What’s New in the Patient Safety World
December 2014
· I-PASS Passes the Test
· Surprise Central Lines
· American Geriatrics Society Guideline on Postoperative Delirium in Older Adults
· Oxygen Should Be AVOIDed
· Another Procedure to Avoid Late in the Day or on Weekends
I-PASS Passes the
Test
Amongst our numerous columns on handoffs/handovers (see the
full list of prior columns at the end of today’s column) we’ve especially been
fond of the I-PASS handoff program. We first described it in our February 14,
2012 Patient Safety Tip of the Week “Handoffs
– More Than Battle of the Mnemonics”, a column that highlighted the need to
tailor handoff formats to the specific tasks at hand. I-PASS came about because
existing formats were not optimal for resident-to-resident handoffs. Then in
our June 2012 What’s New in the Patient Safety World column “I-PASS
Results and Resources Now Available” we noted the release of the very
promising preliminary results of the I-PASS project.
Now the final results of the I-PASS project have been published (Starmer 2014). After implementation of I-PASS the rate of medical errors decreased by 23% and the rate of preventable medical errors decreased by 30%. Significantly, there was no increase in the amount of time spent on handoffs and there was no significant change in resident workflow or the amount of resident contact with patients and families.
Specific medical
error types reduced in the I-PASS collaborative included diagnostic errors, errors
related to medical history or physical examination, multifactorial errors, and
errors related to therapies other than medications or procedures. (Errors
related to medications, procedures, falls, and nosocomial infections did not
change.)
The reduction in
medical errors was significant at six of the nine sites participating. Study
authors had no explanation for the lack of improvement at three sites, since
they also demonstrated improved inclusion of key elements in the handoff
process.
Make no mistake, I-PASS is much more than a mnemonic and format for handoffs. It also involves extensive team training (based on TeamSTEPPS™) and resident training modules, simulation and role playing, faculty development resources and tools, direct observation of handoffs with feedback, and generation of a printed handoff document that can be integrated with the electronic medical record.
In our September 9, 2014 Patient Safety Tip of the Week “The Handback” we noted that a recent collaboration among 23 pediatric hospitals (Bigham 2014) demonstrated a significant decrease in handoff-related are failures for multiple different handoff types. I-PASS was a format utilized in that collaboration. The improvement project was guided by evidence-based recommendations regarding handoff intent and content, standardized handoff tools/methods, and clear transition of responsibility. Hospitals tailored handoff elements to locally important handoff types. Examples of the handoff types included shift-to-shift handoffs, emergency department to inpatient handoffs, and perioperative to inpatient handoffs. Handoff-related care failures decreased from 25.8% at baseline to 7.9% in the final intervention period.
Compliance to critical components of the handoff process improved, as did provider satisfaction. Key elements required, regardless of the handoff type, were that active participation by both the sending and receiving teams were required, discrete times
and mechanisms set aside for the receiving team to ask questions, a proscribed script of important handoff elements was available, and a “read back” summary of basic issues and next steps was accessible. One very interesting finding was that even where baseline compliance with individual elements was pretty good at baseline, relatively small incremental improvements in those individual elements collectively led to very good reductions in overall handoff failures.
Details on the format of I-PASS and reasons for its development can be found in our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics” and June 2012 What’s New in the Patient Safety World column “I-PASS Results and Resources Now Available” as well as in the current article (Starmer 2014) and the I-PASS website.
Though restrictions
on hours that residents may work have increased the number and complexity of
handoffs/handovers, most of the same issues apply to other physician coverage
arrangements. Yes, one resident just finishing a 24-hour shift may have to
leave immediately after morning rounds. But a physician in a community or rural
hospital who is covering for another physician also has competing requirements for
his/her time (eg. office hours, scheduled surgery, etc.). And the same types of
interruptions and distractions (phone calls, pages, nurses or colleagues or
families requesting information, etc.) apply equally well to morning rounds or
the physician cross-coverage handback.
Though neither the I-PASS collaborative nor the previously
mentioned pediatric collaborative (Bigham
2014) looked at the impact of the missed handoff issues on patient
harm or actual patient outcomes, we would certainly predict that improvement in
the handback process would likely prevent many adverse events and outcomes.
