What’s New in the Patient Safety World
December 2016
·
Standardize 4 Safety and Just Bag It!
·
Update on Ambulatory Antibiotic Stewardship
·
The Joint Commission NPSG for CAUTI’s
·
ECRI’s Top 10 Health Technology Hazards for 2017
Standardize 4
Safety and Just Bag It!
A couple nationwide
medication safety campaigns have been in the news lately. Earlier this year
ASHP (American Society of Health-System Pharmacists) was awarded a
3-year contract by the FDA to develop
standardized concentrations for intravenous and oral liquid medications. ASHP
has partnered with ISMP (Institute for Safe Medication Practices), AAMI
(Association for the Advancement of Medical Instrumentation), and PPAG
(Pediatric Pharmacy Advocacy Group) in this endeavor, the Standardize
4 Safety initiative. The coalition just announced one of its Phase 1 (of 3
Phases) outcomes: a list
of recommended standardized concentrations for adult continuous IV infusions.
The list includes the standardized concentration(s), dosing units, status of
commercial availability, and comments for over 30 of the most commonly infused
drugs in adults.
Other activities in
Phase 1 will be development and implementation of concentrations and dosing
units for compounded oral liquids for adults. Phase II addresses concentrations
and dosing units for pediatric continuous IV infusions and standard doses for
oral liquid medications. Phase III addresses intermittent IV medications, PCA
(patient-controlled analgesia) pumps, epidurals, and standard doses for oral
chemotherapy agents.
Another
collaborative medication safety campaign, the Just Bag It Campaign,
was just launched by the National Comprehensive Cancer Network (NCCN 2016). Vincristine is a
chemotherapy agent intended for intravenous use. Yet since the 1960’s there
have been numerous incidents where it has been administered intrathecally
or via Omaya reservoirs. The results are disastrous,
with patients developing quadriplegia, encephalopathy, and usually death. In
2013 ISMP summarized the literature (ISMP
2013) and noted that virtually all cases involved vincristine being
prepared in a syringe and that there were no cases when vincristine was
prepared in an IV bag. There are, of course, other contributing factors in such
incidents. ISMP noted the following contributing factors: mislabeling of
syringes; bringing IV and intrathecal medications into a treatment area
together; failing to administer vinca alkaloids in a
specialty oncology unit or with only experienced, oriented staff familiar with
current operational and clinical standards, procedures, or protocols;
administering chemotherapy outside of normal hours; not conducting an
independent double check or “time out” before intrathecal medication
administration; and incomplete or missing warning labels. But, given that all
reported incidents occurred when vincristine was in a syringe, ISMP recommended
that vincristine instead by diluted in a minibag for
infusion and syringes be avoided.
Now the NCCN Just Bag It Campaign has been launched for
the safe handling of vincristine, calling for health care professionals to always
dilute vincristine in a 50ml mini-IV drip bag and never in a syringe. The
campaign comes with Christopher’s Story, the sad story of a patient who died as
the result of one of the above vincristine errors. All NCCN member institutions
have already adopted this best practice for handling vincristine but the
campaign calls on all other oncology providers to do the same.
References:
ASHP (American Society of Health-System Pharmacists).
Standardize 4 Safety website.
http://www.ashp.org/menu/PracticePolicy/Standardize-4-Safety
ASHP (American Society of Health-System Pharmacists). ASHP
IV ADULT CONTINUOUS INFUSION GUIDELINES. October 2016
NCCN (National Comprehensive Cancer Network). Just Bag It: The NCCN Campaign for Safe
Vincristine Handling. NCCN 2016; accessed November 14, 2016
https://www.nccn.org/justbagit/
ISMP (Institute for Safe Medication Practices). Death and
neurological devastation from intrathecal vinca
alkaloids: Prepared in syringes = 120; Prepared in minibags
= 0. ISMP Medication Safety Alert! Acute Care Edition. September 5, 2013
https://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=58
Print “December
2016 Standardize 4 Safety and Just Bag It!”
Update on
Ambulatory Antibiotic Stewardship
In our November 2015
What's New in the Patient Safety World column “Medications
Most Likely to Harm the Elderly Are…” we noted the paucity of evidence in
the literature about antibiotic stewardship programs in ambulatory care or
other outpatient settings. CDC had previously published on the core elements
for hospitals (CDC
2014) and nursing homes (CDC
2015). Now CDC has published the “Core Elements of Outpatient
Antibiotic Stewardship” (Sanchez
2016).
The Core Elements of Outpatient Antibiotic Stewardship are:
- Commitment: Demonstrate dedication to and accountability for
optimizing antibiotic prescribing and patient safety.
- Action for policy and practice: Implement at least one policy
or practice to improve antibiotic prescribing, assess whether it is
working, and modify as needed.
