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March 17, 2015
Distractions in the OR
Distractions and interruptions are frequent contributing factors to errors in all healthcare settings. In the OR they are especially prone to result in errors that impact patient outcomes. Even short interruptions, especially if they occur during critical parts of procedures or when novel or unexpected events have occurred, could profoundly increase the odds of errors and untoward patient outcomes.
We discussed many aspects related to OR distractions and interruptions in our May 21, 2013 Patient Safety Tip of the Week “Perioperative Distractions”. Interruptions increase the likelihood of errors because we must refocus to resume where we had left off in our task prior to the interruption. It turns out that even very brief interruptions can have a marked impact on our ability to resume those tasks. Altmann and colleagues studied the effect of short interruptions on performance of a task that required participants to maintain their place in a sequence of steps (Altmann 2013). Interruptions averaging just 2.8 s long doubled the rate of sequence errors and interruptions averaging 4.4 s long tripled the rate of sequence errors on post-interruption trials relative to baseline trials.
Another recent study has looked at distractions in the OR (Wheelock 2015). Not surprisingly, distractions occurred in 98% of cases. They occurred at a rate of 10.94 distractions per case or one distraction every 10 minutes.
The most frequent types of distraction were those initiated by external staff entering the operating room. The researchers note that such distractions were unnecessary in 81% of cases! While these researchers actually attributed less significance to their major outcome variables (like teamwork, stress, etc.), they do acknowledge the potential impact on surgical infection rates, which they did not monitor. In several Patient Safety Tips of the Week (“HAI’s: Looking in All the Wrong Places”, “Prolonged Surgical Duration and Time Awareness”, “Operative Duration and Infection”) we’ve noted the risk of infection increases each time the OR door is opened and foot traffic in and out of the OR increases.
Wheelock and colleagues also measured intensity of distractions. They found that the most intense distractions were those that were equipment-related (eg. wrong or missing equipment). Equipment-related distractions impacted all aspects of teamwork and also stress levels for nurses. And such distractions occurred about once every 90 minutes.
Distractions were generally associated with a negative impact on teamwork. Irrelevant conversations had negative influence on coordination and leadership scores for surgeons and anesthesiologists. Such distractions tended to occur more often during periods when workload was low.
Acoustic distractions were associated with higher stress levels for surgeons and higher workload for anesthesiologists. While they did not find a big impact from acoustic distractions, they did note the recent study demonstrating that excessive noise in a pediatric OR was associated with greater levels of surgeon stress and postoperative complications (Engelmann 2014). Also in our May 21, 2013 Patient Safety Tip of the Week “Perioperative Distractions” we noted a study on how background noise in the OR might interfere with surgical team communication (Way 2013). Those researchers found that the impact of noise is considerably greater when the participant is tasked. Moreover, the performance was poorer when the sentences were low in predictability. One can readily see from their results how background noise could interfere with the surgeon’s ability to understand communications during a critical task, particularly if the communication is not a predictable one. The authors conclude that to avoid possible miscommunication in the OR, attempts should be made to reduce ambient noise levels.
Note that the rate of one distraction every 10 minutes seen in the Wheelock study is actually very similar to the rates described in a variety of other healthcare venues and affecting nurses (see our columns August 25, 2009 “Interruptions, Distractions, Inattention…Oops!” and May 4, 2010 “More on the Impact of Interruptions”), ER physicians (March 8, 2011 “Yes, Physicians Get Interrupted Too!”), and radiologists (July 1, 2014 “Interruptions and Radiologists”, November 2014 “More Radiologist Interruptions”). Interestingly, in the Wheelock study distractions had lower frequency in longer cases.
It’s also important to recognize that distractions don’t just apply to the surgical procedure per se. Michelle Feil (Feil 2014), in her excellent article on OR incidents related to distractions in the Pennsylvania PA-PSRS database, notes that almost 20% of the errors were related to laboratory test problems. These included specimen labeling errors, specimen quality problems, and specimen delivery problems.
So what are the strategies that can be employed to minimize the risks due to distractions?
Of course, one way to help ensure that interruptions and distractions do not occur at critical junctures in procedures is use of the “sterile cockpit” concept. In aviation, all extraneous conversations are ceased during preparation for and undertaking takeoffs and landings. That helps ensure all attention is directed to the critical tasks at hand. Hence, the term “sterile cockpit”.
