What’s New in the
Patient Safety World
August 2018
· Thromboembolism: Another Downside of Transfusions
· Burnout and Medical Errors
· Pediatric Adverse Events
· IHI on Safety of Care in the Home
Thromboembolism:
Another Downside of Transfusions
The move in recent years toward more restrictive transfusion policies and practices has been fueled by increased recognition of untoward side effects of transfusions and controlled clinical trials demonstrating as good or better outcomes with the more restrictive practices in most cases (see the list of our prior columns at the end of today’s column).
Now, an additional risk associated with transfusion has been identified: venous thromboembolism. Goel and colleagues Goel 2018
(American Association of Blood Banks) updated its guidelines in 2016 (see our November 2016 What's New in the Patient Safety World column “AABB Updates Transfusion Guidelines Again”)and recommended two tiers of hemoglobin level transfusion triggers (Carson 2016):
- 7 g/dL for hemodynamically stable adults, even those in critical
care
- 8 g/dL for patients with preexisting cardiovascular disease or those
undergoing cardiac or orthopedic surgery
Gupta 2017Note that we discussed the Hopkins program (Sadana 2017) in our December 2017 What's New in the Patient Safety World column “Study Confirms Safety of Restrictive Transfusion Policy”.)
Prior columns on potential detrimental effects related to red blood cell transfusions:
- March 2011 “Downside of Transfusions in Surgery”
- August 2011 “CPOE
Alerts Reduce Blood Transfusions in Children”
- January 2012 “Need
for New Transfusion Criteria?”
- April 2012 “New
Transfusion Guidelines from the AABB”
- February 2013 “More
Evidence Favoring Restriction of Transfusions”
- June 2013 “Hopkins
Blood Ordering Initiative”
- May 2014 “Blood
Transfusion and Infection Risk”
- June 2015 “Economics
and Blood Transfusion”
- November 2016 “AABB
Updates Transfusion Guidelines Again”
- December 2017 “Study
Confirms Safety of Restrictive Transfusion Policy”
- January 2018 “Transfusion
in Cardiac Revision Surgery”
References:
Carson JL, Guyatt G, Heddle NM, et al. Clinical Practice Guidelines from the AABB. Red Blood Cell Transfusion Thresholds and Storage. JAMA 2016; Published online October 12, 2016
http://jamanetwork.com/journals/jama/article-abstract/2569055
Sadana D, Pratzer A, Scher LJ, et al. Promoting High-Value Practice by Reducing Unnecessary Transfusions with a Patient Blood Management Program. JAMA Intern Med 2017; Published online November 20, 2017
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2663855
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2018 Thromboembolism: Another Downside of Transfusions”
Burnout and
Medical Errors
We’ve done numerous columns on the impact of fatigue on medical errors. A recent study published in the Mayo Clinic Proceedings showed that physicians reporting excessive fatigue were almost 40% more likely to have reported . But, more surprisingly, the study showed that physicians reporting symptoms of burnout were more than twice as likely to have reported
The study was based upon physicians in the American Medical Association Physician Masterfile invited to respond to an anonymous survey. The survey was completed by 19% of those who opened the request for participation. Note that the term “burnout” was not used in the survey. Rather, questions included symptoms commonly related to burnout.
(
We, thus, need better ways to recognize physician burnout and interventions to offer support when we recognize it. Other industries have recognized job burnout and developed approaches to address it. We need to borrow from those industries and apply their approaches to healthcare. An excellent review on physician burnout also recently appeared in the Mayo Clinic Proceedings
References:
Blechter B, Jiang N, Cleland C, et al. Correlates of Burnout in Small Independent Primary Care Practices in an Urban Setting. J Am Board Fam Med 2018; 31(4): 529-536
http://www.jabfm.org/content/31/4/529.full
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2018 Burnout and Medical Errors”
Pediatric Adverse
Events
Trigger tools have
provided a good way to identify adverse events in hospitalized patients and in
other healthcare settings (see our prior columns on trigger tools listed
below). Most of the early work on trigger tools was done in adult patients but Stockwell et al. (Stockwell
2015) developed and tested a
trigger tool that would identify the most common causes of harm in pediatric
inpatient environments. Expanding upon that, the safety surveillance
tool GAPPS (Global Assessment of Pediatric Patient Safety) has been validated
and now studied in multiple children’s hospitals.
A new study shows that adverse event (AE) rates remain high in hospitalized pediatric patients and have not substantially improved over time (Stockwell 2018). Researchers used the GAPPS tool to measure temporal trends in AE rates among hospitalized children from 2007 to 2012. They randomly selected pediatric inpatient records from 16 teaching and nonteaching hospitals.
Among 3790 records reviewed, they found 414 AEs (19.1 AEs per 1000 patient days) and 210 preventable AEs (9.5 AEs per 1000 patient days). On average, teaching hospitals had higher AE rates than nonteaching hospitals (26.2 vs 5.1 AEs per 1000 patient days). The most frequently identified AE’s were hospital-acquired infections, intravenous line complications, gastrointestinal events, respiratory-related events, and “other”. As we’d expect, chronically ill children had higher AE rates than patients without chronic conditions (33.9 vs 14.0 AEs per 1000 patient days). They found that neither teaching nor nonteaching hospitals experienced significant variations in AE rate over the time of the study.
