What’s New in the Patient Safety World


August 2009



Bed Rails: Taking Emotion Out of the Debate

Catheter Misconnections Continue to Occur

Bold Experiment: Hospitals Saying No to Sleep Meds

Imaging for Acute Abdominal Pain




Bed Rails: Taking Emotion Out of the Debate


In our last column about the use of bedrails (see our December 18, 2007 Patient Safety Tip of the Week “Bed Rails”) we noted differing philosophies on the two sides of the Atlantic. Whereas bedrails are a scourge on the US side, they are looked at much differently in the United Kingdom.


Another recent UK paper (Healy and Oliver 2009) reviewed the issue from the standpoint of fact vs. emotion or evidence vs. opinion. Their thorough review of the literature unveils a dearth of well-done studies on the impact of bedrails on falls from bed or injuries from falls or injuries from bedrails. The limited evidence suggests that reductions in bedrail use have resulted in increased rates of falls. They also point out that some of the more frequently suggested alternatives to bedrails (such as crash mats, movement alarms, and ultra-low beds) also have an unknown impact on falls and injuries. The paper really does put in perspective how much of the debate is emotion-driven and how much is evidence-driven.


They point out that most of the bedrail entrapment problem has related to outmoded design, unsafe combinations of bedrails and mattresses, or “hybrids” (beds and bedrails that were never intended to be used together).


The article is well worth your reading to get a feel for the evidence base (or lack thereof). While it will not likely sway you one way or the other in the debate, it certainly will raise your awareness that the bedrail issue is not a cut-and-dried one. The authors also offer several practical tips and recommendations. The resources section and bibliography are excellent.


US FDA statistics show that between 1985 and 2008, 772 incidents of patients caught, trapped, entangled, or strangled in beds with rails were reported, including 460 people who died, 136 with nonfatal injuries, and 176 who were not injured because staff intervened. And, of course, the FDA site has a wealth of downloadable documents on bed safety and bedrail use.





Healey F, Oliver D. Bedrails, falls and injury: evidence or opinion? A review of their use and effects. Nursing Times 2009; 105: 26, early online publication 6 July 2009




FDA. A Guide to Bed Safety. Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts.Updated 5/15/2009




Hospital Bed Safety Workgroup. (Brochure) A Guide to Bed Safety. Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts.




FDA. Hospital Beds.





Catheter Misconnections Continue to Occur



Our July 10, 2007 Tip of the Week “Catheter Connection Errors/Wrong Route Errors” focused on catheter misconnections and we continued to see more patient deaths from Luer misconnections in our November 2007 What’s New in the Patient Safety World column.


The October 2007 issue of FDA Patient Safety News highlighted continued deaths from Luer misconnections and cited an excellent summary article by Gallauresi, Eakle, and Morrison in Safe Practices in Patient Care. It includes the history of the Luer connector, multiple real examples of misconnections, and the state of the industry in its attempts to develop standards to avoid this serious problem. It reiterates the recommendations of the 2006 Joint Commission Sentinel Event Alert on this issue.


Now another unfortunate case has occurred in Spain. A woman who was Spain’s first fatal case of the swine flu gave birth to a premature infant, who apparently was doing well until the event occurred.  Then, his tube feeds were erroneously given via the intravenous route, resulting in death of the infant.


The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) also recently learned about the case of a young pregnant woman who was erroneously given tube feeding formula into her IV line, resulting in the death of her 35-week fetus, and shortly thereafter, her death. The A.S.P.E.N. press release above also has links to new resources on avoiding such misconnections.




Medical error ends the life of premature baby of Dalilah Mimouni first of Spain’s swine flu deaths

Barcelona Reporter.com




Tube Feeding Error: Fatal Medical Mistakes






Bold Experiment: Hospitals Saying No to Sleep Meds



Guilty! Despite all we say about sedating agents contributing to falls, delirium, and other adverse events in hospitals, we still often write that standing order for a prn sleep med for our inpatients. Worse yet, we often even include them on the standardized admission order sets we develop for CPOE! Of course, we write the order to promote sleep – mainly our own sleep, so we don’t get that phone call that wakes us up just to order a sleep med for a patient!


