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Patient Safety Tip of the Week 

July 27, 2010 

EMR’s Still Have A

Long Way To Go

Just as the final rule for “meaningful use” in adoption of electronic medical records (EMR’s) has been released, several studies have shown that most “off-the-shelf” EMR’s and even some highly sophisticated systems built in-house still lack some of the important clinical decision support tools we need to improve patient safety. Moreover, these studies highlight the need for practice and workflow transformation. You can’t simply plop an EMR into a practice or a hospital and anticipate all your potential problems will disappear.

On the hospital side, The Leapfrog Group used its simulation tool to test how CPOE systems at over 200 hospitals would handle a variety of medication order entry scenarios. From June 2008 to January 2010, 214 hospitals used the Leapfrog web-based tool to test their CPOE systems’ ability to identify potential problems during medication order entry. The percentage of medication orders that did not receive an appropriate warning was 52% in adult hospitals and 42% in pediatric hospitals. Moreover, for potentially fatal orders, an appropriate warning was not given in about a third of cases at both adult and pediatric hospitals.

Fortunately, the simulation tool is having a positive impact. Nearly all the hospitals used the results of the simulation to improve their CPOE systems. Leapfrog is stressing that ongoing testing and monitoring of CPOE systems is crucial and that collaboration must take place between vendors and hospitals to identify best practices. They call for movement away from proprietary closed systems and call for better sharing of issues and solutions across vendors and across healthcare organizations.

On the outpatient side, Elder et al. looked at management of test results in primary care practices and found that, though those practices with EMR’s did slightly better on certain processes in managing test results, they fell short on notifying patients and in documenting the interpretation and followup of abnormal test results. They did chart audits at 8 family medicine practices in Ohio and compared compliance with certain processes between those practices with and EMR and those without an EMR. Those with EMR’s did have higher percentages of charts with test results in the correct place, signatures by clinicians acknowledging the test results, clinician interpretations of results, and patient notifications. And for the subset of those with abnormal test results 64% of those with an EMR had plans for followup documented, compared to only 40% of those without an EMR.

They also found that methods of patient notification differed between those offices with EMR’s and those without EMR’s. In those practices with EMR’s more patients were notified of test results by mail and fewer were notified of their results only at an office visit.

Note that they also looked at the impact on formalized office processes for test result management. Interestingly, they found that practices with fewer standardized steps were actually more likely to document followup on abnormal test results but that none of the offices had standardized processes for that step.

They often found a discrepancy between high compliance with clinician signature and interpretation of test results but low documentation of followup plans. They point out that EMR’s may automate and make easier the acknowledgement of test results but that does not guarantee the test results get adequate scrutiny and that a plan of action will be undertaken. That is one area where both further refinement of EMR’s and other process changes in workflow and practice procedures will be required. Followup of test results is one of the areas stressed in those practices seeking to become patient-centered medical homes (PCMH’s). It’s also one of the patient safety areas we have most frequently talked about on the ambulatory care side (see our Patient Safety Tips of the Week for December 11, 2007 “Communication…Communication…Communication”, May 1, 2007 “The Missed Cancer”,  February 12, 2008 “More on Tracking Test Results”, October 13, 2009 “Slipping Through the Cracks” and our July 2009 What’s New in the Patient Safety World column “Failure to Inform Patients of Clinically Significant Outpatient Test Results”).

And on the e-prescribing side Matvey 2010 found frequent internal discrepancies in e-prescriptions between what was in structured fields and what was in associated free-text fields. Structured fields contain data such as the name of the drug, the dosage form, the route, the frequency, the duration, and the number of refills. The free text fields typically contain instructions like “take with meals” or more complex dosing regimens (eg. take a whole tablet on even days and a half tablet on odd days). They looked at e-prescribing in the ambulatory arena at Partners HealthCare, known for its relatively sophisticated electronic medical record system. Over 42% of such e-prescriptions contained such free text fields. A random sample of those that contained such free text found discrepancies in 16.1% of e-prescriptions. And over 80% of those with discrepancies were deemed potentially capable of leading to an adverse event (potentially severe in almost 17%).

While mismatches in frequency, route, dosage form, duration and quantity were relatively uncommon, the highest frequency of discrepancies (29% of those prescriptions having discrepancies) related to those having complex regimens. These include examples where a different dose is to be taken on different days of the week, regimens where the dosage or frequency of a drug is to be increased or tapered, etc.

Most importantly, the frequency of such discrepancies was much higher for 3 drugs that are already high alert drugs: coumadin, insulin, and digoxin. So these are already high risk drugs and ones for which complex dosing is often necessary and now ones for which internal discrepancies occur frequently.

