What’s New in the Patient Safety World


January 2010


·        Patient Safety First Campaign Fall Intervention

·        Anemia and Perioperative Beta Blockers

·        Crew Resource Management Training Produces Sustained Results

·        ISMP Article on Double Checks

·        Operative Duration and Infection

·        Falls in the Radiology Suite



Patient Safety First Campaign Fall Intervention


The Patient Safety First campaign (UK) has recently put out a “How to” Guide for Reducing Harm from Falls. Some of the recommendations are ones you are probably already doing: involving leadership, setting up a multidisciplinary falls team, setting aims, measuring baselines and developing outcome measurements. They reinforce tying your falls initiatives to other initiatives such as your delirium prevention and management projects. They stress that the real goal is to prevent injuries from falls, not just preventing falls, and stress the importance of balancing the fall prevention program against the need to foster patient independence, aid in rehabilitation, and preserve privacy, dignity and personal choice.


In their “do’s and don’ts” section they caution against expecting an immediate and dramatic improvement. They note that even the best falls management programs produce improvements on the order of only 18% and it may take many months or even years to reach significant outcome improvements. They also caution against external benchmarking since fall rates and injury rates are heavily dependent upon characteristics of the patient population at each hospital. And as we’ve mentioned before, they caution against using fall risk assessment tools that just “score” patients because such may miss patients who still fall and may make you focus too much attention on patients who will not fall. In fact, they provide a tool to assess the effectiveness of your fall risk assessment tool. Instead, the focus needs to be on identifying and mitigating individual risk factors in the individual patient. They provide a nice example of an individually targeted falls are plan.


They appropriately place a premium on the evaluation of the patient after a fall, stressing identification of factors that may have led to that fall. In fact, they suggest that one of your measurements be the % of falls receiving a complete post-fall evaluation.


And the best part of the “How to” Guide is probably the “useful links” section at the end, plus a good bibliography.





Patient Safety First (UK). The “How To Guide” For Reducing Harm From Falls.




Effectiveness Tool





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Anemia and Perioperative Beta Blockers


We’ve discussed on numerous occasions the changing role of periopative beta blockers (see “December 2009 Updated Perioperative Beta Blocker Guidelines” for links to all those columns). Since the POISE trial showed better cardiovascular outcomes came at the cost of increased mortality and stroke risk, perioperative beta blocker use has plummeted. Nevertheless, many investigators and practitioners remain convinced that appropriate periopertive use of beta blockers may result in better outcomes and have sought to identify subgroups that might benefit from beta blockers or subgroups that may be at greater risk from beta blockers.


A new study (Beattie et al. 2010) sheds some light on why some patients may fare worse on beta blockers during major surgery. They looked retrospectively at a large population underoing noncardiac surgery and used propensity scoring to get cohorts for comparison. They found that a composite of major cardiac outcomes was worse in patients experiencing an acute perioperative reduction in hemoglobin levels of more than 35%. Lesser degrees of acute anemia were not associated with these same adverse outcomes. The authors and the accompanying editorialist (Weiskopf et al. 2010) discuss how the normal physiologic mechanisms that respond to acute blood loss are impaired by beta blockade.





W Scott Beattie WS, Wijeysundera DN, Karkouti K. Acute Surgical Anemia Influences the Cardioprotective Effects of β-Blockade: A Single-center, Propensity-matched Cohort Study. Anesthesiology 2010; 112:12–5



Weiskopf RB. Perioperative Use of β-Adrenergic Antagonists and Anemia: Known Knowns, Known Unknowns, Unknown Unknowns; and Unknown Knowns. Anesthesiology 2010; 112: 25–33





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Crew Resource Management Training Produces Sustained Results


We’ve long been advocates of teamwork training programs and programs that call upon lessons learned in the aviation industry, particularly those related to crew resource management (CRM). However, most studies looking at CRM training have looked only at short-term outcomes. Now a new study (Sax et al 2009) has demonstrated improved outcomes that have been sustained over the long run. Outcomes included increased use of preoperative checklists, increased self reporting, more reporting of near misses and environmental conditions, and several measures indicative of a culture of safety.




Sax HC, Browne P, Mayewski RJ, et al. Can Aviation-Based Team Training Elicit Sustainable Behavioral Change? Arch Surg. 2009; 144(12):1133-1137





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ISMP Article on Double Checks


Despite our frequent comment that double checks are a relatively “weak” safety intervention, we have noted that the literature supports a medication error reduction of about 30% when using a double check system (see our July 15, 2008 Patient Safety Tip of the Week “Heparin Flushes.....Again!”).


The most recent edition of the ISMP Medication Safety Alert includes an article “Santa checks his list twice. Shouldn’t we?” that puts the independent double check process in perspective. They cite some studies done in community pharmacies that show double checks found errors in 2.6% to 4.2% of cases, about half of which were potentially significant. And the “average’ error checking rate is about 5%. But they also discuss how difficult it is for someone to pick up their own errors (because of phenomena such as confirmation bias) and point out that double checks work best when they are performed truly independently.


They recommend that double checks be limited to hi-alert medications (like insulin, heparin, chemotherapy, TPN, etc.) and to very complex processes or hi-risk patient populations. Don’t use double checks when some more fundamental re-engineering of the system is needed. And learn from errors uncovered during the double check process. They do suggest continuation of “natural” double checks you are already doing, such as when a nurse checks the accuracy after a pharmacist has dispensed a drug. We’ll second that one - particularly since over-reliance on computers often discourages those double checks (see our November 3, 2009 Patient Safety Tip of the Week “Medication Safety: Frontline to the Rescue Again!”). We love the concept in John Nance’s book where everyone always asks themselves “Could what I’m about to do cause harm to this patient?” (see our June 2, 2009 Patient Safety Tip of the Week “Why Hospitals Should Fly…John Nance Nails It!”).





