both safety culture and clinical errors with burnout. Two of 3 studies reported an association between burnout and patient outcomes.
Remember also that the relationship between burnout and medical errors is bidirectional. Those physicians or nurses who have been involved in a serious incident, the “second victims”, are at greater risk of burnout (see our August 9, 2016 Patient Safety Tip of the Week “More on the Second Victim”).
A number of the studies on physician burnout point to the electronic health record (EHR) as a significant factor contributing to burnout. Alexander and colleagues (Alexander 2018) discuss the 3 main features of burnout: lack of enthusiasm, lack of accomplishment, and cynicism/depersonalization. Then, in attempt to find reason for a significant increase in burnout prevalence between 2011 and 2014, they analyzed 5 major transformational medical practice events that occurred between 2011 and 2014 (pervasive hospital purchases of medical groups, rising drug prices, the Affordable Care Act, pay for performance, and mandated electronic health records). Analyzing those events for the 3 main burnout features, they concluded that only the HER met all 3 attributes of physician burnout.
A survey last year showed that 60% of neurologists have at least one symptom of burnout (Busis 2017). Bernat and Busis (Bernat 2018), in describing factors contributing to that high burnout rate, also point to the role of the EHR as a major detrimental factor. They state “Completion of EHR data entry during office visits disturbs the patient–physician relationship by diverting physician eye contact and attention away from the patient. Completion of the EHR outside of the visit markedly adds clerical time to already overburdened physicians, further aggravating work–life imbalance. Physicians’ awareness that the usurpation of patient visit time by mandated but unproductive EHR documentation compounds their sense that work is meaningless and increases their dissatisfaction with practice. Patients ultimately become harmed as a result. EHRs were mainly designed for primary care physicians. Successfully practicing neurology depends on a more thorough history and physical examination than many other specialties. It is difficult to enter a complete and accurate neurologic history and examination into an EHR and to review electronic records from colleagues.”
We found these comments from neurologist Steven Sergay (Sergay 2018) about how physician burnout leads to patient burnout particularly compelling:
“Our patients are becoming disillusioned about their caregivers and have dampened expectations for the care they receive. Their doctor no longer seems personally involved. Many patients feel helpless and bear a sense of defeat and resignation. Why, they ask, do we have to cope with both illness and care quality anxiety? My patients often recognize pursuit of efficiency over effectiveness. They complain their doctor is harried, their care hurried, mechanical, and lacking in humanity. They miss eye contact with their doctor, literally and figuratively. Their caregiver does not take the necessary time to know them as a person with an illness rather than as “a disease,” to understand their experiences, anxieties, and preconceptions, all of which may dictate their receptivity to care approaches and methods. They decry the absence of discussion and explanation. They perceive the increased risk of their diagnosis being missed or delayed by regimented care delivery and that this often leads to unnecessary testing and its product: increased cost. They see their caregiver being sidetracked by recordkeeping and administrative requirements. They fear their hospital care may be suboptimal without an advocate.”
A systematic review and meta-analysis of the literature (Rotenstein 2018) showed wide variability of reported rates of burnout or individual burnout symptoms. They note that the prevalence of burnout ranged from 0% to over 80%. They found marked variation in burnout definitions, assessment methods, and study quality. These findings preclude definitive conclusions about the prevalence of burnout and highlight the importance of developing a consensus definition of burnout and of standardizing measurement tools. Most of the published studies on burnout have used the Maslach Burnout Inventory (MBI) as a tool to assess burnout. It measures three main dimensions of burnout: emotional exhaustion, depersonalization and diminished personal accomplishment. In an accompanying editorial (Schwenk 2018) Schwenk and Gold point out the MBI was originally developed for assessing burnout in social service professionals. They question whether it has the same applicability in physicians.
Burnout may begin very early in one’s medical career. Among US resident physicians, symptoms of burnout and career choice regret were prevalent, but varied substantially by clinical specialty (Dyrbye 2018). Training in urology, neurology, emergency medicine, and general surgery were associated with higher relative risks of reported symptoms of burnout relative to training in internal medicine. Another study of residents (Williford 2018) showed that 75% of general surgery residents met criteria for burnout (measured by the MBI), and 39% met criteria for depression (measured by the PHQ-9). Of those with burnout, 48% were at elevated risk of depression. Attendings and residents underestimated the prevalence of these conditions. The top 3 barriers to seeking care for burnout were: inability to take time off to seek treatment, avoidance or denial of the problem, and negative stigma toward those seeking care.
The overall message remains clear: burnout is a real problem and it contributes to medical errors and untoward patient outcomes. We, thus, need better ways to recognize physician burnout and interventions to offer support when we recognize it. Other industries have recognized job burnout and developed approaches to address it. We need to borrow from those industries and apply their approaches to healthcare. An excellent review on physician burnout also recently appeared in the Mayo Clinic Proceedings (Olson 2017).
So where do we start? In a commentary, Linzer (Linzer 2018) notes some factors contributing to burnout (eg. the EHR, chaotic workplaces, regulatory environment). We’re not going to cure the inefficiencies brought on by the EHR and insurance/regulatory climates in today’s column. Linzer also notes that stress and dissatisfaction in their role models and mentors may play a role in trainee’s high rates of burnout. He does note that workflow redesign has been shown to have a positive impact on burnout.
A recent article (Cheyney 2018) showed how workflow optimization addresses physician burnout in physician practices affiliated with Virginia Mason Medical Center, They note that workflow optimization usually targets 3 categories :lack of set up, mismatch of supply and demand, and poor skill-task alignment so they focused primarily on three workflow optimization tactics that foster team work: spreading the work burden among physicians, adoption of standardized work roles, and colocation of team members when feasible. That included having more patients seen by caregivers other than the physicians, including clinical pharmacists, care managers, RN’s, physician assistants, and nurse practitioners. Care managers have a greater role in helping manage patients with diabetes or other chronic diseases. And they make use of clinical pharmacists, who may deal with patients taking antihypertensives, antidepressants, and chronic opioids, and help with medication reconciliation in patients recently discharged from the hospital. They also developed standards that allow staff other than physicians to handle some of the phone calls. They note that having such team members co-located on-site with the rest of the team is very valuable.
Another excellent paper from the National Academy of Medicine (Smith 2018) discusses how implementing optimal team-based care to reduce clinician burnout. Successful teams have the capacity to improve patient outcomes, the efficiency of care, and the satisfaction and well-being of health care clinicians.
And recall that our February 27, 2018 Patient Safety Tip of the Week “Update on Patient Safety Walk Rounds” noted a study in multiple settings in the Michigan Keystone collaborative to determine the impact of Walk Rounds (WR) on domains such as safety culture, employee engagement, burnout and work-life balance. Focus was on the importance of feedback (Sexton 2017). The researchers found that both personal burnout and burnout climate were lowest in work settings that had the highest rates of WR with feedback.
Lastly, we must get a better understanding of the factors related to high burnout rates among residents. We already noted that reducing burnout in attending physicians may help reduce burnout in residents. Some academic practices have implemented innovative programs for developing four “emotional intelligence” skills: self-awareness; self-management; social awareness; and social skills that may improve stress management skills, promote wellness, and prevent burnout in resident physicians (Shahid 2018).
Burnout is real. It’s contagious. It’s bad for physicians, nurses, and all healthcare workers. It’s bad for our future generations of healthcare professionals. And, most of all, it’s bad for our patients. All too long burnout has been treated as a nebulous concept and, as such, there has been little focus on solutions in healthcare. The time has come to focus on mitigating those environmental factors that take the fun and reward out of the practice of medicine.
References:
Tawfik DS, Profit J, Morgenthaler TI, et al. Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reported Medical Errors. Mayo Clinic Proceedings 2018; Published online: July 9, 2018
https://www.mayoclinicproceedings.org/article/S0025-6196(18)30372-0/fulltext
Vaidya A, Zimmerman B, Bean M. 10 top patient safety issues for 2018. Becker’s Hospital Review 2018; January 09, 2018
https://www.beckershospitalreview.com/10-top-patient-safety-issues-for-2018.html
Panagioti M, Geraghty K, Johnson J, et al. Association Between Physician Burnout and Patient Safety, Professionalism, and Patient SatisfactionA Systematic Review and Meta-analysis. JAMA Intern Med 2018; 178(10): 1317-1330
Mossburg SE, Dennison Himmelfarb C. The association between professional burnout and engagement with patient safety culture and outcomes: a systematic review. J Patient Saf 2018; Epub ahead of print June 2018.
Alexander AG, Ballou KA, Work–Life Balance, Burnout, and the Electronic Health Record. Amer J Med 2018; 131(8): 857-858
https://www.amjmed.com/article/S0002-9343(18)30286-9/fulltext
Busis NA, Shanafelt TD, Keran CM, et al. Burnout, career satisfaction, and well-being among US neurologists in 2016. Neurology 2017; 88: 1-12
http://n.neurology.org/content/neurology/early/2017/01/25/WNL.0000000000003640.full.pdf
Bernat JL, Busis NA. Patients are harmed by physician burnout. Neurol Clin Pract 2018 8: 279-280; published ahead of print June 18, 2018
http://cp.neurology.org/content/8/4/279?etoc=
Sergay SM. The burnout patient. Neurol Clin Pract 2018 8: 346-348; published ahead of print June 18, 2018
http://cp.neurology.org/content/8/4/346?etoc=
Rotenstein LS, Torre M, Ramos MA, et al. Prevalence of Burnout Among Physicians. A Systematic Review. JAMA 2018; 320(11): 1131-1150
Schwenk TL, Gold KJ. Physician Burnout—A Serious Symptom, But of What? (editorial). JAMA 2018; 320(11) :1109-1110
https://jamanetwork.com/journals/jama/article-abstract/2702852
Dyrbye LN, Burke SE, Hardeman RR, et al. Association of Clinical Specialty With Symptoms of Burnout and Career Choice Regret Among US Resident Physicians. JAMA 2018; 320(11): 1114-1130
https://jamanetwork.com/journals/jama/article-abstract/2702870
Williford ML, Scarlet S, Meyers MO, et al. Multiple-Institution Comparison of Resident and Faculty Perceptions of Burnout and Depression During Surgical Training. JAMA Surg 2018; 153(8): 705-711
Olson KD. Physician Burnout—A Leading Indicator of Health System Performance? Mayo Clinic Procedings 2017; 92(11): 1608-1611
https://www.mayoclinicproceedings.org/article/S0025-6196(17)30690-0/fulltext
Linzer M. Clinician Burnout and the Quality of Care. JAMA Intern Med 2018; 178(10): 1331-1332
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2698140
Cheney C. How Workflow Optimization Addresses Physician Burnout. HealthLeaders 2018; August 22, 2018
Smith CD, Balatbat C, Corbridge S. et al. Implementing Optimal Team-Based Care to Reduce Clinician Burnout. Discussion Paper. National Academy of Medicine 2017; September 17, 2018
https://nam.edu/implementing-optimal-team-based-care-to-reduce-clinician-burnout/
Sexton JB, Adair KC, Leonard MW, et al Providing feedback following Leadership WalkRounds is associated with better patient safety culture, higher employee engagement and lower burnout. BMJ Qual Saf 2017; Published Online First: 09 October 2017
http://qualitysafety.bmj.com/content/early/2017/10/09/bmjqs-2016-006399
Shahid R, Stirling J, Adams W. Promoting wellness and stress management in residents through emotional intelligence training. Advances in Medical Education and Practice 2018; 9: 681-686
https://www.dovepress.com/articles.php?article_id=40739
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October 23, 2018
Lessons From Yet Another Aviation Incident
In patient safety we frequently use analogies from other industries, particularly aviation. It’s been a couple years since we’ve done a “lessons learned” from an aviation disaster or other transportation disaster. This time we can learn a lot from an aviation near-miss.
On July 7, 2017 an Air Canada flight 759 overflew multiple planes that were in line on a taxiway at San Francisco International Airport (SFO), missing them by only feet, in what could have been one of the worst aviation disasters ever (NTSB 2018). Just as we see in healthcare incidents, there was a cascade of contributing factors that led to this almost-disaster. And we can see that almost each of those contributing factors has an analogous presence in healthcare incidents.
The flight was from Toronto, Ontario to San Francisco and was scheduled to arrive about 11:30 PM (Pacific Time). It left Toronto about 30 minutes late. Autopilot was engaged shortly after takeoff and remained engaged until just before the final approach to SFO. The departure, climb, cruise, and descent phases of flight were uneventful except for an area of thunderstorms about midway through the flight.
The flight was designated to land on runway 28R (R=right). That same night, runway 28L (L=left) was scheduled to be closed from 2300 to 0800 the next morning. The lights on runway 28L were turned off about 2312. As they approached SFO, the pilot inadvertently lined up for Taxiway C (parallel to and to the right of runway 28R), where four large air carrier airplanes were lined up awaiting clearance to take off from runway 28R. The control tower gave Air Canada flight 759 clearance to land on runway 28R. At 2355:45, the flight crew made the following transmission to the controller: “Just want to confirm, this is Air Canada seven five nine, we see some lights on the runway there, across the runway. Can you confirm we’re cleared to land?”. At 2355:52, 1 second after the flight crew completed its transmission, the controller replied, “Air Canada seven five nine confirmed cleared to land runway two eight right. There’s no one on runway two eight right but you.”
The Air Canada plane descended to an altitude of 100 ft above ground level and overflew the first airplane on the taxiway. The flight crew initiated a go-around, and the airplane reached a minimum altitude of about 60 ft as it overflew the second airplane on the taxiway before starting to climb.
Thus, only feet separated this near-miss from being perhaps the worst airline disaster ever.
The NTSB (National Transportation Safety Board) recently issued its investigation report (NTSB 2018). The NTSB, when it investigates, looks at every conceivable contributing factor (equipment, weather, human factors, fatigue, policies and procedures, etc.). Below, we’ve summarized some of the most important points in their investigation and attached analogies that apply in healthcare.
Information about the runway closure not salient enough.
A major factor that contributed to confusion was the closure of the adjacent runway 28L. That runway had been closed around 2300. This was a schedule closure (it was scheduled to be closed from 2300 to 0800 the next morning). The lights on runway 28L were turned off about 2312. The pilots of Air Canada flight 759 were familiar with landing at SFO, but the lack of lights on 28L likely contributed to their aligning inadvertently with the taxiway. They likely saw two “runways” and thought they were aligning with the one to the right (taxiway C was to the right of runway 28R as they approached SFO).
Note that the crew of a different plane that had landed on runway 28R about 4 minutes before the incident reported that, after visually acquiring the runway environment, they, too, questioned whether their airplane was lined up for runway 28R. But they were able to determine that their airplane was lined up for runway 28R after cross-checking the lateral navigation (LNAV) guidance. They stated that, without lateral guidance, they could understand how the runway 28R and taxiway C surfaces could have been confused because the lights observed on the taxiway were in a straight line and could have been perceived as a centerline.
The information about the planned closure of 28L was available to the pilots both prior to their takeoff and while in-flight. Prior to takeoff they had access to the notice to airmen (NOTAM) about the runway 28L closure. However, the first officer stated that he could not recall reviewing the specific NOTAM that addressed the runway closure. The captain stated that he saw the runway closure information, but his actions (as the pilot flying) in aligning the airplane with taxiway C instead of runway 28R demonstrated that he did not recall that information when it was needed. The second opportunity occurred in flight when the crewmembers reviewed automatic terminal information system (ATIS), which also included NOTAM information about the runway 28L closure. Both crewmembers recalled reviewing the ATIS information but could not recall reviewing the specific NOTAM that described the runway closure.
One additional reason the crew may not have paid much attention to the runway closure was that they may have expected to land prior to the closure. Recall, however, that the late departure also resulted in their late arrival at SFO, after the closure of runway 28L.
NTSB subsequently added a highlighted box with a dashed outline for emphasis to alert crews to a runway closure.
Healthcare analogies:
Analogy: ignoring alerts that do not demand a specific action
Analogy: receiving remote training about an issue without reinforcement at a time when such information is needed
Analogy: ignoring warnings about defective piece of equipment (“we had a problem with that yesterday”)
We’ve seen this problem before.
Although the NOTAM about the runway 28L closure appeared in the flight release and the in-flight messages that were provided to the flight crew, the presentation of that information did not effectively convey the importance of the runway closure information and promote flight crew review and retention. Multiple events in the National Aeronautics and Space Administration’s aviation safety reporting system database showed that this issue has affected other pilots, indicating that all pilots could benefit from the improved display of flight operations information.
Healthcare analogies:
We often fail to learn from prior events. See, for example, our March 30, 2010 Patient Safety Tip of the Week “Publicly Released RCA’s: Everyone Learns from Them”. In that column we describe an adverse event that followed an almost identical adverse event several years earlier. There was a failure to disseminate lessons learned from earlier events and implement solutions to prevent future events.
The first officer failed to tune the instrument landing system to the frequency for runway 28R.
The procedures for the approach to runway 28R required the first officer (as the pilot monitoring) to manually tune the instrument landing system (ILS) frequency for runway 28R, which would provide backup lateral guidance during the approach to supplement the visual approach procedures. However, when the first officer set up the approach, he missed the step to manually tune the ILS frequency. The captain was required to review and verify all programming by the first officer but did not notice that the ILS frequency had not been entered.
There are several issues here. Apparently, the instruction on the approach chart to manually tune the ILS frequency was not conspicuous during the crew’s review of the chart. Second, this was the only approach in Air Canada’s Airbus A320 database that required manual tuning for a navigational aid, so the manual tuning of the ILS frequency was not a usual procedure for the flight crew. Third, the captain was required to review and verify all programming by the first officer but did not notice that the ILS frequency had not been entered.
Healthcare analogies:
Analogy: failure to adhere to all the items/actions in a checklist. For example, in a checklist for a surgical timeout, staff may not pay attention to a step that requires independent confirmation that the imaging materials in the OR actually belong to the patient.
Anaology: lack of standardization. For example, a hospital may have different mechanical ventilators in each of its ICU’s. A nurse temporarily called to work in an ICU different from his/her usual ICU may therefore be faced with dials and settings that he/she is not used to.
