Patient Safety Tip of the Week Archive

What’s New in the Patient Safety World

May 2019

· WHO Surgical Safety Checklist Cut Mortality 37% in Scotland

· ECRI 2019 Top 10 Patient Safety Concerns

· Too Much Time on the EMR

· Focus on Prophylactic Antibiotic Duration

WHO Surgical Safety Checklist Cut Mortality 37% in Scotland

We’re, of course, big fans of the use of checklists in healthcare. We’ve done several columns on the successes of the WHO Surgical Safety Checklist. Our July 1, 2008 Patient Safety Tip of the Week “WHO’s New Surgical Safety Checklist” described the tool and provided the link to download the checklist tool and instructions how to use it. We also discussed checklist design and use in our September 23, 2008 Patient Safety Tip of the Week “Checklists and Wrong Site Surgery”.

In our January 20, 2009 Patient Safety Tip of the Week “The WHO Surgical Safety Checklist Delivers the Outcomes” we discussed the striking improvements in patient outcomes following implementation of the WHO Surgical Safety Checklist at hospitals in eight different countries. Haynes and colleagues (Haynes 2009) demonstrated that mortality at 30-days post-op decreased from 1.5% before introduction of the checklist to 0.8% after. Rate of any complication decreased from 11% to 7%. Both these outcomes were highly statistically significant. That’s a relative risk reduction of approximately 36% for mortality and major morbidity!

But, in our April 2014 What's New in the Patient Safety World column “Checklists Don’t Always Lead to Improvement” we noted a study that showed, despite widespread adoption in over 100 hospitals in Ontario, Canada, a surgical checklist failed to demonstrate significant reductions in adjusted rates for mortality or complications (Urbach 2014). The rate of any complication decreased from 3.86% to 3.82% and mortality at 30-days post-op decreased from 0.71% to 0.65% in Canadian study, neither being statistically significant. There was also no significant changes in rates of hospital readmission and emergency department visits within 30 days after discharge. This result was surprising, especially since self-reported compliance with the checklist was over 90% at almost all participating hospitals. We discussed some of the reasons that study may have failed to demonstrate significant improvement after implementation of the checklist.

But in that April 2014 What's New in the Patient Safety World column “Checklists Don’t Always Lead to Improvement” we also noted several other examples where the WHO Surgical Safety Checklist or similar checklists have led to substantial improvements in perioperative outcomes. We also noted other studies demonstrating improvements after implementation of the Surgical Safety Checklist in our What's New in the Patient Safety World columns for May 2015 “The Great Checklist Debate” and May 2017 “Another Success for the Safe Surgery Checklist”.

Now another study from Scotland (Ramsay 2019) showed that implementation of the WHO Surgical Safety Checklist produced striking improvement in mortality. The WHO Surgical Safety Checklist was implemented in Scotland as part of a broader patient safety initiative between 2008 and 2010, Analyzing almost 7 million surgical cases between 2000 and 2014, the researchers found a 37% reduction in mortality. There was no such improvement trend for non-surgical cases over the same timeframe. While some improvement may have been related to other factors, the authors attribute the striking success to adoption of the WHO Surgical Safety Checklist.

Of course, implementing a checklist does not guarantee that it will be fully adhered to. In commenting a Norwegian study (Haugen 2015), several of the coauthors of the original WHO study pointed out that the Norwegian study showed a “dose effect” in that larger reductions in complications were seen when all portions of the checklist were followed (Haynes 2015).

We hope you’ll look at some of the recommendations about how to implement checklists in our November 20, 2018 Patient Safety Tip of the Week “Checklist Implementation” and our many prior columns on checklists listed below.

Some of our prior columns on checklists:

June 5, 2007 “Patient Safety in Ambulatory Surgery”
July 24, 2007 “Serious Incident Response Checklist”
March 11, 2008 “Lessons from Ophthalmology”
July 1, 2008 “WHO’s New Surgical Safety Checklist”
September 23, 2008 “Checklists and Wrong Site Surgery”
November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
November 25, 2008 “Wrong-Site Neurosurgery”
January 20, 2009 “The WHO Surgical Safety Checklist Delivers the Outcomes”
January 19, 2010 “Timeouts and Safe Surgery”
June 2010 “WHO Checklist for Radiological Interventions”
June 8, 2010 “Surgical Safety Checklist for Cataract Surgery”
July 6, 2010 “Book Reviews: Pronovost and Gawande”
September 14, 2010 “Wrong-Site Craniotomy: Lessons Learned”
November 30, 2010 “SURPASS: The Mother of All Checklists”
December 6, 2010 “More Tips to Prevent Wrong-Site Surgery”
February 2011 “SURPASS Checklist Reduces Malpractice Claims”
March 2011 “Michigan ICU Collaborative Wins Big”
June 6, 2011 “Timeouts Outside the OR”
August 16, 2011 “Crisis Checklists for the OR”
July 2012 “VA Checklist Reduces Suicide Risk”
July 2012 “WHO Safe Childbirth Checklist”
October 2012 “Another PCA Pump Safety Checklist”
February 2013 “Checklists for Surgical Crises”
April 2014 “Checklists Don’t Always Lead to Improvement”
May 2015 “The Great Checklist Debate”
August 25, 2015 “Checklist for Intrahospital Transport”
September 1, 2015 “Smarter Checklists”
September 15, 2015 “Another Possible Good Use of a Checklist”
September 13, 2016 “Vanderbilt’s Electronic Procedural Timeout”
November 2016 “Oxygen Tank Monitoring”
November 1, 2016 “CMS Emergency Preparedness Rule”
January 10, 2017 “The 26-ml Applicator Strikes Again!”
May 2017 “Another Success for the Safe Surgery Checklist”
May 2, 2017 “Anatomy of a Wrong Procedure”
June 2017 “Another Way to Verify Checklist Compliance”
August 22, 2017 “OR to ICU Handoff Success”
November 28, 2017 “More on Dental Sedation/Anesthesia Safety”
December 12, 2017 “Joint Commission on Suicide Prevention”
December 19, 2018 “More on Overlapping Surgery”
February 2018 “Oxygen Cylinders Back in the News”
October 30, 2018 “Interhospital Transfers”
November 20, 2018 “Checklist Implementation”

References:

WHO Surgical Safety Checklist

http://www.who.int/entity/patientsafety/safesurgery/tools_resources/SSSL_Checklist_finalJun08.pdf

Haynes A, Weiser T, Berry W, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360(5): 491-499

http://www.nejm.org/doi/full/10.1056/NEJMsa0810119#t=articleTop

Urbach DR, Govindarajan A, Saskin R, et al. Introduction of Surgical Safety Checklists in Ontario, Canada. N Engl J Med 2014; 370: 1029-1038

http://www.nejm.org/doi/full/10.1056/NEJMsa1308261

Ramsay G, Haynes AB, Lipsitz SR, et al. Reducing surgical mortality in Scotland by use of the WHO Surgical Safety Checklist. British Journal of Surgery 2019; Early access 16 April 2019

https://onlinelibrary.wiley.com/doi/10.1002/bjs.11151

Haugen AS, Søfteland E, Almeland SK, et al. Effect of the World Health Organization Checklist on Patient Outcomes: A Stepped Wedge Cluster Randomized Controlled Trial. Annals of Surgery 2015; 261(5): 821-828

http://journals.lww.com/annalsofsurgery/Fulltext/2015/05000/Effect_of_the_World_Health_Organization_Checklist.1.aspx

Haynes AB, Berry WR, Gawande AA. What Do We Know About the Safe Surgery Checklist Now? Annals of Surgery 2015; 261(5): 829-830

http://journals.lww.com/annalsofsurgery/Fulltext/2015/05000/What_Do_We_Know_About_the_Safe_Surgery_Checklist.2.aspx

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ECRI 2019 Top 10 Patient Safety Concerns

Every year ECRI Institute publishes its list of the “Top 10 Patient Safety Concerns for Healthcare Organizations”.

This year’s ECRI Top 10 list (ECRI 2019):

1. Diagnostic Stewardship and Test Result Management Using EHRs

2. Antimicrobial Stewardship in Physician Practices and Aging Services

3. Burnout and Its Impact on Patient Safety

4. Patient Safety Concerns Involving Mobile Health

5. Reducing Discomfort with Behavioral Health

6. Detecting Changes in a Patient’s Condition

7. Developing and Maintaining Skills

8. Early Recognition of Sepsis across the Continuum

9. Infections from Peripherally Inserted IV Lines

10. Standardizing Safety Efforts across Large Health Systems

We’ve covered most of these topics in numerous columns. As usual, we’ll only comment on a few of this year’s topics and let you go to the ECRI document for details of these and all the others.

ECRI’s #1 would also be our #1. It deals with ensuring that we have systems in place to follow up on all diagnostic studies and ways to communicate results to all appropriate parties. While it focuses on using EHR’s for this purpose, it clearly notes the importance of using all forms of communication to ensure “closing the loop”.

New to this year’s list is #9 “Infections from Peripherally Inserted IV Lines”. So add infection risk to the complications of peripheral IV’s we discussed in our February 26, 2019 Patient Safety Tip of the Week “Vascular Access Device Dislodgements”.