One important consideration, however, is that those critical junctures may differ for different OR team members (Feil 2014). Feil notes several examples of different critical junctures for surgeons, anesthesiologists, nurses, etc. A classic example is the surgical sponge and instrument “count” which requires undivided attention by the nurse(s) and surgical tech(s) who may be doing the count but may not reach the same level of attention by the surgeon and anesthesiologist (even though all should be focused on the count)..
In our May 21, 2013 Patient Safety Tip of the Week “Perioperative Distractions” we noted an editorial by Jacqueline Ross (Ross 2013) pointing out that many distractions and interruptions are likely not preventable but others are preventable. During crucial portions of a procedure (eg. pre-op huddle, surgical timeout, induction, surgical incision, closure, debriefing, anesthesia emergence, etc.) there should be no extraneous conversations and all should focus on the task at hand (Ross 2013). She suggests limiting the number of people entering or leaving the OR during those critical tasks.
Restricting OR traffic
As above, each time the door to the OR opens it introduces an opportunity for not only interruptions and distractions but also increases the potential for a surgical site infection. Restricting OR traffic was one of the two types of interventions Ross had noted as potentially useful in reducing interruptions (Ross 2013). Ross had suggested restricting OR traffic during critical periods that merit a sterile cockpit atmosphere. One might envision setting the OR up like a recording studio with its “On the Air” sign lighting up to restrict entry into the OR during such critical periods. But it makes sense to restrict unnecessary OR traffic whenever possible, not just during critical periods. In the Wheelock study (Wheelock 2015) the most frequent types of distractions were those initiated by external staff entering the operating room and such distractions were unnecessary in 81% of cases! Anecdotally, simply having everyone attempting to enter the OR fill out a log entry with the reason for entering substantially reduces the number of people entering.
The value of preoperative huddles/briefings in avoiding delays and preventing unnecessary interruptions and distractions is immeasurable. The typical preoperative huddle/briefing is done before each case. However, some have used a variant “the daily preoperative huddle” (Jain 2015). In the latter, the team convenes and does the huddle at the start of the day and looks at the entire day’s cases. This gives the team a chance to identify potential problems, set expectations, and develop a shared mental model prior to beginning the day’s cases. Such a huddle works best when the entire team will be present for all the day’s cases. Thus, it really is intended for teams operating within specialty settings. In the Jain study all participants were orthopedic surgeons and the orthopedic teams.
In the pilot study by Jain and colleagues (Jain 2015) the daily huddle resulted in improvement of the surgeons’ perception of the “day’s flow”. The number of unexpected delays dropped from 23% per case to 6.45% per case (and from 79% per day to 21% per day). It also impacted on interruptions, particularly those related to equipment issues, antibiotics, and issues regarding planned procedure. Overall, the number of total interruptions/questions decreased by 77% (from 2.51 per case before implementation of the daily huddle to 0.57 per case after).
As we’ve recommended in our numerous columns on preoperative huddles/briefings Jain and colleagues utilized a structured tool to help identify items to be discussed during the daily preoperative huddle.
Note, however, we suspect the daily huddle concept might be vulnerable to last minute changes in the OR schedule or changes in the schedule that occur after the morning huddle. We’ve seen too many disasters take place when patients are “taken out of turn” in the OR schedule. The “immediate” pre-op huddle is better timed to deal with such contingencies than is the “daily” pre-op huddle. So we would hope that some mechanism would be built in to systems using a daily huddle to add an “immediate” huddle any time an unanticipated change in schedule occurs.
Nevertheless, the concept of the “daily” preoperative huddle is one worth further exploring. We’ve actually advocated for the daily morning huddle in several other venues: the office or clinic, hospitalist rounds, bed coordination rounds, etc. (see our December 9, 2008 Patient Safety Tip of the Week “Huddles in Healthcare”).
Post-operative debriefings are also very helpful at reducing interruptions and delays. Obviously they won’t prevent an interruption in the case just finished but the issues identified can definitely help prevent interruptions in future cases. This is especially likely to be helpful in preventing equipment-related or supply-related issues. Think about how many times you’ve heard after an equipment malfunction “Oh, that happened the last time we used it, too!”. Issues raised in debriefings need to be systematically addressed to provide fixes before they recur (see our July 22, 2014 Patient Safety Tip of the Week “More on Operating Room Briefings and Debriefings”).