Analogy: failed double checks. The statistic we often give is that an inspector fails to recognize an error in someone else’s work 10% of the time. That is why truly independent double checks (where each person independently reviews the order or other issue) are necessary when doing things such as administration of a high-alert drug. (See our October 16, 2012 Patient Safety Tip of the Week “What is the Evidence on Double Checks?”).
Planes should be equipped with a system that alerts air crews if the plane is not aligned with their destination runway.
Although the Federal Aviation Administration (FAA) has not mandated the installation of such a system, the results of a simulation showed that such technology, if it had been installed on the incident airplane, could have helped the flight crew identify its surface misalignment error earlier in the landing sequence, which could have resulted in the go-around being performed at a safer altitude.
Healthcare analogies:
Analogy: A (theoretical) system that could inactivate electrosurgical devices while there is free flow of oxygen in head/neck surgery might prevent surgical fires.
There was no system in place to alert air traffic controllers that the plane was aligned with a taxiway rather than a runway.
If an airplane were to align with a taxiway, an automated airport surface detection equipment (ASDE) alert could assist controllers in identifying and preventing a potential taxiway landing as well as a potential collision with aircraft, vehicles, or objects that are positioned along taxiways. An FAA demonstration in February 2018 showed the potential effectiveness of such a system.
Healthcare analogies:
Analogy: a system of detecting RFID tags in surgical sponges might reduce the likelihood of a retained surgical sponge
Need for a method to more effectively signal a runway closure to pilots when at least one parallel runway remains in use.
A runway closure marker with a lighted flashing white “X” appeared at the approach and departure ends of runway 28L when it was closed. The runway closure marker was not designed to capture the attention of a flight crew on approach to a different runway. Increased conspicuity of runway closure markers, especially those used in parallel runway configurations, could help prevent runway misidentification by flight crews while on approach to an airport.
Healthcare analogies:
Analogy: Special warnings on vials of drugs in conspicuous lettering (eg. large font, special color) informing that the drug is not to be used in certain circumstances.
Pilot fatigue
Both the pilot and first officer noted feeling tired after they had navigated an area of thunderstorms about halfway through the flight. The pilot had been awake for more than 19 hours, and first officer for more than 12 hours at the time of the landing. Transport Canada had proposed regulations would better address the challenge of fatigue mitigation for pilots on reserve duty who are called to operate evening flights extending into their window of circadian low. However, Transport Canada has not yet finalized its rulemaking in this area.
It’s also not clear whether fatigue may have impacted the air traffic controller. The air traffic controller began his “midnight” shift at 2230. He had also worked a daytime shift on July 7 from 0530 to 1330. The controller reported that he took a 45-minute nap in between the morning and midnight shifts and that he felt rested for his shifts. The controller also stated that he had “no problems” adjusting to the midnight shift.
Healthcare analogies:
Analogy: see our many columns on the impact of fatigue on healthcare workers
Expectation bias
Expectation bias is “when someone expects one situation, she or he is less likely to notice cues indicating that the situation is not quite what it seems.”
The first officer, on first looking up toward the landing zone, assumed that the pilot had aligned with the correct runway.
The air traffic controller, because he had never seen a plane align with the taxiway before, assumed that the plane was aligned with the correct runway.
Healthcare analogies:
Analogy: hanging the wrong IV bag because another IV bag was expected
A closely related concept is “inattentional blindness” in which we tend to see what we expect to see (as discussed in our April 21, 2015 Patient Safety Tip of the Week “Slip and Capture Errors”)
Confirmation bias
Despite lack of most of the usual visual markers of a runway, the presence of lights in a row (which were actually related to planes waiting in line on the taxiway) conveyed to the pilot the appearance of a runway, confirming in his mind that he was on the correct path.
Healthcare analogies:
Analogy: That vial you picked up looked like the one you always use for flushing an IV line, only it was for a different concentration of heparin or for a totally different medication.
Ignoring disconforming information
The pilot and first officer questioned the presence of certain light patterns (eg. some that appeared to be crossing the “runway”) on what they thought was their designated runway. Yet they continued on that course once the air traffic controller said they were on the correct course.
Healthcare analogies:
Analogy: You ignore a piece of evidence that does not fit with your working diagnosis, leading to a diagnostic error.
Plan continuation bias
Plan continuation bias is an “unconscious cognitive bias to continue an original plan in spite of changing conditions”. The pilots, despite having some uncertainty about visual cues, continued with their plan to land on what they thought was runway 28R.
Healthcare analogies:
Analogy: The surgeon ignores a discrepant “count” and proceeds to close a surgical cavity because a previous discrepant “count” had subsequently been corrected.
The “queasy feeling”
When we talk about the aviation “error chain” we often note the “queasy feeling”, which is confusion or an “empty feeling” or feeling that something is just not right. The flight crew did likely have this when they commented on the unusual light pattern on what they thought was their designated runway. However, there definitely was a “queasy feeling” just in time to avert the disaster. During a postincident interview, the captain stated that, as the airplane was getting ready to land, “things were not adding up” and it “did not look good,” so he initiated a go-around. The captain reported that he thought that he saw runway lights for runway 28L and believed that runway 28R was runway 28L and that taxiway C was runway 28R. During a postincident interview, the first officer reported that he thought that he saw runway edge lights but that, after the tower controller confirmed that the runway was clear, he then thought that “something was not right”; as a result, the first officer called for a go-around because he could not resolve what he was seeing. The captain further reported that the first officer’s callout occurred simultaneously with the captain’s initiation of the go-around maneuver. (See below what Air Canada subsequently did to train its pilots on the importance of “the gut feeling”.)
Healthcare analogies:
Analogy: There are numerous times in healthcare, for example in the OR, when someone suspects that “something does not feel right”. The hierarchical nature of medicine often discourages them from speaking up. We always instruct our medical students, residents, and nurses how to speak up tactfully to convey their concerns. The CUSS acronym is also a good system for bring your concerns to everyone’s attention (see our Patient Safety Tips of the Week for May 8, 2012 “Importance of Nontechnical Skills in Healthcare” and January 7, 2014 “Lessons from the Asiana Flight 214 Crash”).
Analogy: There is also a role for “gut feelings” in the clinical diagnostic process (see our August 2013 What's New in the Patient Safety World column “Clinical Intuition”).
Was there a “sterile cockpit”?
There are certain times in aviation (and in healthcare) when there needs to be a “sterile cockpit”. That means that there are not extraneous conversations ongoing during certain times (including takeoff and landing) and all attention is focused on the tasks at hand. Unfortunately, in this case the cockpit voice recordings were overwritten because Air Canada did not initially appreciate the severity of this incident. So there is no way of determining whether “sterile cockpit” was adhered to during the landing approach.
Healthcare analogies:
Analogy: The surgical timeout demands a “sterile cockpit”, where attention of everyone is focused on the task at hand and there is no extraneous conversation. The same should apply to when the surgical “count” is being performed or when doing double checks during a variety of circumstances.
Incidents shortly after handoffs
About 2349, all air traffic control positions and frequencies were combined, and one controller worked the positions in the tower cab while the other controller took a recuperative break. This was 7 minutes before the incident occurred.
Healthcare analogies:
Analogy: We’ve done several columns in which incidents occurred around the time of change of shift. The period of change of shift should be considered a very vulnerable period.
Automation surprises?
In many of our prior columns on transportation accidents we’ve talked about “automation surprises”. That’s where crew think a computer or system is in one mode, when in fact it is in another mode. An example might be where they think the plane is on autopilot but it is on manual pilot mode. It’s not apparent that any automation surprises occurred in this incident. But one might wonder whether the failure of the first officer to tune the instrument landing system (ILS) frequency for runway 28R might have represented one (did he think that would be automated when, in fact, it required manual input?).
Healthcare analogies:
Analogy: You assume that alarm parameters have been set at certain thresholds for your patient, not realizing they have been set at default thresholds that may not be optimal for your patient.
Need for a method to more effectively signal a runway closure to pilots when at least one parallel runway remains in use.
A runway closure marker with a lighted flashing white “X” appeared at the approach and departure ends of runway 28L when it was closed. The runway closure marker was not designed to capture the attention of a flight crew on approach to a different runway, and the marker did not capture the attention of the incident flight crew as the airplane approached the airport while aligned with taxiway C. Increased conspicuity of runway closure markers, especially those used in parallel runway configurations, could help prevent runway misidentification by flight crews while on approach to an airport.
Healthcare analogies:
Analogy: Preventing people (eg. firefighters, police) from entering an MRI unit
Should construction on a runway take place while planes are landing on parallel runways?
The purpose of the construction project on runway 10R/28L at the time of the incident was to resurface the runway and replace existing light fixtures with improved lighting. The project started in February 2017 and was expected to last about 10 months. The work required the closure of the runway each night and during some weekends. At the time of the incident, 28 portable light plants were located around the construction zone. A runway closure marker (a white flashing lighted “X”) was placed at the approach and departure ends of runway 28L when the runway was closed. But the system was not really designed to alert incoming aircraft to the closure. There was some evidence that the bright construction lights may have contributed to the confusion about what runway the pilots were looking at. The crew of the plane that had landed 4 minutes before Air Canada flight 759 attempted landing noted that there were “really bright” white lights on the left side of runway 28R (similar to the type used during construction), but they knew that runway 28L was closed.
Healthcare analogies:
Analogy: Keeping a piece of equipment in need of repair in close proximity to an active OR.
Things happen when construction ongoing
Construction projects cannot take place in a vacuum. Potential unintended consequences should always be considered and the impact on operations aside from those directly on the area under construction must be taken into account.
Healthcare analogies:
Analogy: Hospital fires often occur in parts closed and under construction.
Analogy: Wandering patients have been found dead in hospital construction zones.
Too many tasks?
The captain of one of the planes that had been on the taxiway also said it was also important to note that the tower controller “was performing way too many functions…Ground, Tower, and at times ops vehicles.” The NTSB investigation also suggested the air traffic controller was likely performing too many tasks. After the incident, air traffic control management issued a guidance indicating that the ground control and local control positions could not be combined before 0015 (when air and ground traffic would be much diminished).
Healthcare analogies:
Analogy: an anesthesiologist preparing medications and responding to questions about a previous patient fails to notice a change in a vital parameter currently being monitored
Technologies available that could prevent a taxiway landing
The NTSB investigation also looked at several existing technological tools that might be used to prevent an inadvertent landing on a taxiway, including an ASSC (airport surface surveillance capability) system enhancement and an EGPWS (Enhanced Ground Proximity Warning System Simulation) module, and concluded that such might prevent taxiway landings.
Healthcare analogies:
Analogy: Biometrics could help avoid patient misidentification in patients with communication barriers such as language problems, cognitive impairment, hearing or speech problems, etc.
Analogy: GPS tags could prevent wandering patients from wandering off units
Do anything possible to avert a disaster
The captain of one of the planes on the taxiway stated, over the tower frequency, “where is that guy going?” at 2355:59. But that was not in time for the air controller to respond. Because the flight crew had already begun the go-around maneuver (at 2356:05), the airplane was climbing at the time of the controller’s go-around instruction (2356:09). However, several planes on the taxiway, seeing the Air Canada plane coming onto the taxiway, turned on various lights on their planes in attempt to warn the oncoming plane. While the pilots of Air Canada 759 don’t recall seeing these, perhaps these were some of the factors that told the Air Canada pilots “something’s not right”.
Healthcare analogies:
Analogy: A nurse shouting out “stop” as a surgeon attempts to use an electrocautery device on the forehead of a patient receiving active flow of oxygen via face mask.
Failure to sequester equipment relevant to investigation
The cockpit voice recordings from the period of the anticipated landing were not available because Air Canada allowed them to be overwritten. Air Canada apparently was not aware of the seriousness of the incident. The captain reported the event to dispatch about 1608 (1908 EDT) on July 8. The dispatcher who spoke with the captain stated that he reported that the airplane was lined up with the wrong runway and that a go-around ensued. The dispatcher also stated that the captain’s report sounded “innocuous” and that, because of the late notification (16 hours after the incident), he did not think that the event was serious. The airplane had also flown about 40 hours before Air Canada senior officials became aware of the severity of the incident and realized that data from the airplane needed to be retrieved.
Healthcare analogies:
Analogy: Failure to report near-misses
Analogy: Every organization needs to have a policy for dealing with serious incidents, whether they resulted in patient harm or not, and should have a checklist to guide all in what to do after such events (see our July 24, 2007 Patient Safety Tip of the Week “Serious Incident Response Checklist” and the actual checklist).
Mitigations to Overcome Expectation Bias
About 3 months before this incident, Air Canada implemented training on plan continuation and expectation bias. The training, which was provided to company pilots during annual recurrent training, comprised a video titled “Understanding Gut Feel,” which explained that a gut feeling was a sense of knowing things before a person could consciously know, communicate, or explain them. The video also explained that a gut feeling indicated a potential threat resulting from a situation that was different or strange or had changed.
Healthcare analogies:
Analogy: There are many good resources on teamwork training, such as TeamSTEPPS™, and crew resource management (CRM) programs that emphasize situational awareness and how to speak up when that “gut feeling” makes anyone on the team feel unsure or uncomfortable with something they perceive.
You may recall that San Francisco International Airport (SFO) was also the site of another tragic airline accident that we discussed in our January 7, 2014 Patient Safety Tip of the Week “Lessons from the Asiana Flight 214 Crash”. That column and the ones listed below have many good lessons learned that apply equally in healthcare. They emphasize how multiple events and conditions combine at the right time to enable serious incidents. Today’s column shows a striking example of how analysis of near-misses is as important as doing a root cause analysis after an incident in which actual harm resulted. Near-misses are learning opportunities that help us prevent future accidents and incidents from occurring.
See some of our previous columns that use aviation analogies for healthcare:
May 15, 2007 “Communication, Hearback and Other Lessons from Aviation”
August 7, 2007 “Role of Maintenance in Incidents”
August 28, 2007 “Lessons Learned from Transportation Accidents”
October 2, 2007 “Taking Off From the Wrong Runway”
May 19, 2009 “Learning from Tragedies”
May 26, 2009 “Learning from Tragedies. Part II”
January 2010 “Crew Resource Management Training Produces Sustained Results”
May 18, 2010 “Real Time Random Safety Audits”
April 5, 2011 “More Aviation Principles”
April 26, 2011 “Sleeping Air Traffic Controllers: What About Healthcare?”
May 8, 2012 “Importance of Non-Technical Skills in Healthcare”
March 5, 2013 “Underutilized Safety Tools: The Observational Audit”
April 16, 2013 “Distracted While Texting”
May 2013 “BBC Horizon 2013: How to Avoid Mistakes in Surgery”
August 20, 2013 “Lessons from Canadian Analysis of Medical Air Transport Cases”
December 17, 2013 “The Second Victim”
January 7, 2014 “Lessons from the Asiana Flight 214 Crash”
January 5, 2016 “Lessons from AirAsia Flight QZ8501 Crash”
Some of our prior columns on RCA’s, FMEA’s, response to serious incidents, etc:
July 24, 2007 “Serious Incident Response Checklist”
March 30, 2010 “Publicly Released RCA’s: Everyone Learns from Them”
April 2010 “RCA: Epidural Solution Infused Intravenously”
March 27, 2012 “Action Plan Strength in RCA’s”
March 2014 “FMEA to Avoid Breastmilk Mixups”
July 14, 2015 “NPSF’s RCA2 Guidelines”
July 12, 2016 “Forget Brexit – Brits Bash the RCA!”
May 23, 2017 “Trolling the RCA”
References:
NTSB (National Transportation Safety Board). Taxiway Overflight. Air Canada Flight 759. Airbus A320-211. C-FKCK. San Francisco, California July 7, 2017. NTSB September 25, 2018
https://www.ntsb.gov/investigations/AccidentReports/Reports/AIR1801.pdf
Print “Lessons From Yet Another Aviation Incident”
October 30, 2018
Interhospital Transfers
We’ve done many columns on problems associated with intrahospital transfers (see list at the end of today’s column). But what about interhospital transfers. There have been several recent publications drawing attention to problems with interhospital transfers.
In our September 2018 What's New in the Patient Safety World column “ECRI Institute Partnership: Closing the Loop” we noted a recent study from University of Minnesota researchers (Usher 2018) which looked at adult patients transferred between 473 acute care hospitals from 5 states from 2011 to 2013. The researchers found that discordance in diagnoses occurred in 85.5% of all patients. 73% of patients gained a new diagnosis following transfer while 47% of patients lost a diagnosis. Moreover, diagnostic discordance was associated with increased adjusted inpatient mortality (OR 1.11).
But when both involved hospitals shared data via health information exchange (HIE) there was a reduced diagnostic discordance index (3.69 vs. 1.87%) and decreased inpatient mortality (OR 0.88).
In the editorial accompanying the Usher study, Tierney (Tierney 2018) appropriately points out that association does not mean causation. He gives several reasons why there was diagnostic discordance, and more diagnoses and longer lengths of stay at the receiving hospitals. He concludes that the patients who died were sicker, had more adverse events, and hence more recorded diagnoses and comorbidities. But he takes heart in the fact that, when both transferring and receiving hospitals participated in HIEs, mortality was significantly lower, even after adjusting for diagnostic discordance.
Another recent study of Medicare beneficiaries (Mueller 2018) also showed that, across 15 top disease categories, interhospital transfer was associated with significantly higher costs, longer LOS and lower odds of discharge home. But the picture was more complicated when it came to mortality. The odds of 3-day and/or 30- day mortality were lower for some disease categories (acute myocardial infarction, stroke, sepsis, respiratory disease) and higher for others (esophageal/gastrointestinal disease, renal failure, congestive heart failure, pneumonia, renal failure, chronic obstructive pulmonary disease, hip fracture/dislocation, urinary tract infection and metabolic disease). Mortality and resource utilization were also higher among children who underwent interhospital transfer to intensive care after initial hospitalization, compared with those transferred directly from emergency to intensive care.(Odetola 2009).
