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October 1, 2019
Electronic Medication Reconciliation: Glass Half Full or Half Empty?
One of the most important things we do during hospital admission, discharge, or any other transition of care is medication reconciliation. But we’ve all learned that this is an imperfect process.
Multiple studies have demonstrated that well-done medication reconciliation reduces medication discrepancies. But does that translate to fewer adverse drug events (ADE’s) or fewer hospital admissions related to medications? The data on whether these are impacted by medication reconciliation is less convincing.
A new Canadian study on electronic medication reconciliation sought to answer these questions. The RightRx study (Tamblyn 2019) was a cluster randomized trial involving patients who were discharged from 2 medical units and 2 surgical units at the McGill University Health Centre in Montreal. Clinicians and researchers used electronically retrieved community drugs from the provincial insurer and aligned them with in-hospital drugs to facilitate reconciliation and communication at care transitions.
Medication discrepancies were significantly reduced in the intervention group compared with the control group (26.4% vs 56.0%). But there was no significant difference in the risk of ADE’s between intervention and control groups (4.6% vs 4.0%), or ED visits (26.2% vs 26.6%), or hospital readmission (10.3% vs 14.2%), or the composite outcome (27.0% vs 27.6%) at 30 days.
The electronic system used at McGill was interesting in that drugs are grouped by pharmacologic class and displayed in order of clinical importance rather than in alphabetic order. This apparently reduces the cognitive load on the user while reconciling drugs such as aspirin, enoxaparin, and warfarin, which would usually appear in 3 separate areas.
The intervention could be used at any point in the patient’s stay to reconcile medications at admission, transfer, and discharge. It consisted of 3 components. First, at admission, the community drug list was electronically retrieved from the provincial health insurer (a prior validation study showed that that insurer’s prescription claims achieve an accuracy of 100% for the drug dispensed and 98.5% for the date of dispensing). They included all drugs dispensed in the last 3 months to prepopulate the community drug list (to allow for nonadherence). The treatment teams then validated the list with the patient and added any medications not listed as well as notes about adherence. Second, all hospital drugs were retrieved from the hospital’s drug information system and then aligned with community medications by generic molecule, dosage, and route of administration. Third, the discharge prescription, including the changes made to community medications and the reasons for the changes, were faxed to each physician and pharmacy involved in the patient’s community-based care.
The authors conclude that their results do not provide empirical support for hospital accreditation requirements that are based on the contention that medication reconciliation will reduce discrepancies that lead to ADEs, ED visits, hospital readmission, or death after discharge.
This study result comes on the heels of the MARQUIS study (Schnipper 2018), which demonstrated that mentored implementation of a multifaceted medication reconciliation QI initiative was associated with a reduction in total medication discrepancies, but not potentially harmful medication discrepancies. In that study, done at 5 US hospitals, the intervention consisted of local implementation of medication reconciliation best practices, utilizing an evidence-based toolkit with 11 intervention components.
Overall, potentially harmful discrepancies did not decrease over time beyond baseline temporal trends, adjusted incidence rate ratio (IRR) 0.97 per month. The intervention was associated with a reduction in total medication discrepancies (IRR 0.92 per month). Of the four sites that implemented interventions, three had reductions in potentially harmful discrepancies. The fourth site, which implemented interventions and installed a new electronic health record (EHR), saw an increase in discrepancies, as did the fifth site, which did not implement any interventions but also installed a new EHR.
The good news is that those sites which seemed to implement the most components of the toolkit did see reductions in potentially harmful discrepancies. The authors attributed those potentially beneficial effects to a combination of the evidence-based components of the toolkit and the mentored implementation approach,
They also questioned the confounding role of the EHR implementation at those sites where there was no reduction and, in fact, an increase in potentially harmful discrepancies. They were quite surprised by the magnitude of the increases seen at those sites, each of which used a different EHR vendor.
The authors are concerned with the amount of resources required for good medication reconciliation. Their previous work had shown that taking a BPMH (best possible medication history) is time consuming, taking approximately 21 min per patient. They suggest that optimal implementation would require hiring additional staff or reallocating staff from other tasks, but that those costs could be more than offset if the results lead to fewer inpatient ADEs and/or fewer readmissions.
You’ll probably want to take a look at the MARQUIS toolkit (Mueller 2013) or the comparable MATCH toolkit (Gleason 2010). Both have multiple evidence-based components that you may want to incorporate into your own medication reconciliation practices.
We’re actually quite surprised at the accuracy of the processes and lists in the RightRx trial. When we did our first electronic medical record implementation in 2007, we were very optimistic that an electronic medication reconciliation program would be easy to accomplish and reliable. Boy, did we get some surprises! We thought that use of electronically downloaded medication lists from sources such as third-party payors, PBM’s, RHIO’s and other sources could supplement the data from our own hospital pharmacy and the EHR used by our affiliated physicians.
But the potential for unintended consequences became apparent early on (see our December 30, 2008 “Unintended Consequences: Is Medication Reconciliation Next?”). 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 (see our August 28, 2018 “Thought You Discontinued That Medication? Think Again” and our other columns listed below on problems associated with discontinuation of medications).
In addition, lists from such sources can be misleading in terms of dosage or adherence. For example, some patients may be taking half a pill for some medications. From the downloaded lists, one might assume the patient is on the full dose and is not adherent because they only refill their prescription every 2 months (note that a good system might use artificial intelligence to flag such patterns as a patient likely taking a half dose).
Also, in our September 24, 2019 Patient Safety Tip of the Week “EHR-related Malpractice Claims” we noted the hazards of copy & paste. Copy & paste errors often led to medication errors, sometimes copying over a medication that had been discontinued since the prior note, and sometimes failing to include a medication that had been started since the prior note.
Also, from our experience with healthcare IT in general, we have learned that some of the unintended consequences may arise from excessive reliance on the computer (caregivers trust the computer to always be correct) and short cuts/workarounds may be seen (i.e. the physician under time constraints may not diligently question you about the medications on that list).
Additionally, confidentiality laws in many states often prohibit release of HIV-related medication or behavioral health medication information on such electronically downloaded lists. That may include medications whose cessation could lead to withdrawal syndromes. And other drugs, such as samples dispensed in a physician’s office, OTC drugs, or drugs administered in a physician office (such as biological agents) may or may not appear on the electronically downloaded lists. Additionally, prescription medications that a patient might pay for out of pocket rather than through their insurer may not make the list. Whether medications in many of the above categories reach the electronic list depends upon the integration of physicians’ EHR’s to the hospital EHR.
We also previously mentioned that compounded medications and topical medications are particularly prone to be absent on best possible medication histories (see our May 13, 2008 Patient Safety Tip of the Week “Medication Reconciliation: Topical and Compounded Medications”).
A recent study (Ashfaq 2019) further illustrates many of our above observations. Researchers compared documentation of medications between the structured medication list extracted from the EHR and medications written into the clinical progress note and transcribed by the study team for patients treated at an ophthalmology service for microbial keratitis. They found that 23.1% of prescribed medications differed between the progress notes and the formal EHR-based medication list. Reasons included medications not prescribed via the EHR ordering system (43.9%), outside medications not reconciled in the internal EHR medication list (40.4%), and medications prescribed via the EHR ordering system and in the formal list, but not described in the clinical note (15.8%). Fortified antimicrobials represented the largest category for medication mismatch between modalities (24.3%). Nearly one-third of patients (32.1%) had at least 1 medication mismatch in their record. Note that many medications used in this patient population may require compounding, something we discussed in that May 13, 2008 Patient Safety Tip of the Week “Medication Reconciliation: Topical and Compounded Medications”.
The bottom line is that your organization must be diligent in truly reconciling the medications that appear on electronically downloaded medication lists. Especially in those patients who are unable to participate themselves in medication reconciliation on admission, you must have systems in place to prompt someone to repeat reconciliation once the patient has improved enough to communicate. And, of course, reconciliation via the patient’s outside physicians and family become even more important in the poorly communicative patient.
We hope you’ll review some of the barriers to medication reconciliation that we discussed in our September 8, 2009 Patient Safety Tip of the Week “Barriers to Medication Reconciliation” and our other columns on the topic listed below.
Medication reconciliation is an extremely important patient safety process. There has not been much written about the downside of medication reconciliation. As we better utilize technological solutions to improve the medication reconciliation process, we are also likely to encounter some unintended consequences. The electronic process may be helpful, but it cannot be accepted as complete or fully accurate. Discussing the list in detail with the patient (or his/her family or caregiver) is essential. Do it diligently…and keep your eyes and ears open!
Some of our previous columns on medication reconciliation:
October 23, 2007 “Medication Reconciliation Tools”
December 30, 2008 “Unintended Consequences: Is Medication Reconciliation Next?”
May 13, 2008 “Medication Reconciliation: Topical and Compounded Medications”
September 8, 2009 “Barriers to Medication Reconciliation”
August 2011 “The Amazon.com Approach to Medication Reconciliation”
January 2012 “AHRQ’s New Medication Reconciliation Tool Kit”
September 2012 “Good News on Medication Reconciliation”
Some of our other columns on failed discontinuation of medications:
May 27, 2014 “A Gap in ePrescribing: Stopping Medications”
March 2017 “Yes! Another Voice for Medication e-Discontinuation!”
February 2018 “10 Years on the Wrong Medication”
August 28, 2018 “Thought You Discontinued That Medication? Think Again”
December 18, 2018 “Great Recommendations for e-Prescribing”
August 2019 “Including Indications for Medications: We Are Failing”
August 6, 2019 “Repeat Adverse Drug Events”
References:
Tamblyn R, Abrahamowicz M, Buckeridge DL, et al. Effect of an Electronic Medication Reconciliation Intervention on Adverse Drug Events: A Cluster Randomized Trial. JAMA Netw Open 2019; 2(9): e1910756 Published online September 20, 2019
Schnipper JL, Mixon A, Stein J, et al. Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study. BMJ Qual Saf 2018; Published Online First: 20 August 2018
https://qualitysafety.bmj.com/content/early/2018/08/20/bmjqs-2018-008233
Mueller SK, Kripalani S, Stein J, et al. A toolkit to disseminate best practices in inpatient medication reconciliation: multi-center medication reconciliation quality improvement study (MARQUIS). Jt Comm J Qual Patient Saf 2013; 39: 371-AP3
https://www.jointcommissionjournal.com/article/S1553-7250(13)39051-5/fulltext
Gleason KM, McDaniel MR, Feinglass J, et al. Results of the Medications at Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission. J Gen Intern Med 2010; 25: 441-447
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2855002/
Ashfaq HA, Lester CA, Ballouz D, Errickson J, Woodward MA. Medication Accuracy in Electronic Health Records for Microbial Keratitis. JAMA Ophthalmol 2019; 137(8): 929-931 Published online May 30, 2019
https://jamanetwork.com/journals/jamaophthalmology/article-abstract/2734211?resultClick=3
Print “Electronic Medication Reconciliation: Glass Half Full or Half Empty?”
October 8, 2019
Another Freezer Accident
In our May 1, 2018 Patient Safety Tip of the Week “Refrigerator Alarms” we discussed incidents at two separate fertility clinics involving loss of tissue when the temperatures in the refrigerating units rose above levels necessary to preserve the specimens. Now, another freezer malfunction resulted in loss of stored stem cells of 56 pediatric cancer patients (Hayes 2019). The stem cells had been harvested from the children before they underwent chemotherapy and radiation treatments. They were in long-term storage in a freezer in case their cancer should return. Apparently, one of the freezer’s sensors failed and there was also failure in the notification process.
In a press release (CHLA 2019), Children’s Hospital Los Angeles stated it sent letters to 56 patients and their families to notify them of a freezer malfunction that resulted in the loss of their child’s blood stem cells. It noted that no child's health was in jeopardy due to this incident.
According to the press release “The cause was a failure of freezer temperature sensors. Safeguards were in place at the time but were insufficient. Since that time, we have replaced the freezer that malfunctioned, upgraded our sensor monitoring and alert system, double-checked all power supply sources, increased our maintenance schedule and launched training for the engineering team on the new system.”
