What’s New in the Patient Safety World

August 2012

 

·        Anesthesiology and Surgical Infections

·        New Joint Commission Tools for Improving Handoffs

·        More on Postoperative Handoffs

·        More on the Weekend Effect

·        Newest MRI Hazard: Ingested Magnets

 

 

 

 

Anesthesiology and Surgical Infections

 

 

In our December 28, 2010 Patient Safety Tip of the Week “HAI’s: Looking In All The Wrong Places” we highlighted an article from the January 2011 issue of Anesthesia & Analgesia on the role of hand contamination of anesthesia providers as a risk factor for intraoperative bacterial transmission (Loftus 2011). They identified bacterial transmission to the operative environment in 89% of cases and anesthesia providers were identified as the source in 12% of these cases. Transmission to the patient IV stopcock setup occurred in 11.5% of cases and anesthesia providers were identified as the origin in almost half (47%) those cases. Note that they were able to culture one or more pathogenic bacteria from 66% of provider hands before intraoperative patient care. Remarkably, this occurred despite 90% compliance with hand hygiene practices during the period of the study, suggesting that the effectiveness rather than the frequency of the hand hygiene techniques is of concern.

 

Other factors identified as independent predictors of environmental transmission included anesthesia provider supervising more than one room, first case of the day, patient age, and discharge to the ICU from the OR. The fact that anesthesia providers moving from one room to another may increase the rates of transmission certainly raises the likelihood that any healthcare worker moving from room to room may increase transmission rates. In some of our prior articles on the relationship between surgical duration and SSI rates (see our March 10, 2010 Patient Safety Tip of the Week “Prolonged Surgical Duration and Time Awareness” and our January 2010 What’s New in the Patient Safety World column “Operative Duration and Infection”), we have noted that OR traffic typically increases in longer duration cases. That likely increases the risk of bacterial transmission as well. As cases go on longer, foot traffic in and out of the OR increases, both as staff go on breaks or change shifts and as interruptions for questions, etc. begin to affect the surgeons and anesthesiologists. Long duration of surgery has long been known to be a factor associated with increased risk of surgical site infection and increased foot traffic may be one factor that increases the likelihood of surgical site infections (Lynch 2009).

 

Now a new study (Gargiulo 2012) in a simulated environment demonstrated significant infection control risks associated with anesthetic drug administration. The authors observed anesthesia personnel during the simulated cases and cultured IV bags, syringes, and needles. Organisms were cultured from 13% of IV bags, 5% of syringes, and 35% of needles. Strikingly, failure to wash hands prior to entry into the simulated environment, failure to use hand gel, placing nonsterile equipment on top of the drug trays, and other practices not considered good infection control were commonly observed. The authors note that confirmation of these findings in a clinical setting is needed. Nevertheless, this study is an eye opener and identifies an area of potentially considerable vulnerability.

 

An editorial accompanying the 2011 Loftus article (Roy 2011) discussed the ubiquity of the bacterial “slime” we all carry and discusses documented cases of bacterial transmission from healthcare workers resulting in actual HAI’s for patients. It raises many interesting issues like “should all OR personnel routinely be cultured?” and “what would we do with the results?”. They also point out we should be developing better disinfecting protocols for not only our anesthesia equipment but for the host of other equipment and “toys” we bring into the OR (stethoscopes, computer keyboards, cell phones, iPads, iPods, pagers, personal bags, etc.).

 

A second editorial (Hollman 2011) noted that anesthesia providers currently participate in tasks designed to reduce SSI’s (eg. timely hanging of prophylactic antibiotics, maintenance of normothermia, etc.) but that SSI rates seem to have plateaued and we need better strategies to further reduce them. They call for improving the effectiveness of decontamination of the anesthesia work area and better hand hygiene practices. An editorial accompanying the Koff article (Hopf 2009) discusses the low rates for hand hygiene by anesthesiology providers in particular and some of the barriers that exist in the OR environment.

 

In our December 28, 2010 Patient Safety Tip of the Week “HAI’s: Looking In All The Wrong Places” we also had noted that the same group from Dartmouth-Hitchcock had previously demonstrated that such transmission was associated with increased patient mortality (Loftus 2008) and that use of a novel hand sanitation strategy dramatically reduced the intraoperative bacterial transmission and reduced healthcare-associated infections (Koff 2009). In the latter study, anesthesia providers were given a hand sanitation device to be worn and used in addition to the typical wall-mounted dispensers. Hourly hand decontamination events increased 27-fold. Contamination of the anesthesia work area and patient IV tubing dropped dramatically and HAI rate dropped to 3.8% compared to the 17.2% rate seen in controls.