There is little question that patients requiring transfer between hospitals are usually sicker and some studies have attributed higher mortality rates in such patients as being primarily due to patient characteristics. Chu et al. (Chu 2016) found higher mortality rates after lower limb bypass surgery in transferred patients but found that infected wounds, contaminated wounds, and need for emergency surgery were factors most impacting tht mortality. Lucas et al. (Lucas 2014), using the American College of Surgeons NSQIP database, also concluded that worse outcomes seen in transferred patients are largely due to confounding by patient characteristics rather than any true harm from transfer. They cautioned that pay-for-performance schemes should adjust for transfer status to avoid unfairly penalizing hospitals that frequently accept transfers. Patel et al. (Patel 2018) analyzed variables associated with 24-h mortality after interhospital transfer to a tertiary medical ICU. They did not find distance traveled to be a predictor of 24-h mortality after interhospital transfer. They did identify air transportation to be a univariate predictor of 24-h and in-hospital mortality after interhospital ICU transfer, but found evidence suggesting sicker patients may be more likely to be air transported.
But other studies have found that interhospital transfer is independently associated with inpatient mortality. Yelverton et al. (Yelverton 2018) focused on interhospital transfers related to emergency general surgery (EGS). Looking at a large database of patients aged ≥18 years with an EGS admission, they found interhospital transfers comprised 2% of EGS admissions. Interhospital transfers were more likely to be white, male, Medicare insured, and had higher rates of comorbidities. Interhospital transfers underwent more procedures/surgeries and had a higher mortality rate. Mortality remained elevated after controlling for patient characteristics.
Sokol‐Hessner and colleagues (Sokol‐Hessner 2016) analyzed a database of almost 900,000 hospital inpatient admissions. They found that, compared with ED admissions, patients transferred from another hospital had a longer average length of stay, higher proportion of time spent in the intensive care unit, higher costs per hospital day, lower frequency of discharges home, and higher inpatient mortality (4.1% vs 1.8%). After adjusting for patient characteristics and risk of mortality measures, transferred patients had a higher risk of in‐hospital death (odds ratio: 1.36).
It’s a given that patients transferred from one hospital to another are, in general, sicker than those that do not need to be transferred. Patients are also transferred for procedures or a certain level of expertise that are not available at the hospital of origin. So, it’s no surprise that mortality would be higher in patients undergoing interhospital transport.
But what else might contribute to that higher mortality? Here are some potential factors related to interhospital transfer that might contribute:
Delays in transfer certainly contribute to higher mortality. Often, hospitals wait for imaging studies to be performed even though receiving hospitals often repeat those studies (whether appropriate or not!) or when the result of that study would not alter the decision to transfer.
In several of our columns on issues with helicopter or air ambulance transport, we’ve discussed a scenario we’ve seen over and over: miscalculation of transport time. The patient presents to a small, rural hospital with acute coronary syndrome and gets transferred to a tertiary center for a percutaneous angioplasty/stenting. But the hospital of origin never looks at its statistics and fails to recognize that almost none of their transported patients actually arrive at the receiving hospital within the ideal 90-minute window for a coronary intervention. The hospital of origin, assuming the patient would be getting a coronary intervention, withheld thrombolytic therapy. Hence, the patient missed an opportunity for thrombolytic therapy that might have saved significant myocardium.
Poor communication between facilities
Sometimes the communication is emergency physician to emergency physician. While that may be appropriate in many cases, there are others where the communication should be with the physician who will ultimately be caring for the patient. For example, in the acute coronary syndrome example above, an interventional cardiologist might tell the sending hospital that thrombolytic therapy should be given because the patient will likely arrive outside the ideal window for a coronary artery procedure.
Mode of transport
Choosing the optimal mode of transport for the patient may not be as simple as it sounds. In most cases the decision is BLS- vs. ALS- vs. MICU-ambulance or helicopter vs. fixed-wing air transport. In our numerous columns on issues related to helicopters and medial air transport, we’ve pointed out that air transport is not necessarily faster than ground ambulance transport in many cases. So you must be familiar with the total time it takes for a helicopter to arrive in addition to the transit time from your hospital to the receiving hospital. You also need to be aware of weather conditions that may have implications for a flight (or for ground transport).
But there are other considerations as well. You may need a helicopter or medical air transport plane for the more sophisticated medical equipment on board or for the personnel to accompany the patient (eg. a receiving hospital may send a medical team to accompany the patient).
And, as pointed out by Kulshrestha and Singh (Kulshrestha 2016), there are patient-related considerations to the choice of transport mode. For example, you need to take into account what effect vibration in a helicopter would have on a patient with a spinal or cranial injury. They also note that high altitude flights may be associated with expansion of gas in body spaces and in medical equipment, so high altitude flights may be contraindicated in patients with trapped gas in body cavities such as untreated pneumothorax, pneumocephalus, recent abdominal surgery and gas gangrene.
Lastly, you may need to take into account the issue of cost for the patient and his/her family. We’ve seen cases where patients received $10,000+ bills for air transports. Probably the most difficult situation is when the patient’s family, for financial/insurance purposes, wants to drive the patient to the other hospital. Fortunately, there would be very few interhospital transfers in which a patient would be stable enough to allow this and most hospitals would not take on the legal liabilities associated with that. But, in a case where a family insisted upon that, you’d still have to do your best to ensure as safe a transport as possible.
Problems in transit
In one study (Gray 2003), 15% of interhospital transports involved a critical incident. Ligtenberg et al. (Ligtenberg 2005) did a prospective audit of the quality of 100 consecutive interhospital transports of critically ill patients to a university hospital-based medical ICU. Adverse events occurred in 34% of transfers. In 50% of these transports, pretransport recommendations given by the intensivist at the receiving ICU were ignored. Approximately 30% of events might be attributed to technical problems. Examples of things that went wrong in transit:
The authors conclude that further improvement must be achieved by better communication between referring and receiving hospitals, and by strict adherence to checklists and to published protocols.
Monitoring during a transport should include all the parameters you’d be monitoring if the patient were in a hospital room/bed. Dunn and colleagues (Dunn 2007) stress an important point about monitoring in-transit: audible alarm systems from monitors and electrical equipment become obsolete in noisy environments and thus visible alarms should be used.
Another problem, which we’ve discussed in our columns on intrahospital transport, is the potential for interruption of therapy. Dunn et al. (Dunn 2007) recommend that syringe or infusion pumps should be used to enable the delivery of all intravenous fluids and drugs, because gravity‐fed drips may be unreliable when moving. But careful planning is also needed to decide whether insulin pumps or other infusion should be continued or suspended during a transport.
And 2 other problems, which we would not have considered, relate to the atmospheric environment of the transport vehicle. Kulshrestha and Singh (Kulshrestha 2016) point out that the environment inside ambulances is usually kept at lower temperature by use of air conditioning. That can cause hypothermia in susceptible patients, especially neonates, so these patients should be covered with warming blankets during transfer. They also note that humidity decreases with altitude in air transport can lead to drying of secretions of respiratory tract and mucous membranes, so use of humidified oxygen and lubrication of eyes by use of artificial tears or drops should be considered.
Poor preparation for transport
So that gets us to perhaps the most critical contributing factor: poor preparation for transport. Just as we’ve emphasized in our many columns on intrahospital transports, running out of oxygen is a significant factor that is almost 100% preventable. That was the original problem that led to development of “Ticket to Ride” checklists for intrahospital transports. There should be a similar checklist in every interhospital transport. Also, because many such transferred patients are intubated and receiving mechanical ventilation, one must be aware of the status of any battery-operated equipment.
Ligtenberg et al. (Ligtenberg 2005) observed a lack of preparation before transfer of patients. Although they consistently advised that a skilled physician accompany the patient, a number of patients arrived without a doctor. They noted that adherence to existing ambulance checklists would have avoided a few events, for example equipment failures, incomplete supplies, shortage of oxygen or batteries, and drug administration errors. They speculated about the role a special retrieval team using a mobile ICU might improve the quality of transports.
Checklists
So, it’s clear that safe interhospital transfer of patients is an incredibly complex process. It involves good bidirectional communication and careful planning. The only way anyone can possibly remember to do everything correctly is to use a checklist. Fortunately, there are some good checklists available (Whiteley 2011). The American College of Critical Care Medicine guideline for the inter-and intrahospital transport of critically ill patients (Warren 2004), though from 2004, has a comprehensive list of the minimum equipment and medication supplies that are necessary for transport of critically ill patients.
We’ve also put together our own Checklist for Interhospital Transfers. However, you’ll recall from some of our prior columns on optimizing checklists that ideal checklists are fairly short. So you may find it preferable to have a series of individual checklists for interhospital transfer, such as deciding whether transfer is necessary, meeting EMTALA requirements, deciding on mode of transport, preparing the patient for transport, communicating with receiving hospital, preparing staff for transport, preparation for departure, actual transport, delivering the patient, post-transport actions, and followup and quality improvement activities. We’ve included those “mini” checklists along with the more comprehensive checklist noted above.
Incomplete medical information
In some ways, the transition to electronic medical records has created a problem for interhospital transfers. Today, in most hospitals, the emergency physician dictates his/her note and it is then transcribed by a transcriptionist (or converted to text by a voice recognition program). The emergency physician then needs to review the notes for completeness and accuracy. So, the notes may not be ready to send with the patient. That puts the onus on the emergency physician to do a comprehensive verbal handoff to a physician at the receiving hospital and to handwrite at least some salient information to accompany the patient. But the receiving hospital needs access to the much more complete medical records of the transferred patient. The Usher study mentioned earlier (Usher 2018) showed that, when both transferring and receiving hospitals participated in HIEs, mortality was significantly lower.
Another study (Herrigel 2016), which looked at practices at 32 tertiary care centers, found some less frequent transfer practices included: electronic medical record (EMR) cross‐talk availability and utilization (23%), real‐time transfer center documentation accessibility in the EMR (32%), and referring center clinical documentation available prior to transport (29%).
Failure to close the feedback loop
Most regional trauma programs have a mechanism by which they provide feedback to all referring hospitals. But they do not cover interhospital transfers that involve non-trauma patients. In our experience, most tertiary care hospitals seldom provide feedback to the sending hospitals. In the acute coronary syndrome example given above, the rural hospitals had no idea their patients were arriving outside the optimal time window for intervention.
Contingencies
Your interhospital transport plan should also have a discussion of contingencies. For example, who should the transfer team call when there is an in-transit problem? What should be done if there is an unforeseen barrier to transport (eg. motor vehicle accident closing a route, vehicle breakdown, etc.). Ironicallly, on the day we had begun writing this column, a friend described an ambulance trip in which her ambulance broke down, resulting in a 40-minute delay in transport.
For those hospitals looking for topics for a FMEA (Failure Mode and Effects Analysis), both intrahospital transport and interhospital transfer are prime candidates. You don’t have to wait for a serious incident to trigger your analysis of all the steps and potential vulnerabilities associated with these processes. Transport plans (for both intrahospital transport and interhospital transfer) should be developed by a multidisciplinary team and should be evaluated and refined regularly using a standard quality improvement process (Warren 2004).
Some of our prior columns on the “Ticket to Ride” concept:
Our prior columns dealing with medical helicopter issues:
July 8, 2008 “Medical Helicopter Crashes”
October 2008 “More Medical Helicopter Crashes”
February 3, 2009 “NTSB Medical Helicopter Crash Reports: Missing the Big Picture”
September 1, 2009 “The Real Root Causes of Medical Helicopter Crashes”
November 2010 “FAA Safety Guidelines for Medical Helicopters Short-Sighted”
March 2012 “Helicopter Transport and Stroke”
April 16, 2013 “Distracted While Texting”
August 20, 2013 “Lessons from Canadian Analysis of Medical Air Transport Cases”
December 29, 2015 “More Medical Helicopter Hazards”
References:
Usher M, Sahni N, Herrigel D, et al. Diagnostic Discordance, Health Information Exchange, and Inter-Hospital Transfer Outcomes: a Population Study. J Gen Intern Med 2018; 33(9): 1447-1453
https://link.springer.com/article/10.1007%2Fs11606-018-4491-x
Tierney, W.M. Breakdowns on the information highway during inter-hospital patient transfers. J Gen Intern Med 2018; 33: 1415
https://link.springer.com/article/10.1007/s11606-018-4538-z#citeas
Mueller S, Zheng J, Orav EJ, Schnipper JL. Inter-hospital transfer and patient outcomes: a retrospective cohort study. BMJ Quality & Safety 2018
https://qualitysafety.bmj.com/content/early/2018/09/26/bmjqs-2018-008087
Odetola FO, Davis MM, Cohn LM, Clark SJ, Interhospital Transfer of Children. J. Hosp. Med 2009; 3; 164-170
https://www.journalofhospitalmedicine.com/jhospmed/article/127193/interhospital-transfer-children
Chu Y, Aziz F, Lehman E. Transfer from Another Hospital is Associated with Increased Morbidity and Mortality after Lower Extremity Bypass Surgery. Journal of the American College of Surgeons 2016; 223(4): e64
https://www.journalacs.org/article/S1072-7515(16)30912-7/fulltext
Lucas DJ, Ejaz A, Haut ER, et al. Interhospital Transfer and Adverse Outcomes after General Surgery: Implications for Pay for Performance. Journal of the American College of Surgeons 2014; 218(3): 393-400
https://www.journalacs.org/article/S1072-7515(13)01259-3/fulltext
Patel JJ, Kurman J, Al-Ghandour E, et al. Predictors of 24-h mortality after inter-hospital transfer to a tertiary medical intensive care unit. Journal of the Intensive Care Society 2018; First Published March 22, 2018
http://journals.sagepub.com/doi/full/10.1177/1751143718765412
Yelverton S, Rozario N, Matthews BD, Reinke CE. Interhospital transfer for emergency general surgery: An independent predictor of mortality. Amer J Surg 2018; 216(4): 787-792
https://www.americanjournalofsurgery.com/article/S0002-9610(18)30059-X/fulltext
Sokol‐Hessner L, White AA, Davis KF, et al. Interhospital Transfer Patients. J. Hosp. Med 2016; 4; 245-250
https://www.journalofhospitalmedicine.com/jhospmed/article/127061/interhospital-transfer-patients
Kulshrestha A, Singh J. Inter-hospital and intra-hospital patient transfer: Recent concepts. Indian J Anaesth 2016; 60(7): 451-457
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4966347/
Gray A, Gill S, Airey M. et al The descriptive epidemiology of adult critical care transfers from the emergency department. Emerg Med J 2003; 20(3): 242-246
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1726082/
Ligtenberg JJ, Arnold LG, Stienstra Y, et al. Quality of interhospital transport of critically ill patients: a prospective audit. Crit Care 2005; 9: R446–R451
https://ccforum.biomedcentral.com/articles/10.1186/cc3749
Dunn MJ, Gwinnutt CL, Gray AJ. Critical care in the emergency department: Patient transfer. Emerg Med J 2007; 24:4 0-44
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658153/
Whiteley S, Macartney I, Mark J, et al. Guidelines for the transport of the critically ill adult (3rd Edition 2011). The Intensive Care Society (UK) 2011
Warren J, Fromm RE, Jr, Orr RA, Rotello LC, Horst HM. American College of Critical Care Medicine. Guidelines for the inter-and intrahospital transport of critically ill patients. Crit Care Med. 2004; 32: 256-262
Checklist for Interhospital Transfers
docs/Checklist_for_Interhospital_Transfers.htm
Herrigel DJ, Carroll M, Fanning C, Steinberg MB, Parikh A, Usher M, Interhospital Transfer Handoff Practices. J Hosp Med 2016;11(6); 413-417
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November 6, 2018
More on Promoting Sleep in Inpatients
Impaired sleep in hospitalized patients may have detrimental impacts on both outcomes and patient satisfaction. There are multiple reasons for sleep disruption in inpatients (see our Patient Safety Tip of the Week for August 6, 2013 “Let Me Sleep!”). And we, of course, want to avoid using sedative/hypnotic medications to induce sleep in such patients because they are risk factors for falls, delirium, medication-induced respiratory depression, and other undesirable complications.
We’ve done several columns discussing the problems inpatients encounter in achieving near-normal sleep patterns (see, for example, our Patient Safety Tips of the Week for August 6, 2013 “Let Me Sleep!” and May 15, 2018 “Helping Inpatients Sleep”). But we’ve relied primarily on anecdotal or intuitive data to tell us we need to do something more to help promote sleep in inpatients. Now, 2 new studies actually quantify the problem.
In a study from the Netherlands (ter Maaten 2018), researchers found that the total sleep time in the hospital was 83 minutes shorter than the patients’ habitual sleep at home. The mean number of nocturnal awakenings was 2.0 times at home vs 3.3 times during hospitalization. Patients also woke up 44 minutes earlier than their habitual wake-up time at home. Moreover, all aspects of sleep quality, as measured using PROMIS (the Dutch-Flemish Patient-Reported Outcomes Measurement Information System) questions, were rated worse during hospitalization than at home.
70.4% reported having been awakened by external causes and 35.8% concerned hospital staff. Sleep-disturbing factors reported most often by inpatients were noise of other patients, medical devices, pain, and toilet visits.
Another recent study used actigraphy to study sleep quality in 40 children and their co-sleeping mothers both when hospitalized and when at home (Bevan 2018). The researchers found that children had on average 62.9 min, and parents 72.8 min, per night less sleep in hospital than at home. Both children and parents had poorer sleep quality in hospital than at home: mean sleep efficiency 77.0% vs 83.2% for children and 77.1% vs 88.9% for parents, respectively. They also measured sound levels and found median sound levels in hospital measured in children averaged 48.6 dBA compared with 34.7 dBA at home (World Health Organization recommends a maximum of 30 dB.). They suggest that a reduction in the level of noise might lead to an improvement in sleep, affecting the quality of stay of both parent and child.
A couple recent publications have focused on noise reduction as a strategy to improve inpatients’ sleep.
McGough et al. (McGough 2018) reported on implementation of an evidence-based practice project conducted in 4 progressive care units in a community hospital. The Quiet Time Bundle implementation improved patient satisfaction and patient and nurse perceptions of noise even though the decrease in noise levels may not be discernible.