This study has implications for the design of e-prescribing systems, the user interface and the training that must take place for all providers entering orders into the system. In addition, it highlights the need for pharmacists receiving such prescriptions to contact the ordering physician for clarification. The latter becomes especially problematic when the person who did the order entry is not available and the covering provider may not know what the ordering provider had in mind.

On the positive side, a poster presented by Helen Halpin at the recent annual APIC meeting demonstrated that hospitals using automated surveillance software to help identify infections more accurately and timely using data from multiple sources in the EMR were also more likely to have implemented best practice strategies to avoid infections. Whether that translates into actual lower infection rates remains to be demonstrated but these are best practices that are evidence-based. APIC has published a position paper recommending use of such automated surveillance technologies as part of an effective infection control program.

The key lessons from all these papers are that clinical decision support tools for electronic medical records are still evolving. Though they have a tremendous capability of improving quality of care and patient safety they are still being refined. Moreover, the best practices for delivering that clinical decision support are also just being discovered. And the biggest message is that EMR’s are only a piece of the puzzle. We need to change practice workflows, responsibilities, and processes to redesign our practices around the EMR.  During the transition period we need to be extremely vigilant and avoid overreliance on the EMR as a panacea.

References:

Center for Medicare and Medicaid Services (CMS). Final rule for meaningful use:

http://www.ofr.gov/OFRUpload/OFRData/2010-17207_PI.pdf

The Leapfrog Group. Leapfrog Group Report on CPOE Evaluation Tool Results June 2008 to January 2010. Executive Summary. June 2010

http://www.leapfroggroup.org/media/file/CPOEEvaluationToolResultsReport.pdf

Elder NC, McEwen TR, Flach J, Gallimore J, Pallerla H. The Management of Test Results in Primary Care: Does an Electronic Medical Record Make a Difference? Fam Med 2010; 42(5): 327-333

http://www.stfm.org/fmhub/fm2010/May/Nancy327.pdf

Matvey B, Palchuk MB, Fang EA, Cygielnik JM, et al. An unintended consequence of electronic prescriptions: prevalence and impact of internal discrepancies

JAMIA 2010;17:472-476

http://jamia.bmj.com/content/17/4/472.abstract?sid=9432e689-ba3b-4b8d-a0c6-7e3216bd44ce

Halpin H, Enanoria W, Vanneman M. Hospital Adoption of Automated Surveillance Technology and the Implementation of Infection Prevention and Control Programs. (Poster Presentation). APIC Annual Meeting July 13, 2010

http://www.abstractsonline.com/plan/ViewAbstract.aspx?mID=2473&sKey=4bf92320-f65a-4668-a0c3-9bfb91f70fd5&cKey=b5f60770-c253-43e4-a4c4-629b59329c5d&mKey={F46D09EA-0E3A-4347-B4CD-2D92C06C88FF}

APIC. Computerized Infection Monitoring Systems Enable Hospitals To Mount More Aggressive Efforts Against Healthcare-Associated Infections. APIC press release

July 12, 2010

http://www.apic.org/AM/Template.cfm?Section=News_Releases&CONTENTID=15869&TEMPLATE=/CM/ContentDisplay.cfm

Greene LR, Cain TA, Khoury R, et al. APIC Position Paper: The Importance of Surveillance Technologies in the Prevention of Healthcare-Associated Infections (HAIs)

APIC May 29, 2009

http://www.apic.org/Content/NavigationMenu/GovernmentAdvocacy/PublicPolicyLibrary/Surveillance_Technologies_position_paper_2009-5_29_09.pdf

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What's New in the Patient Safety World?

August 2010

·Sedation Costs for Pediatric MRI

·Surgical Case Listing Accuracy

·ISMP Advice on Catheter Misconnections

·Suicide Risk By Method Of First Attempt

·SCIP: Disappointing Outcomes on SSI’s. What’s Next?

Sedation Costs for Pediatric MRI

In our May 25, 2010 Patient Safety Tip of the Week “Propofol Issues” we noted that propofol has quietly become the procedural sedating agent of choice in many venues, particularly when dealing with pediatric patients. In fact, at the recent Pediatric Academic Societies meeting research was presented on over 25, 000 cases using propofol sedation in areas outside the OR by emergency physicians. That abstract (Mallory et al 2010) presented data from the Pediatric Sedation Research Consortium. The vast majority of these (22,068) were performed in radiology. We discussed some of the safety issues in that column.