- Tracking and reporting: Monitor antibiotic prescribing
practices and offer regular feedback to clinicians, or have clinicians
assess their own antibiotic prescribing practices themselves.
- Education and expertise: Provide educational resources to
clinicians and patients on antibiotic prescribing, and ensure access to
needed expertise on optimizing antibiotic prescribing.
Regarding commitment,
CDC notes that declaring commitment to antibiotic stewardship in a public
fashion (eg. posters in examination rooms) has been
shown to reduce inappropriate prescription of antibiotics. In larger practices
and healthcare organizations, designating a leader for antibiotic stewardship
programs is recommended. CDC also recommends not only educating all staff on
antibiotic stewardship but also making it part of their job descriptions and evaluation.
CDC stresses that all members of the healthcare team have an important role in
antibiotic stewardship.
Under Action for
policy and practice they recommend adherence to the evidence-based
practices recommended in specialty society guidelines. They note that use of
delayed prescribing practices or watchful waiting, when appropriate, may be
successful strategies. This requires good communication skills and consistent
messages. Systems should provide clinical decision support tools for clinicians
and have informational printouts available for patients and families. Various
triage systems (eg. nurse call lines) should also
reinforce principles of appropriate antibiotic prescribing and may help reduce
unnecessary office/clinic/ER visits. They also recommend documentation in the
medical record of rationale for decisions not to prescribe antibiotics.
Tracking and
reporting consists of audit and feedback, which has been shown to reduce
inappropriate antibiotic prescribing. Items to track should include whether
antibiotics were appropriate, whether the correct antibiotic was prescribed,
and whether the duration of therapy recommended was appropriate. Some systems
or practices might choose a high priority condition, like acute bronchitis, to
monitor. Others might look at percentage of overall visits at which antibiotics
are prescribed. Feedback to individual prescribers can be compared to peers.
Some systems may also track adverse drug events related to antibiotics.
Education applies
both to prescribers and patients. Communication with patients or families
should take into account health literacy issues. Continuing educational
activities should be available for healthcare providers and timely access to
persons with expertise (eg. pharmacists, infectious disease staff) should be made
available.
See also our November
2015 What's New in the Patient Safety World column “Medications
Most Likely to Harm the Elderly Are…” for other recommendations and links
to some of the other studies on antibiotic stewardship in the outpatient
setting.
Some of our prior
columns on antibiotic stewardship:
- October 14, 2014 “Antibiotic
Stewardship”
- November 2015 “Medications
Most Likely to Harm the Elderly Are…”
- July 2016 “NQF/CDC
Guideline on Antibiotic Stewardship”
- August 2016 “Some
Reassurance on Antibiotic Stewardship”
- November 2016 “C.
Diff and Your Predecessor’s Room”
References:
CDC. Core elements of hospital antibiotic stewardship
programs [Internet]. Atlanta, GA: US Department of Health and Human Services,
CDC; 2014; last updated May 25, 2016
http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html
CDC. Core elements of antibiotic stewardship for nursing
homes [Internet]. Atlanta, GA: US Department of Health and Human Services, CDC;
2015; last updated August 18, 2016
http://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html
Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core
Elements of Outpatient Antibiotic Stewardship. Recommendations and Reports.
MMWR 2016; 65(6): 1-12
http://www.cdc.gov/mmwr/volumes/65/rr/rr6506a1.htm?s_cid=rr6506a1_w
Print “December
2016 Update on Ambulatory Antibiotic Stewardship”
The Joint
Commission NPSG for CAUTI’s
The Joint Commission
has revised for 2017 NPSG.07.06.01, its national patient safety goal for
prevention of CAUTI’s (catheter-associated urinary tract infections).
The elements of
performance for NPSG.07.06.01 are:
- Educate staff and licensed independent practitioners involved in the
use of indwelling urinary catheters about CAUTI and the importance of infection
prevention. Education occurs upon hire or granting of initial privileges
and when involvement in indwelling catheter care is added to an
individual’s job responsibilities. Ongoing education and competence
assessment occur at intervals established by the organization.
- Educate patients who will have an indwelling catheter, and their
families as needed, on CAUTI prevention and the symptoms of a urinary
tract infection.
- Develop written criteria, using established evidence-based guidelines,
for placement of an indwelling urinary catheter. Written criteria are
revised as scientific evidence changes. (Examples are provided in the
document and we’ve provided them in our many columns on CAUTI prevention
listed below).
- Follow written procedures based on established evidence-based
guidelines for inserting and maintaining an indwelling urinary catheter.
The procedures address the following:
-
Limiting
use and duration
-
Performing
hand hygiene prior to catheter insertion or maintenance care
-
Using
aseptic techniques for site preparation, equipment, and supplies
-
Securing
catheters for unobstructed urine flow and drainage
-
Maintaining
the sterility of the urine collection system
-
Replacing
the urine collection system when required
-
Collecting
urine samples
(The NPSG acknowledges that there are certain medical conditions, predominantly
neurological ones, that require a prolonged use of an indwelling urinary
catheter in order to avoid adverse events and promote patient safety.)