Goeren et al. (Goeren 2018) used a decibel meter to collect noise data in 4 locations of a neurosurgical intensive care unit every 30 minutes during chosen times for 8 days. Then, quiet time was implemented 1 week after staff, patient, and family education was completed. During quiet time, limiting conversations, eliminating environmental noise, and dimming the lights as a reminder to be quiet were 3 simple strategies used to lessen noise. There were statistically significant reductions in noise levels at two locations. Noise levels were lower, but not significantly so, for the other two locations. Noise levels during quiet time decreased to an average of 10 to 15 decibels lower than baseline data.
However, a randomized controlled trial of a non-pharmacologic multidisciplinary protocol failed to show any significant differences in any of the outcomes between intervention and control patients (Dobing 2017). Researchers used the “TUCK-in” protocol (timed lights-off periods, minimizing night-time noise, distribution of earplugs at bedtime, cued toileting before bedtime, and identification and reduction of modifiable interruptions). The protocol was randomized to two of five identical medicine wards. Self-reported duration of night-time sleep (median 5.0 vs. 5.0 hours) and daytime sleep (1.0 versus 0.5 hours) did not differ between the 40 intervention patients and the 41 control patients. There was also no difference in the cumulative Verran–Snyder-Halpern (VSH) Sleep Score or inpatient sleep pharmaceutical use. The researchers felt that lack of true blinding and overcapacity (they sometimes had 3 patients in rooms designed for two) may have contributed to the lack of statistical improvement. They were encouraged that nursing and other staff felt that the intervention was beneficial to patient care.
In the Dobing study, patient reasons for poor sleep were (in intervention and control patients, respectively):
Noise (48% vs. 44%)
Care interruptions (20% vs 22%)
Uncomfortable beds (20% vs. 17%)
Lighting (7.5% vs. 12%)
Unfamiliarity of surroundings (18% vs. 17%)
Disease-related factors were infrequently cited (<10%) and included pain, anxiety, and cough. Other infrequently cited factors included intravenous lines, temperature, odors, and decreased daytime activity.
One quality improvement project undertaken by UNC Healthcare provides some insight into facilitators and barriers to implementing a Quiet Time program (Hedges 2017). They had found that decibel levels on some units were as high as 90 decibels (equivalent to highway truck traffic!). Implementing "Quiet Time" was shown to improve both patient and staff satisfaction in several units at UNCH. Quiet Time was designated as 2-4 in the afternoon & 12-5am at nighttime. During quiet time lights are dimmed, doors to patients' rooms are closed, overhead paging is reduced in both number and volume (texting was used for messaging), ringer volumes on phones are decreased and patients are cared for but minimally disturbed. They even paid attention to everyday things we tend to overlook, such as replacing the wheels on rolling carts/equipment with wheels that produce less noise. Patients were presented with a “sleep menu” and were given eye masks and ear plugs, if requested.
There was also an attempt to cluster care and provide it more quietly. Patient rooms were prepared in advance (eg. remove dirty trays, check IV pumps, and perform toileting). To minimize interruptions, non-urgent procedures (eg. phlebotomy, radiology studies, PT/OT, etc.) and patient rounds were timed to be undertaken during non-Quiet Time hours.
But they emphasize that quiet time is not “no care time”. Rather staff focus on performing patient care in a quieter and less disruptive manner during these hours.
They identified the following strategies as things that worked:
But the biggest challenges were in:
Most of the protocols that have been used to promote more natural sleep patterns in inpatients (HELP, TUCK-in, Somerville, and Quiet Time) share features in common with Quiet Time.
The “TUCK-in” protocol is as follows:
T Toileting assistance offered prior to 22:00
U Unnecessary interruptions (vital signs, meds, etc.) reviewed
C Cue the lights (minimize lights 22:00 to 06:00)
K Keep it down! (reduce noise, offer earplugs, turn off TV/radio)
The Somerville protocol, which resulted in a 38% reduction in patients noting sleep disruption due to hospital staff and a 49% reduction in patients receiving prn sedatives in one study (Bartick 2010), consists of 10 components:
The Hospital Elder Life Program (HELP) program (Inouye 2013) includes a systemic effort to improve sleep in hospitalized patients by noise reduction, a nonpharmacologic sleep protocol, and coordination of nighttime care. Inouye points out that besides vital sign monitoring and blood draws, patients’ sleep is often disrupted by medication administration, IV changes or IV alarms, intermittent pneumatic compression devices, breathing treatments, fingersticks for glucose monitoring, paging systems, room or hallway lights, conversations, cleaning and waxing floors at night, etc.
In an editorial accompanying the ter Maaten study, Growdon and Inouye (Growdon 2018) point out some of the limitations of the study, including the considerable data gaps in the methodology. But they support the overall message of the study – that we need to do a better job of promoting good sleep in inpatients without negatively impacting their other medical needs. Sharon Inouye, of course, is the architect of the Hospital Elder Life Program (HELP) program (Inouye 2013) mentioned above. Moreover, Inouye notes there is often a striking lack of coordination amongst staff that could minimize these disruptions. Simply having the phlebotomist tag team with the nurse or aide doing vital signs could avoid one disruption.
Bartick and colleagues (Bartick 2010) also felt that the reduction in noise and light probably did not significantly improve patients’ sleep. Rather reduction in the physical disruptions probably played the major role.
In our May 15, 2018 Patient Safety Tip of the Week “Helping Inpatients Sleep” we noted that at many (perhaps most) hospitals, the incoming nursing staff gets vital signs when their shift starts. Hence, many patients get their vital signs checked between 11PM and midnight. Simply changing policy and procedure so that vital signs are checked by the outgoing staff at 10PM can help avoid one obvious potential sleep disruption. (Of course, you’d have to look for potential unintended consequences such as interfering with shift handoffs).
We also mentioned how physicians may inadvertently cause some of those disruptions. Getting physicians to understand that “three times daily” and “every 8 hours”, for example, are not the same takes some time and hard work. If I order a medication today at 10AM and enter it as “every 8 hours” my patient will be wakened at 2AM to get a dose. On the other hand, if the order is written for “three times daily” the hospital will have standard times that such are given to avoid that disruptive nighttime dose. (Note that you have to be very careful. Today’s CPOE systems often don’t make it clear when the first dose will be given. We have seen some systems where the first dose or even all the first day’s doses will not be given when the order is written this way.) And we often reflexly order vital signs to be taken “every 4 hours” or “every 6 hours” when they really don’t need to be taken during the wee hours of the morning (being careful not to overlook times when vital signs really do need to be taken so frequently).
It's certainly logical to focus on noise reduction as one strategy to promote more natural sleep in your inpatients. But your program needs to be a multiple component one and we think the primary focus needs to be on coordinating care so that interruptions are kept to a minimum.
Lastly, don’t forget one of our goals is to minimize use of sedative/hypnotic drugs and their detrimental side effects. It is still common for physicians to leave orders for prn sleep meds in the admission orders, presumably so no phone call is needed at night requesting such. In our March 23, 2010 Patient Safety Tip of the Week “ISMP Guidelines for Standard Order Sets” we stressed the importance of avoiding inclusion of “prn” sleep meds in standard order sets.
Avoiding sleep meds and using non-pharmacologic interventions to promote sleep is something every hospital should strive for. Some of the system changes mentioned in today’s column and our previous columns to avoid unnecessarily waking patients at night should also be an important component of your program.
Some of our previous columns on safety issues associated with sleep meds and promoting sleep in hospitalized patients :
August 2009 “Bold Experiment: Hospitals Saying No to Sleep Meds”
March 23, 2010 “ISMP Guidelines for Standard Order Sets”
May 2012 “Safety of Hypnotic Drugs”
November 2012 “More on Safety of Sleep Meds”
March 2013 “Sedative/Hypnotics and Falls”
June 2013 “Zolpidem and Emergency Room Visits”
August 6, 2013 “Let Me Sleep!”
June 3, 2014 “More on the Risk of Sedative/Hypnotics”
May 15, 2018 “Helping Inpatients Sleep”
June 2018 “Deprescribing Benzodiazepine Receptor Agonists”
References:
ter Maaten C, van den Ende ES, Alsma J, et al. for the “Onderzoeks Consortium Acute Geneeskunde” Acute Medicine Research Consortium. Quality and Quantity of Sleep and Factors Associated With Sleep Disturbance in Hospitalized Patients. JAMA Intern Med 2018; Published online July 16, 2018
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2687528
Bevan R, Grantham-Hill S, Bowen R, et al. Sleep quality and noise: comparisons between hospital and home settings. Archives of Disease in Childhood Published Online First: 17 July 2018
https://adc.bmj.com/content/early/2018/07/05/archdischild-2018-315168
McGough NNH, Keane T, Uppal A, et al. Noise Reduction in Progressive Care Units
Journal of Nursing Care Quality 2018; 33(2): 166-172
Goeren D, John S, Meskill K, et al. CE Article: Quiet Time: A Noise Reduction Initiative in a Neurosurgical Intensive Care Unit Crit Care Nurse 2018; 38: 38-44
http://ccn.aacnjournals.org/content/38/4/38.abstract
Dobing S, Dey A, McAlister F, Ringrose J. Non-pharmacologic interventions to improve sleep of medicine inpatients: a controlled study. Journal of Community Hospital Internal Medicine Perspectives 2017; 7(5) 287-295
Hedges C, Hunt C. Implementing “Quiet Time” to Improve Patient Sleep and Decrease Noise. UNC Institute for Healthcare Quality Improvement 2017
https://www.med.unc.edu/ihqi/files/2017/09/quiet-time-hedges.pdf
Bartick MC, Thai X, Schmidt T, et al. Decrease in As-needed Sedative Use by Limiting Nighttime Sleep Disruptions from Hospital Staff. Journal of Hospital Medicine 2010; 5: E20–E24
Inouye SK. No Rest for the Weary…or the Sick: Comment on “A Prospective Study of Nitghtime Vital Sign Monitoring Frequency and Risk of Clinical Deterioration”. JAMA Intern Med 2013; 173(16): 1555-1556
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/1705720
Growdon ME, Inouye SK. Minimizing Sleep Disruption for Hospitalized Patients. A Wake-up Call. JAMA Intern Med 2018; 178(9): 1208-1209
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2687522
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November 13, 2018
Antipsychotics Fail in ICU Delirium
In our many columns on the diagnosis and management of delirium we’ve noted that pharmacologic management of delirium has been largely unsuccessful. There have been multiple studies looking at use of haloperidol or the newer atypical antipsychotic medications for treating delirium, but all were either small trials or had problems with study design or other methodological issues. Yet we’ve continued to see frequent use of these medications to treat patients experiencing delirium. We’ve long awaited a well-done randomized, controlled trial to finally put the issue to rest. It appears we finally have that study.
The MIND-USA trial, a study conducted at 16 medical centers in the US (Girard 2018), randomized 566 ICU patients with acute respiratory failure or shock and hypoactive or hyperactive delirium to receive intravenous boluses of haloperidol, ziprasidone, or placebo. Patients were assessed twice daily while they were receiving the intervention by trained research personnel using the CAM-ICU tool and the Richmond Agitation–Sedation Scale (RASS), both validated tools we’ve discussed in many of our prior columns.
The median number of days alive without delirium or coma was 8.5 in the placebo group, 7.9 in the haloperidol group, and 8.7 in the ziprasidone group (differences not statistically significant). There were also no significant between-group differences with respect to the secondary end points (30-day and 90-day survival, time to freedom from mechanical ventilation, and time to ICU and hospital discharge) or the frequency of extrapyramidal symptoms. There was also no reduction in the use of sedatives or opioids in those receiving the active drugs compared to those on placebo.
Perhaps one remaining issue is what to do in hyperactive delirium. In the current study, 89% of patients had hypoactive delirium, and only 11% had hyperactive delirium. In the editorial accompanying the MIND-USA trial, Bleck (Bleck 2018) points out that hypoactive delirium, seemingly less of a management problem, nevertheless hampers cooperation with nursing, physical therapy, and other activities.
And, it’s probably good that this study suggests we not use these antipsychotics in delirium in the ICU. Another recent study (Park 2018) had looked at mortality rates in patients with MI who were treated with haloperidol or atypical antipsychotics. Their results suggest a small increased risk of death within seven days of initiating haloperidol compared with initiating an atypical antipsychotic in patients with acute myocardial infarction. 7.8% of haloperidol recipients died within 7 days of treatment initiation, versus 5.5% of atypical antipsychotic recipients. After multivariable adjustment, mortality risk was about 50% higher with haloperidol, and the increased risk appeared only during the first 4 days of treatment.
Use of haloperidol prophylactically to prevent delirium has also been the topic of multiple small or anecdotal studies, with mixed results. Recently, 2 randomized controlled trials failed to demonstrate any benefit from use of haloperidol to prevent delirium. Schrijver et al. (Schrijver 2018) conducted a multicenter, double-blind, stratified, block randomized, placebo-controlled trial at six Dutch hospitals. Patients age ≥70 years, acutely admitted through the emergency department for general medicine or surgical specialties and at risk for delirium were randomized (n = 245) to either low-dose oral haloperidol or placebo. Delirium incidence was 19.5% in the haloperidol group versus 14.5% in the placebo group. There were no statistically significant differences between the groups with respect to delirium duration, hospital length of stay, or 3-month mortality. The authors conclude that prophylactic use of haloperidol in this population is not recommended.
In another study from the Netherlands (van den Boogaard 2018), researchers in the REDUCE trial assessed the impact of prophylactic use of haloperidol on survival among critically ill adults at high risk of delirium. They randomized 1789 critically ill adults treated at 21 ICU’s in a double-blind, placebo-controlled trial. Nonpharmacological interventions for delirium prevention are also routinely used in the study hospitals. There was no difference in the primary study outcome, median days patients survived in 28 days. There was also no difference in 15 secondary outcomes, including delirium incidence, 28-day delirium-free and coma-free days, duration of mechanical ventilation, and ICU and hospital length of stay. The authors conclude their findings do not support the use of prophylactic haloperidol for reducing mortality in critically ill adults.
One drug that has generated significant interest over the past several years is dexmedetomidine, an α2-adrenoreceptor agonist, often used as a sedation agent in the ICU because it might be associated with less delirium. We’ve discussed dexmedetomidine in our Patient Safety Tips of the Week for February 10, 2009 “Sedation in the ICU: The Dexmedetomidine Study” and June 16, 2015 “Updates on Delirium” and our April 2016 What's New in the Patient Safety World column “Dexmedetomidine and Delirium”. See those previous columns for our cautions and concerns about dexmedetomidine despite several promising studies.
And, in our January 24, 2017 Patient Safety Tip of the Week “Dexmedetomidine to Prevent Postoperative Delirium” we discussed a study from China that had results that sounded too good to be true. Su and colleagues (Su 2016) did a randomized, double-blind, placebo-controlled trial in two tertiary-care hospitals on patients aged 65 years or older who were admitted to intensive care units after non-cardiac surgery. They randomly assign patients to receive either low-dose (sub-sedative) intravenous dexmedetomidine or placebo from intensive care unit admission on the day of surgery until 0800 h on the first day after surgery. The incidence of delirium in the dexmedetomidine group was just 9%, compared to 23% in controls. That translates to a number needed to treat (NNT) of 7.4! The results applied equally whether patients were intubated or not and applied to all 3 subtypes of delirium. And there were significant benefits in the dexmedetomidine group compared to the control group for ICU length of stay, time to extubation (in those who were intubated), sleep quality, and early hospital discharge. There was no difference in the incidence of overall adverse events or 30-day mortality. Moreover, the safety profile of dexmedetomidine was excellent. The editorial accompanying the Su study (Kronzer 2016) provided a very thoughtful assessment of the methodology in the Su study that tempered our enthusiasm about the reported results.
But another recent study (Skrobik 2018) sought to see if nocturnal dexmedetomidine prevents delirium and improves sleep in critically ill adults. This two-center, double-blind, placebo-controlled trial randomized 100 delirium-free critically ill adults receiving sedatives to either low-dose IV dexmedetomidine or placebo until ICU discharge. Nocturnal dexmedetomidine was associated with a greater proportion of patients who remained delirium-free during the ICU stay compared to placebo (80% vs. 54%, p=0.006).
These studies are in contrast to another study that randomly assigned elderly (>68 years) patients undergoing major elective noncardiac surgery to dexmedetomidine or saline placebo infused during surgery and for 2 hours in the recovery room (Deiner 2017). The researchers found no difference in postoperative delirium between the dexmedetomidine and placebo groups (12.2% vs 11.4%). After adjustment for age and educational level, there was also no difference in the postoperative cognitive performance between treatment groups at 3 months and 6 months.
So low-dose dexmedetomidine shows some promise as a prophylactic therapy to prevent delirium. But the studies to date have been single- or double-center studies with relatively small numbers. Before we jump on the dexmedetomidine bandwagon, we’d like to see a larger multi-center trial similar to the REDUCE trial.
How about preventing postoperative delirium? Two recent studies looked at the relationship between anesthesia practices and delirium. The STRIDE (A Strategy to Reduce the Incidence of Postoperative Delirium in Elderly Patients) study (Sieber 2018) was a double-blind randomized clinical trial comparing depth of anesthesia to occurrence of delirium in 200 patients ≥65 years who were undergoing nonelective hip fracture repair with spinal anesthesia and propofol sedation. Surprisingly, the researchers found that lighter sedation failed reduce the rate of delirium in severely ill people. Overall incident delirium risk was 36.5% (39% vs 34% in heavier and lighter sedation groups, respectively, not statistically significantly different).
But, in a prespecified subgroup analysis, when stratified by the Charlson comorbidity index (CCI), sedation levels did affect the delirium risk. In low comorbid states (CCI = 0), heavier vs lighter sedation levels more than doubled the risk of delirium (hazard ratio, 2.3).
Another study (Bang 2018), presented so far only in abstract form, looked at more than 96,000 patients in Korea aged 65 years and older receiving hip fracture surgery. Those researchers found patients who received regional anesthesia had better 30-day mortality and delirium outcomes compared to those who received general anesthesia.
