What’s New in the Patient Safety World

February 2011


·        Updated Fall Prevention Guidelines

·        New Journal Highlights Safety in Radiation Oncology

·        Catheters Not Needed in C-Sections?

·        SURPASS Checklist Reduces Malpractice Claims

·        Update on 12-hour Nursing Shifts






Updated Fall Prevention Guidelines


The American Geriatrics Society and British Geriatrics Society have just released their updated “Clinical Practice Guideline for Prevention of Falls in Older Person” (the previous guideline had been written in 2001). The new guideline addresses elderly patients living in the community and those residing in long-term care facilities.


The updated guidelines emphasize the importance of the multifactorial assessment and intervention strategy. Not all elderly patients who have had a fall require assessment. If it was a solitary fall and the patient has no difficulties or unsteadiness during evaluation of gait and balance, a full fall assessment is not necessary. For most others, an assessment is indicated. The guideline describes the multiple components of the assessment, including the focused history, detailed assessment of gait/balance/mobility and lower extremity joint function, full neurological examination, cardiovascular status (including orthostatic blood pressure and pulse), visual acuity, and examination of the feet and footwear. A functional assessment (ADL skills, adaptive equipment and mobility aids, etc.) should be done where appropriate. Also important is the patient’s perceived functional ability and fear of falls. An environmental assessment, including a search for home safety hazards and facilitators, should also be done.


They make a whole host of recommendations regarding interventions. One new change is that certain medications (particularly psychoactive medications) be reduced or withdrawn regardless of the total number of medications a patient is taking (the old guideline focused on reducing these only in patients on 4 or more medications). An exercise component is a mainstay of any multifactorial intervention. The evidence for visual interventions was not considered strong enough to be recommended except that cataract surgery for elderly women with cataracts is recommended. Despite the recent hubbub about the lack of good evidence for many uses of vitamin D, one that does have a good evidence base is its use in community-dwelling or LTC residents with proven or suspected vitamin D deficiency. The recommendations, therefore, are for at least 800 international units of vitamin D per day for those persons with proven or suspected vitamin D deficiency and those with an abnormal gait or balance or who are otherwise at risk for falls.


The resources available include not only the guideline itself but also an algorithm, annotations, details about the interventions, tips, and information for patients and families.



The above guideline does not address falls in the acute care hospital setting. But there is one new resource applicable to the inpatient population. We have found the one of the biggest deficiencies in hospital’s approach to falls is what is done after a fall (see our April 16, 2007 Patient Safety Tip of the Week “Falls with Injury”). Apparently the British feel that way, too. The UK NPSA (National Patient Safety Agency) has just issued a Rapid Response Report “Essential care after an inpatient fall”. They issued that report because their incident reporting database had shown numerous instances of inadequate post-fall evaluation and management. Specifically, they often found delays in recognition of fractures, inadequate neurological assessments and monitoring in those ultimately shown to have intracranial injury, inappropriate movement of patients with fractures or spine injuries, and delays in access to urgent investigations or surgery. They also note failure to consider anticoagulated patients as being more vulnerable (see our July 17, 2007 Patient Safety Tip of the Week “Falls in Patients on Coumadin or Other Anticoagulants“).


The report recommends that all hospitals have protocols readily available for nurses to assess patients for possible fractures and spine injuries and manage those with such injuries. Appropriate equipment to handle such patients needs to be readily available. The protocol should also specify the frequency and duration of neurological observations to be done (including appropriate use of the Glasgow Coma Scale) and timescales for when the medical examination should be done after a fall. Access to diagnostic tests and specialist evaluations should be as rapid as would be expected if the patient was in the emergency room. They recommend the protocol should be kept in a laminated card readily available to all nursing staff.


While that rapid response report does have some good recommendations, it overlooks the need to do a mini-root cause analysis on the spot after every such fall. Often that is the only way to identify factors that led to the fall, which might be modified to prevent future falls.






Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons.

Journal of the American Geriatrics Society 2011; 59(1): 148-157

Article first published online: 13 JAN 2011




on the American Geriatrics Society website:

2010 AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons (Summary of Recommendations).
















Patient education materials on preventing falls




NPSA. Rapid Response Report. Essential care after an inpatient fall. January 13, 2011



supporting information



resource page





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New Journal Highlights Safety in Radiation Oncology



The inaugural issue of a new journal Practical Radiation Oncology published by ASTRO (the American Society for Radiation Oncology) highlights patient safety issues in the field. In early 2010 we did several columns on radiation safety issues after the NY Times publication of its eye-opening 2-part series (Bogdanich 2010a and 2010b) on the hazards of radiation (see our February 2, 2010 Patient Safety Tip of the Week “The Hazards of Radiation” and our March 2010 What’s New in the Patient Safety World column “More on Radiation Safety”).


