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What’s New in the
Patient Safety World
June 2021
· ISMP
on Patch-Related Issues
· Does
Nurse-to-Patient Ratio Legislation Help?
· No
More Lead Aprons for Patients?
· Sleep
Hygiene Program Improves Sleep Quality for Hospitalized Patients
ISMP on
Patch-Related Issues
Transdermal medication patches are an effective way to
administer certain medications under appropriate circumstances. But there are
also dangers associated with their use. We’ve noted
that discarded patches may still contain active drug and children and pets may
be exposed to them. We’ve also noted how a second
patch may be applied to a patient’s skin, not recognizing the presence of
another patch, resulting in an overdose for the patient. And we’ve
also noted that patches containing metal or ferromagnetic components may
overheat during MRI scanning, resulting in burns. Most of our columns have
dealt with opioid patches, particularly Fentanyl, but problems may occur with
virtually any transdermal patch.
ISMP (Institute for Safe Medication Practices) recently
reported on more than 50 reports associated with 12 different transdermal
medication patches submitted to the ISMP MERP within the past 4 years (ISMP
2021). Patches most frequently involved in reported errors included fentaNYL (n = 16), cloNIDine
(n = 10), scopolamine (n = 7), and estradiol (n = 6). ISMP categorized the
problems in the following areas:
- Errors in the Frequency of
Patch Application or Removal
- Lack of Awareness of
Patches on the Patient’s Skin
- Dose Confusion Due to
Labeling
- Inappropriate Patch
Prescribing
- Wrong Dose Dispensing
Errors
- Patch Cover Applied
without the Medication Patch
- Wrong Patch Prescribed Due
to Similar Ingredients
- Miscellaneous Errors
ISMP reiterated the problem of failing to identify patches
on the patient’s skin, not removing an old patch when applying a new patch,
and/or finding multiple patches on patients that had been left on longer than
prescribed. Hospital admission may be a time of vulnerability to the first failure,
since a patch applied prior to admission might be easily overlooked. Failure to
recognize prior patches or presence of multiple patches on the skin of some
patients may be more likely with those patches that are clear or beige.
Inappropriate patch prescribing applied most often to fentaNYL patches. Our multiple columns on
long-acting opioids have stressed that these are intended for opioid-tolerant patients
and should not be prescribed for acute pain or in opioid-naïve patients.
We encourage you to read ISMP’s full article. It provides
examples in each of the above categories and provides very
important recommendations for all patches and for specific patch types.
Our prior articles pertaining to long-acting
and/or extended release preparations of opioids:
- April 2010 “RCA: Epidural Solution
Infused Intravenously”
- July 13, 2010 “Postoperative
Opioid-Induced Respiratory Depression”
- January 18, 2011 “More on Medication
Errors in Long Term Care”
- April 12, 2011 “Medication Issues in
the Ambulatory Setting”
- June 28, 2011 “Long-Acting and Extended-Release Opioid Dangers”
- September 13, 2011 “Do You Use Fentanyl Transdermal Patches Safely?”
