What’s New in the Patient Safety World
November 2007
More Patient Deaths
from Luer Misconnections
1000-fold overdoses by
Transposing “mg” for micrograms
FMEA on Neuromuscular
Blocking Agents
Cost of ICU Adverse
Events
ACR Guidance on MRI
Safety
Tracking Test Results
Guilty, Afraid, and
Alone - Struggling with Medical Error
November
2007
More Patient Deaths from Luer
Misconnections
Our July
10, 2007 Tip of the Week focused on catheter misconnections. The October 2007
issue of FDA Patient Safety News
highlights continued deaths from Luer misconnections and cites an excellent
summary article by Gallauresi, Eakle, and Morrison in Safe Practices in Patient Care. It includes
the history of the Luer connector, multiple real examples of misconnections,
and the state of the industry in its attempts to develop standards to avoid
this serious problem. It reiterates the recommendations of the 2006 Joint Commission Sentinel Event Alert
on this issue.
1000-fold Overdoses by Transposing “mg” for micrograms
The September 6, 2007 ISMP Safety Alert describes
the case of an infant who received a lethal
dose of zinc stemming from an error that occurred during the order entry and
compounding of a TPN solution. Because the automated compounder used for TPN
required entry of zinc in a micrograms/kg dose, the pharmacist converted the
micrograms/mL dose to a micrograms/kg dose. The pharmacist performed this
calculation correctly, but accidentally entered the zinc dose in the pharmacy
computer in mg, not micrograms. This resulted in a final concentration that was
a 1,000-fold overdose. The ISMP provides a very good root cause analysis of the
event, noting multiple system errors, and provides multiple recommendations for
safe practices.
FMEA Related to Neuromuscular Blocking Agents
In our July
31, 2007 Tip of the Week dedicated to errors in use of neuromuscular blocking
agents (MNBA’s), we recommended this is a good issue to address in FMEA
(Failure Mode and Effects Analysis) in your organization. Susan Paparella, from
ISMP, did exactly that in a recent issue of Journal of Emergency Nursing. The
ED staff had recognized NMBA’s as high-alert drugs and were contemplating their
removal from ED stores, to be replaced in kits prepared for rapid-sequence
intubation. FMEA is especially useful in such situations where change is to
take place, because it helps identify potential unintended consequences. The
article nicely describes how you do a FMEA exercise and provides examples for
scoring probability and severity and use of a hazard scoring matrix. She also
lists 10 other problems commonly encountered in emergency rooms that could be
candidates for FMEA.
Paparella, Susan RN, MSN Failure
Mode and Effects Analysis: A Useful Tool for Risk Identification and Injury
Prevention. Journal of Emergency Nursing.
33(4):367-371, August 2007
Cost of adverse events in
intensive care units
Our
August 21, 2007 Tip of the Week quantified the cost of several complications
that are potentially preventable. Add to that the costs of adverse events in
ICU’s. Kaushal et al have just published a study of the cost for adverse events
in ICU’s. The average cost per adverse event for patients in the MICU was $3961
and the attributable increase in LOS was 0.77 days. Corresponding numbers for patients
in the CCU were $3857 and 1.08 days. The extrapolated annual cost for adverse
events in these two 10-bed ICU’s was nearly $1.5 million. Clearly, there is
significant opportunity for costs savings in prevention of adverse events in
this setting. Organizations looking for a good ROI (return on investment) in
their patient safety programs may want to focus on ICU’s.
Kaushal
R, Bates DW, Franz C, Soukup JR, Rothschild JM. Cost of adverse events in
intensive care units. Critical Care Med 2007; 35: 2479–2483
ACR Guidance Document for
Safe MR Practices: 2007
The
American College of Radiology issued its guidance document for safe MR
practices in the June issue of the American Journal of Radiology.
Kanal E
et al. ACR Guidance Document for Safe MR Practices: 2007. AJR 2007; 188: 1-27
Tracking Test Results
This one’s
not really new but we just came across it. In our May 1, 2007 Tip of the Week
we talked about the need for all physicians to have a system for tracking
patient test results to help avoid such disasters as the missed cancer. The
Kentucky Medical Association published a nice tool for Tracking Test Results Within a Physican
Practice. It provides solid advice on setting up a system in your
office, whether electronic or paper-based.
However,
even computerized alert and reminder systems aren’t 100% successful. Singh et al reported
followup on 1017 imaging report alerts transmitted electronically. They found
that over a third of the alerts went unacknowledged, including 4% of abnormal
results. Overall, 0.2% of outpatient imaging was lost to followup. Clearly, we
still have a long way to go in fixing the barriers and system issues in
ensuring test results get appropriately acknowledged and acted upon.
Singh
H, Arora HS, Vij MS, MDc, Rao R, Khan MM, Petersen LA. Communication Outcomes
of Critical Imaging Results in a Computerized Notification System .J Am Med
Inform Assoc. 2007; 14:459-466
Guilty, Afraid, and Alone –
Struggling with Medical Error
This
“Perspective” by Tom Delbanco and Sigall Bell in the October 25, 2007 issue of
the New England Journal of Medicine provides insights
gleaned from interviews with patients and families that had been affected by
medical error. It provides excellent insight into how those same emotions in
clinicians may further compound the emotions the patient or family is going
through. It’s another compelling example of why honest disclosure and sincere
apology are the right thing to do after medical error.
Delbanco
T, Bell SK. Guilty, Afraid, and Alone — Struggling with Medical Error.
NEJM 2007; 357:1682-1683
In addition to this month’s column below, there are 2 important new patient safety resources we’d like to point out:
(1) an excellent paper by ECRI Institute on how to get ready for the CMS final rule on Hospital-Acquired conditions. There is also a video and podcast available. You'll see that you should already have the coding end up and running now even though payment won't be withheld until October. It gives good recommendations on putting together a multidisciplinary team to get ready for this.
(2) AHRQ has made available 17 patient safety toolkits produced under it's Partnerships in Implementing Patient Safety (PIPS) grant program. We’ll be reviewing some of these in future Tip of the Week columns.
http://www.patientsafetysolutions.com
Patient
Safety Tip of the Week Archive
What’s New in the Patient Safety World Archive