Healthcare Consulting Services
PO Box 1230
Grantham, NH 03753
ph: 716-550-1106
btruax
April 6, 2021
ISMP on Just Culture
Perhaps the most important element of patient safety is culture – of the organization, the unit, and the individual. Many years ago, when there was an event with an adverse patient outcome, focus tended to be on finding someone to blame. With the birth of the patient safety movement in the 1980’s we began to recognize that system factors tend to dominate as root causes in most such incidents. Hence, a shift away from the “blame and train” approach. But, it was recognized that in some cases behavior of individuals went beyond typical human errors and included conscious disregard for safety and merited yet a different approach. Thus, the birth of “Just Culture”.
David Marx is the name most people associate with Just Culture. In a 2001 primer for health care executives on patient safety and Just Culture (Marx 2001) Marx described the “4 evils”:
Marx also did a nice summary of Just Culture more recently (Marx 2019). There he describes 5 behaviors:
ISMP recently did one of the most concise, yet informative, reviews on Just Culture (ISMP 2021), describing the differences between human error, at-risk behavior, and reckless behavior with illustrative examples of each type. It begins by pointing out that some of the prior terminology or terms used in disciplinary policies can be problematic. For example, if individuals “knowingly disregard” any policies, procedures, or the usual standard of practice, it frequently results in disciplinary action, even if the breach is widespread due to common system failures or was pursued in good faith due to a mistaken belief that the risk was justified or insignificant. Such “knowing violations” of policies and procedures thus are often considered reckless behavior but most are really at-risk behaviors.
There is one important question we always ask during root cause analyses or incident investigations to help distinguish between reckless and at-risk behavior: “How likely is it that anyone else in our organization might have made the same choice in that set of circumstances?”. If the answer to that question is “yes”, then the behavior was most likely “at-risk” behavior rather than being truly reckless.
ISMP goes on to discuss human error. This includes slips and cognitive biases that often occur in the context of multiple system issues that make error more likely. These are best managed through system redesign to make the system human error-proof or error-resistant.
They then go on to discuss at-risk behaviors. These are behavioral choices that are made when individuals have lost the perception of risk associated with the choice or mistakenly believe the risk to be insignificant or justified. ISMP argues that at-risk behaviors, along with any necessary system redesign, should actually be the primary focus of a patient safety program. “At-risk behaviors are an organization’s greatest safety challenge, as well as its greatest opportunity for improvement.”
They note we often develop unsafe habits for which we fail to see the risk. The rewards for risk taking, such as saved time, are typically immediate and positive, whereas possible adverse outcomes (e.g., patient harm) are often delayed and remote. Shortcuts and workarounds are classic examples of at-risk behaviors. ISMP points out that, over time, the risk associated with these behaviors fades and the entire culture becomes tolerant to these risks. “Individuals are not choosing to put patients in harm’s way; instead, they feel they are still acting safely. In fact, the more experienced you are at what you do, the less likely you are to recognize that you are in a risky situation when engaging in at-risk behavior.” We’ve given numerous examples in the past where our first impression of an individual who turns down the volume of an alarm is to label the behavior as “reckless”, only to later recognize that such particular behavior had become commonplace on that unit and performed by many others. In fact, at-risk behaviors sometimes even get rewarded (such as praise for timely medication administration even though shortcuts were taken).
ISMP points out that most at-risk behaviors are precipitated by large and small system failures that individuals must work around, often daily, to get the job done. Therefore, recognizing these at-risk behaviors should lead to a search for underlying causes and fixes.
ISMP notes that the first step is admitting that at-risk behaviors are occurring. That has been difficult because people have often been harshly criticized or disciplined for violating rules in the past. ISMP notes that, “in a Just Culture, the solution is not to punish those who engage in at-risk behaviors. Instead, managing at-risk behaviors requires removing the barriers to safe behavioral choices, removing the rewards for at-risk behaviors, and coaching individuals to see the risk associated with their choices.“ We have our own manner of identifying many at-risk behaviors. During Patient Safety Walk Rounds, we ask individuals (in a very non-punitive manner) what workarounds they might be employing. You’d be surprised how readily they will identify such workarounds when (1) they have assurance they won’t be punished and (2) they know you’ll try to find a fix for whatever system problem has led to the workaround.
To manage at-risk behaviors, ISMP relies heavily on coaching. This is different from counselling and is a constructive process. Read the full ISMP article for details on coaching. Another advantage of coaching is that individuals can go on to coach other healthcare workers they see with similar at-risk behaviors.
In addition to coaching, ISMP notes you need to remove the rewards inadvertently given to people with at-risk behaviors. And, most importantly, you need to fix the underlying system problems that led to the at-risk behaviors in the first place.
Lastly, reckless behavior is the conscious disregard of a substantial and unjustifiable risk. The individuals know the risk they are taking and understand that it is substantial. They know others are not engaging in the behavior (i.e., it is not the norm). Examples given by ISMP include drug diversion, performing surgery under the influence of alcohol or drugs, or retaliatory breaches in patient confidentiality. Remedial or disciplinary sanctions should be considered according to the organization’s human resources policies to correct the undesired conduct.
One of the important facets of Just Culture is that any disciplinary actions taken are based upon the inappropriate behavior rather than the severity of any harm caused. Before Just Culture, people were often disciplined just because there was a bad patient outcome and the most serious behaviors were often tolerated because no harm had been done (i.e. the severity bias).
ISMP has done a good job in this article explaining Just Culture. We encourage you to read it in full. We also encourage you to read the 2019 article by David Marx (Marx 2019) and go to the Just Culture website for further information and resources.
Some of our prior columns on the impact of “bad behavior” of healthcare workers:
January 2011 “No Improvement in Patient Safety: Why Not?”
March 29, 2011 “The Silent Treatment: A Dose of Reality”
July 2012 “A Culture of Disrespect”
July 2013 “"Bad Apples" Back In?”
July 7, 2015 “Medical Staff Risk Issues”
September 22, 2015 “The Cost of Being Rude”
April 2017 “Relation of Complaints about Physicians to Outcomes”
October 2, 2018 “Speaking Up About Disruptive Behavior”
August 2019 “More on the Cost of Rudeness”
January 21, 2020 “Disruptive Behavior and Patient Safety: Cause or Effect?”
Some of our prior columns related to the “culture of safety”:
April 2009 “New Patient Safety Culture Assessments”
June 2, 2009 “Why Hospitals Should Fly...John Nance Nails It!”
January 2011 “No Improvement in Patient Safety: Why Not?”
March 2011 “Michigan ICU Collaborative Wins Big”).
March 29, 2011 “The Silent Treatment: A Dose of Reality”
May 24, 2011 “Hand Hygiene Resources”
March 2012 “Human Factors and Operating Room Safety”
July 2012 “A Culture of Disrespect”
July 2013 “"Bad Apples" Back In?”
July 22, 2014 “More on Operating Room Briefings and Debriefings”
October 7, 2014 “Our Take on Patient Safety Walk Rounds”
July 7, 2015 “Medical Staff Risk Issues”
September 22, 2015 “The Cost of Being Rude”
May 2016 “ECRI Institute’s Top Ten Patient Safety Concerns for 2016”
June 28, 2016 “Culture of Safety and Catheter-Associated Infections”
April 2017 “Relation of Complaints about Physicians to Outcomes”
April 2017 “Joint Commission Sentinel Event Alert on Safety Culture”
October 2, 2018 “Speaking Up About Disruptive Behavior”
August 2019 “More on the Cost of Rudeness”
January 21, 2020 “Disruptive Behavior and Patient Safety: Cause or Effect?”
Some of our prior columns related to workarounds:
September 4, 2007 “Workarounds as a Safety Issue”
May 2008 “UK NPSA Alert on Heparin Flushes”
June 17, 2008 “Technology Workarounds Defeat Safety Intent”
September 15, 2009 “ETTO’s: Efficiency-Thoroughness Trade-Offs”
August 24, 2010 “The BP Oil Spill - Analogies in Healthcare”
March 6, 2012 “Lab Error”
July 2, 2013 “Issues in Alarm Management”
April 8, 2014 “FMEA to Avoid Breastmilk Mixups”
October 7, 2014 “Our Take on Patient Safety Walk Rounds”
April 5, 2016 “Workarounds Overriding Safety”
June 2016 “ISMP Article on Workarounds”
September 2020 “More on Workarounds”
References:
Marx D. Patient Safety and the “Just Culture”: A Primer for Health Care Executives. Columbia University 2001; April 17, 2001
http://www.chpso.org/sites/main/files/file-attachments/marx_primer.pdf
Marx D. Patient Safety and the Just Culture. Obstet Gynecol Clin North Am 2019; 46(2): 239-245
https://www.sciencedirect.com/science/article/abs/pii/S088985451930004X?via%3Dihub
ISMP (Institute for Safe Medication Practices). The differences between human error, at-risk behavior, and reckless behavior are key to a Just Culture. ISMP Nurse AdvisERR 2021; 19(3): 1-5
https://www.ismp.org/nursing/medication-safety-alert-march-2021
Just Culture website
Print “ISMP on Just Culture”
April 13, 2021
Incidental Findings - What's Your Strategy?
We’ve done many columns on “closing the loop” and communicating significant results to ensure patients do not “fall through the cracks”. One particular area that merits better communication relates to incidental findings.
Incidental findings can occur on several different types of diagnostic tests, but are most prevalent on imaging studies. The most appropriate followup actions depend on the specific nature of the incidental finding. There are numerous guidelines regarding what to do for specific incidental findings. But there are 2 key issues:
Who is responsible for such communication and followup? We’ve stressed that multiple individuals or entities share such responsibility:
A recent review (Crable 2021) looked at management strategies used to promote guideline-concordant follow-up for incidentalomas identified in diagnostic imaging studies. In all, 15 studies met inclusion criteria. Four types of interventions designed to promote guideline-concordant follow-up care for incidentalomas were identified:
Crable et al. note that the ideal completed pathway would have the following steps or “phases”:
Of the strategies identified by Crable et al., enhanced radiology templates were used to prompt actions in phase 2. These would Include standardized follow-up recommendations from various sources.
Several of the reviewed studies utilized electronic guideline references embedded within electronic radiology reporting and communication systems. These provided radiologists easy access to guidelines and follow-up recommendations as they were doing their reports (phase 2). Electronic guideline references were also made available to clinicians when reading radiologists’ reports (phase 3) in some studies.
Physical or verbal guideline reminders and electronic guideline references were used to alter clinical processes in both phases 2 and 3. Examples included incorporating guideline-recommended care for pancreatic or ovarian incidentalomas. Those recommendations might be posted in hard copies at every radiology workstation or provided as verbal reminders at monthly case conferences.
Restructured clinical and communication pathways impacted clinician tasks in phases 2 through 6. Task shifting was an important strategy. For example, a staff person (such as a nurse coordinator or nurse specialist) could be assigned to help manage the process. In one system (Holden 2004), an electronic messaging system notified pulmonary nurse specialists when incidental findings were identified. That nurse specialist collected information about patients’ health and past imaging studies. Then, a pulmonary service consultation team comprised of physicians and a thoracic radiologist reviewed each incidental finding with relevant patient history and created a management plan that was shared with PCP’s and stored in the EHR. A member of the pulmonary service consultation team monitored the EHR until the incidental finding was resolved.
We think having a field in your EHR that can be flagged for “unresolved incidental finding” is a good idea.
Crable et al. provide a long list of various metrics that can be applied to evaluate the management of incidental findings. Of interest is that some monitored not only rates of undermanagement, but also overmanagement (eg. ordering follow-up imaging studies that were not recommended in guidelines).
Crable et al., however, point out the paucity of metrics of incidental finding diagnostic outcomes. And they note that few studies address barriers to improving incidentaloma follow-up from interpretation to patient education of findings and care delivery.
One scenario is worth emphasizing – the incidental finding on an imaging study at the time of hospital discharge. You know the picture: you and your team review the imaging study in the morning and it allows you to discharge the patient. But the official report of that study has not yet been dictated. When the radiologist interprets the study, he/she notes an incidental finding. That report is often not seen by someone in the position to follow up. The report may go to a resident or hospitalist who has moved on to another rotation or other clinician who will not see the patient after discharge. A copy of the report may not go to the patient’s PCP (or other clinician who will be primarily responsible for the patient after discharge). But, we’ve often lamented the unfortunate reality that hospital IT systems often fail to accurately identify the patient’s PCP. So this is your classic “falling through the cracks” scenario. We discussed this in detail in our September 8, 2020 “Follow Up on Tests Pending at Discharge”. That column also highlights similar problems that arise on studies done on patients discharged from the emergency department. The ED physician who ordered the study is no longer at the hospital (and, in some cases, may not return to that hospital). The radiologist may, therefore, have difficulty identifying a clinician who needs to be informed of that incidental finding.
Knowing the guidelines or recommendations regarding specific incidental findings is critical to avoid the “diagnostic cascade” where one study leads to another study or intervention, often resulting in unnecessary interventions or even patient harm. Many specialty societies have issued such guidelines for common incidental findings. It would be very difficult for a primary care physician to be knowledgeable about all these guidelines. Therefore, we really like the idea of the radiology report linking to the guideline specific to that incidental finding. Of course, that puts the onus on the radiology department or practice to keep up to date on those guidelines and links.
Then, there is the problem of consistency and quality of guidelines. A recent study on radiologist awareness of guidelines for pulmonary nodules is illustrative (Gould 2021). Gould et al. state that approximately 1.6 million patients annually are found to have incidental pulmonary nodules on chest CT scans. They state that most have benign etiologies but about 5% are malignant. They go on to state that, because of the low likelihood of malignancy and the risks associated with biopsy, the preferred method for the evaluation of most small nodules is longitudinal surveillance with serial CT scans. There are existing guidelines from the Fleischner Society and the American College of Radiology with recommended intervals for CT surveillance. But these are based largely on indirect evidence and expert opinion, because direct evidence from randomized trials of pulmonary nodule evaluation strategies has not been available. They surveyed radiologists participating in the ongoing Watch the Spot Trial, which is designed to provide higher quality evidence on approach to small pulmonary nodules. They found that radiologists reported high levels of familiarity and agreement with and adherence to guidelines for pulmonary nodule evaluation, but many overestimated the quality of evidence in support of the recommendations.
And, it is not just “incidental” findings that need a system to ensure followup. A recent article showed delays in followup of positive at-home tests for colon cancer screening (Jaklevic 2021). Jaklevic et al. noted that, particularly since the COVID-19 pandemic began, more people are getting their colon cancer screening as fecal immunochemical testing (FIT). The article notes that, depending on population characteristics such as age and sex, 5% to 9% of patients have an abnormal result, and about 1 in 3 of those have a large polyp or cancer.
A study of veterans age 50 to 75 years with an abnormal fecal occult blood test (FOBT) or fecal immunochemical test (FIT) between 1999 and 2010 showed increased time to colonoscopy is associated with higher risk of CRC incidence, death, and late-stage CRC after abnormal FIT/FOBT (Miguel 2021). The authors recommend interventions to improve CRC outcomes should emphasize diagnostic follow-up within 1 year of an abnormal FIT/FOBT result.
So, just as we recommend having a field in your EHR that can be flagged for “unresolved incidental finding” it’s a good idea to have a field that can be flagged for “follow-up action needed” for any significant finding.
There are many reasons, both system- and patient-related, for failure of adequate follow up of incidental findings. And even though many or even the majority of such findings have benign etiologies, we’ve all seen cases where such failures have led to patients developing untreatable cancers. Do you have any idea how often your patients do not get appropriate follow up of such incidental findings? What is your system to ensure adequate follow up?
See also our other columns on communicating significant results:
References:
Crable EI, Feeney T, Harvey J, et al. Management Strategies to Promote Follow-Up Care for Incidental Findings: A Scoping Review. J Amer Coll Radiol 2021; 18(4): 566-579
https://www.jacr.org/article/S1546-1440(20)31225-4/fulltext
Holden WE, Lewinsohn DM, Osborne ML, et al. Use of a clinical pathway to manage unsuspected radiographic findings. Chest 2004; 125: 1753-1760
https://www.sciencedirect.com/science/article/abs/pii/S0012369215321723
Gould MK, Altman DE, Creekmur B, et al. Guidelines for the Evaluation of Pulmonary Nodules Detected Incidentally or by Screening: A Survey of Radiologist Awareness, Agreement, and Adherence From the Watch the Spot Trial. J Amer Coll Radiol 2021; 18(4): 545-533
https://www.jacr.org/article/S1546-1440(20)31119-4/fulltext
Jaklevic MC. The Push for Timely Follow-up After Abnormal At-home Colon Cancer Screening Results. JAMA 2021; Published online March 31, 2021
https://jamanetwork.com/journals/jama/fullarticle/2778236
Miguel YS, Demb J, Martinez ME, et al. Time to Colonoscopy After Abnormal Stool-Based Screening and Risk for Colorectal Cancer Incidence and Mortality. Gastroenterology 2021; Published online February 2, 2021
https://www.gastrojournal.org/article/S0016-5085(21)00325-5/fulltext
Print “Incidental Findings – What’s Your Strategy?”
April 20, 2021
Taser "Slip and Capture Error" Again!
In the midst of a trial of a police officer in the death of an unarmed African-American man in Minneapolis, 10 miles away there was another incident in which a young African-American man was fatally shot by a police officer during a traffic stop. In the latter incident, the police officer apparently intended to use a taser on the man but instead fired her gun, killing the man. “How could that happen?” you ask. It’s not the first time this has happened. In fact, it has happened multiple times. Our April 21, 2015 Patient Safety Tip of the Week “Slip and Capture Errors” noted at least 8 prior instances where police intending to use tasers, instead pulled out their guns and shot someone. It is the classic example of what is known as a “slip and capture” error.
The police stopped the man for a suspected traffic violation but found there was an outstanding arrest warrant on him. When he got back into his vehicle against the commands of the police officers, one officer aimed a weapon at him and shouted “Taser! Taser! Taser!” (Bogel-Burroughs 2021, Broaddus 2021, Navratil 2021). She fired one round, and the man groaned in pain. “Holy shit, I just shot him,” the officer can be heard shouting. The man drove off in the car but crashed a couple blocks away and was pronounced dead at the scene.
A nearly identical incident occurred in 2018 in Kansas (Robertson 2019). A police officer thought she had her Taser in her hand as she watched an unarmed man beating a fellow officer. What she fired, however, was her gun — by mistake. “Oh s---, I shot him,” she shouted. During legal proceedings, she explained her brain immediately went ‘you need to tase this guy, you got to tase, you got to tase him” and she shouted “Taser! Taser! Taser!” She fired what was in her hand, and the assaulter shouted in pain — which would have been normal when hit with a Taser. But the officer said she was stunned that she didn’t see the wires of a Taser gun strike. At this point she realized she had pulled her gun and shot the assaulter by mistake, instead of pulling her Taser. She exclaimed aloud, “Oh s---, I shot him.”
We wrote our April 21, 2015 Patient Safety Tip of the Week “Slip and Capture Errors” after a volunteer police deputy fatally shot a man, thinking he was firing his taser, not his gun (Yan 2015). In 2009 a very similar shooting occurred on the Oakland BART system when the officer fired his gun rather than the intended taser (Force Science Institute 2010). At that time, retired Capt. Greg Meyer noted there were at least 6 similar incidents prior to that 2009 shooting (Meyer 2010). So, when we did our 2015 column, there were at least 8 similar incidents where a police officer inadvertently shot someone, mistakenly thinking they were using a taser and not their gun. After the recent Minnesota shooting, media reports put the number of similar incidents as high as 18 (Elinson 2021). One article actually lists 16 of the prior incidents (Ciavaglia 2021).
Sure sounds like a system problem to us! It’s reminiscent of concentrated potassium chloride issues in healthcare in the past. Multiple incidents occurred disseminated both in time and location, so it took years for us to see a pattern and look for root causes and, ultimately, solutions.
So, this is a patient safety column, not a crime column. Why are we discussing this at all? We discuss it because these are instances of a human factors concept, the “slip and capture error”, and we need to understand why they occur because similar errors can occur in healthcare. We gave many examples in our April 21, 2015 Patient Safety Tip of the Week “Slip and Capture Errors” and such are well worth reiterating.