Policies on cellphone and other device use
The second area noted by Ross in which distractions might be prevented is use of wireless devices in these areas (Ross 2013). Cellphone use has become ubiquitous. There are many great advantages they provide us. But they also have a downside when used in the OR. Our May 21, 2013 Patient Safety Tip of the Week “Perioperative Distractions” discussed multiple examples of distractions related to cell phones in the OR. There are a multitude of issues related to cell phones in the OR including not only interruptions but also infection control issues, security and confidentiality issues, and detrimental effects on communication in the OR (Byrne 2013). Our recommendation is for all the OR team to leave their cellphones at the main OR desk where someone can triage incoming phone calls (we used to say the same thing for pagers but we haven’t seen a pager in a long time!).
Caregiver distractions from smartphones and other mobile devices even made ECRI Institute’s annual list of Top 10 Technology Hazards for 2013 (ECRI 2012). A recent article in the lay press (Hawryluk 2015) discussed in detail the issue of distractions from smartphones in the OR, highlighting some of the work by anesthesiologist Dr. Peter Papadakos (Papadakos 2011) that we discussed in our May 21, 2013 Patient Safety Tip of the Week “Perioperative Distractions”. The Hawryluk article notes several high profile cases in the press in which distractions occurred in the OR due to personal use of smartphones.
You’ll, of course, get the argument “I use my cellphone to access important information pertinent to the case” (like guidelines, images, reports, etc.). But most of that information can be obtained from devices that do not also send instant messages, texts and phone calls. And if the surgeon really wants to see an imaging study you want him or her looking at it on a large computer screen rather than a small smartphone screen.
Nurses, and perhaps anesthesiologists, are increasingly using mobile devices to improve efficiencies in documentation within the OR and ensuring compliance with guidelines (AORN 2015). But, again, such devices can be configured not to allow distracting features like texting and instant messaging.
Michelle Feil, in addition to her excellent article on OR incidents related to distractions (Feil 2014), had previously researched the PA-PSRS database for events related to distractions in multiple healthcare venues (Feil 2013). She noted that most reports did not note the specific nature of the distraction. Nevertheless, she was able to glean insight from the narrative portion of the reports to provide case examples of the impact of distractions on nursing, surgeons, radiology, laboratory, anesthesia, pharmacy and multiple examples of the impact of distractions on medication errors. She provides a nice description of the constructs involved in memory and the effect of distractions on them. She has a section on sources of distractions that emphasizes “small talk” and technological devices as important sources of distraction.
In both articles, Feil provides multiple strategies to ameliorate the impact of distractions. Those include use of the “sterile cockpit” concept and pre-op huddles/briefings as we’ve discussed above. Others are use of checklists and teamwork training (eg. CRM, TeamSTEPPS™). She emphasizes, however, that having a culture of safety is most important and surgeons must be engaged and take leadership roles in developing that culture in the OR. She goes on to provide a list of risk reduction strategies you should consider implementing. Both the articles by Feil are insightful and useful and we encourage you to read them.
Ironically, most of us don’t even recognize when and how often we are being distracted. There are a couple ways to get a better handle on that, though both are resource-intensive. One is to do the sort of direct observation as done by Wheelock and colleagues. The other is to do video/audio recording in the OR and then play it back for all parties in a constructive fashion so they can see how well (or not so well) they communicated and how distractions interfered with their communications. It can also help assess how well the team adheres to protocols like the Universal Protocol or surgical timeout procedures or the sponge/instrument “count”. But it could be used to assess interruptions and distractions as well. Unfortunately, too many surgeons and hospital attorneys are loathe to use video taping even when it is clearly being done for quality improvement activities.
