What’s New in the Patient Safety World

January  2012



·        Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety

·        CAUTI’s Still Get No Respect

·        Need for New Transfusion Criteria?

·        Safely Doing Less

·        AHRQ’s New Medication Reconciliation Tool Kit




Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety



The Joint Commission has just released a new sentinel event alert on healthcare worker fatigue and patient safety. There is a wealth of literature on the effects of fatigue on workers not only in healthcare but in other high risk industries. We’ve done multiple prior columns on the impact of fatigue, shiftwork, etc. on both patient outcomes and adverse personal events for workers themselves (see our November 9, 2010 Patient Safety Tip of the Week “12-Hour Nursing Shifts and Patient Safety” and our April 26, 2011 Patient Safety Tip of the Week “Sleeping Air Traffic Controllers: What About Healthcare?”). Drowsiness, fatigue, and sleep deprivation also have an impact on personal health of nurses. The issue of nurses having accidents while driving home from work drowsy is fairly well known (Scott 2007, Dorrian 2006). While that applies to drowsiness after any shift, it is more prevalent after night shifts. Working while tired also predisposes to more needle sticks, stress levels, and other health issues.


The new sentinel event alert focuses on the consequences of fatigue to both patients and workers and has a good review of the literature, primarily from studies on nurses working extended (>12 hour) shifts and studies looking at the impact of long resident duty hours. The alert provides many good recommendations, many of which are common sense and many of which come from studies on fatigue from organizations like NASA.


First, and foremost, they recommend you assess your organization’s risks for fatigue-related events. While virtually all hospitals keep logs of nursing shifts worked, they almost never keep logs of other healthcare workers’ hours (other than resident hours in teaching hospitals). And when was the last time you saw a graphic presentation of hours worked at one of your quality improvement/patient safety meetings or a Board meeting?


Second, they recommend reviewing your organization’s policies, procedures, and practices for handoffs. Handoffs are high-risk times for patients and fatigued staff may make handoffs even more error-prone. But also keep in mind that most interventions for reducing worker fatigue will also increase the number of handoffs that occur, so we are continuously balancing the effects of both.


Third, they recommend having staff provide input into design of work schedules. (But our caveat: Beware that the desired schedules of workers may not eliminate fatigue. Very often nurses prefer 12-hour shifts because it provides them with more personal time. But that does not guarantee they will be functioning any less fatigued.).


Fourth, implement fatigue management strategies. We’ve discussed the value of naps during work shifts on numerous occasions. In our November 9, 2010 Patient Safety Tip of the Week “12-Hour Nursing Shifts and Patient Safety” we did discuss some of the issues related to working long shifts, varying shifts, consecutive shifts, and night shifts. In that Tip we referred to an excellent 3-part series this year “Is It Time to Pull the Plug on 12-Hour Shifts?” by Geiger-Brown and colleagues. Part 3 of that series contained some great suggestions for protecting nurses working the night shifts (use of “buddy” systems, planned “power naps”, avoiding certain types of tasks during the body’s circadian nadir around 2-4 AM, and encouraging nurses to speak up when they are tired).


In our April 26, 2011 Patient Safety Tip of the Week “Sleeping Air Traffic Controllers: What About Healthcare?” we discussed a study (Fallis 2011) providing timely discussion about napping on the night shift. Fallis and colleagues provide a detailed discussion about the literature on fatigue and threats to both patient and personal safety in nurses (and other healthcare workers) on the night shift and the literature on the effects of napping on night shifts in multiple industries. They then did focused interviews with 13 experienced nurses working the night shift in the emergency room or ICU setting in a community hospital in Canada. Ten of the 13 described themselves are “regular” nappers on the night shift (meaning that they often took brief naps on scheduled breaks if circumstances permitted). Three major themes evolved: the environmental scan, the impact of napping, and the consequences of not napping. The environmental scan was an analysis of all the variables taken into consideration in making a decision as to whether a nap was feasible. Those included things like how busy the unit was, what the mix of experienced vs. inexperienced nurses was, who was available for relieving them, and whether anyone was working a double shift.


The impact of napping could be positive or negative. Most of the regular nappers noted a positive impact, such as awakening refreshed and able to think more clearly. But naps are not for everyone. One of the downsides of naps is occasionally awakening and temporarily feeling disoriented and slow to respond or the phenomenon of “sleep inertia”. Almost a quarter of the interviewees in the Fallis study mentioned this and it was the primary reason that several of them had become “non-nappers”.