Your facility may not have stem cells or patient eggs and embryos stored in a freezer, but we bet you have other important items stored in freezers or refrigerators. Such items might be blood products, vaccines, certain other medications, tissue implants, and others.
While we don’t know the details of the failures in the CHLA incident, it is worth repeating some of our observations and recommendations in our Patient Safety Tips of the Week for February 4, 2014 “But What If the Battery Runs Low?” and May 1, 2019 “Refrigerator Alarms”.
In such cases, alarms would be set to trigger when a temperature sensor showed the freezer temperature had risen above a specified level. It should be no surprise that a freezer might fail or that a sensor might fail. So, you have to make sure your alarm will trigger when the freezer fails and that the alarm will trigger if the sensor were to fail or become disconnected. That calls for redundancy and backup systems.
The technology is available to indicate a sensor malfunction or disconnection. We get a “your motion camera has been disconnected” message by email and text message every time our motion detection camera gets disconnected from our WiFi system. We would assume similar capabilities should exist to alert someone when a freezer alarm system has been disconnected (but keep in mind there could also be an event that disables both your refrigerator alarm and your WiFi system).
Since an electrical failure could affect power to both the refrigerator and the alarm system, you probably don’t want both on the same circuit. In many cases, the alarm system is battery-powered. How do you know the alarm is powered and active? In our February 4, 2014 Patient Safety Tip of the Week “But What If the Battery Runs Low?” we gave the following anecdote: You have an alarm that responds to the temperature in a refrigerator dropping below a set value to protect against loss of the medical products inside. You took great care to make sure the thermometer was not on the same electrical supply as the refrigerator. However, the battery on the thermometer had not been checked recently and had no charge when the refrigerator actually lost power. All the medical products in the refrigerator are lost. The smoke detector or carbon monoxide detector in your home has a button you press that indicates the alarm is functional. Is there a similar capability on these freezer alarms? More importantly, is there a visual indicator of remaining battery capacity on such alarms? And, then, do you have a protocol that requires someone to check that battery level every day?
Then comes your notification and response limbs. You can bet that an event might take place at a time when there is no one physically working near the freezer who might hear an audible alarm. So, you need route the alarm to someone physically able to respond in a timely fashion. In most hospitals, that is probably the on-duty nursing supervisor, though it could also be someone in your 24x7 security department. They might be notified by a text message alert or other means, but you’ll also have to regularly test that such linkage is working. But now you need to make sure the person receiving the alert knows how to respond. There should be a checklist and set of instructions informing the person responding to the alarm what to do. Probably the best place to put this is right on the freezer unit. You don’t want to bury it in a thick policy manual where the respondent may not even find it in a timely fashion.
You also want to make sure that you have an appropriate “escalation” practice (i.e. who to call next if the first person called fails to respond in a timely fashion). While we have such escalation procedures in place for clinical staff, many facilities are less deliberate with regard to non-clinical staff escalation procedures.
It is also worth reiterating that periods around maintenance of equipment are vulnerable times. We discussed this in our August 7, 2007 Patient Safety Tip of the Week “Role of Maintenance in Incidents”, in which we discussed the excellent work of James Reason and Alan Hobbs plus that of Don Norman. In one of the fertility clinic incidents mentioned previously, maintenance issues may have played a role. Also, in our March 5, 2007 Patient Safety Tip of the Week “Disabled Alarms” and several other columns on alarms, we noted instances where the oxygen blender alarms on ventilators had been disabled during maintenance and were not corrected prior to use in patients. When maintenance is done on any equipment we recommend to staff doing maintenance have a checklist they use to remind them of things they must do. And one of those items would be to restore any alarms they might have disabled during the maintenance.
Your facility probably has some refrigerators or freezer units that store important blood or tissue specimens or vaccines. And we know your IT server farm relies on optimal temperature ranges. But how many of you have ever questioned what would happen if there was an alarm malfunction in one of these units? Have you done a FMEA (failure mode and effects analysis) of such alarm systems? Do you look at these alarms when you are doing Patient Safety Walk Rounds? Are the appropriate people alerted when these alarms are triggered? Do those people know how to respond when such alarms trigger? Is there a checklist that helps responders take all necessary steps when such an alarm triggers? Do you know how such alarms are powered and what the impact of a power failure or battery failure might be? Do you have backup systems in place?
So, what should you be doing?
Lastly, a couple comments about the hospital’s response to the patients, family, and the public. Most healthcare incidents involve a single patient (aside from those misidentification incidents that involve pairs of patients). But sometimes incidents, like this one, impact multiple patients and the issues there become much more complex. We refer you to our June 16, 2009 Patient Safety Tip of the Week “Disclosing Errors That Affect Multiple Patients” for recommendations in such cases. The hospital did the right thing in being forthright and honest in letting affected patients know about the error(s) and expressing sincere apology. It also let them know that a proper investigation was being undertaken to address problems so a similar incident does not recur in the future.
It is also important to speak and act with empathy in such situations. CHLA probably made a couple missteps in their response. First, the notification letters were addressed to the children. That fact actually received considerable attention in the media. It certainly might have led to recipient families feeling the hospital had relegated the task of sending out letters to an uninvolved person rather than being supervised by a truly empathetic individual. While letters are the most frequent vehicle used for notification when multiple patients are affected by an incident, one might make the case here that an attempt to first make contact by phone might have been possible with 58 patients rather than several hundred. A phone call offers a better opportunity to convey a heartfelt apology than does a sterile letter. It would also offer the families the opportunity to ask questions immediately. Imagine receiving this letter on a Friday evening and worrying all weekend about what this means. Second, the press release stated no child's health was in jeopardy as a result of the incident. That probably did not sit well with the families or children, who might some day have to face reharvesting of stem cells, which can be quite painful for patients.
Sometimes we learn from incidents that occurred elsewhere. That’s less traumatic than learning from ones that occur at our own facilities. It would be very helpful if CHLA were to publish details of what went wrong in their systems and what specific fixes they put in place. If they don’t want to disseminate that in a publication, they should at least consider sharing the details through a PSO.
Prior Patient Safety Tips of the Week pertaining to alarm-related issues:
References:
Hayes R. Stem cells for dozens of cancer patients destroyed after freezer malfunction at Children's Hospital LA. ABC7 Eyewitness News; September 26, 2019
CHLA (Children’s Hospital Los Angeles). CHLA Apologizes to Patient Families for Freezer Failure. CHLA Published on September 25, 2019
https://www.chla.org/press-release/chla-apologizes-patient-families-freezer-failure
Print “Another Freezer Accident”
October 15, 2019
Lots More on MRI Safety
Our April 2, 2019 Patient Safety Tip of the Week “Unexpected Events During MRI” had a fairly comprehensive discussion of some recent developments in MRI safety. But, since MRI safety made ECRI Institute’s annual Top 10 list for Health Technology Hazards for 2020 (ECRI 2019), we thought this is an opportune time for an another update on MRI safety. Item #8 on the ECRI list, “Missing Implant Data Can Delay or Add Danger to MRI Scans”, is also one we’ve discussed in multiple columns (see the list of our prior columns below). Because some implants can heat, move, or malfunction when exposed to an MRI system’s magnetic field, they must be screened for prior to the procedure. ECRI suggests that, akin to an allergy list, organizations develop an implant list that collects all relevant information in one easy-to-access location in the electronic medical record. We like that idea!
In fact, a recent artificial intelligence (AI) study (Valtchinov 2019) used natural language processing (NLP) to identify such implantable devices from radiology reports, emergency department (ED) notes, and other clinical reports (eg, cardiology, operating room, physician notes, radiology reports, pathology reports, patient letters). The proportion of radiology reports, ED notes, and other clinical reports retrieved containing implantable devices with high safety risks for MRI ranged from 1.47% to 1.88%. This is a very promising approach to developing comprehensive lists of implantable devices posing high safety risks for MRI.
The most recent update of ACR guidelines on MR safety (Greenberg 2019) has a section on screening for both patients and non-MR personnel. Particularly illuminating is the section on ferromagnetic materials in unexpected places that may pose a risk for thermal injury during MRI. In our September 2019 What's New in the Patient Safety World column “New MRI Hazard: Magnetic Eyelashes” we discussed the risks associated with a new phenomenon: magnetic eyelashes. But the ACR guideline update notes that clothing and other related products may have incorporated ferromagnetic and/or conductive materials (eg, antimicrobial silver and copper) that are not reliably disclosed in labeling. Examples given include sportswear (including underwear), brassieres, orthotic‐related items (eg, stump covers or stump shrinkers), and blankets, but there are likely others as well. As a result, the guideline recommends patients wear only MR‐Safe gowns or scrubs supplied by the imaging facility for areas in or around the volume of transmitted RF power. The 2013 updated guidelines also discuss issues related to tattoos and dermal adornments. It also discusses orbital X-rays for screening patients having a history of orbital trauma with possible metallic elements. And see below for recommendations on prisoners with metallic restraints or tracking devices.
A recent review of over 1500 reports over a decade of adverse events related to MR reported to FDA (Delfino 2019) categorized adverse events as thermal (59%), mechanical (11%,), projectile (9%), and acoustic (6%). Mechanical events included things like slips, falls, crush injuries, broken bones, and cuts; musculoskeletal injuries from lifting or movement of the device. The authors thought the majority of these were potentially preventable. There were 3 deaths, two involving MRI technicians and the third due to a pain pump malfunction caused by the magnetic field.
One factor contributing to many of the thermal injuries was the MRI coils used in the examination. They noted inadvertent contact with another coil, electrocardiogram electrodes or leads, patient clothing, or stereotaxic head frames in 28% of such cases and skin-to-skin contact in 16%. The most recent update of ACR guidelines on MR safety (Greenberg 2019) advises that to help safeguard against thermal injuries or burns, “insulating pads should be placed between the patient's skin and any transmit RF coil located behind the walls and ceiling of the bore of the magnet system, especially the area of the transmit RF body coil, to ensure spacing between the bore wall and the patient's skin”. It notes that a single‐layer bed sheet is insufficient insulation or spacing. Interestingly, it acknowledges that large conducting loops may be created within the patient's own tissues by points of skin‐to‐skin contact, such as thigh‐to‐thigh contact. So, providing insulation in such areas may also be required to prevent burns.
Another paper (Cross 2018) stresses the importance of training in prevention of adverse MRI events. The authors suggest tailoring the training in accord with how or how likely the staff person is to come in contact with the MRI unit. Comprehensive training would be given to those who routinely work in and around the MRI scanner. That would include radiologists (or others who may be involved in MRI, such as neurologists), technicians, physicists and engineers, radiology nurses, and anyone who routinely may be in the MRI suite. A lesser level of training might be given to those working near the MRI unit who might occasionally be in the unit (eg. other radiologists, nurses, etc.). Any other individuals would be screened before access to the MRI suite.
And, you have to plan for the unexpected. You want to make sure your MRI unit is secured after hours to prevent housecleaning or building maintenance staff from inadvertently stumbling into any zone of the MRI suite or the scanner room itself. The most recent update of ACR guidelines on MR safety (Greenberg 2019) states that the “entry door to Zone IV (MR system room) should be closed except when it must be open for patient care or room/MR system maintenance. During the times that the door to the MR system room must remain open, a "caution" barrier is recommended at the entry to Zone IV to inhibit unintended passage of personnel and/or materials from Zone III to IV. Examples of caution barriers include easily adjusted straps or plastic chains secured across the scanner room doorway.”
In several previous columns, we’ve noted another group that needs training: first responders. Specifically, your local fire and police departments need training (see, for example, our October 21, 2014 Patient Safety Tip of the Week “The Fire Department and Your Hospital”). You don’t want a fireman with an axe and an oxygen tank racing into a room with an active magnet. Nor do you want a policeman with a ferromagnetic weapon in that room. We recommend you conduct training with the fire and police departments at least annually. The problem is more complex in rural or other communities that rely on volunteer firemen. You need to make sure new volunteers get such training before the annual session.