Basically, a capture error occurs when two potential actions share the same or similar initial sequences, but one action is relatively unfamiliar and the other is a well-known and well-practiced action (the latter often carried out almost automatically or subconsciously). In effect, under certain circumstances the well-practiced action sequence will “capture” the action.
But the capture error is not a new concept. In fact, for years when we are teaching patient safety to medical students, residents, or other healthcare workers and tell them mistakes are inevitable we give them a classic example: “It’s Sunday morning. You intend to go to the grocery store. But you find yourself in your car on the route to your usual workplace/school, instead of the route to the grocery store.” (Usually about two thirds of the audience raises their hands when we ask if that has happened to any of them!) That happens to be a classic capture error. The more practiced activity “captured” the intended but less familiar activity.
Usually there are “enabling” factors that contribute to the occurrence of “capture” errors. These include stressful situations, emergencies, distractions or interruptions and others.
So, what are some healthcare examples of “capture” errors? A nurse or physician, confronted with a new version of a device (eg. ventilator, infusion pump, dialysis machine, etc.), programs in the sequence of keystrokes or dial manipulations he/she used on the old device even though he/she has been inserviced on the new device.
Another example might occur during CPOE. You almost always choose the first option from a drop-down list listing regimens for a certain anticonvulsant. Your software vendor updates the software and the drop-down list is now reordered. Still, you choose the first option and this time your patient gets the wrong drug or wrong dose.
A somewhat similar error may have occurred in the fatal NMBA incident we described in our Patient Safety Tips of the Week for December 11, 2018 “Another NMBA Accident” and February 12, 2019 “From Tragedy to Travesty of Justice”. In that case, a nurse was attempting to retrieve Versed from an automated dispensing cabinet (ADC). She recalled talking to an orientee about something unrelated while entering the first two letters “VE” into the ADC. The first medication on the list was chosen. The nurse did not recognize that the medication chosen was vecuronium, not Versed. The nurse looked at the back of the vial to see how to reconstitute the medication but did not recheck the name of the medication on the vial. Ultimately the fatal dose of the paralyzing agent vecuronium was administered to a patient.
In our April 21, 2015 Patient Safety Tip of the Week “Slip and Capture Errors” we also noted an example where we might incorrectly choose an order set for order set for DKA (diabetic ketoacidosis), which gets used very often, rather than the intended order set for nonketotic hyperosmotic state, which is used much less frequently.
There is probably also some relationship or at least overlap of “capture” errors with another human factors concept: inattentional blindness (ISMP 2009). In the latter, which is really a sort of confirmation bias, we tend to see what we expect to see rather than what we actually see. This is often a contributing factor in incidents where medications are drawn up from the wrong vials.
Another interesting thought: technology may cause some “capture” errors. Autotext or automatic completion of phrases by a word processor or smart phone may lead to such errors. We’ve noted several times that every time we type “EHR” (for electronic health record), our word processor converts it to “HER” and we might miss that on proof-reading. Or our smart phone automatically inserts one email address when we really intended a different one. These examples really meet the definition of a “capture” error in that two actions start with the same sequence of steps and one that is far more familiar than the other (at least far more familiar to the computer!) takes over for the intended action. You can bet that there will be analogies with healthcare technologies.
Capture errors have long been described by human factors pioneers like James Reason and Don Norman. How about some everyday examples of “capture” errors?
James Reason, widely known as the father of human factors research, provides numerous examples (Reason 1990):
Don Norman (see our November 6, 2007 Patient Safety Tip of the Week “Don Norman Does It Again!”) in his two great books on human factors and design of things (Norman 1988, Norman 2009) has some great examples:
Did you ever rent a car on a trip and turn on the windshield wipers instead of the lights because the control knobs were reversed from the car you usually drive?
In fact, the classic predictable error of using the previous year when you write a check in January of a new year is often referred to a “slip” but is probably also really a “capture” error.
In the taser/gun incidents, use of the taser is the relatively unfamiliar action and use of the gun is the more familiar and well-practiced action. Even if the officer has never fired his/her gun on duty, they all spend considerable time on the shooting range so have practiced use of the gun frequently. But we suspect most have practiced using the taser much less frequently and probably never practiced under stressful conditions.
As Don Norman would tell us, design of systems significantly impacts on how humans use those systems. Design of the taser and its holster likely contributed to each of the incidents. In many of the previous taser/gun mistakes the taser had apparently been drawn by the “strong” (dominant) hand, though the location of the taser holster was variable (Meyer 2010). One of the recommendations made by the Forensic Science Institute after the BART case was use “weak-side, weak-hand-draw” taser holsters to minimize the chance of unintentionally drawing one’s gun rather than the taser. It’s not known how the officer in the current Minnesota incident was wearing her weapons and holsters at the time of the shooting. Apparently, the policy was that the tasers were to be holstered on the nondominant side. But, even then, there is a problem. The video of the incident shows another officer wearing the taser holster on the nondominant side but the butt of the taser was positioned such that the officer could easily “cross-draw” the taser with his dominant hand (Hubler 2021). An article in USA Today (Loehrke 2021) has a good graphic showing not only holstering but also all the other equipment police officers typically carry on their belts.
And it’s clear it is not enough to just receive some education/training on use of the taser. Taser use must be practiced just as often (perhaps even more often) than practicing gun use and done under conditions closely simulating those in which a taser is likely to be needed.
But, let’s go back to the concentrated potassium issue in hospitals. You’ll recall that nurses withdrew fluid from what they thought were vials of heparin or insulin but were really vials of concentrated potassium. When injected, that would cause the heart to stop beating. One problem was the similarity of the vials of the various substances. The other problem was that there really was no need for vials of concentrated potassium salts to be on nursing units at all. Many years ago, nurses did have to add potassium to IV fluids but now IV fluids are typically prepared in hospital pharmacies, so nurses don’t have the need for vials of potassium any longer. The solution was to remove vials of potassium from floor stock on nursing units all together.
The taser dilemma needs a similar solution. Not removal of the tasers, of course. But rather redesign of the tasers. We’ve heard all the media pundits say “how could anyone mistake their gun for a taser? The gun and the taser have different weights and the officers are supposed to wear the taser on the side of their nondominant hand. The taser is a different color (usually a bright, often neon, color) to distinguish it from the gun. And officers are supposed to be trained on use of both guns and tasers. But, obviously, all those features have not prevented incidents where guns are mistaken for tasers.
Our take – the taser looks like a gun and has a trigger like a gun! So, it’s no surprise that, in the heat of an emergent situation, someone will pull that trigger. If nothing is done, it is inevitable there will be another inadvertent shooting after mistaking a gun for a taser. The solution should be to redesign tasers so they have a different shape and have an activation mechanism that is different than a gun-style trigger. Maybe add some sort of audible signal that appears when the taser is unholstered. Is that too much to ask? Just be careful the redesign does not have its own unintended consequences (like tasing oneself!).
We have no intention of getting into the discussion of whether tasers or any other forceful actions were appropriate in this incident and we’re focusing just on the taser issue. While there are clearly many other issues and factors contributing to the most recent taser/gun incident, the fact that so many such incidents have occurred tells us that there is a strong underlying system vulnerability that is a primary root cause of such incidents. Just as we had put our nurses in position to inadvertently administer lethal potassium doses years ago, the current design of tasers puts officers in position to inadvertently shoot someone. It’s time for thoughtful analysis and realistic solutions.
References:
Bogel-Burroughs N, Bosman J. Minnesota Officer Who Shot Daunte Wright Meant to Fire Taser, Chief Says. New York Times 2021; April 12, 2021
https://www.nytimes.com/2021/04/12/us/brooklyn-center-police-shooting-minnesota.html
Broaddus A, Yan H, Allen K, Silverman H, Minnesota officer shouted 'Taser!' but fired a gun instead, fatally shooting a man at a traffic stop, police say. CNN 2021; April 12, 2021
https://www.cnn.com/2021/04/12/us/brooklyn-center-minnesota-police-shooting/index.html
Navratil L, Montemayor S, Mannix A. Chief: Officer meant to use Taser, not firearm, on Daunte Wright. Minneapolis Star Tribune 2021; April 13, 2021
Robertson J. A Lawrence police officer meant to use a Taser. She shot a man by mistake.
The Kansas City Star 2019; September 06, 2018 Updated March 26, 2019
https://www.kansascity.com/news/local/crime/article217924280.html
Yan H. How easy is it to confuse a gun for a Taser? CNN 2015; April 14, 2015
http://www.cnn.com/2015/04/14/us/taser-gun-confusion/index.html
Force Science Institute. Force Science explains "slips-and-capture errors" and other psychological phenomena that drove the fateful BART shooting. PoliceOne.com July 22, 2010
Meyer G. The BART shooting tragedy: Lessons to be learned. PoliceOne.com July 12, 2010
http://www.policeone.com/legal/articles/2095072-The-BART-shooting-tragedy-Lessons-to-be-learned
ElinsonZ. Kim Potter mistook her gun for a Taser, police say: How often does that happen? Fox News 2021; April 13, 2021
Ciavaglia J. How could a gun be mistaken for a Taser? There have been at least 16 incidents of 'weapon confusion' since 2001. USA Today 2021; April 13, 2021
ISMP (Institute for Safe Medication Practices). Inattentional blindness: What captures your attention? ISMP Medication Safety Alert Acute Care Edition 2009; February 26, 2009
http://www.ismp.org/newsletters/acutecare/articles/20090226.asp
Reason J. Human Error. Cambridge: Cambridge University Press. 1990. p. 68
Norman D. The Psychology of Everyday Things. New York: Doubleday. 1988. P. 107
Norman D. The Design of Future Things. New York: Basic Books. 2009. P. 107
Hubler S, White J. How Could an Officer Mistake a Gun for a Taser? New York Times 2021; April 13, 2021
Loehrke J, Padilla R, Petras G. Aftermath of fatal shooting: How can a handgun be mistaken for a Taser? USA Today 2021; April 14, 2021
Print “Taser “Slip and Capture Error” Again!”
April 27, 2021
Errors Common During Thrombolysis for Acute Ischemic Stroke
Thrombolytic therapy performed within a relatively narrow temporal window can significantly improve outcomes in patients with acute ischemic stroke. For years, we struggled as only a tiny fraction of patients potentially eligible for thrombolytic therapy were seen, evaluated, and treated within that narrow window. Stroke centers, hub and spoke stroke systems, community triage systems, and teleneurology have significantly helped increase the number of stroke patients eligible for thrombolytic therapy.
But thrombolytic therapy can have adverse consequences, particularly conversion to hemorrhagic stroke. And the risks of such complications increase when errors occur with thrombolytic therapy. A new study (Dancsecs 2021) assessed the occurrence and nature of errors during thrombolytic therapy with altepase in regional hospitals and a Comprehensive Stroke Center (CSC).
Two-hundred-twenty-seven (34%) patients received alteplase at the CSC and 448 (66%) patients received alteplase at regional hospitals. Of the patients receiving alteplase at a regional hospital, 58 patients (12.9%) were at an acute stroke ready facility (ASR) while 55 (12.3%) were at a primary stroke center (PSC). The remaining 335 patients (74.8%) received alteplase at a regional hospital with no stroke certification. There were a total of five regional centers that were ASR hospitals and three regional centers that had a PSC designation.
19.8% of patients had an error associated with alteplase administration. 1.5% occurred at the CSC and 18.2% occurred at regional hospitals. Errors occurred at all 3 levels of stroke care at regional hospitals, though they were most frequent at undesignated centers. The most common error identified was receiving an over-dosage of alteplase, all of which occurred in patients receiving alteplase at a regional hospital. Under-dosing and infusion errors were also very common, as was administration of alteplase in patients with apparent contraindications. The most common contributing factor leading to a medication error with alteplase was an incorrect calculation (23%). Incorrect programming of infusion pumps was also common (20%) and incorrect patient weight being used to calculate the dose occurred in 16%.
There were patient impacts from the errors. Patients who had errors associated with alteplase administration more commonly experienced hemorrhagic conversion compared to those who did not have an error with administration (12.7% vs 7.1%). Fortunately, this did not appear to lead to a significant difference in neurologic outcome.
The authors stress that the most common contributing factor leading to a medication error in patients transferred from other facilities was a calculation error, primarily due to the use of incorrect patient weights rather than faulty computations. We discussed the problem of inaccurate weights in thrombolytic therapy in our December 8, 2015 “Danger of Inaccurate Weights in Stroke Care”. Often, in the urgency to administer thrombolytic therapy in a timely fashion, staff do not formally weigh the patient on a scale. They either ask the patient how much they weigh or they estimate the patient’s weight themselves. It turns out that estimating a patient’s weight frequently results in erroneous weights being used in the dose calculation (Barrow 2016). Clinicians underestimated mean difference weight by 1.13 kg between estimated and actual weight, but disparities were most likely at the upper and lower extremes of weight. So, some patients will be underdosed, others overdosed. Though 80% of patients received a tPA dose within the acceptable range, 11.5% were underdosed and 8.1% overdosed. When they looked at improvement in NIHSS scores, those patients who received a dose in the acceptable range had the greatest improvement. But those in the “underdosed” range (corresponding to the heaviest patients) had less improvement than those in the “overdosed” range. That heavier, underdosed population accounted for about a third of all their stroke patients. Barrow et al. conclude that beds capable of weighing patients should be mandated in emergency rooms for patients with acute stroke.
Dancsecs et al. recommend that regional hospitals who administer alteplase should have a pharmacist involved in some capacity to handle the complexity of dosing administering alteplase. They also note that tenecteplase dosing (a one-time dose of 0.4 mg/kg) may reduce the rate of non-weight and non-calculation errors compared to alteplase. And they suggest use of a standardized infusion pump library in regional hospitals should also be considered in order to help standardize the rate at which alteplase is infused.
Of course, patient weight issues and infusion pump errors are not unique to thrombolytic therapy. We’ve listed below our numerous columns on both issues.
While education and training of personnel in regional hospitals on these issues makes sense, there are also important system implications. In many (or most) cases where thrombolytic therapy is administered in a non-stroke-certified hospital, a telemedicine consultation with a stroke center neurologist is undertaken. So, it is important that the stroke center neurologist be cognizant of the patient weight issue and the infusion pump programming issues and advise the regional personnel accordingly at the time of the consultation. Perhaps the stroke center pharmacist could even participate in those telemedicine consultations.
Timely use of thrombolytic therapy can significantly improve neurological outcomes in those patients with acute ischemic stroke who present within the therapeutic window. But we must ensure that thrombolytic therapy be administered safely. We’ve seen too many cases where past experience with a bad outcome makes regional hospitals hesitant to initiate thrombolytic therapy in patients who are good candidates for it.
Some of our other columns on errors related to patient weights:
March 23, 2010 “ISMP Guidelines for Standard Order Sets”
September 2010 “NPSA Alert on LMWH Dosing”
August 2, 2011 “Hazards of ePrescribing”
January 2013 “More IT Unintended Consequences”
December 8, 2015 “Danger of Inaccurate Weights in Stroke Care”
May 2016 “ECRI Institute’s Top 10 Patient Safety Concerns for 2016”
September 2017 “Weight-Based Dosing in Children”
January 2018 “Can We Improve Barcoding?”
June 2018 “Incorrect Weights in the EMR”
March 2021 “PPSA Reminder: Weigh Your Patients and Do It In Kilograms”
Our prior columns related to infusion pump issues:
References:
Dancsecs KA, Nestor M, Bailey A, et al. Identifying errors and safety considerations in patients undergoing thrombolysis for acute ischemic stroke. Am J Emerg Med 2021; 47: 90-94
https://www.sciencedirect.com/science/article/abs/pii/S0735675721002291?via%3Dihub
Barrow T, Khan MS, Halse O, et al. Estimating Weight of Patients With Acute Stroke When Dosing for Thrombolysis. Stroke 2016; 47(1): 228-231; Published ahead of print November 10, 2015
https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.115.011436
Print “Errors Common During Thrombolysis for Acute Ischemic Stroke”
May 4, 2021
More 10x Dose Errors in Pediatrics
Ten-fold medication errors are a concern for patients of any age. Several of our previous columns (see our Patient Safety Tips of the Week for March 12, 2007 “10x Overdoses”, September 9, 2008 “Less is More….and Do You Really Need that Decimal?”, and January 18, 2011 “More on Medication Errors in Long-Term Care”) provided examples of how 10-fold overdoses occur in a variety of settings.
But, for a variety of reasons, 10-fold errors are more common in children. Our April 17, 2012 Patient Safety Tip of the Week “10x Dose Errors in Pediatrics” highlighted that issue.
A recent bulletin on weight-based medication errors in children from the Healthcare Safety Investigation Branch (HSIB) of UK’s National Health Service brought the issue to our attention again (HSIB 2021). The bulletin was issued after analysis of an incident related to a weight-based medication error involving a child who received ten times the intended dose of dalteparin on five occasions over a period of three days. This occurred following prescribing by a junior doctor, using the Trust’s electronic prescribing and medicines administration (ePMA) system.
A 4-year-old child was hospitalized following complications for a complex cardiac procedure. She developed a DVT. A multidisciplinary team agreed that the child should be prescribed dalteparin 100 units/kg twice daily (a recommendation in accordance with the British National Formulary for Children). The drug was prescribed by an approved prescriber using the Trust’s electronic prescribing and medicines administration system. The child’s weight at the time of the prescription was 15.2kg so the dose for administration should have been 15.2 x 100 = 1520 units twice daily rounded down to 1500 units twice daily. The child was inadvertently prescribed 15,000 units of dalteparin twice daily. The approval, dispensing, checking and administration steps did not identify the incorrect prescription meaning the child received 15,000units (10 times the dose intended) of dalteparin on five occasions over three days.
The report notes 5 important factors that may make pediatric medication errors more common:
As opposed to adults, prescribing in children is individualized, typically based on weight, age, or body surface area. So, doses need to be calculated, incorporating one or more of those variables. Such calculations are often manually undertaken in pediatrics as some electronic prescribing systems do not have automated calculation, and some systems with automated calculation are not used.
Units used in such calculations can sometimes contribute to errors. For example, there are many examples where pounds and kilograms get mixed up. That is why we always recommend that weights be input in one standard: kilograms.
Varying concentrations of liquid formulations are also problematic. Facilities need to consider whether they really need multiple different concentrations of medications. Often, standardization on one concentration makes a lot of sense.
The HSIB report notes that many electronic prescribing and medicines administration (ePMA) systems used by hospitals in the UK are configured locally. These local configurations may mean that some systems designed for adult patients are then modified for pediatric patients. The investigation has also seen that even in pediatric-only facilities, the age and weight ranges of patients may mean adult equivalent doses of medicines are sometimes needed. The report notes it would be beneficial for facilities that have adult and pediatric prescribing supported through the same system to ensure they have adequately risk assessed the way in which the system supports the calculation of doses to ensure that adult doses do not require manipulation for pediatric patients.
Our April 17, 2012 Patient Safety Tip of the Week “10x Dose Errors in Pediatrics” highlighted a study from the Hospital for Sick Children in Toronto, Ontario (Doherty 2012) that reported on 252 10-fold medication errors over a 5-year period. That translated to a mean reporting rate of 0.062 per 100 total patient days. Since this was a retrospective review taken from voluntary incident reporting the authors acknowledge that the true incidence may be higher. Morphine was the most frequently reported medication, and opioids were the most frequently reported drug class, followed by antimicrobials and anticoagulants. Patient harm was described in 22 of the reported cases. Contributing factors included intravenous formulations, paper ordering, drug-delivery pumps, errors of dose calculation, documentation of decimal points, and confusion with zeroes. They note that the errors occurred in all phases of the medication process (prescribing, transcribing, dispensing, administering, and monitoring), though the prescribing and administration phases were overrepresented. Of the errors, 123 ten-fold medication errors were intercepted before reaching the patient, most often by pharmacists or nurses but occasionally by physicians or patients or their families.
It also raises an issue we’ve previously ignored: 10x dosing errors are not always overdoses! They note that almost 30% of the 10-fold dosing errors they found would have resulted in significant underdosing with resultant loss of efficacy. That was especially true for antimicrobials.
The authors do a very good job identifying both sources for the errors and contributing factors. Dosage calculation errors and incorrect programming of delivery devices were the top sources for the errors. But they note that paper-based ordering was frequently an enabling factor. On the other hand, CPOE failed to block almost as many 10-fold errors. In addition, overriding of alerts on delivery devices was also a frequent enabler. Simultaneous programming of multiple intravenous pumps was another mechanism. And, as could be anticipated, urgent clinical scenarios were more prone to errors.