In terms of severity, 1.2% of AEs resulted in permanent harm, 10.1% were potentially life-threatening, 0.7% were fatal or contributed to a patient's death. Perhaps most striking is that 50.7% were considered potentially preventable.
In the accompanying editorial, Quinonez and Schroeder (Quinonez 2018) noted some prior studies had suggested AE rates were decreasing but that the GAPPS tool is better at identifying AE’s. But they also note that GAPPS may miss some harms, such as those related to the “diagnostic cascade” that results from overtesting.
Though the analysis did not look at trends after 2012, the findings suggest that adverse events in pediatric patients remain at high levels and that many are potentially preventable. Use of trigger tools like GAPPS can help with identification of such adverse events and help hospitals and health systems identify areas in need of improvement.
Some of our prior columns on trigger tool methodology:
- October 30, 2007 “Using IHI's Global Trigger Tool”
- April 15, 2008 “Computerizing Trigger Tools”
- January 2011 “No Improvement in Patient Safety: Why Not?”
- May 2011 “Just
How Frequent Are Hospital Medical Errors?”
- March 2013 “Diagnostic
Error in Primary Care”
- January 2014 “Trigger
Tools to Prevent Diagnostic Delays”
References:
Stockwell DC, Bisarya H, Classen DC, et al. A Trigger Tool to Detect Harm in Pediatric Inpatient Settings. Pediatrics 2015; Published online ahead of print May 18, 2015
http://pediatrics.aappublications.org/content/early/2015/05/12/peds.2014-2152
Stockwell DC, Landrigan CP, ToomeySL, et al. for the GAPPS Study Group
Adverse Events in Hospitalized Pediatric Patients. Pediatrics Jul 2018, e20173360
http://pediatrics.aappublications.org/content/early/2018/07/11/peds.2017-3360
Quinonez RA, Schroeder AR. “GAPPS” in Patient Safety. Pediatrics Jul 2018, e20180954
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2018 Pediatric Adverse Events”
IHI on Safety of
Care in the Home
IHI (Institute for Healthcare Improvement) just published an excellent report/monograph “No Place Like Home: Advancing the Safety of Care in the Home” (IHI 2018). It identifies some of the unique issues that apply to care in the home setting. Much is based on a previous IHI report “Patient Safety in the Home: Assessment of Issues, Challenges, and Opportunities” (Carpenter 2017).
They identify the following factors that make safe care in the home especially challenging:
- The provision of care outside the controlled environment of the health care system
- Issues with communication and care coordination among the care team, the care recipient, and the family caregiver
- The need to balance autonomy and risk
- The closeness of the link between the care recipient and those providing care
- The limited health literacy of the care recipient and the family caregiver
- Variable availability of data
- Social and physical isolation
- The variety of needs and populations
They identify risks specific to care in the home and the potential harms associated with those risks, which often have underlying causes that are interrelated:
- Adverse events related to medication and other forms of treatment
- Injuries due to physical hazards in the home (e.g., falls)
- Injuries related to equipment and technology
- Pressure injuries
- Infections
- Conditions related to poor nutrition
- Adverse effects on family caregivers
- Adverse effects on home care workers
- Potential neglect and abuse of care recipients
The report provides
recommendations, strategies, and tools for realizing five guiding principles:
- Principle 1: Self-determination and person-centered care are
fundamental to all aspects of care in the home setting.
- Principle 2: Every organization providing care in the home must
create and maintain a safety culture.
- Principle 3: A robust learning and improvement system is necessary
to achieve and sustain gains in safety.
- Principle 4: Effective team-based care and care coordination are
critical to safety in the home setting.
- Principle 5: Policies and funding models must incentivize the
provision of high-quality, coordinated care in the home and avoid
perpetuating care fragmentation related to payment.
We encourage you to go to the IHI website and download the full report(s). As usual, IHI has done an excellent job of summarizing some of the challenges in yet another healthcare setting.
We also hope you’ll go back to our August 13, 2013 Patient Safety Tip of the Week “Adverse Events in Home Care” that summarized the findings of several excellent Canadian studies on patient safety issues in the home setting.
Some of our prior columns on patient safety issues in the home:
- April 12, 2011 “Medication Issues in the Ambulatory Setting”
- May 7, 2013 “Drug Errors in the Home”
- August 13, 2013 “Adverse Events in Home Care”
- September 16, 2014 “Focus on Home Care”
- August 2016 “Home Infusion Therapy Pitfalls”
References:
IHI (Institute for Healthcare Improvement). No Place Like Home: Advancing the Safety of Care in the Home. IHI 2018
Carpenter D, Famolaro T, Hassell S, et al. Patient Safety in the Home: Assessment of Issues, Challenges, and Opportunities. Cambridge, Massachusetts: Institute for Healthcare Improvement; August 2017
http://www.ihi.org/resources/Pages/Publications/Patient-Safety-in-the-Home.aspx
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2018 IHI on Safety of Care in the Home”
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2018 What's New in the Patient Safety World (full column)”
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2018 Thromboembolism: Another Downside of Transfusions”
Print “August
2018 Burnout and Medical Errors”
Print “August
2018 Pediatric Adverse Events”
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2018 IHI on Safety of Care in the Home”
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