Both are very good studies and have implications for all healthcare
organizations, not just academic ones.
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”
January 29, 2013 “A
Flurry of Activity on Handoffs”
December 10, 2013 “Better
Handoffs, Better Results”
February 11, 2014 “Another
Perioperative Handoff Tool: SWITCH”
March 2014 “The
“Reverse” Perioperative Handoff: ICU to OR”
September 9, 2014 “The
Handback”
References:
Starmer AJ, Spector ND, Srivastava R, et al. Changes in Medical Errors after Implementation of a Handoff Program. N Engl J Med 2014; 371: 1803-1812
http://www.nejm.org/doi/full/10.1056/NEJMsa1405556
Bigham MT, Logsdon
TR, Manicone PE, et al. Decreasing Handoff-Related Care Failures in Children’s
Hospitals. Pediatrics 2014; 134:2 e572-e579; published ahead of print July 7,
2014,
I-PASS Study website.
http://www.ipasshandoffstudy.com/home
Print “December
2014 I-PASS Passes the Test”
Surprise Central
Lines
One of our earliest Patient Safety Tips of the Week was our May 8, 2007 column “Doctor, when do I get this red rubber hose removed?”. In that column we related how embarrassed we were as a young physician when a patient asked that question as we were providing discharge instructions to her. That led us to one of our first patient safety projects in the early 1990’s to reduce the unnecessary use of urinary catheters. Of course, the most important intervention to avoid CAUTI’s is to avoid such catheters in the first place and limit duration of catheters in those patients who do have a legitimate initial indication for one. We were amazed at how often the Foley catheter appears unbeknownst to the primary physician responsible for the patient’s care and how often they are placed without legitimate medical indication.
The same obviously applies to indwelling catheters in any area of the body. The great work done by Peter Pronovost and colleagues on prevention of CLABSI’s emphasized careful attention not just to insertion and maintenance of central lines but also to the issue of indications or continued indications for the central lines.
Now a new study
assessed how often clinicians are unaware of central venous catheters, both
traditional triple-lumen catheters and PICC (peripherally inserted
central catheter) lines, at 3 academic
medical centers (Chopra
2014). In almost 1000 patients the prevalence of a triple-lumen central
venous catheter or PICC line was 21.1% (60% if these were PICC’s). Clinicians
responsible for care of those patients were unaware of the presence of these
catheters in 21.2% of cases. Such unawareness was more common for PICC lines
and more common in non-ICU settings. Teaching attendings and hospitalists were
more often unaware than were housestaff or physician extenders.
Our January 21, 2014 Patient Safety Tip of the Week “The PICC Myth” focused on the widespread use of PICC lines and the general lack of awareness by clinicians of their potential complications. Previous work by Chopra and colleagues as well as others has shown potential complications of PICC lines are at least as frequent as and probably more frequent than those from more traditional central lines. Complications include CLABSI’s, deep vein thrombosis, catheter tip malpositioning, thrombophlebitis, and catheter dysfunction. Both patient-related and device-related factors are important in leading to complications of central lines and PICC lines. But it is clear that the duration of catheter use is an important factor in leading to complications and that many times the catheters are left in place longer than necessary.
One of the most important interventions in prevention of
CLABSI’s (or, for that matter, infection of any indwelling device) is asking on
a daily basis whether the catheter is still necessary. With PICC’s we often
forget to do that, particularly when the patient is not in the ICU. In that January 21, 2014 Patient Safety Tip of the
Week “The
PICC Myth” we noted a study by Tejedor and colleagues (Tejedor
2012) looking at how often central venous catheters and PICC lines were
retained when not needed ("idle days") on non-ICU wards. They found
that significant proportions of ward central line days were unjustified. Patients with PICCs had more days in which
the only justification for the CVC was intravenous administration of
antimicrobial agents. They suggest that reducing "idle CVC-days" and
facilitating the appropriate use of peripheral IV’s may reduce central line
days and CLABSI risk.