The ECRI report also has links to ECRI’s many fine resources for each topic. We’ll let you go to the full ECRI list for details. Click here to go to the ECRI Institute site where you can download the list. And see the links to our many columns on “closing the loop” listed below.

See also our other columns on communicating significant results:

May 1, 2007 “The Missed Cancer”
February 12, 2008 “More on Tracking Test Results”
October 13, 2009 “Slipping Through the Cracks”
July 2009 “Failure to Inform Patients of Clinically Significant Outpatient Test Results”
March 9, 2010 “Communication of Urgent or Unexpected Radiology Findings”
March 1, 2011 “Tests Pending at Discharge”
August 21, 2012 “More on Missed Followup of Tests in Hospital”
October 2, 2012 “Test Results: Everyone’s Worst Nightmare”
March 12, 2013 “More on Communicating Test Results”
October 2013 “New AHRQ Toolkit: Improving Your Office Testing Process”
January 2014 “Email Alerts for Pending Test Results”
July 2015 “Technology to Avoid Delays in Follow-up of Significant Results”
November 17, 2015 “Patient Perspectives on Communication of Test Results”
December 20, 2016 “End-of-Rotation Transitions and Mortality”
September 2018 “ECRI Institute Partnership: Closing the Loop”

References:

ECRI Institute. Top 10 Patient Safety Concerns for 2019. ECRI Institute 2019

https://www.ecri.org/landing-top-10-patient-safety-concerns-2019

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Too Much Time on the EMR

Our April 2017 What's New in the Patient Safety World column “How Much Time Do We Actually Spend on the EMR?” discussed numerous studies documenting how much time various healthcare professionals are spending on electronic medical records, often at the expense of time directly interacting with patients.

Now a recent observational study of interns (Chaiyachati 2019) found that they spent a mean of 15.9 hours of a 24-hour period (66%) in indirect patient care, mostly interactions with the patient’s medical record or documentation. A mean of only 3.0 hours was spent in direct patient care (13%) and 1.8 hours in education (7%). This pattern was consistent across the 4 periods of the day. Direct patient care and education frequently occurred when interns were performing indirect patient care. Multitasking with 2 or more indirect patient care activities occurred frequently. The study confirms that interns spend more time participating in indirect patient care than interacting with patients or in dedicated educational activities. It serves as a wakeup call that we need to investigate ways to better balance our time between direct and indirect patient care.

Our April 2017 What's New in the Patient Safety World column “How Much Time Do We Actually Spend on the EMR?” noted some studies showing how use of scribes or other forms of dictation support may lead to freeing up more time for direct patient care. But is also again raised a concern that we may neglect import elements of the EMR. In our March 22, 2011 Patient Safety Tip of the Week “An EMR Feature Detrimental to Teamwork and Patient Safety” we noted a study that had very bothersome results. Hripcsak and colleagues (Hripcsak 2011) analyzed time spent authoring notes and time spent reading notes in the EMR. They found most users spent 90 minutes a day authoring notes, 30 minutes a day reading notes. But the bothersome feature was a striking disparity in the rates of notes read that were authored by various healthcare workers. They found 97% of attending notes were read by someone and 99% of resident notes were read by someone. But fewer than 20% of nurses’ notes were read by attendings or residents! And only 38% of nurse’s notes were read by other nurses. 16% of all notes were never read by anyone!

Electronic medical records bring great opportunities to improve patient care but, in their current state of the art, have a tendency to intrude on workflows and detract from face-to-face interaction with our patients.

See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:

June 19, 2007 “Unintended Consequences of Technological Solutions”
May 20, 2008 “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?”
June 17, 2008 “Technology Workarounds Defeat Safety Intent”
August 26, 2008 “Pattern Recognition and CPOE”
September 9, 2008 “Less is More….and Do You Really Need that Decimal?”
December 16, 2008 “Joint Commission Sentinel Event Alert on Hazards of Healthcare IT”
February 2009 “Healthcare IT The Good and The Bad”
March 3, 2009 “Overriding Alerts…Like Surfin’ the Web”
October 2009 “A Cautious View on CPOE”
November 24, 2009 “Another Rough Month for Healthcare IT
April 20, 2010 “HIT’s Limited Impact on Quality To Date”
March 22, 2011 “An EMR Feature Detrimental to Teamwork and Patient Safety”
January 24, 2012 “Patient Safety in Ambulatory Care”
June 26, 2012 “Using Patient Photos to Reduce CPOE Errors”
June 2012 “Leapfrog CPOE Simulation: Improvement But Still Shortfalls”
July 17, 2012 “More on Wrong-Patient CPOE”
January 2013 “More IT Unintended Consequences”
April 30, 2013 “Photographic Identification to Prevent Errors”
October 8, 2013 “EMR Problems in the ED”
March 11, 2014 “We Miss the Graphic Flowchart!”
October 2014 “Ebola Exposes Fundamental Flaw”
January 2015 “Beneficial Effect of EMR on Patient Safety”
March 2015 “CPOE Fails to Catch Prescribing Errors”
March 31, 2015 “Clinical Decision Support for Pneumonia”
August 2015 “Newborn Name Confusion”
December 2015 “Opioid Alert Fatigue”
January 12, 2016 “New Resources on Improving Safety of Healthcare IT”
January 19, 2016 “Patient Identification in the Spotlight”
February 9, 2016 “It was just a matter of time…”
April 5, 2016 “Workarounds Overriding Safety”
May 2016 “Name Confusion in the Pharmacy”
May 3, 2016 “Clinical Decision Support Malfunction”
May 24, 2016 “Texting Orders – Is It Really Safe?”
August 23, 2016 “ISMP Canada: Automation Bias and Automation Complacency”
November 22, 2016 “Leapfrog, Picklists, and Healthcare IT Vulnerabilities”
January 2017 “Joint Commission Thinks Twice About Texting Orders”
February 28, 2017 “The Copy and Paste ETTO”
March 2017 “Yes! Another Voice for Medication e-Discontinuation!”
April 2017 “How Much Time Do We Actually Spend on the EMR?”
June 27, 2017 “Texting – We Told You So!”
August 1, 2017 “Progress on Wrong Patient Orders”
January 2018 “Can We Improve Barcoding?”
January 16, 2018 “Just the Fax, Ma’am”
January 30, 2018 “Texting Errors Revealed”
June 19, 2018 “More EHR-Related Problems”
September 2018 “More Clinical Decision Support Successes”

· December 11, 2018 “Another NMBA Accident”

· January 1, 2019 “More on Automated Dispensing Cabinet (ADC) Safety”

· February 5, 2019 “Flaws in Our Medication Safety Technologies”

References:

Chaiyachati KH, Shea JA, Asch DA, et al. Assessment of Inpatient Time Allocation Among First-Year Internal Medicine Residents Using Time-Motion Observations. JAMA Intern Med 2019; Published online April 15, 2019

https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2730353

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Focus on Prophylactic Antibiotic Duration

Prophylactic antibiotics are important for reducing the risk of surgical site infections (SSI’s) for many surgical procedures. We know from previous studies that benefits of antimicrobial prophylaxis are limited to the first 24 hours postoperatively. Hence, guidelines and patient safety initiatives have been focused not only on the timing of administration of prophylactic antibiotics, but also on ensuring that such are promptly discontinued following surgical procedures.

Most national guidelines and quality measures state that surgical antimicrobial prophylaxis be initiated <1 hour prior to surgery and discontinued <24 hours post-operatively, and <48 hours for cardiac surgery. Notably, several surgical societies have noted lack of evidence that continuing prophylactic antibiotics after wound closure reduces SSI’s and thus recommend cessation of prophylactic antibiotics at the time the wound has been closed, with certain exceptions (Ban 2017).

A new study focused on the harms of longer duration of exposure to such prophylactic antibiotics (Branch-Elliman 2019). The study looked at patients who underwent cardiac, orthopedic total joint replacement, colorectal, and vascular procedures within the national Veterans Affairs health care system. The researchers separated duration of postoperative antimicrobial prophylaxis into the following categories: <24 hours, 24-<48 hours, 48-<72 hours, and ≥72 hours. They found that increasing duration of antimicrobial prophylaxis was associated with higher odds of acute kidney injury (AKI) and C difficile infection in a duration-dependent fashion. Extended duration did not lead to additional SSI reduction.

Number needed to harm (NNH) is a concept that puts the issue in a perspective that often emphasizes the size effect of an intervention. The researchers found that the NNH for AKI after 24 to less than 48 hours, 48 to less than 72 hours, and 72 hours or more of postoperative prophylaxis were 9, 6, and 4, respectively. For C difficile infection the NNH were 2000, 90, and 50, respectively.

These results reinforce that stewardship efforts to limit duration of prophylaxis have the potential to reduce adverse events without increasing SSI.

References:

Ban KA, Minei JP, Laronga C, et al. American College of Surgeons and Surgical Infection Society: Surgical Site Infection Guidelines, 2016 Update. J Amer Coll Surg 2017; 224(1): 59-74

https://www.journalacs.org/article/S1072-7515(16)31563-0/fulltext

Branch-Elliman W, O’Brien W, Strymish J, et al. Association of Duration and Type of Surgical Prophylaxis With Antimicrobial-Associated Adverse Events. JAMA Surg 2019; Published online April 24, 201

https://jamanetwork.com/journals/jamasurgery/fullarticle/2731307

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