What’s New in the Patient Safety World

August 2017

 

 

·         Adverse Events in Hospitalized Neurological Patients

·         Medication Errors Outside of Healthcare Facilities

·         More on Pediatric Dosing Errors

·         ROI for a Second Victim Program

 

 

 

Adverse Events in Hospitalized Neurological Patients

 

 

There has been a relative paucity of studies on patient safety issues in neurological patients. Neurological conditions that require hospitalization have a number of features that predispose to a variety of potential adverse events. For example, many are associated with neurogenic bladder dysfunction that may be a factor in high rates of catheter-associated urinary tract infections (CAUTI’s). Many of the conditions are associated with reduced mobility, increasing the risk for pressure ulcers and DVT and venous thromboembolism. Some (eg. stroke, Parkinson’s) may be associated with disordered sawallowing that predisposes to aspiration and pneumonia. Impairment of balance and/or righting reflexes may lead to falls. Those neurological conditions that impair cognition may also predispose to delirium when other medical insults occur. And several neurological conditions may be associated with obstructive sleep apnea, which may increase the risk of respiratory depression in relation to opioids or other drugs that depress respiration. So we would expect neurological inpatients would have relatively high rates of adverse events while hospitalized.

 

A new Canadian study provides some perspective on adverse events in this population. Sauro and colleagues (Sauro 2017) did a retrospective cohort study of over 175,000 children and adults admitted to Alberta hospitals from 2009 to 2015 with 1 of 9 neurologic conditions (Alzheimer disease and related dementia, brain tumor, epilepsy, motor neuron disease, multiple sclerosis, parkinsonism/Parkinson disease, spinal cord injury, traumatic brain injury, and stroke).

 

The mean age of the admitted neurologic patients was 66.5 years and, as you’d expect, multiple comorbid conditions were common. It’s not surprising that age and the presence of comorbidities increased the odds of having an adverse event. The overall proportion of admissions associated with an adverse events among those with a neurologic condition was 11 per 100 admissions and, of those cases with adverse events, 16.1% had more than one. The occurrence of adverse events did vary by diagnosis, being highest for those patients with spinal cord injuries (39.4 per 100 admissions). The most common adverse events were infections and respiratory complications (32.0% and 16.7%, respectively). But for those conditions where surgery was likely (eg. brain tumor, spinal cord injury), surgery-related complications were more common.

 

As in most studies on adverse events, having an adverse event was associated with increased mortality and increased length of hospital stay. Those experiencing an adverse event had 2.4 times the odds of mortality.

 

Length of stay was 35.4 days longer for those who had an adverse event compared to those who did not. At first glance, we wondered whether that reported extremely large increase in LOS was a typo because most studies on adverse events in hospitalized patient reveal a more moderate increase in LOS related to adverse events. But we must remember that the relationship between LOS and adverse events is complicated. Not only do adverse events cause longer hospital stays, but the chance of having an adverse event increases with each day of hospitalization.

 

The most common adverse events in this study were those related to infections and respiratory-related adverse events, anesthesia-related adverse events, CNS-related adverse events, and delirium accounted for a small proportion of adverse events. The authors were somewhat surprised that falls did not rise to a higher level in their ranking of adverse event rates, given that patients with many of the neurological conditions studied are prone to falls. However, the authors explain that this may be related to the difficulties in documenting falls by using ICD-10 codes, which is how they identified most of the adverse events.

 

We’re also somewhat surprised that adverse drug events were not more frequent in this population. They found only 1.46% of the adverse events related to drugs, a proportion we would have expected to be much higher in a population with this age and comorbidity distribution.

 

Many of the adverse events seen in neurological inpatients may be preventable. We’ve done numerous columns on CAUTI prevention, swallowing assessment in stroke patients prior to initiating oral feeding, frequent turning of immobile patients, fall prevention strategies, risk assessment for obstructive sleep apnea, delirium prevention strategies, and VTE prophylaxis.

 

We’re glad to see this study by Sauro and colleagues and hope this stimulates an interest by our neurological colleagues to undertake more patient safety initiatives.