Also in that January
21, 2014 Patient Safety Tip of the Week “The
PICC Myth” we stressed how our systems make it very easy for a patient to
get a PICC line, often for reasons of staff convenience rather than for
evidence-based indications. Sometimes they are ordered at night by a
cross-covering physician. And since most PICC lines are inserted by specially
trained nurses, most physicians are not involved in insertion of the PICC. So
it’s fairly easy to be unaware of a PICC line. We’re not at all surprised by
the findings of the current Chopra study.
The editorial accompanying the Chopra study (Taichman 2014) questions that, if we are not seeing catheters when we round on our patients daily, “what else are we missing?”. Is it that we are doing perfunctory exams on such rounds or not even doing that? Are we missing things like early decubiti?
The bottom line is
that we are all human and we tend to look for things we expect or things we are
trying to avoid. If we are not expecting our patient to have a central line or
PICC line we may easily overlook its presence when we are rounding. This might
even be another example of “inattentional blindness”.
Therefore, we need
to include such oversight as another example of a predictable error and
put systems in place to help us avoid the problem. One of the items on our
checklist for daily rounds on patients in all locations should be “Does this
patient have any catheters or lines in place and, if so, are they still
necessary?” Use of such lines should be evidence-based where possible. Alert
fatigue aside, we also recommend that flags be set in the electronic medical
record (EMR) to highlight for the clinician that such catheters are in place
and need to be reviewed for continuation on a daily basis.
References:
Chopra V, Govindan S, Kuhn L, et al. Do Clinicians Know Which of Their Patients Have Central Venous Catheters?: A Multicenter Observational Study. Ann Intern Med 2014; 161(8): 562-567
http://annals.org/article.aspx?articleid=1916822
Tejedor SC, Tong D, Stein J, et al. Temporary central venous catheter utilization patterns in a large tertiary care center: Tracking the "Idle central venous catheter". Infection Control and Hospital Epidemiology 2012; 33(1): 50-57
Taichman DB. Whose Line Is It Anyway? Ann Intern Med 2014; 161(8): 607-608
http://annals.org/article.aspx?articleid=1916831
Print “December
2014 Surprise Central Lines”
American
Geriatrics Society Guideline on Postoperative Delirium in Older Adults
Of our many columns on recognition, diagnosis, prevention and management of delirium (see the full list at the end of today’s column) postoperative delirium has been a major focus.
The American Geriatrics Society has just published a best practice statement for Postoperative Delirium in Older Adults (AGS Expert Panel 2014). It’s a guideline that really only recommends evidence-based best practices.
The guideline notes that between 5% and 50% of older adults develop delirium after surgery and that delirium may be preventable in up to 40% of cases. Yet the topic of delirium has been under-represented in surgical teaching. So this guideline/best practice statement is of significant importance since it is published in the Journal of the American College of Surgeons.
It emphasizes that delirium is a relationship between a physiologic stressor (in this case the surgery) and predisposing risk factors. Major risk factors listed are age > 65, chronic cognitive decline or dementia, poor vision or hearing, severe illness, presence of infection, functional dependence, self-reported alcohol abuse, and specific laboratory/electrolyte abnormalities. It notes that patients having 2 or more risk factors are at greater risk and that the risk for delirium is generally greater in the emergency setting.
The guideline notes that healthcare professionals caring for postsurgical patients must be trained to recognize and document the signs and symptoms of delirium, including hypoactive delirium. When a screening tool suggests delirium a healthcare professional competent in diagnosing delirium should perform a full clinical assessment. It emphasizes, as we have, that patients undergoing elective procedures should have baseline assessments of cognitive function pre-operatively. The guideline has multiple tables and appendices covering things like risk factors, symptoms and signs, screening tools, and diagnostic tools. It recommends that the healthcare team consider instituting daily postoperative screening of older patients for delirium.
The guideline notes there is a dearth of solid evidence about specific intraoperative factors in the prevention of postoperative delirium. In fact, the only recommendation is that the anesthesiology practitioner may use processed EEG monitors of anesthetic depth (eg. Bispectral Index) during sedation or general anesthesia of older patients to reduce postoperative delirium.
