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October 4, 2022
Successfully Reducing OR Traffic
Opening and closing doors to the OR is of concern for two primary reasons:
Our November 24, 2015 Patient Safety Tip of the Week “Door Opening and Foot Traffic in the OR” discussed a study from Johns Hopkins that formally studied how often OR doors are opened during joint arthroplasty surgeries and the impact on OR air flow (Mears 2015). The effects of the door opening on OR pressure and air flow clearly has implications for surgical infections. Our July 26, 2016 Patient Safety Tip of the Week “Confirmed: Keep Your OR Doors Closed” discussed a Canadian study on a program to reduce unnecessary door openings and reduce surgery-related infections (Camus 2016). They achieved an amazing reduction in OR traffic from between 42 and 70 door openings to 3.2 door openings per case. They felt this intervention may have contributed to a decrease in orthopedic SSI’s from 2.8 percent to 2.1 percent.
Regarding distractions, our January 11, 2022 Patient Safety Tip of the Week “Documenting Distractions in the OR” discussed a recent pilot study used Operating Room Black Box (ORBB) technology in a Canadian tertiary care academic hospital (Nensi 2021). The researchers documented an incredible average 89 door openings per case! That translates to an OR door opening every 1.8 minutes!
A recent article in AORN Journal (AORN 2022) highlighted a quality improvement project at one large hospital that substantially reduced the number of OR door openings. Nurses at Houston Methodist Hospital gathered baseline data on the frequency of door openings during procedures, the job titles of staff members who were responsible for the door openings, and the reasons for the door openings. They also did an online survey to all perioperative staff members to determine their knowledge regarding OR traffic and to identify reasons for door openings
The most common reason to open doors was to retrieve supplies and equipment. The staff members most commonly opening doors were the RN circulators and scrub nurses. More than 95% of respondents knew that door openings alter OR airflow and contribute to SSI’s. Suggested interventions to reduce OR door openings were more accurate surgeon preference cards, verification of equipment and supplies during the time out, and signs on the doors to remind staff to keep OR traffic to a minimum.
They found that almost 70% of staff members did not feel comfortable speaking up about unnecessary traffic in the OR. Therefore, during inservices, they focused on calling OR traffic a patient safety issue and speaking up and holding others accountable for unnecessary traffic in and out of the OR.
They designed a sign to place on each OR door, with the slogan “Mo’ Traffic Mo’ Problems”, a photo of a construction worker, and message that foot traffic should be limited.
Because of a hurricane, the COVID-19 pandemic, and a lack of staffing and resources, they were only able to obtain follow-up data in one OR suite. But an audit in that suite showed that the average number of door openings decreased by 32%. Door openings for the top five job roles contributing to door openings also decreased.
The signs on the doors served as a “conversation starter” and helped staff members educate each other about the importance of minimizing door opening.
One barrier they encountered was that the door signs sometimes fell or otherwise disappeared. Future plans include having more signs available and designating someone in each unit to ensure the signs are posted on the doors.
In our thinking, two of the most important opportunities to reduce OR door openings are the pre-op huddle and the post-op debriefing. During the pre-op huddle it is imperative that the team ensure that all necessary equipment, supplies (and implants if applicable), medical records, documents, and images are present in the OR. During the post-op debriefing concerns about equipment and supplies should be discussed. Did we have to go outside the OR to get any equipment or supplies during the case? Were there problems with any of the equipment we already had in the OR. We can’t tell you the number of times, when a piece of equipment fails, that staff says “yeah, we had a problem with that last week” and no one did anything about it.
We’ve previously suggested two “nudges” that could reduce OR door openings: (1) using a sign akin to the “On Air” signs recording studios use to indicate a procedure is in progress and (2) requiring those opening and closing the OR doors to record the reason for their action. Having data is essential for any quality improvement project. The Houston Methodist project collected data on both the frequency of and reasons for OR door opening. You can’t get buy-in from OR staff if you can’t convince them you have a problem. And you can’t fix the problem unless you understand the reasons behind frequent OR door opening. Video recording in the OR, as described in our January 11, 2022 Patient Safety Tip of the Week “Documenting Distractions in the OR” can provide a good estimate of the frequency of door opening and might give you a good idea of the reasons for door opening, but more formal recording of the reasons is important. That may mean putting someone outside the OR to actually record those reasons or having the person opening the door record the reason(s) in a log.
The Canadian study by Camus et al. (Camus 2016) that we discussed in our July 26, 2016 Patient Safety Tip of the Week “Confirmed: Keep Your OR Doors Closed” found reasons for entering and exiting the OR during their total joint operations included retrieving charts, instruments, or equipment, and taking a break. Their CUSP (Comprehensive Unit-Based Program) team brainstormed and came up with key changes, including stopping all traffic in and out of the OR between total joint capsule opening and closure, communicating by phone, and increasing the use of templates to identify implant size prior to each operation. They also put a sign on the OR door reminding staff to minimize traffic and asking them to record why they are entering the OR during an operation.
Reducing OR door opening is important for reducing surgical infections and reducing distractions that can lead to errors in the OR. Not enough hospitals or other surgical venues have paid attention to the frequency of and reasons for OR door opening. This remains an important patient safety issue that merits more attention.
Our prior columns focusing on surgical OR foot traffic and door opening:
References:
Mears SC, Blanding R, Belkoff SM. Door Opening Affects Operating Room Pressure During Joint Arthroplasty. Orthopedics 2015; 38(11): e991-e994
https://journals.healio.com/doi/10.3928/01477447-20151020-07
Camus S. Operating Room Traffic Monitoring Improves Patient Safety. Abstract session presentation at the 2016 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) Conference. July 18, 2016 as reported in ACS (American College of Surgeons). Minimizing Operating Room Traffic May Improve Patient Safety by Lowering Rates of Surgical Site Infections. ACS Press Release July 18, 2016
https://www.facs.org/media/press-releases/restricted/ssi
Nensi A, Palter V, Reed C, et al. Utilizing the Operating Room Black Box to Characterize Intraoperative Delays, Distractions, and Threats in the Gynecology Operating Room: A Pilot Study. Cureus 2021; 13(7): e16218
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8341265/
AORN. Decreasing Traffic In and Out of the OR. AORN Journal 2022; 115(6): P12-P14 First Published:26 May 2022
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13704
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October 11, 2022
Good Intentions, Unintended Consequences
In several of our columns we have pointed out that medications we think we have discontinued, in fact, get continued. One of the biggest gaps in medication safety is failed discontinuation of medications. In our February 2018 What's New in the Patient Safety World column “10 Years on the Wrong Medication” we noted a case in which a patient was inadvertently continued on a wrong medication for 10 years!
How does this happen? We once again highlight a critical issue: stopping a medication is much different than starting one. Starting a medication requires an active process – you either write a prescription, enter one into a computer, or call the pharmacy. You are usually in a situation where you can utilize an electronic order system (CPOE or e-prescribing tool) and you may have access to the many clinical decision support tools in those systems. But discontinuing a medication is often more passive – you might get a call from your patient after hours and just tell the patient over the phone to stop it when the patient tells about a potential side effect. You don’t call the pharmacy to stop it. And, if there was no associated office visit, you might even forget to update the patient’s medication list in your EMR (or paper records) until the patient’s next office visit. Our multiple prior columns on this problem are listed below.
In our October 2021 What's New in the Patient Safety World column “Tool to Prevent Discontinued Medications from Being Dispensed” we discussed the CancelRx tool. CancelRx integrates with clinic EHR and pharmacy dispensing software and automates the manual process that was previously delegated to clinic and pharmacy staff. It automatically sends an electronic notification of a medication discontinuation from a clinic’s EHR to a pharmacy’s dispensing software. After a clinic prescriber has discontinued a medication and indicated that the pharmacy should be notified, the order is processed by a third-party vendor.
In that column, we highlighted a study from the University of Wisconsin that clearly demonstrated the value of CancelRx in reducing outpatient medication discrepancies by ensuring communication of medication discontinuation to pharmacies (Watterson 2021).
A new study (Pitts 2022) demonstrated that CancelRx implementation did prevent prescriptions from being sold after discontinuation in the EHR. CancelRx implementation prevented prescriptions from being sold after discontinuation in the EHR in 42 of 392 instances versus none of 387 instances prior to implementation. However, there was an unintended consequence - some medications might have been unintentionally canceled. Medical record review of reordered prescriptions after CancelRx implementation found that 10 of 49 might have been unintentionally canceled.
Pitts et al. used medications refilled within 120 days of discontinuation as a surrogate for unintended cancellation. There are obviously reasons one might restart a medication, so their estimate of unintended discontinuation likely is overestimated. Nevertheless, the study does caution us that there may be unintended consequences of this otherwise very promising tool.
But the study emphasizes another point we have made over and over – there is not only a need to document the indication for a drug when we prescribe it, but also a need to document the reason a drug is being discontinued. In the Pitts study, intent to discontinue the medication was documented in the EHR in only 15 of 392 instances (3.8%). A reason for that intent was probably even more rare.
We’ve emphasized the importance of providing the reason for discontinuation. There are many potential reasons for discontinuing a medication, including:
Knowing why a medication was discontinued can have important downstream implications. For example, let’s say I am considering putting a patient with essential tremor on propranolol. The patient recalls being on it once before – for migraine. It would be helpful to know that the propranolol was previously discontinued because it did not help prevent the migraine rather than being discontinued because of a side effect.
Or a medication might have been discontinued due to an interaction with another medication. Now the patient is no longer on the other medication in that interaction. The patient could go back on the original medication if it is indicated.
It’s also especially important when a drug is discontinued and the question of allergy has been raised. All too often a patient is denied an effective medication because he/she thought they were allergic to it when, in fact, they simply had a minor side effect of that medication.
In addition to transmission of the reason for discontinuation, Pitts et al. suggest strategies to increase situational awareness of providers and pharmacy staff, including increased visibility of CancelRx, and clear distinctions between active and expired prescriptions.
CancelRx appears to be a good tool, but the Pitts study lets us know it is not infallible. A few tweaks, such as requiring a reason for discontinuation, should make it even better.
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”
October 2021 “Tool to Prevent Discontinued Medications from Being Dispensed”
Some of our other columns on including indication for medication orders:
March 23, 2010 “ISMP Guidelines for Standard Order Sets”
December 18, 2018 “Great Recommendations for e-Prescribing”
August 2019 “Including Indications for Medications: We Are Failing”
March 1, 2022 “Including the Indication on Prescriptions”
May 24, 2022 “Requiring Indication for Antibiotic Prescribing”
References:
Watterson TL, Stone JA, Brown R, et al. CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting, Journal of the American Medical Informatics Association 2021; 28(7): 1526-1533
https://academic.oup.com/jamia/article-abstract/28/7/1526/6211610?redirectedFrom=fulltext
Pitts SI, Yang Y, Woodroof T, et al. The Impact of Electronic Communication of Medication Discontinuation (CancelRx) on Medication Safety: A Pilot Study. Journal of Patient Safety 2022; 18(6): e934-e937
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October 18, 2022
Methotrexate Again, With a Twist
We’ve now done multiple columns on errors with methotrexate therapy. The basic problem is that methotrexate is used in different doses and different regimens when used for oncological indications or immunomodulating indications for conditions like rheumatoid arthritis, psoriasis, and inflammatory bowel disease. For the latter conditions, low dose methotrexate is used, typically administered in once-a-week doses.
Nimkar et al. (Nimkar 2022) recently described a case of an unintentional overdose of methotrexate in a patient with psoriasis, resulting in severe myelosuppression and mucositis. The patient was a 65-year-old woman with a past medical history of psoriasis for 10 years. She was taken to the emergency department by her family with a complaint of increased skin lesions, bleeding from the lesions, and painful mouth ulcers for the last 15 days. She also had high-grade fever and shivering for the last three days and black-colored stools for the last two days. She had stopped taking food due to painful ulcerations in her mouth.
Exam showed multiple ulcerated and necrotic psoriatic plaques with redness and tenderness on various parts of the body, with signs of active bleeding from the skin lesions. There was also blood in the stool. Her hemoglobin was 7.7, leukocyte count 100/mm3, and platelets 48,000/mm3. She continued to deteriorate in the hospital and, despite multiple medical interventions, she died.
The patient had a long history of psoriasis and had been taking methotrexate 7.5 mg once a week and folic acid 5 mg once a day for 10 years. However, for the last 15 days, a relative had accidentally gave her methotrexate 7.5 mg once daily and folic acid 5 mg once a week, after which signs of toxicity appeared.
Obviously, in this case, the family relative transposed the dosing frequency of methotrexate and folate. But it raises a key question we have raised with other medication issues, particularly IV infusions. That question is “Why would you ever allow a potentially lethal dose of a medication to be given if it were to be given over a much shorter time frame than intended?” We’ve raised that question in cases where IV infusions of 5-Fluorouracil (5-FU), intended to be infused over several days, instead get infused over several hours. But the concept here is similar – why should a patient have a supply of methotrexate large enough to be lethal if taken daily by accident? The monthly supply of methotrexate for these patients should only be 4-5 tablets. We don’t know details of how the methotrexate was prescribed or dispensed in the current case. Perhaps the patient was given a 90-day supply, which could have allowed for the 15 daily doses she received.
In the study highlighted in our June 21, 2016 Patient Safety Tip of the Week “Methotrexate Errors in Australia” Cairns et al. (Cairns 2016) noted that folate and methotrexate were both small yellow tablets, likely increasing the chance the two might be mixed up. We wonder whether that might have been a factor in the current case (such detail was not provided in the current case).
In 2018, ISMP issued a “Call to Action” to prevent accidental daily methotrexate dosing (ISMP 2018), noting that harmful or fatal errors with daily oral methotrexate for nononcologic use had been reported to ISMP and published in more than 60 ISMP Medication Safety Alert! Newsletters since early 1996.
The fundamental problem is that relatively few medications are dosed weekly. So, it is not surprising that accidental daily dosing of oral methotrexate might occur. ISMP notes that this type of wrong frequency error has originated in all stages of the medication use process, from prescribing to self-administration.
IMSP notes that titrated methotrexate doses or divided weekly doses have often caused confusion. Patients may misunderstand complex regimens. ISMP (ISMP 2018) gave such an example. An 8-week supply of 2.5 mg tablets (30 tablets) had been dispensed with label instructions that said, “Take 3 tablets by mouth one day for 2 weeks then increase to 4 tablets by mouth 1 day per week thereafter.” Despite counseling, the patient was confused by the label instructions and took 3 tablets (7.5 mg) daily for 5 days before serious symptoms led his doctor to identify the error.
ISMP also notes that computer order entry systems may contribute to this type of incorrect dosing. They noted that some systems present common orders for oral methotrexate in both daily and weekly dosing frequencies. A clinician may pick the first choice that matches the desired dose, without noticing that the frequency of administration listed is daily, not weekly. Methotrexate today is far more often used for non-oncologic conditions, so it makes sense that CPOE or ePrescribing systems should default to weekly dosing rather than daily dosing.
ISMP has the following recommendations:
ISMP also encourages the FDA to require manufacturers to package oral methotrexate for nononcologic use in patient dose packs that direct consumers to the correct weekly dosing. They note that, in Spain, blister packs of oral methotrexate limit the quantity of tablets available to patients. The outer carton and blister packs include the nononcologic indications and a specific warning that the dose is once a week for these approved indications.
ISMP’s 2022-2023 ISMP Targeted Medication Safety Best Practices for Hospitals (ISMP 2022) includes BEST PRACTICE 2:
a) Use a weekly dosage regimen default for oral methotrexate in electronic systems when medication orders are entered.
b) Require a hard stop verification of an appropriate oncologic indication for all daily oral methotrexate orders.
i) For manual systems and electronic order entry systems that cannot provide a hard stop, clarify all daily orders for methotrexate if the patient does not have a documented appropriate oncologic diagnosis.
ii) Hospitals need to work with their software vendors and information technology departments to ensure that this hard stop is available. Software vendors need to ensure that their order entry systems are capable of this hard stop as an important patient safety component of their systems.
c) Provide specific patient and/or family education for all oral methotrexate discharge orders.
i) Double-check all printed medication lists and discharge instructions to ensure that they indicate the correct dosage regimen for oral methotrexate prior to providing them to the patient.
ii) Ensure that the process for providing discharge instructions for oral methotrexate includes clear written instructions AND clear verbal instructions that specifically review the dosing schedule, emphasize the danger with taking extra doses, and specify that the medication should not be taken “as needed” for symptom control.
iii) Require the patient to repeat back the instructions to validate that the patient understands the dosing schedule and toxicities of the medication if taken more frequently than prescribed.
iv) Provide all patients with a copy of the free ISMP high-alert medication consumer leaflet on oral methotrexate.