Prior Patient Safety Tips of the Week dealing with interruptions and distractions:
See our prior columns on huddles, briefings, and debriefings:
Altmann EM, Trafton JG, Hambrick DZ. Momentary Interruptions Can Derail the Train of Thought. Journal of Experimental Psychology: General, Jan 7, 2013
Wheelock A, Suliman A, Wharton RBM, et al. The Impact of Operating Room Distractions on Stress, Workload, and Teamwork. Annals of Surgery 2015; published ahead of print January 23, 2015
Engelmann CR, Neis JP, Kirschbaum C, et al. A noise-reduction program in a pediatric operation theatre is associated with surgeon’s benefits and a reduced rate of complications: a prospective controlled clinical trial. Ann Surg 2014; 259(5): 1025-1033
Way TJ, Long A, Weihing J, et al. Effect of Noise on Auditory Processing in the Operating Room. J Am Coll Surg 2013; 216(5): 933-938
Feil M. Distractions in the Operating Room. Pa Patient Saf Advis 2014; 11(2): 45-52
Ross J. Distractions and Interruptions in the Perianesthesia Environment: A Real Threat to Patient Safety. J Perianesth Nursing 2013; 28(1): 38-39
Jain AL, Jones KC, Simon J, Patterson MD. The impact of a daily pre-operative surgical huddle on interruptions, delays, and surgeon satisfaction in an orthopedic operating room: a prospective study. Patient Safety in Surgery 2015; 9: 8
Byrne MD. Mobile Devices in the Perianesthesia Environment. J Perianesth Nursing 2013; 28(1): 26-30
ECRI Institiute. Top 10 Health Technology Hazards for 2013. Health Devices 41(11): November 2012
Hawryluk M. Is your surgeon focused on you or his smartphone? The Bulletin (Bend, OR) 2015; Published Feb 1, 2015, Updated Feb 2, 2015
Papadakos PJ. Electronic Distraction: An Unmeasured Variable in Modern Medicine. Anesthesiology News 2011; 37:11 November 2011
Association of Perioperative Registered Nurses (AORN) Surgical Conference 2015. Presented March 9, 2015. As reported by Frellick M. Operating Room Best Practices Move to Handheld Devices. Medscape March 09, 2015
Feil M. Distractions and their impact on patient safety. Pa Patient Saf Advis 2013; 10(1): 1-10
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March 24, 2015
Specimen Issues in Prostate Cancer
Imagine getting surgery, radiation or chemotherapy for a condition you really did not have! In our January 22, 2013 Patient Safety Tip of the Week “You Don’t Know What You Don’t Know” we discussed the possibility that you might have a biopsy specimen which was either not yours or was yours but also had some tissue from another patient on the slide(s). Such errors are known as occult specimen provenance complications (SPC’s). In that Tip we noted a study providing an estimate of how often such SPC’s occur (Pfeifer 2013). They examined about 13,000 prostate biopsy specimens from a wide variety of urology practices and pathology laboratories using a DNA identification technology. They found the frequency of occult type 1 errors (a complete transposition between patients) was 0.26% and type 2 errors (contamination of the patient’s tissue with 1 or more unrelated patients) was 0.67%. Overall, the mean frequency of SPCs across practice settings was 0.22% for type 1 errors and 1.69% for type 2 errors.
Basically, it means that around 1% of patients might be given an incorrect diagnosis that no one even suspects is incorrect! Perhaps just as striking is the fact that virtually every lab or clinical setting they studied had at least one SPC identified.
Now a new study in the Journal of Urology has estimated the economic impact of such errors (Wojno 2015). The researchers extracted data from published studies on specimen provenance complications (SPC) rates, prostate cancer treatment efficacy, treatment cost, litigation/settlement costs after false diagnoses of prostate biopsies and patient quality of life. They then estimated how many cases with SPC’s would have their management impacted by the SPC. Note, for example, that a biopsy specimen of a patient with true prostate cancer whose specimen was cross contaminated with that of another patient with prostate cancer would probably not lead to inappropriate treatment of the patient. So they focused on those cases where an SPC would likely have a clinical implication, i.e. those receiving a false positive or false negative diagnosis.
They estimated that approximately 2.5% of the 800,000+ prostate biopsies done in the US annually would involve a specimen switch or contamination overall and that would result in 4,570 clinically meaningful false diagnoses. That would result in an estimated loss of 634 QALY’s and an average cost impact of $3,776 per positive cancer diagnosis. The total estimated impact for the whole country would be $879.9 million annually!
Though no pathology lab was immune to SPC’s in prior studies, rates do vary by site. Sensitivity analyses in this study showed their results were sensitive to the rate of transpositions at independent reference laboratories. Results were also sensitive to litigation/settlement costs.