The next section focuses on medications that commonly induce delirium, especially anticholinergic drugs, sedative/hypnotics, meperidine, diphenhydramine, and benzodiazepines. Also, use of 5 or more total medications is associated with an increased risk of delirium. It emphasizes that management must be individualized. For example, while benzodiazepines should be avoided in most at-risk patients they may be necessary in a patient with a history of alcohol or benzodiazepine dependence.
The guideline has an excellent focus on pain and pain management. Insufficient pain control can contribute to delirium as can some of the medications used to treat pain. The guideline recommends non-opioid analgesics where possible and notes that use of regional anesthesia has been found to reduce delirium in some studies.
The guideline points out the contradictory evidence on the effect of antipsychotics in preventing delirium and does not recommend their use for prevention. It also recommends against administration of newly prescribed cholinesterase inhibitors.
The guideline goes on to describe the nonpharmacologic prevention and treatment of postoperative delirium. It recommends that hospitals and healthcare systems have educational programs with frequent refresher sessions on delirium. It recommends that an interdisciplinary team implement a multicomponent nonpharmacologic intervention program.and follow that patient throughout the hospital course. It notes such interventions have reduced the incidence of delirium 30-40%. It stops short of recommending use of specialized hospital units, however, since the evidence is insufficient.
It goes on to describe the medical evaluation that should be undertaken once a patient is diagnosed as having delirium. It notes again that multicomponent interventions have been successful in reducing delirium duration and severity, length of stay, etc. but that it is not possible to conclude which specific component(s) are responsible.
If delirious patients are severely agitated or distressed and are considered a risk to self or others, judicious use of antipsychotics (at the lowest effective dose and for the shortest possible duration) may be considered. These should be used only when behavioral interventions have failed. It also emphasizes that benzodiazepines should not be used except where specifically indicated (such as patients undergoing withdrawal from alcohol or benzodiazepines).
We’ve discussed most of these issues more extensively in our many previous columns on delirium listed below. We’d again like to emphasize that we consider assessment for delirium risk one of the 3 most important elements of the preoperative evaluation (the other two being screening for frailty and screening for sleep apnea or other potential cause for post-operative opioid-induced respiratory depression). These simple screens can usually be done in the office by the surgeon or a geriatrician or primary care giver.
Some of our prior
columns on delirium assessment and management:
·
October
21, 2008 “Preventing
Delirium”
·
October
14, 2009 “Managing
Delirium”
·
February
10, 2009 “Sedation
in the ICU: The Dexmedetomidine Study”
·
March
31, 2009 “Screening
Patients for Risk of Delirium”
·
June 23,
2009 “More
on Delirium in the ICU”
·
January
26, 2010 “Preventing
Postoperative Delirium”
·
August
31, 2010 “Postoperative
Delirium”
·
September
2011 “Modified
HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery”
· December 2010 “The ABCDE Bundle”
·
February
28, 2012 “AACN
Practice Alert on Delirium in Critical Care”
·
April 3, 2012 “New
Risk for Postoperative Delirium: Obstructive Sleep Apnea”
·
August
7, 2012 “Cognition,
Post-Op Delirium, and Post-Op Outcomes”
·
September
2013 “Disappointing
Results in Delirium”
·
October
29, 2013 “PAD:
The Pain, Agitation, and Delirium Care Bundle”
·
February
2014 “New
Studies on Delirium”
·
March
25, 2014 “Melatonin
and Delirium”
·
May 2014
“New
Delirium Severity Score”
·
August
2014 “A
New Rapid Screen for Delirium in the Elderly”
·
August
2014 “Delirium
in Pediatrics”
·
November
2014 “The
3D-CAM for Delirium”
References:
The American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. Postoperative Delirium in Older Adults: Best Practice Statement from the American Geriatrics Society. Journal of the American College of Surgeons 2014; Published Online: November 14, 2014
http://www.journalacs.org/article/S1072-7515%2814%2901793-1/fulltext
Print “December
2014 American Geriatrics Society Guideline on Postoperative Delirium in Older
Adults”
Oxygen Should Be
AVOIDed
In several of our prior columns on use of oxygen (see our Patient Safety Tips of the Week April 8, 2008 “Oxygen as a Medication” and January 27, 2009 “Oxygen Therapy: Everything You Wanted to Know and More!”) we have commented that in the past we often routinely gave oxygen to patients with myocardial infarction or stroke. But such use was more reflexive in nature and not evidence-based.