The most recent update of ACR guidelines on MR safety (Greenberg 2019) has a section on management of prisoners and on prison or security personnel weapons (ie, firearms). “Ferromagnetic firearm weapons should not be permitted into Zone III unless deemed absolutely essential for maintenance of security due to the design of the facility. Furthermore, ferromagnetic firearms that are loaded pose a serious threat in Zone IV (the MR system room) due to the possibility of inadvertent discharge”. The 2013 update of ACR guidelines on MR safety (Kanal 2013) recommended that, “in cases where requested to scan a patient, prisoner, or parolee wearing RF bracelets or metallic handcuffs or anklecuffs, request that the patient be accompanied by the appropriate authorities who can and will remove the restraining device before the MR study and be charged with its replacement following the examination.”
The Cross article also describes the important roles played by the MRI medical director, safety officer, and safety expert.
The American College of Radiology (ACR) has published guidelines on MR safety, beginning in 2002 (Kanal 2002) with periodic updates, including major updates in 2013 (Kanal 2013) and most recently in 2019 (Greenberg 2019).
That most recent update (Greenberg 2019) also emphasizes the "full‐stop and final check" concept. “In instances where the patient is sedated or anesthetized, an inpatient, or an emergent case, a ‘full‐stop and final check’ performed by the MRI technologist along with support staff is recommended to confirm the completion of MR safety screening for the patient, support equipment, and personnel MR screening immediately prior to crossing from Zone III to Zone IV. ‘Full‐stop and final check’ may also be useful for nonsedated outpatients and inpatients prior to movement from Zone III to Zone IV. The purpose of this final check is to confirm patient name, ensure that all screening has been appropriately performed, and that there has been no change in patient and/or equipment status while in Zone III.” This is the equivalent of the surgical timeout. For years we have stressed the importance of timeouts outside the OR (see our June 6, 2011 Patient Safety Tip of the Week “Timeouts Outside the OR”).
The update also discusses some emerging issues in MR safety. Particularly of concern is that MR systems are increasingly being installed in environments outside of conventional diagnostic MR facilities (intraoperative/interventional MR, positron emission tomography (PET) MR, and MR‐guided radiation therapy). We refer you to that update for details of the many considerations in such “unconventional” sites.
Lastly, the update alerts us to the need for safety guidelines that will be related to 7T MR. The FDA has now cleared 7T MR for clinical use. It notes that many implants, devices, and foreign bodies, that don’t significantly overheat at lower strength MR, might heat excessively at 7T strength. And certain devices that may retain functionality at lower MR strengths might lose functionality at 7T. A very recent paper (Hoff 2019) outlines the safety risks and associated risk-avoidance strategies of clinical 7-T MRI. Of particular concern are metallic implants and the risk for thermal injury. They note that over 6,000 metallic devices that have undergone evaluation at 1.5- and 3-tesla imaging, but that only 300 or so metallic implants and RF transmit coils have been tested for safety at 7-tesla MRI. Hoff et al. are also concerned about patient bioeffects such as vertigo, dizziness, false feelings of motion, nausea, nystagmus, magnetophosphenes, and electrogustatory effects that are more common and potentially more pronounced at 7 T than at lower field strengths. They suggest that earplugs and headphones could help reduce acoustic noise and related inner-ear and vision abnormalities and that increasing the amount of time patients spend in the 7-tesla static magnetic field as they enter and exit the scanner might help alleviate any physical issues
7T MR will undoubtedly have some diagnostic advantages over lower strength MR units. But, as with any new technology, we need to be vigilant for unintended consequences.
Lastly, one unanswered MR patient safety issue has to do with use of gadolinium contrast agents. Studies have shown cumulative exposure to gadolinium leads to deposition in brain tissue. This is especially a concern in patient with known or suspected multiple sclerosis (MS), in whom multiple MRI’s are commonly part of management. The FDA issued an alert in 2017 (FDA 2017) about tissue retention of gadolinium-based contrast agents that called for MRI units to provide a Medication Guide to patients undergoing MRI with gadolinium-based contrast agents. It notes that, on the whole, benefits of use of gadolinium-based contrast agents probably outweigh the risks but that further investigation is needed. A recent study (Zivadinov 2019) confirmed cumulative retention of gadolinium in brain tissue in MS patients but found no clinical or radiologic correlates of more aggressive disease. The accompanying editorial (Haider 2019) notes that, although no evidence currently exists linking brain gadolinium deposits with clinical consequences, regulatory agencies both in the United States and Europe clearly caution that GBCA should only be administered when informative for patient care.
Some of our prior columns on patient safety issues related to MRI:
References:
ECRI Institute. 2020 Top 10 Health Technology Hazards Executive Brief. October 2019
https://www.ecri.org/landing-2020-top-ten-health-technology-hazards
Valtchinov VI, Lacson R, Wang A, et al. Comparing Artificial Intelligence Approaches to Retrieve Clinical Reports Documenting Implantable Devices Posing MRI Safety Risks. Journal of the American College of Radiology 2019; Published online first August 16, 2019
https://www.jacr.org/article/S1546-1440(19)30862-2/fulltext
Greenberg TD., Hoff MN, Gilk TB, et al. for the ACR Committee on MR Safety. ACR guidance document on MR safe practices: Updates and critical information 2019. J Magn Reson Imaging 2019; published online July 29, 2019
Delfino JG, Krainak DM, Flesher SA, et al. MRI‐Related FDA Adverse Event Reports: A 10‐Year Review. Medical Physics 2019; First published: 16 August 2019
https://aapm.onlinelibrary.wiley.com/doi/10.1002/mp.13768
Cross NM, Hoff MN, Kanal KM. Avoiding MRI-Related Accidents: A Practical Approach to Implementing MR Safety. Journal of the American College of Radiology 2018; 15(12): 1738-1744
https://www.jacr.org/article/S1546-1440(18)30762-2/fulltext
Kanal E, Barkovich AJ, Bell C, et al for the Expert Panel on MR Safety. ACR guidance document on MR safe practices: 2013. J Magn Reson Imaging 2013; 37: 501-530
https://onlinelibrary.wiley.com/doi/10.1002/jmri.24011
Kanal E, Borgstede JP, Barkovich AJ, et al. American College of Radiology White Paper on MR safety. AJR AM J Roentgenol 2002; 178: 1335-1347
https://www.ajronline.org/doi/full/10.2214/ajr.178.6.1781335
Hoff MN, McKinney A, Shellock FG, et al. Safety Considerations of 7-T MRI in Clinical Practice. Radiology 2019 292: 3: 509-551
https://pubs.rsna.org/doi/10.1148/radiol.2019182742
FDA (US Food and Drug Administration). FDA Drug Safety Communication: FDA warns that gadolinium-based contrast agents (GBCAs) are retained in the body; requires new class warnings. FDA 12/19/2017 and 5/16/2018 Update
Zivadinov R, Bergsland N, Hagemeier J, et al. Cumulative gadodiamide administration leads to brain gadolinium deposition in early MS. Neurology 2019; 93(6): e611-e623
https://n.neurology.org/content/93/6/e611
Haider L, Naismith RT, Rovira A. Use of gadolinium for MRI diagnostic or surveillance studies in patients with MS. Neurology 2019, 93(6): 239-240
https://n.neurology.org/content/93/6/239
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November 5, 2019
A Near-Fatal MRI Incident
The last column we did before our recent vacation was on MRI safety (see our October 15, 2019 Patient Safety Tip of the Week “Lots More on MRI Safety”). Ironically, a week later there was a near-fatal MRI accident in Sweden (Fornell 2019 , Fischer 2019, Forrest 2019, Ward 2019). Though details are still limited, there is sufficient information for dissemination of some of the lessons learned.
A patient was in the MRI machine in a mobile MRI unit based in a truck/trailer outside the Swedish hospital. A radiology nurse approached the patient while the magnetic field was active. The nurse got pinned against the MRI unit by some sort of “weight vest” containing ferrous material (this was described as a sort of vest worn during exercise). The strap of the vest was wrapped around his neck as the vest was being pulled into the magnet. The patient being scanned recognized something was wrong when he heard screams and saw a hand inside the MRI tunnel. He managed to crawl out the back of the machine and tried to help the nurse. In addition, two hospital security guards responded. They and the patient tried to release the strap from the nurse’s neck but were unsuccessful. The nurse was already unconscious. One guard then used a knife to cut the strap and they pulled the nurse out of the mobile unit.
The guard’s baton and shackles apparently got stuck to the scanner, though the media articles don’t mention what happened to the knife. The patient who had been getting the MRI scan was unhurt. The two security guards apparently suffered minor injuries. The nurse was taken by ambulance to the hospital and admitted to an ICU. He later recovered and was ultimately discharged from the hospital.
It is unclear if the nurse was wearing the “weight vest” or if it came from elsewhere. The media reports and statements from the MRI company and local health officials did not comment on the nature of the vest. The fact that the strap was around the nurse’s neck suggests he was wearing it. This was apparently a very experienced nurse who was employed by the MRI company. In several of our recent columns we’ve talked about how ferrormagnetic materials are often present in places you’d least expect them. In our October 15, 2019 Patient Safety Tip of the Week “Lots More on MRI Safety” we mentioned that the recent ACR guideline update (Greenberg 2019) notes that clothing and other related products may have incorporated ferromagnetic and/or conductive materials (eg, antimicrobial silver and copper) that are not reliably disclosed in labeling. Examples given include sportswear (including underwear), brassieres, orthotic‐related items (eg, stump covers or stump shrinkers), and blankets, but there are likely others as well. Perhaps the nurse in the current incident was unaware that the weight vest contained ferromagnetic material and the mobile unit likely lacked metal detector gates. The AuntMinnie.com article (Ward 2019) mentions that the mobile MRI units in Sweden typically do not have metal detector gates.
One important facet is that this was a mobile MRI unit, housed in a truck/trailer parked outside the hospital. Way back in our October 25, 2011 Patient Safety Tip of the Week “Renewed Focus on MRI Safety” we noted 2 scenarios where training of hospital staff for MRI safety is likely deficient. One is when an MRI unit within a hopital is owned and operated by a separate entity (such as a physician group). The other is when the MRI unit is a mobile one housed in a truck or trailer and operated by an outside entity. The radiology nurse who was injured was employed by the company owning and operating the portable MRI unit. The security guards who responded, however, were apparently hospital employees. In our many columns on MRI safety we’ve emphasized the importance of staff training on MRI safety. But when hospitals utilize mobile MRI scanners (that are typically owned and operated by someone other than the hospital), they often do not provide adequate training for those nurses or other staff that might accompany patients to the mobile MRI unit. We strongly recommend you review all aspects of safety if your staff does go on transports to such mobile MRI units. We’ve also emphasized the need for training your local fire and police personnel who might respond to an incident in an MRI unit.
Regarding the security guards who responded, they likely had no training on MRI safety and they noted that there was apparently no signage warning them about metallic items. The AuntMinnie.com article (Ward 2019) states “Following the accident at Luleå, 90-minute training sessions for the security guards at the Karolinska group were scheduled to be held on October 31 and next week. The guards will receive information about MRI, and they will enter the MRI suite to learn about the strength of the magnetic field, how to behave in the safety zone, and what to do and what not to do.”
Perhaps the most important new lesson is the danger of working alone near an MRI unit (Ward 2019). The rapid action of the security guards and the patient obviously saved the nurse’s life. It is a wonder that no one else suffered serious injury in this incident.
Investigations are being undertaken by both the MRI company and the local police. Hopefully, further details will be released upon completion of those investigations because valuable lessons are likely to be learned to prevent similar accidents in other venues. But, this incident suggests you consider performing a FMEA (Failure Mode and Effects Analysis) in your organization or facility to see what vulnerabilities you may have if a similar set of circumstances occurred.