Where we had previously talked about sticking keys or keys that don’t work on infusion pumps, they noted that the keyboard layout on many pumps may lead to errors. They point out that the “zero”, “decimal point”, and “confirm” or “enter” keys are often in close proximity on many keyboards, making it too easy to hit more than one key at the same time.
The authors put together many excellent recommendations to minimize the risk of 10-fold errors. Solutions to address dose calculation errors would include mandatory use of dose calculators, increased on-ward clinical pharmacists, and a system for prescribing high-risk medications that requires no calculations by the prescribing physician, such as use of fixed-dose order sets or CPOE that automatically calculates drug dose based on patient weight. Of course, that assumes the correct weight has been input into the EMR. If that weight is incorrect, it would make all such calculations incorrect.
Having decision support systems (tied to CPOE, barcoding systems, and automated dispensing machines) that flag doses of medications falling outside conventional dose ranges is another good way of helping avoid 10-fold medication errors. But beware that computer systems in their study were often enablers since they allowed many 10-fold errors to pass through the system.
Tse and Tuthill (Tse 2020) evaluated 10-fold or greater or a tenth or less medication errors in children aged <16 years in Wales. They found 50 cases over a 3-year period, 43 being overdoses and 7 underdoses. 33 of these incidents occurred in children <5 years of age. The incidents occurred across multiple different healthcare settings. Enteral medications were involved in 31 cases and liquid preparations were often used. Overall, 37 different medications were involved. Five children suffered temporary harm but all fully recovered.
Though they note the overall risk was low, calculating a minimum annual incidence of 1 per 3797 admissions, or 4.6/100 000 children, they recommend improvements can be made to further reduce the risk.
They note that, similar to other studies, errors occurred mainly in the very young and with small volumes of liquid medication.
They reiterate particular issues in pediatrics which make errors more likely:
Recognizing that liquid preparations are often problematic, Tse and Tuthill recommend switching to tablets whenever possible. They also recommend involving pediatric pharmacists.
Tse and Tuthill also recognized communication issues contributing to these medication errors. They recommend that, to avoid mistakes, advice given over the telephone for infrequently used medicines should be supported by both employing verbal communication tools such as SBAR (Situation, Background, Assessment, Recommendation) and written confirmation of the dose.
One recommendation in most studies has been to incorporate calculations into CPOE or ePrescribing systems and populate the equations with a weight from the electronic medical record (EMR). Of course, that assumes the correct weight has been input into the EMR. If that weight is incorrect, it would make all such calculations incorrect. And standardization of how those weights are input is critical. The error of mixing up pounds and kilograms is critical. Weights should always be input in kilograms. A good system will always force the clinician to input the wight in kilograms (or ask the clinician if the input weight is in kilograms or pounds and convert the latter to kilograms).
Mixing up mg, g, µg can also give rise to 10-fold (or more) errors. Therefore, it is critical to avoid dangerous abbreviations. ISMP recommends using “mcg” for micrograms rather than µg (ISMP 2021).
In addition to mixing up pounds and kilograms, another common error is mixing up milligrams and milliliters. Many medication formulations are in mg/mL. If the order was for 10 mg of a medication and one inadvertently drew up 10 mL from a vial where the concentration was 10 mg/mL, you’d have a 10-fold overdose. See also our April 2015 What's New in the Patient Safety World column “Pediatric Dosing Unit Recommendations”, which cited the AAP (American Academy of Pediatrics) policy statement “Metric Units and the Preferred Dosing of Orally Administered Liquid Medications” (AAP 2015). The latter includes a reminder that an important facet of avoiding pediatric medication errors is providing appropriate education to the parents at the time of prescribing (and dispensing). Health literacy and numeracy are factors important in contributing to medication errors (see our prior columns for June 2012 “Parents’ Math Ability Matters”, November 2014 “Out-of-Hospital Pediatric Medication Errors”, and January 13, 2015 “More on Numeracy”). Therefore, the AAP statement includes attention to use of tools and techniques such as teach-back, show-back, dose demonstration, pictures and drawings when educating the parents about the medication.
The HSIB case was also an example of how many systems of double checking are weak (see our prior columns on double checking listed below). Though we’ve noted that many reported 10-fold medication errors have not been prevented by double checks, that does not mean double checks should be scrapped. Particularly for high-alert medications, double checks can be important. But they must be truly independent double checks.
And we have long lamented the apparent death of the “mental double check”. In the past, nurses would typically look at a dose they are about to administer and ask themselves if that dose makes sense. Unfortunately, in the computer era all too much confidence is put on CPOE and barcoding and the “mental double check” seems to have become a thing of the past.
Clinical decision support systems (CDSS) are important in reducing the risk of significant medication overdoses. For many drugs, a typical therapeutic dose range can be programmed in and if an order for a medication includes a dose that exceeds the upper limit, a “hard” stop can be initiated. But, unfortunately, that may not work for all medications. For example, insulin doses can range from a few units to over 100 units. And the CDSS tools would need to distinguish between adult and pediatric patients.
Missing decimal points are a big reason for 10x overdoses and decimal points very frequently appear when dosages must be calculated, as they are in pediatrics. Our September 9, 2008 Patient Safety Tip of the Week “Less is More….and Do You Really Need that Decimal?” we raised the issue of decimal points leading to excessive doses and whether you really need decimal points at all. When do you really need them? You all know you should never use a “trailing zero”, i.e. a zero following a decimal point, because if the decimal point is not seen there is a risk of a 10-fold (or higher) overdose. But what about other numbers following a decimal point? They are important in certain circumstances (eg. a dose of 0.3 mg or 2.7 mg). However, at higher doses they become much less relevant. For example, let’s say you performed a calculation and the result was a recommended dose of a drug is 72.2 mg. Is there really a difference if the patient gets 72 mg or 72.2 mg of most drugs? Yet ordering the latter dosage increases the risk that the decimal point may not be seen or not input into a computer or missed in a faxed order and the patient gets a 10x overdose. So, we strongly recommend that in writing medication orders one specifically decides whether such fractional doses are important or merely place the patient at increased risk of an error. In our September 2011 What's New in the Patient Safety World column “Dose Rounding in Pediatrics” we discussed when dose rounding is appropriate and when it is not. To avoid decimal point errors, we need to heed ISMP’s long-standing recommendations (ISMP 2021):
Lastly, don’t forget that faxes can have a role in promoting 10-fold medication errors. A smudge on the fax can obscure a decimal point, resulting in a 10-fold overdose. And a small dot on a fax can be mistaken for a decimal point, resulting in a 10-fold underdose. While most healthcare facilities no longer accept faxed orders, a clinician might be referring to faxed medical records as he/she enters orders via CPOE or an ePrescribing system. See our May 2021 What's New in the Patient Safety World column “Axe the Fax” for more comments on why we need to get rid of the fax in healthcare.
Update 5/11/2021: Here’s another unusual cause of 10-fold medication errors that just came to our attention after last week’s column. After a Windows computer system upgrade, the computer system in several Australian hospitals began to duplicate the last digit of medication doses (Keane 2021). For example, if a medication dose was supposed to be 17 mg, the computer would record it as 177 mg. This is another reminder that system upgrades are a time of vulnerability to many of our patient safety tools. Close scrutiny for unwanted consequences are indicated any time your system undergoes an upgrade.
Keane D. Health boss unsure how many patients impacted by dosage bungle blamed on Windows upgrade. ABC News 2021; May 7, 2021
Some of our other columns on pediatric medication errors:
November 2007 “1000-fold Overdoses by Transposing mg for micrograms”
December 2007 “1000-fold Heparin Overdoses Back in the News Again”
September 9, 2008 “Less is More and Do You Really Need that Decimal?”
July 2009 “NPSA Review of Patient Safety for Children and Young People”
June 28, 2011 “Long-Acting and Extended-Release Opioid Dangers”
September 13, 2011 “Do You Use Fentanyl Transdermal Patches Safely?”
September 2011 “Dose Rounding in Pediatrics”
April 17, 2012 “10x Dose Errors in Pediatrics”
May 2012 “Another Fentanyl Patch Warning from FDA”
June 2012 “Parents’ Math Ability Matters”
September 2012 “FDA Warning on Codeine Use in Children Following Tonsillectomy”
May 7, 2013 “Drug Errors in the Home”
May 2014 “Pediatric Codeine Prescriptions in the ER”
November 2014 “Out-of-Hospital Pediatric Medication Errors”
January 13, 2015 “More on Numeracy”
April 2015 “Pediatric Dosing Unit Recommendations”
September 2015 “Alert: Use Only Medication Dosing Cups with mL Measurements”
November 2015 “FDA Safety Communication on Tramadol in Children”
October 2016 “Another Codeine Warning for Children”
January 31, 2017 “More Issues in Pediatric Safety”
May 2017 “FDA Finally Restricts Codeine in Kids; Tramadol, Too”
August 2017 “Medication Errors Outside of Healthcare Facilities”
August 2017 “More on Pediatric Dosing Errors”
September 2017 “Weight-Based Dosing in Children”
February 19, 2019 “Focus on Pediatric Patient Safety”
June 2020 “EMR and Medication Safety: Better But Not Yet There”
December 2020 “Guidelines for Opioid Prescribing in Children and Adolescents After Surgery”
Some of our other columns on double checks:
January 2010 “ISMP Article on Double Checks”
October 26, 2010 “Confirming Medications During Anesthesia”
October 16, 2012 “What is the Evidence on Double Checks?”
December 9, 2014 “More Trouble with NMBA’s”
April 19, 2016 “Independent Double Checks and Oral Chemotherapy”
December 11, 2018 “Another NMBA Accident”
January 1, 2019 “More on Automated Dispensing Cabinet (ADC) Safety”
March 5, 2019 “Infusion Pump Problems”
August 27, 2019 “Double Check on Double Checks”
November 19, 2019 “An Astonishing Gap in Medication Safety”
April 14, 2020 “Patient Safety Tidbits for the COVID-19 Pandemic”
March 2020 “ISMP Smart Infusion Pump Guidelines”
August 4, 2020 “Intravenous Issues”
August 18, 2020 “More Caution on Double Checks”
Some of our previous columns on the impact of abbreviations in healthcare:
March 12, 2007 “10x Overdoses”
June 12, 2007 “Medication-Related Issues in Ambulatory Surgery”
September 2007 “The Impact of Abbreviations on Patient Safety”
July 14, 2009 “Is Your “Do Not Use” Abbreviations List Adequate?”
April 2015 “Pediatric Dosing Unit Recommendations”
December 22, 2015 “The Alberta Abbreviation Safety Toolkit”
May 14, 2019 “Wrong-Site Surgery and Difficult-to-Mark Sites”
References:
Healthcare Safety Investigation Branch (HSIB). Interim bulletin. Weight-based medication errors in children. HSIB 2021; March 2021
Doherty C, McDonnell C. Tenfold Medication Errors: 5 Years’ Experience at a University-Affiliated Pediatric Hospital. Pediatrics 2012; 129 (5): 916-924 Published online April 2, 2012
https://pediatrics.aappublications.org/content/129/5/916
Tse Y, Tuthill D. Incidence of paediatric 10-fold medication errors in Wales. Archives of Disease in Childhood 2020; Published Online First: 27 October 2020
https://adc.bmj.com/content/early/2020/10/26/archdischild-2020-319130
ISMP (Institute for Safe Medication Practices). List of Error-Prone Abbreviations. ISMP 2021; February 5, 2021
https://www.ismp.org/recommendations/error-prone-abbreviations-list
AAP (American Academy of Pediatrics). Committee on Drugs. Policy Statement. Metric Units and the Preferred Dosing of Orally Administered Liquid Medications. Pediatrics 2015; 135(4): 784-787; originally published online March 30, 2015
http://pediatrics.aappublications.org/content/early/2015/03/25/peds.2015-0072.full.pdf
Print “More 10x Dose Errors in Pediatrics”
May 11, 2021
How Are Alerts in Ambulatory CPOE Doing?
When we did our first CPOE implementation back in 2007, we were flooded with suggestions for potential alerts that could be used for patient safety. We had many ideas for alerts ourselves. But we readily recognized the need to limit such alerts in order to avoid alert fatigue.
Perhaps the prime opportunity to use alerts to drive clinician behavior is in medication safety. Computers can work rapidly in the background to identify issues like allergies, drug-drug interactions, drug-disease contraindications, effects of renal or hepatic dysfunction, and other considerations that should be taken into account when prescribing medications. Most clinicians cannot take the time to consider all those factors when prescribing. So, computer-generated alerts can provide important information to the clinician at the time of order entry.
There are 2 types of alerts: “soft” alerts and “hard” alerts. Soft alerts are suggestions that the clinician can choose to implement or ignore. Hard alerts are ones that require the clinician to do something, such as accept the recommendation or explain why he/she is overriding the alert (or, in the extreme, would prevent the clinician’s action all together). Interruptive alerts are ones that require interruption of a clinician’s workflow to answer questions or input additional information. Hard alerts are examples of interruptive alerts. There are probably also some “soft” alerts that are interruptive (eg. the alert might make the clinician read a long message).
A recent review (Cerqueira 2021) assessed the effectiveness of interruptive medication-prescriber alerts in changing prescriber behavior and improving patient outcomes in ambulatory care settings via computerized provider order entry (CPOE) systems. The authors found that clinician behavior was influenced in the majority of studies, with most noting a positive change. They found that alerts decreased pharmaceutical costs, moved medications toward preferred medications tiers and steered treatments toward evidence-based choices. Importantly, they also decreased prescribing errors.
But they also found that clinician feedback was rarely solicited and, when it was, showed frustration with alerts creating a time delay. Notably, only one of the nine studies in their review reported feedback that was overall ‘positive’. Clinicians often commented that the alerts were inappropriate and intrusive.
Shi et al. (Shi 2021) recently studied barriers to using clinical decision support in ambulatory care. One of the 7 primary barriers they identified was the use of false and disruptive alarms. Another barrier was the requirement to redesign workflow.
Bombarding clinicians with alerts that are inappropriate and interruptive leads to the phenomenon of “alert fatigue” in which clinicians begin to ignore and override most alerts, even those that have the potential to avert unwanted outcomes.
There have been many studies linking clinician burnout to use of electronic medical records (EMR’s). While most relate to the overall time spent on the EMR (see our May 2021 What's New in the Patient Safety World column “More on Time Spent on the EMR”), frustration with clinical decision support (CDS) systems has been identified as a key factor in leading to clinician burnout. Jankovic and Chen (Jankovic 2020) reviewed articles dealing with aspects of CDS that contribute to burnout and identify key themes for improving the acceptability of CDS to clinicians, with the goal of decreasing said burnout.
In our June 2020 What's New in the Patient Safety World column “EMR and Medication Safety: Better But Not Yet There” we discussed results from the Leapfrog CPOE EHR evaluation tool shows some improvement over time but highlights the persistence of vulnerabilities and the wide variability of hospital CPOE EHR systems to identify medication errors and prevent adverse drug events (ADE’s). Classen et al. (Classen 2020) looked at results from over 2300 hospitals. The overall mean total score increased from 53.9% in 2009 to 65.6% in 2018. The mean hospital score for the “basic” CDS category increased from 69.8% in 2009 to 85.6% in 2018. The mean hospital score for the “advanced” CDS category increased from 29.6% in 2009 to 46.1% in 2018. Hospital EHR’s did better on some categories than others. For example, they did best on the drug-allergy category in each year, increasing from 92.9% in 2009 to 98.4% in 2018. The lowest performing category throughout the study was drug-diagnosis contraindications, where the mean score was only 20.4% in 2009 and 33.2% in 2018. The authors conclude “these systems have only modestly increased their safety performance during a 10-year period, leaving critical deficiencies in these systems to detect and prevent critical safety issues.”
So, why haven’t we been able to use CDS more effectively to improve medication safety and efficacy? It largely boils down to issues related to design and implementation of clinical alerts and reminders.
When the phenomenon of “alert fatigue” became apparent to us, we recognized the need to limit our alerts to those situations we considered most important for patient care. We did the following:
Those actions were very much in line with the recommendations the whitepaper “Safe Practices to Reduce CPOE Alert Fatigue through Monitoring, Analysis, and Optimization” from ECRI's Partnership for Health IT Patient Safety (see our March 2021 What's New in the Patient Safety World column “ECRI Partnership Whitepaper on Alert Fatigue”). The ECRI whitepaper (ECRI 2021) actually goes into more detail about the metrics you should be following.
Regarding metrics, one unique metric not mentioned in the ECRI whitepaper but potentially very valuable was described by Einbinder and colleagues (Einbinder 2014): the “number needed to remind” (NNR). Analogous to the number needed to treat (NNT), this is the number of patients reached by a reminder to result in one recommended action being taken. They compared this to the “reminder performance” (RP), which is simply the measure of how often a recommended action is subsequently taken when the reminder is displayed.
Alagiakrishnan et al. (Alagiakrishnan 2019) used the NNR in primary care and geriatric clinics to assess clinical decision support for potentially inappropriate medications (PIM’s) from Beers criteria. Their CDS system used alerts known as Best Practice Advisories (BPA’s) to direct providers to a navigator where orders management, clinical information and educational materials were available. The BPA’s were used to advise clinicians of PIM’s among their patients' medication lists or new orders. The reminder performance (RP) across both clinics was 17.3%, which corresponds to an NNR of 5.8. The reminder performance was 37.1% in geriatric clinics vs. 13.4% in primary care clinics. The NNR in the primary care clinic was 7.4 and NNR in the geriatric clinic was 2.7.
They also developed a metric “Number Needed to Deprescribe” (NND) or the number of alert presentations specific to a medication and patient presented to a physician user before there was a deprescribing event. The reminder performance for deprescribing events was lower at 1.2%. The number needed to deprescribe (NND) was 82, with values for the primary care clinic of 80 and the geriatrics clinic of 96. There was considerable variation in all 3 parameters by the class of medication for which the BPA alerts fired.
The ECRI Partnership whitepaper reiterates the “5 Rights” model of clinical decision support (CDS) adopted from Osheroff et al. (Osheroff 2012):
One of the metrics in the ECRI whitepaper looks at whom the alert is targeted to. That raises a point we’ve often made in the past: you need to target the alert to the individual(s) most likely to get the desired action accomplished. That may not always be the clinician ordering something on CPOE or an ePrescribing system. For example, when an antidiarrheal medication is ordered on a patient receiving antibiotics, an alert to consider C. diff infection might be better targeted to an infection control worker than to the ordering clinician. Or alerts regarding some medication issues might be better targeted to clinical pharmacists.
The ECRI whitepaper also asks one very important question: “Is an alert the appropriate tool?”. Essentially, that is askng whether there is an alternative to accomplish the same goal. We’d like to emphasize that last point. In our March 3, 2009 Patient Safety Tip of the Week “Overriding Alerts…Like Surfin’ the Web” we noted that use of standardized order sets may avoid the need to generate some alerts (though standardized order sets can create some problems of the own, particularly when they contain outdated information that is no longer appropriate).
There is another phenomenon we’ve seen over and over. That is the disparity in effectiveness between “prospective” alerts and “look-back" alerts. When we’ve tried to use alerts to avoid using a “potentially inappropriate” medication (an example might be tricyclic antidepressants in an elderly patient), we found that clinicians almost never stopped that medication once they had already previously prescribed it. On the other hand, the alert was effective at preventing new prescriptions for that medication in the elderly. Awdishu et al. (Awdishu 2016), looking at the impact of alerts on prescribing in patients with renal disease, also found that prospective alerts had a greater impact than look-back alerts (55.6% vs 10.3%).
Marcilly et al. developed evidence-based usability design principles for medication alerting systems (Marcilly 2018). They note that alerts should:
The Marcilly paper notes that alert design should take into account parameters such as the
patient’s clinical context or the clinician’s specialty. That makes sense. An alert to a primary care physician reminding them to adjust a medication dose based upon the patient’s renal function might just create unnecessary “noise” for a nephrologist entering a similar order. Similarly, regarding context, some alerts about renal dosing may not be appropriate for a patient already on dialysis.
Alerts are also more likely to be complied with if they offer “actionable” tools. For example, an alert that offers an alternative action or choice is much more likely to be complied with than one that simply suggests the original action is discouraged.
