What’s New in the Patient Safety World

December 2011


·        AORN Perioperative Handoff Toolkit

·        Columbia-Suicide Severity Rating Scale

·        Novel Technique to Prevent Wrong Level Spine Surgery

·        ECRI’s Annual Top 10 Health Technology Hazards

·        IOM Report on Health IT and Patient Safety

·        Beers’ Criteria Update in the Works




AORN Perioperative Handoff Toolkit



We’ve done many columns on the problems associated with handoffs in healthcare (see the listing and links at the end of today’s column). Handoffs are perhaps the most common transactions in hospital-based healthcare and are also among the processes most prone to error. We know that breakdowns in communication are contributing factors to 70% of all Sentinel Events in Joint Commission’s Sentinel Event database and many of those breakdowns occur during handoffs.


AORN (the Association of periOperative Registerd Nurses) has worked with the Department of Defense Patient Safety Program to develop a Perioperative Patient 'Hand-Off' Tool Kit. Though many of the principles are applicable to handoffs in any environment, these are tailored specifically for those occurring in the perioperative environment. Given that it was developed in conjunction with the DoD it is not surprising that it heavily incorporates materials from the TeamSTEPPS™ program.


The toolkit discusses the Joint Commission requirements for 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.


Structured handoff formats are discussed at length and examples of the various formats used in different hospitals are provided. These include SBAR, ISBAR, I Pass the Baton, PACE, and the 5 P’s. They do also note, as we have in the past, that a combination of verbal and written components in a handoff works better than either alone and they note the potential for use of information technology to enhance the handoff process.


These are good tools. In particular, if you are looking for a form, template or checklist to use in your perioperative handoffs you’ll probably be able to find it here.




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








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






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Columbia-Suicide Severity Rating Scale



Recently we discussed suicide risk assessment tools and resources (see our September 27, 2011 Patient Safety Tip of the Week The Canadian Suicide Risk Assessment Guide”). Now another new suicide risk assessement tool, the Columbia-Suicide Severity Rating Scale (C-SSRS), has been demonstrated to be valid in several different patient populations.


The tools actually come in multiple versions (eg. a “lifetime” version, a “since last visit” version, a “risk assessment version”, pediatric versions, and versions for patients in clinical trials, etc.). They studied the validity of the C-SSRS in 3 separate patient populations and demonstrated high sensitivity and specificity for suicidal behavior.


This appears to be a simple-to-use but very valuable tool in assessing the potential risk for suicide.



Some of our prior columns on preventing hospital suicides:


·        January 6, 2009 Patient Safety Tip of the Week “Preventing Inpatient Suicides

·        February 9, 2010 Patient Safety Tip of the Week “More on Preventing Inpatient Suicides

·        March 16, 2010 Patient Safety Tip of the Week A Patient Safety Scavenger Hunt

·        December 2010 What’s New in the Patient Safety World column “Joint Commission Sentinel Event Alert on Suicide Risk Outside Psych Units

·        September 27, 2011 Patient Safety Tip of the Week The Canadian Suicide Risk Assessment Guide





Posner K, Brown GK, Stanley B, et al. The Columbia–Suicide Severity Rating Scale: Initial Validity and Internal Consistency Findings From Three Multisite Studies With Adolescents and Adults. Am J Psychiatry 2011; 10.1176/appi.ajp.2011.10111704

Published online November 8, 2011




C-SSRS scales for clinical practice.






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Novel Technique to Prevent Wrong Level Spine Surgery



Despite focused attention on prevention of wrong-site surgery over the past 15 years, we continue to see cases of wrong-site surgery. While methods for site marking have been adopted widely, marking sites related to spine levels has remained particularly problematic. That’s because of things like anatomical variation in the number of rib-bearing vertebrae, obesity, osteoporosis, etc.


Recently, a novel technique was applied to site marking for thoracic spine surgery (Upadhyaya 2011). The authors inserted “fiducial” screws, under conscious sedation and with CT guidance, into the spine preoperatively in an ambulatory setting. Plain x-rays or reconstructed CT scan views could then be utilized intraoperatively to reference the spinal level at which the fiducial screw had been placed. The screw placement took about an hour and involved an amount of radiation roughly equivalent to a chest x-ray.


The authors then studied 26 cases of thoracic spine surgery and compared these to 26 historical controls. No wrong-level procedures occurred in either group. They found that the amount of intraoperative fluoroscopy required in cases with the fiducial screws was on average 12 minutes shorter than that in the control cases, thus exposing the patient (and operating room staff) to less radiation. The procedure was roughly cost neutral, since the extra cost of the screw was offset by the shorter OR time.


We previously mentioned an update on wrong-site surgery in the VA medical system (Neily 2011) that showed a reduction in adverse events in and out of the OR after implementation of a number of patient safety interventions, including their Medical Team Training (MTT) program. But the service with the highest rate of wrong-site adverse events was Neurosurgery, largely because of problems localizing the correct spine level in spine surgery. We suspect that spine surgery remains most problematic in most centers, largely for the reasons noted above. It will be interesting to see if the above method of spine level localization is successful in reducing wrong-level spine surgery. However, given the overall low incidence of wrong-site surgery, it is very difficult to be able to attribute improvement to any one specific intervention and it would be impractical to do a randomized control trial because of the huge population that would be required.