In response to the multiple concerns raised in the New York Times series, ASTRO and multiple other stakeholder organizations convened a meeting to address patient safety in radiation oncology. That meeting is summarized in one of the papers in the new journal (Hendee 2011). They identified numerous causes and contributing factors to adverse outcomes in radiation oncology. These included not only issues related to the ever-increasing complexity of technology involved but also issues related to the human-technology interface. They noted growing dependence on computerized aspects had led to diminished knowledge and direct control of actual treatment by the radiation therapist. But many more mundane factors are operative as well: cluttered workstations, interruptions, multiple computer screens, lack of warning systems to identify settings outside usual parameters, etc. Added to these were the usual culprits of communication issues and failure to buck the authority gradient. They came up with 20 key recommendations (see the full text of the actual paper for details).


The second paper (Marks 2011) takes a more fundamental FMEA (failure mode and effects analysis) approach and identifies numerous challenges and potential opportunities for errors to occur in radiation oncology. It emphasizes that total error prevention is unlikely and that identification of errors before they cause patient harm should be the most important goal. They do discusss the scant available data reported on radiation oncology incidents (we’ve previously lamented that the biggest database on such incidents was not one put together by any regulatory body but rather the one put together by the New York Times!). They make a case for centralized data repositories to better categorize and analyze errors so that solutions can be widely disseminated. They did recognize that the rapid advancements in technology have caused a shift in the type and frequency of errors. For example, data entry errors have decreased but operator errors have increased. Lack of standardization (eg. often staff are working with multiple different machine types in the same center) becomes an issue, as does the sense of infallibility of the computer. They also note that the rapidly changing technologies have increased time pressures on everyone involved in radiation oncology and recognize that “rush to treat” often spawns error-prone workarounds. Newer technologies allow for much more focused radiation beams. But this also means the radiation units per dose are higher and, if delivered to the wrong tissues, can have serious side effects. Along the same lines, the newer technologies deliver radiation over much shorter time frames. In the past, a dosage error on one day could be compensated by a change in dosage on other days. Not so anymore. Importantly, some of the traditional quality assurance tools of the past are no longer applicable with the newer technologies.


But many of the changing features of the general medical landscape have also contributed. They note the transition from paper to electronic medical records has had an impact that has been at times disruptive to workflows. Some simple things, like drawings, that appeared in paper records have been difficult to replicate in electronic records. And the lack of interconnectivity has resulted in time-consuming double data entry in many cases. The number of handoffs has also increased. All these have added to the complexities of managing radiation therapy and introduced opportunities for error.


They go on with multiple practical recommendations to improve patient safety. Some topics are specific and include staffing, workflow, efficiency (including discussion of “lean” or Toyota Production System techniques), and standardization. But they also cover the more overriding concepts in patient safety such as the importance of developing a culture of safety, using human factors engineering concepts in design of facilities and workflows and equipment, using “huddles”, doing safety rounds, etc. And they stress prioritizing interventions according to the hierarchy of effectiveness (eg. that constraints and forcing functions are much more effective than education and policies).


Whether you and your organization are involved in radiation oncology or whether you are simply interested in patient safety overall, this issue of Practical Radiation Oncology is very worthwhile reading.






Bogdanich W. The Radiation Boom. Radiation Offers New Cures, and Ways to Do Harm. New York Times. January 24, 2010




Bogdanich W. The Radiation Boom. As Technology Surges, Radiation Safeguards Lag.

The New York Times. January 26, 2010




Marks LB, Jackson M, Xie L, et al. The challenge of maximizing safety in radiation oncology. Practical Radiation Oncology 2011; 1(1): 2-14


full text




Hendee WR, Herman MG. Improving patient safety in radiation oncology. Practical Radiation Oncology 2011; 1(1): 16-21


full text






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Catheters Not Needed in C-Sections?



In our multiple columns on avoiding catheter-associated urinary tract infections (CAUTI’s), we’ve stressed that the most important “intervention” is avoiding the catheter in the first place. We’ve talked about when catheters are appropriate and when they are not but there have always been a few gray areas. One of those is whether urinary catheters are necessary in patients undergoing C-sections.


A new systematic review (Li 2010) addresses that very issue. They found 3 controlled trials (2 randomized, 1 nonrandomized) totaling slightly over 1000 patients. They found that not using a urinary catheter resulted in a significantly lower incidence of UTI’s. They also found patients without catheters had a lower rate of discomfort on first voiding, less time to first voiding, and less time until ambulation. At the same time there were no differences in rates of urinary retention, operating time, or intraoperative difficulties. Shorter hospital stays and lower costs may be other advantages of avoiding catheter use in C-section patients.


The authors do caution, however, that the studies reviewed had small numbers and varying degrees of methodological rigor. They suggest that larger well-designed randomized controlled trials should be undertaken.