Our June 21, 2016 Patient Safety Tip of the Week “Methotrexate Errors in Australia” highlighted a study by Cairns and colleagues (Cairns 2016) on methotrexate-related adverse events. Unintended daily dosing was the predominant contributing factor. Mistaking methotrexate for another medication (most often folic acid or prednisone) was another common contributing factor. Several cases were due to error by a caregiver or nursing home. Other reasons noted were newly prescribed methotrexate, dosette packing errors by pharmacists, misunderstood instructions, prescribing error, dispensing/labeling error, and one case where the patient believed it would improve efficacy.
That study emphasized that taking methotrexate daily for even 3 consecutive days could be fatal but noted wide variability in the duration of daily dosing before toxic effects occurred. Possible contributory factors cited included increasing patient age, renal function and hydration status. Since first-time users and older patients appear to be at greater risk, they emphasized the importance of taking time to counsel these patients. The authors also note that in addition to physiologic changes that might alter methotrexate metabolism and excretion, the elderly may have other problems like confusion, memory impairment, visual decline, and others that could put them at increased risk of dosing errors.
ISMP’s QuarterWatch™ (ISMP 2019) noted that even 1 week of daily administration of methotrexate can result in many painful and severe adverse effects, including death. They reviewed 14 cases of methotrexate overdoses, all of which occurred in patients age 65 and older. In 6 of the cases, the error was made by the patient. They note that an older population is likely to take multiple daily medications and have trouble reading the instructions on medication labels; thus, it is not surprising some patients became confused. That’s especially the case if the “weekly” dose is ordered in 3 smaller divided doses taken 12 hours apart. Patients have also been confused by directions for escalating doses. In the other 8 cases, the oral methotrexate was ordered, labeled, or dispensed incorrectly.
That QuarterWatch™ notes that the warning against daily administration is buried about halfway through the Patient Information label and fails to effectively communicate the potentially fatal consequences of non-adherence to weekly administration. ISMP’s high-alert medication consumer leaflet on oral methotrexate is a much better tool for conveying to patients the risks of methotrexate.
An article by ISMP’s Matthew Grissinger (Grissinger 2018), based on an ISMP Canada Safety Bulletin (ISMP Canada 2015) discusses most of the points made in the above resources, but also reminds us that computer systems should include a robust drug–drug and drug–disease interaction module for methotrexate, with links to laboratory results where possible, so prescribers and pharmacists can effectively evaluate the potential for toxic effects. He also suggests that, if folate has not been prescribed, the pharmacist should follow up with the prescriber to suggest initiation of this supplement.
In our What's New in the Patient Safety World columns for July 2011 “More Problems With Methotrexate” and February 2016 “Avoiding Methotrexate Errors” we noted that the patient in a long-term care facility may be especially vulnerable. In such cases, the original order for methotrexate is usually written by a specialist. It’s especially likely to occur when an LTC patient gets admitted to a hospital and then gets transferred back to the LTC unit. The patient is then followed in the LTC facility typically by a primary care physician who may be less knowledgeable about the particular use of methotrexate for that condition. Also, the LTC patient may not be seen by a physician for periods as long as a month. And many LTC patients have cognitive impairments that might prevent them from understanding issues about their medications. So, if a medication reconciliation error has occurred and a patient intended for once weekly dosing is now on daily dosing, the opportunity for toxicity is greatly increased. So LTC facilities should take steps to ensure that any of their residents taking methotrexate get the same level of supervision and protections that non-LTC patients would get.
We’ve often harped on the need to include the indication when we order or prescribe a medication. In our August 2019 What's New in the Patient Safety World column “Including Indications for Medications: We Are Failing” we gave a methotrexate example. We said if a pharmacist saw an order for daily methotrexate and the indication was “rheumatoid arthritis” (or other non-oncologic indication), the pharmacist might recognize the dosing error.
One recommendation that appeared in some of the older studies but seems to have disappeared was to tell the patient to take the methotrexate on a specific day of the week (but avoid “every Monday”, since that may be confused with “every morning”) in order to emphasize that the medication is to be taken weekly rather than daily. We’ve always liked that recommendation.
The twist in the current case is what a relative did. That relative probably never received any education or counselling about methotrexate dosing. Of all the actions and interventions we’ve talked about in this and our previous columns, probably the only one that might have prevented this catastrophe would have been limiting the number of methotrexate tablets available to the patient. Perhaps that is the most important lesson here. With more than 1 million patients currently taking methotrexate in the US (ISMP 2019), the risks of this type of accidental overdose remain substantial.
Our prior columns related to methotrexate issues:
References:
Nimkar SV, Yelne P, Gaidhane SA, et al. Fatal Manifestations of Methotrexate Overdose in Case of Psoriasis Due to Dosing Error. Cureus 2022; 14(10): e30041
Cairns R, Brown JA, Lynch A-M, et al. A decade of Australian methotrexate dosing errors. Med J Aust 2016; 204(10): 384
https://www.mja.com.au/system/files/issues/204_10/10.5694mja15.01242.pdf
ISMP (Institute for Safe Medication Practices). Call to Action: Longstanding Strategies to Prevent Accidental Daily Methotrexate Dosing Must Be Implemented. ISMP Medication Safety Alert! Acute Care Edition 2018; 23(16): August 9, 2018
Institute for Safe Medication Practices (ISMP). 2022-2023 ISMP Targeted Medication Safety Best Practices for Hospitals. ISMP 2022
https://www.ismp.org/system/files/resources/2022-02/2022-2023%20TMSBP%20final.pdf
ISMP high-alert medication consumer leaflet on oral methotrexate. Accessed October 9, 2022
https://www.ismp.org/sites/default/files/attachments/2018-11/Methotrexatefinal.pdf
ISMP (Institute for Safe Medication Practices). QuarterWatch™ (includes new data from Quarter 2, 2019) Methotrexate Errors, Trends Among Addictive Drugs, and Underreporting of Serious Events. ISMP Medication Safety Alert! Acute Care Edition 2019; December 5, 2019
Grissinger M. Severe Harm and Death Associated With Errors and Drug Interactions Involving Low-Dose Methotrexate. P&T 2018; 43(4): 191-248
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5871236/
ISMP Canada. Severe harm and deaths associated with incidents involving low-dose methotrexate. ISMP Canada Safety Bulletin 2015; 15(9): 1-5
https://ismpcanada.ca/wp-content/uploads/ISMPCSB2015-09_Methotrexate.pdf
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October 25, 2022
Which Room Do You Want?
If you are hospitalized, you’d like to think that it doesn’t matter what room you are put into. But, in reality, your risks may depend upon a number of features of that room.
Researchers from the University of Michigan (Mead 2022) studied almost 4000 patients who underwent 13 high-risk surgical procedures at the University of Michigan Hospital. They looked at clinical outcomes as related to certain features of patient rooms - window or no window, single occupancy, double occupancy, distance to the nursing station, and line of sight to clinicians.
Key findings of that study:
A 2010 study looking at ICU design (Leaf 2010) compared patient mortality between rooms that were not visible from the MICU central nursing station (low-visible rooms or LVR’s) to high-visible rooms (HVR’s). The researchers found that severely ill patients (those with Acute Physiology and Chronic Health Evaluation II scores > 30) had significantly higher hospital mortality when admitted to an LVR than did similarly ill patients admitted to an HVR. ICU mortality showed a similar pattern.
Most hospitals have probably already been putting some of their sicker patients in rooms with these features. The University of Michigan study found that sicker patients were more likely to get single rooms, closer to a nursing station and within direct line of sight, and a window view.
The UM researchers are looking to replicate their study across other hospital systems.
We do have one caveat: one unintended consequence is that there is a risk of alarm fatigue if the rooms are too close to nursing station. We’ve seen instances where alarm volumes have been lowered in those rooms because the noise in the nurses’ or physicians’ work areas has been distracting.
Of course, there have been other studies looking at the impact of room design on patient outcomes, particularly as related to hospital-acquired infections (HAI’s). McDonald et al. (McDonald 2019) looked at HAI rates after inpatients in an older, tertiary care, 417-bed hospital in Montréal, Canada, that consisted of mainly mixed 3- and 4-person ward-type rooms were moved to a new 350-bed facility with all private rooms. The new hospital had 100% single-patient rooms equipped with individual toilets and showers and easy access to sinks for hand washing. The move appeared to be associated with a sustained decrease in the rates of new MRSA and VRE colonization and VRE infection. However, the move was not associated with a reduction in CDI or MRSA infection. Another study (O’Neill 2018) found that patients who stay in private rooms as opposed to double occupancy rooms have a reduced risk of central line infections.
And our many columns on delirium have pointed out the importance of having a window to the outside to promote normal day/night cycles as one factor combating the risk of delirium.
We still have a lot to learn about the impact of patient rooms on clinical outcomes. The Michigan study has implications for future hospital design, but it also has important implications for hospital bed triage.
References:
Mead MJ, et al. Evaluating Mortality and Hospital Room Design after High-Risk Inpatient Surgery. Scientific Forum. American College of Surgeons Clinical Congress 2022. As reported by the ACS October 16, 2022
Leaf DE, Homel P, Factor PH. Relationship between ICU design and mortality. Chest 2010; 137(5): 1022-1027
https://journal.chestnet.org/article/S0012-3692(10)60225-5/fulltext
McDonald EG, Dendukuri N, Frenette C, et al. Time-Series Analysis of Health Care–Associated Infections in a New Hospital with All Private Rooms. JAMA Intern Med 2019; Published online August 19, 2019
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2747870
O’Neill L, Park S-H, Rosinia F. The role of the built environment and private rooms for reducing central line-associated bloodstream infections. PLOS One 2018; Published: July 27, 2018
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0201002
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November 1, 2022
APSF on Criminialization of Medical Error
We’ve done multiple columns on the unfortunate incident at Vanderbilt in which a patient was administered a fatal dose of a neuromuscular blocking agent (NMBA) instead of the intended sedating agent. The tragedy resulted from a series of both human errors and system errors. But we decried the subsequent criminal prosecution for its inappropriateness and its potential adverse impact on reporting of adverse events in the future.
Multiple healthcare organizations have similarly protested the criminalization of medical mishaps such as this (see our April 12, 2022 Patient Safety Tip of the Week “A Healthcare Worker’s Worst Fear”). And multiple individuals have also spoken out about this travesty (Raths 2022, Presti 2022, Murtha 2022).
The most recent position statement against criminalization of medical error comes from the Anesthesia Patient Safety Foundation (APSF 2022). “APSF believes that criminal prosecution of healthcare providers will make the work of preventing harm more difficult since it continues to shift the focus away from system improvements.” “We believe the prosecution and conviction of the nurse involved was counterproductive to the pursuit of prevention of harm to future patients and health care professionals. However, we strongly advocate for systemic changes that will enhance health care’s culture of safety and will reject the acceptance of “normalization of deviance” that enables unsafe medical practices.”
While the APSF position statement does not absolve the nurse of wrongdoing, it states that her prosecution does not align with principles of “Just Culture” that are now widely accepted and improve health care. “This prosecution may lead to greater risk for patients when health care professionals’ fear of significant retribution causes errors to go unreported and unaddressed, thus allowing the unidentified error to continue to harm more patients in the future.” It goes on to note that “many health care professionals have voiced concern that they may be similarly prosecuted for actions they have taken in good faith that led to an adverse outcome in part as a result of their error. This understandable fear could lead to health care professionals leaving the profession or failing to report errors as needed to identify and address causes of error and possible patient harm.”
The authors of the APSF position statement describe some of the key contributing factors in a separate editorial (Cooper 2022) and recognize that the nurse has culpability and that in such cases, disciplinary and other actions may be warranted, but explain why criminalization of medical error is unjust and counterproductive. They express their hope that health care organizations will support a “Just Culture,” where prevention of harm is the focus, and where managers and health care providers are encouraged to design safety systems and make safe choices for patient care.
We won’t repeat the details of this unfortunate event now. You can go to any of our columns below for the full details. But, suffice it to say, we identified at least 19 steps or events that contributed to this disastrous outcome. Yes, Redonda Vaught unquestionably made critical errors and missteps, but the multitude of system factors led to her being the person at the sharp end of the error cascade. When we do a root cause analysis or incident investigation, the most important question we ask is “Might another individual have acted similarly, given the same set of circumstances?”. We bet there are many nurses out there saying “that could’ve been me”. Vaught was contrite, honest, and forthcoming right from the beginning in this case. We’ve all learned a lot from this case. Lessons from errors like these should be disseminated widely, but not through the court system. We fear that criminalization of medical errors will have a deleterious effect on reporting medical errors, and it’s already led to some healthcare workers leaving the field.
Our prior columns on the neuromuscular blocking agent accident at Vanderbilt:
December 11, 2018 “Another NMBA Accident”
January 1, 2019 “More on Automated Dispensing Cabinet (ADC) Safety”
February 12, 2019 “From Tragedy to Travesty of Justice”
April 2019 “ISMP on Designing Effective Warnings”
February 2021 “ISMP: 2 Alerts on NMBA’s”
September 7, 2021 “The Vanderbilt Tragedy Gets Uglier”
April 12, 2022 “A Healthcare Worker’s Worst Fear”
References:
APSF Criminalization of Error Task Force. Position Statement on Criminalization of Medical Error and Call for Action to Prevent Patient Harm from Error. APSF Newsletter 2022; 37(3): 78,80-81 September 2022
Cooper J, Thomas B, Rebello E, et al. Editorial: APSF’s Statement About Criminalization of Medical Error and Call to Action Against Preventable Adverse Events. APSF Newsletter 2022; 37(3): 78,82 September 2022
Murtha J. How the criminalization of medical error hurts doctors—and their patients. MDLinx 2022; Published October 21, 2022
Raths D. Patient Safety Leaders Respond to Prosecution of Medication Error. Healthcare Innovation 2022; Sept. 15, 2022
Presti C. What hospitals can learn from the RaDonda Vaught case. Kevin MD 2022; October 10, 2022
https://www.kevinmd.com/2022/10/what-hospitals-can-learn-from-the-radonda-vaught-case.html
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November 8, 2022
Spinning It
Our February 16, 2010 Patient Safety Tip of the Week “Spin/Hype…Knowing It When You See It” discussed in detail the problem of “spin”. Spin is the manipulation of messaging when the primary endpoint of a clinical trial is not met but results are presented in a positive light. For example, a paper may focus on analysis of a subgroup that fared better or on some secondary endpoint that was met. Post hoc subgroup analysis should only be hypothesis-generating and subject to a new clinical trial to test that hypothesis. Or they might focus on a result that is statistically significant but not clinically significant. Or they might use composite outcomes, which are especially likely to give rise to inappropriate conclusions when the outcomes are driven by one component of that composite, when that component is not as clinically significant as other components.
Unfortunately, reviewers and editors of our medical journals are not doing a very good job of preventing “spin” in published articles. In our February 16, 2010 Patient Safety Tip of the Week “Spin/Hype…Knowing It When You See It” we gave multiple examples, including one study rife with spin that led to publication in not one, not two, but three “respected” medical journals.
Recently, two physicians who have served as editors-in-chief of several JAMA journals have spoken out about spin and the need for responsible reporting of trial results to the media and other stakeholders. Particularly in this age of disinformation, it is all too easy for the media to latch onto spin from a medical investigator and disseminate it widely, raising hopes of some unrealistically or even leading to unnecessary harm of others.