 

 

 

References:

 

 

Sauro KM, Quan H, Sikdar KC, et al. Hospital safety among neurologic patients. A population-based cohort study of adverse events. Neurology 2017; 89(3): 284-290

http://www.neurology.org/content/89/3/284.abstract?etoc

 

 

 

 

 

 

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Medication Errors Outside of Healthcare Facilities

 

 

Much of what we know about medication errors is derived from inpatient studies and, to a lesser degree, long-term care studies. Medication errors that occur in the home or other non-healthcare settings are less well studied.

 

One method of identifying potential medication errors in those latter facilities is analyzing data from our multiple poison control centers. Such recent analysis of National Poison Database System (NPDS) data from 2000 through 2012 showed a significant increase in errors that result in serious medical outcomes (Hodges 2017). Those researchers found 67,603 exposures related to unintentional therapeutic pharmaceutical errors that occurred outside of health care facilities that resulted in serious medical outcomes (overall average rate 1.73 per 100,000 population). Most notably, there was a 100% rate increase over that 13-year study period. Increases were seen for all age groups except children younger than 6 years of age.

 

Common types of medication errors included:

 

The medication categories most frequently associated with serious outcomes were:

 

The analgesic errors were dominated by three classes:

 

Interestingly, serious medication errors were more frequent among females in all age categories. Two-thirds of the errors involved solid medications but 20% involved liquid medications, primarily in children.

 

Cough and cold medications were frequent offenders in children under the age of 6 but a suspected reason for the lack of an increase in overall errors in children under the age of 6 over the course of the study was a reduction in the number due to cough and cold medications, attributable to warnings from the FDA and numerous specialty societies.

 

And for children younger than 6 years, 10.9% of the errors were classified as "ten-fold dosing error", a problem we’ve often noted for pediatric patients (see list of columns on pediatric medication errors below). But for children 6–12 years old, the percentage of medication errors attributed to inadvertently taking/giving someone else’s medication was nearly double that of any other age group. The authors speculate that some children in this age group may be administering their own medication, and due to their age, may be more likely to take another family member’s medication by mistake.

 

Medical outcome was most commonly reported as moderate effect (93.5%), followed by major effect (5.8%) and death (0.6%). A third of exposures resulted in hospital admission. Not surprisingly, categories of medications resulting in the highest proportion of admissions to a critical or non-critical care unit were anticoagulants, analgesics, antineoplastics, anticonvulsants, and cardiovascular medications.

 

The authors stress that most non-health care facility medication errors are preventable, particularly those due to dosing errors, taking or administering the wrong medication, and inadvertently taking or administering the same medication twice. They also stress the growing body of literature regarding use of proper dosing devices in children (see the list of our prior columns below and another of this month’s What's New in the Patient Safety World columns More on Pediatric Dosing Errors”).

 

But they also note that in young children the second most common type of medication error was “health professional iatrogenic error” (related to mistakes made by physicians, nurses, pharmacists, or other health care professionals, and cases in which a contraindicated medication was given).

 

The authors offer many potential improvements that could reduce the frequency of these medication errors, including:

 

 

 

Some of our prior columns on medication errors in other ambulatory settings:

June 12, 2007              Medication-Related Issues in Ambulatory Surgery

August 14, 2007         More Medication-Related Issues in Ambulatory Surgery

March 24, 2009           Medication Errors in the OR

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

January 15, 2008         Managing Dangerous Medications in the Elderly

April 2010                   Medication Incidents Related to Cancer Chemotherapy

September 2010          Beers List and CPOE

October 19, 2010        Optimizing Medications in the Elderly

April 12, 2011             Medication Issues in the Ambulatory Setting

June 2012                    Parents' Math Ability Matters

May 7, 2013                Drug Errors in the Home

May 5, 2015                Errors with Oral Oncology Drugs

September 15, 2015    Another Possible Good Use of a Checklist

February 2016             Avoiding Methotrexate Errors

April 19, 2016             Independent Double Checks and Oral Chemotherapy

June 21, 2016              Methotrexate Errors in Australia

 

 

Some of our other columns on pediatric medication errors:

 

November 2007          1000-fold Overdoses by Transposing mg for micrograms

December 2007           1000-fold Heparin Overdoses Back in the News Again

September 9, 2008      Less is More and Do You Really Need that Decimal?