A bit of concern is the fact that it appears all the authors of the current study have financial ties to a company that does the type of DNA analysis that would need to be done to avoid mistakes related to SPC’s. However, the key previous study (Pfeifer 2013) that identified the SPC problem as widespread did not appear to have such a potential conflict of interest (see our January 22, 2013 Patient Safety Tip of the Week “You Don’t Know What You Don’t Know”). However, we noted there might be some selection bias in that the urology practices submitting specimens for DNA testing may not be representative of all urology practices.
In one of our earliest columns on lab errors (see our October 9, 2007 Patient Safety Tip of the Week “Errors in the Laboratory“) we noted a paper (Suba 2007) that suggested we consider the “DNA timeout” akin to the surgical timeout where we ask the question “Is this the correct diagnosis for the correct patient?” before doing an invasive procedure. One of the co-authors of that 2007 paper subsequently did the study providing an estimate of how often such SPC’s occur (Pfeifer 2013).
The current study looked only a prostate biopsies. It could be anticipated that SPC’s would likely occur with almost any other tissue specimens as well. Application of DNA identification techniques therefore shows promise in reducing the chances a patient may get an incorrect diagnosis and treatment with serious implications. But there important unanswered questions. It needs to be tested in a randomized fashion in a variety of settings with collection of patient-specific outcome data and good analysis of cost (both costs of testing and potential cost savings from reduction of errors) for each of the conditions assessed.
See also our prior columns, listed below, that deal with “lab” errors (most of which do not originate in the lab itself), lost lab specimens, specimen misidentification, labeling issues, and use of FMEA or LEAN techniques to improve safety and efficiency in laboratories.
Some of our other columns on errors related to laboratory studies:
Pfeifer JD, Liu J. Rate of Occult Specimen Provenance Complications in Routine Clinical Practice. Am J Clin Path 2013; 139: 93-100
Wojno K, Hornberger J, Schellhammer P, et al. The Clinical and Economic Implications of Specimen Provenance Complications in Diagnostic Prostate Biopsies. Journal of Urology 2015; Published online: November 13, 2014
Suba EJ, Pfeifer JD, Raab SS. Patient Identification Error Among Prostate Needle Core Biopsy Specimens—Are We Ready for a DNA Time-Out? J Urol 2007; 178(4): 1245-1248
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March 8-14, 2015 is Patient Safety Awareness Week
The National Patient Safety Foundation is sponsoring Patient Safety Awareness Week March 8-14, 2015. Visit the NPSF website for tools to use at your organization to promote patient safety awareness.
We’re always amazed at the varied circumstances in which hospitalized patients may suffer iatrogenic burns. While we’ve mentioned heat from light sources such as fiberoptic light as a potential heat source for OR fires (see our December 4, 2007 Patient Safety Tip of the Week “Surgical Fires”), we have not discussed light sources in other iatrogenic burns.
Now halogen lights have been identified as the cause for burns of multiple patients in operating rooms at an Oregon hospital (Wozniacka 2015). The report says that about 10 patients, possibly more, suffered burns over a period of several months. The hospital director of quality and risk services was quoted as saying the hospital initially “looked at more common culprits: solutions used to prep skin before surgery, bandages or dressings used after surgery, and cautery devices used to stop bleeding during surgery”. It was only later that a surgery team member recalled maintenance had been done on the OR lights. Apparently halogen lamps require filters for UV light and those were not changed at the time of maintenance. Subsequently, the hospital has switched to light-emitting diodes (LED’s) and it has changed procedures for medical equipment maintenance, requiring the engineering department or the equipment's vendor to do any kind of maintenance.
Sometimes causes for unusual events are not readily apparent. But it sure helps to disseminate such lessons so another facility won’t need months to solve the problem.
Our prior columns on iatrogenic burns:
Wozniacka G. The Associated Press. Oregon hospital patients burned by lights in operating rooms. CTV News. Published Thursday, January 22, 2015
Our readers might get the erroneous impression that we are not advocates of CPOE from reading our many columns outlining some of the untoward consequences and other problems with CPOE and healthcare IT in general. Nothing could be further from the truth. We remain huge supporters of CPOE and clinical decision support and IT applications in healthcare. However, once again, we find ourselves commenting on yet another example of problematic CPOE.
