What’s New in the Patient Safety World

October 2011



·        IV Medication Administration Errors

·        Another Unintended Consequence of Hand Hygiene Device?

·        ISMP on Storytelling

·        The Procedural Sedation Debate Rages On

·        Surgeons’ Mode of Intraoperative Decision Making

·        ISMP Updates Look-Alike/Sound-Alike Drug List




IV Medication Administration Errors



A number of studies have shown high rates of adverse events related to IV administration of medications. Whereas many errors in earlier steps of the medication process may be intercepted before reaching the patient, the administration phase already reaches the patient, thus increasing the potential for serious outcomes.


A new study (Westbrook 2011) from Australia, using direct observation of nurses administering IV medications, found that in almost 70% of cases at least one error was made. Up to a quarter of these were considered potentially serious errors. Most of the errors fell into one of 4 categories and wrong rate was the most frequent. Bolus medications were most problematic.


There was little use of infusion pumps in the settings studied but errors still occurred in cases where such pumps were used.


The experience level of nurses was important. For every year of experience up to 6 years, they noted the risk of error decreased by 11%. After 6 years experience, there was no further change.


Failure to check the identification of the patient occurred in over 50% of cases and was significantly related to increased risk of error. While this was not a cause/effect releationship, the authors felt it likely served as an indicator of general failure to follow correct administration protocols. The authors suggest this variable could be used as a proxy measure for increased risk of clinical error. (Note that this concept is similar to the one in aviation we mentioned in our October 2, 2007 Patient Safety Tip of the Week “Taking Off From the Wrong Runway”in which pilots who routinely violate standard operating procedures such as the “sterile cockpit rule” are three times more likely to make other errors). Fortunately, use of BMV (bedside medication verification) barcoding techniques reduces such failures to identify patients. However, in some settings BMV is bypassed for IV medications or IV infusions.


The authors suggest targets for improvement might include more focus on training and supervision of new nurses doing medication administration, use of fewer bolus medications, and more feedback to all nurses on performance and errors during IV medication administration.


There is also a financial cost to IV medication errors. In our January 22, 2008 Patient Safety Tip of the Week “More on the Cost of Complications” we discussed a study (Nuckols 2008) that demonstrated IV adverse drug events in ICU’s resulted in $6647 higher costs and 4.8 day longer stays compared to control patients in academic ICU’s but no significant difference in cost or LOS in nonacademic ICU’s.






Westbrook JI, Rob MI, Woods A, Parry D. Errors in the administration of intravenous medications in hospital and the role of correct procedures and nurse experience. BMJ Qual Saf 2011; Published Online First: 20 June 2011




Nuckols TK. MD, Paddock S, Bower AG, Rothschild JM, Fairbanks RJ. Carlson B, Panzer RJ, Hilborne LH. Costs of Intravenous Adverse Drug Events in Academic and Nonacademic Intensive Care Units. Medical Care 2008; 46(1):17-24





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Another Unintended Consequence of Hand Hygiene Device?



In our May 2011 What’s New in the Patient Safety World column “The Best Laid Plans... Electronic Water Faucet Paradox” we noted the possible association of new automated water faucets with bacterial colonization, particularly Legionella species. Thus, an intervention intended to reduce transmission of infection possibly having the unintended consequence of actually increasing transmission of infection!


Now a new paper (Blaney 2011) raises a possible association between use of alcohol-based sanitizers and norovirus outbreaks in long-term care facilities. That, of course, does not mean that the alcohol-based hand sanitizers actually cause norovirus spread. More likely it means that they are simply not effective in eradicating norovirus from the hands. Keep in mind that we see a similar situation with C. difficile infections, where the hand sanitizers are not effective in preventing spread.


Current CDC recommendations regarding prevention of norovirus spread call for washing hands with running water and plain soap or antiseptic soap and caution that the use of alcohol-based or other hand sanitizers is controversial at the present time.


So while we generally promote the use of alcohol-based hand sanitizers as a good hand hygiene practice, it may have unintended consequences when certain pathogens are prevalent in a facility.






Blaney DD, Daly ER, Kirkland KB, et al. Use of alcohol-based hand sanitizers as a risk factor for norovirus outbreaks in long-term care facilities in northern New England: December 2006 to March 2007. Am J Infect Control 2011; 39: 296–301




CDC. Updated Norovirus Outbreak Management and Disease Prevention Guidelines. MMWR 2011; 60(RR03): 1-15





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ISMP on Storytelling



You’ve heard us on numerous occasions utter the mantra “Stories…not statistics” (see our December 2009 What’s New in the Patient Safety World column “Stories, Not Statistics” and our March 30, 2010 Patient Safety Tip of the Week “Publicly Released RCA’s: Everyone Learns from Them”).