July 2009                     NPSA Review of Patient Safety for Children and Young People

June 28, 2011              Long-Acting and Extended-Release Opioid Dangers

September 13, 2011    Do You Use Fentanyl Transdermal Patches Safely?

September 2011          Dose Rounding in Pediatrics

April 17, 2012             10x Dose Errors in Pediatrics

May 2012                    Another Fentanyl Patch Warning from FDA

June 2012                    Parents’ Math Ability Matters

September 2012          FDA Warning on Codeine Use in Children Following Tonsillectomy

May 7, 2013                Drug Errors in the Home

May 2014                    Pediatric Codeine Prescriptions in the ER

November 2014          Out-of-Hospital Pediatric Medication Errors

January 13, 2015         More on Numeracy

April 2015                   Pediatric Dosing Unit Recommendations

September 2015          Alert: Use Only Medication Dosing Cups with mL Measurements

November 2015          FDA Safety Communication on Tramadol in Children

October 2016              Another Codeine Warning for Children

January 31, 2017         More Issues in Pediatric Safety

May 2017                     FDA Finally Restricts Codeine in Kids; Tramadol, Too

August 2017               More on Pediatric Dosing Errors

 

 

 

References:

 

 

Hodges NL, Spiller HA, Casavant MJ, et al. Non-health care facility medication errors resulting in serious medical outcomes. Journal of Clinical Toxicology 2017; Published online: 10 Jul 2017

http://www.tandfonline.com/doi/full/10.1080/15563650.2017.1337908

 

 

 

 

 

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More on Pediatric Dosing Errors

 

 

Medication errors in children, particularly for liquid medications, have numerous contributing factors. Health literacy and “numeracy” issues in the parents or caregivers administering the medications clearly contribute. But there are also contributions related to the dosing instruments used (eg. syringe vs. cup vs. teaspoon) and to the way instructions are provided with the medications.

 

Several of our columns have focused on the sorts of dosing errors made by parents or other caregivers for children (see the full list at the end of today’s column). Proper dosing devices, labels, and parent/caregiver education are critical in attempts to reduce such errors.

 

A recent randomized controlled trial attempted to determine which components of such programs are most effective in reducing pediatric dosing errors. Yin and colleagues (Yin 2017) randomly assigned English- and Spanish-speaking parents of children 8 years old or younger to 1 of 4 groups and given labels and dosing tools that varied in label instruction format (text and pictogram, or text only) and units (“mL" or "mL/tsp").

 

83.5% of parents made one or more dosing errors and 12.1% of all errors involved overdosing. And 29.3% of parents made one or more “large” errors (greater than double dose). The dosing tools provided did make a difference. When the tool was more closely matched to the prescribed dose volumes, there were fewer errors. For example, when a 2 mL dose was prescribed there were fewer errors when a 5 mL syringe was used compared to a 10 mL syringe. And for a 7.5 mL prescribed dose there were fewer errors with a 10 mL syringe than a 5 mL syringe (the 5 mL syringe would require multiple fills, whereas the 10 mL syringe did not).

 

Using “mL” only also led to fewer errors than using “mL/teaspoon”. More “large” errors were also made when parents received “mL/teaspoon” instructions than just “mL”. Fewer “large” errors were also seen when parents were given both text and pictogram instructions than text only instructions.

 

The impact of these errors is unknown because this was a simulation study (the parents were given several scenarios and asked to demonstrate how they would provide the medication for the child). But it clearly confirms that optimal use of dosing tools and instructions can have a positive impact on reducing pediatric medication errors.

 

We’ve previously described how parental health literacy, numeracy in particular, can render children vulnerable to medication errors (see our What’s New in the Patient Safety World columns for June 2012 “Parents' Math Ability Matters” and November 2014 “Out-of-Hospital Pediatric Medication Errors” and our January 13, 2015 Patient Safety Tip of the Week “More on Numeracy”).