In the new study, researchers culled the MEDMARX database for medication errors which included some indication that CPOE may have played a role (Schiff 2015). They then developed a taxonomy and coding for the types of errors, why they occurred, and what preventive strategies might be employed. From their list they then developed multiple scenarios and tested on a representative sample of CPOE systems at multiple facilities whether these error-prone scenarios might pass through.
From over 1 million reports available in MEDMARX they found 6.1% reported as CPOE-related. The reviewers actually found only about half of these were truly CPOE-related. The taxonomy was then developed on a sample of these reports and 21 scenarios were developed for vulnerability testing on representative systems.
Overall, 79.5% of the erroneous order scenarios were able to be placed (28% “easily” placed with no additional steps or warnings and 28.3% placed with only “minor workarounds”). Specific computer-generated warnings occurred for 26.6% of the erroneous orders but the vast majority of these (69%) were passive alerts and another 29% required workarounds that could be done. Interestingly, they encountered one system in which no alerts were triggered at all. It was found that alerts in that system had been turned off several months earlier during an upgrade and were never turned back on!
This process, of course, is quite similar in concept to that developed and used by The Leapfrog Group to simulate problematic medication orders (see our previous columns for July 27, 2010 “EMR’s Still Have a Long Way to Go” and June 2012 “Leapfrog CPOE Simulation: Improvement But Still Shortfalls”). That tool was to be used by hospitals to assess the vulnerabilities of their CPOE systems to medication errors. Voluntary testing at over 200 hospitals (Leapfrog 2010) then revealed that about half of errors on “routine” medication orders were missed and almost a third of potentially fatal medication errors were also missed. Those hospitals adjusted their CPOE systems and protocols and nearly all showed improvement when retested. A similar test was conducted in 2011 by over 250 hospitals (Leapfrog 2012). The rate of missed potentially fatal errors dropped to just over 1% but the rate of missed “routine” medication errors was still on average about one third.
Tools like these to identify potential vulnerabilities are really needed to help prevent such errors from occurring elsewhere. Just like the problems we identify in our RCA’s and other case reviews, issues that occur at one facility or organization are likely to also occur at others. It is only through sharing experiences and lessons learned that we are likely to make progress in reducing errors and their consequences.
This is good work. Schiff and colleagues are to be commended for this considerable undertaking.
See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:
Schiff GD, Amato MG, Eguale T, et al. Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems. BMJ Qual Saf 2015; Published Online First 16 January 2015
The Leapfrog Group. Leapfrog Group Report on CPOE Evaluation Tool Results
June 2008 to January 2010. June 2010
The Leapfrog Group. Lack of Testing and Monitoring of Health IT by Hospitals and Vendors Potentially Jeopardizes Patients -- Hospital Performance Is Improving, but More Must Be Done. PR Newswire April 27, 2012
We all know that sometimes our patient safety interventions may have unintended consequences. In fact, sometimes they may paradoxically worsen the condition for which we implemented them. For example, in our What’s New in the Patient Safety World columns for June 2010 “Seeing Clearly a Common Sense Intervention” and June 2014 “New Glasses and Fall Risk” we noted that sometimes new glasses may paradoxically result in increased falls even though impaired vision is a risk factor for falls.
Now another paradox has been reported: devices designed to aid walking may produce an increase in falls! Researchers looked at 43 elderly patients living in residential aged care facilities and compared 22 patients who used walking aids (predominantly walkers) to 21 who did not use walking aids (Roman de Mettelinge 2015). Those who used them were slightly older, more likely to report fear of falling, and more likely to be taking psychotropic medications. They also fell more frequently. 68% of those using walking aids had at least one fall during the one year of followup, compared to 35% for those not using walking aids. Those using a walking aid demonstrated a significantly different gait pattern than those not using them. They walked slower and took shorter steps, greater step times, and fewer steps per minute.
We need to be careful in interpreting the results of this study. It does show an association between use of an assistive device for walking and future falls. However, the study was based upon a small population. More importantly, the association does not necessarily imply a cause-and-effect relationship, a point readily acknowledged by the authors. It is almost impossible to exclude selection bias in such studies (i.e. those patients using walking aids may have been doing so because they were already at greater risk of falls than those not using them). Indeed, the group using walking aids did have more risk factors for falls, such as more use of psychotropic medications.