In our What’s New in the Patient Safety World columns for July 2010 “Cochrane Review: Oxygen in MI” and February 2012 “More Evidence of Harm from Oxygen” we discussed the lack of evidence to support the routine use of oxygen in the acute MI patient and the possible deleterious effects in these and some other cardiac patients.
Then in our March 2014 What’s New in the Patient Safety World column “Another Strike Against Hyperoxia” we noted a study showing that hyperoxia was independently associated with in-hospital death as compared with either normoxia or hypoxia in ventilated stroke patients admitted to ICU’s.
Such studies have called for large randomized controlled
trials to answer the important questions about if and when to use oxygen in
patients with stroke or MI. One such study, The Stroke
Oxygen Study (SO2S) in the UK, was recently completed in stroke patients (see our June 17, 2014 Patient Safety Tip of
the Week “SO2S
Confirms Routine Oxygen of No Benefit in Stroke”) and showed no benefit of
oxygen therapy in stroke patients who were not hypoxemic.
Now we finally also have the results of a randomized controlled trial of oxygen vs. no oxygen in patients with STEMI (S-T segment elevation myocardial infarction). Results of the Air Versus Oxygen in Myocardial Infarction (AVOID) study were just presented at the American Heart Association 2014 Scientific Sessions (Stub 2014). Patients with STEMI by EKG who had normal oxygen saturation were randomized in the pre-hospital transport system to receive either oxygen 8L/min or no supplemental oxygen. Those who received supplemental oxygen had larger infarct size by measurement of CPK (but not by troponin levels) and by cardiac MRI at 6 months. They also had a higher rate of recurrent myocardial infarction and an increase in frequency of cardiac arrhythmias. Mortality did not differ between the two groups but the study was not powered to demonstrate any difference in mortality. A much larger ongoing study in Sweden may be able to answer the question about impact on mortality. Thus the study showed supplemental oxygen therapy in patients with STEMI but without hypoxia increased early myocardial injury and was associated with larger myocardial infarct size assessed at six months.
As we’ve recommended before, hospitals need to look at their existing protocols (and actual practices) for managing a variety of medical conditions where oxygen use may be considered. How many of you have standardized order sets that directly (or indirectly by poor use of checkboxes) encourage inappropriate use of oxygen in MI or stroke patients? Going back to our Patient Safety Tips of the Week April 8, 2008 “Oxygen as a Medication” and January 27, 2009 “Oxygen Therapy: Everything You Wanted to Know and More!” we strongly support facilities doing audits of their oxygen practices. You’ll probably be surprised at the opportunities you uncover to improve practices (and save money at the same time!). And make sure your pre-hospital emergency response teams are aware of the results of the AVOID study.
Some of our prior columns on potential harmful effects of oxygen:
April 8, 2008 “Oxygen as a Medication”
January 27, 2009 “Oxygen Therapy: Everything You Wanted to Know and More!”
July 2010 “Cochrane
Review: Oxygen in MI”
February 2012 “More
Evidence of Harm from Oxygen”
March 2014 “Another
Strike Against Hyperoxia”
June 17, 2014 “SO2S
Confirms Routine O2 of No Benefit in Stroke”
References:
Stroke Oxygen Study website
Stub D, Smith K, Bernard, S, et al. A randomised controlled trial of oxygen therapy in acute ST-segment elevation myocardial infarction: The Air Versus Oxygen in Myocardial Infarction (AVOID) study. American Heart Association 2014 Scientific Sessions; November 19, 2014; Chicago, IL
http://www.abstractsonline.com/pp8/#!/3547/presentation/46505
Print “December
2014 Oxygen Should Be AVOIDed”
Another Procedure
to Avoid Late in the Day or on Weekends
Add yet another
procedure to the growing lists of procedures you don’t want done late in the day
or on weekends. In our October 2014 What’s New in the Patient Safety World
column “What
Time of Day Do You Want Your Surgery?” we discussed issues related to
laparoscopic cholecystectomies done after hours. In our September 2009 What’s
New in the Patient Safety World column “After-Hours
Surgery – Is There a Downside?” we discussed adverse outcomes associated with doing certain types of orthopedic
surgery after hours. We think the issues raised are significant to almost every
type of surgery and probably other procedures as well.