Links to our other columns on urinary catheter-associated UTI’s:








L Li L, Wen J, Wang L, et al. Is routine indwelling catheterisation of the bladder for caesarean section necessary? A systematic review.  BJOG 2010

Published online on Dec 23, 2010





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SURPASS Checklist Reduces Malpractice Claims



We discussed the SURPASS (SURgical PAtient Safety System) checklist (de Vries 2010a) in our November 30, 2010 Patient Safety Tip of the Week “SURPASS: The Mother of All Checklists”. SURPASS is really a series of much shorter checklists, each of which contains items that could be easily overlooked if one were counting on memory alone. Also, it does not contain many items that would seldom be overlooked. Each component checklist requires signing off (and dating) by the appropriate person(s). The authors found that at the Netherlands’ hospitals implementing SURPASS the total number of complications per 100 patients decreased from 27.3 to 16.7 and in-hospital mortality decreased from 1.5% to 0.8%.


The group that developed SURPASS (de Vries 2011) went back and reviewed malpractice claims from a database of the largest insurer in the Netherlands and analyzed the factors contributing to those malpractice cases. They then looked to see how many of those factors might have been covered, and perhaps avoided, if the SURPASS checklist had been used. They found that almost a third (29%) of the contributing factors could have been covered by adherence to SURPASS. And issues related to 4 of the 10 deaths in the database might have been prevented by adherence to SURPASS.

Of course, many of the items may have also been covered by use of other checklists. You’ll recall from our January 20, 2009 Patient Safety Tip of the Week “The WHO Surgical Safety Checklist Delivers the Outcomes” that mortality at 30-days post-op decreased from 1.5% before introduction of the WHO checklist to 0.8% after and the rate of any complication decreased from 11% to 7% (Haynes 2009).


The bottom line is that checklists are valuable tools that not only help you improve outcomes and avoid adverse patient events but may also prove useful in reducing malpractice claims and costs.






de Vries EN,  Prins HA, Crolla RMPH, et al. for the SURPASS Collaborative Group.Effect of a Comprehensive Surgical Safety System on Patient Outcomes. N Engl J Med 2010; 363: 1928-1937



the SURPASS checklist




de Vries EN; Eikens-Jansen MP, Hamersma AM et al. Prevention of Surgical Malpractice Claims by a Surgical Safety Checklist. Annals of Surgery. (published ahead of print) January 4, 2011




Haynes AB, Weiser TG, Berry WR, et al. for the Safe Surgery Saves Lives Study Group. A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. N Engl J Med. Online First January 14, 2009 (DOI: 10.1056/NEJMsa0810119), in Print January 29, 2009






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Update on 12-hour Nursing Shifts



We previously reviewed the available literature on the impact of 12-hour shifts for nursing (see our November 9, 2010 Patient Safety Tip of the Week “12-Hour Nursing Shifts and Patient Safety”) and concluded the literature to date really did not answer the question as to whether those shifts had a detrimental impact on patient outcomes.


Now a new study (Trinkoff 2011) has attempted to correlate patient outcomes with the duration of the nursing shift. The authors retrospectively looked at a number of AHRQ Quality Indicators at hospitals in two states where they had data on nursing shifts. They also analyzed survey responses from nurses working at those facilities. Indeed, they found that a number of undesirable outcomes, including mortality for select conditions like pneumonia, were higher in those hospitals where nurses reporting the longer shifts. Just as significant was the association between such undesirable outcomes and nurses’ lack of time off. This is very good work and adds to our increasing concerns about the 12-hour shift.


However, the question is still not resolved. The problem with almost all research to date on the issue is that there are too many confounding variables in retrospective studies. If we are asking the question “Are patient outcomes better with 8-hour work shifts better than with 12-hour work shifts?” we need to control for other factors such as time off and whether nurses are working the same shift each day or rotating shifts. The only way we are going to be able to answer that question is to do a randomized controlled trial where the only variable changing is the duration of the individual shift. It would require a well-designed study with hard outcome parameters done in a setting where a legitimate control group can be used (for example, implementing 12-hour shifts on one or several med/surg floors where the other comparable floors maintain their current 8-hour shifts). That will be a difficult study to actually carry out. But the time has come to get those critical answers.






Trinkoff AM, Johantgen M,  Storr C, et al. Nurses' Work Schedule Characteristics, Nurse Staffing, and Patient Mortality. Nursing Research 2011; 60: 1-8






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

Print “February 2011 Updated Fall Prevention Guidelines

Print “February 2011 New Journal Highlights Safety in Radiation Oncology

Print “February 2011 Catheters Not Needed in C-Sections?

Print “February 2011 SURPASS Checklist Reduces Malpractice Claims

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