Howard Bauchner and Frederick Rivara (Bauchner 2022) point out that, especially during the COVID-19 pandemic era, misinformation and disinformation on social media platforms have heightened the need for scientists to responsibly report the results of their work. They discuss avoiding use of terms and words that should be avoided in communicating results. They say “Statements and adjectives that reflect extremes should be avoided. Few studies are the first of their kind, transformative, critically important, or provide definitive evidence that a treatment cures a disease.” Furthermore, they note it is the responsibility of the investigators to also review for spin any press releases put out by their institutions, funders, or publishing journal. They cite a study (Sumner 2014) that analyzed 462 press releases and their associated peer-reviewed manuscript from 20 leading UK universities and found that 40% of the press releases contained exaggerated advice and 33% causal claims. They also note that the presence of the lay press at large scientific meetings and the propensity for meeting organizers to issue press releases increases the need to consider the potential impact on the public.
They note that for RCT’s (randomized controlled trials), investigators should focus on the preplanned primary and secondary outcomes and acknowledge that any other outcomes are only hypothesis-generating. But they also note that observational studies, which have been increasingly published, don’t have preplanned primary outcomes.
How results are presented is an important consideration regarding spin. Data presented emphasizing relative differences often lead to exaggeration of the importance of the outcome. They make a case that all RCT’s and observational studies should report the number needed to treat (NNT) or number needed to harm (NNH). That better informs the public that not everyone receiving a particular treatment will have a successful outcome.
They also note that publishing the limitations of a study is important but that the media is less likely to be interested in those limitations.
Lastly, they issue a word of caution to those experts and influencers who are asked to comment on the results of a study that they themselves did not participate in. Those individuals “could decline to comment, or make it clear, on the basis of the information presented, that they have a specific opinion, noting that the manuscript has not yet been published. The media can then acknowledge that such comments are based on preliminary non-peer-reviewed results”.
A number of studies have shown that spin is evident in publications, even in some of our most respected journals. One study (Jellison 2019) reviewed results published between 2012 and 2017 in six top psychology and psychiatry journals. Of 116 trials in which the primary results had not been statistically significant, they found evidence of spin in the abstracts of more than half (56%) of the published trials. This included titles (2%), results sections (21%), and conclusion sections (49%). In 15%, spin was identified in both the results and conclusion sections of the abstract. Spin was more common in trials that compared a particular drug/behavioral approach with a placebo intervention or usual care. Interestingly, industry funding was not associated with a greater likelihood of spinning the findings.
That last point is of interest. We would certainly have predicted that industry funding of a study would have been a prime driver of spin. But it is clear that other factors may contribute to researchers spinning their results. These might include prestige, increasing the number of citations, promoting further funding, meeting requirements for tenure, etc. Khan et al. (Khan 2019) speculate on the reasons authors use positive spin. They note that incentives likely play a role. Publication in high-impact journals fosters career advancement and future grant funding. And, of course, studies with “positive” results are more likely to be published than those with negative or neutral results.
Another study (Khan 2019) analyzed 93 RCT’s published in 1 of 6 high-impact journals (New England Journal of Medicine, The Lancet, JAMA, European Heart Journal, Circulation, and Journal of the American College of Cardiology) with primary outcomes that were not statistically significant. Spin was identified in 57% of abstracts and 67% of main texts of published articles. 11% of reports had spin in the title, 38% in the results section, and 54% in the conclusions. Among abstracts, spin was observed in 41% of results sections and 48% of conclusions sections.
Closely related to “spin” is “hype”. Hype has been defined as hyperbolic and/or subjective language that may be used to glamorize, promote, or exaggerate aspects of research. Millar et al. (Millar 2022) recently looked for evidence of “hype” in successful NIH grant applications. They used a technique known as “keyword analysis”, in which the frequency of certain adjectives was used as a measure of “hype”. They found that, among 139 “hype” adjective forms, 130 hype adjectives increased in frequency in grant applications between 1985 and 2020. Only 9 hype adjectives decreased in frequency. Hype most often serves to promote the significance, novelty, scale, and rigor of a project; the utility of the expected outcomes; the qualities of the investigators and research environment; and the gravity of the problem; as well as conveying the personal attitudes of the applicants.
Bauchner and Rivara have once again given this problem the attention it deserves. Reviewers and editors of all our healthcare journals need to do a better job of identifying “spin” and “hype” and eliminating them from publication. And all those interacting with the media, whether they are authors or editorialists or others commenting on publications, need to be wary that the media plays a big role in dissemination of information that may not be meaningful.
References:
Bauchner H, Rivara FP. The scientific communication ecosystem: the responsibility of investigators. The Lancet 2022; 400(10360): 1289-1290 Published:October 15, 2022
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01898-0/fulltext
Sumner P, Vivian-Griffiths S, Boivin J, et al. The association between exaggeration in health-related science news and academic press releases: retrospective observational study. BMJ 2014; 349: g7015
https://www.bmj.com/content/349/bmj.g7015
Jellison S, Roberts W, Bowers A, et al. Evaluation of spin in abstracts of papers in psychiatry and psychology journals. BMJ Evid Based Med 2019: 178-181 Epub ahead of print August 5, 2019
https://ebm.bmj.com/content/25/5/178.long
Khan MS, Lateef N, Siddiqi TJ, et al. Level and Prevalence of Spin in Published Cardiovascular Randomized Clinical Trial Reports with Statistically Nonsignificant Primary Outcomes: A Systematic Review. JAMA Netw Open 2019; 2(5): e192622
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2732330
Millar N, Batalo B, Budgell B. Trends in the use of promotional language (hype) in abstracts of successful national institutes of health grant applications, 1985–2020. JAMA Netw Open 2022; 5: e2228676
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2795635
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November 15, 2022
Which Antiseptic?
When we evaluate a medication or a procedure or any intervention, we look at both benefits and risks. When it comes to skin disinfectants, the obvious benefit is avoidance of infection. The most serious potential risk is flammability and risk of surgical fire.
Chlorhexidine is the most widely used skin disinfectant in surgery. It is an alcohol-based preparation. In our May 19, 2015 Patient Safety Tip of the Week “Dueling Chlorhexidine Studies” we discussed a series of studies on chlorhexidine for a number of purposes, some of which were pro, and others con. The issue, of course, was complicated by patient safety’s infamous “first scandal”, in which the editor of the Journal of Patient Safety lobbied the National Quality Foundation to include verbiage favorable to chlorhexidine in its recommendations, at a time when he had an undisclosed financial conflict of interest. (He was subsequently removed from NQF committees and his post as editor of the Journal of Patient Safety.)
But chlorhexidine has largely remained the #1 skin disinfectant now for many years. The newest AORN guidelines (AORN 2022) states that rapid, persistent, and cumulative action can be achieved by selecting a surgical skin preparation agent that combines alcohol with another antiseptic. Further, “the collective evidence supports that alcohol-based skin antiseptics are more effective than aqueous-based skin antiseptics in reducing SSI incidence. Use an alcohol-based skin antiseptic for surgical site preparation unless contraindicated.” It does discuss contraindications to alcohol-based antiseptics, such as proximity to areas of mucosa, open wounds, or the patient’s cornea or ear, or if dry-time is likely to be inefficient or unachievable due to large amounts of hair, of which removal may not be feasible or desired. It says that selection of an alcohol-based antiseptic should be based on individual patient assessment, including consideration of allergies or sensitivities and the location of the surgical site to which it will be applied.
Two recent studies, published in two Lancet journals, add to our knowledge base of efficacy of skin disinfectants.
Jalalzadeh and colleagues (Jalalzadeh 2022) did a systematic review and network meta-analysis comparing different preoperative skin antiseptics in the prevention of SSI;s in adult patients undergoing surgery of any wound classification. They looked at studies that directly compared two or more antiseptic agents (ie, chlorhexidine, iodine, or olanexidine) or concentrations in aqueous and alcohol-based solutions. Their study was published in The Lancet Microbe. 33 studies were eligible for the systematic review, and 27 studies with 17,735 patients reporting 2144 SSI’s were included in the quantitative analysis. Only 2.0-2.5% chlorhexidine in alcohol (relative risk 0·75) and 1.5% olanexidine (RR 0.49) significantly reduced the rate of SSI’s compared with aqueous iodine. But bias was evident in many of the studies. Seven of the RCT’s (randomized controlled trials) were at high risk of bias, 24 had some concerns, and two had low risk of bias. Heterogeneity across the studies was moderate. But overall, in line with previous research, they found a benefit of chlorhexidine in alcohol over both aqueous iodine and iodine in alcohol for the prevention of SSI’s in all wound classifications, particularly 2.0-2.5% chlorhexidine in alcohol. In contrast to a previous network meta-analysis, they found no additional benefit from 4.0% chlorhexidine in alcohol. The efficacy of olanexidine was established by a single randomized trial, so further investigation is needed. Of note, the studies that mentioned adverse events noted only mild events and none reported a substantial difference in adverse events between groups.
Most comparative studies have been performed in patients undergoing clean surgery. What about those with open wounds? Many surgeons avoid alcohol-based solutions for antisepsis of open wounds because of the potential for tissue toxicity and the risk of electrocautery fire or chemical burn hazard from alcohol pooling in the wound or beneath a surgical tourniquet. So investigators (PREP-IT Investigators 2022) conducted a cluster-randomized, crossover trial at 14 hospitals in Canada, Spain, and the USA on adults aged 18 years or older with an open extremity fracture were treated with a surgical fixation implant. Participating sites were randomly assigned (1:1) to use either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate immediately before surgical incision; sites then alternated between the study interventions every 2 months. Participants, health-care providers, and study personnel were aware of the treatment assignment due to the color of the solutions, but the outcome adjudicators and data analysts were masked to treatment allocation. The primary outcome was surgical site infection. An SSI occurred in 7% of 787 participants in the povidone-iodine group and 7% of 784 in the chlorhexidine gluconate group. The report does not specify adverse events. The researchers concluded that, for patients who require surgical fixation of an open fracture, either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate can be selected for skin antisepsis on the basis of solution availability, patient contraindications, or product cost.
We’ve previously noted that chlorhexidine preparations with alcohol are typically flammable and have been implicated in some surgical fires (see our Patient Safety Tips of the Week for December 13, 2011 “Surgical Fires Again”, August 12, 2014 “Surgical Fires Back in the News”, and December 16, 2014 “More on Each Element of the Surgical Fire Triad”). After a case described in the latter column a hospital implemented a policy prohibiting alcohol-based skin preps in any emergency surgery that does not allow sufficient drying time (usually 3 minutes or longer). Instead, they went back to non-alcohol-based preps like Betadine for such emergency cases. And in our April 24, 2012 Patient Safety Tip of the Week “Fire Hazard of Skin Preps, Oxygen” we noted a hospital in New Zealand switched from alcohol-based skin disinfectants to aqueous-based skin preps for ob/gyn procedures after a surgical fire during a C-section. We’ve also noted problems with “the fine print” on package inserts and labels in some cases. In several of our prior columns (see our January 10, 2017 Patient Safety Tip of the Week “The 26-ml Applicator Strikes Again!”) we noted another surgical fire in which a hospital had switched from the 10.5 ml Chloraprep applicator, which did not have the warning to avoid use in head and neck surgery, to the 26 ml applicator which did have the warning. It was actually quite predictable that staff would assume the new supplies were the same as the old and not “read the fine print”.
Skin disinfectants are important in avoiding surgical site infections. Be sure you choose the most appropriate one, based on the type and location of surgery. And make sure you follow recommended procedures for use of each type of disinfectant.
References:
AORN (Association of periOperative Registered Nurses). Key Takeaways: New Recommendation: Guideline for Patient Skin Antisepsis. Periop Today 2022; Publish Date: October 12, 2022
Jalalzadeh H, Groenen H, Buis DR, et al. Efficacy of different preoperative skin antiseptics on the incidence of surgical site infections: a systematic review, GRADE assessment, and network meta-analysis. Lancet Microbe 2022; Published Online First August 16, 2022
https://www.thelancet.com/journals/lanmic/article/PIIS2666-5247(22)00187-2/fulltext
PREP-IT Investigators. Aqueous skin antisepsis before surgical fixation of open fractures (Aqueous-PREP): a multiple-period, cluster-randomised, crossover trial. The Lancet 2022; 400(10360): 1334-1344 October 15, 2022
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01652-X/fulltext
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November 22, 2022
The Apple Watch and Patient Safety
Your next patient safety tool might be right on your wrist already. You probably already know that the Apple Watch can detect atrial fibrillation and falls, but it also has several other potential patient safety uses. (Many of our comments likely also apply to several other smartwatches. The Apple Watch is simply the one we are most familiar with.)
Researchers at the Mayo Clinic recently applied a proprietary AI (artificial intelligence) algorithm using the single lead EKG function available on the smartwatch to see if it might predict patients at risk of cardiac dysfunction (Attia 2022). Almost 2500 patients used a Mayo Clinic iPhone application that sends watch ECG’s to a secure data platform. 421 participants had at least one watch-classified sinus rhythm ECG within 30 days of an echocardiogram, of whom 16 (3.8%) had an EF ≤ 40%. The Mayo AI algorithm detected patients with a low EF (ejection fraction) with a high degree of reliability.
That made us wonder whether the Apple Watch might also be able to detect QTc prolongation in patients at risk for Torsade de Pointes. We speculated on that in our February 16, 2021 Patient Safety Tip of the Week “New Methods for QTc Monitoring”. It turns out that such a study has already been done. Italian researchers (Spaccarotella 2021) did conventional ECG’s on 119 patients, then obtained via the Apple Watch ECG’s tracings on leads I, II, and V2. (Lead I was recorded with the smartwatch on the left wrist and the right index finger on the crown. Lead II was obtained with the smartwatch on the left lower abdomen and the right index finger on the crown. The V2 lead was recorded with the smartwatch in the fourth intercostal space left parasternal with the right index finger on the crown.) They found good agreement among the QT intervals of I, II, and V2 leads and the QT mean using the smartwatch and the standard ECG. A previous study (Strik 2020) had shown Apple Watch ECG tracings allowed adequate QT measurements, though performance depended on factors such as electrocardiographic tracing quality and T-wave amplitude. Those researchers suggested that identifying the best smartwatch position at baseline might improve accuracy. These 2 studies certainly suggest that in situations where monitoring of QTc intervals is important, such as when a patient is being treated with one of the many drugs known to increase the QTc, monitoring via a smartwatch may be useful.
Note that, with a bit of jockeying of placement, it is possible to obtain a 12-lead ECG using an Apple Watch (Cobos Gil 2020). That article includes a video demonstrating how to obtain the 12-lead ECG using the Apple Watch. The author concludes this could potentially revolutionize our approach to cardiac emergencies.
Though the Apple Watch can detect bradycardia and tachycardia, its most widely touted capability is detection of atrial fibrillation (AF). But its detection of AF is not infallible. In the Apple Heart Study, 34% of individuals who received a notification of arrhythmia were later found to have atrial fibrillation (AF), and the positive predictive value in participants notified of an irregular pulse was 0.84 (Perez 2019). Another study (Seshadri 2020) found that the single-lead electrocardiographic waveform saved as a PDF provided a more reliable means of detecting AF than the rhythm notification of the watch. Moreover, coexisting ECG anomalies may complicate the accuracy of smartwatch detection of atrial fibrillation (Racine 2022).
In addition to the functions related to cardiac function, the Apple Watch (and presumably several other smartwatches) have lots of other patient safety applications.
Many smartwatches can now measure pO2. During the COVID-19 pandemic, some patients were using this capability rather than using a finger pulse oximeter to identify worrisome trends in oxygen saturation, though studies have not shown that such use had an impact on COVID-19 outcomes.
Measuring nocturnal pO2 has the potential to identify patients at risk for OSA (obstructive sleep apnea). However, most smartwatches with pO2 measurement capability only measure pO2 on demand. Periodic sampling of pO2 during the night while a patient is sleeping would be a major improvement in identifying potential OSA and some smartwatches will soon have the capability. In the meantime, identifying patients at risk for OSA can benefit from the ability of some smartwatches to identify snoring at night.
In addition to the potential to identify OSA risk, many smartwatches are now able to measure sleep duration, another important health indicator.