There are, of course, many other aspects to MRI safety than simply considering the impact of projectiles or other items being pulled into the magnetic field. In addition to the recent ACR guideline update on MRI safety (Greenberg 2019), the FDA recently published a draft guidance “Testing and Labeling Medical Devices for Safety in the Magnetic Resonance (MR) Environment” (FDA 2019). Importantly, the safety and performance of medical devices should be assessed for all of the magnetic field strengths to which that device may potentially be exposed (see our October 15, 2019 Patient Safety Tip of the Week “Lots More on MRI Safety” for comments on the introduction of 7T MRI). Devices should be tested for both magnetically induced displacement force, magnetically induced torque, gradient induced vibration of the medical device, as well as for the potential drvice heating and thermal injury. In addition, they should be tested for malfunction of medical devices or inadvertent device stinulation. And, lastly, they should be assessed for producing imaging artifacts.
Some of our prior columns on patient safety issues related to MRI:
References:
Fornell D. Nurse Injured in MRI Accident at Swedish Hospital. Metal in weighted vest believed to have caused extensive injuries that landed nurse in intensive care. Imaging Technolgy News 2019; October 25, 2019
https://www.itnonline.com/article/nurse-injured-mri-accident-swedish-hospital
Fischer JR. MR incident in Sweden lands nurse in intensive care unit. DOTmed.com 2019; October 29, 2019
https://www.dotmed.com/news/story/49000
Forrest W. Hospital staff injured in MRI accident in Sweden. AuntMinnie.com 2019; October 24, 2019
https://www.auntminnie.com/index.aspx?sec=sup&sub=mri&pag=dis&ItemID=126925
Ward P. Details emerge on MRI accident in Sweden. AuntMinnie.com 2019; October 31, 2019
https://www.auntminnie.com/index.aspx?sec=sup&sub=mri&pag=dis&ItemID=126979
Greenberg TD., Hoff MN, Gilk TB, et al. for the ACR Committee on MR Safety. ACR guidance document on MR safe practices: Updates and critical information 2019. J Magn Reson Imaging 2019; published online July 29, 2019
FDA (US Food and Drug Administration). Testing and Labeling Medical Devices for Safety in the Magnetic Resonance (MR) Environment. Draft Guidance for Industry and Food and Drug Administration Staff. DRAFT GUIDANCE August 2, 2019
https://www.fda.gov/media/129541/download
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November 12, 2019
Patient Photographs Again Help Radiologists
We’ve long been advocates of including patient photographs as a patient safety tool. But there has been a relative dearth of studies demonstrating their utiliy in this regard.
In our December 2008 What’s New in the Patient Safety World column “Patient Photographs Improve Radiologists’ Performance” we noted a paper presented at the Radiological Society of North America’s annual meeting showing that inclusion of photographs of patients improved accuracy of radiologists’ reports. Putting a photograph of the patient aside their images on a PAC screen resulted not only in the radiologists feeling more empathy toward the patient but they also identified more incidental findings (the files were chosen because of incidental findings in this randomized study) without taking more time to review the images.
Since that time, work out of Emory University has shown how else patient photographs can be very useful to radiologists. First, a small study (Tridandapani 2013) looked at whether facial and chest photographs obtained simultaneously with radiographs might increase radiologists’ detection rate of labeling errors. The researchers obtained simultaneous portable radiographs and photographs of 34 patients. They created multiple pairs of radiographs, some of which had a true match and some of which were mismatched. ). They were then given a second set of 20 pairs containing mismatches but photographs of the patients obtained at the time of imaging were attached to the radiographs. They then asked radiologists to read these blindly (they were also not told the purpose of the photographs). The error detection rates with photographs was 64%, compared to only 12.5% without photographs. Moreover, the average interpretation times without and with photographs were 35.73 and 26.51 minutes, respectively.
Then, another study (Sadigh 2015) estimated the prevalence of reported near-miss wrong-patient events in radiology at two large academic hospitals. They searched their databases for reports containing the phrases “incorrect patient” or “wrong patient.” These imaging reports were categorized into either mislabeled or misidentified patient or wrong dictation or report events. The mislabeling-misidentification events involved patients whose images were incorrectly placed in another patient's folder. In wrong dictation or report events, a patient's images were placed in the correct imaging folder, but another patient's images were used in error for dictation of the report. The estimated event rate was 4 per 100,000 examinations (mislabeling-misidentification, 52%; wrong dictation, 48%), with monthly averages of 0.7 mislabeling-misidentification events and 0.6 wrong dictation events was 0.6. Wrong dictation reports were usually identified fairly rapidly but the median time for mislabeling-misidentification reports to be identified was 22 hours. and for wrong dictation reports was 0 hours. Portable chest X-rays were were the modality most often involved (69% of reported mislabeling-misidentification and 44% of wrong dictation events). Both types of events were more common on inpatients and more common when done during off hours.
So then, Emory researchers (Tridandapani 2019) set out to see whether inclusion of patient photographs might help reduce such errors during portable X-rays. They attached smart cameras to the portable radiolography systems and took wide-angle photos of the patients simultaneously with the X-rays and the photos were included in the PACS system alongside the radiographic images. Their preliminary data detected 2 errors in the first 8000 cases. That would be a higher rate than the estimated event rate was 4 per 100,000 examinations in the study noted above. However, these numbers are still small so the statistical significance is unknown at this time.
But, the wide-angle photographs added clinical context as well. For example, the radiologists can see external portions of lines or tubes on the photographs and that helped them in determining placement of items like feeding tubes. That saved considerable time in reading and reporting results. They also noted that the simultaneous patient photographs helped avoid confusion about laterality when individual limbs were X-rayed. The authors conclude that their initial use such point-of-care photographs in cases ranging from cardiothoracic and abdominal imaging to musculoskeletal imaging was clinically beneficial.
While our initial interest in patient photographs was largely to help avoid wrong patient events, these studies out of Emory show a much broader patient safety potential. Rather than using a single facial photo taken, for example, on admission, these photos are taken simultaneously with the radiographs and add considerable clinical context. Kudos to the Emory researchers for this valuable addition to the patient safety armamentarium!
Some of our prior columns on use of patient photographs in patient safety:
December 2008 “Patient Photographs Improve Radiologists’ Performance”
January 12, 2010 “Patient Photos in Patient Safety”
June 26, 2012 “Using Patient Photos to Reduce CPOE Errors”
April 30, 2013 “Photographic Identification to Prevent Errors”
January 19, 2016 “Patient Identification in the Spotlight”
March 26, 2019 “Patient Misidentification”
References:
Tridandapani S, Ramamurthy S, Galgano SJ, Provenzale JM. Increasing Rate of Detection of Wrong-Patient Radiographs: Use of Photographs Obtained at Time of Radiography. American Journal of Roentgenology 2013; 200: W345-W352
https://www.ajronline.org/doi/pdf/10.2214/AJR.12.9521
Sadigh G, Loehfelm T, Applegate KE, Tridandapani S. JOURNAL CLUB: Evaluation of Near-Miss Wrong-Patient Events in Radiology Reports. American Journal of Roentgenology 2015; 205(2): 337-343
https://www.ajronline.org/doi/abs/10.2214/AJR.14.13339
Tridandapani S, Bhatti P, Krupinski E, et al. Initial Experience With Patient Visible Light Images Obtained Simultaneously With Portable Radiographs. American Journal of Roentgenology 2019; 0 0:0, 1-4 Published online October 8, 2019
https://www.ajronline.org/doi/abs/10.2214/AJR.19.21719
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November 19, 2019
An Astonishing Gap in Medication Safety
We’ve made remarkable progress in preventing medication errors in the hospital setting. Tools include barcoding, CPOE with clinical decision support, double checks, segregation of LASA (look-alike sound-alike) drugs in storage, ADC’s (automated dispensing cabinets) with alerts, “Do Not Disturb” vests to minimize distractions and interruptions during nurse medication rounds, smart pumps, and others. But those valuable tools are not used in multiple other healthcare venues. Recent incidents have highlighted gaps in medication safety in community vaccination programs.
This month ten people at a group home in Oklahoma were to have flu shots but were instead erroneously administered insulin (Watts 2019, Lee 2019, Giles 2019). This followed another incident just weeks earlier in which 16 high school students were erroneously injected with insulin instead of tuberculin testing for TB (Romine 2019, Bradley 2019).
Insulin is not the only dangerous medication erroneously administered in vaccination programs. In several of our columns on NMBA’s (neuromuscular blocking agents) we mentioned a paper (Koczmara 2007) that described an incident where atracurium was administered subcutaneously instead of hepatitis B vaccine to seven infants. The infants developed respiratory distress within 30 minutes. Five infants recovered, one sustained permanent injury, and another died. And in a 2014 incident in Syria, approximately 75 infants received the NMBA atracurium, instead of the measles vaccine and 15 of the infants died as a result (Kroll 2014).
The most recent insulin incident, involving 8 residents of the group home plus 2 staff members, resulted in hospitalization of all 10 people. Emergency responders found multiple unresponsive subjects at the scene. The situation was even more complicated because many of the group home residents were incapable of communicating their symptoms and needs. Apparently, the insulin preparation was a long-acting one, so several people had to be hospitalized for more than a day. The pharmacist who injected the insulin had over 40 years of experience and was a contractor who went to the facility to administer the flu shot to residents and employees.
We don’t have many details of how things went wrong in these two recent incidents, but we’ll comment in general about some of the things that could go wrong in such incidents.
Obviously, look-alike vials probably played a role. It is easy to imagine how a vial of insulin might be mistaken for a vial containing a vaccine. That is why storage of vaccines in proximity to other potentially dangerous medications is problematic. Note that in the first NMBA paper (Koczmara 2007) neuromuscular blocking agents had never been available as floor stock in the nursery. For convenience, an anesthesiologist from a nearby OR had placed the vial of atracurium in the unit refrigerator near vaccine vials of similar appearance. In the current Oklahoma incident, storage may well have played a key role. One individual at the home was apparently on insulin, and it is believed that the pharmacist accidentally grabbed the insulin out of the fridge in the group home's medicine room instead of the flu vaccine that he intended to give (Giles 2019).
In the incident where insulin was mistaken for tuberculin, both the insulin and tuberculin were apparently stored in the school nurse’s office (Bradley 2019). Media reports did not detail if they were stored in proximity or whether they were segregated.
So, a key lesson learned is that, while your own hospital or pharmacy may take steps to segregate insulin or other potentially dangerous medications from vaccines, such may not be the case when some other facility (group home, school, etc.) is storing the vaccine.
The other obvious question in the Oklahoma incident is “Didn’t the pharmacist look at the label?”. Unfortunately, many adverse medication events occur because someone failed to look at labels. That is why barcoding has been such an important contribution to medication safety in hospitals. But in the group home setting there was no electronic medical record or CPOE capability and no barcoding capability so there was no opportunity to warn the pharmacist the wrong drug/substance was about to be used.
While not applicable to the current incident, note that it is conceivable that someone could look at the vial of a vaccine at the time of administration and confirm it is the correct vaccine but still be administering a dangerous product. In the Syrian incident noted above (Kroll 2014), it was suspected that the mix-up with atracurium occurred with the solution used to reconstitute or dilute the measles vaccine. That's usually a sterile saline solution packaged together with the dried vaccine. One could picture how insulin could be mistakenly used as a diluent for any of those vaccines requiring diluents and then the person administering the vaccine would only see the label on the vaccine vial and assume that is correct.
Given that there was no barcoding as a layer of defense, you might fall back on an old technique – the independent double check. We’ve done several columns on double checks, noting that they are not infallible. They are used most often when dealing with high risk medications. But perhaps in settings lacking barcoding it may make sense to have a second person confirm the vaccine/medication being given. It sounds like the pharmacist in the Oklahoma incident was the only healthcare professional present. In hospitals, having a second set of eyes is useful even if independent double checks are not being used. Typically, a pharmacist prepares and dispenses the medication and then a nurse checks it before administering it. In the current incident there was only one person preparing and administering the vaccine.
That the pharmacist was likely solo also raises the question about monitoring after vaccine administration. Was he appropriately trained to respond to any adverse consequence of a “vaccination”? Was his attention diverted from those who had already received the “vaccination”?