- November 8, 2011 “WHO’s
Multi-Professional Patient Safety Curriculum Guide”
- May 2012 “Another Fentanyl Patch Warning from FDA”
- July 24, 2012 “FDA and Extended-Release/Long-Acting Opioids”
- September 2012 “Joint Commission
Sentinel Event Alert on Opioids”
- March 2013 “Try Googling Fentanyl Accidents”
- September 2013 “ISMP Outreach on Fentanyl Patch Safety”
- October 2013 “Opioid Safety Actions and Resources”
- February 24, 2015 “More Risks with Long-Acting Opioids”
- February 2017 “FDA Approves Even More
Long-Acting Opioids”
- February 12, 2019 “2 ER Drug Studies:
Reassurances and Reservations”
- February 2020 “The FDA and Long-Acting
Opioids”
- August 2020 “Fentanyl Patches in the
Crosshairs Again”
Our prior columns on
iatrogenic burns:
- March 2009 “Risk
of Burns during MRI Scans from Transdermal Drug Patches”
- June 1, 2010 “Iatrogenic
Burns”
- October 5, 2010 “More
Iatrogenic Burns”
- December 23, 2014 “Iatrogenic Burns in the News Again”
- March 2015 “Another Source of Iatrogenic Burns”
- September 5, 2017 “Another
Iatrogenic Burn”
- June 5, 2018 “Pennsylvania
Patient Safety Authority on Iatrogenic Burns”
- July 28, 2020 “Electrosurgical Safety”
- January 2021 “New MRI Risk: Face
Masks”
References:
ISMP (Institute for Safe Medication Practices). Analysis of
Transdermal Medication Patch Errors Uncovers a “Patchwork” of Safety
Challenges. ISMP Medication Safety Alert! Acute Care Edition 2021; 26(5): March
11, 2021
Print “June 2021 ISMP on Patch-Related Issues”
Does
Nurse-to-Patient Ratio Legislation Help?
We’ve done multiple columns
discussing how better nursing staffing leads to better patient outcomes and
improved patient safety. We’ve stressed the importance
of nurse workload rather than staffing levels per se. But most attempts
to improve nurse staffing have focused on nurse-to-patient ratios. What is the
evidence that just mandating a minimum nurse-to-patient ratio improves
outcomes? One of the problems is that all prior studies have been
before-and-after evaluations and none were
prospective.
A recent study from Queensland, Australia appears to answer
that. McHugh et al. (McHugh
2021) were able to prospectively compare patient outcomes at 27 hospitals
subject to minimum nurse-to-patient ratios (the “intervention” hospitals) with
28 hospitals that were not (the “comparison” hospitals).
After implementation, mortality rates
were not significantly higher than at baseline in comparison hospitals (adjusted
odds ratio 1.07) but were significantly lower than at baseline in intervention
hospitals (aOR 0.89). From baseline to post-implementation,
readmissions increased in comparison hospitals (1.06), but not in intervention
hospitals (1.00). Length of stay (LOS) decreased in both groups
post-implementation, but the reduction was more pronounced in intervention
hospitals than in comparison hospitals. Staffing improvements by one patient
per nurse produced reductions in mortality (OR 0.93), readmissions (0.93), and
LOS (adjusted incident rate ratio 0.97).
And here’s the key point for administrators and policy makers: in addition
to producing better outcomes, the costs avoided due to fewer readmissions and
shorter LOS were more than twice the cost of the additional nurse staffing. We
always add a point of caution when using formulas to impute cost savings from
fewer admissions and shortened length of stay – those savings would come from actually reducing personnel costs. Those hospitals that can
benefit the most from such reductions are those that can close a whole nursing
unit. Lesser reductions are more difficult to achieve. We also reiterate our
position that some flexibility is needed. Rather than just focusing on the
nurse-to-patient ratio, we need to match nurse workload to patient load. But
improving the nurse-to-patient ratio is a good first step.
We hope that the naysayers to mandated minimum
nurse-to-patient ratios who say such mandates would be too costly will look at
the results from Queensland and reassess their opposition to such mandates.
As pointed out in the editorial accompanying the McHugh
study (Ullman
2021), the current and likely near-future shortage of nurses makes
improving nurse-to-patient ratios challenging. Ullman calls for robust efforts
to boost the nursing workforce.
Some of our other columns on nursing workload and missed
nursing care/care left undone:
November 26, 2013 “Missed Care: New Opportunities?”
May 9, 2017 “Missed
Nursing Care and Mortality Risk”
March 6, 2018 “Nurse
Workload and Mortality”
May 29, 2018 “More
on Nursing Workload and Patient Safety”
October 2018 “Nurse
Staffing Legislative Efforts”
February 2019 “Nurse
Staffing, Workload, Missed Care, Mortality”
July 2019 “HAI’s
and Nurse Staffing”
September 1, 2020 “NY State and Nurse Staffing
Issues”
February 9, 2021 “Nursing Burnout”
References:
McHugh MD, Aiken LH, Sloane DM, et al. Effects of
nurse-to-patient ratio legislation on nurse staffing and patient mortality,
readmissions, and length of stay: a prospective study in a panel of hospitals.