Nevertheless, there are several factors that may make patients more prone to falls when using a walking aid. They note patients must have sufficient strength, balance, coordination, and attention to master the walking aid. And the environment comes into play as well. Stairs present a challenge to those walking with walkers. Also, the devices may put excessive strain on the patient’s upper limbs. And using such devices may inhibit compensatory grasping that a patient might use to prevent a fall. And incorrect posture while using the devices, particularly walkers, may result in both falls and injuries related to the falls.
Prior studies have had mixed results regarding use of walking aids and risk of falls. But a systematic review and meta-analysis (Deandrea 2013) found that walking aid use was one of the three strongest associations with falls in nursing home residents (the other two being history of falls and moderate disability). Walking aid use roughly doubled the risk of falls.
Several studies have shown high rates of injury with falls related to walking aids, particularly walkers. Stevens and colleagues (Stevens 2009) found an estimated 47,312 older adult fall injuries associated with walking aids were treated annually in U.S. ED’s (87.3% with walkers, 12.3% with canes, and 0.4% with both). Walkers were associated with seven times as many injuries as canes and women's injury rates exceeded those for men. The most prevalent injuries were fractures and contusions or abrasions. Approximately one-third of subjects were hospitalized for their injuries.
A study done in the Netherlands also showed that falls associated with use of four-wheeled walkers in adults 65 and older were at high risk for serious injury (van Riel 2014). The majority of injuries were fractures (60%) with hip fracture (25%) being the most common injury. Contusions and abrasions accounted for 23% of injuries. The lower extremity, including hip, leg and foot, was the most frequently injured body region. As a second most common injury, men injured their head and neck, whereas women more often injured their arm or hand. Nearly half of all four-wheeled walker related injuries required hospitalization, mostly due to hip fractures.
The importance of training the patients on how to correctly use the walking devices is obvious. Many patients first use their device when recovering from surgery or other hospital event and the training may be very brief and never reinforced following discharge.
Roman de Mettelinge T, Cambier D. Understanding the Relationship Between Walking Aids and Falls in Older Adults: A Prospective Cohort Study. Journal of Geriatric Physical Therapy 2015; Published Ahead-of_Print January 15, 2015
Deandrea S, Bravi F, Turati F, Lucenteforte E, La Vecchia C, Negri E. Risk factors for falls in older people in nursing homes and hospitals. A systematic review and meta-analysis. Arch Gerontol Geriatr 2013; 56 (3): 407-415
Stevens JA, Thomas K, Teh L, Greenspan AI. Unintentional fall injuries associated with walkers and canes in older adults treated in U.S. emergency departments. J Am Geriatr Soc 2009; 57(8): 1464-1469
van Riel KMM, Hartholt KA, Panneman MJM, Patka P, van Beeck EF, van der Cammen TJM. Four-wheeled walker related injuries in older adults in the Netherlands. Inj Prev 2014; 20(1): 11-15
Emergency Department visits related to medication issues are very common in adults. In our May 2011 What’s New in the Patient Safety World column “Adverse Drug Events and the ER” we cited a study from Vancouver (Hohl 2011) which found that 12.2% of patients presenting to the emergency room were there because of medication-related issues. Most were for unintended consequences of appropriately prescribed drugs. Compared to patients who did not have such reactions these patients had 50% higher rates of hospitalization, 20% higher outpatient encounters, and almost double the healthcare median monthly costs.
Now another Canadian study found an almost as many pediatric ED visits are due to medication-related issues. Zed and colleagues (Zed 2015) found that medication-related issues accounted for one in every 12 pediatric ED visits and that almost two-thirds of these were potentially preventable. Adverse drug reactions accounted for 26.4%, subtherapeutic dosage 19.0%, and nonadherence. Of these patients, 7.2% required hospitalization and medication-related issues contributed to prolonged lengths of stay.
The most commonly implicated drugs were anti-infective, respiratory, and nervous system agents.
Basically, the study highlights the fact that medication-related events lead to increased utilization of emergency department and inpatient resources not only in adults but in children as well.
Hohl CM, Nosyk B, Kuramoto L, et al. Outcomes of Emergency Department Patients Presenting With Adverse Drug Events. Ann Emerg Med 2011; online ahead of print February 28, 2011
Zed PJ, Black KJL, Fitzpatrick EA. Medication-Related Emergency Department Visits in Pediatrics: a Prospective Observational Study. Pediatrics 2015; Published online February 2, 2015
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