The consequences of not napping included slowed mental processes and “foggy thinking”. Nurses found themselves having to check things multiple times. They gave examples of missing arrhythmias on telemonitoring screens because of decreased vigilance. Many found the period between 4AM and 6AM to be most vulnerable. (Note that almost all studies on fatigue and sleepiness on the night shift do identify a roughly two-hour period where concentration abilities are at their worst but the exact time of that nadir differs from study to study).


The sentinel event alert notes that you must provide the proper environment (including ensuring staff are truly going to be allowed to nap without interruptions) for naps or sleep breaks. In our April 26, 2011 Patient Safety Tip of the Week “Sleeping Air Traffic Controllers: What About Healthcare?” we noted that putting systems in place to allow napping on the night shift is not easy. First, you have to provide adequate “relief” staffing to ensure full coverage of your units at all times. You already must do this for other breaks (meal breaks, bathroom breaks, etc.) that nurses need on any shift. Most nurses will tell you they often work shifts with no breaks at all because of staffing shortages or mismatches between staffing and patient acuity. Second, you need to provide an appropriate physical environment conducive to taking a brief nap (quiet and comfortable, free from interruptions, yet close enough for the nurse to be aroused to respond to patient care emergencies). Third, you need to have in place a system of prioritization in which naps would be allowed only if all preset criteria are met. And lastly you need to have in place a management culture that recognizes the problem as real and is supportive of efforts to address the problem rather than approach it in a punitive manner.


Many (or most) nurses may have difficulty napping if they have one or more patients who are unstable. One other barrier mentioned by several nurses in the Fallis study was fear of what the public would think about nurses “napping on the job”. Given the news media responses in the recent air traffic controller cases, it is clear that raising public awareness about the dangers of fatigue and the benefits of napping under appropriate circumstances is very important.


In addition to providing for naps, the sentinel event alert recommends things like strategic caffeine consumption, doing something involving physical action, and engaging in conversations.


Fifth, the sentinel event alert recommends educating your staff about sleep hygiene improvement techniques and educating them about the effects of fatigue on patient safety and their own safety.


And the alert notes the importance of your culture of safety. Staff must have the opportunity to express concerns about fatigue and be supported (with action, not just words) when those concerns are raised. They recommend use of teamwork when working extended shifts and use of things like independent double checks for critical tasks. (But another caveat from us: Prior studies in nursing (Dorrian 2006) concluded that less sleep may lead to the increased likelihood of making an error, and importantly, the decreased likelihood of catching someone else's error.)


Lastly, you always need to consider whether fatigue was a contributing factor when you are doing root cause analyses (RCA’s) of untoward events or near misses.



Overall, this sentinel event alert is timely and practical. But also keep in mind that when you do undertake an intervention, be sure that your intervention does not inadvertently increase the problem! See our January 3, 2012 Patient Safety Tip of the Week Unintended Consequences of Restricted Housestaff Hours”.








The Joint Commission. Sentinel Event Alert. Health care worker fatigue and patient safety. Issue #48. December 14, 2011




Scott LD, Hwang W-T, Rogers AE, et al. The Relationship between Nurse Work Schedules, Sleep Duration, and Drowsy Driving. Sleep 2007; 30(12): 1801-1807




Dorrian J, Lamond N, van den Heuvel C, et al. A Pilot Study of the Safety Implications of Australian Nurses' Sleep and Work Hours. Chronobiology International 2006; 23(6): 1149–1163




Geiger-Brown J. Trinkoff AM. Is It Time to Pull the Plug on 12-Hour Shifts? Part 3. harm reduction strategies if keeping 12-Hour Shifts. Journal of Nursing Administration 2010;  40(9): 357-9, 2010 Sep




Fallis, WM, McMillan DE, Edwards MP. Napping During Night Shift: Practices, Preferences, and Perceptions of Critical Care and Emergency Department Nurses

Crit Care Nurse March 31, 2011 vol. 31 no. 2 e1-e11







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CAUTI’s Still Get No Respect



In our January 8, 2008 Patient Safety Tip of the Week “Urinary Catheter-Associated Infections” we noted a study by Sanjay Saint, M.D. and colleagues at the University of Michigan (Saint 2008) showing that 56% of hospitals did not have a system for monitoring which patients had urinary catheters placed, and 74% did not monitor catheter duration. Thirty percent of hospitals reported regularly using antimicrobial urinary catheters and portable bladder scanners; 14% used condom catheters, and only 9% used catheter reminders.