The Lancet 2021; Published: May 11, 2021
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00768-6/fulltext
Ullman AJ, Davidson PM. Patient safety: the value of the
nurse. The Lancet 2021; Published: May 11, 2021
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00981-8/fulltext
Print “June 2021 Does Nurse-to-Patient Ratio
Legislation Help?”
No More Lead
Aprons for Patients?
The time-honored procedure of shielding patients’ gonads
from radiation with lead aprons during diagnostic radiology exams has come to
an end. In January 2021 both the American College of Radiology (ACR
2021) and the National Council on Radiation Protection and Measurement (NCRP
2021) announced that routine gonadal shielding during abdominal and pelvic
radiography is no longer recommended.
Gonadal shielding has been used since the 1950’s with the
rationale that it prevented radiation damage to reproductive organs and
consequent heritable genetic defects. The NCRP statement notes that the risks
of heritable genetic effects are now considered to be much less than previously
estimated and that improvements in technology since the 1950’s have resulted in
up to a 95 % reduction in the absorbed dose to pelvic organs from radiography.
It also notes that gonadal shielding can interfere with the
use of automatic exposure control, thereby causing an increase in dose to other
pelvic and abdominal organs that may be more radiosensitive. It also may not
completely shield the gonads in the majority of
patients due to the limited area of the shield and the normal variations in patient
anatomy. Moreover, a substantial portion of gonadal dose to the ovaries is
delivered by scattered x rays that are not attenuated by gonadal shielding.
Gonadal shielding also obscures portions of pelvic anatomy
and may obscure important findings on radiographs, limiting the practical
dimensions and area of the shield.
Thus, NCRP concludes that in most circumstances gonadal
shielding use does not contribute significantly to reducing risks from exposure
and may have the unintended consequences of increased exposure and loss of
valuable diagnostic information. Therefore, use of gonadal shielding is not
justified as a routine part of radiological protection.
NCRP notes that gonadal shielding may be used for circumstances
where a patient, parent or caregiver requests that gonadal
shielding be used. It recommends such requests for use of gonadal shielding
should be discussed to facilitate informed and mutual decision making. Information
should be provided that will help to answer the patient’s questions and
understand the risks and benefits. Gonadal shielding may be permissible when it
will not interfere with the purpose of the examination. If consent for the
examination cannot be obtained without its use, gonadal shielding use should
adhere to institutional or practice guidelines or policies that minimize or eliminate
the negative impact on diagnostic potential.
Acknowledging that many will question this move away from
such a time-honored practice, NCRP also issued a companion statement “Implementation
Guidance for Ending Routine Gonadal Shielding During Abdominal and Pelvic
Radiography”.
References:
ACR (American College of Radiology). NCRP Recommends Against
Routine Gonadal Shielding. American College of Radiology 2021; January 13, 2021
NCRP (National Council on Radiation Protection and
Measurement). NCRP Recommendations for Ending Routine Gonadal Shielding During
Abdominal and Pelvic Radiography. NCRP Statement No. 13, January 12, 2021
https://ncrponline.org/wp-content/themes/ncrp/PDFs/Statement13.pdf
NCRP (National Council on Radiation Protection and
Measurement). Implementation Guidance for Ending Routine Gonadal Shielding
During Abdominal and Pelvic Radiography. Companion to NCRP Statement No. 13,
January 12, 202
https://ncrponline.org/wp-content/themes/ncrp/PDFs/Stat13_Companion_Comm.pdf
Print “June 2021 No More Lead Aprons for Patients?”