The Apple Watch also offers fall detection, though you must enable that function. Remember those old “I’ve fallen and can’t get up!” commercials for medical alert devices and services? Now, when someone has fallen, they can use their Apple Watch (with cellular service) to call a friend or relative or summon 911 help. And it is not just the elderly who might use the Apple Watch after a fall. Recently, a teen slipped and fell 130 feet into a valley while hiking and was badly injured, breaking both ankles (Gallagher 2022). He did not have his smartphone with him but was able to call friends with his Apple Watch, leading to his rescue.
In addition to the Apple Watch capabilities, newer iPhone models may provide important information about certain patient safety risks, such as walking steadiness.
Most users of the Apple Watch or other smartwatches are well aware of the fitness applications like step counting, heart rate monitoring, etc. But collection of such health data over time can also identify trends that might be important. For example, trends in the 6-minute walk test measured via the Apple Watch (Apple 2021) might provide evidence of deterioration of physical function. Conversely those trends might provide evidence of improvement in physical function after a medical event.
Gait speed is an important potential indicator of frailty (see our August 14, 2012 Patient Safety Tip of the Week “Gait Speed: A New Vital Sign?”) and the Apple Watch can provide a measure of gait speed. Of course, you can also just use the timer on the Apple Watch to do the Timed Up-and-Go Test (see our November 2011 What's New in the Patient Safety World column “Timed Up-and-Go Test and Surgical Outcomes”). Note also that an iPhone app from the University of Toronto, iWalkAssess, provides easy access to stroke-specific walk test protocols, timing tools, a 6-minute walk test length counter, and algorithms for comparing test performance to normative and community ambulation values.
Newer smartwatches are expected to have temperature sensors that could identify febrile patients. But even older smartwatches, that can measure heart rate, can identify potential fever by identifying the elevated heart rate that usually accompanies fever.
Beware that false alarms may be triggered by the smartwatch. We’ve had the “It looks like you have fallen” alert trigger on our Apple Watch after doing a twist entry into a kayak off a dock. And it might trigger if you are wearing the watch on your dominant arm when serving a tennis ball! And once, after an awkward bicycle dismount, we even accidentally triggered the emergency call function of the Apple Watch (fortunately, we were able to cancel that before EMT’s were summoned!).
Also keep in mind that the Apple Watch and iPhone might have unintended consequences related to implanted cardiac devices (see our October 2021 What's New in the Patient Safety World column “More on Smartphones and Watches Effect on Cardiac Devices”).
In this era where most remote monitoring is fairly expensive, it is refreshing to see that many important patient safety monitoring capabilities can be provided relatively inexpensively.
References:
Attia ZI, Harmon DM, Dugan J, et al. Prospective evaluation of smartwatch-enabled detection of left ventricular dysfunction. Nat Med 2022; November 14, 2022
https://www.nature.com/articles/s41591-022-02053-1#citeas
Spaccarotella CAM, Migliarino S, Mongiardo A, et al. Measurement of the QT interval using the Apple Watch. Scientific Reports 2021; 11: 10817 May 24, 2021
https://www.nature.com/articles/s41598-021-89199-z#citeas
Strik M, Caillol T, Ramirez FD, et al. Validating QT-interval measurement using the Apple Watch ECG to enable remote monitoring during the COVID-19 pandemic. Circulation 2020; 142(4): 416-418
https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.048253
Cobos Gil MA. Standard and Precordial Leads Obtained with an Apple Watch. Ann Intern Med 2020; 172(6): 436-437
https://www.acpjournals.org/action/showCitFormats?doi=10.7326%2FM19-2018
Perez MV, Mahaffey KW, Hedlin H, et al; Apple Heart Study Investigators. Large-scale assessment of a smartwatch to identify atrial fibrillation. N Engl J Med 2019; 381: 1909-1917
https://www.nejm.org/doi/10.1056/NEJMoa1901183
Seshadri DR, Bittel B, Browsky D, et al. Accuracy of Apple Watch for Detection of Atrial Fibrillation. Circulation 2020; 141(8): 702-703
https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.119.044126
Racine H-P, Strik M, van der Zande J, et al. Role of Coexisting ECG Anomalies in the Accuracy of Smartwatch ECG Detection of Atrial Fibrillation. Canadian Journal of Cardiology 2022; 38(11): 1709-1712 November 01, 2022
https://www.onlinecjc.ca/article/S0828-282X(22)00756-5/fulltext#relatedArticles
Gallagher W. Apple Watch gets help for badly injured teen after 130-foot fall. AppleInsider 2022; November 17, 2022
Apple. Using Apple Watch to Estimate Six-Minute Walk Distance. May 2021
Apple. Measure your walking steadiness with your iPhone.
https://support.apple.com/en-us/HT212503
University of Toronto. iWalkAssess (app). Apple Store
https://apps.apple.com/us/app/iwalkassess/id1415990058
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November 29, 2022
Preventing Newborn Falls
One special category of falls, with unique contributing factors, is newborn falls. We discussed factors contributing to newborn falls in detail in the 3 columns list below.
The Children’s Hospital at Dartmouth Hitchcock Medical Center implemented a series of interventions to reduce newborn falls (Whatley 2022). In 2017 the hospital had 3 newborn falls occurring in a two-month period and a resultant newborn fall rate of 71.8 falls per 10,000 births. Root cause analysis (RCA) and chart review found prenatal maternal opioid intake in 4 of 10 cases. Mothers’ fatigue due to medication, delivery-related complications, the postpartum state, hesitancy to accept help, and being accustomed to co-sleeping were all cited as factors that might increase newborn falls. Interestingly, the mechanism of fall differed by mode of delivery, with more drops by a sleeping caregiver following vaginal deliveries and falls due to maternal trips after cesarean deliveries.
An interprofessional team developed and implemented parent education materials, a nursing Newborn Fall Risk Assessment tool and job aid, attention to physical layout, and a standardized reporting system. After interventions, the fall rate decreased to 15.5 per 10,000 births. Days between falls increased from a low of 9 days to a high of 467 days. No newborn injuries have occurred since early 2017. This improvement was accomplished while preserving rooming-in on a mother-baby unit with many opioid-exposed newborns.
We are still waiting to see if anyone has tried an intervention we suggested in our January 14, 2020 Patient Safety Tip of the Week “More on Newborn Falls”. Since mom’s drowsiness and falling asleep while feeding the baby is a major cause of newborn falls, that should be an area of focus. There is an iPhone app called “Keep Alert”. You focus the iPhone camera on your face and, if your eyelids droop or close, it sets off an alarm. We tried it on ourselves, and it clearly delivered as advertised. This could be a simple, inexpensive intervention on a maternity ward to trigger an alarm when a mom is breastfeeding or otherwise holding her newborn.
The Pennsylvania Patient Safety Authority has identified multiple factors contributing to newborn falls. In our July 28, 2015 Patient Safety Tip of the Week “Not All Falls Are the Same” and our March 2019 What's New in the Patient Safety World column “Newborn Falls” and our January 14, 2020 Patient Safety Tip of the Week “More on Newborn Falls” we highlighted a Pennsylvania Patient Safety Authority review that found a surprising number of newborn injuries related to falls (Wallace 2014) and a followup study a few years later (Kukielka 2019).
Kukielka and Wallace estimated annual rates of newborn falls as ranging from 3.7 to 5.9 falls per 10,000 live births from 2014 to 2018, with an average annual rate of newborn falls of 4.8 falls per 10,000 live births over the five-year study period. Almost 70% occurred within the first 72 hours following birth and 90% within the first 7 days.
56.6% of newborn falls occurred between midnight and 7 a.m. 52.8% of events took place after the caregiver fell asleep. A couple happened when a caregiver lost consciousness following a seizure. Other circumstances included caregiver dropping the newborn while in motion (19.8%), caregiver dropping the newborn while stationary (12.6%), and the newborn falling from another surface, such as a bed or couch (5.7%).
There were 5 cases (1.6%) in which the newborn fall occurred following a precipitous delivery.
The following contributing factors were identified:
84.6% of events involved the mother, 10.3% the father, 2.9% another family member (most often a grandparent), and 1.9% a member of the hospital staff (most often a nurse).
Regarding harm to the newborn, 10.4% were classified as Serious Events though, fortunately, none of the events resulted in permanent harm or death. In 63% of those classified as Serious Events, the newborn experienced temporary harm that required treatment or intervention. In the remaining 36.4%, the newborn experienced temporary harm (eg. bumps, bruises, swelling, hematomas, hemorrhages, and fractures) that required initial or prolonged hospitalization.
The authors of both PPSA studies focused heavily on feeding and, in particular, breastfeeding as important contributing factors. Since many hospitals allow the infants to sleep in-room (in bassinettes) with the mothers, the importance of putting the infant back in the bassinette becomes apparent.
The reports focus heavily on the sleepiness of the parents, particularly the mothers, noting studies demonstrating maternal sleep deprivation in the peripartum and postpartum periods. One of the most important points made by the authors is “The cluster of events during hours when parents or caregivers would otherwise be sleeping suggests that maternal sleep in the immediate postpartum period should be a focal point in newborn fall prevention strategies.”
Focusing on education for new parents may be an important intervention to prevent newborn falls. The authors give examples from some hospital interventions, such as giving new parents a welcome letter that includes information on newborn safety and safe sleep and discourages co-sleeping.
Parents should be encouraged to give their baby to nursing staff to take to the nursery if they are feeling tired or just need a break. Some also encourage parents to have a break in visiting hours from 2 p.m. to 4 p.m. each day to give them the opportunity to rest.
The earlier PPSA study mentioned hourly rounding as a potential preventive intervention, with nurses intervening when finding a sleepy mother with a newborn in her arms. One of the hospitals in the more recent PPSA study noted nurses were already rounding every hour on the maternity ward, so they increased this to every 15 minutes as an added precaution when mothers are breastfeeding. Some even use handheld timers to support the nurses in this practice.
Staff training should include education on the American Academy of Pediatrics recommendations for safe sleep practices to prevent sleep-related deaths among infants, and learning how to lock hospital beds in the lowest position to reduce the likelihood of injury if a newborn were to fall from the bed.
The earlier PPSA review (Wallace 2014) did note their literature review of risk factors noted cesarean birth, pain medication in the last two to four hours, and history of narcotic substance use and/or methadone treatment program as potential risk factors.
The Joint Commission, in a Quick Safety alert “Preventing Newborn Falls and Drops” (TJC 2018), advocated doing a risk assessment to identify newborns most at risk for falls, then educating the parents based on that assessment. The Joint Commission Quick Safety alert also recommends:
Note that we have stressed in several prior columns on falls the importance of doing post-fall assessments promptly. We’re not just talking about examining the newborn for evidence of physical harm. We are talking about determining factors that likely contributed to the event so that recurrences can be prevented. In prior columns we gave links to some examples of post-fall evaluation tools, such as an excellent form for post-fall huddles after newborn falls on the PPSA website.
.
The National Health Service (UK) also in 2019 released a safety alert on assessment and management of babies who are accidentally dropped in hospitals (NHS 2019a). A search of their National Reporting and Learning System (NRLS) for a recent 12-month period identified 182 babies who had been accidentally dropped in obstetric/midwifery inpatient settings, 66 babies accidentally dropped on pediatric wards, and two in mother and baby units in mental health trusts. Almost all of these 250 incidents occurred when the baby was in the care of parents or visiting family members. Eight of those dropped in the obstetrical settings had significant reported injuries, including fractured skulls and/or intracranial bleeds,
The NHS found that responses to such incidents were quite variable, so the alert provided a resource to support providers to develop or update a tailored local guide on the initial actions to take when a baby has been accidentally dropped. Guidelines for the latter (NHS 2019b) include recommendations on:
The 2 PPSA reviews, and other studies in our March 2019 What's New in the Patient Safety World column “Newborn Falls” such as the one from Driscoll et al. (Driscoll 2019), have emphasized breastfeeding and rooming-in as significant risk factors. Of course, we encourage breastfeeding. So, we need to take extra precautions to ensure that breastfeeding is done safely. In addition to the “educational” interventions, we like the ideas for signage and for upping the hourly rounding to every 15-minute rounding when the mother is breastfeeding. But that can be difficult on labor and delivery units, especially when there are several ongoing labors that may require staff be elsewhere during those nocturnal hours when newborns are at greatest risk. Is this a scenario where technology might help? Companies are working on smart cameras to detect when a car driver’s eyelids are getting heavy, such as the “Keep Alert” iPhone app we noted above. We strongly suspect that sort of technology could be used to identify mothers (or fathers) at risk of falling asleep while holding their newborns.
We like the idea of a technology intervention since most of the other interventions mentioned above rely heavily on education (of parents and staff). In one of our other January 2020 What's New in the Patient Safety World columns “ISMP Canada: Change Management to Prevent Recurrences” we again remind everyone that education/training rank lowest on our list of strengths of interventions. However, we also caution against overreliance on technology, since we may become complacent and assume the technology will prevent untoward events at the expense of our other interventions (see our Patient Safety Tips of the Week for August 23, 2016 “ISMP Canada: Automation Bias and Automation Complacency” and June 11, 2019 “ISMP’s Grissinger on Overreliance on Technology”).
And, yes, don’t forget dads, too. Fathers are the caregiver with the newborn in about 10% of the newborn falls. While moms have done all the work and are entitled to be fatigued, dads may get fatigued trying to balance visits to the maternity wing with caring for the other kids at home.
And what about those falls/drops that occur during deliveries? The viral video and the other report of newborns falling or being dropped during deliveries are particularly distressing. In one incident, a newborn was dropped on her head while being handled by staff immediately following delivery (Westfall 2019). Video of the incident shows three staff members transferring the baby from one set of blankets to another. The newborn is lifted up by one of them, who is still gripping a medical instrument. Then the worker loses control of her. The baby flips, lands on her head on the table and almost falls over the edge. The workers snatch her up, turn her over and wrap her in a blanket. The baby apparently had some sort of cerebral hemorrhage, though the article did not clarify whether that was the result of the drop or due to prematurity.
In the other incident, a newborn died during delivery (Penza 2019). His mother had reportedly been told to push, but he came out too fast and fell onto the ground. According to the father “My wife was in labor and was just about to have the baby and they asked her to push and she pushed so he would come out. He came out really fast and no-one grabbed him and he fell to the floor. The midwife didn’t have time to catch him and the obstetrician didn’t react.”
Seems to be a rarity. However, the UK NHS alert (NHS 2019a) also notes that 4% of their incidents occurred during “precipitate” birth and the recent PPSA study (Kukielka 2019) found 5 events over the 5 year period (1.6% of the total newborn falls) in which the newborn fall occurred following a precipitous delivery. Few details were provided though they note high-risk situations have been identified including delivery, especially when the mother has lost a significant amount of blood. The infant in the case described above (Westfall 2019) was a twin, though the article does not mention whether she was the first or second delivered (though one of many articles with the viral video said the father was watching delivery of the other twin while he was filming the video). Either way, it suggests some sort of urgency during the delivery. So, we’d probably add distractions (such as maternal hemorrhage or multiple births) as risk factors for newborn falls during delivery.
The increase in occurrence of newborn falls as noted by the PPSA and the Joint Commission and UK NHS should raise our awareness of the risks and contributing factors. Dartmouth Hitchcock did a nice job with their program to reduce risk factors for newborn falls. Particularly if your organization takes care of newborns in any setting, you should review RCA’s on any newborn falls you’ve encountered but also consider doing a FMEA (Failure Mode and Effects Analysis) to identify your potential vulnerabilities. And learn from the many valuable lessons in this and our other columns on newborn falls.