In 2008 CMS implemented its plan to stop payment for various hospital-acquired infections (HAI’s), including catheter-associated urinary tract infections (CAUTI’s). It would be anticipated that most hospitals would have adopted best practices to reduce their CAUTI rates as well as the rates of other HAI’s. So Saint and colleagues (Krein 2011) did another nationwide survey to see how practices changed since that time. They found that most hospitals had put an increased priority on avoiding CLABSI, VAP and CAUTI. But, whereas most hospitals had implemented multiple practices to prevent CLABSI and VAP, only one CAUTI prevention practice was used by at least 50% of hospitals. They also note that CLABSI and VAP rates nationwide have declined but CAUTI rates have not.


They note that for CLABSI and VAP there have been “bundles” of recommended best practices and large collaboratives focusing on reducing these complications but such have been scant for CAUTI. They also feel that the CMS payment rule probably has had little impact on the rates.


The system you put in place should have both a pre-emptive component and a surveillance component. The pre-emptive component can be either low-tech or hi-tech. The simple colored sticker alert shown in our January 8, 2008 Patient Safety Tip of the Week “Urinary Catheter-Associated Infections” has given way to computerized physician order entry (CPOE) order entry screens that request indication and expected duration any time someone orders a Foley catheter. Adding lines for indication and duration to standardized order sets or pre-printed order sheets can also be effective. Alternatives to Foley catheters may include condom catheters in males or intermittent catheterization and use of portable bladder scanners may reduce the need for any kind of catheter in the first place.


The second component of your system is the surveillance component. That means assessing all patients with urinary catheters to see if they still need them. We routinely look for unnecessary catheters during patient safety “walk rounds” and so should you. However, you need a system in place so they are looked for on a daily basis. Make this activity a “checklist” item on nursing rounds or teaching rounds. Also, if your hospital uses a barcode system to track inventory, adapt that system to alert you to every patient to whom a catheter was attached. Educating your patients to question why they need or still need a catheter should be part of your patient-oriented patient safety program.


And, of course, good nursing care for those catheters that are indicated is also crucial.

Be sure to include monitoring and measuring in your QI activities because the initial Hawthorne effect of implementing such a system often fades with time. Posters and screensavers about preventing CAUTI’s may generate some enthusiasm for your program early on but you need more to ensure durability of your program long-term. Feedback and celebrating success are important in that regard.







Saint S, Kowalski CP, Kaufman SR, et al. Preventing Hospital-Acquired Urinary Tract Infection in the United States: A National Study. Clinical Infectious Diseases 2008; 46: 243–250




Krein SL, Kowalski CP, Hofer TP, Saint S. Preventing Hospital-Acquired Infections: A National Survey of Practices Reported by U.S. Hospitals in 2005 and 200 Gen Intern Med 2011; published online December 6, 2011






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Need for New Transfusion Criteria?



There continues to be great debate about the role of transfusions in patients undergoing surgical procedures. In our March 2011 What’s New in the Patient Safety World column “Downside of Transfusions in Surgery” we discussed the mounting evidence that transfusions during surgery are associated with increased morbidity and mortality. We also noted that some performance improvement programs were successful in reducing the frequency of transfusions and resulted in considerable cost savings.


But a recent study (Musallam 2011) using the American College of Surgeons’ NSQIP database showed that preoperative anemia, even when mild, was independently associated with increased risk of 30-day morbidity and mortality in patients undergoing major non-cardiac surgery.


No one disputes the findings of the Musallam study. But it does not specifically answer the question: “Does correction of anemia by transfusion improve morbidity and mortality in surgical patients?”. Newly published results of the FOCUS study (Carson 2011) do address this question. This study looked at over 2000 patients, aged 50 or older and having risk factors for cardiovascular disease, who were undergoing surgery for hip fracture. All patients had hemoglobin levels below 10 gm per deciliter. They randomized the patients to a “liberal” transfusion strategy or a “restrictive” strategy. The liberal strategy allowed transfusion at a hemoglobin threshold of 10 gm or below. The restrictive strategy used a hemoglobin threshold below 8 gm. Transfusions could be given for symptomatic anemia in either strategy. They found no statistically significant difference between the 2 strategies for the primary outcome of death or inability to walk across a room without human assistance at 60 days. There was also no statistically significant difference between the 2 strategies for in-hospital acute coronary syndrome or death or 60-day mortality. Rates of other complications were also similar, though the study was not powered to fully assess all the latter.