Shah et al. (Shah 2021) looked at CDS alerts regarding renal dosing in hospitalized patients. They found that alerts were nearly always presented inappropriately and were all overridden during the 1-year period studied. This was distinctly different from data they had previously seen in a legacy system in which medication-related CDS alerts associated with renal insufficiency had been found to be the most clinically beneficial. They identified several potential reasons why the current medication-related CDS alerts associated with renal insufficiency were less effective than they had been in the legacy homegrown system:
The Shah study tells us we cannot simply adopt all vendor-generated CDS alerts and reminders. Rather, we must apply the same rigorous evaluation and monitoring to those alerts and reminders that we used when we designed all our own alerts and reminders. We need to make sure they are evidence-based, are actionable, offer alternatives where appropriate, are prospective, fit with workflow, take clinical context and clinician specialty into consideration, and, most of all, are limited in volume to those that are most likely to impact patient safety and patient outcomes so we can avoid alert fatigue.
We can’t duplicate the extensive literature review done by the ECRI Partnership. We encourage you to go back to their whitepaper (ECRI 2021). Their “evidence tables” in the appendix includes a summary of the findings from 12 key studies. We hope you’ll use lessons learned in those plus the key elements in today’s column to make sure you are getting the most out of your clinical decision support tools without generating alert fatigue and contributing to clinician burnout.
See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:
See some of our previous columns dealing with the Leapfrog CPOE EHR evaluaton tool:
References:
Cerqueira O, Gill M, Swar B, et al. The effectiveness of interruptive prescribing alerts in ambulatory CPOE to change prescriber behaviour & improve safety. BMJ Quality & Safety 2021; Published Online First: 19 April 2021
https://qualitysafety.bmj.com/content/early/2021/03/14/bmjqs-2020-012283
Shi Y, Amill-Rosario A, Rudin RS, et al. Barriers to using clinical decision support in ambulatory care: Do clinics in health systems fare better? Journal of the American Medical Informatics Association 2021; ocab064 Published: 25 April 2021
Jankovic I., Chen JH. Clinical Decision Support and Implications for the Clinician Burnout Crisis. Yearbook of medical informatics 2020; 29(1): 145-154
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7442505/
Classen DC, Holmgren AJ, Co Z, et al. National Trends in the Safety Performance of Electronic Health Record Systems From 2009 to 2018. JAMA Netw Open 2020; 3(5): e205547
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2766545?resultClick=3
ECRI Partnership for Health IT Patient Safety. Safe Practices to Reduce CPOE Alert Fatigue through Monitoring, Analysis, and Optimization. ECRI 2021
Einbinder J, Hebel E, Wright A, Panzenhagen M, Middleton B. The number needed to remind: a measure for assessing CDS effectiveness. AMIA Annu Symp Proc 2014; 14: 506-515
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4419960/
Alagiakrishnan K, Ballermann M, Rolfson D, et al. Utilization of computerized clinical decision support for potentially inappropriate medications. Clin Interv Aging 2019; 14: 753–762
Osheroff JA, Teich JM, Levick D, et al. Improving outcomes with clinical decision support: an implementer’s guide. 2nd ed. Chicago (IL): Healthcare Information and Management Systems Society; 2012
Awdishu L, Coates CR, Lyddane A, et al. The impact of real-time alerting on appropriate prescribing in kidney disease: a cluster randomized controlled trial. J Am Med Inform Assoc 2016; 23(3): 609-616
https://academic.oup.com/jamia/article/23/3/609/2909002
Marcilly R, Ammenwerth E, Roehrer E, et al. Evidence-Based usability design principles for medication alerting systems. BMC Med Inform Decis Mak 2018; 18: 69
https://bmcmedinformdecismak.biomedcentral.com/articles/10.1186/s12911-018-0615-9
Shah SN, Amato MG, Garlo KG, et al. Renal medication-related clinical decision support (CDS) alerts and overrides in the inpatient setting following implementation of a commercial electronic health record: implications for designing more effective alerts. Journal of the American Medical Informatics Association 2021; ocaa222
Print “How Are Alerts in Ambulatory CPOE Doing?”
May 18, 2021
Medical Overuse Is Not Just An Economic Problem
We often do presentations on what’s wrong with our current healthcare system. Two significant factors we highlight are unnecessary testing and low-value care. The economic consequences of the “diagnostic cascade” are well known and frequently reported on. But that diagnostic cascade can also result in patient harm, particularly when it ultimately leads to a low-value procedure or other intervention.
Fisher and Welch (Fisher 1999) developed a schematic showing the mechanisms by which more medical care can lead to harm. More diagnosis creates the potential for labeling and detection of pseudodisease—disease that would never become apparent to patients during their lifetime without testing. More treatment may lead to tampering, interventions to correct random rather than systematic variation, and lower treatment thresholds, where the risks outweigh the potential benefits. Because there are more diagnoses to treat and more treatments to provide, physicians may be more likely to make mistakes and to be distracted from the issues of greatest concern to their patients.
Korenstein et al. (Korenstein 2018) developed a conceptual map that documents that overused tests and treatments and resultant downstream services generate 6 domains of negative consequences for patients:
They note that negative consequences can result from overused services or from downstream services. They can also trigger further downstream services that in turn can lead to more negative consequences, in an ongoing feedback loop. One example they provide is a screening colonoscopy in an 80-year-old man leading to a biopsy, hospitalization, and follow-up imaging tests and, perhaps, even a bowel perforation during a colonoscopy which may, in turn, lead to chronic gastrointestinal symptoms. Another was an unnecessary screening low-dose computed tomography (LDCT) scan which revealed scattered nodules. This finding led to a 3-month follow-up scan, which then led to a positron emission tomography (PET) scan, a surgical evaluation, and ultimately another follow-up scan. Another was unnecessary CT angiography showing coronary artery disease, which led to coronary angiography and ultimate 3-vessel CABG, with heart failure as a complication of the CABG.
Their review of cases in the literature found 54 case descriptions with a total of 63 overused services. Nearly all case descriptions (91%) described the overuse cascade, with a mean of 4.2 downstream services identified per case and 227 downstream services mentioned in total. Physical harms predominated (69%), followed by psychological consequences (16%) and treatment burden (9%), financial consequences (3%), dissatisfaction with health care (2%), and social consequences (1%). The authors do acknowledge that the high frequency of cases reporting physical harm may result from publication bias.
Over the last decade, the Choosing Wisely campaign has compiled lists from national organizations representing medical specialists to identify tests or procedures commonly used in their field whose necessity should be questioned and discussed. Many examples of what is referred to as “low-value” care have come from such lists. In addition, the JAMA Internal Medicine “Less is More” series has provided multiple examples of low-value care leading to unwanted consequences.
There has been a spate of articles recently about low-value care and unnecessary testing.
One classic example deals with cataract surgery. One of the American Academy of Ophthalmology’s Choosing Wisely items is “Don’t perform preoperative medical tests for eye surgery unless there are specific medical indications.” That statement notes that, for many, preoperative tests are not necessary because eye surgeries are not lengthy and don’t pose serious risks. It further states that an EKG should be ordered if patients have heart disease and, in general, patients scheduled for surgery do not need medical tests unless the history or physical examination indicate the need for a test, e.g., the existence of conditions noted above. Institutional policies should consider these issues. Yet many patients undergoing cataract surgery still get some preoperative testing. Ganguli et al. (Ganguli 2019a) looked at preoperative electrocardiogram (EKG) for Medicare patients undergoing cataract surgery without known heart disease. They compared downstream testing and events in those who got a preoperative EKG versus those that did not. Those who received a preoperative EKG experienced between 5.11 and 10.92 additional events per 100 beneficiaries relative to the comparison group. This included between 2.18 and 7.98 tests, 0.33 treatments, 1.40 new patient cardiology visits, and 1.21 new cardiac diagnoses. Spending for the additional services was up to $565 per Medicare beneficiary, or an estimated $35,025,923 annually across all Medicare beneficiaries in addition to the $3,275,712 paid for the preoperative EKG’s. They estimated that 14.7% of preoperative EKG recipients had a potential cascade event.
Though Ganguli et al. were not able to determine how many of those patients suffered harm as a result of having a preop EKG, they cited the US Preventive Services Task Force statement (Curry 2018) that screening EKG in low-risk, asymptomatic patients can lead to harms including “unnecessary invasive procedures, overtreatment, and labeling”. Ganguli et al. do acknowledge that, lacking clinical details on all patients, some may also have benefitted from the diagnostic cascade.
Ganguli et al. (Ganguli 2020) also assessed the prevalence of several low-value tests (routine electrocardiograms, urinalyses, and thyrotropin tests) during Medicare Annual Wellness Visits and how these related to cascades of further tests or care. They found that 18.6% of patients received at least 1 low-value test including an ECG (7.2%), urinalysis (10.0%), or thyrotropin test (8.7%) during such visits. A total of 6.1 cascade-attributable events per 100 beneficiaries occurred in the 90 days following routine ECGs and 5.4 following urinalyses. Cascade-attributable cost per beneficiary were $9.62 for ECG’s and $7.46 for urinalyses. No cascade-attributable events or costs were found to be associated with thyrotropin tests.
Among patients who received any routine test, 13.5% had a potential cascade laboratory test, 6.6% had a potential cascade imaging test, 3.9% had a potential cascade procedure, 8.6% had a potential cascade visit, 2.0% had a potential cascade new diagnosis, and 0.3% had a potential cascade hospitalization. Again, lacking clinical details, it is unknown whether some patients were harmed as a result of these and it is very conceivable that some patients benefited.
Similarly, Bouck et al. (Bouck 2020) looked at low-value testing with subsequent care among low-risk primary care outpatients undergoing an annual health examination (AHE) in Ontario, Canada. Specifically, they identified patients who received 1 of 3 tests identified by Choosing Wisely Canada as low value in low-risk populations: chest radiographs, electrocardiograms (ECG’s), and Papanicolaou tests. At 90 days, patients receiving any of these tests were more likely to see specialists and more likely to undergo both additional noninvasive and invasive testing or procedures compared to patients who did and did not receive an initial low-value test.
We discussed the issue of incidental findings in our April 13, 2021 Patient Safety Tip of the Week “Incidental Findings – What’s Your Strategy?”. While our focus was on avoiding “falling through the cracks”, it is important to recognize the cascade effect that results from incidental findings on lab or imaging studies. Once again, Ganguli and colleagues (Ganguli 2019b) have assessed the cascade effect that follows incidental findings on screening and diagnostic tests. In a nationally representative survey of physicians, almost all respondents reported experiencing cascades, including cascades with clinically important and intervenable outcomes and cascades with no such outcome. Physicians reported cascades caused their patients psychological harm (68.4%), physical harm (15.6%), and financial burden (57.5%) and personally caused the physicians wasted time and effort (69.1%), frustration (52.5%), and anxiety (45.4%).
When asked about their most recent cascade, 33.7% reported the test revealing the incidental finding may not have been clinically appropriate. During that most recent cascade, physicians reported that guidelines for follow-up testing were not followed (8.1%) or did not exist to their knowledge (53.2%). To lessen the negative consequences of cascades, 62.8% of respondents chose accessible guidelines and 44.6% chose decision aids as potential solutions. We discussed implementation of such solutions in our April 13, 2021 Patient Safety Tip of the Week “Incidental Findings – What’s Your Strategy?”.
Chalmers et al. (Chalmers 2021) looked at low-value services provided to Medicare patients. Head imaging for syncope was the highest-volume low-value service (29.9%), followed by coronary artery stenting for stable coronary disease (15.8%). They developed a composite overuse score ranging from 0 (no overuse of services) to 1 (relatively high overuse of services) to compare hospital performance. They found the highest scores were associated with nonteaching and for-profit hospitals, particularly in the South. This work was related to the Lown Institute, which publishes a Hospital Index that compares hospital performance on twelve low-value services, such as hysterectomy for benign disease, coronary stents for stable heart disease, and head imaging for syncope.
The recent trend toward more employment of physicians by hospitals may have had a negative impact on overuse of some services. Young et al. (Young 2021) investigated inappropriate ordering of MRI scans in Massachusetts for three common medical conditions: lower back pain, knee pain, and shoulder pain. They found that the odds of a patient receiving an inappropriate MRI referral increased by more than 20 percent after a physician transitioned to hospital employment. Most patients who received an MRI referral by an employed physician obtained the procedure at the hospital where the referring physician was employed. These results point to hospital-physician integration as a potential driver of low-value care.
Müskens et al. (Müskens 2021) reviewed the literature on diagnostic testing overuse. They concluded that substantial overuse of diagnostic testing is present with wide variation in overuse. The highest prevalence of overuse was reported for: use of electrocardiograms, chest X-rays or pulmonary function tests in low-risk patients having low-risk surgery (97.5%); imaging for low back pain within the first 6 weeks of symptom onset in the absence of red flags (86.2%); knee arthroscopy for meniscal derangements (81.7%); baseline lab tests for low-risk patients receiving low risk surgery (78.6%); and knee arthroscopy for osteoarthritis (71.7%). Overall, imaging in case of nonspecific low back pain and preoperative tests, such as preoperative baseline lab tests, echocardiography or exercise stress tests, were the most often assessed diagnostic practices identified in this study.
Low-value care includes not only examples from diagnostic testing but also procedures and other interventions. As above, low-value procedures often result from low-value diagnostic testing. For example, screening an asymptomatic high-risk patient for carotid stenosis may lead to a carotid endarterectomy. Procedures are the most likely to be associated with patient harm or other patient safety issues. Attempts have been made to measure harms from low-value care indirectly by measuring rates of both low value care and hospital complications (Brownlee 2017). But Badgery-Parker et al. (Badgery-Parker 2019) sought a more direct measurement. They looked at the following low-value procedures (chosen from Choosing Wisely and other sources) in a large patient database in Australia:
They used 16 hospital-acquired complications (HAC’s) as a measure of harm associated with low-value care.
The percentage of low-value episodes with any HAC ranged from 0.1% for endoscopy to 15.0% for EVAR. Predictably, HAC rates were higher for those procedures done in high-risk patients, such as carotid endarterectomy and EVAR, but high rates were also seen for renal artery angioplasty and spinal fusion. Moreover, the occurrence of a HAC at least doubled the hospital length of stay for each of the 7 procedures studied.
For most procedures, the most common HAC was healthcare-associated infection, which accounted for 26.3% of all HAC;s observed. But cardiac complications occurred relatively frequently for carotid endarterectomy, EVAR, and renal artery angioplasty (9.7%, 5.7%, and 4.6% respectively).
And, of course, the other major area of more medical care leading to harm has to do with medications. Sometimes it’s hard to distinguish “overuse” form “misuse” but both can give rise to patient harm. Overuse would include inappropriate prescribing of antibiotics for conditions not likely to require antibiotics. Misuse would include examples like polypharmacy or prescription of potentially inappropriate medications (PIM’s) in the elderly. Discussion of these medication-related harms is beyond the scope of today’s column but can be found in our many columns on medication safety.
All this has led to calls for “deimplementation science”. Anderson and Lin (Anderson 2020), in a commentary on the Bouck study, called for more focused research on testing cascades and their outcomes. They note that most studies have utilized administrative data, which lacks the clinical details we need to better understand cause and effect, rationales, and factors contributing to low-value testing.
So, how do we cut down on low-value care? One study showed that Choosing Wisely had minimal impact on one example, whereas stopping payment for the low-value service had a dramatic impact. Henderson et al. (Henderson 2020) looked at the impact of Choosing Wisely recommendations regarding 2 low-value tests (vitamin D screening and triiodothyronine tests). Choosing Wisely recommendations were associated with reductions 13.8% for US Veterans Health Administration, and 14.0% for US employer-sponsored insurance. They compared that to the impact of an Ontario, Canada payment policy change that eliminated reimbursement of vitamin D screening. That was associated with a 92.7% relative reduction in such screening. (There was no significant difference in the frequency of triiodothyronine testing.)
Wolf et al. (Wolf 2021), in a viewpoint on deimplementation in pediatrics, offer insights into the problem of low-value care in general. They note that, despite significant progress in the identification of low-value services, overuse continues. And, as we’ve noted, guidelines alone seem insufficient to change clinical practice. They describe factors at the level of the patient (parental pressures, direct-to-consumer advertising), clinician (fear of missing a diagnosis, malpractice suits), and health care system (fee-for-service reimbursement, short visit times) that continue to drive overuse. Cognitive biases such as the “endowment effect” also make clinicians less likely to end historical practices.
One additional factor contributing to overdiagnosis and medical overuse was recently emphasized: we regularly overestimate the probability of disease. Morgan et al. (Morgan 2021) surveyed practitioners and presented them with clinical scenarios and asked them to estimate pretest probability of disease and posttest probabilities after both positive and negative test results. Individual testing questions pertained to mammograms for breast cancer, stress testing for cardiac ischemia, chest radiography for pneumonia, and urine cultures for urinary tract infection (UTI). They found that, for common diseases and tests, practitioners overestimate the probability of disease before and after testing. Pretest probability was overestimated in all scenarios, whereas adjustment in probability after a positive or negative result varied by test. They conclude that widespread overestimates of the probability of disease likely contribute to overdiagnosis and overuse.
Wolf et al. (Wolf 2021) note many different approaches to reduce low-value care in adults have been used, including reimbursement restriction, risk sharing, patient and clinician education, audit and feedback of clinician performance, and clinical decision support tools. They note that that multicomponent interventions may be most successful.
Focusing on the fiscal costs of low-value care and medical overuse can stay in the realm of administrators and health policy wonks. But it has done little to solve the problem. Focusing on the human costs of low-value care and medical overuse is what is needed to get the attention of clinicians, who are key to solving the problem. You’ve heard us extol over and over the power of stories over statistics. One example we often note in our presentations and webinars was from Richard Shannon, MD back in 2007 at a conference on patient safety sponsored by the NY State Department of Health. He spoke about how for years data would be presented on rates of CLABSI’s and likely costs due to CLABSI’s and how this generated little interest in action. Then something caught his attention: over half his ICU patient who got a CLABSI died! That’s what spurred him and his colleagues to action, resulting in a dramatic reduction in CLABSI’s in his ICU. It’s that focus on the impact on our patients, rather than the pocketbook, that gets clinicians to act.