Now a new study (Vanderby 2010) addresses the financial impact of sedation for MRI scanning in pediatrics. They analyzed the workflow, personnel, and costs involved in MRI scanning of children at Hospital for Sick Children in Toronto, Ontario. They found that the average time spent in the MRI suite was 2 hours and 21 minutes for children scanned awake, 3 hours 38 minutes for those sedated, and 4 hours 7 minutes for those anesthetized. Corresponding average costs (in Canadian dollars) were $54.68, $177.27, and $522.73 respectively.

The Toronto group used their analyis to significantly redesign workflow and scheduling. This article has a good discsussion about those workflow and personnel issues and has some good lessons learned that you may apply in your organization. To their recommendations we would add that strong consideration needs to be given to the appropriateness of the MRI scan, in light of the patient safety and cost issues involved.

References:

Smith M. PAS: Propofol Widely Used to Sedate Children. MedPageToday.com. May 3, 2010

http://www.medpagetoday.com/MeetingCoverage/PAS/19892

Mallory MD, Baxter AL, Yanosky DJ,  Cravero. JP. Use of Propofol for Sedation of Pediatric Patients by Emergency Physicians: A Report from the Pediatric Sedation Research Consortium (abstract). Pediatric Academic Societies meeting May 1, 2010

http://www.abstracts2view.com/pas/view.php?nu=PAS10L1_3860

Vanderby SA, Babyn PS, Carter MW, et al. Effect of Anesthesia and Sedation on Pediatric MR Imaging Patient Flow. Radiology 2010; 256(1): 229-237

http://radiology.rsna.org/content/256/1/229.abstract

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Surgical Case Listing Accuracy

Wrong site/wrong patient surgery continues to occur despite use of universal protocol, surgical timeouts, and various surgical checklists like the WHO Surgical Safety Checklist.

One opportunity for errors to occur that could lead to wrong site/wrong patient surgery is when surgical cases are “booked”. A new paper (Cima 2010) looked at the frequency of errors in the surgical case listing at a large academic medical center and found such errors in 1.38% of cases. Fortunately, there were no cases of wrong site/wrong patient surgery in their organization because the errors were picked up by a variety of healthcare workers preoperatively or in the OR. But the sheer number of cases with errors in booking highlights the serious potential during his step to set the stage for a wrong site surgery to occur.

They found that missing laterality was the most common error (66%), followed by incorrect laterality (14%) and incorrect listing besides laterality (11%). Such listing errors were found across the gamut of surgical specialties.

The findngs prompted the organization to revise its procedures for surgical case listing. They implemented an electronic surgical listing system using standardized case descriptions that required input of the laterality. Implementation of that system in ob/gyn surgery reduced the frequency of errors from 1.50% to 0.54% and in colorectal surgery from 2.06% to 0.49%.

We recommend you do this sort of audit in your organization to see what your potential vulnerability is during the booking process. Equally importantly, look at how your other “defenses” would pick up such potential problems prior to surgery. Are 100% of your cases reviewed the day prior to surgery by healthcare workers trained to identify such errors? Any case not reviewed until the day of surgery is one step closer to being a sentinel event. Who do you allow to book cases? Do you require formal designation of laterality at the time of booking? How do you ensure that all cases with imaging findings have laterality reconciliation prior to surgery?

References:

The Joint Commisssion. Universal Protocol. Updated 2010.

http://www.jointcommission.org/PatientSafety/UniversalProtocol/

WHO Surgical Safety Cheklist

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

Cima RR, Hale C, Kollengode A, et al. Surgical Case Listing Accuracy: Failure Analysis at a High-Volume Academic Medical Center. Arch Surg. 2010; 145(7): 641-646

http://archsurg.ama-assn.org/cgi/content/abstract/145/7/641

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ISMP Advice on Catheter Misconnections

ISMP (Institute for Safe Medication Practices) reported two more cases of catheter misconnections last month but noted progress in initiatives to get industry to adopt standards that would render certain catheter fittings incompatible with tubing sets intended for other purposes.

One case involved administration of cholestyramine into an IV catheter and the other administration of barium into a central venous line. The article lists many other published examples of catheter misconnections and a link to a page with all their previous articles dealing with catheter misconnections.

References:

ISMP. Preventing catheter/tubing misconnections: Much needed help is on the way.

ISMP Medication Safety Alert (Acute Care Edition) 2010; 15(14): 1-2  July 15, 2010

http://www.ismp.org/newsletters/acutecare/articles/20100715.asp

ISMP. Collection of all their catheter misconnection articles.

http://www.ismp.org/newsletters/acutecare/articles/Catheter-Misconnections.asp

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Suicide Risk By Method Of First Attempt

Most studies show about a 10% risk of suicide in a patient who has previously attempted suicide and that the risk is highest in the year following the attempt. Therefore, most assessments of patients after a suicide attempt focus on identification of risk factors for current and future suicide. Such assessments focus on known risk factors like male sex, older age in women, presence of a psychiatric disorder, and level of suicidal intent (considering things like “was there a well-thought out plan?”).