Some of our prior columns related to newborn falls:
References:
Whatley C, Schlogl J, Whalen BL, Holmes AV. A Longitudinal Study of a Multifaceted Intervention to Reduce Newborn Falls While Preserving Rooming-In on a Mother-Baby Unit. The Joint Commission Journal on Quality and Patient Safety 2022; 48(10): 521-528
https://www.sciencedirect.com/science/article/abs/pii/S155372502200126X
Wallace SC. (Pennsylvania Patient Safety Authority). Balancing Family and Newborn Bonding with Patient Safety. Pa Patient Saf Advis 2014; 11(3): 102-108
http://patientsafety.pa.gov/ADVISORIES/Pages/201409_102.aspx
Kukielka E, Wallace SC. Newborn Falls in Pennsylvania: An Analysis of Recent Events and a Review of Prevention Strategies. Patient Safety 2019; 1(2): 45-53 December 2019
https://patientsafetyj.com/index.php/patientsaf/article/view/newborn-falls/55
The Joint Commission. Quick Safety 40: Preventing Newborn Falls and Drops. The Joint Commission 2018; March 27, 2018
PPSA (Pennsylvania Patient Safety Authority). Newborn Fall UOR Debrief Form. PPSA 2014
http://patientsafety.pa.gov/pst/Pages/Newborn.Injuries/form.aspx
NHS (National Health Service UK). Patient Safety Alert. Assessment and management of babies who are accidentally dropped in hospital. NHS 2019; 9 May 2019
NHS (National Health Service UK). Creating a local guide for the assessment and management of babies who are accidentally dropped in hospital. NHS 2019
Driscoll CAH, Pereira N, Lichenstein R. In-hospital Neonatal Falls: An Unintended Consequence of Efforts to Improve Breastfeeding. Pediatrics 2019; 143(1): e20182488
Westfall A, Sanders RL. Graphic video shows baby dropped on head by staff at Chandler hospital. Arizona Republic 2019; May 3, 2019
Penza N. Freak Accident. Newborn baby died seconds after birth when medics failed to catch him and he fell headfirst on to the floor. The Sun 2019; 19 Dec 2019
https://www.thesun.co.uk/news/10566959/newborn-baby-died-birth-medics-fell-headfirst-floor/
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December 6, 2022
Rare Risk - Defibrillator Fires
It’s rare, but it’s a serious risk. A patient recently died after a fire triggered by defibrillator paddles (McGee 2022). The patient had been bedridden for several years and was hospitalized at TriStar Centennial Medical Center in Tennessee for bed sores and a foot infection. At the hospital, he coded and staff tried to revive him. According to his wife “…they started the paddles, and it just blew up, everything,” She saw flames cover her husband’s body. “He got burned in the throat, the face, the head, the chest and his hands.” He was transferred to another hospital with a burn unit but ended up dying that night.
On second thought, maybe not as rare as you’d think. Last year a 69 y.o. woman died in a similar incident at a Texas hospital. That patient, who was being treated for COVID-19, was being resuscitated with a defibrillator when something caught fire and caused a small explosion (Willey 2021). Officials were looking into the presence of an open medical oxygen tank as a possible factor. And 2 years before that, at yet another Texas hospital, a defibrillator being used to resuscitate a man sparked, igniting oxygen in the room that had been left on and causing his body to catch fire (Bennett 2021). In that fire, the defibrillator used by the medical team arced and “a spark went off and ignited the oxygen in the room that had been accidentally left on” (Wright 2019).
In 2004, when paramedics were attempting to resuscitate a woman in Connecticut, a spark from defibrillator paddles started the patient’s clothing on fire. And, in 2003, there was a report on a case of a fire attributable to a defibrillation attempt in a 10-day-old neonate following open-heart surgery (Theodorou 2003), with special emphasis on the importance of removing oxygen from the immediate environment during defibrillation attempts.
In our December 2015 What's New in the Patient Safety World column “Unique Ignition Sources in Surgical/OR Fires” we described an OR fire related to a cardioversion procedure occurred in Michigan (Counts 2015). Though the hospital apparently did not release details of the incident, news releases (Allen 2015) state that a spark from the cardioverter pad ignited a paper drape and mask covering the patient in an oxygen-rich environment. That resulted in a fire that injured the patient and several staff members.
And that was not the first time that a cardioverter or defibrillator has served as the heat source for an OR fire. In 2012 an OR fire in North Carolina that was fatal to a patient was triggered by a defibrillator (WRAL 2012). And in June 25, 2013 Patient Safety Tip of the Week “Update on Surgical Fires” we discussed a study from a closed claims database (Mehta 2013) in which there was one case where a defibrillator was the heat source. The 2008 ASA Practice Advisory for the Prevention and Management of Operating Room Fires (ASA 2008) also mentions defibrillator paddles or pad as potential heat sources.
While most cases have involved use of defibrillator paddles in emergent life-saving situations, presumably the same risks would apply to patients undergoing elective cardioversions. In fact, ECRI (ECRI 2020) received a report in which a patient's beard and the oxygen mask caught on fire when the shock was delivered during cardioversion.
One of the earliest case reports of a fire during defibrillation came in 1972 (Miller 1972). In that case a spark from one of the defibrillator paddles to one of the monitoring electrodes was immediately followed by flames at the patient’s neck, shoulders, upper chest, face, and head. Her hair and bed linens were in flames and flames were also noted in the oxygen face mask, which was still in place. The patient survived but the fire resulted in significant hair loss and second degree burns on the shoulder, neck, and scalp. Miller’s advice rings true to today “…the person operating a defibrillator must be certain that the paddles are thoroughly covered with conductive gel and that they are in firm and complete contact with the chest wall before they are discharged. In addition, confirmation that the oxygen has been temporarily turned off must become as automatic as checking to see that no member of the resuscitation team is still in contact with the patient or the bed before the defibrillator is discharged.”
Of course, you need all 3 elements of the fire triad – fuel, oxydizer, and heat source – for a fire to occur. The defibrillator paddles only supply the heat source. The various media reports of this incident do implicate oxygen and the patient’s wife was apparently told there was a defective wire in the paddles that led to the spark. We’d be highly surprised if this occurred in the absence of a rich oxygen source. And, while almost anything can serve as a fuel source, we’d wonder whether any alcohol-based solutions or vapors might have been present.
Oxygen is arguably the most critical element in these fires. We haven’t come across a case in which oxygen did not play a major role. A case described in the ASA Monitor (ASA 2020) involved defibrillation in a post-op patient who developed recurrent V-fib. In this case, the fire was ignited due to the arcing that occurred as a result of poor contact of the gel defibrillation pads with the patient's skin. After the fact, a crease in the defibrillation pad was noted with burn markings clearly visible in this crease. But an oxygen-rich environment clearly played a major role. The patient had been on oxygen via nasal cannula at 4L/min. When the code team initially started ventilating the patient, they removed the nasal cannula from the patient and tucked it under the patient without shutting off the oxygen flow at 4 liters/minute. Secondly, when it came time to defibrillate the patient, the Ambu®-bag was disconnected from the endotracheal tube and placed next to the patient's shoulder. High flow oxygen continued to flow out of the reservoir end of the Ambu®-bag onto the patient's torso.
An APSF review on defibrillation fires (APSF 2009) cites the extensive work of the ECRI Institute. ECRI has noted cases in which the breathing circuit containing a high oxygen concentration was disconnected and laid near the patient, flooding the chest area with oxygen. APSF also notes that the American Heart Association Guidelines for CPR specify that rescuers should try to ensure that defibrillation is not attempted in an oxygen-enriched atmosphere. APSF notes the pros and cons of disconnecting the patient from a ventilator before defibrillation. It concludes that leaving the patient connected to a ventilator during defibrillation can be done safely if exhaled gases and other sources of oxygen are vented away from the patient. However, it goes on to note there is a small risk of a sudden, acute increase in peak airway pressure and possibly barotrauma if the ventilator should cycle during the shock, but the risk of barotrauma should be mitigated by the high pressure limit features of the ventilator. If the patient is left connected, the ventilator should likely be paused. It cautions that, if the ventilator is paused, a person should be assigned to only operate the ventilator and restart ventilation after defibrillation. It emphasizes the risk of not remembering to turn the ventilator back on after defibrillation.
The heat source is obviously related to the defibrillation equipment, but how? Some reports talk about defective equipment, but defective technique is more likely. Arcing can occur as a result of poor contact of the gel defibrillation pads with the patient's skin. Potential causes of poor contact with the patient include: an insufficient or excessive amount of conductive gel, use of the wrong gel (e.g., ultrasound gel), application of paddles over irregular surfaces (e.g., bony prominences, wires, ECG electrodes), or misapplication of paddles (e.g., the metal surface of the paddle not completely on the pad, a fold in the pad, a pad smaller than the paddle's metal surface, a dry pad) (Health Devices 1994; 23: 307-309). When the pad or paddle is placed improperly, such as the pad not fully in contact with the skin, or the paddle placed on a bony prominence, an electric arc can occur during the discharge. The APSF review states that one way to potentially improve patient contact with gel pads, used by some Emergency Department physicians, is to place a pad then rip it off. This will remove the body hair and allow a second gel pad to be placed in good contact with the skin.
The fuel source can be almost anything. Common fuels in these scenarios are alcohol preps or vapors, bed linens, clothing, drapes, plastic tubing, and body hair.
We hope that TriStar Centennial Medical Center, where the current tragedy occurred, will make publicly available the results of their incident review and root cause analysis. That way, the lessons learned can help avert similar tragedies not only at their facility but at any facility.
Defibrillator-related fires are a danger not only to the patient, but also to staff and potentially other patients and visitors. In the 2019 case (Wright 2019) it was noted that the entire 10th floor was so full of thick smoke that staff could barely see. In the North Carolina case (WRAL 2012) several staff were also injured and several patients had to be transferred to an ICU because of smoke inhalation. In the case reported in the ASA Monitor (ASA 2020), five staff members were treated in the ED for smoke inhalation, one RN suffered second-degree burns to the arm, and staff involved in the case were emotionally traumatized.
Also, in our October 2022 What's New in the Patient Safety World column “Portable Oxygen and Ambulance Fire” we described a fatal explosion and fire in an ambulance when a patient was being switched to a portable oxygen source. We noted that the back compartment of an ambulance could have a high concentration of oxygen and any sort of spark could trigger such an event. We mentioned defibrillator paddles as one potential source for such a spark.
So, fires triggered by defibrillators do occur. This case is a stark reminder of dangers to both patients and staff. While use of defibrillators is usually undertaken in emergency situations (though the same would apply to elective cardioversion), it is imperative that care is taken to ensure there is no free flow of oxygen near the patient.
We teach our staffs in hospitals and ambulatory surgery centers about the risks of surgical fires but how many of you teach your staffs about the risks of fires during defibrillation or cardioversion? It’s easy to see from many of the above cases that, during a code situation, staff may forget to minimize the oxygen threat. You should probably include some cases in your simulation training for your code teams in which such potential oxygen threats are present.
The ASA Monitor article (ASA 2020) recommends preventative strategies that should be reviewed with code team members:
– Remove all sources of oxygen (>1 meter)
– Do NOT disconnect Ambu®-bag from ETT during shock
– If disconnected, remove Ambu®-bag >1 meter away
– Direct bag reservoir away from the patient's body
Our prior columns on iatrogenic burns:
Our prior columns on surgical fires:
References:
McGee N. Man dies after catching on fire at Nashville hospital. WKRN.com News 2022; Nov 28, 2022
Willey J. Patient badly burned in fire involving defibrillator at Kingwood hospital. ABC13 News (Houston) 2021; June 30, 2021
Bennett A. Homicide detectives looking into woman’s death at Kingwood hospital after defibrillation and fire. KHOU (Houston) news 2021; July 1, 2021
Wright A. Patient's body set on fire as medical staff attempt CPR. KENS (Houston) News 2019; May 24, 2019
Patient Set Afire by Defibrillator Paddles. Journal of Clinical Engineering 2004; 29(2): 60
Theodorou AA, Gutierrez JA, Berg RA. Fire Attributable to a Defibrillation Attempt in a Neonate. Pediatrics 2003; 112(3 Pt 1): 677-679 October 2003
Counts J. U-M cardiovascular center fire started during operation on patient, spread to curtain. Ann Arbor News 2015; July 7, 2015
https://www.mlive.com/news/ann-arbor/2015/07/u-m_cardiovascular_center_fire.html#incart_m-rpt-2
Allen J. U-M not releasing report on cardiovascular center fire that burned patient. Ann Arbor News 2015; August 7, 2015
https://www.mlive.com/news/ann-arbor/2015/08/u-m_not_releasing_report_of_ca.html
WRAL. Fatal Durham hospital fire may have started during defibrillation. WRAL.com Posted November 6, 2012
http://www.wral.com/explosion-reported-on-sixth-floor-of-durham-regional-hospital/11742138/
Mehta SP, Bhananker SM, Posner KL, Domino KB. Operating Room Fires: A Closed Claims Analysis. Anesthesiology 2013; 118(5): 1133-1139, May 2013
ASA (American Society of Anesthesiologists). American Society of Anesthesiologists Task Force on Operating Room Fires. Practice advisory for the prevention and management of operating room fires. Anesthesiology 2008; (108): 786-801
ECRI. External Defibrillators: Electrical Arcing in an Oxygen-Enriched Atmosphere May Present Risk of Fire. April 30, 2020
https://www.ecri.org/components/PSOCore/Pages/HDAlert_043020.aspx
Miller PH. Potential fire hazard in defibrillation. JAMA 1972; 221(2): 192
https://jamanetwork.com/journals/jama/article-abstract/343422
ASA. Learning From Others: A Case Report from the Anesthesia Incident Reporting System. ASA Monitor August 2020; 84: 14
https://pubs.asahq.org/monitor/article/84/8/14/108612/Learning-From-Others-A-Case-Report-from-the
APSF (Anesthesia Patient Safety Foundation). The Committee on Technology. Reducing the Risk of Defibrillation Fires. APSF Newsletter 2009; 24(3): 36-37
https://www.apsf.org/article/reducing-the-risk-of-defibrillation-fires/
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December 13, 2022
Surgical Teams - the "Consistency Score"
In our several columns on “after hours” surgery (see list below) we noted one of the likely contributing factors may be that you are often operating with a team that is likely different from your daytime team. We can’t overemphasize the importance of teamwork in the OR.
So, what about surgery during regular hours? Does inconsistency of team composition impact performance in the OR then as well? Researchers at the Hospital for Special Surgery in New York developed a unique metric to study that issue. The “consistency score” was developed after it was anecdotally observed that significant variability may exist between surgical teams depending on scheduling and hiring cycles at their institution (Kirksey 2022).
Because more than 500 members of hospital staff were involved in total joint arthroplasty procedures with 38 surgeons, the consistency score calculation was a percentage based on the weighted graph consisting of all team members who had worked with the surgeon over the prior 90 days until the time of the particular surgery. (Team roles taken into consideration in this calculation were the surgeon, anesthesiologist, scrub technician, circulating nurse, first assistant, and second assistant.)
The actual score is quite complicated, so you have to go to the original article for details. But the score assigns weights to various factors and additional covariates were created to account for confounding and effect modification. The consistency score association with over 18,000 total joint arthroplasties was then analyzed.
THA (Total Hip Arthroplasty) surgical teams with greater consistency were associated with shorter surgical processing times compared with surgeries with team members who have worked together less frequently: there was a significant 4.1-minute decrease (p = 0.008) in surgery duration for a single 10-percentage point increase in the consistency score. In addition, for a single 10-percentage point increase in consistency score, the patient-in-to-procedure-start time was 3.0 minutes faster (p = 0.0006), and there was a 0.3-minute decrease in procedure-end-to-patient-out duration (p = 0.009) and a 1.7-minute decrease in turnover time (p = 0.001). The consistency score was not significantly associated with hospital-acquired complications.
TKA (Total Knee Arthroplasty) surgical teams with greater consistency had shorter surgical processing times than surgeries with team members who have worked together less frequently. Patient-in-to-procedure-start time was 2.6 minutes faster (p = 0.0001) and surgery duration was 3.4 minutes faster (p = 0.05) for a single 10-percentage point increase in consistency score. In addition, there was a 0.2-minute decrease in time from procedure-end-to-patient-out (p = 0.01) and a 1.1-minute decrease in turnover time (p = 0.03) for a single 10-percentage point increase in consistency score. Hospital-acquired complications were not significantly associated with consistency scores for TKA.
Thus, for both THA and TKA, the consistency score showed that better team consistency was associated with improved OR efficiency without any increase in adverse events.
The authors note that they were able to develop the “consistency score” metric because they had that huge database on total joint arthroplasty procedures. They suspect hospitals with low volumes of such surgeries might have difficulty using the metric.