References:
Fisher ES, Welch HG. Avoiding the unintended consequences of growth in medical care: how might more be worse? JAMA.1999; 281(5): 446-553
https://jamanetwork.com/journals/jama/article-abstract/188743
Korenstein D, Chimonas S, Barrow B, Keyhani S, Troy A, Lipitz-Snyderman A. Development of a conceptual map of negative consequences for patients of overuse of medical tests and treatments. JAMA Intern Med 2018; 178(10): 1401-1407
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2696732
Choosing Wisely
JAMA Internal Medicine “Less is More” series
https://jamanetwork.com/collections/44045/less-is-more
Ganguli I, Lupo C, Mainor AJ, et al. Prevalence and Cost of Care Cascades After Low-Value Preoperative Electrocardiogram for Cataract Surgery in Fee-for-Service Medicare Beneficiaries. JAMA Intern Med 2019; 179(9): 1211-1219
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2735387?resultClick=1
Curry SJ, Krist AH, Owens DK, et al; US Preventive Services Task Force. Screening for cardiovascular disease risk with electrocardiography: US Preventive Services Task Force Recommendation Statement. JAMA 2018; 319(22): 2308-2314
https://jamanetwork.com/journals/jama/fullarticle/2684613
Ganguli I, Lupo C, Mainor AJ, et al. Assessment of Prevalence and Cost of Care Cascades After Routine Testing During the Medicare Annual Wellness Visit. JAMA Netw Open 2020; 3(12): e2029891
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2774080?resultClick=1
Bouck Z, Calzavara AJ, Ivers NM, et al. Association of Low-Value Testing With Subsequent Health Care Use and Clinical Outcomes Among Low-risk Primary Care Outpatients Undergoing an Annual Health Examination. JAMA Intern Med 2020; 180(7): 973-983
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2766917
Ganguli I, Simpkin AL, Lupo C, et al. Cascades of Care After Incidental Findings in a US National Survey of Physicians. JAMA Netw Open 2019; 2(10): e1913325
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2752991?resultClick=1
Chalmers K, Smith P, Garber J, et al. Assessment of Overuse of Medical Tests and Treatments at US Hospitals Using Medicare Claims. JAMA Netw Open 2021; 4(4): e218075
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2779118?resultClick=3
Lown Institute. 2021 Winning Hospitals: Avoiding Overuse
Young GJ, Zepeda ED, Flaherty S, Thai N. Hospital Employment of Physicians In Massachusetts Is Associated With Inappropriate Diagnostic Imaging. Health Affairs 2021; 40(5):710-718
https://www.healthaffairs.org/doi/10.1377/hlthaff.2020.01183
Müskens JLJM, Kool RB, van Dulmen SA, et al. Overuse of diagnostic testing in healthcare: a systematic review. BMJ Quality & Safety 2021; Published Online First: 10 May 2021
https://qualitysafety.bmj.com/content/early/2021/05/09/bmjqs-2020-012576
Brownlee S, Chalkidou K, Doust J, et al. Evidence for overuse of medical services around the world. Lancet 2017; 390(10090): 156-168
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32585-5/fulltext
Badgery-Parker T, Pearson S, Dunn S, Elshaug AG. Measuring Hospital-Acquired Complications Associated With Low-Value Care. JAMA Intern Med 2019; 179(4): 499-505
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2725081
Anderson TS, Lin GA. Testing Cascades—A Call to Move From Descriptive Research to Deimplementation Science. JAMA Intern Med 2020; 180(7): 984-985
https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2766913
Henderson J, Bouck Z, Holleman R, et al. Comparison of Payment Changes and Choosing Wisely Recommendations for Use of Low-Value Laboratory Tests in the United States and Canada. JAMA Intern Med 2020; 180(4): 524-531
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2760344
Wolf ER, Krist AH, Schroeder AR. Deimplementation in Pediatrics: Past, Present, and Future. JAMA Pediatr 2021; 175(3): 230-232
https://jamanetwork.com/journals/jamapediatrics/article-abstract/2772456
Morgan DJ, Pineles L, Owczarzak J, Magder L, Scherer L, Brown JP, Pfeiffer C, Terndrup C, Leykum L, Feldstein D, Foy A, Stevens D, Koch C, Masnick M, Weisenberg S, Korenstein D. Accuracy of Practitioner Estimates of Probability of Diagnosis Before and After Testing. JAMA Intern Med 2021; Apr 5:e210269
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2778364
Print “Medical Overuse Is Not Just An Economic Problem”
May 25, 2021
Yes, Radiologists Have Handoffs, Too
We’ve done many columns on handoffs in multiple venues and for various specialties. But we’ve never done one about radiologists. We.ve done multiple columns on radiologists and “closing the loop” to make sure significant imaging findings to not “fall through the cracks”. That process is, of course, a form of handoff. But radiologists also have several other types of handoffs.
A recent article by Burns et al. (Burns 2021) discussed those handoffs in both diagnostic and interventional radiology and offered recommended actions.
One form of handoff is from clinical staff to diagnostic radiology. This includes exam requests, special precautions (like allergies, isolation, etc.), initiation of consults, physical transfers, patient registration and identification, and technologist notes.
These clinician-to-radiology handoffs are critical, given the host of medical problems that may arise in the radiology suite. The vast majority of patient safety issues that arise in the radiology suite have little to do with the radiology procedure itself. Rather, seriously ill patients with complicated problems are sent to radiology and multiple problems can arise while the patient is in the radiology suite. See all our columns on such issues listed below. Intrahospital transport of patients is also a very vulnerable period, and the majority of such transports are to and from radiology. Our multiple columns on the “Ticket to Ride” checklist/handoff (also listed below) have stressed all the considerations when transporting such patients to and from radiology.
We cannot overemphasize the clinician’s role in providing the radiologist with adequate information as to why an imaging study is requested. In the “old days” (before CPOE) a clinician would often simply order an imaging study on the order sheet. Sometimes, then, clerical staff would simply fill out a requisition and under “reason for study” they might just write down the admitting diagnosis. Radiologists thus might get a requisition for a CT scan of the head for “pneumonia”! Fortunately, most CPOE systems and radiology information systems now require the clinician to provide more specific reasons for ordering imaging studies but even that often still just includes selecting a reason from a drop-down menu. The clinician really needs to let the radiologist what he/she is looking for or what he/she is looking to exclude. Often a verbal clinician-to-radiologist communication may be necessary and that further provides an opportunity for the radiologist to suggest the best imaging modality or protocol to use.
Another form of handoff is from radiology to clinical staff. This includes return on consults (communication of choice of appropriate imaging, protocols, follow-up recommendations, etc.). Also included would be preliminary and final reports and communication of significant or unexpected findings (see our columns on closing the loop listed below). It also includes physical transport of the patient from radiology back to the clinicians and nursing staff.
Many of the same items (in both directions) are part of handoffs for interventional radiology. But Burns and colleagues note that for these procedures pre-operative assessment, clinical notes, direct care team sign-outs, and intraprocedural discussions and decisions are also part of the clinician-to-radiologist handoff. In the reverse direction (radiologist-to-clinician) the handoff would also include pre-procedure orders, direct care team sign-outs, post-procedure notes and orders, including monitoring needs and plans for follow-up.
They then discuss adaptation of the Institute for Healthcare Improvement’s (IHI) reliability science framework for improving handoffs in radiology. They discuss 3 key levels of actions to improve handoffs:
Strategies targeted to the individual include training and reminders, standardization, checklists, mnemonics, and active listening skills. They caution about unclear handwritten orders and transcriptional errors and emphasize proofreading reports. Even though voice dictation software has made great strides, we still get reports with some outrageous mistakes. The authors note that transcriptional errors occur in as many as 22% of reports. And, unfortunately, we still occasionally see dictated reports appear in charts stating “signed but not read”. A focus on active listening behaviors is something that should apply to everyone in healthcare, not just radiologists. We always also stress the importance of “read back”, “hear back”, and “repeat back” to help ensure that all parties understand communications.
Checklists are important tools in handoffs. They help remind us to pay attention to details we might otherwise overlook. One checklist they describe for interventional radiology is called RADPASS (Koetser 2013). We’d again recommend use of “Ticket to Ride” style checklists for intrahospital transports (see columns listed below).
Burns et al. also introduced a new mnemonic, I-SCAN, for handoffs in radiology that is designed to incorporate important elements of I-PASS® with a tighter focus on radiologic findings. I-SCAN can be used in both diagnostic and interventional practice. I-SCAN stands for:
I Importance of results and identification of study, patient, sender, receiver
S Summary of imaging findings or interventional procedure
C Clinical context; any questions or additional concerns
A And
N Next steps” (further imaging, clinical workup, other recommendations)
Focus on team behaviors includes designation of time with minimal noise and interruption during handoffs “to ensure that the ideas expressed are completely and clearly reflected”. They suggest this can be achieved in a manner similar to the time-outs used in surgery. They also note that simulation practice is another useful tool.
Strategies targeted toward the organization include steps to promote a culture of safety and “Just Culture”. This encourages error reporting and learning without fear of blame or punishment. Error reporting should include not only incidents with patient harm but also near misses. And non-punitive peer learning also includes communication of “great calls” and “great catches”.
We refer you to the Burns article itself for many details of their strategies. Every radiology department or practice can learn from their work to improve handoffs and patient safety.
And, since we mentioned IPASS®, it’s worth noting that the IPASS® Patient Safety Institute just celebrated its 5-year anniversary. Of course, studies on IPASS® began over a decade ago and it is probably today the most widely used handoff format and system.
In a recent commentary on a study from Argentina (Jorro-Barón 2021) that showed IPASS® implementation in pediatric intensive care units showed significant improvement in handoff compliance but failed to reduced adverse events, Shahian (Shahian 2021) eloquently discusses the problem of linking handoffs to outcomes and events. He describes multiple studies that validate the usefulness of IPASS® and makes a plea for more urgent adoption of its principles to improve handoffs at every level of healthcare.
Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:
May 15, 2007 “Communication, Hearback and Other Lessons from Aviation”
May 22, 2007 “More on TeamSTEPPS™”
August 28, 2007 “Lessons Learned from Transportation Accidents”
December 11, 2007 “Communication…Communication…Communication”
February 26, 2008 “Nightmares….The Hospital at Night”
September 30, 2008 “Hot Topic: Handoffs”
November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
December 2008 “Another Good Paper on Handoffs”.
June 30, 2009 “iSoBAR: Australian Clinical Handoffs/Handovers”
April 25, 2009 “Interruptions, Distractions, Inattention…Oops!”
April 13, 2010 “Update on Handoffs”
July 12, 2011 “Psst! Pass it on…How a kid’s game can mold good handoffs”
July 19, 2011 “Communication Across Professions”
November 2011 “Restricted Housestaff Work Hours and Patient Handoffs”
December 2011 “AORN Perioperative Handoff Toolkit”
February 14, 2012 “Handoffs – More Than Battle of the Mnemonics”
March 2012 “More on Perioperative Handoffs”
June 2012 “I-PASS Results and Resources Now Available”
August 2012 “New Joint Commission Tools for Improving Handoffs”
August 2012 “Review of Postoperative Handoffs”
January 29, 2013 “A Flurry of Activity on Handoffs”
December 10, 2013 “Better Handoffs, Better Results”
February 11, 2014 “Another Perioperative Handoff Tool: SWITCH”
March 2014 “The “Reverse” Perioperative Handoff: ICU to OR”
September 9, 2014 “The Handback”
December 2014 “I-PASS Passes the Test”
January 6, 2015 “Yet Another Handoff: The Intraoperative Handoff”
March 2017 “Adding Structure to Multidisciplinary Rounds”
August 22, 2017 “OR to ICU Handoff Success”
October 2017 “Joint Commission Sentinel Event Alert on Handoffs”
October 30, 2018 “Interhospital Transfers”
April 9, 2019 “Handoffs for Every Occasion”
November 2019 “I-PASS Delivers Again”
August 2020 “New Twist on Resident Work Hours and Patient Safety”
September 29, 2020 “ISHAPED for Nursing Handoffs”
See also our other columns on communicating significant results:
Some of our prior columns on intrahospital transports and the “Ticket to Ride” concept:
Some of our prior columns on patient safety issues in the radiology suite:
References:
Burns J, Ciccarelli S, Mardakhaev E, et al. Handoffs in Radiology: Minimizing Communication Errors and Improving Care Transitions. JACR 2021; May 11, 2021
https://www.jacr.org/article/S1546-1440(21)00323-9/fulltext
Koetser IC, de Vries EN, van Delden OM, et al. A checklist to improve patient safety in interventional radiology. Cardiovasc Intervent Radiol 2013; 36: 312-319
https://link.springer.com/article/10.1007/s00270-012-0395-z
IPASS® Patient Safety Institute
https://www.ipassinstitute.com/
Jorro-Barón F, Suarez-Anzorena I, Burgos-Pratx R, et al. Handoff improvement and adverse event reduction programme implementation in paediatric intensive care units in Argentina: a stepped-wedge trial. BMJ Quality & Safety 2021; Published Online First: 23 April 2021
https://qualitysafety.bmj.com/content/early/2021/04/22/bmjqs-2020-012370
Shahian D. I-PASS handover system: a decade of evidence demands action. BMJ Quality & Safety 2021; Published Online First: 23 April 2021
https://qualitysafety.bmj.com/content/early/2021/04/22/bmjqs-2021-013314
Print “Yes, Radiologists Have Handoffs, Too”
June 1, 2021
Stronger Magnets, More MRI Safety Concerns
In our October 15, 2019 Patient Safety Tip of the Week “Lots More on MRI Safety” we noted that the FDA has now cleared 7T MR for clinical use. While stronger magnets can enhance the benefits of MRI scanning, they also bring some new safety concerns and other unintended consequences.
We already discussed some of the concerns in our October 15, 2019 Patient Safety Tip of the Week “Lots More on MRI Safety” and multiple other columns listed below. We noted that the most recent update of ACR (American College of Radiology) guidelines on MR safety (Greenberg 2019) reminded us of the need for safety guidelines that will be related to 7T MR. It notes that many implants, devices, and foreign bodies, that don’t significantly overheat at lower strength MR, might heat excessively at 7T strength. And certain devices that may retain functionality at lower MR strengths might lose functionality at 7T. Another paper (Hoff 2019) outlined the safety risks and associated risk-avoidance strategies of clinical 7-T MRI. Of particular concern are metallic implants and the risk for thermal injury. They note that over 6,000 metallic devices that have undergone evaluation at 1.5- and 3-tesla imaging, but that only 300 or so metallic implants and RF transmit coils have been tested for safety at 7-tesla MRI. Hoff et al. are also concerned about patient bioeffects such as vertigo, dizziness, false feelings of motion, nausea, nystagmus, magnetophosphenes, and electrogustatory effects that are more common and potentially more pronounced at 7 T than at lower field strengths. They suggest that earplugs and headphones could help reduce acoustic noise and related inner-ear and vision abnormalities and that increasing the amount of time patients spend in the 7-tesla static magnetic field as they enter and exit the scanner might help alleviate any physical issues.
AuntMinnie.com recently reported on a presentation by Filiz Yetisir, PhD at the 2021 International Society for Magnetic Resonance in Medicine (ISMRM) virtual meeting on the potential effects stronger MRI’s have on patients (Morton 2021). Perhaps the most obvious is the potential projectile effect. Any ferromagnetic item in proximity to the magnet can be captured by the magnetic field. The Morton article has a photograph of an office chair sucked into the MRI. Our February 19, 2008 Patient Safety Tip of the Week “MRI Safety” described the catastrophic case where a 6-year-old boy suffered a fatal head injury when an oxygen cylinder was sucked into the MRI bore. Our November 5, 2019 Patient Safety Tip of the Week “A Near-Fatal MRI Incident” discussed a similar potentially serious MRI accident in Sweden. Our January 7, 2020 Patient Safety Tip of the Week “Even More Concerns About MRI Safety” discussed a Swedish national survey on MR safety (Hansson 2019) that had some striking data on incidents involving projectiles. The following items were reported in 6 or more incidents in a 12-month period: scissors or knife, walker, wheelchair, bed, infusion pump, oxygen tank, and metal object in pocket. Projectiles reported in fewer incidents included ventilator or monitor, cart or cleaning cart, crutches, keys, phone, forceps, laryngoscope, sharp object, magnetic object, equipment part, glasses, hair clip, hair pin, basket lid, rescue stretcher, screw, vacuum cleaner.
But, in addition to the main magnet, Yetisir notes problems can arise from the gradient coils or the radiofrequency coils. The magnetic field produced by the gradient coils in the MR scanner can induce an electric field in the patient's body and this may form "hot spots", which can create enough electric potential to stimulate large nerves. This phenomenon is known as peripheral nerve stimulation (PNS). That can appear as an uncomfortable tingling or tapping sensation. If that occurs, it is possible to switch to another mode. But keep in mind that you must have an adequate method of communication with the patient to monitor for PNS.
The electric fields induced by the gradient coils can even stimulate the heart, leading to cardiac arrhythmias.
Another phenomenon related to the gradient coils is mechanical vibration that can cause acoustic noise and lead to acoustic trauma. Earplugs can be used to protect hearing but keep in mind, as above, you’ll need to have some other method of communication with the patient during the scan. If the mechanical vibrations are strong, she recommends use of table pads. And, if these are very discomforting, the scan should be stopped.
The radiofrequency coils have a magnetic field that can induce an electric current in conductive human tissue and this can lead to temperature elevation and thermal injury. Several of our columns have discussed how burns can result from currents in things like EKG leads, ferromagnetic medication patches, or almost any ferromagnetic item.
But Yetisir also points out that "limb loops" can increase local RF heating by up to a factor of three. Such loops caused by things like hands touching hips or clasping of hands.
Lastly, she comments on implants. We’ve previously discussed importance of screening for implants and checking to see if any such implants are MRI-safe. But keep in mind that sometimes that “safety” has been determined for MRI’s of lesser magnet strength.
These are some good observations and recommendations. As we move to magnets of greater strength, we need to be cognizant that there may be unwanted effects we did not see at lower strengths.
We refer you back to our multiple columns on MRI safety but especially to our Patient Safety Tips of the Week for October 15, 2019 “Lots More on MRI Safety” and January 7, 2020 “Even More Concerns About MRI Safety”.
And any time you upgrade your magnet, that is a good time to reorient your staff and anyone who might enter the MRI suite for any reason about the safety issues that must be observed. That includes working with your local first responders who might show up for a fire or other incident.
Some of our prior columns on patient safety issues related to MRI:
References:
Greenberg TD., Hoff MN, Gilk TB, et al. for the ACR Committee on MR Safety. ACR guidance document on MR safe practices: Updates and critical information 2019. J Magn Reson Imaging 2019; published online July 29, 2019
Hoff MN, McKinney A, Shellock FG, et al. Safety Considerations of 7-T MRI in Clinical Practice. Radiology 2019 292: 3: 509-551
https://pubs.rsna.org/doi/10.1148/radiol.2019182742
Morton W. As MRI strength increases, so do concerns about magnet safety. AuntMinnie.com 2021; May 20, 2021
https://www.auntminnie.com/index.aspx?sec=rca&sub=ismr_2021&pag=dis&ItemID=132442
Hansson, B., Olsrud, J., Wilén, J. et al. Swedish national survey on MR safety compared with CT: a false sense of security? Eur Radiol 2019; Online first December 13, 2019
https://link.springer.com/content/pdf/10.1007%2Fs00330-019-06465-5.pdf
Print “Stronger Magnets, More MRI Safety Concerns”
June 8, 2021
Cut OR Traffic to Cut Surgical Site Infections
We’ve done many columns on the likely contribution of OR traffic and opening/closing OR doors to surgical site infections (SSI’s). Way back in our March 10, 2009 Patient Safety Tip of the Week “Prolonged Surgical Duration and Time Awareness” we noted a study (Lynch 2009) that suggested increased foot traffic may be factor related to prolonged procedures that increases the likelihood of surgical site infections.
In our November 24, 2015 Patient Safety Tip of the Week “Door Opening and Foot Traffic in the OR” we discussed a study from Johns Hopkins that formally studied how often OR doors are opened during joint arthroplasty surgeries and the impact on OR air flow (Mears 2015). The researchers measured how often and for how long OR doors were opened during 191 hip and knee arthroplasty procedures. They also measured air pressures in the OR and adjacent corridors. They found that, on average, OR doors were open 9.5 minutes per case and the average time between door openings was 2.5 minutes. As you’d expect the number and duration of door openings correlated with the length of surgery. In 77 of the 191 cases positive pressure within the OR was defeated. The implications are obvious. While they found only one surgical infection in the 191 cases, the effects of the door opening on OR pressure and air flow theoretically would predispose to surgical infections. OR’s have positive pressure to avoid flow of air and airborne pathogens from nonsterile adjacent areas.
Our April 23, 2019 Patient Safety Tip of the Week “In and Out the Door and Other OR Flow Disruptions” discussed multiple other studies identifying common reasons for OR door opening/closing.
A recent report on a quality improvement project to reduce OR traffic (Parent 2021) was successful in both reducing OR traffic and reducing SSI’s. But perhaps its biggest contribution is identification of the barriers and challenges to success.
Parent implemented the project in 2 orthopedic OR’s. There were four principal interventions:
Signs were intended to warn the staff about entering the OR, particularly after the initial surgical incision had been made. The original “sign” was a safety strap across the doorway but, for several reasons, that was abandoned and replaced by a sign placed on the door. The sign was green on one side, stating that the sterile field was open, and that staff should enter only if necessary. The other side of the sign was red and stated that the incision had been made and that the person should call into the OR before entering.
The second intervention, batching of staff breaks, proved impossible to implement (see barriers below).
The third intervention was review of surgeon’s preference cards to help ensure that all required supplies and instruments were available and minimize the need to exit the OR to procure more supplies or instruments. Parent found that the preference cards were actually in good shape but the supplies and instrumentation for the first procedures of the day appeared to be less accurate than subsequent procedures. That was because sterile processing staff members who prepare the supplies and instruments for the first procedures of the day were not necessarily familiar with the intricacies of each procedure and surgeon preferences.
The fourth intervention occurred after the project had begun. OR staff members suggested moving the waterless scrub from the scrub sink area to inside the OR. Staff members could now perform the surgical hand scrub within the room. (OR staff members liked this intervention and adopted it for all the OR’s, not just the orthopedic OR’s.)