 

 

 

How many of you audit infection control practices within the OR and include the sort of detail outlined in the studies above?

 

 

 

References:

 

 

Loftus, RW, Muffly MK, Brown JR, et al. Hand Contamination of Anesthesia Providers Is an Important Risk Factor for Intraoperative Bacterial Transmission. Anesth Analg  2011; 112: 98-105

http://www.anesthesia-analgesia.org/content/112/1/98.abstract

http://www.anesthesia-analgesia.org/content/112/1/98.full.pdf+html

 

 

Lynch RJ, Englesbe MJ, Sturm L, et al. Measurement of Foot Traffic in the Operating Room: Implications for Infection Control. American Journal of Medical Quality 2009; 24: 45-52

http://ajm.sagepub.com/cgi/content/abstract/24/1/45

 

 

Roy, RC, Brull SJ, Eichorn JH. Surgical Site Infections and the Anesthesia Professionals' Microbiome: We've All Been Slimed! Now What Are We Going to Do About It?

Anesth Analg January 2011 112:4-7

http://www.anesthesia-analgesia.org/content/112/1/4.full.pdf+html

 

 

Hollmann MW, Roy RC. Antisepsis in the Time of Antibiotics: Following in the Footsteps of John Snow and Joseph Lister (editorial). Anesth Analg January 2011 112:1-3

http://www.anesthesia-analgesia.org/content/112/1/1.full.pdf+html

 

 

Hopf HW, Rollins MD. Reducing Perioperative Infection Is as Simple as Washing Your Hands. Anesthesiology 2009; 110(5): 959-960

http://journals.lww.com/anesthesiology/Fulltext/2009/05000/Reducing_Perioperative_Infection_Is_as_Simple_as.4.aspx

 

 

Vogel TR, Dombrovskiy VY, Lowry SF. In-Hospital Delay of Elective Surgery for High Volume Procedures: The Impact on Infectious Complications. Journal of the American College of Surgeons 2010; 211(6): 784-790

http://www.journalacs.org/article/S1072-7515%2810%2901007-0/abstract

 

 

Alter SM, Merlin MA. Nosocomial and community-acquired infection rates of patients treated by prehospital advanced life support compared with other admitted patients. American Journal of Emergency Medicine 2011; 29: 57–64

http://www.ajemjournal.com/article/S0735-6757%2809%2900389-1/abstract

 

 

Gargiulo DA, Sheridan J, Webster CS, et al. Anaesthetic drug administration as a potential contributor to healthcare-associated infections: a prospective simulation-based evaluation of aseptic techniques in the administration of anaesthetic drugs. BMJ Qual Saf doi:10.1136/bmjqs-2012-000814 Online First 16 June 2012

http://qualitysafety.bmj.com/content/early/2012/06/15/bmjqs-2012-000814.short?g=w_qshc_ahead_tab

 

 

Loftus RW, Koff, MD, Burchman CC, et al. Transmission of Pathogenic Bacterial Organisms in the Anesthesia Work Area. Anesthesiology 2008; 109(3): 399-407

http://journals.lww.com/anesthesiology/Fulltext/2008/09000/Transmission_of_Pathogenic_Bacterial_Organisms_in.9.aspx

 

 

Koff MD, Loftus RW, Burchman CC, et al. Reduction in Intraoperative Bacterial Contamination of Peripheral Intravenous Tubing Through the Use of a Novel Device. Anesthesiology 2009; 110(5): 978-985

http://journals.lww.com/anesthesiology/Fulltext/2009/05000/Reduction_in_Intraoperative_Bacterial.10.aspx

 

 

 

 

Print “August 2012 Anesthesiology and Surgical Infections

 

 

 

 

New Joint Commission Tools for Improving Handoffs

 

 

The Joint Commission recently released its new Targeted Solutions Tool™ (TST) for Hand-off Communications. This is an outstanding tool that every healthcare organization can utilize to improve patient care and coordination across all levels of the continuum of care. The Targeted Solution Tools are free to organizations accredited by The Joint Commission. Previous TST’s have addressed hand hygiene and wrong-site surgery and have proven very valuable. You’ll find this one even more valuable.