 

Dosing errors related to the vehicles used for administration of medications to children have also been problematic. In our What's New in the Patient Safety World columns for April 2015 “Pediatric Dosing Unit Recommendations” and September 2015 “Alert: Use Only Medication Dosing Cups with mL Measurements” we discussed use of metric units for liquid medications administered to pediatric patients (AAP 2015). Use of measures such as “teaspoon” and “tablespoon” should no longer be used. Moreover, the correct abbreviation for milliliters is “mL” (rather than “ml”, “ML”, or “cc”). Dispensing devices are also critical. Pharmacies, hospitals, and healthcare centers should distribute appropriate-volume milliliter-based dosing devices such as syringes. And the syringe (or other dosing device) should not be significantly larger than the dose prescribed. And a national alert recommended hospitals replace medication dosage cups that use units other than mL (NAN 2015).

 

The 2015 AAP statement also recommends that manufacturers avoid labeling, instructions or dosing devices that contain units other than metric units. But poorly designed labels and packaging continue to contribute to errors. A recent study in 3 urban pediatric clinics (Yin 2016) randomly assigned parents to 1 of 5 study arms and given labels and dosing tools that varied in unit pairings. 84.4% of parents made 1 or more dosing errors and 21.0% made 1 or more large error. More errors were seen with cups than syringes, especially for smaller doses. Use of a teaspoon-only label (with a milliliter and teaspoon tool) was associated with more errors than when milliliter-only labels and tools were used. The authors recommend that use of oral syringes over cups, particularly for smaller doses, should be part of a comprehensive pediatric labeling and dosing strategy to reduce medication errors.

 

Children are also more vulnerable to 10-fold dosing errors, primarily because dose calculations often result in results with decimal points. The decimal points can be overlooked, resulting in administration of a dose that is 10 times (or 100 times if there are two digits following the decimal point) higher than intended. In our September 2011 “Dose Rounding in Pediatrics” we discussed under which circumstances it might be appropriate to keep a decimal point and when the dose should simply be rounded to eliminate the need for a decimal point.

 

More information on pediatric medication errors outside the hospital can be found in our What's New in the Patient Safety World columns for November 2014 “Out-of-Hospital Pediatric Medication Errors” and August 2017 “Medication Errors Outside of Healthcare Facilities” and our May 7, 2013 Patient Safety Tip of the Week “Drug Errors in the Home.

 

We’ve also discussed the problems often seen with opioids in children, particularly those related to use of codeine (see columns listed below). These columns described the original cases of death and serious adverse effects in children treated with codeine following adenotonsillectomy for obstructive sleep apnea. The problem originally noted for codeine was that there are genetic variations that cause some people to be “ultra-rapid metabolizers” of codeine, which leads to higher concentrations of morphine in the blood earlier. But recommendations have now gone further than just avoiding codeine after adenotonsillectomy and it is now recommended that codeine not be used for pain or cough in children. And children are often the victims of accidental ingestion of discarded transdermal patches of fentanyl or other dangerous medications.

 

 

 

Some of our other columns on pediatric medication errors:

 

November 2007          1000-fold Overdoses by Transposing mg for micrograms

December 2007           1000-fold Heparin Overdoses Back in the News Again

September 9, 2008      Less is More and Do You Really Need that Decimal?

July 2009                     NPSA Review of Patient Safety for Children and Young People

June 28, 2011              Long-Acting and Extended-Release Opioid Dangers

September 13, 2011    Do You Use Fentanyl Transdermal Patches Safely?

September 2011          Dose Rounding in Pediatrics

April 17, 2012             10x Dose Errors in Pediatrics

May 2012                    Another Fentanyl Patch Warning from FDA

June 2012                    Parents’ Math Ability Matters

September 2012          FDA Warning on Codeine Use in Children Following Tonsillectomy

May 7, 2013                Drug Errors in the Home

May 2014                    Pediatric Codeine Prescriptions in the ER

November 2014          Out-of-Hospital Pediatric Medication Errors

January 13, 2015         More on Numeracy

April 2015                   Pediatric Dosing Unit Recommendations

September 2015          Alert: Use Only Medication Dosing Cups with mL Measurements