Results were quite encouraging. At week six of the project, the number of door openings dropped from an average of 1.96 door openings per minute. to an average of 1.04 per minute, a decrease of 46.9%. The SIR (standardized infection ratio) during the planning stages of the project was 1.75. dropped to 0.44 at week 6, and by the end the project, the number of infections and the SIR were 0,
There were other ongoing interventions aimed at reducing SSI’s during the implementation of this project, so the improvement in SSI rates cannot be fully ascribed to this project. Nevertheless, the results of the project were encouraging enough that staff have adopted the measures to their general surgery OR’s as well.
Parent provides a table of the reasons for OR door openings at Weeks 1 and 6. The biggest reductions after implementation were in patient-related factors, hand scrubbing, instruments, supplies and equipment.
Parent also analyzed who was entering and leaving the OR. Vendors remained the largest reason for OR traffic, especially after the incision was made. Vendors typically did not bring their carts with implants into the room until after the sterile field was open. Vendor-related door openings did decrease 34% (from an average of 23 door openings per day to 15 per day). Staff member relief was the second most common reason for OR traffic. RN circulator exiting the room did not change (average of 13 times both before and after the interventions). Entering the room after scrubbing was the third most common reason for OR traffic, and it improved dramatically after moving the scrub product into the OR.
Regarding the barriers to implementation, one big challenge related to vendors. Because this was an orthopedic OR, vendors often entered the room with the necessary implants for the procedures. Those implants were typically housed outside the OR. Often there were last-minute modifications to the surgical plans, so the vendor had to leave the room to retrieve the new implant. Another stated challenge was that “Operating room personnel have limited control over vendors because they are not hospital employees.” Several of the studies discussed in our April 23, 2019 Patient Safety Tip of the Week “In and Out the Door and Other OR Flow Disruptions” also noted the vendor issue as a major barrier to reducing OR door openings.
A second major challenge was that there was “pushback” to the project from the anesthesia group and the vendors. Parent notes that their lack of willingness to fully participate in the project was limiting. Apparently, OR leaders did speak with the vendors but with limited to no success.
Another barrier related to union rules. Parent had hoped to “batch” breaks by members of the OR team so the doors would be opened and closed less frequently. However, timing of staff member breaks was prescribed by union contractual obligations. But there were other barriers that rendered this intervention impossible. It was difficult for the anesthesia staff members to go on break during induction of anesthesia or emergence from anesthesia (handoffs at these critical would have been unsafe) so anesthesia personnel could really only go on break after incision. Nursing staff relief patterns were dependent upon relief staff members arriving at different times to relieve the day shift staff members.
Another study looked at decreasing OR traffic during orthopedic surgery (DiBartola 2019). DiBartola and colleagues implemented a bundle, including education, OR signage, team-based accountability and behavioral interventions. Average door openings per minute decreased by 22% after intervention. All surgical groups excluding anesthesia had significant reductions in OR traffic following the intervention.
Input from multiple stakeholders was collected prior to implementation for suggestions and helped identify unnecessary OR behavior and processes. A practice guideline for room traffic reduction was implemented. The guideline consisted primarily of staff education concerning the potential risks associated with a high volume of OR traffic, decreasing staff break frequency, creating rules for door openings, and placing signs on the doors to remind people to open the door only if necessary. Another product of the intervention was the installation of electronic door counters. (Note that we consider that a key to any such implementation project to reduce OR traffic. We always say “You don’t know what you don’t know”, meaning you can’t improve what you don’t measure. People are astonished when they actually see how often OR doors are opening and closing. See our April 23, 2019 Patient Safety Tip of the Week “In and Out the Door and Other OR Flow Disruptions” for further details.) DiBartola et al. did not used the door counters as a means to collect data. Rather, they served as a constant and real-time reminder to reduce room traffic.
The results were based upon a relatively small number of observations (35 cases before and 42 cases after the intervention). Total door openings in the pre-intervention group were 124.3 openings per case and 86.7 in the postintervention group. There was a statistically significant difference in room traffic rate (openings per minute) from 0.58 openings/min before to 0.45 openings/min after the intervention. Although pre-incision room traffic rates remained largely unchanged by the intervention, post-incision room traffic rates were significantly different (preintervention door openings of 0.41 per minute, postintervention 0.12 openings per minute).
Nursing staff, surgical staff, vendor, and radiology team members all had significant reductions in postintervention room traffic when compared to preintervention traffic. Only the anesthesia team did not have a significant change in room traffic, but that team had overall low room traffic prior to intervention strategies.
The DiBartola study did not attempt to link OR traffic to surgical site infection rates, though it notes that orthopedic SSI rates have traditionally been low to start with.
Our April 23, 2019 Patient Safety Tip of the Week “In and Out the Door and Other OR Flow Disruptions” noted that purely educational interventions are seldom successful in reducing OR traffic.
Our December 2017 What's New in the Patient Safety World column “A Fix for OR Foot Traffic?” noted a study which looked at the impact of an audible alarm on reducing OR foot traffic during total joint arthroplasties (Eskildsen 2017). Researchers placed an audible alarm on the substerile operating room door that sounded continuously when the door was ajar. This resulted in a significant difference in the overall mean door openings per minute between the period with no alarm and with an alarm. However, this effect slowly decreased over the time of the intervention. We suspect alarm fatigue likely set in there. Also, we’d be very concerned distractions due to the alarm could potentially lead to other surgical mishaps.
Signs have also had a limited impact. Sometimes they are simply ignored and other times they may be removed. Rovaldi et al. (Rovaldi 2015) went to a pull-down shade that was pulled down at the time of incision to warn outsiders not to enter the OR. This was a shade that, when pulled down, covered half the window on the door and stated “Incision” and would be seen from the sterile inner core area. Worried you might forget to pull down the shade? Add this to your timeout/safe surgery checklist! That sign is basically a version of one of the interventions we’ve recommended in several of our columns – a sign akin to the “On the Air” sign in TV, radio, or recording studios that lights up when the case is in progress.
We’ve also discussed in multiple columns the importance of pre-op huddles and post-op debriefings. The pre-op huddle can help ensure you have all the equipment and supplies you’ll need during a case, reducing the need to exit and re-enter the OR. And, in the post-op debriefing you can discuss events or circumstances that led to more OR door opening so that you might avoid similar ones in the future.
So, why are short-term reductions in OR traffic not sustainable? The answer is simple: that outcome is not important to clinicians. What is important is the rate of surgical site infections. So, it is critical that you tie your QI project to your SSI rate.
Our prior columns focusing on surgical OR foot traffic and door opening:
References:
Lynch RJ, Englesbe MJ, Sturm L, et al. Measurement of Foot Traffic in the Operating Room: Implications for Infection Control. American Journal of Medical Quality 2009; 24: 45-52
http://ajm.sagepub.com/content/24/1/45.abstract
Mears SC, Blanding R, Belkoff SM. Door Opening Affects Operating Room Pressure During Joint Arthroplasty. Orthopedics 2015; 38(11): e991-e994
Parent, M. (2021), OR Traffic and Surgical Site Infections: A Quality Improvement Project. AORN J, 113: 379-388
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13355
DiBartola AC, Barron C, Smith S, Quatman-Yates C, Chaudhari AMW, Scharschmidt TJ, Moffatt-Bruce SD, Quatman CE. Decreasing Room Traffic in Orthopedic Surgery: A Quality Improvement Initiative. Am J Med Qual 2019; 34(6): 561-568
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7388153/
Eskildsen SM, Moskal PT, Laux J, Del Gaizo DJ. The Effect of a Door Alarm on Operating Room Traffic During Total Joint Arthroplasty. Helio Orthopedics 2017; 40(6): e1081-e1085
Rovaldi CJ, King PJ. The Effect of an Interdisciplinary QI Project to Reduce OR Foot Traffic. AORN Journal 2015; 101(6): 666-681
https://aornjournal.onlinelibrary.wiley.com/doi/pdf/10.1016/j.aorn.2015.03.011
Print “Cut OR Traffic to Cut Surgical Site Infections”
June 15, 2021
What's Happened to Your Patient Safety Walk Rounds?
We regret to say that one of the biggest casualties of the COVID-19 pandemic has been Patient Safety Walk Rounds. Social distancing, masks, and the sheer volume of workload for all our hospital staffs took their toll on Walk Rounds. But, as the masks come off…it’s time to start Patient Safety Walk Rounds up again.
In our February 27, 2018 Patient Safety Tip of the Week “Update on Patient Safety Walk Rounds” we reported on a cross-sectional survey, administered to a convenience sample of 31 hospitals, through the Michigan Health and Hospital Association MHA Keystone Center as part of their routine safety culture and engagement assessment (Sexton 2018). That study showed the importance of feedback in conjunction with Walk Rounds (WR). Work settings reporting more WR with feedback had substantially higher safety culture domain scores and significantly higher engagement scores for four of six domains in the study. The authors suggest that “when WR’s are conducted, acted on, and the results are fed back to those involved, the work setting is a better place to deliver and receive care as assessed across a broad range of metrics, including teamwork, safety, leadership, growth opportunities, participation in decision-making and the emotional exhaustion component of burnout.”
Sexton and colleagues now report on a similar cross-sectional survey at the Duke University Health System (Sexton 2021). Note that the data in their current study was taken from a survey done in 2016, well before the COVID-19 pandemic.
Their Walk Rounds (WR) were modified to elicit more positive emotions, in addition to building the essential elements of traditional safety WR—trust, psychological safety, and meaningful connections. This new focus on what is going well was intended as a shift away from deficiencies and fear, toward successes that might elicit positive emotions such as pride and hope. They termed this new form of WR “Positive Leadership WalkRounds” (PosWR). Typical PosWR visits would occur monthly, last 30 to 60 minutes, and involve 3 to 10 HCWs, a local leader, and a senior leader. PosWR prompts to elicit positive interactions were generic and open to modification but included questions that sought to highlight successes and what was going well.
Their survey was taken from data collected in the SCORE (Safety, Communication, Operational Reliability, and Engagement) survey. The SCORE scale includes 7 domains: Work-Life Balance (WLC), Burnout Climate, Emotional Exhaustion, Improvement Readiness, Local Leadership, Teamwork Climate, and Safety Climate. They had an overall response rate of 81.5% from over 13,000 potential respondents in 396 work sties. Respondents reflected the gamut of healthcare workers, though the top three respondent groups were registered nurses (31.7%), attending physicians (9.7%), and technologists (8.2%).
63.4% of respondents reported being exposed to PosWR in their work setting. They divided responses into quartiles based upon level of exposure to PosWR. Compared to work settings in the fourth ( < 50%) quartile for PosWR exposure, those in the first ( > 88%) quartile revealed a higher percentage of respondents reporting good patient safety norms (49.6% vs. 69.6%); good readiness to engage in quality improvement activities (60.6% vs. 76.6%); good leadership accessibility and feedback behavior (51.9% vs. 67.2%); good teamwork norms (36.8% vs. 52.7%); and good work-life balance norms (61.9% vs. 68.9%), all being statistically significant. Compared to the fourth quartile, the first quartile had a lower percentage of respondents reporting emotional exhaustion in themselves (45.9% vs. 32.4%), and in their colleagues (60.5% vs. 47.7%). Basically, every domain of the SCORE safety culture and workforce well-being survey was robustly associated with exposure to PosWR.
The results of the 2 studies strongly suggest that conducting Patient Safety Walk Rounds with a focus on the positive and providing positive feedback to staff help ensure a culture of safety and lower the risk of healthcare worker burnout.
So, as you begin to reinstitute your Patient Safety Walk Rounds now that the COVID-19 pandemic is waning, it’s worth reiterating some of the observations and recommendations we’ve made in our Patient Safety Tips of the Week for October 7, 2014 “Our Take on Patient Safety Walk Rounds” and February 27, 2018 “Update on Patient Safety Walk Rounds”:
How often should you do Walk Rounds? Unfortunately, there are no hard and fast guidelines. We usually recommend that each unit be visited at least every two months, perhaps supplemented by monthly rounds done by other staff.
One bad habit organizations have is only doing Patient Safety Walk Rounds on the day shift. It is extremely important that you do them on all shifts. That takes planning and commitment. Why is it important? Because two-thirds of the staff you want to include in your safety culture work on those other shifts! Not only do you need to convey to them your commitment to improving patient safety, but you will also better see and hear about some of the barriers to patient safety on the evening and night shifts. The most recent Sexton study echoes this: “Staff are consistently pleasantly surprised when a chief nursing officer shows up on a night shift or weekend to ask about what is going well in that work setting.”
Who should be there on Patient Safety Walk Rounds? Your core team should include your CEO, COO, CMO, CNO, and head of Quality and Patient Safety. But there are others that should also participate. You’ll want a pharmacist for rounds on almost all units. Bringing your CFO on such rounds is a good way of giving him/her a better understanding of how patient safety issues can impact the bottom line. Your CIO may also gain valuable insights into how staff interact with technology and many of the safety issues resulting from complex IT issues or ones that could use an IT solution. Including representatives from other departments (eg. engineering, housekeeping, SPD, etc.) can also bring unique perspectives. We also recommend that you include your Board members in Patient Safety Walk Rounds. Not every rounds, but mandate that each Board member attend at least one walk rounds session annually. Not only will that help educate them about patient safety, but you’ll be pleasantly surprised by the insights they bring to your rounds, either by their perspective as a “consumer” or patient or the perspective of whatever industry they happen to come from. For example, a banker might cringe looking at patients in line in your antiquated patient registration system and have good ideas for improving efficiency and patient flow. Note also that a previous review by Singer & Tucker (Singer & Tucker 2014) mentioned the importance of including physicians in such rounds. We wholeheartedly agree. Almost every study done on culture of safety shows disparities between the impressions of frontline staff and physicians (and administrators). However, equally important is not having the physician presence stifle open discussion of issues with staff. We’ve all too often seen situations in which behavior of a physician is the critical safety issue and staff are unwilling to speak about it in front of another physician, even the CMO. Lastly, some include a patient or patient family member. A Board member might fulfill that role, but Board members may have an “insider” bias. Having an “outsider” pair of eyes and ears may be important.
Singer (Singer 2018) also cautions us not to ignore middle managers when engaging front-line workers because that can risk “igniting middle managers’ fears and negative repercussions”. Rather, she recommends engaging middle managers as hosts, guides, and navigators during WR. She also notes the importance of recognizing informal social networks as potential vehicles to promote positive messages.
Should all those individuals be on every Walk Rounds? Definitely not. Having too many upper management people on rounds can be very intimidating to staff. So split them up. Have 2-3 team members do walk rounds on one unit and others do them on another unit or another shift. You really want to be able to interact with your frontline staff and make them feel comfortable in speaking up.
What units should get Walk Rounds? Answer: all of them. But some may need particular attention, particularly those that are “melting pots” like the Radiology suite. In our October 22, 2013 Patient Safety Tip of the Week “How Safe Is Your Radiology Suite” we discussed the multitude of safety issues seen in Radiology suites that have little to do with radiology per se. And don’t forget to include non-clinical units. You’d be surprised how often your Walk Rounds with your housekeeping department provides insights into patient safety issues.
Remember, you are not just doing walk rounds for show. The most important thing you can do is identify issues and follow up. One member of each team should keep a formal issues log that includes action items and dates for expected actions. Timely feedback to frontline staff on actions taken for each item is extremely important. And beware of simply telling staff “that’s been referred to Committee X” because that often conveys the message “nothing is going to be done”. You will encounter some items that cannot be fixed simply or expediently. In such cases you need to be honest with your staff and tell them, for example, that a current budgetary or technical restraint won’t allow a quick fix (eg. “that is in the software version update to be installed in 3 months”). But at least they will know that it is still on your list. Singer & Tucker also stress that frontline staff become frustrated when senior management spends too much time prioritizing issues rather than taking actions. We recommend that you use the same process for follow up that you use to ensure actions taken when you do a Root Cause Analysis. That means you keep a list of actions not yet completed or other “open” items and discuss these at each of your regular Quality Improvement/Patient Safety Committee meetings until you have closed the loop.
In addition to feedback showing what actions you’ve taken as a result of items identified during Patient Safety Walk Rounds, positive feedback to staff is also an important element of successful Patient Safety Walk Rounds. Sexton et al. also note that healthcare workers who receive handwritten letters from senior leaders are remarkably proud, grateful, and hopeful about their future in the organization.
Body language on Walk Rounds is extremely important. Not theirs, yours!!! The old adage that 90% of communication is nonverbal holds true. If your body language conveys disinterest or “let’s just get this over” it won’t matter what you are saying with your staff. They will recognize that such rounds are perfunctory. But don’t ignore the body language of your workers either. You may notice one worker “squirm” a bit when something is being said. In such cases, it is worthwhile to have someone later meet that worker in a very non-threatening setting and say “I noticed you seemed uncomfortable when so-and-so was saying…”. You may be surprised at what you hear.
We agree with Singer & Tucker that “surveillance” on walk rounds can be counterproductive but that applies mainly to surveillance of people. That doesn’t mean you shouldn’t look for some unsafe conditions when doing your safety rounds. For example, if your facility handles behavioral health patients (even if it is only in your ER) you should be looking for things like “loopable” items in the bathrooms in your radiology suite that might be used for suicide. Or you might check floor stock to make sure you don’t have vials of concentrated heparin that might mistakenly be given to patients during a heparin “flush”. Or some of the battery charging/recharging issues we raised in our February 4, 2014 Patient Safety Tip of the Week “But What If the Battery Runs Low?”. And we always recommend vigilance to alarm safety issues during Walk Rounds (see our July 2, 2013 Patient Safety Tip of the Week “Issues in Alarm Management”) or issues with filled and unfilled oxygen cylinders being intermingled. Looking for all those things can be done in a less conspicuous and non-threatening manner.
The most important thing on Walk Rounds is encouraging staff to speak up about potential safety issues. To do this you need a comfortable, nonpunitive culture in which staff understand that they will be praised, not vilified, for their openness. For example, we all know that workarounds are usually potentially dangerous, yet they are ubiquitous. Workarounds are almost always a sign of an underlying root cause that needs to be fixed, so identifying workarounds is important. When you ask staff about workarounds you need to let them know you are looking to fix whatever problem makes them do a workaround and that you are not going to punish them for doing a workaround.
Walk Rounds are also a good way to get a feel for safety culture on each unit. We feel you get a much better understanding of “local (unit)” culture on such rounds than you get on the many formal safety culture assessment tools used by many organizations.
Be considerate of your workers’ time constraints. The last thing you want is for them to be thinking “Oh no! Here we go again! I’ll never get my work done today!”. There are no hard and fast rules for the time duration of individual walk rounds. But planning with the middle managers ahead of time can help ensure that workers are freed up to engage and participate without fear that their workload is accumulating in the background.
Lastly, how do you measure the impact of your Walk Rounds? That, of course, is difficult because it’s hard to separate out the results from Walk Rounds from all the other patient safety activities your organization is doing. And surveys such as that in the Sexton study can be expensive to administer and analyze. We think the most important measure is looking at the issues log you accumulated through WR and being able to report the percentage of safety issues identified and resolved. We don’t think you need to do a formal survey such as SCORE in the Sexton studies, but you can solicit informal feedback from staff on how they perceive such rounds.
We still think Patient Safety Walk Rounds are a very important component of your patient safety efforts. They are probably more important than ever in the post-COVID-19 era to boost staff morale and combat burnout. But be sure you do them constructively!
Some of our previous columns on Patient Safety Walk Rounds:
October 7, 2014 “Our Take on Patient Safety Walk Rounds”
February 27, 2018 “Update on Patient Safety Walk Rounds”
References:
Sexton JB, Adair KC, Profit J, et al. Safety Culture and Workforce Well-Being Associations with Positive Leadership WalkRounds. Jt Comm J Qual Patient Saf 2021; Epub Apr 22, 2021
https://www.sciencedirect.com/science/article/pii/S1553725021000945?via%3Dihub
Sexton JB, Adair KC, Leonard MW, et al Providing feedback following Leadership WalkRounds is associated with better patient safety culture, higher employee engagement and lower burnout. BMJ Qual Saf 2018; 27: 261-270 Published Online First: 09 October 2017
https://qualitysafety.bmj.com/content/27/4/261
Singer SJ, Tucker AL. The evolving literature on safety WalkRounds: emerging themes and practical messages. BMJ Qual Saf 2014; 23: 789-800
http://qualitysafety.bmj.com/content/23/10/789.full.pdf+html
Singer SJ. Successfully implementing Safety WalkRounds: secret sauce more than a magic bullet. BMJ Qual Saf 2018; 27: 251-253 Published Online First: 09 February 2018
https://qualitysafety.bmj.com/content/27/4/251
Print “What’s Happened to Your Patient Safety Walk Rounds?”