 

In our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics” and March 2012 What’s New in the Patient Safety World column “More on Perioperative Handoffs” we stressed that you need to implement tools that address the needs of each particular type of handoff that occurs in your organization. Though using a structured communication format or tool is important, the exact tool or format needed will vary by the nature of the handoff so “one size does not fit all”. The new Joint Commission TST for Hand-Off Communications takes on that very philosophy. It stresses that because there are so many root causes of failed handoffs you need to implement those proven solutions tailored to the root causes in play at your organization, not an off-the-shelf generic solution that addresses things you may already be doing well. Many of those root causes are listed in the summary document describing the program.

 

Their tools are tailored for a variety of handoffs. In their introductory webinar they highlighted handoffs between long-term care and acute care hospitals and handoffs from the emergency department to the inpatient units. But they have solutions in place for all the most common handoff scenarios. They have not yet posted tools for the shift-to-shift handoff but are in the process of piloting solutions for that as well and expect those tools to be up online within a few months. The tools and solutions were developed and implemented by the Joint Commission Center for Transforming Healthcare in conjunction with many participating hospitals you’ll readily recognize for their commitment to quality.

 

They stress the importance of the “sender” and the “receiver” getting together early in the implementation process to align their goals. They emphasize that the sender and receiver often have very different expectations about what they will get from a handoff. They have tools to help you determine what common root causes are present in suboptimal communications between your organization and your partners. Once you choose a type of handoff to focus on they provide tools that have been proven effective for that type of handoff and those types of root causes you’ve identified. Further, they provide measuring tools and audit tools so that you get feedback on your improvement endeavors. Since their programs heavily involved staff trained in LEAN and Six Sigma and RPI (Robust Process Improvement™), you will see statistical process control charts of defect rates, pareto charts of reasons for failed hanoffs, times series charts, etc. in their toolkits.

 

Are their solutions successful? In one handoff project involving an acute care hospital and long-term care facilities they were able to reduce 30-day readmission rates substantially and also helped lower hospital length of stay. In another they achieved a 33% reduction in the time to transfer patients from the ED to the acute care units

 

We have no doubt that any healthcare organization will find a tool to address handoff problems relevant to their own circumstances. This TST is a very valuable tool.

 

 

 

Read about many other handoff issues (in both healthcare and other industries) in some of our other 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

 

 

 

Reference:

 

 

The Joint Commission. Center for Transforming Healthcare. Joint Commission introduces new, customized tool to improve hand-off communications. June 27, 2012

http://www.jointcommission.org/issues/article.aspx?Article=RZlHoUK2oak83WO8RkCmZ9hVSIJT8ZbrI4NznZ1LEUk%3D

 

Joint Commission Center for Transforming Healthcare. Improving Transitions of Care: Hand-off Communications.

http://www.centerfortransforminghealthcare.org/assets/4/6/CTH_Hand-off_commun_set_final_2010.pdf

 

 

A Look at the Joint Commission. Robust Process Improvement™ at the Joint Commission. Bulletin of the American College of Surgeons. August 2011 p. 75

http://www.facs.org/fellows_info/bulletin/2011/jointcomm0811.pdf

 

 

 

 

Print “August 2012 New Joint Commission Tools for Improving Handoffs

 

 

 

 

 

Review of Postoperative Handoffs

 

 

In our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics” we noted that a structured communication format or tool is important but that the exact tool or format needed will vary by the nature of the handoff so “one size does not fit all”. Particularly in the perioperative setting, the nature of handoffs is often very different from the resident-to-resident or nurse-to-nurse handoffs done on a medical unit.

 

We highlighted the AORN toolkit in our December 2011 What’s New in the Patient Safety World column “AORN Perioperative Handoff Toolkit”. It focuses on standardized handoff communications and stresses that handoffs should be held where there is adequate time, with minimal distraction, and allow for interactive discussion where the recipient is able to review all relevant material and has ample opportunity to ask questions. They stress the importance of using language that is clearly understood by all parties and use of “read-back”, “repeat-back” and “hear-back” to ensure that communication is understood by all parties. They also stress the importance of not only passing on information during a handoff but also passing on responsibility for care of the patient.