In hospitals, we also try to ensure that nurses administering medications are free of distractions and interruptions. That means they are often freed up from other nursing responsibilities during medication administration and they may also use “Do Not Disturb” vests. It’s not known whether there may have been distractions or interruptions in the group home setting.
So, we wondered “Are there guidelines for doing mass vaccination programs?”. There are. The CDC has published “Guidelines for Large-Scale Influenza Vaccination Clinic Planning” (CDC 2015). The CDC guideline also has a link to a valuable skills checklist from Immunize.org for those administering the vaccines. CDC also has a “Vaccine Storage and Handling Toolkit” and Immunize.org also has a nice “Checklist for Safe Vaccine Storage and Handling”. Immunize.org has a wealth of valuable materials for those providing immunizations. One of their resources is a handout “Don’t Be Guilty of These Preventable Error s in Vaccine Administration!”, which describes common mistakes in vaccine administration.
Maybe someday computerized order entry and barcode scanning will be available in all settings. We’ll be using biometric identification, and everyone will have on record a scan of their finger or palm prints or retina or iris so we can avoid patient misidentification and we can barcode to ensure correct medications or vaccines are being given. But until that time, we need to look at how we deliver vaccinations.
If your organization provides vaccinations, what should you be asking, given the lessons in these incidents?
There are obviously many other considerations in vaccine programs. We are only considering some of the safety issues associated with the processes of vaccine programs. We refer you to many other good resources involving all those other vaccination program issues, such as the CDC guidelines, Immunize.org resources, and ACIP (ACIP, Ezeanolue 2019) recommendations.
Fortunately, such serious incidents related to vaccination are very rare, but now is a good time for all organizations that provide vaccinations to review their practices. This is a good topic for a FMEA (Failure Mode and Effects Analysis) to identify potential vulnerabilities.
References:
Watts A, Spells A. 10 hospitalized after insulin administered instead of flu shots. CNN 2019; November 8, 2019
https://www.cnn.com/2019/11/07/us/oklahoma-flu-shot-mix-up/index.html
Lee BY. 10 People Got Insulin Instead Of The Flu Shot. Forbes 2019; November 8, 2019
Giles G. Insulin Case Being Handled by Board of Pharmacists. Bartlesville Radio 2019; November 14, 2019
Romine T. 16 students in Indiana were accidentally injected with insulin during a TB test, school district says. CNN 2019; September 30, 2019
https://www.cnn.com/2019/09/30/health/16-students-accident-indiana/index.html
Bradley D, Sánchez R, Ridle C. Student, mother intend to sue after insulin mix-up at McKenzie Center. Theindychannel.com 2019; October 3, 2019
Koczmara C, Jelincic V. Neuromuscular blocking agents: Enhancing safety by reducing the risk of accidental administration. ISMP Canada 2007 in the Spring 2007 publication of the Canadian Association of Critical Care Nurses (CACCN).
http://www.ismp-canada.org/download/CACCN-Spring07.pdf
Kroll D. Vaccine Mix-Up In Syria Not Uncommon In US, Canada. Forbes 2014; September 18, 2014
CDC. Guidelines for Large-Scale Influenza Vaccination Clinic Planning. CDC 2015; December 16, 2015
https://www.cdc.gov/flu/professionals/vaccination/vax_clinic.htm
Immunize.org
Immunize.org. Skills Checklist
https://www.immunize.org/catg.d/p7010.pdf
Immunize.org. Don’t Be Guilty of These Preventable Error s in Vaccine Administration!
https://www.immunize.org/catg.d/p3033.pdf
CDC. Vaccine Storage and Handling Toolkit. CDC
https://www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf
Immunize.org. Checklist for Safe Vaccine Storage and Handling.
https://www.immunize.org/catg.d/p3035.pdf
ACIP (Advisory Committee on Immunization Practices). ACIP Vaccine Recommendations and Guidelines.
https://www.cdc.gov/vaccines/hcp/acip-recs/index.html
Ezeanolue E, Harriman K, Hunter P, Kroger A, Pellegrini C. General Best Practice Guidelines for Immunization. Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP). Accessed on November 16, 2019.
https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/downloads/general-recs.pdf
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November 26, 2019
Pennsylvania Law on Notifying Patients of Test Results
We’ve done many columns, listed below, on serious patient injuries occurring when significant test or imaging findings are not promptly conveyed to responsible physicians or to patients. There are many reasons, related to both human factors and system issues, that significant results “fall through the cracks”. Responsibility to ensure closing the loop is the responsibility of the ordering physician, the radiologist/imager (or lab for lab test results), the physician primarily responsible for management of the patient, and the patient him/herself.
We’ve described systems that need to be put into place to help avoid such failures. Physicians ordering a test or imaging study need to have some sort of tickler mechanism that alerts them when results of a test or study have not been received within a specified time frame. Especially problematic is when the ordering physician is different from the physician primarily responsible for management of the patient. Such vulnerability is often seen when patients are hospitalized or seen in an emergency department (ED) and the formal report of that study is not yet available when the patient is discharged. Systems must be put in place to alert the next care physician that there is a “pending” test result so that that physician can appropriately follow up.
Patients also have a responsibility. After all, it is their health and well-being that is at risk. We always counsel patients that “no news is not good news” and that they should always discuss with their physician how test results will be communicated to them and that they need to contact the physician if they have not heard from him/her within a reasonable time.
Lastly, the radiologist or other imager (or the lab in the case of lab testing) has a responsibility to make sure the presence of any significant finding gets communicated to the responsible physician and, ultimately, the patient. Failure to communicate significant findings is also a factor in a large percentage of malpractice claims against radiologists.
To address the latter issue, Pennsylvania has passed a new law, the “Patient Test Result Information Act” (Pennsylvania General Assembly 2018), that will go into effect in December 2019. The act requires that the patient be directly notified within 20 days when a diagnostic imaging exam is performed that identifies a “significant abnormality” may exist. “Significant abnormality” is defined as one that “would cause a reasonably prudent person to seek additional or follow-up medical care within three months.” The law was actually passed in 2018 but implementation was delayed until December 2019 in order to give hospitals and imaging practices time to implement systems to facilitate compliance.
Here’s what the “Patient Test Result Information Act” (Pennsylvania General Assembly 2018) says:
“When, in the judgment of the entity performing a diagnostic imaging service, a significant abnormality may exist, the entity performing the diagnostic imaging service shall directly notify the patient or the patient's designee by providing notice that the entity has completed a review of the test performed on the patient and has sent results to the health care practitioner who ordered the diagnostic imaging service. The notice shall include all of the following:
(a)
(1) The name of the ordering health care practitioner.
(2) The date the test was performed.
(3) The date the results were sent to the ordering health care practitioner.
(4) The following statements:
‘You are receiving this notice as a result of a determination by your diagnostic imaging service that further discussions of your test results are warranted and would be beneficial to you.’
‘The complete results of your test or tests have been or will be sent to the health care practitioner that ordered the test or tests. It is recommended that you contact your health care practitioner to discuss your results as soon as possible.’
(5) The contact information necessary for the patient to obtain a full report.
(b) Exceptions.- The following shall be exempted from the requirements of subsection (a):
(1) Routine obstetrical ultrasounds used to monitor the development of a fetus.
(2) Diagnostic imaging services performed on a patient who is being treated on an inpatient basis or in an emergency room.
(3) Diagnostic radiographs.”
Apparently, a separate notice is not required if the patient was told of the result at the time of the visit or if the patient was given a copy of the report during the visit.
Note that the act specifically exempts 2 scenarios we mentioned above as significant vulnerabilities – patients admitted to hospitals or seen in the ED. It also exempts “diagnostic radiographs” from the notification requirement. We don’t know why the latter would be exempted since one of the most common scenarios is an X-ray ordered looking for pneumonia may yield a significant unrelated finding.
While it is critical that patients be informed about significant findings on imaging studies, imagine yourself (as a patient) getting such a notice by mail! You’d probably panic! Therefore, many imaging practices will contact and discuss with the physician responsible for management of the patient, then delay for several days sending out the notice to the patient (so sufficient time has elapsed for the patient’s physician to discuss the findings with the patient).
A recent article in the Journal of the American College of Radiology (Mittl 2019) discusses how imaging practices in Pennsylvania are complying with the new law. Some organizations or groups are using a “hard-stop” approach. That means the imager, when dictating his/her report, would indicate whether a patient notification is required. Some include a sentence at the end of the report that then gets incorporated into an automated letter of notification to the patient. Yet others use standardized language within the report to flag cases that require a letter to the patient.
Flagging significant findings that merit follow up and tracking for that follow up can be difficult, given that sometimes items can appear in different fields in electronic medical records. One article (Farrington 2019) discusses use of AI (artificial intelligence) and NLP (natural language program) or machine learning to identify these items in different parts of the EMR.
The Farrington article also notes corrupt speech files often cause incorrect dictation. We’ve previously discussed problems with voice dictation software in radiology (see our Patient Safety Tips of the Week October 4, 2011 “Radiology Report Errors and Speech Recognition Software” and July 24, 2018 “More on Speech Recognition Software Errors”).
But, besides needing such a process to flag reports that require patient notification, imagers face other challenges in communicating the need for follow up to the responsible parties. One problem encountered too frequently is inability to correctly identify the physician responsible for management of the patient. Sometimes the ordering physician is different from the physician responsible for management of the patient (it might be a covering physician or a physician rotating through an outpatient clinic). In other cases, the name of the wrong physician is entered into the radiology IT system. Another problem we’ve seen in some hospital electronic medical record systems is that the number of physician ID fields is limited and sometimes the field for the patient’s PCP (primary care physician) gets used for other purposes. The other problem, of course, is when the patient changes PCP’s and the systems are not updated to reflect the change. Therefore, it is always wise to ask the patient at the time they register for the imaging study who is their responsible physician and to whom they want reports to be sent. (But please see our October 13, 2009 Patient Safety Tip of the Week “Slipping Through the Cracks” in which we cite a paper (Singh 2009) that demonstrated dual alerts (those sent to both the referring physician and the primary care physician) were twice as likely to go unacknowledged.)
Organizations and practices also need to determine how to notify patients of the significant findings. Apparently, the notice may be delivered to the patient using any one of the following methods, as long as it is acceptable to the patient (HAP USA 2018):
Thus, it would make sense to, at the time of patient registration for the imaging study, notify the patient of the new law’s requirement, and ask them not only which physicians they want the report sent to, but also what method they themselves prefer if such notification is necessary.
But, note that we do not recommend faxing the reports to patients. We highlighted the surprising continued role faxes still play in healthcare and the problems associated with them in our January 16, 2018 Patient Safety Tip of the Week “Just the Fax, Ma’am” and the several other columns listed below. The risk of violating patient privacy is too great. Not only does it risk having a relative or coworker read the letter, but the last thing you want is your faxed letter erroneously going to a local supermarket or other unintended phone number!
Then there is the problem of tracking whether the patient actually gets appropriate follow up. Some radiology IT systems help track whether a patient has had a recommended follow up. But those may not find instances where such follow ups were done at a facility outside their own organization(s). In other cases, the findings may have been discussed by the responsible physician and the patient, but the decision was made, for whatever reason, not to pursue follow up. The radiology practice would have no way of knowing that. For example, an imaging practice in the Northeast might look for follow up on a patient who happens to be a “snowbird”, wintering in Florida. That patient may well have had the recommended follow up in Florida but records of that follow up may not be available to the Northeast imaging practice.
We are cautiously optimistic that the new Pennsylvania law will reduce the number of cases of serious findings “slipping through the cracks”. Measuring its impact may be difficult. Probably the only way to do this will be to look at malpractice claims and that may not provide an accurate picture. We would also be on the alert for potential unintended consequences. We’re also concerned that the exemptions for patients hospitalized or seen in the ED and those for plain radiographs will leave unaffected areas we see as especially vulnerable.