June 22, 2021
Remotely Monitoring Suicidal Patients in Non-Behavioral Health Areas
One problematic area for hospitals is safely managing potentially suicidal patients who must be housed in non-behavioral health areas of the hospital, such as the emergency department or a med/surg floor. We’ve done multiple columns on in-hospital suicides (see list below). When patients at risk for suicide or self-harm, elopement, or even jumping from windows are housed in such areas, we typically put them on 1:1 continuous observation. But that is expensive, and we often have a lack of appropriately trained “sitters” to monitor such patients in these areas. And there are many incidents in which an adverse event took place despite the presence of a “sitter”.
Researchers at the Brigham and Women’s Hospital in Boston (Kroll 2020) assessed the feasibility of using continuous virtual monitoring in such situations. Kroll and colleagues note multiple reasons that make continuous monitoring of such patients difficult:
So, they piloted continuous virtual monitoring as a method of patient observation in which an observer provides continuous observation to one or more patients at once from a central location with the assistance of high-definition live stream video surveillance technology. Their setup of the unit includes a 360-degree view of the clinical area, continuous monitoring by a staff member, and linkage to immediate intervention by staff if called for. Because this was a new concept, the implementation team sought to identify patients who had a lower risk of impulsivity for assignment to virtual monitoring. They also excluded patients with psychosis, patients at risk for elopement, those with a prior history of attempted suicide or self-harm in hospital, and several other exclusionary criteria. The decision to include individual patients in the virtual monitoring program was made by consulting psychiatrists and nurses together.
A monitoring technician (MT) received a live video stream from a panel of 1-10 patients. The MT had flexibility to reduce the maximum number of monitored patients if they felt the panel was sufficiently acute so that it would be difficult to accommodate new patients.
The MT was housed in a dedicated room with the monitoring equipment. He/she could communicate with patients directly through a speaker box attached to the device and could call the patient's nurse on a cell phone associated with the mobile device if he/she noticed concerning behavior or environmental hazards. He/she could also activate a “stat alarm” if there was no response to urgent phone calls, or there was rapidly escalating behavior, or there was loss of visualizing the patient.
Nurse educators trained nurses on inpatient medical units in the protocol for monitoring patients on suicide precautions, including the option to use virtual monitoring. The MT’s also received this training.
The pilot project included 39 patients, 27 (69%) on hospital floors and 12 (31%) in the ED. No adverse behavioral events were reported among this group of patients. In 4 patients the virtual monitoring was discontinued because the patient could not be redirected by the MT or exhibited new signs or symptoms to indicate a higher impulsivity risk, requiring a shift to 1:1 in-room continuous observation. In the others, virtual monitoring was terminated upon discharge, transfer, or discontinuation of suicide precautions.
The researchers did report a number of incidents in at-risk patients who were not on the pilot protocol, but we consider any such comparison inappropriate because of the strict selection criteria.
The maximum number of patients receiving virtual monitoring for an indication of suicide precautions at a single time was 3 but the average daily census for the MT’s was 6.2 patients (they were also apparently performing virtual monitoring for other indications on all hospital and ED units).
The authors conclude their pilot demonstrates that virtual monitoring can feasibly be used to monitor suicide risk in patients who are carefully screened for impulsivity.
Because general hospitals are bound to deal with patients at risk for suicide or self-harm regardless of whether they have a behavioral health unit, it is incumbent upon such hospitals to plan for safe care of such patients when they are in the ED or non-behavioral health inpatient units.
Our February 2, 2021 Patient Safety Tip of the Week “MGH Protocols Reduce Risk of Self-Harm in ED” described a program the Massachusetts General Hospital put in place to reduce self-harm in ED patients (Donovan 2021). You should go to that column for details.
In addition to adequately training any personnel you might use as “sitters” or “observers” for at-risk patients, there are a number of other important considerations for all such hospitals. We recommend that such hospitals might dedicate one or more rooms specifically for such patients. That means they should meet all the requirements in the the VA Mental Health Environment of Care Checklist (MHEOCC), which looks at issues such as loopable fixtures. You might even consider installing in those rooms windows that are resistant to patient attempts to jump from them.
Particular attention needs to be paid to use of bathroom facilities (see our August 29, 2017 Patient Safety Tip of the Week “Suicide in the Bathroom”). That means not only ensuring there are no loopable fixtures or other dangerous items in the bathrooms, but also ensuring that a reasonable balance be achieved between patient privacy and adequate monitoring/observation while the patient is in the bathroom.
Since these patients are usually not on a behavioral health unit because they have a medical or surgical condition, you must anticipate they may at some point require transport to other areas of the hospital, such as the radiology suite or the OR. Such transports can be very vulnerable periods. Patients may abscond during transports or they might go into a bathroom (or other room) that has features which could be used for suicide or self-harm. Therefore, it is essential that your “Ticket to Ride” intrahospital transport checklist include some provision for suicide or elopement risk and all staff accompanying the patient during the transport (as well as those who might take responsibility for the patient in the destination site) are adequately trained to deal with such patients.
The Kroll study suggests that there may well be a low-risk group of patients for whom continuous virtual monitoring may be useful, safe, and cost-effective. But you need to have strict patient selection criteria for such programs. You also need to have in place a more comprehensive program to deal with patients at higher risk for suicide, self-harm, jumping, or elopement.
Some of our prior columns on preventing hospital suicides:
Some of our past columns on DVT risk in behavioral health settings:
Some of our past columns on issues related to behavioral health:
References:
Kroll DS, Stanghellini E, DesRoches SL, et al. Virtual monitoring of suicide risk in the general hospital and emergency department. General Hospital Psychiatry 2020; 63: 33-38
https://www.sciencedirect.com/science/article/abs/pii/S0163834318302226
Donovan AL, Aaronson EL, Black L, et al. Keeping Patients at Risk for Self-Harm Safe in the Emergency Department: A Protocolized Approach. Joint Commission Journal on Quality and Patient Safety 2021; 47(1): 23-30
https://www.jointcommissionjournal.com/article/S1553-7250(20)30215-4/fulltext
Mental Health Environment of Care Checklist (VA)
http://www.patientsafety.va.gov/docs/MHEOCCed092016508.xlsx
video
http://www.patientsafety.va.gov/professionals/onthejob/mentalhealth.asp
Print “Remotely Monitoring Suicidal Patients in Non-Behavioral Health Areas”
June 29, 2021
Barriers to Deprescribing
We’ve done lots of columns on both polypharmacy and potentially inappropriate medications in the elderly. Those two topics, of course, lead to discussions about deprescribing (see our prior columns on deprescribing listed below). Yet initiatives to promote deprescribing often fall short. We’ve always said that stopping a medication is much more difficult that starting one!
A recent study is illustrative. Campbell et al. (Campbell 2021) implemented a multicomponent behavioral intervention to reduce the use of high-risk anticholinergic medications in primary care older adults. A provider-focused component was computerized decision support alerting of the presence of a high-risk anticholinergic and offering dose- and indication-specific alternatives. The patient-focused component was a story-based video providing education and modeling an interaction with a healthcare provider resulting in a medication change. Alerts within the medical record triggered staff to play the video for a patient.
There were 552 older adults visits to primary care sites during the study period. Of the 276 staff alerts, 4.7% were confirmed to activate the patient-focused intervention. The intervention resulted in no significant differences in either the number of discontinued orders for anticholinergics or the proportion of the population using anticholinergics following the intervention. Of the 259 alerts directed toward providers in the Campbell study, 94% of alerts fired for existing medications and only 6% for new orders of the targeted anticholinergics. And, of these 259 provider-focused alerts, only three (1.2%) led to a medication change. This disappointing result occurred despite strong support from medical, nursing, and pharmacy leadership.
So, what are the barriers to successful deprescribing?
In our May 11, 2021 Patient Safety Tip of the Week “How Are Alerts in Ambulatory CPOE Doing?” we noted the disparity in effectiveness between “prospective” alerts and “look-back" alerts. Awdishu et al. (Awdishu 2016), looking at the impact of alerts on prescribing in patients with renal disease, also found that prospective alerts had a greater impact than look-back alerts (55.6% vs 10.3%).
Note that this is probably a form of “continuation” bias. That is the cognitive bias “to continue with the original plan in spite of changing conditions and growing evidence that you should reconsider”. In several of our columns we’ve described a past project where we alerted physicians about their elderly patients taking amitriptyline, one of the medications on Beers List and other lists of potentially inappropriate medications in the elderly. The effect of the alert is that there was a subsequent reduction in new orders for amitriptyline but almost never did a physician discontinue amitriptyline in a patient already taking it. We often think “the patient is already on this medication and doing well on it”, without taking into consideration the aging of the patient and the effects of other medications or the effects on other clinical conditions.
In that May 11, 2021 Patient Safety Tip of the Week “How Are Alerts in Ambulatory CPOE Doing?” we also discussed a study which assessed the “reminder performance” (RP) and the “number needed to remind” (NNR) to assess clinical decision support for potentially inappropriate medications (PIM’s) from Beers criteria in primary care and geriatric clinics (Alagiakrishnan 2019). The reminder performance (RP) across both clinics was 17.3%, which corresponds to an NNR of 5.8. The reminder performance was 37.1% in geriatric clinics vs. 13.4% in primary care clinics. The NNR in the primary care clinic was 7.4 and NNR in the geriatric clinic was 2.7. The disparity betweeb primary care and geriatrics should not surprise anyone, since geriatricians have long been trained in avoiding PIM’s in their patient population. Yet, the majority of older adults in the US are not cared for by geriatricians. Rather they are most often cared for by internists and family physicians or medical specialists performing as primary care physicians.
Alagiakrishnan et al. also developed a metric “Number Needed to Deprescribe” (NND) or the number of alert presentations specific to a medication and patient presented to a physician user before there was a deprescribing event. The reminder performance for deprescribing events was even lower at 1.2%. The number needed to deprescribe (NND) was 82 for the study population as a whole.
Campbell et al. speculated that characteristics of the primary care physicians in their study may have played a role. They speculated there may be a low rate of demand for deprescribing support in that clinical environment. They also felt that “until the practice of deprescribing is normalized in routine clinical care, or timing of alerts can be improved with contextual awareness, deprescribing alerts may continue to be unsuccessful.”
Campbell et al. also noted that their alerts were non-interruptive, i.e. they did not force the clinician to take an action, such as changing to a different medication or providing an explanation for lack of deprescribing. They speculated that different alert design, with some degree of interruption, might have been more successful.
They also wondered whether some methodological factors contributed (eg. small sample size, limited duration).
They speculate that human- or expert-intensive approaches to deprescribing anticholinergic medications or policy-based restrictions on high-risk medications may be needed.
Doherty et al. (Doherty 2020) did a systematic review of studies on deprescribing in primary care. They found that the cultural and organizational barriers included:
They also noted interpersonal and individual-level barriers, including:
But there were also facilitators:
They concluded that a whole systems, patient-centered approach to safe deprescribing interventions is required, involving key decision-makers, healthcare professionals, patients, and carers.
Wallis et al. (Wallis 2017) did semi-structured interviews with select primary care physicians to get their views on the barriers and facilitators to deprescribing in everyday practice. Physicians described deprescribing as “swimming against the tide” of patient expectations, the medical culture of prescribing, and organizational constraints. They said “deprescribing came with inherent risks for both themselves and patients and conveyed a sense of vulnerability in practice. The only incentive to deprescribing they identified was the duty to do what was right for the patient.” Physicians often felt that patients expected there to be “a pill for every ill” and that this expectation was exacerbated by direct-to-consumer advertising of medicines (their study was in New Zealand, the only country other than the US that allows DTC advertising). Wallis et al. also found some physicians were concerned about uncertainty and fear. They feared repercussions should a patient suffer a potentially preventable adverse outcome following deprescribing and feared reputational damage. Lack of time for discussion on deprescribing was a barrier also noted by Wallis et al.
Problems with coordination of care are often a barrier. Particularly since many of these elderly patients have multiple comorbidities, they are often seeing multiple specialists. PCP’s are often reluctant to discontinue or deprescribe a medication that one of those specialists had originally prescribed. Wallis et al. found that was especially noted by younger and less experienced primary care physicians.
Zechmann et al. (Zechmann 2019) interviewed patients in Switzerland to identify both barriers and enablers for deprescribing. Twenty-two (25.3%) of 87 patients receiving an offer to change drugs chose not to pursue at least one of their GPs’ offers. They interviewed 19 of those 22 patients and found that “conservatism/inertia and fragmented medical care were the main barriers towards deprescribing.” With regard to conservatism/inertia, 15/19 patients felt that all of their drugs were necessary or beneficial for their daily living and 9/19 mentioned the feeling of security entailed with their drugs. 6/19 patients felt deprescribing actually took away something which had been beneficial for them in the past. Fragmentation of medical care was also noted, feeling that too many physicians were involved in medication management. Interestingly, trust in their physician was not related to continue or stop a medication.
The type of medication may also be a factor. Zechmann et al. noted that patients were more likely to fear loss of drugs having “symptomatic rather than prognostic effects”. Examples were drugs for acid-related disorders, analgesics or anti-inflammatory /antirheumatics.
Concerning enablers, Zechmann et al. note the literature suggests the provision of enough time dedicated to deprescribing, a step by step plan how to change drugs, and the option to restart the drug whenever necessary or required by the patient.
Ironically, hospitalization may be a facilitator for deprescribing. Edey and colleagues (Edey 2019) at a Canadian tertiary care hospital did pharmacist-led deprescribing rounds upon hospital discharge. Deprescribing rounds resulted in significantly more medications deprescribed compared to control (65% vs. 38%). The rates of readmission and emergency department visits were reduced in the arm receiving deprescribing rounds.
Reeve et al. (Reeve 2015) noted barriers at the medical practitioner, system, patient and carer levels. These include inadequate guidelines, incomplete medical histories, lack of time, avoidance of negative consequences, established beliefs in the benefits and harms of medication use and others. They specifically looked at optimizing prescribing for older people with dementia and noted additional complicating factors: diminished decision making capacity, difficulties with comprehension and communication, increasing involvement of carers and difficulties establishing goals of care.
The COVID-19 pandemic has created additional barriers to deprescribing. Elbeddini et al. (Elbeddini 2021) note barriers to deprescribing before the pandemic include patient and system related factors, such as resistance to change, patient's knowledge deficit about deprescribing, lack of alternatives for treatment of disease, uncoordinated delivery of health services, prescriber's attitudes and/or experience, limited availability of guidelines for deprescribing, and lack of evidence on preventative therapy. But the COVID-19 pandemic has prevented the sort of face-to-face interaction that might facilitate deprescribing. So much deprescribing has had to occur via telemedicine and that has several challenges in the elderly population: inability to use technology, lack of literacy, lack of assistance from others, greater propensity for withdrawal effects, and increased risk of severe consequences, if hospitalized. Our November 2020 What's New in the Patient Safety World column “Telemedicine Here to Stay But Use It Safely” discussed challenges in telemedicine sessions due to patients having impaired hearing, neurological conditions impacting ability to communicate, and patient-related difficulties dealing with technology.
Some have included lack of guidelines as a barrier to deprescribing. In fact, there are guidelines and tools available for stopping several specific medications (see our November 27, 2018 Patient Safety Tip of the Week “Focus on Deprescribing”).
Our own list of the biggest barriers to deprescribing:
Lack of time is a significant barrier. No one can be reasonably expected to carry out deprescribing during a 15-minute clinic or office visit. The ideal venue for deprescribing is on the annual “brown bag” medication review or the annual Medicare wellness visit.
We described the continuation bias above.
As above, it is much easier to deprescribe medications that are working “under the radar” than those that were begun to treat symptoms. But often symptoms do not recur when you stop a medication that was begun for specific symptoms. For example, a patient may not have a recurrence of heartburn upon stopping a proton pump inhibitor after they had been on it for several months. And you can reassure the patient that the medication could be restarted should symptoms recur.
Lack of alternatives is often blamed for failure to deprescribe. But there may be alternatives, often non-pharmacological ones, for some medications. For example, we think there is almost never an indication for long-term use of sleep medications (actually, there are few indications for short-term use, either!). But good sleep hygiene practices can usually be implemented to alleviate insomnia, thus allowing deprescribing of sleep medications.
Deprescribing a medication that another clinician originally prescribed is difficult. It should require not only discussion with the patient but also with the clinician who prescribed it. Many clinicians won’t take the time to do the latter discussion. And, sometimes, the clinician who originally prescribed the medication is no longer accessible (retirement, relocation, etc.).
But, ironically, it is often more difficult to stop a medication that you, yourself, prescribed! The fear is that the patient will think “If this drug is so bad, why did you prescribe it in the first place?” On the contrary, in our September 30, 2014 Patient Safety Tip of the Week “More on Deprescribing” we pointed out there is one area in which the greatest opportunity exists to help in medication cessation – when you first prescribe a drug! When you prescribe a medication for a patient you should have an exit strategy. You should be asking yourself (and discussing with your patient) the following questions:
How important are clinical decision support (CDS) tools in facilitating deprescribing? In addition to the Campbell (Campbell 2021), Awdishu (Awdishu 2016), and Alagiakrishnan (Alagiakrishnan 2019) studies noted above, Monteiro et al. (Monteiro 2019) did a systematic review on reducing potentially inappropriate prescriptions for older patients using computerized decision support tools. They found that most studies in the literature had both methodological problems and likely biases. While, overall, the studies consistently showed CDS tools reduced the mean number of prescriptions for PIM’s started and the total number of PIM prescriptions. However, in several cases statistical significance was not achieved for some of the assessed measures, such as for PIM discontinuation or for change in PIM’s. Does this mean you should not use CDS alerts? No. They clearly are effective in reducing new orders for PIM’s. You just need to be realistic and understand they may have limited or no impact on deprescribing PIM’s. You have to recognize all the barriers to deprescribing and alter your strategies accordingly.
Some of our past columns on deprescribing:
Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:
References:
Campbell, NL, Holden, RJ, Tang, Q, et al. Multicomponent behavioral intervention to reduce exposure to anticholinergics in primary care older adults. J Am Geriatr Soc 2021; 69: 1490-1499
https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17121
Alagiakrishnan K, Ballermann M, Rolfson D, et al. Utilization of computerized clinical decision support for potentially inappropriate medications. Clin Interv Aging 2019; 14: 753–762
Awdishu L, Coates CR, Lyddane A, et al. The impact of real-time alerting on appropriate prescribing in kidney disease: a cluster randomized controlled trial. J Am Med Inform Assoc 2016; 23(3): 609-616
https://academic.oup.com/jamia/article/23/3/609/2909002
Doherty AJ, Boland P, Reed J, et al. Barriers and facilitators to deprescribing in primary care: a systematic review. BJGP Open 2020; 4 (3)
https://bjgpopen.org/content/4/3/bjgpopen20X101096
Wallis KA, Andrews A, Henderson M. Swimming Against the Tide: Primary Care Physicians’ Views on Deprescribing in Everyday Practice. The Annals of Family Medicine 2017, 15 (4) 341-346
https://www.annfammed.org/content/15/4/341.full
Zechmann S, Trueb, Valeri F, et al. Barriers and enablers for deprescribing among older, multimorbid patients with polypharmacy: an explorative study from Switzerland. BMC Fam Pract 2019; 20: 64
https://bmcfampract.biomedcentral.com/articles/10.1186/s12875-019-0953-4
Edey R, Edwards N, Von Sychowski J, et al. Impact of deprescribing rounds on discharge prescriptions: an interventional trial. Int J Clin Pharm 2019; 41(1): 159-166
https://link.springer.com/article/10.1007/s11096-018-0753-2
Reeve E, Bell JS, Hilmer SN. Barriers to Optimising Prescribing and Deprescribing in Older Adults with Dementia: A Narrative Review. Curr Clin Pharmacol 2015; 10(3): 168-177
https://www.eurekaselect.com/134184/article
Elbeddini A, Prabaharan T, Almasalkhi S, Tran C, Zhou Y. Barriers to conducting deprescribing in the elderly population amid the COVID-19 pandemic. Res Social Adm Pharm 2021; 17(1): 1942-1945
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7256521/
Print “Barriers to Deprescribing”
To get "Patient Safety Tip of the Week "emailed to you, click here and enter "subscribe" in the subject field.