- Measure and monitor catheter-associated urinary tract infection
prevention processes and outcomes in high-volume areas by doing the
following:
-
Selecting
measures using evidence-based guidelines or best practices
-
Having a
consistent method for medical record documentation of indwelling urinary
catheter use, insertion, and maintenance.
-
Monitoring
compliance with evidence-based guidelines or best practices
-
Evaluating
the effectiveness of prevention efforts
(The NPSG notes that surveillance may be targeted to areas with a high volume
of patients using in-dwelling catheters, as identified through the hospital’s
risk assessment.)
Of course, we are
advocates of incorporating your evidence-based criteria into your CPOE system.
That can help ensure appropriate use of catheters and may help you meet some of
the documentation requirements. Innovative hospitals will also use barcoding to
help create documentation for things like time of insertion, review for
continuation, etc.
This NPSG and all
the other 2017 National Patient Safety Goals are now available on The Joint
Commission website (TJC
2016).
Our other columns on
urinary catheter-associated UTI’s:
- May 8,
2007 Tip of the Week “Doctor,
when do I get this red rubber hose removed?”
- January
8, 2008 Tip of the Week “Urinary
Catheter-Associated Infections”
- April 2008 What’s New in the
Patient Safety World column “More
on Nosocomial UTI’s”
- June
24, 2008 Tip of the Week “Urinary
Catheter-Related UTI’s: Bladder Bundles”
- April
21, 2009 Tip of the Week “Still
Futzing with Foleys?”
- June
9, 2009 Tip of the Week “CDC
Update to the Guideline for Prevention of CAUTI”
- March 2010 “IDSA
CAUTI Guidelines”
- February
2011 What’s New in the Patient Safety World
column “Catheters
Not Needed in C-Sections?”
- January 2012 “CAUTI’s
Still Get No Respect”
- May 2012 “Foley
Catheter Hazards”
- November 2012 “CAUTI
Conundrum”
- December 18, 2012 “Unintended
Consequences of the CAUTI Measure?”
- January 2013 “Silver-Coated
Urinary Catheters Don’t Reduce CAUTI’s”
- June 2013 “Barriers
to CAUTI Prevention”
- November 2013 “Further
Reducing Urinary Catheter Use”
- June 2014 “Updated
HAI Prevention Guidelines from SHEA/IDSA”
- June 30, 2015 “What
Are Appropriate Indications for Urinary Catheters?”
- December 2015 “CAUTI
Prevention Tools”
- July 2016 “Holy
Moly, My Patient has a FOLEY!”
References:
The Joint Commission. Hospital Accreditation Program. National
Patient Safety Goals Effective January 2017. Accessed November 18, 2016
https://www.jointcommission.org/assets/1/6/NPSG_Chapter_HAP_Jan2017.pdf
Print “December
2016 The Joint Commission NPSG for CAUTI’s”
ECRI’s Top 10
Health Technology Hazards for 2017
ECRI Institute has published its annual list of its Top 10
Health Technology Hazards for 2017 (ECRI 2016). The full
report details the risks of each of the technologies and makes very useful
recommendations on what your organization should be doing to minimize those
risks. Their 2017 list:
- Infusion errors
- Inadequate cleaning of complex reusable instruments
- Missed ventilator alarms
- Undetected opioid-induced respiratory depression
- Infection risks with heater-cooler devices used in cardiothoracic
surgery
- Software management gaps
- Occupational radiation hazards in hybrid ORs
- Automated dispensing cabinets setup and use errors
- Surgical stapler misuse and malfunction
- Device failures caused by cleaning products and practices
As is our usual practice we don’t go into detail about items
on their list because we encourage you to go right to their excellent resources
on these topics. We’re happy to see that under alarm management they have highlighted
failures to communicate alarms effectively to staff, a topic we discussed in detail
in our February 9, 2016 Patient Safety Tip of the Week “It
was just a matter of time…”.
Go to the ECRI site to download the full
report. It is a free download but you’ll need to register to receive it.
References:
ECRI Institute. Top 10 Health Technology Hazards for 2017.
https://www.ecri.org/Pages/2017-Hazards.aspx
Print “December
2016 ECRI’s Top 10 Health Technology Hazards for 2017”
Print “December
2016 What's New in the Patient Safety World (full
column)”
Print “December
2016 Standardize 4 Safety and Just Bag It!”
Print “December
2016 Update on Ambulatory Antibiotic Stewardship”
Print “December
2016 The Joint Commission NPSG for CAUTI’s”
Print “December
2016 ECRI’s Top 10 Health Technology Hazards for 2017”
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version”
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