Some of our prior columns related to wrong-site surgery:


Patient Safety Tip of the Week columns:

  September 23, 2008 “Checklists and Wrong Site Surgery

  June 5, 2007 “ Patient Safety in Ambulatoy Surgery

  March 11, 2008 “Lessons from Ophthalmology

  September 14, 2010 “Wrong-Site Craniotomy: Lessons Learned

  November 25, 2008 “Wrong-Site Neurosurgery

  January 19, 2010 “Timeouts and Safe Surgery

  June 8, 2010 “Surgical Safety Checklist for Cataract Surgery

  December 6, 2010 “More Tips to Prevent Wrong-Site Surgery

  June 6, 2011 “Timeouts Outside the OR


What’s New in the Patient Safety World columns:

  July 2007 “Pennsylvania PSA: Preventing Wrong-Site Surgery

  August 2011 “New Wrong-Site Surgery Resources









Upadhyaya CD, Wu J-C, Chin CT, et al. Avoidance of wrong-level thoracic spine surgery: intraoperative localization with preoperative percutaneous fiducial screw placement: Clinical article. Journal of Neurosurgery: Spine 2011; Posted online on 4 Nov 2011.




Neily J, Mills PD, Eldridge N, et al. Incorrect Surgical Procedures Within and Outside of the Operating Room. A Follow-up Report.

Arch Surg. 2011; 146(11): 1235-1239





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ECRI’s Annual Top 10 Health Technology Hazards



ECRI Institute has again done their now annual compilation of the Top 10 Health Technology Hazards for the year 2012. The reprint can be downloaded for free from the ECRI site but you must register for that download.


The list is quite similar to their annual list of its Top 10 Health Technology Hazards for 2011 (see our January 2011 What’s New in the Patient Safety World column “ECRI’s Top 10 Health Technology Hazards for 2011”) though the order of rankings has changed somewhat.


At the top of this year’s list is alarm hazards. They provide an excellent discussion of not only alarm fatigue but a whole host of problems related to alarm systems in general and they provide a solid set of recommendations that each organization should consider.


Number 2 on their list is exposure hazard from radiation therapy and CT. Other hazards making the list include infusion pumps, surgical fires, cross-contamination of endoscopes, enteral feeding misconnections, needlesticks/sharps injuries, and pre-inspection of anesthesia equipment before use on patients. A new topic this year is failure to contemplate effects on all devices connected to a system when a change to one part of the system is undertaken. Another new one deals with poor usability of medical devices for home use.







ECRI Institute 2012 Top 10 Health Technology Hazards




ECRI. ECRI Institute’s 2011 Top 10 Health Technology Hazards. Health Devices 2010; 39(11): 386-398







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IOM Report on Health IT and Patient Safety


We’ve written frequently about the unintended consequences of CPOE and other high tech interventions. Even as we undergo the inexorable journey to electronic health records, the healthcare industry has begun to recognize that new technologies, while solving many problems, also bring new problems with them.


Now the Institute of Medicine (IOM) has released a new report: Health IT and Patient Safety: Building Safer Systems for Better Care advocating better systems to monitor the impact of health IT on patient safety, including dissemination of lessons learned from the unintended consequences of HIT.


The report calls for an independent federal entity to investigate deaths, serious injuries or unsafe conditions associated with health IT similar to the way the National Transportation Safety Board investigates transportation accidents.


It also calls for removal of “gag” clauses and “hold harmless” clauses that are commonly included in contracts with medical software vendors and which might impede dissemination of lessons learned from adverse events involving HIT.


The report clearly notes that not all the patient safety issues resulting from HIT are the fault of the software, per se, but rather that the human-user interface and how clinicians and other users react to the software are equally important. We’ve often commented on how overreliance of “the computer” to do the right thing leads providers down a path destined to produce errors and adverse outcomes.


The report does give examples of some of the unintended consequences of HIT and also how lessons learned can be used to help design and implement better systems. For example, they describe how researchers learned from a rocky implementation of CPOE in Pittsburgh to implement much more smoothly CPOE in Seattle.


The report has good discussions about multiple technologies, including CPOE, bedside medication verification (barcoding), clinical decision support tools, medication management systems, patient engagement tools, and others. Though the literature on adverse effects of HIT is limited, they do provide an extensive bibliography of what studies are available. They provide good discussion about how users react to HIT, including workarounds.


Lastly, they have good discussions about HIT design and implementation with patient safety in mind and call for more intensive interdisciplinary research going forward.