But now some Pennsylvania hospitals have taken the bold step of literally banning sleep meds for inpatients in an attempt to reduce falls and other adverse events. Doylestown Hospital on July 1 implemented a policy virtually eliminating the use of sleep medications by inpatients. Doylestown had already implemented a significant noise reduction program in the previous six months. And they try to make the inpatient environment conducive to sleep by lowering the lights, closing doors, allowing masks or earplugs, using more private rooms, and allowing personal stereos to be used. They’ll be collecting outcome data to determine whether the medication ban results in fewer adverse events.


It’ll be an interesting experiment. Both lack of sleep and use of sedating agents may increase the risk of delirium and probably falls as well.


Other hospitals have not gone that far but have often taken steps to minimize use of sleep medications, such as not allowing sleep meds to be taken in close temporal relationship to analgesics or antianxiety agents. Others won’t allow their use after a certain time of night. Still others discourage their use in patients over the age of 65 and then use them in lower doses.


Are there potential unintended consequences? Of course. It is conceivable that patients who had been taking sleep meds chronically could develop withdrawal syndromes or seizures. Doylestown’s policy excludes such patient who have been taking sleep meds regularly at home prior to admission.


The pennies saved on medication expense don’t justify the policy. But what will justify it is a significant reduction in adverse events which should translate into a reduction in length of stay as well. That’s where the significant cost savings will appear.


Time will tell! Stay tuned.




Hospital says goodnight to sleeping pills


The Intelligencer

July 17, 2009







Imaging for Acute Abdominal Pain


In the past few months there have been multiple studies published on imaging for acute abdominal pain. In a longitudinal study of  imaging in patients with acute abdominal pain in emergency departments (Pines et al 2009), CT use increased from 10.1% in 2001 to 22.5% in 2005. Ultrasound use increased from 11.1% to 13.6% over the same time period. However, detection rates for appendicitis, diverticulitis, and gall bladder disease did not increase and admission rates did not decrease.


Another paper (Pines 2009b) found that risk-taking behavior correlated with ordering imaging studies in emergency department patients with abdominal pain but that fear of malpractice did not.


Two studies looked at sequential imaging strategies in patients with acute abdominal pain. In a study of acute appendicitis (Poortman et al) found that using ultrasound, followed by CT scan in cases where the ultrasound is negative, had high diagnostic accuracy without adverse events related to delay in diagnosis. Although ultrasound had less diagnostic accuracy than CT, it can be used as the primary imaging modality and avoid the disadvantages of CT such as radiation exposure and use of contrast agents.


A similar study in the UK (Lameris et al for the OPTIMA study group 2009) was reported on patients with urgent acute abdominal pain. CT detected more urgent diagnoses than did ultrasonography: sensitivity was 89% for CT and 70% for ultrasonography but a conditional strategy with CT only after negative or inconclusive ultrasonography yielded the highest sensitivity, missing only 6% of urgent cases. With this strategy, only 49% of patients would have CT.


The conditional strategy (ultrasound followed by CT only if the ultrasound is negative) thus appears to be quite accurate, safe, efficient and economical and avoids some of the potential adverse effects of CT scanning.





Pines JM. Trends in the Rates of Radiography Use and Important Diagnoses in Emergency Department Patients With Abdominal Pain. Medical Care 2009; 47: 782-786




Pines JM, Hollander JE, IssermanJA et al. The association between physician risk tolerance and imaging use in abdominal pain. J Emerg Med 2009; 27: 552-557




Poortman P, Oostvogel HJM, Bosma E et al. Improving Diagnosis of Acute Appendicitis: Results of a Diagnostic Pathway with Standard Use of Ultrasonography Followed by Selective Use of CT. J Am Coll Surg 2009; 208: 434-441



Laméris W, Adrienne van Randen A, H Wouter van Es HW, et al., on behalf of the OPTIMA study group. Imaging strategies for detection of urgent conditions in patients with acute abdominal pain: diagnostic accuracy study. BMJ 2009; 338: b2431 Published 26 June 2009







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