Well, we can’t provide better recommendations about storytelling than ISMP does in one of its most recent newsletters (ISMP 2011). ISMP tells how stories get our attention and set the stage for learning and remembering and how they are powerful tools for changing our culture. They also provide great advice for crafting the stories, when and where to use them, and barriers to storytelling.


Great article and good set of references!





Institute for Safe Medication Practices (ISMP). Telling true stories is an ISMP hallmark Here’s why you should tell stories, too…  ISMP Medication Safety Alert! Acute Care Edition. September 8, 2011





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The Procedural Sedation Debate Rages On



Many of you have had battles at your Credentials Committee meetings about who should be privileged to perform and/or supervise moderate sedation (aka conscious sedation). While your Department of Anesthesiology probably lays claim to the organizational oversight of moderate sedation, reality is that providers in multiple departments or services (the emergency department, radiology, orthopedics, surgery, cardiology, GI, and others) may need to participate in moderate sedation.


A new position paper from the American College of Emergency Physicians (O’Connor 2011) has recommendations on credentialing and privileging for procedural sedation in the emergency department. First and foremost they recommend that each organization should have a multidisciplinary committee that provides organizational oversight for procedural sedation. We think that’s a wise idea. We have some experience with that in other areas. For example, when vascular interventional procedures developed in the 1990’s we had physicians in multiple departments requesting privileges to perform these procedures. The only way to address the privileging issue and, more importantly, the quality improvement issues was to create such multidisciplinary committees for general oversight. So applying the same concept to procedural sedation has precedent and makes sense.


The ACEP paper has good recommendations on the performance of moderate sedation as well. It talks about the need for ED physicians to consider potentially competing tasks in the ED before they undertake a procedure requiring moderate sedation. It also discusses the pre-procedural needs, including assessment of the patient’s last oral intake and the performance of a timeout per Universal Protocol. It stresses the importance of interactive monitoring, with someone other than the proceduralist doing the monitoring, and recommends that use of continuous capnography also be considered during monitoring (see previous discussions on capnography in our Patient Safety Tips of the Week for June 10, 2008 “Monitoring the Postoperative COPD Patient”, March 2, 2010 Alarm Sensitivity: Early Detection vs. Alarm Fatigue” and May 25, 2010 “Propofol Issues”). And though we often focus on high-tech monitoring, don’t forget good old-fashioned attention to physical findings such as eye movements (Tourtier 2011).


There are several good resources available for your moderate sedation educational programs. We recently mentioned the video on conscious sedation for minor procedures in adults (Jones 2011) in the new New England Journal of Medicine video series (see our August 2011 What’s New in the Patient Safety World column “NEJM Video on Conscious Sedation for Minor Procedures in Adults”). In addition, the most recent edition of the VA’s TIPS (Topics in Patient Safety) references the VA’s new moderate sedation toolkit for non-anesthesiologists (Murphy 2011). Though the full toolkit is not yet downloadable for anyone outside the VA system, you can view 2 very useful one-page aids for moderate sedation on the NPSC website. You’ll also find of interest a discussion with questions and answers on procedural sedation from an Annals of Emergency Medicine Journal Club (Menchine 2011).


See also our prior January 25, 2011 Patient Safety Tip of the Week “Procedural Sedation in Children” and our May 2011 What’s New in the Patient Safety World column “Update on Pediatric Procedural Sedation” for good discussions and resources on procedural sedation.






O'Connor RE, Sama A, Burton JH, et al. Procedural Sedation and Analgesia in the Emergency Department: Recommendations for Physician Credentialing, Privileging, and Practice. Ann Emerg Med 2011; 58: 365-370




Tourtier J-P, Diraison Y, Auroy Y. Conscious Sedation for Minor Procedures in Adults. N Engl J Med 2011; 365:1159-1160




Jones DR, Salgo P, Meltzer J. Conscious Sedation for Minor Procedures in Adults.

N Engl J Med 2011; 364: e54 June 23, 2011




Murphy J. New Moderate Sedation Toolkit for Non-Anesthesiologists. TIPS (Topics in Patient Safety) 2011; 11(2): 1,4




NPSC (VA National Patient Safety Center). Moderate Sedation Toolkit for Non-Anesthesiologists. Moderate Sedation Study Aid.