Now a new study (Runeson 2010), using data from linked databases in Sweden, has captured long-term data on the risk of successful suicide after a prior attempted suicide. In this study, 12% of patients committed suicide after a prior attempted suicide during a followup period of 21-31 years.

The most important finding, however, was that the risk varied significantly by the method used during the first attempted suicide. Whereas poisoning (overdoses) and cutting are far and away the most common methods of attempted suicide, the highest relative risk for successful suicide was for those whose index attempt was by hanging, strangulation, or suffocation/drowning and 87% of these suicides occurred within one year of the initial attempt. The risks were also higher for those whose index attempt involved firearms or explosives, gassing, or jumping from heights. Most successful suicides also used the same method that had been tried in the index attempted suicide.

The presence of a psychotic or affective disorder were additional independent risk factors for suicide. So a patient with such a severe psychiatric disorder and a suicide attempt by a method such as hanging, drowning or firearms would be at particularly high risk.

The implications of this study are that method of attempted suicide should be included in the overall risk assessment and that those patients deemed to be at the highest risk merit close followup, especially during the first year. The editorial accompanying the study (Hawton 2010) points out that the study was unable to determine whether the method used in the index attempt may have simply reflected the degree of lethality or intent on the part of the patient. It also notes that while these statistics accurately describe a population, it is still difficult to apply them in individual cases. Would you followup a patient who had attempted suicide by overdose any less rigorously than one who attempted suicide by hanging? Probably not. But you can expect the key points of this study to probably be incorporated into some existing suicide risk assessment tools.

References:

Runeson B, Tidemalm D, Dahlin M, et al. Method of attempted suicide as predictor of subsequent successful suicide: national long term cohort study.

BMJ  2010; 341: c3222

http://www.bmj.com/cgi/reprint/341/jul13_1/c3222

Hawton K. Completed suicide after attempted suicide. BMJ  2010; 341:c3064

http://www.bmj.com/cgi/content/extract/341/jul13_1/c3064

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SCIP: Disappointing Outcomes on SSI’s. What’s Next?

Most of us read with a certain degree of disappointment the recent publication (Stulberg 2010) of outcomes using the SCIP (Surgical Care Improvement Project) measures. Adherence reported on individual SCIP measures was not associated with a significantly lower probability of infection, though adherence to the global all-or-none composite infection prevention score was associated with a lower incidence of SSI’s (surgical site infections).

But some empirical observations have led to another possible approach for reducing SSI’s: selection of anesthesia type. A new population-based study (Chang 2010) showed that patients having total hip or total knee replacement surgery done under general anesthesia are 2.21 times more likely to develop an SSI within 30 days of surgery compared to those done under epidural or spinal anesthesia.

The authors propose several potential biological explanations for the findings, all of which should be considered hypotheses at this time. Because this was a retrospective analysis and not a randomized controlled trial, one cannot be sure that there was not patient selection bias or some confounding variable that led to these results. Nevertheless, this empirical observation is striking and should lead to a randomized controlled trial.

The accompanying editorial (Sessler 2010) notes that the magnitude of difference here is similar to that seen with timely use of prophylactic antibiotics. He points out that other promising interventions, such as potential use of supplemental oxygen, did not hold up when assessed under the scrutiny of randomized controlled trials.

References:

Stulberg JJ, Delaney CP, Neuhauser DV, et al. Adherence to Surgical Care Improvement Project Measures and the Association With Postoperative Infections
JAMA 2010; 303: 2479-2485 June 23/30, 2010

http://jama.ama-assn.org/cgi/content/abstract/303/24/2479?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=scip&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

Chang C-C, Lin H-C; Lin H-W, Lin H-C. Anesthetic Management and Surgical Site Infections in Total Hip or Knee Replacement: A Population-based Study. Anesthesiology 2010; 113(2): 279-284 August 2010

http://journals.lww.com/anesthesiology/Fulltext/2010/08000/Anesthetic_Management_and_Surgical_Site_Infections.10.aspx

Sessler, DI. Neuraxial Anesthesia and Surgical Site Infection. Anesthesiology 2010; 113(2) :265-267  August 2010

http://journals.lww.com/anesthesiology/Fulltext/2010/08000/Neuraxial_Anesthesia_and_Surgical_Site_Infection.3.aspx

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