We’re not at all surprised to see that OR efficiency improved as consistency of the OR teams improved. We are a little surprised that there was not a concomitant decrease in surgical complications. Our multiple columns below have discussed the association of complications or adverse events with procedure duration. It may be that the mean decrease in OR duration, though statistically significant, may not have been great enough to reduce complications.
Some of our previous columns on “after-hours” surgery:
Our prior columns focusing on surgical case duration:
References:
Kirksey M, Sasaki M, Grace D, et al. A Novel Network-Based Metric of Surgical Team Consistency Opens Opportunities to Improve Hospital Performance and Care Value. NEJM Catalyst 2022; 3(12): December 2022
https://catalyst.nejm.org/doi/full/10.1056/CAT.22.0244
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December 20, 2022
Amazing Results from I-PASS Implementation
Handoffs present vulnerabilities that often lead to untoward outcomes and patient safety events and have been one of our most frequent topics over the years. We’ve discussed the various formats that have been used for handoffs and note that many are tailored for specific types of handoff.
We’ve extolled the success of the I-PASS handoff format and culture in many columns. We first described I-PASS in our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics”, a column that highlighted the need to tailor handoff formats to the specific tasks at hand. I-PASS came about because existing formats were not optimal for resident-to-resident handoffs. But I-PASS is much more than a mnemonic and format for handoffs. It also involves extensive team training (based on TeamSTEPPS™) and resident training modules, simulation and role playing, faculty development resources and tools, direct observation of handoffs with feedback, and generation of a printed handoff document that can be integrated with the electronic medical record.
In our December 2014 What's New in the Patient Safety World column “I-PASS Passes the Test” we discussed the publication of the final results of the I-PASS project (Starmer 2014). After implementation of I-PASS the rate of medical errors decreased by 23% and the rate of preventable medical errors decreased by 30%. Significantly, there was no increase in the amount of time spent on handoffs and there was no significant change in resident workflow or the amount of resident contact with patients and families.
Then, in our November 2019 What's New in the Patient Safety World column “I-PASS Delivers Again” we noted another study demonstrating that implementation of a handoff bundle, modeled on the intervention in the original I-PASS study, was associated with decreased medical errors and preventable adverse events on an academic family medicine inpatient unit (Dewar 2019).
We thought those previous reports on the success of I-PASS were impressive. Well, results of implementation of I-PASS in diverse clinical environments are even more impressive. Starmer et al. (Starmer 2022) recently published results of implementation of I-PASS at a diverse group of 32 adult, pediatric, academic, and community hospitals. They found a 47.1% reduction in the frequency of handoff‐related major adverse events and a 46.9% reduction in handoff‐related, minor harm events after I-PASS implementation. Improvements were similar across provider types (adult vs. pediatric) and settings (community vs. academic).
In addition, there were marked improvements in the completeness and quality of handoff communications. Completeness of verbal handoffs improved from 20 percent prior to implementation to 66 percent after implementation. Completeness of written handoffs improved from 10 percent prior.to 74 percent. And there were dramatic improvements in the perception of quality of the handoffs by those on both the giving and receiving ends of the handoffs.
Note that this study was focused on resident physician end‐of‐shift handoffs, with a primary focus on general pediatric and internal medicine units. But we have no reason to think that I-PASS would not be equally successful for residents in specialty programs or attendings such as hospitalists.
Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:
May 15, 2007 “Communication, Hearback and Other Lessons from Aviation”
May 22, 2007 “More on TeamSTEPPS™”
August 28, 2007 “Lessons Learned from Transportation Accidents”
December 11, 2007 “Communication…Communication…Communication”
February 26, 2008 “Nightmares….The Hospital at Night”
September 30, 2008 “Hot Topic: Handoffs”
November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
December 2008 “Another Good Paper on Handoffs”.
June 30, 2009 “iSoBAR: Australian Clinical Handoffs/Handovers”
April 25, 2009 “Interruptions, Distractions, Inattention…Oops!”
April 13, 2010 “Update on Handoffs”
July 12, 2011 “Psst! Pass it on…How a kid’s game can mold good handoffs”
July 19, 2011 “Communication Across Professions”
November 2011 “Restricted Housestaff Work Hours and Patient Handoffs”
December 2011 “AORN Perioperative Handoff Toolkit”
February 14, 2012 “Handoffs – More Than Battle of the Mnemonics”
March 2012 “More on Perioperative Handoffs”
June 2012 “I-PASS Results and Resources Now Available”
August 2012 “New Joint Commission Tools for Improving Handoffs”
August 2012 “Review of Postoperative Handoffs”
January 29, 2013 “A Flurry of Activity on Handoffs”
December 10, 2013 “Better Handoffs, Better Results”
February 11, 2014 “Another Perioperative Handoff Tool: SWITCH”
March 2014 “The “Reverse” Perioperative Handoff: ICU to OR”
September 9, 2014 “The Handback”
December 2014 “I-PASS Passes the Test”
January 6, 2015 “Yet Another Handoff: The Intraoperative Handoff”
March 2017 “Adding Structure to Multidisciplinary Rounds”
August 22, 2017 “OR to ICU Handoff Success”
October 2017 “Joint Commission Sentinel Event Alert on Handoffs”
October 30, 2018 “Interhospital Transfers”
April 9, 2019 “Handoffs for Every Occasion”
November 2019 “I-PASS Delivers Again”
August 2020 “New Twist on Resident Work Hours and Patient Safety”
September 29, 2020 “ISHAPED for Nursing Handoffs”
May 25, 2021 “Yes, Radiologists Have Handoffs, Too”
February 2022 “Communication Failures and Malpractice”
June 7, 2022 “SBAR to the Rescue!”
References:
I-PASS Study website.
http://www.ipasshandoffstudy.com/home
Starmer AJ, Spector ND, Srivastava R, et al. Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med 2014; 371: 1803-1812
http://www.nejm.org/doi/full/10.1056/NEJMsa1405556
Dewar Z, Yurkonis T, Attia M. Hand-off bundle implementation associated with decreased medical errors and preventable adverse events on an academic family medicine in-patient unit: A pre-post study. Medicine 2019; 98(40): e17459, October 2019
https://insights.ovid.com/crossref?an=00005792-201910040-00080
Starmer, AJ, Spector, ND, O'Toole, JK, et al. Implementation of the I-PASS handoff program in diverse clinical environments: A multicenter prospective effectiveness implementation study. J Hosp Med. 2022; 1- 10 First published: 03 November 2022
https://shmpublications.onlinelibrary.wiley.com/doi/10.1002/jhm.12979
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Amazing Results from I-PASS Implementation
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Surgical Teams – the “Consistency Score”
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Rare Risk – Defibrillator Fires
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Methotrexate Again, With a Twist
October 11, 2022
Good Intentions, Unintended Consequences
October 4, 2022
Successfully Reducing OR Traffic
September 27, 2022
September 20, 2022
September 13, 2022
Smart Socks and Robots for Fall Prevention?
September 6, 2022
AORN and Others on Retained Surgical Items
August 30, 2022
August 23, 2022
Yes, There is a Proper Way to Assess Orthostatic Hypotension
August 16, 2022
August 9, 2022
Tip of the Week on Vacation
August 2, 2022
Tip of the Week on Vacation
July 26, 2022
More Risks in the Radiology Suite
July 19, 2022
Sucked Out of the Plane at 17,000 Feet
July 12, 2022
Radiologists Racked by Interruptions
July 5, 2022
Tip of the Week on Vacation
June 28, 2022
Pneumonia in Nervous System Injuries
June 21, 2022
June 14, 2022
June 7, 2022
May 31, 2022
NHS Serious Incident Response Framework
May 24, 2022
Requiring Indication for Antibiotic Prescribing
May 17, 2022
Patient Harm in Medicare Inpatients
May 10, 2022
May 3, 2022
April 26, 2022
Challenges with Early Warning Systems
April 19, 2022
April 12, 2022
A Healthcare Worker’s Worst Fear
April 5, 2022
Follow-up on Incidental Findings
March 29, 2022
Disturbing Stats on Perioperative Benzodiazepine Use in Elderly Patients
March 22, 2022
Not Just Politicians That Behave Badly
March 15, 2022
Medication Errors in Home Care
March 8, 2022
Update on Retained Surgical Items
March 1, 2022
Including the Indication on Prescriptions
February 22, 2022
Medication Reconciliation at ICU Exit
February 15, 2022
February 8, 2022
ED to Inpatient Delays Increase Mortality
February 1, 2022
Perioperative Delirium is Not Just Postoperative
January 25, 2022
More on Dental Patient Safety Issues
January 18, 2022
January 11, 2022
Documenting Distractions in the OR
January 4, 2022
Spin or Not: A Useful Secondary Finding in a Study
December 28, 2021
Tip of the Week on Vacation
December 21, 2021
December 14, 2021
Delayed Hemorrhage After Head Trauma in Anticoagulated Patients
December 7, 2021
November 30, 2021
November 23, 2021
The Perils of Hypertonic Sodium Chloride
November 16, 2021
Cognitive Biases and Heuristics in the Delivery Room
November 9, 2021
November 2, 2021
Adverse Drug Events After Hospitalization
October 26, 2021
Opioid-Induced Respiratory Depression Costly in Fiscal as Well as Human Terms
October 19, 2021
COVID-19 Vaccine/ Flu Vaccine Mixups
October 12, 2021
FDA Approval of Concussion Tool – Why Not a Fatigue Detection Tool?
October 5, 2021
September 28, 2021
Barcoding Better? Not So Fast!
September 21, 2021
Repeat CT in Anticoagulated Patients After Minor Head Trauma Not Cost-Effective
September 14, 2021
September 7, 2021
The Vanderbilt Tragedy Gets Uglier
August 31, 2021
The Community Pharmacy and Patient Safety
August 24, 2021
More Home Infusion Safety Issues
August 17, 2021
Tip of the Week on Vacation
August 10, 2021
Tip of the Week on Vacation
August 3, 2021
Obstetric Patients More At-Risk for Wrong Patient Orders
July 27, 2021
July 20, 2021
FDA Warning: Magnets in Consumer Electronics May Affect Medical Devices
July 13, 2021
The Skinny on Rapid Response Teams
July 6, 2021
Tip of the Week on Vacation
June 29, 2021
June 22, 2021
Remotely Monitoring Suicidal Patients in Non-Behavioral Health Areas
June 15, 2021
What’s Happened to Your Patient Safety Walk Rounds?
June 8, 2021
Cut OR Traffic to Cut Surgical Site Infections
June 1, 2021
Stronger Magnets, More MRI Safety Concerns
May 25, 2021
Yes, Radiologists Have Handoffs, Too
May 18, 2021
Medical Overuse Is Not Just An Economic Problem
May 11, 2021
How Are Alerts in Ambulatory CPOE Doing?
May 4, 2021
More 10x Dose Errors in Pediatrics
April 27, 2021
Errors Common During Thrombolysis for Acute Ischemic Stroke
April 20, 2021
Taser “Slip and Capture Error” Again!
April 13, 2021
Incidental Findings – What’s Your Strategy?
April 6, 2021
March 30, 2021
Need for Better Antibiotic Stewardship
March 23, 2021
Nursing Staffing and Sepsis Outcomes
March 16, 2021
Sleep Program Successfully Reduces Delirium
March 9, 2021
Update: Disclosure and Apology: How to Do It
March 2, 2021
Barriers to Timely Catheter Removal
February 23, 2021
February 16, 2021
New Methods for QTc Monitoring
February 9, 2021
February 2, 2021
MGH Protocols Reduce Risk of Self-Harm in ED
January 26, 2021
This Freezer Accident May Cost Lives
January 19, 2021
Technology to Identify Fatigue?
January 12, 2021
January 5, 2021
Dilaudid/HYDROmorphone Still Problematic
December 29, 2019
Tip of the Week on Vacation
December 22, 2019
Tip of the Week on Vacation
December 15, 2020
Our Perennial Pre-Holiday Warning: “Be Careful Out There!”
December 8, 2020
Maternal Mortality: Looking in All the Wrong Places?
December 1, 2020
An Early Warning System and Response System That Work
November 24, 2020
November 17, 2020
A Picture Is Worth a Thousand Words
November 10, 2020
November 3, 2020
Reminder: Infant Abduction Risk
October 27, 2020
Conflicting Studies on Technology to Reduce RSI’s
October 20, 2020
More on Post-operative Risks for Patients with OSA
October 13, 2020
October 6, 2020
Successfully Reducing Opioid-Related Adverse Events
September 29, 2020
September 22, 2020
VA RCA’s: Suicide Risks Vary by Site
September 15, 2020
September 8, 2020
Follow Up on Tests Pending at Discharge
September 1, 2020
NY State and Nurse Staffing Issues
August 25, 2020
The Off-Hours Effect in Radiology
August 18, 2020
August 11, 2020
Above-Door Alarms to Prevent Suicides
August 4, 2020
July 28, 2020
July 21, 2020
Is This Patient Allergic to Penicillin?
July 14, 2020
A Thesis on Intrahospital Transports
July 7, 2020
Another Patient Found Dead in a Stairwell
June 30, 2020
What Happens after Hospitalization?
June 23, 2020
June 16, 2020
June 9, 2020
Perioperative Medication Safety
June 2, 2020
May 26, 2020
May 19, 2020
Reminder on Telephone or Verbal Orders
May 12, 2020
May 5, 2020
COVID-19 and the Dental Office
April 28, 2020
April 21, 2020
Parenteral Nutrition Safety Issues
April 14, 2020
Patient Safety Tidbits for the COVID-19 Pandemic
April 7, 2020
From Preoperative Assessment to Preoperative Optimization
March 31, 2020
Intrahospital Transport Issues in Children
March 24, 2020
Mayo Clinic: How to Get Photos in Your EMR
March 17, 2020
March 10, 2020
Medication Harm in the Elderly
March 3, 2020
Opportunities to Reduce Unnecessary Contact Precautions
February 25, 2020
More on Perioperative Gabapentinoids
February 18, 2020
February 11, 2020
February 4, 2020
Drugs and Chronic Kidney Disease
January 28, 2020
January 21, 2020
Disruptive Behavior and Patient Safety: Cause or Effect?
January 14, 2020
January 7, 2020
Even More Concerns About MRI Safety
December 31, 2019
Tip of the Week on Vacation
December 14, 2019
Tip of the Week on Vacation
December 17, 2019
December 10, 2019
December 3, 2019
Overlapping Surgery Back in the News
November 26, 2019
Pennsylvania Law on Notifying Patients of Test Results
November 19, 2019
An Astonishing Gap in Medication Safety
November 12, 2019
Patient Photographs Again Help Radiologists
November 5, 2019
October 29, 2019
Tip of the Week on Vacation
October 22, 2019
Tip of the Week on Vacation
October 15, 2019
October 8, 2019
October 1, 2019
Electronic Medication Reconciliation: Glass Half Full or Half Empty?
September 24, 2019
EHR-related Malpractice Claims
September 17, 2019
American College of Surgeons Geriatric Surgery Verification Program
September 10, 2019
Joint Commission Naming Standard Leaves a Gap
September 3, 2019
Lessons from an Inpatient Suicide
August 27, 2019
August 20, 2019
Yet Another (Not So) Unusual RSI
August 13, 2019
Betsy Lehman Center Report on Medical Error
August 6, 2019
July 30, 2019
Lessons from Hospital Suicide Attempts
July 23, 2019
Order Sets Can Nudge the Right Way or the Wrong Way
July 16, 2019
July 9, 2019
Spinal Injection of Tranexamic Acid
July 2, 2019
Tip of the Week on Vacation
June 25, 2019
June 18, 2019
June 11, 2019
ISMP’s Grissinger on Overreliance on Technology
June 4, 2019
Medication Errors in the OR – Part 3
May 28, 2019
May 21, 2019
Mixed Message on Number of Open EMR Records
May 14, 2019
Wrong-Site Surgery and Difficult-to-Mark Sites
May 7, 2019
Simulation Training for OR Fires
April 30, 2019
Reducing Unnecessary Urine Cultures
April 23, 2019
In and Out the Door and Other OR Flow Disruptions
April 16, 2019
AACN Practice Alert on Alarm Management
April 9, 2019
Handoffs for Every Occasion
April 2, 2019
Unexpected Events During MRI
March 26, 2019
March 19, 2019
March 12, 2019
Update on Overlapping Surgery
March 5, 2019
Infusion Pump Problems
February 26, 2019
Vascular Access Device Dislodgements
February 19, 2019
Focus on Pediatric Patient Safety
February 12, 2019
From Tragedy to Travesty of Justice
February 12, 2019
2 ER Drug Studies: Reassurances and Reservations
February 5, 2019
Flaws in Our Medication Safety Technologies
January 29, 2018
National Patient Safety Goal for Suicide Prevention
January 22, 2019
Wandering Patients
January 15, 2019
Another Plus for Prehabilitation
January 8, 2019
Maternal Mortality in the Spotlight
January 1, 2019
More on Automated Dispensing Cabinet (ADC) Safety
December 25, 2018
Happy Holidays!