Menchine M, Arora S, Schriger D. Procedural Sedation: Is Two Better Than One? Answers to the May 2011 Journal Club Questions. Ann Emerg Med 2011; 58: 383-394





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Surgeons’ Mode of Intraoperative Decision Making



We’ve done several columns talking about the way physicians make decisions and how decisions are made in other industries. Our May 29, 2008 Patient Safety Tip of the Week “If You Do RCA’s or Design Healthcare Processes…Read Gary Klein’s Work” focused on pattern recognition and recognition-primed decision making that typically takes place in more acute scenarios. Our August 12, 2008 Patient Safety Tips of the Week “Jerome Groopman’s “How Doctors Think” and September 28, 2010 “Diagnostic Error” focused on the work of Jerry Groopman, Gordon Schiff, and others demonstrating how various processes are involved in physicians’ thinking in diagnostic situations. And our October 12, 2010 Patient Safety Tip of the Week “Slowing Down in the OR” discussed how surgeons refocus their attention at critical times during surgical procedures.


Now a new study (Pauley 2011) of surgeons’ mode of intraoperative decision making shows that surgeons in urgent situations are split about equally between the rapid recognition-primed and the analytical method where multiple potential responses are compared. Moreover, the type of decision making used was not associated with the type of operation, the context (emergency vs. elective), or the time pressures involved. The authors also looked at how surgeons perceived risk or threats in each case (risk assessment), managed risk, and what their risk tolerance was. The degree of risk assessment did depend on the decision making strategy used. For example, in the more intuitive rapid recognition-primed method they assessed the risk of the single action chosen, whereas in the more analytical method they assessed the risk of multiple choices. They summarize that decision making and risk assessment and management likely reflect many of the individual surgeon’s personality traits.


These findings contrasted with prior work (Flin 2007) by the same authors. In that work the authors had suggested surgeons should or would adopt strategies similar to those used by pilots for in-flight decision making. In the current study their predictions did not bear out. They ascribe the difference to the fact that pilots generally have only seconds in which to arrive at their decisions whereas surgeons, in most circumstances, have a longer timeframe within which to assess the situation, assess risks, and decide on a course of action. Nevertheless, you’ll find the 2007 paper by Flin et al to be useful reading.


The “science” of how we think and make decisions in various scenarios is fascinating. But it is also important in our learning how to use various approaches to solve problems and how some of the same processes can lead to bad outcomes in other circumstances.






Pauley K, Flin R, Yule S, Youngson G. Surgeons' intraoperative decision making and risk management. American Journal of Surgery 2011; 202(4): 375-381




Flin R, Youngson G, Yule S. How do surgeons make intraoperative decisions? Qual Saf Health Care 2007; 16(3): 235–239





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ISMP Updates Look-Alike/Sound-Alike Drug List



Earlier this summer ISMP updated its list of commonly confused drug names (ISMP 2011a). Then last month ISMP reported a mixup of Durasal (a salicylate-containing wart removal solution) with Durezol (a steroid eye drop preparation) that resulted in serious harm to a patient’s eye (ISMP 2011b).


That drug pair is on ISMP’s updated list. However, a potential mixup we recently mentioned between Pradaxa and Plavix as reported by ISMP Canada (see our July 2011 What’s New in the Patient Safety World column “First Thoughts on Dabigatran”) is not yet on the ISMP list.


The ISMP list is a most valuable resource. The recently confused drug pair (Durasal/Durezol) illustrates though that pharmacies need to periodically review drugs in their formularies that have been implicated in such LASA errors. That ISMP alert also points out the barriers in mobilizing appropriate responses when such dangerous situations are identified and the long periods that may elapse before appropriate actions are taken.






ISMP. ISMP”s List of Confused Drug Names. Updated through June 2011.




ISMP. Durasal-Durezol mix-up illustrates how dangerous product problems persist long after recognition. ISMP Medication Safety Alert! Acute Care Edition. September 22, 2011




ISMP Canada. Drug Name Alert: Potential for Confusion between Pradax and Plavix.

ISMP Canada Safety Bulletin 2011; 11(4): 1-2 May 27, 2011






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Print “October 2011 What's New in the Patient Safety World (full column)

Print “October 2011 IV Medication Administration Errors

Print “October 2011 Another Unintended Consequence of Hand Hygiene Device?

Print “October 2011 ISMP on Storytelling

Print “October 2011 The Procedural Sedation Debate Rages On

Print “October 2011 Surgeons’ Mode of Intraoperative Decision Making

Print “October 2011 ISMP Updates Look-Alike/Sound-Alike Drug List













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