The delirium prevalence was 22.7% in those receiving general anesthesia vs. 18.1% in those receiving regional anesthesia (p<0.0001). The difference remained statistically significant even after matching by use of propensity scores. The regional anesthesia patients also had lower rates of ICU admission, ventilator care, hospital costs, and complications including pulmonary embolism, cerebral hemorrhage and cerebral infarction.
Quite frankly, we were surprised at the relatively low rates of delirium for a patient population that we know in the US has much higher rates for delirium. But the answer lies in the manner in which they defined delirium. They were using an administrative database and defined delirium as the record of intravenous administration of haloperidol, risperidone and quetiapine at least once during the indexed period, That obviously vastly underidentifies delirium compared to use of tools like the CAM. So the jury is still out on this issue, though it certainly makes sense from a biological plausibility standpoint that patients undergoing regional anesthesia might have lower rates of delirium than those undergoing general anesthesia.
So, now that we know we shouldn’t be using antipsychotic drugs in patients with delirium, and aren’t yet sure if there is pharmacological prophylaxis to prevent delirium, what are we to do?
We need to stick with multi-component non-pharmacological interventions such as HELP, the Hospital Elder Life Program (see our October 21, 2008 Patient Safety Tip of the Week “Preventing Delirium” and our September 2011 What's New in the Patient Safety World column “Modified HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery”) or tools like the ABCDEF Bundle (see our September 20, 2016 Patient Safety Tip of the Week “Downloadable ABCDEF Bundle Toolkits for Delirium”).
Treating clinicians in the MIND-USA trial mentioned above were educated about the “ABCDE” treatment bundle (assess, prevent, and manage pain; both spontaneous awakening and breathing trials; choice of analgesia and sedation; assess, prevent, and manage delirium; and early mobility and exercise) and were encouraged to perform the treatment bundle to mitigate delirium among the patients in the ICU.
In an editorial accompanying the REDUCE study, Delaney et al. (Delaney 2018) comment on the attractiveness of the non-pharmacological interventions used in the study. They categorize these as “doing less” (avoiding excessive sedation, benzodiazepines, nocturnal noise, stimulation) and continued provision of relatively “simple therapies” (mobilization, maintaining a day-night schedule, noise reduction). They note some may require planning and cooperation of a multidisciplinary team, but they are readily undertaken “irrespective of the complexity and challenge of the environment”. They also say future studies on the efficacy of non-pharmacologic strategies should include evaluation of sleep hygiene bundles (earplugs, eye patches, music therapy, reduced noise levels). See also our November 6, 2018 Patient Safety Tip of the Week “More on Promoting Sleep in Inpatients”.
In our January 24, 2017 Patient Safety Tip of the Week “Dexmedetomidine to Prevent Postoperative Delirium” we also described a pragmatic clinical trial that used the EMR to implement several elements of multifactorial interventions that have been used for delirium prevention in patients age 65 and older who underwent surgery for hip fracture (Freter 2016). That program resulted in a substantial reduction in delirium rates in the intervention group compared to a control group.
One of the components of many of the multidimensional programs for delirium is putting familiar objects from home in the patient rooms and encouraging family and friends visit with patients. One meta-analysis (Nassar 2018) found that flexible visiting policies in ICU’s were associated with a 61% reduced frequency of delirium (odds ratio 0.39). Family members’ satisfaction was also improved. But there may be a downside: they may be associated with an increased risk of burnout among ICU professionals.
An innovative study looked at storytelling as a way to reduce delirium (Danila 2018). A pilot study of 50 patients age 65 or older was conducted at UAB (University of Alabama at Birmingham) Highlands Hospital. Two artists-in-residence, part of UAB’s Institute for Arts in Medicine, visited the patients once for 15 minutes of bedside storytelling or poetry during their hospital stay. Patients were asked if they would like to hear a story or poem, and could choose the type, whether it be religious, humorous, a folk or fairy tale, or a legend or myth. The session was designed to be interactive, with the patient’s having the opportunity to reflect on the story or poem and share stories from his or her own life. Participants exposed to the storytelling/poetry intervention had a lower delirium screening score at hospital discharge compared with those in the control group. The result remained significant after adjusting for age, baseline cognitive impairment, and general well-being.
And don’t forget that delirium is a risk factor for other patient safety issues, especially falls. A recent study (Ferguson 2018) showed that a nursing-driven hospital-wide delirium program targeting improvements in risk identification, prevention, detection, and treatment resulted in reduced rates of delirium-related falls. A delirium risk identification form to be completed for every hospitalized patient at the time of admission facilitated appropriate, timely initiation of the bundle. The bundle consisted of evidence-based nonpharmacological interventions that included efforts to minimize, treat, or prevent sensory deprivation or overload; impaired sleep-wake cycle; immobility; poor nutrition or dehydration; urinary retention; constipation; suboptimal pain management; deliriogenic medications; unnecessary lines or tethers; hypoxia; and alcohol withdrawal. Over the course of the program, delirium falls decreased from 0.91 to 0.50 per patient day (P = .0002). A decrease in overall falls was also noted (P = .0007).
Lastly, we’d be remiss if we didn’t refer you to Sharon Inouye’s description of her journey in geriatric medicine and delirium research (Inouye 2018). Her work in developing HELP, the Hospital Elder Life Program, led to many of our multi-component non-pharmacological interventions for delirium.
Some of our prior columns on delirium assessment and management:
References:
Girard TD, Exline MC, Carson SS, et al. Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness. NEJM 2018; published online first Oct. 22, 2018
https://www.nejm.org/doi/full/10.1056/NEJMoa1808217?query=featured_home
Bleck TP. Dopamine Antagonists in ICU Delirium. NEJM 2018; published online first Oct. 22, 2018
https://www.nejm.org/doi/full/10.1056/NEJMe1813382?query=pfw&jwd=000012043750&jspc=N
Park Y, Bateman BT, Hyun KD, et al. Use of haloperidol versus atypical antipsychotics and risk of in-hospital death in patients with acute myocardial infarction: cohort study BMJ 2018; 360: k1218
https://www.bmj.com/content/360/bmj.k1218
Schrijver EJM, De Vries OJ, Van De Ven PM, et al. Haloperidol Versus Placebo for Delirium Prevention in Acutely Hospitalised Older at Risk Patients. A Multi-centre Double-blind Randomised Controlled Clinical Trial. Age Ageing 2018; 47(1): 48-55
https://academic.oup.com/ageing/article-abstract/47/1/48/3970846?redirectedFrom=fulltext
van den Boogaard M, Slooter AJC, Brüggemann RJM, et al. Effect of Haloperidol on Survival Among Critically Ill Adults With a High Risk of Delirium: The REDUCE Randomized Clinical Trial. JAMA 2018; 319(7): 680-690
https://jamanetwork.com/journals/jama/article-abstract/2673149?resultClick=1&redirect=true
Su X, Meng Z-T, Wu X-H, et al. Dexmedetomidine for prevention of delirium in elderly patients after non-cardiac surgery: a randomised, double-blind, placebo-controlled trial. The Lancet 2016; 388(10054): 1893-1902 Published: 15 October 2016
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30580-3/fulltext
Kronzer VL, Avidan MS. Preventing postoperative delirium: all that glisters is not gold. The Lancet 2016; 388(10054): 1854-1856 Published: 15 October 2016
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31353-8/fulltext
Skrobik Y, Duprey MS, Hill NS, Devlin JW. Low-dose nocturnal dexmedetomidine prevents ICU delirium: a randomized, placebo-controlled trial. American Journal of Respiratory and Critical Care Medicine 2018; Published online: March 2, 2018
https://www.atsjournals.org/doi/pdf/10.1164/rccm.201710-1995OC
Deiner S, Luo Z, Lin H-M, et al. Intraoperative Infusion of Dexmedetomidine for Prevention of Postoperative Delirium and Cognitive Dysfunction in Elderly Patients Undergoing Major Elective Noncardiac Surgery. A Randomized Clinical Trial. JAMA Surg 2017; 152(8): e171505
https://jamanetwork.com/journals/jamasurgery/fullarticle/2629730?resultClick=1
Sieber FE, Neufeld KJ, Gottschalk A, et al. Effect of Depth of Sedation in Older Patients Undergoing Hip Fracture Repair on Postoperative Delirium: The STRIDE Randomized Clinical Trial. JAMA Surg 2018; Online First August 8, 2018
Bang SR, Ahn EJ, Kim HJ, et al. General Anesthesia Versus Regional Anesthesia in Mortality and Delirium of Elderly Hip Fracture Patients: A Nationwide Population-Based Study. Abstract 5222. American Society of Regional Anesthesia and Pain Medicine (ASRA) 2018; April 20, 2018
https://epostersonline.com/ASRAWORLD18/node/1947?view=true
Delaney A, Hammond N, Litton E. Preventing Delirium in the Intensive Care Unit. JAMA 2018; 319(7): 659-660
https://jamanetwork.com/journals/jama/article-abstract/2673130?resultClick=1&redirect=true
Freter S, Koller K, Dunbar M, MacKnight C, Rockwood K. Translating Delirium Prevention Strategies for Elderly Adults with Hip Fracture into Routine Clinical Care: A Pragmatic Clinical Trial. J Am Geriatr Soc 2016; Early View 22 NOV 2016
http://onlinelibrary.wiley.com/doi/10.1111/jgs.14568/epdf
Nassar AP, Besen BAMP, Robinson CC, et al. Flexible Versus Restrictive Visiting Policies in ICUs: A Systematic Review and Meta-Analysis. Critical Care Medicine 2018; 46(7): 1175-1180
Danila MI, Melnick JA, Mudano A, et al. A Performing Arts Intervention Improves Cognitive Dysfunction in 50 Hospitalized Older Adults. Innov Aging. 2018 Jun; 2(2): igy013 Published online Jun 18, 2018
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6004786/
Ferguson A, Uldall K, Dunn J, et al. Effectiveness of a Multifaceted Delirium Screening, Prevention, and Treatment Initiative on the Rate of Delirium Falls in the Acute Care Setting. Journal of Nursing Care Quality 2018. 33(3): 213-220, July/September 2018
Inouye S. Delirium—A Framework to Improve Acute Care for Older Persons. J Amer Geriatr Soc 2018; 66(3): 446-451 First published: 23 February 2018
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November 20, 2018
Checklist Implementation
A recent survey of pediatric surgeons regarding surgical safety checklists (SSCs) revealed some disturbing, but not really surprising, results (Roybal 2018). While 93.6% of respondents use SSCs and 62.6% would want one used in their own child’s operation, only 54.7% felt that checklists improve patient safety.
Reasons for checklist skepticism included the length of the checklist process, a distraction from thoughtful patient care, and lack of data supporting use. Literature review shows that checklists improve communication, promote teamwork, and identify errors, but do not necessarily decrease morbidity. Staff perception is a major barrier to implementation.
Checklists are incredibly valuable safety tools in healthcare and many other industries. But their implementation encounters all the barriers that implementation of any change project encounters. Like almost any change project, things that are imposed from the outside are doomed to failure. And, when you don’t encounter some “noise” early during implementation, you are also likely doomed.
Some of the comments in the Roybal pediatric study are particularly insightful.
“Checklists only work if they are short.” That is a point we’ve made several times. In our recent October 30, 2018 Patient Safety Tip of the Week “Interhospital Transfers”, we broke down a long checklist into several shorter checklists to facilitate use.
“There are generic elements to all surgical procedures that have some applications in the generic checklists currently available. What would be far more effective would be computer generated checklists SPECIFIC for the procedure scheduled.” A good point. You wouldn’t want a checklist designed for a 747 if you were flying an airbus. So why would you want to use a checklist designed for a cholecystectomy when you are doing a total hip replacement? But some checklists may apply to all types of surgery. For example, malignant hyperthermia might occur in almost any surgical procedure, so a checklist specific for malignant hyperthermia could be used during any surgical procedure if malignant hyperthermia were suspected.
“All this devotion to checklists and process has become a form of fetishism, and often is a distraction from the task at hand.” In our May 2015 What's New in the Patient Safety World column “The Great Checklist Debate” we discussed “checklist fatigue”.
“There may be one case in 10,000 in which it makes a difference. I personally haven’t seen it.” Failure to make a compelling case as to why a particular checklist is needed is one of the biggest barriers to checklist adoption.
“The surgical checklist is highly ineffective in modern Western hospitals. This was shown, but ignored, in the original paper. It is a meme, a trend, and a fad. It does not actually improve real mindfulness, and often distracts from it.” Perhaps a little bit of truth and a lot of chutzpah in that statement! See our What's New in the Patient Safety World columns for April 2014 “Checklists Don’t Always Lead to Improvement” and May 2015 “The Great Checklist Debate”.
Fortunately, there is now a terrific resource available to help with meaningful implementation of checklists. The OR Emergency Checklist Implementation Toolkit, from Ariadne Labs, Emergency Manuals Implementation Collaborative (EMIC), and Stanford University School of Medicine, takes you through all the steps necessary in successful checklist implementation.
Researchers involved in development of that toolkit used data gathered through a Web-based survey to examine factors that might be related to success in implementing OR cognitive aids (Alidina 2018).
Completing more implementation steps was significantly associated with more successful implementation. In fact, each implementation step completed was associated with just over 50% higher odds of more successful implementation. Leadership support and dedicated time to train staff were other factors associated with successful implementation. Small facility size was also associated with a fourfold increase in the odds of a facility reporting more successful implementation. Previous quality improvement experience was associated with success in OR cognitive aid implementation: the greater its number of quality improvement initiatives, the more likely a facility was to successfully implement OR cognitive aids. More successful implementation was associated with the use of the tool in emergency drills, in preparation for complex cases, and in debriefing after a critical event.
Factors associated with less successful implementation were resistance among clinical providers to using cognitive aids, absence of an implementation champion, and unsatisfactory content or design of the cognitive aid,
The following were associated with more successful implementations:
So the OR Emergency Checklist Implementation Toolkit, recommends the following strategies:
The toolkit tells you to expect to spend 6-12 months or more for implementation and training.
The need for a clinical champion speaks for itself. In getting buy-in, it’s important to get support of clinical and administrative leadership. Early communication and outreach to staff is essential. Key hospital leaders need to be engaged in a multidisciplinary implementation team. Get the word out about the project at department meetings and joint conferences.
A key feature of any successful change project is also to identify key people who are likely to resist the change and meet with them 1-on-1 and invest time in educating them about project. In-house marketing (videos, other promotional materials, periodic announcements and updates, etc.) can be helpful.
Since this toolkit is specifically about OR checklists, you need to establish a multidisciplinary team that is representative of all perioperative personnel. Best team members are thoughtful, respected, reliable, collaborative, able to participate, and experienced in quality improvement. They don’t have to be titled leaders.
After you’ve selected checklist(s), customize them to fit your clinical setting. The toolkit provides good recommendations about the pros and cons of printed vs. electronic checklists and provides practical recommendations about best format, visual design, writing style, etc. Test your checklists in team simulations and revise them as necessary. Train your staff on use of the checklists and utilize any of several simulation techniques described in the toolkit. One key success factor is ensuring that time is provided for training of staff.
Phase in your checklists. Don’t roll them out to all areas at once. Get them up and running in a few key areas, learn from them, tweak them, and test them again.
Monitor the use of the checklists. Which ones are being used? Encourage their use and provide feedback on both their use and usefulness.
Share your successes with other areas of the organization (emergency department, ICU’s, labor & delivery, etc.) so they can model similar checklist implementations.
You’ve heard us over and over use the phrase “stories, not statistics”. At each stage where you are training or promoting a checklist, try to give a personal story of how a use of a checklist was important. If, for example, you just say something like “we have not had a wrong site surgery since we implemented…” you won’t get the same enthusiasm as if you tell a story about how, in a specific case, the checklist actually helped avert a near-miss.
When we’ve seen successful projects using checklists, we always wonder whether success was due to the checklist itself or to the teamwork and culture changes that were involved in implementing the checklist. We suspect the latter are probably as or more important than the checklist. So never be hasty in pushing out checklists. Follow the steps outlined in the toolkit and you’ll likely find that your checklists result in the improvements you were looking for.
Some of our prior columns on checklists:
References:
Roybal J, Tsao K, Rangel S, et al. Surgical Safety Checklists in Children’s Surgery: Surgeons’ Attitudes and Review of the Literature. Pediatr Qual Saf 2018; 3: e108; Published online October 16, 2018
Ariadne Labs/EMIC/Stanford. The Operating Room Emergency Checklist Implementation Toolkit. 2018
https://www.implementingemergencychecklists.org/
Alidina S, Goldhaber-Fiebert SN, Hannenberg AA, et al. Factors associated with the use of cognitive aids in operating room crises: a cross-sectional study of US hospitals and ambulatory surgical centers. Implement Sci 2018; 13(1): 50
https://implementationscience.biomedcentral.com/articles/10.1186/s13012-018-0739-4
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November 27, 2018
Focus on Deprescribing
A recent study relating inappropriate prescribing to hospital admission has highlighted the need for a focus on deprescribing. Perez and colleagues (Perez 2018) looked at the prevalence of potentially inappropriate prescribing assessed using 45 criteria from the Screening Tool for Older Persons’ Prescription (STOPP) in adults aged 65 years or over in 44 general practices in Ireland. The overall prevalence of potentially inappropriate prescribing ranged from 45.3% to 51.0%. After adjustment for multiple factors, hospital admission was independently associated with a higher rate of distinct potentially inappropriate prescribing criteria met (adjusted hazard ratio 1.24). Moreover, among participants who were admitted to hospital, the likelihood of potentially inappropriate prescribing after admission was even higher than before admission (adjusted odds ratio 1.72).
The accompanying editorial (Avery 2018) points out that there are opportunities to identify inappropriate prescribing both at hospital admission and at the outpatient followup visit after hospital discharge. It notes several factors that are barriers. Many hospital-based physicians may be reluctant to discontinue medications started by someone else. And the fact that many hospital-based physicians do not participate in post-hospital outpatient care is another factor. Another factor is that additional comorbidities often lead to potentially inappropriate prescribing. Communication between outpatient and inpatient physicians is clearly important. The editorialists also note that effective mulltidisciplinary working, involvement of pharmacists, and use of electronic health records for identifying patients at risk and providing decision support are important in the deprescribing process.