The FOCUS study and the accompanying editorial (Barr 2011) recommend that the decision to transfuse should be based upon a combination of signs, symptoms and laboratory values and not just based upon a single hemoglobin level but that more restrictive transfusion policies may be safe and likely to be cost-effective.


Changing practice, though, is likely to be more difficult. In our August 2011 What’s New in the Patient Safety World column “CPOE Alerts Reduce Blood Transfusions in Children” we cited a study in children (Adams 2011) which demonstrated that evidence-based rules to alert physicians if parameters were outside those recommended for transfusion successfully reduced RBC transfusions. But not all attempts to use clinical decision supports within CPOE have been successful in reducing unnecessary transfusions. At Brigham and Women’s Hospital (Scheurer 2010) studied appropriateness of transfusions 2 years after transfusion guidelines were instituted and clinical decision support tools implemented within CPOE. Over half the transfusions ordered were still considered inappropriate 2 years after implementation. It was found that decision support was bypassed altogether in two-thirds of transfusion orders (by indicating “active bleeding” even though chart review failed to substantiate that in almost half the cases) and that over two-thirds of the overrides indicated a superior had instructed the transfusion. The authors conclude that clinical decision support, by itself, is not likely to eliminate inappropriate transfusions and that other front-end interventions aimed at the decision maker are likely needed. The authors felt that this study showed that the decision to transfuse had “already been made” prior to the CPOE so that, in effect, the clinical decision support was rendered too late. In addition, they felt that CPOE targeted the intern or more junior resident in most cases and might be better directed toward the more senior clinicians making the decision to transfuse.


So, while best practices may be developing to be more conservative regarding transfusions, best practices for implementing such practices are lagging behind. Audit and constructive feedback may prove more fruitful than CPOE reminders.






Musallam KM, Tamim HM, Richards T, et al.  Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study

The Lancet 2011; 378(9800): 1396 - 1407, 15 October 2011




Carson JL, Terrin ML, Noveck H, et al. Liberal or Restrictive Transfusion in High-Risk Patients after Hip Surgery. NEJM 2011; published online first December 14, 2011




Barr PJ, Bailie KEM. Transfusion Thresholds in FOCUS (editorial). NEJM 2011; published online first December 14, 2011




Adams ES, Longhurst CA, Pageler N. Computerized Physician Order Entry With Decision Support Decreases Blood Transfusions in Children. Pediatrics 2011; 127(5): e1112 -e1119  (doi: 10.1542/peds.2010-3252)




Scheurer DB, Roy CL, McGurk S, Kachalia A. Effectiveness of Computerized Physician Order Entry with Decision Support to Reduce Inappropriate Blood Transfusions. JCOM 2010; 17(1): 17-26






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Safely Doing Less



A much needed commentary on patient safety recently appeared in the pediatric literature. Schroeder, Harris, and Newman (Schroeder 2011), in commenting on the American Academy of Pediatrics recent policy statement Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care, note that missing in almost all the literature on patient safety is a statement about avoiding many of those interventions that eventually cause harm.


When we do a root cause analysis (RCA) after an untoward incident or near-miss one of the first questions we usually ask is “Was the procedure/surgery/medication indicated?”. You’d be surprised how many organizations fail to consider that during their RCA’s.


There are plenty of examples of improving patient safety by doing less. We know that the most important step in reducing healthcare-associated infections like CAUTI’s and CLABSI’s is avoiding unnecessary use of the catheters in the first place. And we see over and over again complications of procedures that were done for ambiguous indications. A recent article in the Archives of Internal Medicine “Less is More” series (Sirovich 2011) found that many US primary care physicians believe that their own patients are receiving too much medical care. They cite the need for malpractice reform, realignment of financial incentives, and more time with patients to remove pressure on physicians to do more than they feel is needed. And another recent article in that series (Bellizzi 2011) showed that a high percentage of older adults continue to be screened for colorectal, breast, cervical, and prostate cancers in the face of ambiguity of recommendations for this group. Complications may occur from those screening directly or related to the actions the results lead to.