December 18, 2018
Great Recommendations for e-Prescribing
December 11, 2018
December 4, 2018
Don’t Use Syringes for Topical Products
November 27, 2018
November 20, 2018
November 13, 2018
Antipsychotics Fail in ICU Delirium
November 6, 2018
More on Promoting Sleep in Inpatients
October 30, 2018
October 23, 2018
Lessons From Yet Another Aviation Incident
October 16, 2018
October 9, 2018
October 2, 2018
Speaking Up About Disruptive Behavior
September 25, 2018
Foley Follies
September 18, 2018
September 11, 2018
September 4, 2018
The 12-Hour Nursing Shift: Another Nail in the Coffin
August 28, 2018
Thought You Discontinued That Medication? Think Again
August 21, 2018
Delayed CT Scan in the Anticoagulated Patient
August 14, 2018
ISMP Canada’s Updated “Do Not Use” Abbreviation List
August 7, 2018
Tip of the Week on Vacation
July 31, 2018
Surgery and the Opioid-Tolerant Patient
July 24, 2018
More on Speech Recognition Software Errors
July 17, 2018
OSA Screening in Stroke Patients
July 10, 2018
Another Jump from a Hospital Window
July 3, 2018
Tip of the Week on Vacation
June 26, 2018
Infection Related to Colonoscopy
June 19, 2018
June 12, 2018
Adverse Events in Cancer Patients
June 5, 2018
Pennsylvania Patient Safety Authority on Iatrogenic Burns
May 29, 2018
More on Nursing Workload and Patient Safety
May 22, 2018
Hazardous Intrahospital Transport
May 15, 2018
May 8, 2018
May 1, 2018
April 24, 2018
April 17, 2018
More on Tests Pending at Discharge
April 10, 2018
Prepping the Geriatric Patient for Surgery
April 3, 2018
March 27, 2018
March 20, 2018
Minnesota Highlights Lost Tissue Samples
March 13, 2018
March 6, 2018
February 27, 2018
Update on Patient Safety Walk Rounds
February 20, 2018
February 13, 2018
February 6, 2018
Adverse Events in Inpatient Psychiatry
January 30, 2018
January 23, 2018
Unintentional Hypothermia Back in Focus
January 16, 2018
January 9, 2018
More on Fire Risk from Surgical Preps
January 2, 2018
Preventing Perioperative Nerve Injuries
December 26, 2017
Tip of the Week on Vacation
December 19, 2017
December 12, 2017
Joint Commission on Suicide Prevention
December 5, 2017
Massachusetts Initiative on Cataract Surgery
November 28, 2017
More on Dental Sedation/Anesthesia Safety
November 21, 2017
OSA, Oxygen, and Alarm Fatigue
November 14, 2017
Tracking C. diff to a CT Scanner
November 7, 2017
Perioperative Neuropathies
October 31, 2017
Target Drugs for Deprescribing
October 24, 2017
Neurosurgery and Time of Day
October 17, 2017
Progress on Alarm Management
October 10, 2017
More on Torsade de Pointes
October 3, 2017
Respiratory Compromise: One Size Does Not Fit All
September 26, 2017
Tip of the Week on Vacation
September 19, 2017
Tip of the Week on Vacation
September 12, 2017
Can You Hear Me Now?
September 5, 2017
Another Iatrogenic Burn
August 29, 2017
Suicide in the Bathroom
August 22, 2017
August 15, 2017
Delayed Emergency Surgery and Mortality Risk
August 8, 2017
Sedation for Pediatric MRI Rising
August 1, 2017
Progress on Wrong Patient Orders
July 25, 2017
Can We Influence the “Weekend Effect”?
July 18, 2017
Another Hazard from Alcohol-Based Hand Gels
July 11, 2017
The 12-Hour Shift Takes More Hits
July 4, 2017
Tip of the Week on Vacation
June 27, 2017
June 20, 2017
June 13, 2017
June 6, 2017
NYS Mandate for Sepsis Protocol Works
May 30, 2017
Errors in Pre-Populated Medication Lists
May 23, 2017
May 16, 2017
Are Surgeons Finally Ready to Screen for Frailty?
May 9, 2017
Missed Nursing Care and Mortality Risk
May 2, 2017
Anatomy of a Wrong Procedure
April 25, 2017
April 18, 2017
Alarm Response and Nurse Shift Duration
April 11, 2017
Interruptions: The Ones We Forget About
April 4, 2017
Deprescribing in Long-Term Care
March 28, 2017
More Issues with Dental Sedation/Anesthesia
March 21, 2017
Success at Preventing Delirium
March 14, 2017
More on Falls on Inpatient Psychiatry
March 7, 2017
February 28, 2017
February 21, 2017
Yet More Jumps from Hospital Windows
February 14, 2017
February 7, 2017
January 31, 2017
More Issues in Pediatric Safety
January 24, 2017
Dexmedetomidine to Prevent Postoperative Delirium
January 17, 2017
January 10, 2017
The 26-ml Applicator Strikes Again!
January 3, 2017
What’s Happening to “I’m Sorry”?
December 27, 2016
Tip of the Week on Vacation
December 20, 2016
End-of-Rotation Transitions and Mortality
December 13, 2016
More on Double-Booked Surgery
December 6, 2016
Postoperative Pulmonary Complications
November 29, 2016
Doubling Down on Double-Booked Surgery
November 22, 2016
Leapfrog, Picklists, and Healthcare IT Vulnerabilities
November 15, 2016
November 8, 2016
Managing Distractions and Interruptions
November 1, 2016
CMS Emergency Preparedness Rule
October 25, 2016
Desmopressin Back in the Spotlight
October 18, 2016
Yet More Questions on Contact Precautions
October 11, 2016
New Guideline on Preop Screening and Assessment for OSA
October 4, 2016
September 27, 2016
September 20, 2016
Downloadable ABCDEF Bundle Toolkits for Delirium
September 13, 2016
Vanderbilt’s Electronic Procedural Timeout
September 6, 2016
August 30, 2016
Can You Really Limit Interruptions?
August 23, 2016
ISMP Canada: Automation Bias and Automation Complacency
August 16, 2016
How Is Your Alarm Management Initiative Going?
August 9, 2016
August 2, 2016
Drugs in the Elderly: The Goldilocks Story
July 26, 2016
Confirmed: Keep Your OR Doors Closed
July 19, 2016
Infants and Wrong Site Surgery
July 12, 2016
Forget Brexit – Brits Bash the RCA!
July 5, 2016
Tip of the Week on Vacation
June 28, 2016
Culture of Safety and Catheter-Associated Infections
June 21, 2016
Methotrexate Errors in Australia
June 14, 2016
Nursing Monitoring of Patients on Opioids
June 7, 2016
CPAP for Hospitalized Patients at High Risk for OSA
May 31, 2016
More Frailty Measures That Predict Surgical Outcomes
May 24, 2016
Texting Orders – Is It Really Safe?
May 17, 2016
Patient Safety Issues in Cataract Surgery
May 10, 2016
Medical Problems in Behavioral Health
May 3, 2016
Clinical Decision Support Malfunction
April 26, 2016
Lots More on Preventing Readmissions But Where's the Beef?
April 19, 2016
Independent Double Checks and Oral Chemotherapy
April 12, 2016
April 5, 2016
Workarounds Overriding Safety
March 29, 2016
March 22, 2016
Radiology Communication Errors May Surprise You
March 15, 2016
March 8, 2016
Tip of the Week on Vacation
March 1, 2016
February 23, 2016
February 16, 2016
February 9, 2016
February 2, 2016
January 26, 2016
More on Frailty and Surgical Morbidity and Mortality
January 19, 2016
Patient Identification in the Spotlight
January 12, 2016
New Resources on Improving Safety of Healthcare IT
January 5, 2016
Lessons from AirAsia Flight QZ8501 Crash
December 29, 2015
More Medical Helicopter Hazards
December 22, 2015
The Alberta Abbreviation Safety Toolkit
December 15, 2015
Vital Sign Monitoring at Night
December 8, 2015
Danger of Inaccurate Weights in Stroke Care
December 1, 2015
TALLman Lettering: Does It Work?
November 24, 2015
Door Opening and Foot Traffic in the OR
November 17, 2015
Patient Perspectives on Communication of Test Results
November 10, 2015
Weighing in on Double-Booked Surgery
November 3, 2015
Medication Errors in the OR - Part 2
October 27, 2015
Sentinel Event Alert on Falls and View from Across the Pond
October 20, 2015
Updated Beers List
October 13, 2015
Dilaudid Dangers #3
October 6, 2015
Suicide and Other Violent Inpatient Deaths
September 29, 2015
More on the 12-Hour Nursing Shift
September 22, 2015
The Cost of Being Rude
September 15, 2015
Another Possible Good Use of a Checklist
September 8, 2015
TREWScore for Early Recognition of Sepsis
September 1, 2015
August 25, 2015
Checklist for Intrahospital Transport
August 18, 2015
Missing Obstructive Sleep Apnea
August 11, 2015
New Oxygen Guidelines: Thoracic Society of Australia and NZ
August 4, 2015
Tip of the Week on Vacation
July 28, 2015
July 21, 2015
Avoiding Distractions in the OR
July 14, 2015
July 7, 2015
June 30, 2015
What Are Appropriate Indications for Urinary Catheters?
June 23, 2015
Again! Mistaking Antiseptic Solution for Radiographic Contrast
June 16, 2015
June 9, 2015
Add This to Your Fall Risk Assessment
June 2, 2015
May 26, 2015
May 19, 2015
May 12, 2015
More on Delays for In-Hospital Stroke
May 5, 2015
Errors with Oral Oncology Drugs
April 28, 2015
April 21, 2015
April 14, 2015
Using Insulin Safely in the Hospital
April 7, 2015
March 31, 2015
Clinical Decision Support for Pneumonia
March 24, 2015
Specimen Issues in Prostate Cancer
March 17, 2015
March 10, 2015
FDA Warning Label on Insulin Pens: Is It Enough?
March 3, 2015
Factors Related to Postoperative Respiratory Depression
February 24, 2015
More Risks with Long-Acting Opioids
February 17, 2015
Functional Impairment and Hospital Readmission, Surgical Outcomes
February 10, 2015
The Anticholinergic Burden and Dementia
February 3, 2015
CMS Hopes to Reduce Antipsychotics in Dementia
January 27, 2015
The Golden Hour for Stroke Thrombolysis
January 20, 2015
He Didn’t Wash His Hands After What!
January 13, 2015
January 6, 2015
Yet Another Handoff: The Intraoperative Handoff
December 30, 2014
Data Accumulates on Impact of Long Surgical Duration
December 23, 2014
Iatrogenic Burns in the News Again
December 16, 2014
More on Each Element of the Surgical Fire Triad
December 9, 2014
December 2, 2014
ANA Position Statement on Nurse Fatigue
November 25, 2014
Misdiagnosis Due to Lab Error
November 18, 2014
Handwashing Fades at End of Shift, ?Smartwatch to the Rescue
November 11, 2014
Early Detection of Clinical Deterioration
November 4, 2014
Progress on Fall Prevention
October 28, 2014
RF Systems for Retained Surgical Items
October 21, 2014
The Fire Department and Your Hospital
October 14, 2014
October 7, 2014
Our Take on Patient Safety Walk Rounds
September 30, 2014
More on Deprescribing
September 23, 2014
Stroke Thrombolysis: Need to Focus on Imaging-to-Needle Time
September 16, 2014
Focus on Home Care
September 9, 2014
The Handback
September 2, 2014
Frailty and the Trauma Patient
August 26, 2014
Surgeons’ Perception of Intraoperative Time
August 19, 2014
Some More Lessons Learned on Retained Surgical Items
August 12, 2014
Surgical Fires Back in the News
August 5, 2014
Tip of the Week on Vacation
July 29, 2014
The 12-Hour Nursing Shift: Debate Continues
July 22, 2014
More on Operating Room Briefings and Debriefings
July 15, 2014
Barriers to Success of Early Warning Systems
July 8, 2014
Update: Minor Head Trauma in the Anticoagulated Patient
July 1, 2014
Interruptions and Radiologists
June 24, 2014
Lessons from the General Motors Recall Analysis
June 17, 2014
SO2S Confirms Routine Oxygen of No Benefit in Stroke
June 10, 2014
Another Clinical Decision Support Tool to Avoid Torsade de Pointes
June 3, 2014
More on the Risk of Sedative/Hypnotics
May 27, 2014
A Gap in ePrescribing: Stopping Medications
May 20, 2014
May 13, 2014
Perioperative Sleep Apnea: Human and Financial Impact
May 6, 2014
Monitoring for Opioid-induced Sedation and Respiratory Depression
April 29, 2014
More on the Unintended Consequences of Contact Isolation
April 22, 2014
Impact of Resident Workhour Restrictions
April 15, 2014
Specimen Identification Mixups
April 8, 2014
FMEA to Avoid Breastmilk Mixups
April 1, 2014
Expensive Aspects of Sepsis Protocol Debunked
March 25, 2014
March 18, 2014
Systems Approach Improving Stroke Care
March 11, 2014
We Miss the Graphic Flowchart!
March 4, 2014
Evidence-Based Prescribing and Deprescribing in the Elderly
February 25, 2014
Joint Commission Revised Diagnostic Imaging Requirements
February 18, 2014
February 11, 2014
Another Perioperative Handoff Tool: SWITCH
February 4, 2014
But What If the Battery Runs Low?
January 28, 2014
Is Polypharmacy Always Bad?
January 21, 2014
January 14, 2014
Diagnostic Error: Salient Distracting Features
January 7, 2014
Lessons From the Asiana Flight 214 Crash
December 24-31, 2013
Tip of the Week on Vacation
December 17, 2013
December 10, 2013
Better Handoffs, Better Results
December 3, 2013
Reducing Harm from Falls on Inpatient Psychiatry
November 26, 2013
Missed Care: New Opportunities?
November 19, 2013
Can We Improve Dilaudid/HYDROmorphone Safety?
November 12, 2013
More on Inappropriate Meds in the Elderly
November 5, 2013
Joint Commission Sentinel Event Alert: Unintended Retained Foreign Objects
October 29, 2013
PAD: The Pain, Agitation, and Delirium Care Bundle
October 22, 2013
How Safe Is Your Radiology Suite?
October 15, 2013
October 8, 2013
October 1, 2013
Fuels and Oxygen in OR Fires
September 24, 2013
Perioperative Use of CPAP in OSA
September 17, 2013
September 10, 2013
Informed Consent and Wrong-Site Surgery
September 3, 2013
Predicting Perioperative Complications: Slow and Simple
August 27 2013
Lessons on Wrong-Site Surgery
August 20 2013
Lessons from Canadian Analysis of Medical Air Transport Cases
August 13 2013
August 6, 2013
July 9-30, 2013
Tip of the Week on Vacation
July 2, 2013
June 25, 2013
June 18, 2013
DVT Prevention in Stoke – CLOTS 3
June 11, 2013
June 4, 2013
May 28, 2013
The Neglected Medications: IV Fluids
May 21, 2013
May 14, 2013
Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)
May 7, 2013
April 30, 2013
Photographic Identification to Prevent Errors
April 23, 2013
Plethora of Medication Safety Studies
April 16, 2013
April 9, 2013
Mayo Clinic System Alerts for QT Interval Prolongation
April 2, 2013
Absconding from Behavioral Health Services
March 26, 2013
Failure to Recognize Sleep Apnea Before Surgery
March 19, 2013
Dealing with the Violent Patient in the Emergency Department
March 12, 2013
More on Communicating Test Results
March 5, 2013
Underutilized Safety Tools: The Observational Audit
February 26, 2013
Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?