One category of medications on most “inappropriate” lists is high‐risk anticholinergics. This category includes medications such as antidepressants, antimuscarinics, and antihistamines that may have significant anticholinergic side effects. However, despite concern over negative outcomes associated with these drugs in older adults, researchers found that the overall prescribing trends of these medications remained largely unchanged between 2006 and 2015 (Rhee 2018).
While we usually refer to inappropriate prescribing for a population, such as those age 65 and older, don’t forget that there is also inappropriate prescribing based upon certain conditions a patient may have. The classic one is Parkinson’s Disease (see our prior columns for August 2011 “Problems Managing Medications in Parkinson’s Disease”, December 2012 “More on Hospitalized Parkinson’s Disease Patients”, and June 2015 “More Risks for Parkinson Inpatients”). A new study (Mantri 2018) looked at patterns of dementia treatment and frank prescribing errors in older adults with Parkinson Disease. 27.2% were given a prescription for at least 1 antidementia medication. Of those receiving an acetylcholinesterase inhibitor (ACHEI), 44.5% experienced at least 1 high-potency anticholinergic–ACHEI event. They did find variation in such prescribing by race/ethnicity, sex, and geography.
Don’t forget that deprescribing should also consider medications intended only for short term use. The classic examples are PPI’s (proton pump inhibitors) that were begun while a patient was in the ICU and never discontinued. While good medication reconciliation done at both transfer out of the ICU and at hospital discharge should catch the error of continuing PPI’s, these are commonly missed and patients continue on them. Then, at the first primary care visit following discharge, physicians may not question the indication for continued use of the PPI’s and simply continue to renew prescriptions for them. PPI’s did make the most recent update of Beers’ Criteria (American Geriatrics Society 2015).
For many years, drugs reducing gastric acid secretion were felt to benefit patients in ICU settings who are considered at risk for the development of stress ulceration and bleeding. But even that premise has been challenged recently. Krag and colleagues (Krag 2018) randomized ICU patients who were at risk for gastrointestinal bleeding to intravenous pantoprazole (a proton-pump inhibitor) or placebo. They found that mortality at 90 days and the number of clinically important events were similar in those assigned to pantoprazole and those assigned to placebo.
Whether the Krag study will change use of PPI’s in the ICU or not, it’s important for us to recognize when PPI’s are continued beyond their intended duration. In fact, a new name has been given to such practice: "legacy prescribing" refers to the prescribing of drugs for a longer period than is typically needed to treat a condition.
Canadian researchers (Mangin 2018) noted that commonly prescribed drugs with legacy prescribing potential include antidepressants, bisphosphonates, and proton pump inhibitors (PPIs), so they evaluated the proportion of legacy prescribing within these drug classes. Using a large population-based database, they calculated rates of legacy prescribing of antidepressants (prescription longer than 15 months), bisphosphonates (longer than 5.5 years), and PPIs (longer than 15 months). The proportion of patients having a legacy prescription at some time during the study period was 46% for antidepressants, 14% for bisphosphonates, and 45% for PPIs. The mean duration of prescribing for all legacy prescriptions was significantly longer than that for non–legacy prescriptions. Concurrent legacy prescriptions for both antidepressants and PPIs was common, which the authors suspect may signal a potential prescribing cascade (that is, side effects of one potentially inappropriate medication may lead to prescription of a second potentially inappropriate medication).
Bytzer (Bytzer 2018) noted prescribing of PPIs increased fourfold in Denmark over the last decade, with the increase particularly marked among older patients. 7% of all adults and 14% of adults over 60 were covered by PPI prescriptions. The increased prescribing of PPIs was driven primarily by the accumulation of existing users rather than by new users; inappropriate prescribing and long term use, rather than genuine clinical need for ulcer prophylaxis, appear to underlie the high prevalence of PPI prescribing.
One of the unintended consequences of healthcare information technology may contribute to “legacy” prescribing. In our May 27, 2014 Patient Safety Tip of the Week “A Gap in ePrescribing: Stopping Medications” and our March 2017 What's New in the Patient Safety World column “Yes! Another Voice for Medication e-Discontinuation!” we highlighted what we consider to be a major flaw in current e-prescribing systems, namely that they do not put the same emphasis on stopping medications as they do on starting them.
Yet another factor contributing to “legacy” prescribing is the fact that most of our systems do not include any way to input the original indication for a medication. Some medications, most notably beta-blockers, have numerous potential indications. Having access to the reason a medication was originally started may help in both the medication reconciliation process and the deprescribing process. For example, if a physician could see a PPI was ordered “for prophylaxis while in the ICU”, it would be easy to see it should no longer be continued after discharge from the ICU.
Ironically, healthcare IT should be a potential solution to the problems of both inappropriate prescribing and legacy prescribing. Good clinical decision support systems should be able to alert clinicians to potentially inappropriate medications any time a clinician utilizes a CPOE or e-prescribing system. And they should flag medications that are usually intended for short courses that appear to be prescribed for longer periods.
So that gets us to the deprescribing process. Results of the D-PRESCRIBE (Developing Pharmacist-Led Research to Educate and Sensitize Community Residents to the Inappropriate Prescriptions Burden in the Elderly) trial were recently published (Martin 2018). That studied the effectiveness of a consumer-targeted, pharmacist-led educational intervention vs usual care on discontinuation of inappropriate medication among community-dwelling older adults in Quebec. They included patients prescribed 1 of 4 Beers Criteria medications (sedative-hypnotics, first-generation antihistamines, glyburide, or nonsteroidal anti-inflammatory drugs), At 6 months, 43% in the intervention group no longer filled prescriptions for inappropriate medication compared with 12% in the control group.
In the intervention vs control group, discontinuation of inappropriate medication occurred in 43.2% vs. 9.0% for sedative-hypnotic drug users, 30.6% vs. 13.8% for glyburide, and 57.6% vs. 21.7% for nonsteroidal anti-inflammatory drugs.
Importantly, no adverse events requiring hospitalization were reported, although 29 of 77 patients (38%) who attempted to taper sedative-hypnotics reported withdrawal symptoms. The latter statistic reminds us that many medications should not simply be discontinued all at once. Fortunately, there are evidence-based algorithms available for deprescribing many medications. One website, deprescribing.org, has links to algorithms for deprescribing several drugs, including PPI’s, benzodiazepine receptor agonists, antipsychotics, cholinesterase inhibitors and memantine, and antihyperglycemics. In addition to the algorithm for deprescribing PPI’s available on that website, there is also a toolkit for deprescribing PPI’s on the Choosing Wisely Canada website (Wintemute 2017).
In our October 31, 2017 Patient Safety Tip of the Week “Target Drugs for Deprescribing” we noted Douglas Paauw’s “11 Drugs You Should Seriously Consider Deprescribing”. His list has recently been updated (Paauw 2018) and is a good place to start when you begin your deprescribing programs:
But don’t forget that, in our desire to minimize polypharmacy, we also need to focus on medications that patients should be taking (for their comorbidities). We addressed “optimizing” medications in our October 19, 2010 Patient Safety Tip of the Week “Optimizing Medications in the Elderly”. While you are focusing on deprescribing, that is also an opportunity to determine whether patients are missing medications they should be taking.
Some of our past columns on deprescribing:
Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:
References:
Perez T, Moriarty F, Wallace E, et al. Prevalence of potentially inappropriate prescribing in older people in primary care and its association with hospital admission: longitudinal study. BMJ 2018; 363 Published 14 November 2018
https://www.bmj.com/content/363/bmj.k4524
Avery AJ, Coleman JJ. Tackling potentially inappropriate prescribing (editorial). BMJ 2018; 363 Published 14 November 2018
https://www.bmj.com/content/363/bmj.k4688
Rhee TG, Choi YC, Ouellet GM, Ross JS. National Prescribing Trends for High‐Risk Anticholinergic Medications in Older Adults. J Am Geriatr Soc 2018; 66(7): 1382-1387
https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.15357
Mantri S, Fullard M, Gray SL, et al. Patterns of Dementia Treatment and Frank Prescribing Errors in Older Adults With Parkinson Disease. JAMA Neurol 2018; Published online October 1, 2018
https://jamanetwork.com/journals/jamaneurology/article-abstract/2704469
American Geriatrics Society. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Amer Geriat Soc 2015; 63(11): 2227-2246 Article first published online 8 Oct 2015
https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.13702
Krag M, Marker S, Perner A, et al. Pantoprazole in patients at risk for gastrointestinal bleeding in the ICU. N Engl J Med 2018; Published online October 24, 2018
https://www.nejm.org/doi/full/10.1056/NEJMoa1714919
Mangin D, Lawson J, Cuppage, J, et al. Legacy Drug-Prescribing Patterns in Primary Care. Ann Fam Med 2018; 16(6): 515-520
http://www.annfammed.org/content/16/6/515.full
Bytzer P. Deprescribing proton pump inhibitors: why, when and how. Med J Aust 2018; 209(10): 436-438
https://www.mja.com.au/journal/2018/209/10/deprescribing-proton-pump-inhibitors-why-when-and-how
Martin P, Tamblyn R, Benedetti A, et al. Effect of a Pharmacist-Led Educational Intervention on Inappropriate Medication Prescriptions in Older AdultsThe D-PRESCRIBE Randomized Clinical Trial. JAMA 2018; 320(18): 1889-1898
https://jamanetwork.com/journals/jama/article-abstract/2714531
Deprescribing.org
Wintemute K. Bye, bye, PPI: a toolkit for deprescribing proton pump inhibitors in EMR-enabled primary care settings. Version 1.2. Toronto, Ontario: Choosing Wisely Canada; July 2017.
https://choosingwiselycanada.org/wp-content/uploads/2017/07/CWC_PPI_Toolkit_v1.2_2017-07-12.pdf
Paauw DS. 11 Drugs You Should Seriously Consider Deprescribing: 2018 Update. Medscape 2018; November 5, 2018
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December 4, 2018
Don't Use Syringes for Topical Products
A new ISMP Canada Safety Bulletin (ISMP Canada 2018) reminds us to never use a syringe for a topical product. That’s because the topical product might be accidentally injected into a patient if it is in a syringe. While parenteral injection of almost any topical product could lead to devastating consequences, the ISMP Canada bulletin focuses on chlorhexidine.
The Safety Bulletin prompts our recall of devastating injuries resulting from inadvertent parenteral injection of chlorhexidine. Most of us remember an unfortunate case a decade ago where a patient was inadvertently given intraarterially the antiseptic skin prep solution, chlorhexidine, instead of contrast media (ISMP 2004). That resulted in a leg amputation, followed by a stroke and multiple organ failure and, ultimately, death. In that case there were two unlabeled basins containing clear solutions that looked alike. So, it was not surprising that such accidents might occur.
We discussed this issue in detail in our June 23, 2015 Patient Safety Tip of the Week “Again! Mistaking Antiseptic Solution for Radiographic Contrast”. The National Health Service in England issued an alert following three incidents involving inadvertent injection of skin antiseptic solutions since 2012, and one additional near miss (NHS 2015). Two incidents involved severe harm from confusion between 2% chlorhexidine and x-ray contrast media in circumstances where both substances were in unlabeled basins. The near miss also involved confusion between chlorhexidine and x-ray contrast material despite the fact the two solutions were on different tables. The other incident involved flushing a renal dialysis line with chlorhexidine rather than saline. These cases occurred despite two previous alerts from the National Patient Safety Agency in the UK (NPSA 2007, NPSA 2010).
A common scenario for such serious incidents is where chlorhexidine solution and a solution intended for injection (e.g., a local anesthetic or an injectable medical dye) are poured into open, unlabeled bowls in the operating room or angiography suite. Someone then draws up the incorrect solution into a syringe and administers the solution parenterally. The error probably occurs more often with clear, rather than tinted, chlorhexidine solutions. Note that the switch in antiseptics from a brown povidone-iodine solution to a clear chlorhexidine solution likely played a role in some of these incidents, such as the one described in the 2004 ISMP alert.
One patient safety blog (patientsafe blog) has catalogued incidents related to accidental misuse of chlorhexidine. These include not only cases of accidental intravenous injection of chlorhexidine but also cases where it was injected epidurally, or into the eye or a joint space, and cases where it was given orally to patients. There’s even been an incident involving a buccal injection during a dental procedure (Hiremath 2016).
A root cause analysis of an epidural incident (O’Connor 2012) was also informative. A 32 y.o. woman was to receive an epidural block during labor. The anesthetist mistakenly injected 8 ml of an alcoholic solution of chlorhexidine, The patient developed paralysis and hydrocephalus. Chlorhexidine and saline, both clear liquids, were in two identical metal containers in the anesthetist’s work space. Staff had decanted the solutions into the unlabeled containers. Apparently, previous chlorhexidine solutions had been slightly colored but the facility had recently switched to a new preparation that was lighter in color. Saline was apparently usually used in a syringe that was used to help the anesthetist know when the needle was in the epidural space. But the anesthetist had the wrong solution in the syringe and injected chlorhexidine into the epidural space.
The regional Department of Health subsequently recommended removal of the skin antiseptic preparation and associated swabs after the skin is prepped. It also recommended that when a nurse or midwife was required to prepare a medication dose for administration by a provider in a sterile set-up, there needs to be a double check by the provider prior to administration. Some hospitals, in response, apparently switched to povidone-iodine skin prep, though questions persist about the relative antiseptic capabilities of povidone-iodine vs. chlorhexidine. Physical separation of antiseptic solutions from the epidural sterile tray has also been used.
Incidents involving injection of the wrong substance when two look-alike substances are in proximity and are unlabeled have occurred in multiple venues (angiography suites, cath labs, dialysis units, hospital OR’s, ambulatory surgery centers, and others). Most hospitals have really focused on enforcing the “no unlabeled syringes” and “no unlabeled solutions in basins” in the OR. But it may be that those other areas (radiology suites, cath labs, dialysis units, etc.) may be even more vulnerable to such incidents. And don’t forget bedside procedures. They are probably even more prone to such mistakes. Clear, colorless skin antiseptics might be easily confused with substances intended for spinal injection or injection into other body cavities.
In our June 23, 2015 Patient Safety Tip of the Week “Again! Mistaking Antiseptic Solution for Radiographic Contrast” we noted some of the human factors that may contribute to such incidents. There’s always that tendency to think “I know what’s in that basin” and “there will only be one basin”. Then another basin shows up with a substance similar in appearance, often unbeknownst to the person who will actually be injecting.
There’s also a tendency to keep the skin antiseptics around “just in case we might need them”. Once you’ve prepped the skin, the antiseptic agent should be removed from the sterile field (and even adjacent stands). There is usually easy access to these in most venues if you really do need them again so there is little reason to “keep them around just in case you might need them again”. And remember that the alcohol-based antiseptics are also flammable so you especially don’t want them sitting around where they might get ignited by a heat source during a procedure.
We previously noted the steps recommended by ISMP in that 2004 Alert (ISMP 2004):
And we added these recommendations:
Now ISMP Canada adds the following recommendations regarding chlorhexidine products:
Though the ISMP Canada Safety Bulletin focuses on chlorhexidine, it notes similar issues with use of topical epinephrine in the operating room and, theoretically, almost any topical medication could be involved in similar incidents. So, ISMP Canada adds the following general recommendations to mitigate the risk of inadvertent injection of topical products:
The Joint Commission, of course, requires that all basins, syringes, and other containers in the sterile field be appropriately labeled. Moreover, when any such liquid is to be injected into a patient there should be a verification that the agent is the one intended for injection.
Much like the concentrated potassium chloride situation years ago, we are putting our healthcare workers in jeopardy of making a mistake by making available containers of chlorhexidine in multiple venues. There is actually little reason for that. Applicators are available for skin preparation with chlorhexidine and you should not ever need to pour chlorhexidine solution into any type of container. (But don’t forget that chlorhexidine in alcohol solutions is highly flammable and the appropriate size applicator may be needed in some circumstances. See our January 10, 2017 Patient Safety Tip of the Week “The 26-ml Applicator Strikes Again!”.)
The best way to get your staff’s attention to vulnerabilities to relatively rare incidents is to tell a story. So go ahead and show them the YouTube video Gina’s Story, the full story of a woman who lost her leg after chlorhexidine was inadvertently injected instead of contrast during an angiogram in 2013.
References:
ISMP Canada. Do Not Use a Syringe for a Topical Product – A Focus on Chlorhexidine Disinfectant Solutions. ISMP Canada Safety Bulletin 2018; 18(9): 1-3 November 21, 2018
https://www.ismp-canada.org/download/safetyBulletins/2018/ISMPCSB2018-i9-Chlorhexidine.pdf
ISMP (Institute for Safe Medication Practices). Loud wake-up call: Unlabeled containers lead to patient's death. ISMP Medication Safety Alert! Acute Care Edition. December 2, 2004
https://www.ismp.org/resources/loud-wake-call-unlabeled-containers-lead-patients-death
NHS (National Health Service) England. Patient Safety Alert NHS/PSA/W/2015/005. Stage One: Warning. Risk of death or severe harm due to inadvertent injection of skin preparation solution. May 26, 2015
http://www.england.nhs.uk/wp-content/uploads/2015/05/psa-skin-prep-solutions-may15.pdf
National Patient Safety Agency. Promoting safer use of injectable medicines. Patient Safety Alert 20, 2007
National Patient Safety Agency. Injectable medicines in theatres. Signal 1162, 2010;
http://www.nrls.npsa.nhs.uk/resources/?entryid45=66753
patientsafe. Accidental Chlorhexidine Injections. Patientsafe (blog) accessed November 24, 2018
https://patientsafe.wordpress.com/accidental-chlorhexidine-injections/
Hiremath H, Agarwal RS, Patni P, Chauhan S. Accidental injection of 2% chlorhexidine gluconate instead of an anesthetic agent: A case report. J Conserv Dent 2016; 19(1): 106-108
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4760004/
O’Connor M. Responsiveness to the Chlorhexidine Epidural Tragedy: A Mental Block? J Law Med 2012; 19(3): 436-443
https://patientsafe.files.wordpress.com/2015/11/chlorhexidine-mental-block.pdf
Doncaster and Bassetlaw Hospitals NHS Foundation Trust. The Human Factor: Learning from Gina’s Story (YouTube video). September 8, 2014
https://www.youtube.com/watch?v=IJfoLvLLoFo&feature=youtu.be
Print “Don’t Use Syringes for Topical Products”
December 11, 2018
Another NMBA Accident
Mistaken administration of NMBA’s (neuromuscular blocking agents) is rare but, unfortunately, the consequences are usually catastrophic. Actually, maybe not so rare. The Pennsylvania Patient Safety Authority reported 154 event reports over a 5-year period that mentioned medication errors involving the use of NMBAs (PPSA 2009). The most common medication error event types associated with this class of medications were wrong-drug errors (37%) followed by wrong-dose/overdosage errors (16.2%). Most importantly, 47.4% of the intended medications were not NMBAs. Moreover, the risk of patient harm was 13 times greater for NMBA’s when compared to all medication errors reported to the Authority.