The new Pennsylvania law is a start. Imagers are but one of several persons who must be responsible for ensuring adequate tracking and follow up of studies ordered and/or done on patients. See our prior columns, listed below, for comments on what each person should be doing to avoid “slipping through the cracks”.
See also our other columns on communicating significant results:
See our prior columns on problems related to use of fax in healthcare:
June 19, 2012 “More Problems with Faxed Orders”
January 16, 2018 “Just the Fax, Ma’am”
September 2018 “ECRI Institute Partnership: Closing the Loop”
January 2019 “Still Faxing?”
References:
Pennsylvania General Assembly. PATIENT TEST RESULT INFORMATION ACT – ENACTMENT. Act of Oct. 24, 2018, P.L. 719, No. 112 Cl. 35
https://www.legis.state.pa.us/cfdocs/legis/li/uconsCheck.cfm?yr=2018&sessInd=0&act=112
Mittl GS. Hill PA, Cook TS, et al. Ensuring Patient Follow-up of Significant Abnormalities Under Pennsylvania Act 112. Journal of the American College of Radiology 2019; Published online: September 28, 2019
https://www.jacr.org/article/S1546-1440(19)31104-4/fulltext
Farrington R. How to protect your practice from missed follow-ups. AuntMinnie.com 2019; October 7, 2019
https://www.auntminnie.com/index.aspx?sec=sup&sub=imc&pag=dis&ItemID=126733
Singh H, Thomas EJ, Mani S, et al. Timely Follow-up of Abnormal Diagnostic Imaging Test Results in an Outpatient Setting. Arch Intern Med. 2009; 169(17): 1578-1586
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/224747
HAP USA (Healthcare Administrative Partners). Pennsylvania’s “Patient Test Result Information Act”. HAP USA 2018; December 21, 2018
https://info.hapusa.com/blog-0/pennsylvanias-patient-test-result-information-act
Print “Pennsylvania Law on Notifying Patients of Test Results”
December 3, 2019
Overlapping Surgery Back in the News
We’ve long been critical of overlapping surgery. It’s now been over 4 years since the Boston Globe’s Spotlight investigative series (Abelson 2015) ignited the controversy on double-booked surgery and led to a subsequent review by the Senate Finance Committee (Senate Finance Committee 2016). It didn’t take long for everyone to agree that concurrent surgery (where critical parts of two surgeries might be taking place simultaneously) should be banned but we’ve been left with the debate about “overlapping” surgery.
Over subsequent years there have been multiple retrospective cohort studies purporting to demonstrate the safety of overlapping surgery and very few noting an increased risk of complications with overlapping surgery. So, the debate has largely stayed out of the media. That is, until the last few weeks. Once again, the Boston Globe Spotlight team brought renewed attention to the issue with 3 new stories.
In the first (Saltzman 2019a), it was revealed that the Massachusetts General Hospital paid a settlement of $13 million for wrongful termination to the surgeon who was dismissed from the MGH who had been critical of the practice of double-booked surgery. The settlement included offering that surgeon his old job back at the MGH (which he has declined) and naming a patient safety initiative for him.
A day later, it was revealed that a second major hospital chain agreed to a multi-million dollar settlement to resolve concerns over concurrent surgery (Saltzman 2019b). The claim was paid in part to three whistle-blowers who claimed that a urologist allowed trainees to perform surgery without proper supervision while he operated on patients in another room. And part was paid to the federal government because the hospital system had billed Medicare for operations performed by the trainees. And yet another malpractice settlement was announced recently against a surgeon who did as many as 14 operations a day, sometimes 3 at one time (Taylor 2019, Mulder 2019).
The third Boston Globe story (Saltzman 2019c) cited materials from the court file of the recently settled wrongful termination lawsuit against MGH. You’ll recall that, after the first Spotlight report, the MGH responded with a fact sheet and multiple posts on its website. It noted that it had done a review of concomitant surgery cases done in calendar year 2014 and found that the rate of complications was no higher than for cases of single (non-overlapping) surgery. The MGH did revise its policy and procedure on concomitant surgery in 2012. But the materials from the recent wrongful termination suit do appear to identify several cases in which complications happened while primary surgeons were off in different OR’s. See that last Boston Globe article for details. The Globe had also reported earlier in 2019 (Saltzman 2019d) on a settlement in a malpractice made by former major league baseball pitcher, Bobby Jenks, regarding complications of spine surgery in which had had not been told his surgeon was overseeing a second simultaneous operation.
The Seattle Times has done a series of articles on overlapping surgery at Seattle’s Swedish Cherry Hill Hospital. The initial article described a case in which a young woman with Ehlers-Danlos Syndrome died from post-operative complications of spine surgery (Baker 2017a). The primary problems described centered more around lack of physical presence of the primary surgeon post-operatively and failure to rescue. But subsequent articles focused on the practice of double-booked surgeries. In one article (Baker 2017b), the newspaper interviewed 13 patients who were treated in double-booked procedures and found that none recalled being told the surgeon would not be in the room for the entire procedure. The Times reported some detailed time schedules showing 4 surgeons routinely participating in overlapping in 50-70+ percent of their cases and showed that some cases had significant overlapping. Following the series of articles, the hospital CEO and a top neurosurgeon resigned, and the hospital revised its policy on overlapping surgery.
Pennsylvania Patient Safety Authority analysts queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) database for events involving concurrent and overlapping surgery and procedures in hospitals and ambulatory surgical facilities that occurred during calendar year 2017 (PPSA 2019). They identified 15 events in which the narrative or recommendations indicated that the surgeon was operating in more than one room at the same time (i.e., overlapping); for example, the attending surgeon started the second case while the resident was closing the first case. Eleven of these events indicated that the overlap contributed to the reason for which the event was reported; for example, the overlap contributed to a delay in starting the next case. None of the 15 events resulted in patient harm.
In our March 12, 2019 Patient Safety Tip of the Week “Update on Overlapping Surgery” we discussed multiple large retrospective studies (Sun 2019, Ponce 2018, Hyder 2018, Goldfarb 2018, Dy 2018) that were supportive of overlapping surgery, noting that overall complication rates or mortality rates were as good or better than those from non-overlapping cases.
Since that last column on overlapping surgery, there have been several more studies published in the medical literature touting the safety of overlapping surgery. Howard and colleagues (Howard 2018) did a retrospective cohort study of patients who underwent neurosurgical procedures at Emory University Hospital over a 2 year period. A total of 2275 patients underwent neurosurgery, 42.7% were nonoverlapping and 57.3% were overlapping. Overlapping surgery (OS) was more frequently elective. Regression analysis failed to demonstrate an association between OS and complications, As we’ve seen in almost all prior studies, median surgical times were significantly longer for patients in the OS cohort vs the nonoverlapping surgery cohort (in-room time, 219 vs 188 minutes; skin-to-skin time, 141 vs 113 minutes). The authors conclude their data suggest that OS can be safely performed if appropriate precautions and patient selection are followed.
Another study on 1018 neurosurgical and spine patients found no significant difference in overall or serious complications between those having overlapping surgery and those having non-overlapping surgery (Guan 2016). Another study (DiGiorgio 2018) compared before and after results when the neurosurgery service at an academic, safety-net hospital transitioned from routinely allowing one room per day (period one) to overlapping rooms (period two), with the second room being staffed by the same attending surgeon. Allowing overlapping rooms significantly reduced length of stay and complication rate and increased the rate of discharges to home in a population significantly weighted toward uninsured and Medicaid patients.
While most studies on overlapping surgery have looked at orthopedic, spine, or neurosurgical procedures, a recent study analyzed patients undergoing plastic surgery. Parikh et al. (Parikh 2019) did a retrospective cohort study of 866 consecutive patients undergoing plastic surgery procedures (35.9% overlapping, 64.1% non-overlapping) at a tertiary academic center over a 2 year period. They found no differences in complications, reoperations, readmissions, or emergency room visits between the 2 groups.
So, how do we reconcile all these studies showing that overlapping surgery seems to be safe and not associated with more complications with those isolated or anecdotal reports of complications that appear to be related to the practice? The answer is clear to us: statistical dilution.
We think the recent disclosures about the MGH experience hit home on a point we have made over and over. The MGH review of concomitant surgery cases done in calendar year 2014 probably really did show that the rate of complications was no higher than for cases of single (non-overlapping) surgery. Yet, the recent revelations appear to show that there were complications. Complications, particularly ones with serious patient consequences, are not common events. So, when anyone reports on a large series of overlapping surgery, the serious events are likely to get “buried” or “diluted out”. In fact, the bigger the series, the less likely we are to identify cases in which the overlap contributed to an adverse outcome. Given that a randomized controlled trial is not likely to ever take place, the only real way to determine whether overlapping surgery caused or contributed to such events is to perform root cause analysis of all cases with adverse events, a time- and resource-intensive process.
There is a second problem with those retrospective reviews: even in those studies that used propensity score adjustments to minimize bias, there is likely an element of selection bias. There is really no way from administrative data or even chart review to fully understand why non-overlapping surgery was chosen over overlapping surgery or vice versa. It is quite likely that surgeons may avoid overlapping surgery in patients they consider to be at more risk. Note that the subgroup analysis in the Sun study (Sun 2019) did indicate that complications may be more common with overlapping surgery in more complex cases. So, when we see a retrospective cohort study that says patients undergoing overlapping surgery do better than those with non-overlapping surgery, we are not at all surprised. If they are less at risk, they should have fewer complications. And, in our March 12, 2019 Patient Safety Tip of the Week “Update on Overlapping Surgery” we also speculated there might be an element of publication bias as well.
Those of us involved in patient safety have all seen instances in which overlapping surgery was a contributing factor to or root cause of an adverse event. And just because the population-based studies seem to show a relative safety of overlapping surgery, it does not mean we don’t need to pay attention to the dangers. Wrong-site surgery and retained surgical items are also relatively rare events. Yet we strive to prevent all such cases of those. Why should events related to overlapping surgery be treated differently?
Our December 19, 2017 Patient Safety Tip of the Week “More on Overlapping Surgery” had our detailed comments on the following considerations for overlapping surgery:
We hope you’ll go back to that column (and all our columns listed below) to see our arguments against the practice of overlapping surgery. However, even though we personally would not consent to undergo overlapping surgery, we are pragmatic and understand the practice is not likely to go away any time soon. Therefore, we developed our “Overlapping Surgery Checklist” to help guide you in planning for safe implementation.