Sleep Hygiene
Program Improves Sleep Quality for Hospitalized Patients
Our August 6, 2013
Patient Safety Tip of the Week “Let Me Sleep!” highlighted the problem of sleep deprivation
amongst hospitalized inpatients. Interference with sleep is also a contributing
factor to other problems, such as delirium. For years we’ve
espoused the “Say no to sleep meds” approach to hospitalized patients. That
means identifying the numerous things we do that prevent patients from getting
needed sleep and using nonpharmacological approaches to improve their sleep
while hospitalized.
Herscher et al. (Herscher
2021) recently reported on successful implementation of a
nonpharmacologic sleep hygiene intervention to improve sleep quality in hospitalized
patients. The intervention consisted of a bundle with the following components:
- A short script with sleep
hygiene prompts, such as whether patients would like the shades closed or
the lights turned off
- A sleep package including
an eye mask, earplugs, lavender scent pad, and non-caffeinated tea
- Relaxing music was played
at bedtime
- Signs promoting the
importance of quietness at night were placed around the unit
Their program also included provider education and use of front-line
“champions”.
Patients’ sleep was measured by the Richards-Campbell Sleep
Questionnaire (RCSQ). 931 patients received the intervention. A sample of
surveyed patients showed an increase in the RCSQ global score from 6.0 to 6.2
from the pre- to post- intervention periods (p = 0.041), plus increases in
three of the five individual survey components. In addition, there was an
improvement in the HCAHPS “quietness at night” score, from 34.1%
pre-intervention to 42.5% post-intervention.
Those results are modest and we
don’t know if they are sustainable or generalizable, but it is a step in the
right direction.
We recommend you go
back to our Patient Safety Tips of the Week for November 6, 2018 “More
on Promoting Sleep in Inpatients”
and March 16, 2021 “Sleep Program Successfully
Reduces Delirium” and our August
2019 What's New in the Patient Safety World column “Tools
for Reducing Sleep Meds in Hospitals” for more nonpharmacologic interventions
to promote healthier sleep in hospitalized inpatients.
Some of our previous
columns on safety issues associated with sleep meds and promoting sleep in
inpatients:
August 2009 “Bold
Experiment: Hospitals Saying No to Sleep Meds”
March 23, 2010 “ISMP
Guidelines for Standard Order Sets”
May 2012 “Safety of Hypnotic Drugs”
November 2012 “More on Safety of Sleep Meds”
March 2013 “Sedative/Hypnotics and Falls”
June 2013 “Zolpidem and Emergency Room Visits”
August 6, 2013 “Let Me Sleep!”
June 3, 2014 “More on the Risk of Sedative/Hypnotics”
May 15, 2018 “Helping
Inpatients Sleep”
June 2018 “Deprescribing
Benzodiazepine Receptor Agonists”
November 6, 2018 “More
on Promoting Sleep in Inpatients”
June 2019 “FDA
Boxed Warning on Sleep Meds”
August 2019 “Tools
for Reducing Sleep Meds in Hospitals”
March 16, 2021 “Sleep Program Successfully
Reduces Delirium”
References:
Herscher M, Mikhaylov
D, Barazani S, et al. A Sleep Hygiene Intervention to
Improve Sleep Quality for Hospitalized Patients. The Joint Commission Journal
on Quality and Patient Safety 2021; 47(6): 343-346. Published: February 10,
2021
https://www.jointcommissionjournal.com/article/S1553-7250(21)00032-5/fulltext
Print “June 2021 Sleep Hygiene Program Improves
Sleep Quality for Hospitalized Patients”
Print “June
2021 What's New in the Patient Safety World (full column)”
Print “June 2021 ISMP on Patch-Related Issues”
Print “June 2021 Does Nurse-to-Patient Ratio
Legislation Help?”
Print “June 2021 No More Lead Aprons for Patients?”
Print “June 2021 Sleep Hygiene Program Improves
Sleep Quality for Hospitalized Patients”
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