We’ve reported on cases of errors related to NMBA administration several times over the years (see full list at the end of today’s column). But, another unfortunate incident with an NMBA was recently reported (NewChannel5 2018), (Kelman 2018a), (Kelman 2018b), (Ellison 2018). The case came to the attention of the media when CMS issued a termination letter to the hospital (CMS apparently later accepted the hospital’s plan of correction and rescinded the proposed termination). We’ve had to piece together details from multiple media reports and CMS’s inspection report (CMS 2018) that led to its action. These do provide enough information about the incident for multiple lessons to be learned.
A 75 y.o. woman with an intracranial hematoma (media reports say subdural hematoma but the CMS inspection report says it was an intraparenchymal hematoma) was admitted to a hospital’s Neuro ICU. Two days later she was alert and oriented and stable and was now in the Neuro Stepdown Unit and waiting for a bed on the regular floor. On that day she was sent to the radiology department for a total body PET scan. The patient told staff about claustrophobia and a physician ordered Versed 2 mg intravenously for sedation for the procedure. PET scan staff requested a nurse from the Neuro ICU administer the Versed because their own nurses would not be able to perform monitoring of the patient.
That nurse from the Neuro ICU was already going to the ER to administer a swallowing study. The nurse looked in the patient’s profile on the ADC (Automated Dispensing Cabinet) for the Versed but could not find it. (The ADC was in the Neuro Intensive Care Unit, not in radiology.) Therefore, the nurse used the override function on the ADC to search for it. The nurse recalled talking to an orientee about the swallowing study while entering the first two letters “VE” into the ADC. The first medication on the list was chosen. The nurse did not recognize that the medication chosen was vecuronium, not Versed. The nurse looked at the back of the vial to see how to reconstitute the medication but did not recheck the name of the medication on the vial. The nurse grabbed a sticker from the patient’s medication file, a handful of flushes, alcohol swabs, and a blunt-tip needle. The nurse put the medication vial in a baggie and wrote on the baggie “PET scan, Versed 1-2 mg” and went to Radiology to administer the medication. The nurse found the patient waiting in the PET scan area, reconstituted the medication, and administered the medication intravenously to the patient, then left the PET scan area. In the CMS interview the nurse could not remember the exact dose administered but thought it was 1 milliliter. The nurse put the leftover medication in the baggie and gave it to another nurse. The nurse did not monitor the patient after administering the medication.
The order for Versed had been entered at 2:47 PM. It was verified by a pharmacist at 2:49 PM. It was never dispensed from the ADC. Vecuronium, however, was dispensed from the ADC at 2:59 PM, via the override function. There was never an order for vecuronium and no verification from a pharmacist.
The nurse did not document the administration of the medication. Apparently the nurse had been told that the “new system” would capture it in the MAR.
Some time after the administration of the vecuronium the patient was found unresponsive. CPR was administered and resuscitation efforts included intubation and restoration of a heart beat. The patient was not actually in the PET scan when she suffered the arrest. The patient was first in an “injection room” where she received injection of the radioactive tracer and then the injection of what was thought to be Versed. The patient was then moved to a “patient room” where they are expected to wait for up to an hour for the radioactive tracer to circulate. It was in this room where the patient was found by a transport attendant to be “unresponsive”. Radiology technicians were able to visualize the patient in that room (via camera) and noted she had her eyes closed but resolution was not good enough for them to detect whether she was breathing or not. It was estimated that 30 minutes had elapsed from the time the patient was put in that “patient room” and the time she was found unresponsive.
Nurses in the Neuro ICU heard the code call to Radiology and wondered whether it might be for their patient who was having a PET scan. It was their patient, and she was brought back to the Neuro ICU after the resuscitation. There a second nurse showed the baggie to the first nurse and asked “Is this the med you gave the patient?”. When the nurse answered “yes”, the second nurse said “This isn’t Versed. It’s vecuronium.”
The patient was subsequently put on comfort care after discussion with family about the neurological sequelae and died the following day.
As sad as this case is, there are numerous lessons learned that we hope can help other hospitals avoid similar incidents. As with almost every incident that results in serious patient harm, there was a cascade of errors, contributing factors, and root causes that played roles in the unfortunate outcome. You will likely find that several of vulnerabilities identified could be present in your own organizations.
Bypassing medication safety safeguards
In most places in a hospital a medication is ordered via CPOE. This ties into pharmacy computer systems, an EMAR (electronic medication administration record), and ultimately a bedside medication verification (barcoding) system. One problem we often see in hospitals is that the bedside medication verification (barcoding) system may not be available in the Radiology suite. In this particular case, the barcode implementation in Radiology was “pending”.
Overrides are problematic.
Overrides are really intended for truly STAT or emergent situations. They often are used in response to verbal orders. Since they bypass pharmacist review and barcode verification safety nets, their use in non-emergent situations increases the likelihood of errors. But overrides, of course, are built into all ADC’s (Automated Dispensing Cabinets). Hospitals do monitor the frequency of overrides as part of their quality improvement programs. That data is used to identify inappropriate overrides or to identify the need for better access to certain drugs. However, that is a retrospective process. What is needed is something to better ensure the correct drug is being removed from the ADC during an override. Requiring an independent double check would make sense. But double checks have their own problems. The statistic we often give is that an inspector fails to recognize an error in someone else’s work 10% of the time. That is why truly independent double checks (where each person independently reviews the order or other issue) are necessary when doing things such as administration of a high-alert drug. (See our October 16, 2012 Patient Safety Tip of the Week “What is the Evidence on Double Checks?”). However, the literature suggests a medication error reduction of about 30% when using a double check system. ISMP Canada (ISMP Canada 2005) describes the independent double check process and calculates that independent double checks would reduce the error rate of a process having an error rate of 5% all the way down to 1 in 400.
In this case, since the medication was removed from an ADC in the Neuro ICU, there should have been ample accessibility to other nurses who could have been involved in a double check. Had this been an ADC in the Radiology suite, one answer we often get is “but we only have one nurse in the suite”. Well, the person doing the double check does not need to be a nurse. It can be another qualified healthcare professional, like the radiologist or the other physician who ordered the drug.
In our December 9, 2014 Patient Safety Tip of the Week “More Trouble with NMBA’s” we mentioned a “mental” double check in a similar case. The nurse could have thought in the current case “I don’t recall ever having to reconstitute Versed before…”
Most ADC’s have the capability of presenting messages when certain drugs are selected. In this case, there apparently was a warning in a red box visible for an override stating that it should be for STAT orders (but apparently no warning that this medication should only be for patients who are intubated and mechanically ventilated or in the process of being intubated). We suspect it might have been possible to program the ADC to force the nurse to verify the patient was intubated/ventilated or about to be intubated. A message that the override is only for STAT orders is much too vague (the nurse obviously assumed there was an urgent need for the medication).
The Joint Commission now includes assessment of the override process as a performance element in its medication management standard (Traynor 2018).
In 2015 the Penssylvania Patient Safety Authority published an advisory about overrides of healthcare technologies (Grisinger 2015). Over 75% of the overrides involved ADC’s. The most common type of event involving overrides of ADCs were unauthorized medications (e.g., obtaining a medication for a patient with no prescribed order for the patient), followed by wrong-drug events and wrong dosage form events (e.g., selecting a sustained-release product instead of the immediate-release form, selecting an oral formulation instead of the injection) (Figure 4). A majority of the unauthorized medication events specifically stated there were no orders for the medication, and over 30% of the unauthorized medication events involved a high-alert medication. Many of the cases involved withdrawal of a medication from the ADC before pharmacist verification or when the pharmacy was closed.
One of the things we’d look at during an RCA on this case would be whether overrides were used commonly by multiple staff in this unit (that is, had routine overrides become part of the culture of the unit?). We’d also want to know if double checks were required for all ADC overrides. One of the problems we see is that requirements for double checks typically appear in a hospital’s “Transfusion” policy and the “High Alert Medication” policy and often the latter just refers to specific medications or drug classes. These often do not state that double checks should be done for all ADC overrides.
Why is vecuronium in the ADC in the first place?
It is essential that NMBA’s only be kept in areas where they are truly needed (OR, ICU, ER). They should not be stored in floor stock or ADC’s on other units. Keeping NMBA’s out of the ADC (or other source of floor stock) in other areas is probably the most important action to prevent nurses from inadvertently grabbing an NMBA and administering it.
Before we had access to the CMS Inspection Report, we had thought the ADC might have been in the Radiology suite. That would have been totally inappropriate. But the vecuronium in this case was taken from the ADC in the Neuro Intensive Care Unit, not one in radiology. Even on those units where they are needed, NMBA’s should be kept segregated from other drugs, such as in lidded containers or rapid sequence intubation kits (ISMP 2016).
ISMP (Institute for Safe Medication Practices) has very important practical recommendations regarding accessibility and storage of NMBA’s (ISMP 2016). Regarding limiting access, ISMP recommends:
And regarding storage, ISMP recommends:
No monitoring?
The patient was inadequately monitored in this case. In fact, there was no monitoring after the administration of what the nurse and radiology staff thought was a sedating agent. Though the nurse did not know vecuronium had been administered and, instead, thought Versed (midazolam) had been administered, there should have been monitoring for the latter. We don’t know how many PET scan sedation protocols include provisions for monitoring. Probably the vast majority of PET scans are done on outpatients. But an inpatient with a neurological problem like an intracranial hematoma, and who is going to be alone in a room where they cannot be directly observed, must be monitored. Such patients may be more vulnerable to the respiratory depressant effects of benzodiazepines, other sedative/hypnotic drugs, and opioids. Monitoring should include at least EKG monitoring and pulse oximetry (capnography would be even better but would be technically difficult in this setting). Such monitoring would likely have identified the respiratory arrest at a time when intervention might have been successful in preventing brain injury.
The patient was first in an “injection room” where she received injection of the radioactive tracer and then the injection of what was thought to be Versed. The nurse who administered what he/she thought was Versed left the PET suite shortly after administering it. The patient was then moved to a “patient room” where they are expected to wait for up to an hour for the radioactive tracer to circulate. Radiology technicians were able to visualize the patient in that room (via camera) and noted she had her eyes closed but resolution was not good enough for them to detect whether she was breathing or not.
Preparation for a PET scan should include a question about possible claustrophobia, which might flag the need for sedation. Actually, mild sedation is often given prior to PET scan even when claustrophobia is not an issue. That is because patients must lie still during the scan. A typical scan might take 20-40 minutes. However, patients are to minimize activity during the hour after injection of radioactive tracer in order to maximize tracer going to areas of interest rather than to areas affected by activity. So sedation may be needed for about an hour and a half in all. And choice of sedating agent is important. There are some agents that are contraindicated because they may interfere with specific types of tracer or tracer localization. Bottom line: there should be a pre-PET questionnaire and also a PET sedation protocol that would include a section about what monitoring, if any, will be necessary.
LASA (look-alike, sound-alike) error, juxtaposition error, or truncation error?
Maybe we need to add a category “spell-alike” since the similarity was just in the first two letters of the drugs that were confused. Rather than being a true LASA error, it really is one of two types of error we’ve seen over and over in the EMR era: the juxtaposition error (also known as the cursor error or pick list error and other names) in which we erroneously click on an item in a drop down list different from the intended one, or the “truncation” error, where is a tendency for us to select the first item in a list on a computer screen and fail to scroll down to see if there are other selections that might be correct. In this case, the nurse selected the “first medication on the list”.
Ironically, vecuronium has been implicated in “sound-alike” instances of other NMBA accidents in the past. Norcuron (a brandname for vecuronium) has been mistaken for Narcan, and vecuronium for vancomycin. But this new instance of the truncated “VE” leading to mistaking vecuronium for Versed should be added to that list.
Problem: brand names vs. generic names
The search function on the ADC in this case defaulted to generic names. Versed is the brand name for midazolam. Had the nurse switched the search mode to brand names, perhaps Versed would have been found under the patient’s profile (since a pharmacist had already verified the order). But this also raises another question: should the order have been converted to “midazolam” rather than “Versed” during order entry via CPOE? Especially since the ADC’s default to searching for generic names, one would think that CPOE should similarly default to generic names for the sake of consistency. Yes, there are a few (very few) instances where a brand name drug is intended rather than a generic but there are ways to present that option in CPOE.
Was the PET scan indicated? Was there an adequate plan for intrahospital transport?
When we do a root cause analysis (RCA) on any incident that occurs during a procedure, one of the first questions we ask is “was the procedure indicated?”. We, of course, don’t have access to the medical details of this case so we cannot answer that question. In our August 25, 2015 Patient Safety Tip of the Week “Checklist for Intrahospital Transport” we mentioned studies suggesting that care plans were changed for patients after intrahospital transports in only 24-39% of cases. So one really needs to consider how likely the imaging study (or other procedure the patient may be going for) is really going to change patient management. In that column we noted an excellent review of issues related to intrahospital transport by Day (Day 2010), who describes “the 5 W’s. The first “W” is “Why” or “Why does the patient need to leave the ICU for the procedure?”. Important questions to ask here are “Are there bedside alternatives for the procedure? And “Is the patient’s condition stable?”. If the patient is considered unstable, the next questions are “Is the transport for a lifesaving intervention?” and “Is the transport to a diagnostic test pivotal to decision for emergent plan?”.
(We hate to speculate when we don’t have the necessary medical information, but we suspect there was likely a legitimate indication for the PET scan here. There was probably something about the intracranial hemorrhage that made physicians suspect the possibility of a hemorrhagic metastasis (certain primary cancers may be associated with hemorrhagic brain metastases). So, they were probably performing a total body PET scan looking for a potential tumor source.)
Preparation for a PET scan should include a question about possible claustrophobia, which might flag the need for sedation. Actually, mild sedation is often given prior to PET scan even when claustrophobia is not needed. That is because patients must lie still during the scan. A typical scan might take 20-40 minutes. However, patients are to minimize activity during the hour after injection of radioactive tracer in order to maximize tracer going to areas of interest rather than to areas affected by activity. So sedation may be needed for about an hour and a half in all. And choice of sedating agent is important. There are some agents that are contraindicated because they may interfere with specific types of tracer or tracer localization. Bottom line: there should be a pre-PET questionnaire and also a PET sedation protocol that would include a section about what monitoring, if any, will be necessary.
Then, when preparing a “Ticket to Ride” intrahospital transport plan (see our numerous coloumns on “Ticket to Ride” and intrahospital transport below), it could have been decided that the patient would need monitoring after administration of a sedating agent and appropriate monitoring equipment would have been sent with the patient to Radiology, with accompaniment of a nurse to monitor the patient.
Communication
The PET scan staff recognized the need for monitoring the patient after sedation. That is why they called the Neuro ICU and requested a nurse come down to administer the sedation. But it is not clear that the message for the need to monitor the patient was ever conveyed to the nurse who was sent down to administer the intended sedation. “RN #2 had asked RN#1 to go downstairs to Radiology PET scan and administer the medication Versed to Patient #1 because the patient was not able to tolerate the PET scan procedure or they would have to send the patient back and reschedule it.”
A radiology technician asked the patient's nurse (RN#2) if the patient would need to be monitored and he/she said “no” and he/she would send another nurse.
So it is not clear whether RN#1 knew that he/she was expected to monitor the patient in any way other than the brief observation that is done after administration of any medication.
Was there an adequate warning on the vial of vecuronium?
A warning on an NMBA must capture the attention of all involved and convey the message that this medication is to be used only in patients who are intubated or in the process of being intubated. For warnings we usually use bold letters and bright colors. Regarding labeling, ISMP (Institute for Safe Medication Practices) had the following recommendations (ISMP 2016): Place auxiliary labels on all storage bins and final medication containers (e.g., vials, syringes, IV bags) of neuromuscular blockers that state: “WARNING: PARALYZING AGENT—CAUSES RESPIRATORY ARREST,” to clearly communicate that respiratory paralysis will occur and ventilation is required.
We don’t think that is enough. The vial in the current case did have a red top and message “WARNING: PARALYZING AGENT”. Yet that was not conspicuous enough to get the attention of the nurse. It seems to us you need to put it in some unique sort of container, perhaps a cardboard or plastic “cage” or something that makes it more difficult to remove as a means of attracting attention to the high-risk nature of the medication. But even that could be risky if it obscures any warning message. You’d have to add the same warning to the outside of the “cage”. The ISMP recommendations for storage outlined in an earlier paragraph do serve as warnings. Also, some ADC’s do have messaging capabilities. They could be programmed to request confirmation that the intended patient is intubated or about to be intubated before an override request is granted.
Also, don’t forget the importance of warning labeling anywhere else the NMBA is used (IV bags, IV lines or ports, syringes, etc.). If in an IV infusion, be very careful not to cover any of the important warning information.
Role of the “new system”
The hospital had rolled out its new IT system for documenting the month prior to the incident and had expanded bar code scanners to the ED, PACU, and Holding Rooms. As above, Radiology was next on the list for bar code implementation. Other than the issue of not knowing how to document the administration of a drug in Radiology, it is not clear whether there were any aspects of the “new” IT system that might have contributed to confusion in this case.