ISMP. Santa checks his list twice. Shouldn’t we? Medication Safety Alert. Acute Care Edition. December 17, 2009





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Operative Duration and Infection


Risk factors for perioperative infections are not all modifiable. However, operative duration is one risk factor that is potentially modifiable. A number of studies in the past have demonstrated an association between perioperative infection and the duration of the surgical procedure. A new study (Proctor et al 2010) looked at a large database of general surgical procedures and demonstrated a linear relationship between duration of surgery and infectious complications. This relationship persisted even after adjustment for a variety of other risk factors for perioperative infections. The unadjusted infectious complication rate increased by 2.5% per half hour. Hospital length of stay (LOS) also inceased geometrically by 6% per half hour.


The authors discuss some of the plausible links between infectios complications and duration of surgery such as increased exposure to airborne pathogens and greater surgical trauma. Increased foot traffic may be another factor related to prolonged procedures that increases the likelihood of surgical site infections (Lynch et al. 2009).


They also discuss some of the many factors that may lead to increased surgical durations. These include factors such as case type, emergency vs. elective nature, and proficiency of the surgeon. But they also include such modifiable factors such as presence of trainees and poor communication.


Out March 10, 2009 Patient Safety Tip of the Week “Prolonged Surgical Duration and Time Awareness” discussed time unawareness during many surgeries. In addition to the potential impact on infectious complications, we noted that there are other potential patient safety issues related to prolonged surgical duration such as DVT, decubiti, hypothermia, fluid/electrolyte shifts, nerve compression, compartment syndromes, and rhabdomyolysis. We recommend that the OR team, during the surgical timeout or during the presurgical huddle, should discuss issues related to prolonged cases. For example, they should discuss whether intraoperative DVT prophylaxis should begin if the procedure lasts beyond a certain duration. Or discuss at what duration a repositioning of the patient (to avoid nerve compression, compartment syndrome, or rhabdomyolysis) might be wise. And it would be very useful to have an estimate of time remaining to again trigger some discussion on the above issues. In addition to the DVT prophylaxis and repositioning issues, it might raise questions about the need to temporarily ease up on traction. It might direct attention to maintenance of the patient’s body temperature. In a very prolonged case it might raise questions about the need for further doses of prophylactic antibiotics. An IT system solution to alert clinicians to duration of surgery and estimated time remaining has been proposed (Dexter et al 2009).






Procter LD, Davenport DL, Bernard AC, Zwischenberger JB. General Surgical Operative Duration Is Associated with Increased Risk-Adjusted Infectious Complication Rates and Length of Hospital Stay, Journal of the Amercican College of Surgeons 2010; 210: 60-65




Lynch RJ, Englesbe MJ, Sturm L, et al. Measurement of Foot Traffic in the Operating Room: Implications for Infection Control. American Journal of Medical Quality 2009; 24: 45-52




Dexter F, Epstein RH, Lee JD, Ledolter J. Automatic Updating of Times Remaining in Surgical Cases Using Bayesian Analysis of Historical Case Duration Data and "Instant Messaging" Updates from Anesthesia Providers. Anesth Analg 2009; 108:929-940





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Falls in the Radiology Suite


Many of our columns have highlighted the radiology suite as a site where many patient safety issues occur (see our Patient Safety Tips of the Week for October 16, 2007 “Radiology as a Site at High-Risk for Medication Errors”, September 16, 2008 “More on Radiology as a High Risk Area” and October 7, 2008 “Lessons from Falls....from Rehab Medicine”). In the latter we noted that radiology is an area where falls often happen. Patients are often on a gurney or a table or in a wheelchair and may fall when they attempt to get up to use the bathroom. They may be tethered to IV poles or other equipment that become obstacles to trip over. And they may have received benzodiazepines or other sedating medications for the radiology procedure, further increasing their fall risk. So it is critical that the fall risk of a patient is accurately conveyed to all staff when a patient is sent to radiology. One way to facilitate such handoffs would be to include information on fall risk in a structured communication tool for transports like the “ticket to ride” we described in our April 8, 2008 column. The use of color-coded wristbands continues to gain momentum and may be used to identify patients at greater risk for falls.


But most of our discussion has focused on inpatients in the radiology suite. A new paper presented by Abujudeh and colleagues at the Massachusetts General Hospital at the 2009 RSNA annual meeting focused on falls in outpatient radiology areas (see Yee 2009). They analyzed 82 falls in radiology over a 2 ½ year period and found that 80% involved outpatients. About a third of the falls resulted in injury. They noted that risk factors for falls were present in 85% of the patients who fell and 20% had had a previous fall within the past 3 months. Medications, in particular were common predisposing factors.


While the number of falls is small compared to the large volume of outpatient radiological procedures, this still represents a significant patient safety risk and liability risk. It would be interesting to see if incorporation of at least a brief risk assessment at the time a procedure is scheduled or on patient registration would have any impact on falls. In those more integrated systems having good IT capabilities it would make sense to develop risk flags that follow the patient from inpatient to outpatient.






Yee KM. Postcards from the edge: Tracking falls in outpatient radiology.
AuntMinnie.com December 21, 2009





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Print “January 2010 What's New in the Patient Safety World (full column)

Print “January 2010 Patient Safety First Campaign Fall Intervention

Print “January 2010 Anemia and Perioperative Beta Blockers

Print “January 2010 Crew Resource Management Training Produces Sustained Results

Print “January 2010 ISMP Article on Double Checks

Print “January 2020 Operative Duration and Infection

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