 

A new systematic review of the literature (Segall 2012) found of dearth of studies on postoperative handoffs that offered interventions and even fewer that measured the impact of recommended interventions. They describe numerous barriers to effective communication at such handoffs, including distractions (eg. performing other clinical duties at the same time), lack of participation by all team members, incomplete transfer of information, lack of structure or consistency, poor standardization and others. They do note strategies recommended, including the “sterile cockpit” concept, completing urgent care tasks prior to the handoff, having all team members present but ensuring only one person talks at a time, using structured tools (checklists, protocols), use of various support documentation, and providing enough time for questions and clarification. They list the types of information that must typically be communicated during such postoperative handoffs and note that automated population of handoff checklist from electronic health records might make handoffs more efficient. They note that poor handoffs and poor patient outcomes go hand in hand but raise the interesting question as to which comes first, i.e. do the poor handoffs lead to the poor outcomes or do unstable patients lead to poor handoffs. The latter possibility certainly raises the issue of structuring such handoffs to ensure complete communication despite unstable patients. Good review of the current status of postoperative handoffs and good bibliography. Interestingly, all 4 of the studies that included an assessment of the impact of a handoff intervention were on the same kind of population – pediatric cardiac patients. That raises the question of how generalizable the results are. Tells us, however, that there is considerable room for improvement and further research.

 

Recall that our March 2012 What’s New in the Patient Safety World column “More on Perioperative Handoffs” highlighted work from Johns Hopkins that took the perioperative handoff to a new level (Petrovic 2012a). That handoff process is a true multidisciplinary and interdisciplinary handoff, designed for transfers of patients from OR to PACU or PACU to ICU, etc. It consists of a protocol and series of checklists. The protocol has 5 steps and takes place with the entire team in the patient room. The first step involves identifying the patient and introducing all members of the team. Step 2 involves “transfer of technology” (monitors, lines, etc.). Subsequent steps are checklist-guided handoffs by the surgeon, anesthesiologist, and OR nurse. Each of the latter 3 handoffs concludes with a statement of “anticipatory guidance” by the presenter, stating what he/she is most concerned about regarding the patient. Plenty of time is provided for members of the receiving team to ask questions and clarify items. The handoff formally concludes with an announcement “the handoff is now complete”. The article includes copies of the checklists and protocol and delineates the steps you need to go through to implement the protocol. The authors also have prepared a multimedia toolkit for those who want to implement the protocol at their institutions.

 

In a companion paper, they also have published some outcome measures from that protocol and process (Petrovic 2012b). After the protocol's implementation, the presence of all handoff core team members at the bedside increased from 0% at baseline to 68%, the percentage of missed information in the surgery report decreased from 26% to 16% , and handoff satisfaction scores among intensive care unit (ICU) nurses increased from 61% to 81%. On average, the duration of handoff increased by 1 minute.

 

 

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

 

 

 

Reference:

 

 

AORN. Perioperative Patient 'Hand-Off' Tool Kit.

http://www.aorn.org/PracticeResources/ToolKits/PatientHandOffToolKit/

 

 

Segall N, Bonifacio AS, Schroeder RA, et al. Review Article: Can We Make Postoperative Patient Handovers Safer? A Systematic Review of the Literature

Anesth Analg 2012; 115: 102-115; published ahead of print April 27, 2012

http://www.anesthesia-analgesia.org/content/115/1/102.abstract

 

 

Petrovic MA, Martinez EA, Aboumatar H. Implementing a Perioperative Handoff Tool to Improve Postprocedural Patient Transfers. Joint Commission Journal on Quality and Patient Safety 2012; 38(3): 135-4AP(-130)
http://www.ingentaconnect.com/content/jcaho/jcjqs/2012/00000038/00000003/art00006

 

 

Petrovic MA, Aboumatar H , Baumgartner WA. Pilot Implementation of a Perioperative Protocol to Guide Operating Room–to–Intensive Care Unit Patient Handoffs. J Cardiothorac Vasc Anesth 2012; 26(1): 11-16

http://www.jcvaonline.com/article/S1053-0770%2811%2900528-3/abstract

 

 

 

 

Print “August 2012 Review of Postoperative Handoffs

 

 

 

 

 

 

More on the Weekend Effect

 

 

The “weekend effect” is a term used to refer to an increase in untoward events or suboptimal outcomes occurring in patients admitted to hospitals over the weekend. In some cases we use the term “after hours effect” since some of the same issues occur in patients admitted at night. We’ve discussed the numerous factors that may contribute to the “weekend effect” in our previous columns:

 

Now 3 more studies add to the growing list of undesirable outcomes on patients admitted on weekends. One study done in the UK (Palmer 2012) affirmed what has been previously reported in the US and elsewhere: patients admitted with strokes on weekends have higher mortality rates. The adjusted 7-day mortality rate was almost 20% higher in those admitted over the weekend. While the authors cannot exclude the possibility that patients admitted over the weekend might have confounding factors to explain the disparity (eg. they might have more severe strokes), they did identify process measures that indicated probable inferior care on weekends. For example, the rate of patients receiving prompt imaging studies was almost 20% lower in those admitted over the weekend and almost 20% fewer patients received thrombolytic therapy when admitted over the weekend. There was also a trend toward higher rates of aspiration pneumonia in those admitted over the weekend. And the number of patients being discharged to places other than home was higher in those admitted over the weekend. The potential cost implications related to this phenomenon are large.

 

The second study (Deshmukh 2012) demonstrated patients admitted on weekends with atrial fibrillation (AF) were 24% more likely to die in hospital than those admitted on weekdays. They were substantially less likely to receive cardioversion. Those who were cardioverted had longer lengths to the cardioversion procedure. They also had longer lengths of stay. After adjustment for other factors, the cardioversion issues may have been responsible for both the increased mortality and longer lengths of stay. Interestingly, costs were lower in those admitted on weekends, most likely because of the lower rates of cardioversion. The authors discuss potential contributing factors, including staffing issues, physician cross-coverage issues, and availability of ancillary studies and procedures. They suggest that perhaps an organized model, such as those regionalized programs established for trauma or acute MI, might be developed for patients in atrial fibrillation.

 

The third study (Worni 2012) looked at outcomes for patients operated upon for diverticulosis on weekends compared to weekdays. Those having the surgery on weekends were less likely to get a primary anastamosis, had increased rates of postsurgical complications, higher likelihood of nonroutine discharge, longer lengths of stay and higher average hospital costs.

 

 

Our healthcare systems clearly do not deliver uniform care 24x7. With reduced hospital margins leading to staffing cuts and fewer physicians being “on-call” for patients with whom they are familiar it is unlikely that the “weekend effect” will disappear any time soon. Perhaps the time has come to consider models where patients get selectively directed to true full-service hospitals on weekends. But ensuring that even those hospitals remain truly full-service is likely to be challenging.

 

 

Update: Make that 4 articles! Another recent article (Johns Hopkins Medicine 2012) showed that older patients admitted with head trauma on weekends had higher mortality rates (14% higher) than those admitted on weekdays, even when severity of head injury and comorbidities were less. The authors used the HCUP database to identify cases. However, they were unable to determine which type of facility these patients were admitted to. Prior studies have shown that the weekend effect does not usually apply to patients at Level I trauma centers. Many of these patients may have been at facilities with lower levels of trauma care or community hospitals.

 

 

 

References:

 

 

Palmer WL, Bottle A, Davie C, et al. Dying for the Weekend. A Retrospective Cohort Study on the Association Between Day of Hospital Presentation and the Quality and Safety of Stroke Care. Arch Neurol 2012; (): 1-7 published online July 9, 2012

http://archneur.jamanetwork.com/article.aspx?articleid=1212192

 

 

Deshmukh A, Pant S, Kumar G, et al. Comparison of Outcomes of Weekend Versus Weekday Admissions for Atrial Fibrillation. Am J Cardiol 2012; 110(2): 208-211

http://www.ajconline.org/article/S0002-9149%2812%2900935-6/abstract

 

 

Worni M, Schudel IM, Řstbye T, et al. Worse Outcomes in Patients Undergoing Urgent Surgery for Left-Sided Diverticulitis Admitted on Weekends vs WeekdaysA Population-Based Study of 31 832 Patients. Arch Surg. 2012; 147(7): 649-655

http://archsurg.jamanetwork.com/article.aspx?articleid=1217292

 

 

Johns Hopkins Medicine. Weekend Hospital Stays Prove More Deadly Than Other Times for Older People with Head Trauma. Press Release 8/6/2012

http://www.hopkinsmedicine.org/news/media/releases/weekend_hospital_stays_prove_more_deadly_than_other_times_for_older_people_with_head_trauma_

 

 

 

 

 

Print “August 2012 More on the Weekend Effect

 

 

 

 

 

Newest MRI Hazard: Ingested Magnets

 

 

We’ve done multiple columns on hazards related to MRI. And we’ve emphasized the dangers of metallic or ferromagnetic items overheating during MRI and causing injury. But we’ve just come across one we have not encountered before: harm due to MRI in patients who have ingested magnets. A recent paper (Bailey 2012) describes a case of a 5 y.o. boy who had ingested magnets and had an MRI that led to bowel perforation. The authors review the literature and come up with a recommended tool to screen for magnets before MRI is performed.