Multitasking
The nurse involved was clearly multitasking. When asked to go down to the PET suite, the nurse was already on the way to the ER to perform a swallow test on an ER patient. Moreover, the nurse was orienting an “orientee”. As noted above, the nurse was explaining the need for and performance of the swallowing test to the orientee while inputting the medication name into the ADC search function. He/she than also had to reconstitute the medication. And he/she was apparently unfamiliar with the location of the PET scan unit and had to ask directions to get there. Then, after administering the medication to the patient in the PET unit, the nurse left to go to the ER for the swallowing study.
RN was the “help-all” nurse, not the patient’s primary nurse
The involved nurse on that day was a “help-all” nurse. There apparently was no formal description of the role of the “help-all” nurse but it appears that in this role the nurse is not the primary nurse for any one patient but rather interacts with multiple patients on the unit as needed. It’s not clear how much information, if any at all, that nurse would have had about the patient who was now down in the Radiology department. The patient had been described as stable and awaiting transfer to a regular floor, so it is conceivable this nurse may have had no contact or interaction with this patient prior to going to the Radiology suite.
The time and date
Most of the important events in this case occurred around 3:00 PM. That is a traditional “change of shift” time for nursing and many other healthcare workers. Note that there is nothing in the CMS inspection report to indicate that change of shift issues contributed in this case. But it’s worth reminding our readers that change of shift times are periods of vulnerabilities to errors.
Why is the date important? It was December 26, 2017, the day after Christmas. As we’ve wished our readers “Happy Holidays” in several of our December columns over the years, we’ve also cautioned them to “be careful out there”. We don’t have statistics to verify that medical errors and incidents are more frequent around the holidays. But we have had two dear friends suffer serious incidents while inpatients on Christmas Day. Staffing issues, coverage issues, and distractions are more common on holidays and are potential factors contributing to incidents. Again, there is nothing in the CMS inspection report to suggest there were staffing issues. We do know that the PET scan unit was very busy that day. Perhaps there were time pressures on either end (due to lack of ancillary studies the previous day). We’ll never know but it is worth our annual reminder to you all to be extra vigilant around the holidays.
Time pressures?
The radiology technician mentioned it was a busy day and the PET unit had a full schedule. They were going to send the patient back if ICU staff could not come down to administer the drug. RN#2 had asked RN#1 to go downstairs to Radiology PET scan and administer the medication Versed to Patient #1 because the patient was not able to tolerate the PET scan procedure or they would have to send the patient back and reschedule it. So there probably was some time pressure. Perhaps this contributed to a sense of “urgency” that made use of an ADC override seem appropriate.
The Radiology suite is a dangerous place!
The case, of course, also illustrates another point we’ve made in multiple columns: the radiology suite is a dangerous place. We’ve identified the radiology suite as a high-risk area for untoward incidents in many of our columns listed below, noting that most such incidents have little to do with the radiologic procedure being done. It simply reflects that many vulnerable patients with complex medical problems need to go to radiology, where many of the safety features we use elsewhere may slip through the cracks.
Other issues:
The CMS inspection report discussed several other issues, including lack of documentation of the error/event in the chart, failure to inform the medical examiner of the drug error, lack of attempt to get an autopsy, failure to report the event to the state, and lack of alacrity in moving this sentinel event up through the system overseeing quality and patient safety and performing nursing education.
Things done right
When we perform RCA’s or review investigations, we always also try to comment on things that were done correctly.
Blame and shame?
The CMS inspection report notes that the involved nurse was terminated shortly after the incident. On the day of the incident the nurse ended up in the nurse educator’s office (about 4 PM) once the nature of the mistake became evident. He/she gave his/her phones to the Charge Nurse and the orientee was assigned to someone else. The nurse then filled out incident reports and recalled leaving the nurse educator’s office around 8 PM. The nurse was described as “distraught” after the incident. When he/she returned to the hospital about a week later, he/she was notified of termination and was sent to an employee resource counsellor “for (his/her) personal well-being”.
When interviewed by CMS investigators, the Director of Clinical Risk Management said “In the end, there were so many things the nurse did - the 5 rights, basic nursing care.” And the RO (Regulatory Officer) stated, "The number of safety points this nurse went through was numerous."
Was termination of the nurse justified? There is little question that the nurse made some egregious errors (failure to verify and administer the correct medication, failure to monitor the patient, use of the override function on the ADC for a non-urgent medication, failure to document administration of the medication, etc.). But one question we would always ask when personnel actions are contemplated after a serious incident is “might another nurse have possibly made a similar error given the same set of circumstances?”. There were plenty of system issues here that contributed to the incident and put that nurse in a position to make that mistake. We need to do a better job to make sure we never put any of our staff in such jeopardy. That nurse was likely left at the “sharp end” of an error cascade that had multiple root causes and contributing factors upstream at the “blunt end”.
What were those circumstances?
So, might another nurse have possibly made a similar error given the set of circumstances? We think the answer is “yes”. In fact, that is why we are using this case today to provide valuable lessons learned so your hospital does not have similar vulnerabilities.
Ironically, the one person likely to never again make these errors was terminated. The hospital also lost an opportunity to have someone involved in a horrible incident tell the story and describe how it affected their own life. Most of you have heard some of the ISMP personal stories of nurses or pharmacists involved at the sharp end of serious incidents. There is nothing more compelling in getting people to focus on patient safety than these stories. You come away from such a story and say “Wow. That could happen here.” Or “That could have happened to me.”.
We hope you’ll go back to our December 9, 2014 Patient Safety Tip of the Week “More Trouble with NMBA’s” that outlines many lessons learned from another NMBA accident and has recommendations about NMBA safety. You’ll also want to look at ISMP’s 2016 “Paralyzed by mistakes” article (ISMP 2016) that outlines steps your facility should be taking to improve NMBA safety. The 2009 PPSA report (PPSA 2009) also recommended strategies to address these problems such as limiting access to NMBAs, segregating NMBAs from other medications, sequestering and affixing warning labels to vials of NMBAs stocked in the pharmacy, and requiring independent double checks before dispensing and administering NMBAs.
Some of our prior columns on neuromuscular blocking agents (NMBA’s):
June 19, 2007 “Unintended Consequences of Technological Solutions”
July 31, 2007 “Dangers of Neuromuscular Blocking Agents”
November 2007 “FMEA Related to Neuromuscular Blocking Agents”
May 20, 2008 “CPOE Unintended Consequences - Are Wrong Patient Errors More Common?”
January 31, 2012 “Medication Safety in the OR”
February 7, 2012 “Another Neuromuscular Blocking Agent Incident”
October 22, 2013 “How Safe Is Your Radiology Suite?”
December 9, 2014 “More Trouble with NMBA’s”
Some of our prior columns on patient safety issues in the radiology suite:
Some of our prior columns on the “Ticket to Ride” concept:
Some of our prior columns on Disclosure & Apology:
July 24, 2007 “Serious Incident Response Checklist”
June 16, 2009 “Disclosing Errors That Affect Multiple Patients”
June 22, 2010 “Disclosure and Apology: How to Do It”
September 2010 “Followup to Our Disclosure and Apology Tip of the Week”
November 2010 “IHI: Respectful Management of Serious Clinical Adverse Events”
April 2012 “Error Disclosure by Surgeons”
June 2012 “Oregon Adverse Event Disclosure Guide”
December 17, 2013 “The Second Victim”
July 14, 2015 “NPSF’s RCA2 Guidelines”
June 2016 “Disclosure and Apology: The CANDOR Toolkit”
August 9, 2016 “More on the Second Victim”
January 3, 2017 “What’s Happening to “I’m Sorry”?”
October 2017 “More Support for Disclosure and Apology”
April 2018 “More Support for Communication and Resolution Programs”
Other very valuable resources on disclosure and apology:
Some of our prior columns on “the second victim”:
References:
PPSA (Pennsylvania Patient Safety Authority). Neuromuscular blocking agents: reducing associated wrong-drug errors. PA Patient Saf Advis 2009; 6(4): 109-114
http://patientsafety.pa.gov/ADVISORIES/Pages/200912_109.aspx
NewChannel5. Vandy patient dies after nurse gives lethal dose of wrong drug; threatened Medicare reimbursements. NewsChannel5 (Nashville, TN) 2018; November 29, 2019
Kelman B, Vanderbilt didn’t tell medical examiner about deadly medication error, feds say. Nashville Tennessean 2018; Published Nov. 29, 2018 | Updated Nov. 30, 2018
Kelman B, At Vanderbilt, a nurse's error killed a patient and threw Medicare into jeopardy. Nashville Tennessean 2018; Published Nov. 29, 2018
Ellison A. CMS threatens to terminate Vanderbilt's Medicare contract after fatal medication error. Becker’s Hospital CFO Report 2018; November 29, 2018
CMS (Centers for Medicare and Medicaid Services). Statement of Deficiences. Complaint #TN00045852. CMS 2018; Date of survey 11/08/2018
ISMP Canada. Lowering The Risk Of Medication Errors: Independent Double Checks. ISMP Canada Safety Bulletin 2005; 5(1): 1-2, Janauary 2005
http://www.ismp-canada.org/download/safetyBulletins/ISMPCSB2005-01.pdf
Traynor K. Joint Commission eyes overrides of dispensing cabinets. American Journal of Health-System Pharmacy 2018; 75(9): e172-e173
http://www.ajhp.org/content/75/9/e172.1
Grisinger M. Medication Errors Involving Overrides of Healthcare Technology. Pa Patient Saf Advis 2015; 12(4): 141-148
http://patientsafety.pa.gov/ADVISORIES/Pages/201512_141.aspx
ISMP (Institute for Safe Medication Practices). Paralyzed by mistakes. Reassess the safety of neuromuscular blockers in your facility. ISMP Medication Safety Alert! Acute Care Edition. ISMP 2016; June 16, 2016
Day D. Keeping Patients Safe During Intrahospital Transport. Crit Care Nurse 2010; 30: 18-32
http://ccn.aacnjournals.org/content/30/4/18.full
Commins J. Vanderbilt's Medicare Status Threatened After Patient Death. HealthLeaders Media 2018; September 29, 2018
https://www.healthleadersmedia.com/vanderbilts-medicare-status-threatened-after-patient-death-1
Print “Another NMBA Accident”
December 18, 2018
Great Recommendations for e-Prescribing
The theme of the November 2018 issue of Health Affairs (Health Affairs 2018) was patient safety. There were several articles that are very valuable. But one really caught our attention. The article “A Prescription For Enhancing Electronic Prescribing Safety” (Schiff 2018) carries 2 key things we have long been advocating for. One is inclusion of the indication for each medication. The other is a mechanism for proper notification of pharmacies (and others that need to know) when a medication is discontinued, that is “e-discontinuation”.
Providing the indication for a prescription is important for more than one reason. First, there are many medications that are used for treating multiple conditions. For example, beta blockers may be used in the treatment of MI, CHF, migraine, essential tremor, hypertension, etc. Knowing the reason for the initial prescription, thus, is important when decisions about discontinuation are being pondered.
Second, seeing the indication may help a pharmacist recognize when a wrong drug has been prescribed. That is especially important when LASA (“look-alike, sound-alike”) errors are made. For example, if a prescriber erroneously clicked on “Dilaudid” instead of “Dilantin” but a pharmacist saw the indication was “for seizures”, the pharmacist would recognize a problem and contact the prescriber for clarification. As the article also points out, the same concept should be used at the time of order entry to prevent prescribing the wrong medication. In the example above, if you looked for “seizures” as an indication under the erroneously chosen “Dilaudid” you’d realize you had chosen the wrong drug.
Third, seeing the indication can help avoid wrong-dosing errors. The article includes the methotrexate problem that we’ve discussed in multiple columns. That is when methotrexate is ordered for treating an autoimmune condition, like rheumatoid arthritis, rather than for oncologic conditions. For the former, once weekly dosing is used. So, if the pharmacist saw an order for daily methotrexate and the indication was “rheumatoid arthritis”, the pharmacist might recognize the dosing error.
Regarding “e-discontinuation”, we’ve often pointed out the gap we have where a patient is told to discontinue a medication but that never gets communicated to other parties that need to know (see our May 27, 2014 Patient Safety Tip of the Week “A Gap in ePrescribing: Stopping Medications”, our March 2017 What's New in the Patient Safety World column “Yes! Another Voice for Medication e-Discontinuation!” and our August 28, 2018 Patient Safety Tip of the Week “Thought You Discontinued That Medication? Think Again”). The critical issue: stopping a medication is much different than starting one. Starting a medication requires an active process – you either write a prescription, enter one into a computer, or call the pharmacy. You are usually in a situation where you can utilize an electronic order system (CPOE or e-prescribing tool) and you may have access to the many clinical decision support tools in those systems. But discontinuing a medication is often more passive – you might get a call from your patient after hours and just tell the patient over the phone to stop it when the patient tells about a potential side effect. You don’t call the pharmacy to stop it. And, if there was no associated office visit, you might even forget to update the patient’s medication list in your EMR (or paper records) until the patient’s next office visit.
With today’s integration of the EMR to the physician’s smartphone, almost all opportunities to do e-discontinuation should be done with a formal process that should include more than just the discontinuation order. The EMR system could ask “Have you notified the patient to discontinue the medication?”, “What is the reason for the discontinuation?”, and “Do you wish to notify the patient’s pharmacy of the discontinuation?”. The system’s clinical decision support tools should then also consider whether any drug-drug interactions might be in play that would necessitate changing the dosage of another medication.
And don’t forget there is one other mechanism by which discontinued medications get inappropriately continued. Our February 28, 2017 Patient Safety Tip of the Week “The Copy and Paste ETTO” reminds us how the copy/paste function in today’s healthcare IT systems can lead to erroneous medication lists that might result in a patient being inappropriately restarted on a medication that had actually been discontinued.
The current Schiff article discusses the CancelRx, a format for sending discontinuation messages to pharmacies but notes some barriers that have delayed widespread adoption (eg. workflow issues, alert fatigue, etc.).
Of course, all the above presumes that the physician discontinuing the medication enters a discontinuation order in CPOE or an ePrescribing tool (and that those tools have a discontinuation capability). As pointed out above, the discontinuation is often made via a patient phone call at a time when the physician may not have ready access to an e-prescribing system.
Another important feature the Schiff article calls for are structured and codified prescription instructions. It points out that most instructions (the “sig” on a prescription) are transmitted via free-text and that there is tremendous variation in how those “sig” instructions are written. They note that, when using free-text, the simple instruction to “Take one tablet by mouth once daily” can be represented in 832 different ways! Using structured, codified instructions via e-prescribing has numerous workflow improvement capabilities in the pharmacy and should considerably reduce the variation in instructions on labels.
The article calls for better clinical decision support. The authors describe both the basic and advanced elements for an ideal clinical decision support system, noting that such does not just consist of alerts and reminders. See the actual article for details of all the elememts.
And, a very important concept put forward in the Schiff article is facilitating the ordering of nondrug alternatives. We know that clinical decision support alerts often fail because they do not include alternatives. Usually the alternatives we’d like to point out are other medications. But what about suggesting alternatives that are not drugs at all? The Schiff article provides an example that, when a provider attempts to prescribe a sleep medication, a message with alternative sleep hygiene interventions be presented. (See our June 3, 2014 Patient Safety Tip of the Week “More on the Risk of Sedative/Hypnotics” for a discussion on alternatives to sedative/hypnotics).
A single shared medication list is a goal that everyone wants to see. Long ago we envisioned being able to populate medication lists with data from numerous sources, such as EMR’s, hospital pharmacies, community pharmacies, payer databases, pharmacy benefit managers, etc. (see our December 30, 2008 Patient Safety Tip of the Week “Unintended Consequences: Is Medication Reconciliatin Next?”). But we found that those electronically downloaded lists may include drugs that a patient is not or never has been taking. Such medications can get on those lists for several reasons. In some cases, fraudulent activity is involved (eg. the medication is for a friend or relative) or there is medical identity theft involved. In most cases, though, it is simply due to honest mistakes taking place in the billing process. Remember, those lists are largely generated for the purpose of fulfilling the payment transaction between the pharmacy and the third-party payor. How many of you have ever had an item that you never purchased show up on your credit card statement? Probably most of you. Usually a harmless error that you can easily rectify via a phone call. Though we don’t know the frequency of such ID errors in healthcare, your ID number at the pharmacy often differs from that of one of your family members by only one digit so we would not be surprised at all if such errors are more frequent than in the credit card industry. And if such an error leads to appearance on your best possible medication history of a drug you have never taken, that can lead to problems. Shouldn’t that discrepancy be resolved when your physician goes over that list with you on admission? Certainly. But what if you are obtunded or comatose or otherwise not able to communicate on admission? You may well be started on a medication you have never taken. And you could ultimately also be discharged on that medication and have it continued indefinitely.
But the Schiff article focuses not on populating medication lists from all those sources but rather on interfacing all prescribing software with a single online database. They note a benefit would be that access to patients’ current medication lists would not be constrained by geography, institution, practice type, pharmacy, or insurance plan. And prescribers would not have to worry about which pharmacy a patient goes to, and pharmacies would be able to fill any active prescription (with checks to avoid duplicate filling). Primary care physicians would be able to readily see any changes a specialist or hospitalist has made in a patient’s regimen. Now that virtually all hospitals use CPOE and e-prescribing is mandated in most other venues, this concept is now feasible.
Note one thing missing from the Schiff article that we’d also like to see is a “reason for discontinuation”. It may be important to know whether a medication was discontinued because of:
For example, I might consider prescribing a beta blocker for migraine prophylaxis and the patient tells me that he/she was once on that medication. It would be important for me to know whether it had been discontinued because it was ineffective for the initial indication (other than migraine prophylaxis) or because of an untoward side effect or true allergy.
The article by Schiff and colleagues is not just a pipedream. The concepts are feasible and, though there may be barriers, their implementation is something we ought to be able to see in the near future.
References:
Health Affairs 2018; 37(11): November 2018. Patient Safety
https://www.healthaffairs.org/toc/hlthaff/37/11
Schiff G, Mirica MM, Dhavle AA, Galanter WL, et al. A Prescription For Enhancing Electronic Prescribing Safety. Health Affairs 2018; 37(11): 1877-1883
https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2018.0725
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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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