February 19, 2013
Practical Postoperative Pain Management
February 12, 2013
CDPH: Lessons Learned from PCA Incident
February 5, 2013
Antidepressants and QT Interval Prolongation
January 29, 2013
A Flurry of Activity on Handoffs
January 22, 2013
You Don’t Know What You Don’t Know
January 15, 2013
January 8, 2013
More Lessons Learned on Retained Surgical Items
January 1, 2013
Don’t Throw Away Those View Boxes Yet
December 25, 2012
Tip of the Week on Vacation
December 18, 2012
Unintended Consequences of the CAUTI Measure?
December 11, 2012
December 4, 2012
Unintentional Perioperative Hypothermia: A New Twist
November 27, 2012
November 20, 2012
Update on Perioperative Management of Obstructive Sleep Apnea
November 13, 2012
The 12-Hour Nursing Shift: More Downsides
November 6, 2012
Using LEAN to Improve Stroke Care
October 30, 2012
October 23, 2012
Latent Factors Lurking in the OR
October 16, 2012
What is the Evidence on Double Checks?
October 9, 2012
Call for Focus on Diagnostic Errors
October 2, 2012
Test Results: Everyone’s Worst Nightmare
September 25, 2012
Preoperative Assessment for Geriatric Patients
September 18, 2012
September 11, 2012
In Search of the Ideal Early Warning Score
September 4, 2012
August 28, 2012
New Care Model Copes with Interruptions Better
August 21, 2012
More on Missed Followup of Tests in Hospital
August 14, 2012
August 7, 2012
Cognition, Post-Op Delirium, and Post-Op Outcomes
July 31, 2012
Surgical Case Duration and Miscommunications
July 24, 2012
FDA and Extended-Release/Long-Acting Opioids
July 17, 2012
July 10, 2012
Tip of the Week on Vacation
July 3, 2012
Recycling an Old Column: Dilaudid Dangers
June 26, 2012
Using Patient Photos to Reduce CPOE Errors
June 19, 2012
More Problems with Faxed Orders
June 12, 2012
Lessons Learned from the CDPH: Retained Foreign Bodies
June 5, 2012
Minor Head Trauma in the Anticoagulated Patient
May 29, 2012
Falls, Fractures, and Fatalities
May 22, 2012
Update on Preoperative Screening for Sleep Apnea
May 15, 2012
May 8, 2012
Importance of Nontechnical Skills in Healthcare
May 1, 2012
April 24, 2012
Fire Hazard of Skin Preps Oxygen
April 17, 2012
April 10, 2012
April 3, 2012
New Risk for Postoperative Delirium: Obstructive Sleep Apnea
March 27, 2012
March 20, 2012
Adverse Events Related to Psychotropic Medications
March 13, 2012
Medical Emergency Team Calls to Radiology
March 6, 2012
February 28, 2012
AACN Practice Alert on Delirium in Critical Care
February 21, 2012
Improving PCA Safety with Capnography
February 14, 2012
Handoffs More Than Battle of the Mnemonics
February 7, 2012
Another Neuromuscular Blocking Agent Incident
January 31, 2012
January 24, 2012
Patient Safety in Ambulatory Care
January 17, 2012
Delirium and Contact Isolation
January 10, 2012
January 3, 2012
Unintended Consequences of Restricted Housestaff Hours
December 20, 2011
December 13, 2011
December 6, 2011
Why You Need to Beware of Oxygen Therapy
November 29, 2011
November 22, 2011
Perioperative Management of Sleep Apnea Disappointing
November 15, 2011
November 8, 2011
WHOs Multi-professional Patient Safety Curriculum Guide
November 1, 2011
So Whats the Big Deal About Inserting an NG Tube?
October 25, 2011
October 18, 2011
October 11, 2011
October 4, 2011
Radiology Report Errors and Speech Recognition Software
September 27, 2011
The Canadian Suicide Risk Assessment Guide
September 20, 2011
When Practice Changes the Evidence: The CKD Story
September 13, 2011
Do You Use Fentanyl Transdermal Patches Safely?
September 6, 2011
August 30, 2011
Unintentional Discontinuation of Medications After Hospitalization
August 23, 2011
Catheter Misconnections Back in the News
August 16, 2011
August 9, 2011
Frailty and the Surgical Patient
August 2, 2011
July 26, 2011
July 19, 2011
Communication Across Professions
July 12, 2011
Psst! Pass it onHow a kids game can mold good handoffs
July 5, 2011
Sidney Dekker: Patient Safety. A Human Factors Approach
June 28, 2011
Long-Acting and Extended-Release Opioid Dangers
June 21, 2011
June 14, 2011
June 6, 2011
May 31, 2011
Book Review Human Factors and Team Psychology in a High Stakes Environment
May 24, 2011
May 17, 2011
Opioid-Induced Respiratory Depression Again!
May 10, 2011
Preventing Preventable Readmissions: Not As Easy As It Sounds
May 3, 2011
April 26, 2011
Sleeping Air Traffic Controllers: What About Healthcare?
April 19, 2011
DVT Prophylaxis in Acute Stroke: Controversy Reappears
April 12, 2011
Medication Issues in the Ambulatory Setting
April 5, 2011
March 29, 2011
The Silent Treatment:A Dose of Reality
March 22, 2011
An EMR Feature Detrimental to Teamwork and Patient Safety
March 15, 2011
March 8, 2011
Yes, Physicians Get Interrupted Too!
March 1, 2011
February 22, 2011
February 15, 2011
Controversies in VTE Prophylaxis
February 8, 2011
February 1, 2011
January 25, 2011
Procedural Sedation in Children
January 18, 2011
More on Medication Errors in Long-Term Care
January 11, 2011
NPSA (UK) How to Guide: Five Steps to Safer Surgery
January 4, 2011
December 28, 2010
HAIs: Looking In All The Wrong Places
December 21, 2010
More Bad News About Off-Hours Care
December 14, 2010
NPSA (UK): Preventing Fatalities from Medication Loading Doses
December 6, 2010
More Tips to Prevent Wrong-Site Surgery
November 30, 2010
SURPASS: The Mother of All Checklists
November 23, 2010
Focus on Cumulative Radiation Exposure
November 16, 2010
November 9, 2010
12-Hour Nursing Shifts and Patient Safety
November 2, 2010
Insulin: Truly a High-Risk Medication
October 26, 2010
Confirming Medications During Anesthesia
October 19, 2010
Optimizing Medications in the Elderly
October 12, 2010
October 5, 2010
September 28, 2010
September 21, 2010
September 14, 2010
Wrong-Site Craniotomy: Lessons Learned
September 7, 2010
Patient Safety in Ob/Gyn Settings
August 31, 2010
August 24, 2010
The BP Oil Spill Analogies in Healthcare
August 17, 2010
Preoperative Consultation Time to Change
August 10, 2010
Its Not Always About The Evidence
August 3, 2010
Tip of the Week on Vacation
July 27, 2010
EMRs Still Have A Long Way To Go
July 20, 2010
More on the Weekend Effect/After-Hours Effect
July 13, 2010
Postoperative Opioid-Induced Respiratory Depression
July 6, 2010
Book Reviews: Pronovost and Gawande
June 29, 2010
Torsade de Pointes: Are Your Patients At Risk?
June 22, 2010
Disclosure and Apology: How to Do It
June 15, 2010
Dysphagia in the Stroke Patient: the Scottish Guideline
June 8, 2010
Surgical Safety Checklist for Cataract Surgery
June 1, 2010
May 25, 2010
May 18, 2010
Real-Time Random Safety Audits
May 11, 2010
May 4, 2010
More on the Impact of Interruptions
April 27, 2010
April 20, 2010
HITs Limited Impact on Quality To Date
April 13, 2010
April 6, 2010
March 30, 2010
Publicly Released RCAs: Everyone Learns from Them
March 23, 2010
ISMPs Guidelines for Standard Order Sets
March 16, 2010
A Patient Safety Scavenger Hunt
March 9, 2010
Communication of Urgent or Unexpected Radiology Findings
March 2, 2010
Alarm Sensitivity: Early Detection vs. Alarm Fatigue
February 23, 2010
Alarm Issues in the News Again
February 16, 2010
Spin/HypeKnowing It When You See It
February 9, 2010
More on Preventing Inpatient Suicides
February 2, 2010
January 26, 2010
Preventing Postoperative Delirium
January 19, 2010
January 12, 2010
Patient Photos in Patient Safety
January 5, 2010
December 29, 2009
Recognizing Deteriorating Patients
December 22, 2009
December 15, 2009
December 8, 2009
December 1, 2009
Patient Safety Doesnt End at Discharge
November 24, 2009
Another Rough Month for Healthcare IT
November 17, 2009
November 10, 2009
Conserving ResourcesBut Maintaining Patient Safety
November 3, 2009
Medication Safety: Frontline to the Rescue Again!
October 27, 2009
Co-Managing Patients: The Good, The Bad, and The Ugly
October 20, 2009
Radiology AgainBut This Time Its Really Radiology!
October 13, 2009
October 6, 2009
Oxygen Safety: More Lessons from the UK
September 29, 2009
Perioperative Peripheral Nerve Injuries
September 22, 2009
Psychotropic Drugs and Falls in the SNF
September 15, 2009
ETTOs: Efficiency-Thoroughness Trade-Offs
September 8, 2009
Barriers to Medication Reconciliation
September 1, 2009
The Real Root Causes of Medical Helicopter Crashes
August 25, 2009
Interruptions, Distractions, InattentionOops!
August 18, 2009
Obstructive Sleep Apnea in the Perioperative Period
August 11, 2009
August 4, 2009
July 28, 2009
Wandering, Elopements, and Missing Patients
July 21, 2009
Medication Errors in Long Term-Care
July 14, 2009
Is Your Do Not Use Abbreviations List Adequate?
July 7, 2009
Nudge: Small Changes, Big Impacts
June 30, 2009
iSoBAR: Australian Clinical Handoffs/Handovers
June 23, 2009
June 16, 2009
Disclosing Errors That Affect Multiple Patients
June 9, 2009
CDC Update to the Guideline for Prevention of CAUTI
June 2, 2009
Why Hospitals Should FlyJohn Nance Nails It!
May 26, 2009
Learning from Tragedies. Part II
May 19, 2009
May 12, 2009
May 5, 2009
Adverse Drug Events in the ICU
April 28, 2009
Ticket Home and Other Tools to Facilitate Discharge
April 21, 2009
April 14, 2009
More on Rehospitalization After Discharge
April 7, 2009
March 31, 2009
Screening Patients for Risk of Delirium
March 24, 2009
March 17, 2009
March 10, 2009
Prolonged Surgical Duration and Time Awareness
March 3, 2009
Overriding AlertsLike Surfin the Web
February 24, 2009
Discharge Planning: Finally Something That Works!
February 17, 2009
Reducing Risk of Overdose with Midazolam Injection
February 10, 2009
Sedation in the ICU: The Dexmedetomidine Study
February 3, 2009
NTSB Medical Helicopter Crash Reports: Missing the Big Picture
January 27, 2009
Oxygen Therapy: Everything You Wanted to Know and More!
January 20, 2009
The WHO Surgical Safety Checklist Delivers the Outcomes
January 13, 2009
January 6, 2009
December 30, 2008
Unintended Consequences: Is Medication Reconciliation Next?
December 23, 2008
December 16, 2008
Joint Commission Sentinel Event Alert on Hazards of Healthcare IT
December 9, 2008
December 2, 2008
Playing without the ballthe art of communication in healthcare
November 25, 2008
November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
November 11, 2008
November 4, 2008
October 28, 2008
More on Computerized Trigger Tools
October 21, 2008
October 14, 2008
October 7, 2008
Lessons from Falls....from Rehab Medicine
September 30, 2008
September 23, 2008
Checklists and Wrong Site Surgery
September 16, 2008
More on Radiology as a High Risk Area
September 9, 2008
Less is More.and Do You Really Need that Decimal?
September 2, 2008
August 26, 2008
August 19, 2008
August 12, 2008
Jerome Groopmans How Doctors Think
August 5, 2008
July 29, 2008
Heparin-Induced Thrombocytopenia
July 22, 2008
Lots New in the Anticoagulation Literature
July 15, 2008
July 8, 2008
July 1, 2008
WHOs New Surgical Safety Checklist
June 24, 2008
Urinary Catheter-Related UTIs: Bladder Bundles
June 17, 2008
Technology Workarounds Defeat Safety Intent
June 10, 2008
Monitoring the Postoperative COPD Patient
June 3, 2008
UK Advisory on Chest Tube Insertion
May27, 2008
If You Do RCAs or Design Healthcare ProcessesRead Gary Kleins Work
May20, 2008
CPOE Unintended Consequences Are Wrong Patient Errors More Common?
May13, 2008
Medication Reconciliation: Topical and Compounded Medications
May 6, 2008
Preoperative Screening for Obstructive Sleep Apnea
April 29, 2008
ASA Practice Advisory on Operating Room Fires
April 22, 2008
CMS Expanding List of No-Pay Hospital-Acquired Conditions
April 15, 2008
April 8, 2008
April 1, 2008
Pennsylvania PSAs FMEA on Telemetry Alarm Interventions
March 25, 2008
March 18, 2008
Is Desmopressin on Your List of Hi-Alert Medications?
March 11, 2008
March 4, 2008
Housestaff Awareness of Risks for Hazards of Hospitalization
February 26, 2008
Nightmares.The Hospital at Night
February 19, 2008
February 12, 2008
February 5, 2008
Reducing Errors in Obstetrical Care
January 29, 2008
Thoughts on the Recent Neonatal Nursery Fire
January 22, 2008
More on the Cost of Complications
January 15, 2008
Managing Dangerous Medications in the Elderly
January 8, 2008
Urinary Catheter-Associated Infections
January 1, 2008
December 25, 2007
December 18, 2007
December 11, 2007
CommunicationCommunicationCommunication
December 4, 2007
November 27,2007
November 20, 2007
New Evidence Questions Perioperative Beta Blocker Use
November 13, 2007
AHRQ's Free Patient Safety Tools DVD
November 6, 2007
October 30, 2007
Using IHIs Global Trigger Tool
October 23, 2007
Medication Reconciliation Tools
October 16, 2007
Radiology as a Site at High-Risk for Medication Errors
October 9, 2007
October 2, 2007
Taking Off From the Wrong Runway
September 25, 2007
Lessons from the National Football League
September 18, 2007
Wristbands: The Color-Coded Conundrum
September 11, 2007
Root Cause Analysis of Chemotherapy Overdose
September 4, 2007
August 28, 2007
Lessons Learned from Transportation Accidents
August 21, 2007
Costly Complications About To Become Costlier
August 14, 2007
More Medication-Related Issues in Ambulatory Surgery
August 7, 2007
Role of Maintenance in Incidents
July 31, 2007
Dangers of Neuromuscular Blocking Agents
July 24, 2007
Serious Incident Response Checklist
July 17, 2007
Falls in Patients on Coumadin or Other Anticoagulants
July 10, 2007
Catheter Connection Errors/Wrong Route Errors
July 3, 2007
June 26, 2007
Pneumonia in the Stroke Patient
June 19, 2007
Unintended Consequences of Technological Solutions
June 12, 2007
Medication-Related Issues in Ambulatory Surgery
June 5, 2007
Patient Safety in Ambulatory Surgery
May 29, 2007
Read Anything & Everything Written by Malcolm Gladwell!
May 22, 2007
May 15, 2007
Communication, Hearback and Other Lessons from Aviation
May 8, 2007
Doctor, when do I get this red rubber hose removed?
May 1, 2007
April 23, 2007
April 16, 2007
April 9, 2007
Make Your Surgical Timeouts More Useful
April 2, 2007
March 26, 2007
Alarms Should Point to the Problem
March 19, 2007
Put that machine back the way you found it!
March 12, 2007
March 5, 2007
February 26, 2007
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