AORN (Association of periOperative Registered Nurses) also recently noted 3 tips from Pat Turner, RN, BSN, MPA on patient safety actions nurses can take in relation to overlapping surgery (AORN 2019):
See our previous columns on double-booked, concurrent, or overlapping surgery:
And our “Overlapping Surgery Checklist”
References:
Abelson J, Saltzman J, Kowalcyzk L, Allen S. Clash in the Name of Care. Boston Globe October 26, 2015
http://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/
Senate Finance Committee. Concurrent and Overlapping Surgeries: Additional Measures Warranted. A Senate Finance Committee Staff Report 2016; December 6, 2016
http://www.finance.senate.gov/imo/media/doc/Concurrent%20Surgeries%20Report%20Final.pdf
Saltzman J. MGH settles for $13m with doctor who challenged double-booked surgeries. Boston Globe 2019; November 7, 2019
Saltzman J. Second major hospital chain agrees to pay millions to resolve concerns over concurrent surgery. Boston Globe 2019; November 8, 2019
Taylor A. Jury: Orthopedic Surgeon's Routine of Performing 14 Concurrent Surgeries a Day Negligent. $2M verdict in 'assembly line' surgery case. Outpatient Surgery 2019; Published: August 6, 2019
Mulder JT. CNY malpractice case reveals 'assembly line’: 14 operations a day, 3 at one time. Syracuse.com 2019; Jul 30, 2019
Saltzman J. Double-booked surgery cited in death at Mass. General, records indicate
Boston Globe 2019; November 23, 2019
Saltzman J. Former Red Sox pitcher settles claim with doctor, MGH for $5.1 million. Boston Globe 2019; May 8, 2019
Baker M. A Lost Voice. Seattle Times 2017; Published February 10, 2017
https://projects.seattletimes.com/2017/quantity-of-care/talia/
Baker M, Mayo J. Swedish double-booked its surgeries, and the patients didn’t know. Seattle Times 2017; May 28, 2017
PPSA (Pennsylvania Patient Safety Authority). Incidence of Concurrent Surgery in Pennsylvania . Pa Patient Saf Advis 2019; 16(1) March 2019
http://patientsafety.pa.gov/ADVISORIES/Pages/201903_ConcurrentSurgery.aspx
Sun E, Mello MM, Rishel CA, et al. Association of Overlapping Surgery With Perioperative Outcomes. JAMA 2019; 321(8): 762-772
https://jamanetwork.com/journals/jama/article-abstract/2725689
Ponce BA, Wills BW, Hudson PW, et al. Outcomes With Overlapping Surgery at a Large Academic Medical Center. Annals of Surgery 2018; Publish Ahead of Print - February 1, 2018
Hyder JA, Hanson KT, Storlie CB, et al. Assessing the Safety of Overlapping Surgery at a Children's Hospital. Annals of Surgery 2018; Publish Ahead of Print – January 25, 2018
Goldfarb CA, Rizzo MG, Rogalski BL, et al. Complications Following Overlapping Orthopaedic Procedures at an Ambulatory Surgery Center. The Journal Of Bone And Joint Surgery 2018; 100(24): 2118-2124
Dy CJ, Osei DA, Maak TG, et al. Safety Of Overlapping Inpatient Orthopaedic Surgery. The Journal Of Bone And Joint Surgery 2018; 100(22): 1902-1911
Howard BM, Holland CM, Mehta CC, et al. Association of Overlapping Surgery With Patient Outcomes in a Large Series of Neurosurgical Cases. JAMA Surg 2018; 153(4): 313-321
https://jamanetwork.com/journals/jamasurgery/fullarticle/2661297
Guan J, Brock A, Karsy M, et al. Managing overlapping surgery: An analysis of 1018 neurosurgical and spine cases. Journal of Neurosurgery 2016; 127: 1-9
https://thejns.org/view/journals/j-neurosurg/127/5/article-p1096.xml
DiGiorgio A. Change in Policy Allowing Overlapping Surgery Decreases Length of Stay in an Academic, Safety-net Hospital. Paper presented during the 2018 American Association of Neurological Surgeons (AANS) Annual Scientific Meeting. As noted in:
American Association of Neurological Surgeons. Press release: Change in Policy Allowing Overlapping Surgery Decreases Length of Stay in an Academic, Safety-net Hospital. 26-Apr-2018
Parikh RP, Sharma K, Thornton M, et al. Overlapping Surgery in Plastic Surgery
An Analysis of Patient Safety and Clinical Outcomes. Plast Reconstr Surg 2019; 143(6): 1787-1796
Our own “Overlapping Surgery Checklist”.
http://www.patientsafetysolutions.com/docs/Overlapping_Surgery_Checklist.htm
AORN (Association of periOperative Registered Nurses). Overlapping Surgeries: 3 Patient Safety Actions Nurses Can Take. AORN 2019; September 25, 2019
Print “Overlapping Surgery Back in the News”
December 10, 2019
Dialysis Line Dislodgements
We’ve previously discussed cases of dialysis patients suffering massive blood loss after their dialysis catheters became dislodged (see our Patient Safety Tips of the Week for March 26, 2007 “Alarms Should Point to the Problem” and April 25, 2017 “Dialysis and Alarm Fatigue”).
Last year, The Renal Association (UK) was made aware of three cases over a period of several months of disconnections during hemodialysis treatment with consequent significant blood loss and/or suspected air embolism (The Renal Association 2018a).
We first discussed a dialysis catheter disconnection incident in our March 26, 2007 Patient Safety Tip of the Week “Alarms Should Point to the Problem”. An ESRD patient was having his regularly scheduled dialysis session. Since he would be in the dialysis center for several hours, he was in a comfortable lounge chair that tipped back. Also, since it was somewhat cool, he was offered a blanket to keep warm. Midway through the dialysis session, the low-pressure alarm rang. The nurse turned off the alarm and eyeballed the patient and saw no blood. Nothing further was done. Soon thereafter the low pressure alarm triggered again. This time it was recognized that the dialysis catheter had become dislodged and the patient had, in fact, had considerable blood loss. It had not been appreciated immediately because the blanket had been covering up the catheter site and the blood, rather than being visible on the floor, had been pooling in the webbing of the lounge chair.
The thrust of our March 26, 2007 Patient Safety Tip of the Week “Alarms Should Point to the Problem” was that alarm system setups should focus visual attention to that part of the system where the problem originates. Anyone who has ever spent time in an ICU or other high tech medical environment knows that the usual first response to an alarm is to turn the alarm off. Proper design of medical equipment therefore should force the responder to focus on the source of the problem. In the case at hand, the equipment and alarm were on the side of the patient opposite from the involved limb so that the visual attention of the responder was not directed immediately to the site the alarm was drawing attention to.
A second consideration is the complexity of the alarm screen. That complexity may lead to responders simply taking the easy way out and clearing the alarm, particularly if they anticipate the alarm will be re-triggered if something serious is really going on. The most reliable patient safety interventions are forcing functions. We’ve, therefore, suggested that these alarm systems program in a “hard” stop for this particular alarm that requires the responder to verify that he/she has inspected the access site. That verification should then become part of the medical record.
In our April 25, 2017 Patient Safety Tip of the Week “Dialysis and Alarm Fatigue” we discussed a case with striking similarities to that in our previous column (CDPH 2017). A patient admitted with an MI suffered deterioration of his chronic renal disease and was begun on continuous renal replacement therapy (CRRT) with a femoral catheter for dialysis access (technically, it was continuous veno-venous hemofiltration or CVVH). For comfort, the patient was covered with a blanket, which obscured the catheter access site. Unfortunately, at some point the return line became loose and disconnected from the femoral catheter which caused massive blood loss and cardiac arrest. He received CPR and blood transfusions and was resuscitated but died several days later. That case had a cascade of errors that all contributed to the fatal incident (see the prior column for details) but, once again, failure to heed the alarm was a major one.
In both the cases described in our prior columns, blankets had obscured the access sites. In another case of a dislodged dialysis needle (Fields 2010), a blanket also covered the access site. So, that is a recurrent theme. Use of the blankets is a well-intentioned effort to keep the patients comfortable. But it obviously subverts the recommendation to maintain visualization of the access site at all times. We’ve previously recommended that, if a blanket is necessary, it should be one that has a substantial cut-out section that allows adequate visualization of the access site.
In their review of hemodialysis emergencies, Saha and Allon (Saha 2017) discuss venous needle dislodgement (VND) as a rare but life threatening complication of hemodialysis, noting that at a typical dialysis blood flow of 300–500 ml/min, hemorrhagic shock ensues within minutes (after loss of 30%–40% of total blood volume). They note the following major factors leading to needle dislodgement:
They describe the role of the venous alarm monitor but note that multiple factors aside from venous pressure can affect the alarm. Plus, there are differences in venous pressure between grafts and fistulas. As a result of wide variation in venous pressures, staff often set the alarm thresholds at levels below that at which a dislodgement should have triggered an alarm.
They then discuss various sensors that can detect blood leaks during VND. They note the tradeoff between safety and cost. Although blood sensors add substantially to the cost (one of the more popular sensors adds about $550), they suggest that such might be considered in high-risk patients and patients on home hemodialysis They caution, however, against overreliance on such sensors and note there is no substitute for adherence to good practices, such as those outlined by the American Nephrology Nurses’ Association (ANNA).
Axley et al. (Axley 2012) described the work of the American Nephrology Nurses’ Association (ANNA) Venous Needle Dislodgement Special Project Workgroup, which reviewed recommendations of care for venous needle dislodgement prevention and detection. They developed a set of easy-to-use tools outlining their recommendations. These focused especially on the procedures for taping and positioning of needles and lines. But they stressed that vascular access and needles should be visible at all times during hemodialysis. Checking the vascular access should be part of the monitoring routine. And, most importantly, “When the venous pressure alarm is activated, the vascular access, needle sites, and blood line positions should always be inspected prior to resetting the alarm and/or the alarm limits.” They also discussed the importance of patient and staff education about needle dislodgement, including caution that alarm systems are not infallible. They also included a risk assessment tool to help identify patients at high risk for venous needle displacement. When such high risk patients are identified, they suggest interventions such as stabilizing the access limb, using one-on-one monitoring, and consideration of a blood leak detection device.
Likewise, The Renal Association (The Renal Association 2018a) recommends that connections and lines are kept in full view of dialysis staff during dialysis, secured with tape if necessary, and that any alarm should prompt visual inspection of these. It is customary in most units to place the dialysis machine on the same side as patient access, a practice we have recommended since our first column. They recommend local dialysis nursing supervision guidelines should be adhered to, though these vary from unit to unit. Some units have double-checking of line connections by 2 nurses included in their protocols for starting dialysis.
The exact incidence of dialysis needle dislodgement is unknown but the Fields article (Fields 2010) quotes a patient survey that found 5% of dialysis patients had a needle dislodge mid-treatment within the previous three months. Saha and Allon (Saha 2017) gave estimates of the incidence of venous needle dislodgement at 1 in 60,00 to 70,000 dialysis sessions, though it occurred in 1 in 11,000 sessions in Canadian studies of home hemodialysis. Though these statistics might make the issue seem rare, the fact that so many of these cases are fatal belies the seriousness of the problem.
Hemorrhage from dislodged venous access is not the only problem. In that original alert (The Renal Association 2018a), The Renal Association noted it had also been made aware of a patient death after femoral dialysis catheter removal, due to haemorrhage. In a subsequent alert (The Renal Association 2018b), it noted that the National Reporting and Learning System of NHS Improvement provided an analysis of reports of harm from late bleeding following femoral line removal in the last 3 years. Six incidents were reported. Of these, 3 resulted in patient deaths (including the incident reported above) and 2 others resulted in the major blood loss of over 1 liter of blood.
The Renal Association recommends the following precautions and patient monitoring when the removal of a femoral dialysis catheter is planned:
Subsequently, a national guideline was developed in the UK. The Renal Association, The British Renal Society, and The Intensive Care Society developed a “Recommendation for the safe removal of a temporary femoral dialysis line.” (BRS 2019).
Fatal hemorrhage in dialysis patients is not confined to those actually undergoing a dialysis treatment. Jose and colleagues (Jose 2017) reviewed reports on episodes of death due to vascular access bleeding in Australia and New Zealand over a 14-year period, together with individual dialysis units’ root cause analyses on each event. They note that data from Australia and New Zealand and from the US show that the majority of fatal bleeds occur from spontaneous access rupture away from the dialysis facility (most often at home, assisted living, or a nursing home), and it is therefore likely that the family and caregivers are confronting these large bleeds rather than dialysis unit staff. Hence, the importance of educating patients and their families or caregivers on what to do in case of such bleeding.
They identified 3 broad groups of causal factors for fatal vascular access hemorrhage (FVAH), noting these may operate independently or in combination:
Risk factors they identified included access with a central vascular catheter (CVC) or a synthetic AV graft (AVG). (Note that the hemorrhage risk with CVC’s may relate more to catheter disconnection than to needle displacement). Physical location of the vascular access may also be important, with thigh vascular access overrepresented. Infection at the access site is also a risk factor. Finally, where the person is when the bleed occurs
may be an important risk for death. Lack of readily available expertise to manage the bleeding may explain why fatal bleeding is more common when patients were in the community (home or nursing home), rather than during a dialysis session.
Due to several reported incidents of life-threatening bleeding (LTB) or life-threatening hemorrhages (LTH) from arteriovenous fistulae (AVF) and grafts (AVG), the British Renal Society Vascular Access Special Interest Group has compiled recommendations for managing life-threatening bleeds from AV fistula /grafts (BRS 2018). Patients, carers, transport staff and emergency care staff should be educated about the action to take in the event of a LTB from an AVF/AVG.