November 2015          FDA Safety Communication on Tramadol in Children

October 2016              Another Codeine Warning for Children

January 31, 2017         More Issues in Pediatric Safety

May 2017                     FDA Finally Restricts Codeine in Kids; Tramadol, Too

August 2017               Medication Errors Outside of Healthcare Facilities

 

 

 

References:

 

 

Yin HS, Parker RM, Sanders LM, et al. Pictograms, Units and Dosing Tools, and Parent Medication Errors: A Randomized Study. Pediatrics 2017; Published Ahead of Print June 27, 2017

http://pediatrics.aappublications.org/content/early/2017/06/23/peds.2016-3237?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token

 

 

 

 

 

 

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ROI for a Second Victim Program

 

 

But while we recognized the issue of the second victim in those early days of patient safety, we didn’t really know how to best help them. We often simply made available to them professional assistance (employee assistance programs or psychological counselling). Over the years, helping the “second victim” has evolved considerably and such referral for professional help is not a good first line strategy and may even be counterproductive. Support from peers is extremely important if such programs are to be successful.

Some healthcare organizations have been reluctant to help fund the resources needed to have successful second victim programs. At Johns Hopkins, where Albert Wu originally coined the term “second victim” to describe such individuals and their plight (Wu 2000), its RISE (Resilience In Stressful Events) program is an emotional peer support structure to support “second victims” who were emotionally impacted by a stressful patient-related event or unanticipated adverse event. A multidisciplinary peer responder team who have volunteered to support second victims responds when an unanticipated patient-related event occurs. Researchers there recently did a cost benefit analysis of their program as it pertains to nursing staff, modeling the cost of running the RISE program, nurse turnover, and nurse time off (Moran 2017).

 

Their model predicted the RISE program has a net monetary benefit savings of US $22,576.05 per nurse who initiated a RISE call. They estimated that a hospital could save US $1.81 million each year because of the RISE program. The annual cost of the RISE program per nurse was roughly $656 but the expected annual cost saved from nurse time off or nurse turnover was $23,232, for the estimated net cost savings of $22,576. The authors conclude that hospitals should be encouraged by these findings to implement institution-wide support programs for staff, based on a high demand for this type of service and the potential for cost savings.

 

As an aside, while the Moran study focuses preferentially on nurses as second victims, don’t forget that any healthcare worker may be a second victim. Another recent study (Han 2017) looked at surgeons involved in intraoperative adverse events (iAE’s). They surveyed surgeons at 3 major teaching hospitals. They found the emotional toll of iAE’s was significant, with 84% of respondents reporting a combination of anxiety (66%), guilt (60%), sadness (52%), shame/embarrassment (42%), and anger (29%). Colleagues constituted the most helpful support system (42%) rather than friends or family; a few surgeons needed psychological therapy/counseling.

 

We refer you to our previous columns on the second victim for descriptions of good programs to help address the issues impacting second victims. We don’t doubt that the sort of ROI on such programs would apply to all healthcare workers, though the relative dollar amounts as seen in the Moran study may vary by type of worker.

 

 

Some of our prior columns on “the second victim”:

 

 

References:

 

 

Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ 2000; 320: 726–727

http://www.bmj.com/content/320/7237/726?ijkey=455554e5354d21b654c631effb8fdc215e040cf0&keytype2=tf_ipsecsha

 

 

Moran D, Wu AW, Connors C, et al. Cost-Benefit Analysis of a Support Program for Nursing Staff. Journal of Patient Safety 2017; Post Author Corrections: April 27, 2017

http://journals.lww.com/journalpatientsafety/Abstract/publishahead/Cost_Benefit_Analysis_of_a_Support_Program_for.99506.aspx

 

 

Han K, Bohnen JD, Peponis T, et al. The Surgeon as the Second Victim? Results of the Boston Intraoperative Adverse Events Surgeons' Attitude (BISA) Study. J Amer Coll Surg 2017; 224(6): 1048-1056 Published online: January 14, 2017

http://www.journalacs.org/article/S1072-7515(17)30035-2/fulltext

 

 

 

 

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