See also some of our prior Patient Safety Tip of the Week columns on unintended consequences of healthcare IT:







Institute of Medicine. Health IT and Patient Safety: Building Safer Systems for Better Care. The National Academies Press 2011; Released: November 8, 2011






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Beers’ Criteria Update in the Works



The American Geriatrics Society (AGS) has convened an expert panel, with representatives from the fields of medicine, nursing and pharmacy to update the Beers’ Criteria for Potentially Inappropriate Medication (PIM’s) Use in Older Adults.  A preliminary draft document with the update was recently released for public comment. The comment period ended November 28, 2011 so we can expect release of the updated Beers’ List soon.


We’ve done many prior columns on Beers’ List. Most recently, in our June 21, 2011 Patient Safety Tip of the Week “STOPP Using Beers’ List?”, we again noted that the original Beers’ List and subsequent updates were primarily consensus-based rather than truly evidence-based. The new updated version will be much improved in that regard since there has been an extensive review of the evidence in the new work effort.


In our June 21, 2011 Patient Safety Tip of the Week “STOPP Using Beers’ List?we also noted that the literature has been mixed on the ability of Beers’ List to predict adverse drug events (ADE’s). The STOPP criteria, on the other hand, identified potentially avoidable ADE’s impacting on hospitalization over twice as often as did Beers’ criteria and such ADE’s are extremely common (Hamilton 2011).


In addition to the study demonstrating that the STOPP list is better than Beers’ list at predicting ADE’s related to hospitalization, a study just published (Budnitz 2011) on emergency hospitalizations related to ADE’s concluded that drugs on Beers’ list account for only a small percentage of hospitalizations. In that study, 6.6% of the ADE-related hospitalizations were related to potentially inappropriate medications on Beers’ list and if digoxin is excluded this is reduced to only 3.17%. On the other hand, two thirds of the hospitalizations were related to only four medications or medication categories: warfarin/anticoagulants, antiplatelet agents, insulins, and oral hypoglycemia agents.



While we still feel that Beers’ list is useful, one of the biggest barriers to getting physicians to avoid PIM’s in the elderly is not knowing what alternatives are available. A recent study looking at decision support for CPOE (Hume 2011) found 2 key things that clinicians wanted when viewing alerts: (1) the alerts needed to be “short and sweet” and (2) rather than just telling them they were attempting to prescribe a PIM they wanted alternative choices. So the group developed 15 evidence-based treatment algorithms suggesting alternative therapies. These are actually quite useful. The article also provides valuable insight into how clinicians interact with alerts during CPOE. The editorial accompanying the Hamilton paper (Schnipper 2011) also talks about using tools like STOPP to improve design and implementation of clinical decision support tools to minimize “alert fatigue” that we see so commonly with CPOE systems. And our What’s New in the Patient Safety World column for September 2010 “Beers List and CPOE  noted a study (Mattison 2010) in which researchers were able to demonstrate approximately a 20% reduction in prescribing of flagged drugs by using a carefully chosen subset of potentially inappropriate drug (PIM’s) from Beers’ list drugs to which to attach computerized warnings.




We’ll do a full review of the updated Beers’ List after its official publication.



Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:


Patient Safety Tips of the Week:

·        January 15, 2008 “Managing Dangerous Medications in the Elderly

·        October 19, 2010 “Optimizing Medications in the Elderly

·        September 22, 2009 “Psychotropic Drugs and Falls in the SNF

·        June 21, 2011 “STOPP Using Beers’ List?


What’s New in the Patient Safety World columns:

·        June 2008  Potentially Inappropriate Medication Use in Elderly Hospitalized Patients

·        September 2010 “Beers List and CPOE







The American Geriatrics Society (AGS). Public Comment Period for AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.




Hamilton H, Gallagher P, Ryan C, et al. Potentially Inappropriate Medications Defined by STOPP Criteria and the Risk of Adverse Drug Events in Older Hospitalized Patients. Arch Intern Med 2011; 171(11): 1013-1019




Budnitz DS, Lovegrove MC, Shehab N, et al. Emergency Hospitalizations for Adverse Drug Events in Older Americans. NEJM 2011; 365: 2002-2012




Hume AL, Quilliam BJ, Goldman R, et al. Alternatives to potentially inappropriate medications for use in e-prescribing software: triggers and treatment algorithms. BMJ Qual Saf 2011; 20: 875-884 Published Online First: 30 June 2011




Schnipper JL. Medication Safety: Are We There Yet?: Comment on "Potentially Inappropriate Medications...
Arch Intern Med 2011; 171(11): 1019-1020




Mattison MLP, Afonso KA, Ngo LH, Mukamal KJ. Preventing Potentially Inappropriate Medication Use in Hospitalized Older Patients With a Computerized Provider Order Entry Warning System. Arch Intern Med. 2010; 170(15): 1331-1336







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Print “December 2011 What's New in the Patient Safety World (full column)

Print “December 2011 AORN Perioperative Handoff Toolkit

Print “December 2011 Columbia-Suicide Severity Rating Scale

Print “December 2011 Novel Technique to Prevent Wrong Level Spine Surgery

Print “December 2011 ECRI’s Annual Top 10 Health Technology Hazards for 2012

Print “December 2011 IOM Report on Health IT and Patient Safety

Print “December 2011 Beers’ Criteria Update in the Works













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