So it should come as no surprise that some non-emergent procedures done in the cath lab or OR might also be problematic. Hsu and colleagues (Hsu 2014) demonstrated in a large, real-world population, that implantable cardioverter-defibrillator (ICD) recipients implanted in the afternoon/evening and on weekends/holidays more often experienced adverse events, particularly prolonged hospital stays. Those patients implanted in the afternoon or evening had an 8% higher likelihood of any complication and 29% higher likelihood of a prolonged hospital stay. In-hospital death, however, was not increased.
In our previous columns
noted above (and the full list is at the end of today’s column) we’ve discussed
many of the factors contributing to problems for cases done after hours or on
weekends. Hsu and colleagues acknowledge that implantable
cardioverter-defibrillator procedures performed later in the day and on
weekends/holidays may be associated with adverse events due to a variety of
factors including operator fatigue, handoffs, reduced staffing, and limited
resource availability.
But keep in mind
that this was not a randomized controlled trial. Rather it was a retrospective
review of a real-world population. Even though they adjusted their analysis for
a variety of factors, it is conceivable that there may be unrecognized
patient-related factors that led to cases being done late in the day.
Some of the
contributory factors may not be modifiable. However, others may be. For
example, if the cardiac electrophysiologist or surgeon doing the implant
perceives difficulty scheduling the procedure for the following morning (or has
a conflict with his/her own schedule that next morning) he/she may push to do
the procedure late on the current day. Maintaining scheduling flexibility to
accommodate such cases the next day may be an important system fix.
Take a look at the
experience with ICD implantation at your own hospital. Because Hsu’s data came
from the National Cardiovascular Data Registry-ICD Registry™ you’ll likely find
similar patterns at your hospital.
Some of our previous columns on the “weekend” and “after hours” effects:
· February 26, 2008 “Nightmares….The Hospital at Night”
· December 15, 2009 “The Weekend Effect”
· July 20, 2010 “More on the Weekend Effect/After-Hours Effect”
· October 2008 “Hospital at Night Project”
· September 2009 “After-Hours Surgery – Is There a Downside?”
· December 21, 2010 “More Bad News About Off-Hours Care”
·
June
2011 “Another
Study on Dangers of Weekend Admissions”
·
September
2011 “Add
COPD to Perilous Weekends”
·
August
2012 “More
on the Weekend Effect”
·
June
2013 “Oh
No! Not Fridays Too!”
·
November
2013 “The
Weekend Effect: Not One Simple Answer”
·
August 2014
“The
Weekend Effect in Pediatric Surgery”
·
October
2014 “What
Time of Day Do You Want Your Surgery?”
References:
Hsu JC, Varosy PD, Parzynski CS, et al. Procedure Timing as a Predictor of In-Hospital Adverse Outcomes from Implantable Cardioverter-Defibrillator Implantation: Insights from the NCDR®. Amer Heart J 2014; Published Online: October 25, 2014
http://www.ahjonline.com/article/S0002-8703%2814%2900612-7/abstract
Print “December
2014 Another Procedure to Avoid Late in the Day or on Weekends”
Print “December
2014 What's New in the Patient Safety World (full column)”
Print “December
2014 I-PASS Passes the Test”
Print “December
2014 Surprise Central Lines”
Print “December
2014 American Geriatrics Society Guideline on Postoperative Delirium in Older
Adults”
Print “December
2014 Oxygen Should Be AVOIDed”
Print “December
2014 Another Procedure to Avoid Late in the Day or on Weekends”
Print “December
2014 What's New in the Patient Safety World (full column in PDF version)”
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