So we agree wholeheartedly: safely do less!






Schroeder AR, Harris SJ, Newman TB. Safely Doing Less: A Missing Component of the Patient Safety Dialogue (Commentary). Pediatrics 2011; 128:e1596-e1597




Steering Committee on Quality Improvement and Management and Committee on Hospital Care. Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care. Pediatrics 2011; 127: 1199-1210




Sirovich BE, Woloshin S, Schwartz LM. LESS IS MORE. Too Little? Too Much? Primary Care Physicians' Views on US Health Care. A Brief Report. Arch Intern Med. 2011; 171(17): 1582-1585




Bellizzi KM, Breslau ES, Burness A, Waldron W. LESS IS MORE. Prevalence of Cancer Screening in Older, Racially Diverse Adults. Still Screening After All These Years. Arch Intern Med. 2011; 171(22): 2031-2037





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AHRQ’s New Medication Reconciliation Tool Kit



In 2005 Joint Commission included medication reconciliation as one of its national patient safety goals (NPSG’s). However, because of the considerable difficulties organizations encountered in implementing medication reconciliation and lack of clearcut best practices, Joint Commission temporarily removed grading of compliance with the standard from formal accreditation surveys.


In 2009 the Society of Hospital Medicine convened a conference of key stakeholders, including IHI and ISMP among others, to develop a consensus statement and key priniciples and necessary first steps in making medication reconciliation patient centered, clinically relevant, and implementable (Greenwald 2010). While they reaffirmed that medication reconciliation must take place across all transitions of care, they recognized that a phased approach, tailored to local organizational structures and workflows, was probably necessary for overall success. They also identified the need for development of clinically meaningful measures of medication reconciliation and alignment of reimbursement systems with medication safety goals. They strongly encouraged clinical research into best practices for medication reconciliation and dissemination of lessons learned and best practices from multiple organizations.


AHRQ has just published its new toolkit “Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation” (Gleason 2011). The toolkit starts at square one and discusses getting leadership buy in to medication reconciliation as a key patient safety program and developing the business case for medication reconciliation. It has good recommendations about building teams, mapping workflows, developing tools, educating and rollout strategies, metrics and monitoring, piloting projects, and involving the patient and families.


A few of their key lessons learned:


·        There is no electronic substitution for a thorough medication interview with patients and/or their caregivers to obtain and verify current medication regimens.

·        Medication reconciliation should be an integral part of handoffs and communication during transitions in care.

·        The patient plays a key role in medication reconciliation and should be educated on the importance of managing medication information at the time of discharge or at the end of an outpatient encounter.

·        They stress the importance of the patient giving a list to their primary care provider, updating their own list when medications are discontinued, doses are changed, or new medications (including OTC’s) are added, and carrying their medication information at all times in case of an emergency.

·        They also stress the importance of enlisting the support of primary care physicians and community pharmacists to encourage patients to carry and update their medication list at every encounter.


They also stress integrating medication reconciliation into processes other than just transitions of care. They recommend integrating medication review and reconciliation in daily rounds so medications can be reviewed at the point when clinical decisions are made and modified accordingly.


They provide good tips for medication interviews with patients and families, and good tips for your discussions with physicians.


They have lots of good examples of tools, forms, scripts, etc. that will be helpful to you regardless of whether your organization is still struggling with medication reconciliation or whether you have well-developed processes.






Greenwald JL, Halasyamani L, Greene J, et al. Making inpatient medication reconciliation patient centered, clinically relevant and implementable: A consensus statement on key principles and necessary first steps. Journal of Hospital Medicine 2010; 5(8): 477–485




Gleason KM, Brake H, Agramonte V, Perfetti C. Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation. (Prepared by the Island Peer Review Organization, Inc., under Contract No. HHSA2902009000 13C.) AHRQ Publication No. 11(12)-0059. Rockville, MD: Agency for Healthcare Research and Quality. December 2011.





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Print “January 2012 What's New in the Patient Safety World (full column)

Print “January 2012 Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety

Print “January 2012 CAUTI’s Still Get No Respect

Print “January 2012 Need for New Transfusion Criteria?

Print “January 2012 Safely Doing Less

Print “January 2012 AHRQ’s New Medication Reconciliation Tool Kit













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