 

The authors note that most cases of ingested magnets occur in young children and most often boys and are often, in fact typically, not witnessed. Most are passed in the stool without incident and less than 10% require intervention (only 1% requiring surgery). However, swallowing multiple magnets may be more troublesome since the magnets adhere to each other, increasing the likelihood they might obstruct the bowel.

 

In their index case, the authors note the patient actually presented to an ED with complaints of neck pain. Initial workup focused on the cervical spine and included a normal CT scan of the neck and normal lumbar puncture. A decision to do an MRI of the brain and cervical spine was then done under moderate sedation and was also negative. The following day his neck pain was better but he now had severe abdominal pain and would not eat. Abdominal X-rays showed air in the peritoneal cavity and 11 small round metallic objects in the left upper quadrant.  At surgery, four full-thickness small intestinal perforations were found and 11 small spherical magnets were removed from the peritoneal cavity. The magnets were most likely from a magnetic game the child had been playing near. He had an uneventful recovery.

 

The hospital changed their MRI screening protocol. While they still do a written and verbal questionnaire of the children and parents for presence of metallic objects, they now also have all children change into a hospital gown and undergo screening using a hand-held ferromagnetic detection scanner.

 

Very interesting case. Children do frequently ingest non-food items and may not be able to verbally tell you they did so. So maybe use of ferromagnetic scanners will become routine in children. Conceivably it might also find a role in screening older patients whose medical condition precludes providing a history of metallic objects ingested or implanted.

 

 

Interestingly, the day after we had prepared this column the US Consumer Product Safety Commission filed an administrative complaint against a manufacturer of toy magnets (CPSC 2012) based on more than 2 dozen reports of young children and teenagers swallowing the magnets. Many of those had visceral perforations or intestinal obstructions and required surgery. That report does not specifically mention the MRI risk noted in the Bailey paper. But it certainly points out that such ingestion of magnets is not rare.

 

 

Some of our prior columns on patient safety issues in the radiology or MRI suite:

·        October 16, 2007        Radiology as a Site at High-Risk for Medication Errors

·        September 16, 2008     More on Radiology as a High Risk Area

·        October 7, 2008          Lessons from Falls....from Rehab Medicine

·        January 2010                Falls in the Radiology Suite

·        August 2010                 Sedation Costs for Pediatric MRI

·        January 25, 2011          Procedural Sedation in Children

·        February 19, 2008       MRI Safety

 

 

 

 

References:

 

 

Bailey JR, Eisner EA, Edmonds EW. Unwitnessed magnet ingestion in a 5 year-old boy leading to bowel perforation after magnetic resonance imaging: case report of a rare but potentially detrimental complication. Patient Safety in Surgery 2012; 6: 16 (19 July 2012)

http://www.pssjournal.com/content/6/1/16/abstract

 

 

CPSC (U.S. Consumer Product Safety Commission). CPSC Sues Maxfield & Oberton Over Hazardous Buckyballs® and Buckycube™ Desk Toys. Action prompted by ongoing harm to children from ingested magnets. News Release July 25, 2012

http://www.cpsc.gov/cpscpub/prerel/prhtml12/12234.html

 

 

 

 

Print “August 2012 Newest MRI Hazard: Ingested Magnets

 

 

 

 

Print “August 2012 What's New in the Patient Safety World (full column)

Print “August 2012 Anesthesiology and Surgical Infections

Print “August 2012 New Joint Commission Tools for Improving Handoffs

Print “August 2012 Review of Postoperative Handoffs

Print “August 2012 More on the Weekend Effect

Print “August 2012 Newest MRI Hazard: Ingested Magnets

 

 

 

 

 


 

 


http://www.patientsafetysolutions.com/

 

Home

 

Tip of the Week Archive

 

What’s New in the Patient Safety World Archive