.·Patients should dial 999 (911 in the US) immediately,for any bleeding which soaks through a dressing despite direct pressure.
oThe priority for patients in this situation is to get help
oThis should not be delayed whilst trying to stop the bleeding, as loss of consciousness can occur quickly in a life-threatening bleed
oThe priority is to stop the bleeding, not preserve AVF or AVG function
Their “Do’s and Don’ts” are also very informative:
References:
The Renal Association (UK). Severe blood loss in haemodialysis patients from dialysis line disconnection and femoral catheter removal. July 23, 2018
CDPH (California Department of Public Health). Complaint Intake Number: CA00471877; posted 4/20/2017
http://www.cdph.ca.gov/certlic/facilities/Documents/2567_Kaiser220012544_IJAP_SanFrancisco.pdf
Fields R. When Needles Dislodge, Dialysis Can Turn Deadly ProPublica 2010; Nov. 10, 2010
https://www.propublica.org/article/when-needles-dislodge-dialysis-can-turn-deadly
Saha M, Allon M. Diagnosis, Treatment, and Prevention of Hemodialysis Emergencies. Clinical Journal of the American Society of Nephrology 2017; 12(2): 357-369
https://cjasn.asnjournals.org/content/12/2/357
Axley B, Speranza-Reid J, Williams H. Venous needle dislodgement inpatients on hemodialysis. Nephrology Nursing Journal 2012; 39(6): 435-445
https://www.annanurse.org/download/reference/journal/vndArticle.pdf
The Renal Association (UK). Patient Safety Alert: response to reported death from blood loss following removal of a temporary femoral dialysis catheter. November 29, 2018
The Renal Association, The British Renal Society, The Intensive Care Society. Recommendation for the safe removal of a temporary femoral dialysis line. Accessed December 7, 2019
Jose MD, Marshall MR, Read G, et al. Fatal Dialysis Vascular Access Hemorrhage. Am J Kidney Dis 2017; 70(4): 570-575
https://www.ajkd.org/article/S0272-6386(17)30749-7/pdf
British Renal Society. Recommendations for Managing Life-Threatening Bleeds from AV Fistulae/Grafts. Accessed December 7, 2019
British Renal Society. Information for Patients. Arteriovenous fistula (AVF) or graft
https://renal.org/wp-content/uploads/2018/07/Information-for-Patients-AVF-and-graft-BRS-Final.pdf
Print “Dialysis Line Dislodgements”
December 17, 2019
Tale of Two Tylers
Back in our days in Western New York, the Buffalo Sabres hockey team had a player named Tyler Ennis and the Syracuse University basketball team had a player named Tyler Ennis. They used to joke about getting mixed up. People would ask the basketball Tyler Ennis if he was a hockey player, and vice versa.
It was funny then. But not so funny recently, when x-rays from one Tyler Ennis were mistaken for those on the other Tyler Ennis (Mendes 2019). Hockey Tyler Ennis had suffered a broken bone in his ankle after taking a puck to the ankle while playing for the Toronto Maple Leafs in 2018. He anticipated having to miss 1-2 months of the hockey season. But he then received a call from the medical staff saying he had a severely displaced fracture, that would likely end his hockey season. Stunned by the bad news, Ennis said to the medical staff right away “But you said this wasn’t displaced,” as Ennis remembered them saying at the time of the injury. Confused, the medical staff went back and re-examined the image. It turns out they did have the X-ray image of a badly displaced ankle bone from Tyler Ennis. But it was the x-ray of Basketball Tyler Ennis. The latter had been playing basketball overseas on a team affiliated with the Toronto Raptors basketball team and had suffered a leg fracture around the same time. He had returned to Toronto to rehab the injury.
Of course, two factor patient identification verification should have prevented this mix up since the two players had different ages and different dates of birth. But one can easily understand how two individuals with a relatively uncommon name get misidentified.
Now, admittedly, we do not know the details of how the mix up occurred. We don’t know if a radiology staff person located actual films and gave them to the medical staff or whether the medical staff looked at digital films on the electronic medical record (EMR) or radiology PACS system. One can suspect what might have happened to lead to this mix up. Likely, a computer search for "Tyler Ennis" (in an electronic medical record or a radiology PACS system) may have truncated after the first Tyler Ennis was listed. Since sometimes there are many patients with the same name, it is inevitable that such truncation may occur, even if your system was programmed to not truncate after finding the first name. We have advocated that electronic medical records should flag in some manner that there are additional patients with the same name. Such a flag could be presenting the name in a special color or with an asterix in order to let the user know that there are additional patients with the same name. That would force the user to then go to a second identification factor (like a date of birth) in order to identify the correct patient.
But even that is not infallible. In our March 26, 2019 Patient Safety Tip of the Week “Patient Misidentification” we noted a near-miss when two patients had the same name and same date of birth (Frost 2018) and the fact 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 2017).
A national patient identifier (NPI) system has long been proposed as a means of preventing patient misidentifications. But the above incident begs the question, since the event(s) took place outside the US! It would take an international or global patient identifier system to have prevented this mix up. Both Tylers were born in Canada and both had their x-rays done in Canada. But Canada also does not have a national patient identification number program.
Many, including ourselves, have long advocated for a national patient identifier (NPI) system. But Congress had banned funding for an NPI system. Congress’ reason for not providing funding primarily stemmed from a privacy concern (Jason 2019). However, in June 2019 Congress voted to overturn that prior ban on funding for a national patient identifier system (Monica 2019). Healthcare industry stakeholders including AHIMA, AMIA, CHIME, eHealth Initiative, Intermountain Healthcare, and MMGA had issued a joint letter to Congress expressing their support for the bill.
The major benefit of an NPI system is that it improves interoperability of medical records. As we integrate medical information from many sources into one electronic medical record, an NPI would reduce the chance of entering data from a different patient into one patient’s record. That could also help avoid unnecessary duplication of tests.
In theory, an NPI system should also reduce the likelihood of patient misidentification. EMR’s and other electronic healthcare systems could be searched using the NPI rather than patient names. Of course, we doubt healthcare professionals are likely to search for records by primarily using an NPI unless their patient has an extremely common name that is likely to be shared by multiple patients. We are still always likely to search using the patients name.
But there is one tool we bet could have helped avoid this misidentification – use of photographs. We’ve long been advocates for patient photographs in the EMR. Digital photos are easy enough to obtain and most EMR’s have a field in which you can place a photo. See our April 30, 2013 Patient Safety Tip of the Week “Photographic Identification to Prevent Errors” for examples of how photos can help prevent identification errors. We have even done several columns on the utility of patient photographs in the electronic medical record, including several in which radiologists were helped by the presence of patient photographs.
A study just recently presented at the ACEP 2019 Research Forum (Blanchfield 2019) demonstrated that a passive display of patient photos in the EHR is associated with reduced rates of wrong patient orders and near misses in the Brigham and Women’s Emergency Department. While the study looked at how having patient photos in the EHR helped physicians identify the correct patient when entering orders in the EHR, one can readily see how having the photo at the top of every screen (in the EHR or the radiology PACS system), along with their name and DOB and medical record number, would help whomever is searching for an image identify the correct patient.
In the case of the two Tyler Ennis’s, photos in the EHR or radiology PACS system should have easily helped the medical staff correctly identify their patient:
Hockey Tyler Ennis | Basketball Tyler Ennis
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If you are medical staff who have directly interacted with the player, you should have little difficulty identifying your patient by photo. If your search screen truncated at the first Tyler Ennis it found, you’d say to yourself “That doesn’t look like my patient” and you’d scroll down to see if there was another Tyler Ennis.
But you also need to be wary that circumstances may make use of photos unhelpful. For example, they may not be useful in patients with facial trauma. And you have to have a system to ensure your photos are not outdated. Butler (Butler 2018), in an article on best practices for accurate patient identification, also strongly endorses use of patient photographs. She also points out that requiring a photo ID, such as a driver’s license or state identification card, is a preferred practice but isn’t always available for populations such as children and seniors and others who don’t drive.
People’s appearances change as they age and their appearance may also change for other reasons. So that raises the issue of when and how patient photographs should be taken.
Our November 12, 2019 Patient Safety Tip of the Week “Patient Photographs Again Help Radiologists” showed how real-time photographs, taken at the same time a radiology study was being done, were of great value not only in identifying the correct patient but also improving the clinical information available to the radiologist. And, in the Blanchfield study (Blanchfield 2019) the patient photographs were taken when the patient presented to the ED. The ease with which we can today take a digital photograph today and upload it to the EHR enables the use of up-to-date patient photos. In the Blanchfield study, they created a new standard of care and implemented a new workflow for ED registration staff. Using iPod touch devices, ED registration staff took photos of consenting patients either at the front desk when patients check-in, or at the end of the registration process.
In other venues, such as ambulatory care, we could have policies and protocols for updating photos at specified intervals, akin to what happens with driver’s licenses.
So, the time has come to use patient photographs more extensively in healthcare. They now have been shown to reduce radiology errors and medication errors and today’s example shows how they could also reduce other misidentification errors.
Some of our prior columns on use of patient photographs in patient safety:
December 2008 “Patient Photographs Improve Radiologists’ Performance”
January 12, 2010 “Patient Photos in Patient Safety”
June 26, 2012 “Using Patient Photos to Reduce CPOE Errors”
April 30, 2013 “Photographic Identification to Prevent Errors”
January 19, 2016 “Patient Identification in the Spotlight”
March 26, 2019 “Patient Misidentification”
November 12, 2019 “Patient Photographs Again Help Radiologists”
Some of our prior columns related to patient identification issues:
May 20, 2008 “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?”
November 17, 2009 “Switched Babies”
July 17, 2012 “More on Wrong-Patient CPOE”
June 26, 2012 “Using Patient Photos to Reduce CPOE Errors”
April 30, 2013 “Photographic Identification to Prevent Errors”
August 2015 “Newborn Name Confusion”
January 12, 2016 “New Resources on Improving Safety of Healthcare IT”
January 19, 2016 “Patient Identification in the Spotlight”
August 1, 2017 “Progress on Wrong Patient Orders”
June 19, 2018 “More EHR-Related Problems”
November 2018 “More on Hearing Loss”
March 26, 2019 “Patient Misidentification”
September 10, 2019 “Joint Commission Naming Standard Leaves a Gap”
References:
Mendes I. The case of two Tyler Ennises and a near mistaken diagnosis. TSN 2019; December 2, 2019
https://www.tsn.ca/the-case-of-two-tyler-ennises-and-a-near-mistaken-diagnosis-1.1406936
Frost S. Patient ‘lucky’ to avoid disaster after hospital’s identity mistake. Mercury (UK) 2019; 07 April 2018
Lippi G, Chiozza L, Mattiuzzi C, Plebani M. Patient and Sample Identification. Out of the Maze? J Med Biochem 2017; 36(2): 107-112. Published online 2017 Apr 22
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5471642/
Jason C. The Pros and Cons of a National Patient Identifier (NPI) System. Ehrintelligence.com 2019; December 4, 2019
https://ehrintelligence.com/news/the-pros-and-cons-of-a-national-patient-identifier-npi-system
Monica K. House Overturns Ban on Funding for National Patient Identifier. Ehrintelligence.com 2019; June 14, 2019
https://ehrintelligence.com/news/house-overturns-ban-on-funding-for-national-patient-identifier
Blanchfield BB, Salmaisian H, Landman A. Abstract #56. Adding Patient Photos to the Electronic Health Record to Improve Patient Identification and Reduce Wrong Patient Order Errors. Ann Emerg Med 2019; 74(4s): S22-23 :October 2019
https://www.annemergmed.com/article/S0196-0644(19)30733-4/fulltext
Butler, Mary. Show Me Some ID: Tips for Trusting Identity in the Era of Cybercrime and Fraud. Journal of AHIMA 2018; 89(6): 24-27
http://bok.ahima.org/doc?oid=302514#.W3sfy7gnZPZ
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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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