Click on the "Contact Us" button at the left to send us your comments on our "Patient Safety Tip of the Week" cases.
To get "Patient Safety Tip of the Week "emailed to you, click here and enter "subscribe" in the subject field.
January 31, 2023
January 24, 2023
January 17, 2023
Patient Safety with NOAC’s and DOAC’s
January 10, 2023
January 3, 2023
Helping Inpatients Sleep – Failing Grades
December 27, 2022
Tip of the Week on Vacation
December 20, 2022
Amazing Results from I-PASS Implementation
December 13, 2022
Surgical Teams – the “Consistency Score”
December 6, 2022
Rare Risk – Defibrillator Fires
November 29, 2022
November 22, 2022
The Apple Watch and Patient Safety
November 15, 2022
November 8, 2022
November 1, 2022
APSF on Criminalization of Medical Error
October 25, 2022
October 18, 2022
Methotrexate Again, With a Twist
October 11, 2022
Good Intentions, Unintended Consequences
October 4, 2022
Successfully Reducing OR Traffic
September 27, 2022
September 20, 2022
September 13, 2022
Smart Socks and Robots for Fall Prevention?
September 6, 2022
AORN and Others on Retained Surgical Items
August 30, 2022
August 23, 2022
Yes, There is a Proper Way to Assess Orthostatic Hypotension
August 16, 2022
August 9, 2022
Tip of the Week on Vacation
August 2, 2022
Tip of the Week on Vacation
July 26, 2022
More Risks in the Radiology Suite
July 19, 2022
Sucked Out of the Plane at 17,000 Feet
July 12, 2022
Radiologists Racked by Interruptions
July 5, 2022
Tip of the Week on Vacation
June 28, 2022
Pneumonia in Nervous System Injuries
June 21, 2022
June 14, 2022
June 7, 2022
May 31, 2022
NHS Serious Incident Response Framework
May 24, 2022
Requiring Indication for Antibiotic Prescribing
May 17, 2022
Patient Harm in Medicare Inpatients
May 10, 2022
May 3, 2022
April 26, 2022
Challenges with Early Warning Systems
April 19, 2022
April 12, 2022
A Healthcare Worker’s Worst Fear
April 5, 2022
Follow-up on Incidental Findings
March 29, 2022
Disturbing Stats on Perioperative Benzodiazepine Use in Elderly Patients
March 22, 2022
Not Just Politicians That Behave Badly
March 15, 2022
Medication Errors in Home Care
March 8, 2022
Update on Retained Surgical Items
March 1, 2022
Including the Indication on Prescriptions
February 22, 2022
Medication Reconciliation at ICU Exit
February 15, 2022
February 8, 2022
ED to Inpatient Delays Increase Mortality
February 1, 2022
Perioperative Delirium is Not Just Postoperative
January 25, 2022
More on Dental Patient Safety Issues
January 18, 2022
January 11, 2022
Documenting Distractions in the OR
January 4, 2022
Spin or Not: A Useful Secondary Finding in a Study
December 28, 2021
Tip of the Week on Vacation
December 21, 2021
December 14, 2021
Delayed Hemorrhage After Head Trauma in Anticoagulated Patients
December 7, 2021
November 30, 2021
November 23, 2021
The Perils of Hypertonic Sodium Chloride
November 16, 2021
Cognitive Biases and Heuristics in the Delivery Room
November 9, 2021
November 2, 2021
Adverse Drug Events After Hospitalization
October 26, 2021
Opioid-Induced Respiratory Depression Costly in Fiscal as Well as Human Terms
October 19, 2021
COVID-19 Vaccine/ Flu Vaccine Mixups
October 12, 2021
FDA Approval of Concussion Tool – Why Not a Fatigue Detection Tool?
October 5, 2021
September 28, 2021
Barcoding Better? Not So Fast!
September 21, 2021
Repeat CT in Anticoagulated Patients After Minor Head Trauma Not Cost-Effective
September 14, 2021
September 7, 2021
The Vanderbilt Tragedy Gets Uglier
August 31, 2021
The Community Pharmacy and Patient Safety
August 24, 2021
More Home Infusion Safety Issues
August 17, 2021
Tip of the Week on Vacation
August 10, 2021
Tip of the Week on Vacation
August 3, 2021
Obstetric Patients More At-Risk for Wrong Patient Orders
July 27, 2021
July 20, 2021
FDA Warning: Magnets in Consumer Electronics May Affect Medical Devices
July 13, 2021
The Skinny on Rapid Response Teams
July 6, 2021
Tip of the Week on Vacation
June 29, 2021
June 22, 2021
Remotely Monitoring Suicidal Patients in Non-Behavioral Health Areas
June 15, 2021
What’s Happened to Your Patient Safety Walk Rounds?
June 8, 2021
Cut OR Traffic to Cut Surgical Site Infections
June 1, 2021
Stronger Magnets, More MRI Safety Concerns
May 25, 2021
Yes, Radiologists Have Handoffs, Too
May 18, 2021
Medical Overuse Is Not Just An Economic Problem
May 11, 2021
How Are Alerts in Ambulatory CPOE Doing?
May 4, 2021
More 10x Dose Errors in Pediatrics
April 27, 2021
Errors Common During Thrombolysis for Acute Ischemic Stroke
April 20, 2021
Taser “Slip and Capture Error” Again!
April 13, 2021
Incidental Findings – What’s Your Strategy?
April 6, 2021
March 30, 2021
Need for Better Antibiotic Stewardship
March 23, 2021
Nursing Staffing and Sepsis Outcomes
March 16, 2021
Sleep Program Successfully Reduces Delirium
March 9, 2021
Update: Disclosure and Apology: How to Do It
March 2, 2021
Barriers to Timely Catheter Removal
February 23, 2021
February 16, 2021
New Methods for QTc Monitoring
February 9, 2021
February 2, 2021
MGH Protocols Reduce Risk of Self-Harm in ED
January 26, 2021
This Freezer Accident May Cost Lives
January 19, 2021
Technology to Identify Fatigue?
January 12, 2021
January 5, 2021
Dilaudid/HYDROmorphone Still Problematic
December 29, 2019
Tip of the Week on Vacation
December 22, 2019
Tip of the Week on Vacation
December 15, 2020
Our Perennial Pre-Holiday Warning: “Be Careful Out There!”
December 8, 2020
Maternal Mortality: Looking in All the Wrong Places?
December 1, 2020
An Early Warning System and Response System That Work
November 24, 2020
November 17, 2020
A Picture Is Worth a Thousand Words
November 10, 2020
November 3, 2020
Reminder: Infant Abduction Risk
October 27, 2020
Conflicting Studies on Technology to Reduce RSI’s
October 20, 2020
More on Post-operative Risks for Patients with OSA
October 13, 2020
October 6, 2020
Successfully Reducing Opioid-Related Adverse Events
September 29, 2020
September 22, 2020
VA RCA’s: Suicide Risks Vary by Site
September 15, 2020
September 8, 2020
Follow Up on Tests Pending at Discharge
September 1, 2020
NY State and Nurse Staffing Issues
August 25, 2020
The Off-Hours Effect in Radiology
August 18, 2020
August 11, 2020
Above-Door Alarms to Prevent Suicides
August 4, 2020
July 28, 2020
July 21, 2020
Is This Patient Allergic to Penicillin?
July 14, 2020
A Thesis on Intrahospital Transports
July 7, 2020
Another Patient Found Dead in a Stairwell
June 30, 2020
What Happens after Hospitalization?
June 23, 2020
June 16, 2020
June 9, 2020
Perioperative Medication Safety
June 2, 2020
May 26, 2020
May 19, 2020
Reminder on Telephone or Verbal Orders
May 12, 2020
May 5, 2020
COVID-19 and the Dental Office
April 28, 2020
April 21, 2020
Parenteral Nutrition Safety Issues
April 14, 2020
Patient Safety Tidbits for the COVID-19 Pandemic
April 7, 2020
From Preoperative Assessment to Preoperative Optimization
March 31, 2020
Intrahospital Transport Issues in Children
March 24, 2020
Mayo Clinic: How to Get Photos in Your EMR
March 17, 2020
March 10, 2020
Medication Harm in the Elderly
March 3, 2020
Opportunities to Reduce Unnecessary Contact Precautions
February 25, 2020
More on Perioperative Gabapentinoids
February 18, 2020
February 11, 2020
February 4, 2020
Drugs and Chronic Kidney Disease
January 28, 2020
January 21, 2020
Disruptive Behavior and Patient Safety: Cause or Effect?
January 14, 2020
January 7, 2020
Even More Concerns About MRI Safety
December 31, 2019
Tip of the Week on Vacation
December 14, 2019
Tip of the Week on Vacation
December 17, 2019
December 10, 2019
December 3, 2019
Overlapping Surgery Back in the News
November 26, 2019
Pennsylvania Law on Notifying Patients of Test Results
November 19, 2019
An Astonishing Gap in Medication Safety
November 12, 2019
Patient Photographs Again Help Radiologists
November 5, 2019
October 29, 2019
Tip of the Week on Vacation
October 22, 2019
Tip of the Week on Vacation
October 15, 2019
October 8, 2019
October 1, 2019
Electronic Medication Reconciliation: Glass Half Full or Half Empty?
September 24, 2019
EHR-related Malpractice Claims
September 17, 2019
American College of Surgeons Geriatric Surgery Verification Program
September 10, 2019
Joint Commission Naming Standard Leaves a Gap
September 3, 2019
Lessons from an Inpatient Suicide
August 27, 2019
August 20, 2019
Yet Another (Not So) Unusual RSI
August 13, 2019
Betsy Lehman Center Report on Medical Error
August 6, 2019
July 30, 2019
Lessons from Hospital Suicide Attempts
July 23, 2019
Order Sets Can Nudge the Right Way or the Wrong Way
July 16, 2019
July 9, 2019
Spinal Injection of Tranexamic Acid
July 2, 2019
Tip of the Week on Vacation
June 25, 2019
June 18, 2019
June 11, 2019
ISMP’s Grissinger on Overreliance on Technology
June 4, 2019
Medication Errors in the OR – Part 3
May 28, 2019
May 21, 2019
Mixed Message on Number of Open EMR Records
May 14, 2019
Wrong-Site Surgery and Difficult-to-Mark Sites
May 7, 2019
Simulation Training for OR Fires
April 30, 2019
Reducing Unnecessary Urine Cultures
April 23, 2019
In and Out the Door and Other OR Flow Disruptions
April 16, 2019
AACN Practice Alert on Alarm Management
April 9, 2019
Handoffs for Every Occasion
April 2, 2019
Unexpected Events During MRI
March 26, 2019
March 19, 2019
March 12, 2019
Update on Overlapping Surgery
March 5, 2019
Infusion Pump Problems
February 26, 2019
Vascular Access Device Dislodgements
February 19, 2019
Focus on Pediatric Patient Safety
February 12, 2019
From Tragedy to Travesty of Justice
February 12, 2019
2 ER Drug Studies: Reassurances and Reservations
February 5, 2019
Flaws in Our Medication Safety Technologies
January 29, 2018
National Patient Safety Goal for Suicide Prevention
January 22, 2019
Wandering Patients
January 15, 2019
Another Plus for Prehabilitation
January 8, 2019
Maternal Mortality in the Spotlight
January 1, 2019
More on Automated Dispensing Cabinet (ADC) Safety
December 25, 2018
Happy Holidays!
December 18, 2018
Great Recommendations for e-Prescribing
December 11, 2018
December 4, 2018
Don’t Use Syringes for Topical Products
November 27, 2018
November 20, 2018
November 13, 2018
Antipsychotics Fail in ICU Delirium
November 6, 2018
More on Promoting Sleep in Inpatients
October 30, 2018
October 23, 2018
Lessons From Yet Another Aviation Incident
October 16, 2018
October 9, 2018
October 2, 2018
Speaking Up About Disruptive Behavior
September 25, 2018
Foley Follies
September 18, 2018
September 11, 2018
September 4, 2018
The 12-Hour Nursing Shift: Another Nail in the Coffin
August 28, 2018
Thought You Discontinued That Medication? Think Again
August 21, 2018
Delayed CT Scan in the Anticoagulated Patient
August 14, 2018
ISMP Canada’s Updated “Do Not Use” Abbreviation List
August 7, 2018
Tip of the Week on Vacation
July 31, 2018
Surgery and the Opioid-Tolerant Patient
July 24, 2018
More on Speech Recognition Software Errors
July 17, 2018
OSA Screening in Stroke Patients
July 10, 2018
Another Jump from a Hospital Window
July 3, 2018
Tip of the Week on Vacation
June 26, 2018
Infection Related to Colonoscopy
June 19, 2018
June 12, 2018
Adverse Events in Cancer Patients
June 5, 2018
Pennsylvania Patient Safety Authority on Iatrogenic Burns
May 29, 2018
More on Nursing Workload and Patient Safety
May 22, 2018
Hazardous Intrahospital Transport
May 15, 2018
May 8, 2018
May 1, 2018
April 24, 2018
April 17, 2018
More on Tests Pending at Discharge
April 10, 2018
Prepping the Geriatric Patient for Surgery
April 3, 2018
March 27, 2018
March 20, 2018
Minnesota Highlights Lost Tissue Samples
March 13, 2018
March 6, 2018
February 27, 2018
Update on Patient Safety Walk Rounds
February 20, 2018
February 13, 2018
February 6, 2018
Adverse Events in Inpatient Psychiatry
January 30, 2018
January 23, 2018
Unintentional Hypothermia Back in Focus
January 16, 2018
January 9, 2018
More on Fire Risk from Surgical Preps
January 2, 2018
Preventing Perioperative Nerve Injuries
December 26, 2017
Tip of the Week on Vacation
December 19, 2017
December 12, 2017
Joint Commission on Suicide Prevention
December 5, 2017
Massachusetts Initiative on Cataract Surgery
November 28, 2017
More on Dental Sedation/Anesthesia Safety
November 21, 2017
OSA, Oxygen, and Alarm Fatigue
November 14, 2017
Tracking C. diff to a CT Scanner
November 7, 2017
Perioperative Neuropathies
October 31, 2017
Target Drugs for Deprescribing
October 24, 2017
Neurosurgery and Time of Day
October 17, 2017
Progress on Alarm Management
October 10, 2017
More on Torsade de Pointes
October 3, 2017
Respiratory Compromise: One Size Does Not Fit All
September 26, 2017
Tip of the Week on Vacation
September 19, 2017
Tip of the Week on Vacation
September 12, 2017
Can You Hear Me Now?
September 5, 2017
Another Iatrogenic Burn
August 29, 2017
Suicide in the Bathroom
August 22, 2017
August 15, 2017
Delayed Emergency Surgery and Mortality Risk
August 8, 2017
Sedation for Pediatric MRI Rising
August 1, 2017
Progress on Wrong Patient Orders
July 25, 2017
Can We Influence the “Weekend Effect”?
July 18, 2017
Another Hazard from Alcohol-Based Hand Gels
July 11, 2017
The 12-Hour Shift Takes More Hits
July 4, 2017
Tip of the Week on Vacation
June 27, 2017
June 20, 2017
June 13, 2017
June 6, 2017
NYS Mandate for Sepsis Protocol Works
May 30, 2017
Errors in Pre-Populated Medication Lists
May 23, 2017
May 16, 2017
Are Surgeons Finally Ready to Screen for Frailty?
May 9, 2017
Missed Nursing Care and Mortality Risk
May 2, 2017
Anatomy of a Wrong Procedure
April 25, 2017
April 18, 2017
Alarm Response and Nurse Shift Duration
April 11, 2017
Interruptions: The Ones We Forget About
April 4, 2017
Deprescribing in Long-Term Care
March 28, 2017
More Issues with Dental Sedation/Anesthesia
March 21, 2017
Success at Preventing Delirium
March 14, 2017
More on Falls on Inpatient Psychiatry
March 7, 2017
February 28, 2017
February 21, 2017
Yet More Jumps from Hospital Windows
February 14, 2017
February 7, 2017
January 31, 2017
More Issues in Pediatric Safety
January 24, 2017
Dexmedetomidine to Prevent Postoperative Delirium
January 17, 2017
January 10, 2017
The 26-ml Applicator Strikes Again!
January 3, 2017
What’s Happening to “I’m Sorry”?
December 27, 2016
Tip of the Week on Vacation
December 20, 2016
End-of-Rotation Transitions and Mortality
December 13, 2016
More on Double-Booked Surgery
December 6, 2016
Postoperative Pulmonary Complications
November 29, 2016
Doubling Down on Double-Booked Surgery
November 22, 2016
Leapfrog, Picklists, and Healthcare IT Vulnerabilities
November 15, 2016
November 8, 2016
Managing Distractions and Interruptions
November 1, 2016
CMS Emergency Preparedness Rule
October 25, 2016
Desmopressin Back in the Spotlight
October 18, 2016
Yet More Questions on Contact Precautions
October 11, 2016
New Guideline on Preop Screening and Assessment for OSA
October 4, 2016
September 27, 2016
September 20, 2016
Downloadable ABCDEF Bundle Toolkits for Delirium
September 13, 2016
Vanderbilt’s Electronic Procedural Timeout
September 6, 2016
August 30, 2016
Can You Really Limit Interruptions?
August 23, 2016
ISMP Canada: Automation Bias and Automation Complacency
August 16, 2016
How Is Your Alarm Management Initiative Going?
August 9, 2016
August 2, 2016
Drugs in the Elderly: The Goldilocks Story
July 26, 2016
Confirmed: Keep Your OR Doors Closed
July 19, 2016
Infants and Wrong Site Surgery
July 12, 2016
Forget Brexit – Brits Bash the RCA!
July 5, 2016
Tip of the Week on Vacation
June 28, 2016
Culture of Safety and Catheter-Associated Infections
June 21, 2016
Methotrexate Errors in Australia
June 14, 2016
Nursing Monitoring of Patients on Opioids
June 7, 2016
CPAP for Hospitalized Patients at High Risk for OSA
May 31, 2016
More Frailty Measures That Predict Surgical Outcomes
May 24, 2016
Texting Orders – Is It Really Safe?
May 17, 2016
Patient Safety Issues in Cataract Surgery
May 10, 2016
Medical Problems in Behavioral Health
May 3, 2016
Clinical Decision Support Malfunction
April 26, 2016
Lots More on Preventing Readmissions But Where's the Beef?
April 19, 2016
Independent Double Checks and Oral Chemotherapy
April 12, 2016
April 5, 2016
Workarounds Overriding Safety
March 29, 2016
March 22, 2016
Radiology Communication Errors May Surprise You
March 15, 2016
March 8, 2016
Tip of the Week on Vacation
March 1, 2016
February 23, 2016
February 16, 2016
February 9, 2016
February 2, 2016
January 26, 2016
More on Frailty and Surgical Morbidity and Mortality
January 19, 2016
Patient Identification in the Spotlight
January 12, 2016
New Resources on Improving Safety of Healthcare IT
January 5, 2016
Lessons from AirAsia Flight QZ8501 Crash
December 29, 2015
More Medical Helicopter Hazards
December 22, 2015
The Alberta Abbreviation Safety Toolkit
December 15, 2015
Vital Sign Monitoring at Night
December 8, 2015
Danger of Inaccurate Weights in Stroke Care
December 1, 2015
TALLman Lettering: Does It Work?
November 24, 2015
Door Opening and Foot Traffic in the OR
November 17, 2015
Patient Perspectives on Communication of Test Results
November 10, 2015
Weighing in on Double-Booked Surgery
November 3, 2015
Medication Errors in the OR - Part 2
October 27, 2015
Sentinel Event Alert on Falls and View from Across the Pond
October 20, 2015
Updated Beers List
October 13, 2015
Dilaudid Dangers #3
October 6, 2015
Suicide and Other Violent Inpatient Deaths
September 29, 2015
More on the 12-Hour Nursing Shift
September 22, 2015
The Cost of Being Rude
September 15, 2015
Another Possible Good Use of a Checklist
September 8, 2015
TREWScore for Early Recognition of Sepsis
September 1, 2015
August 25, 2015
Checklist for Intrahospital Transport
August 18, 2015
Missing Obstructive Sleep Apnea
August 11, 2015
New Oxygen Guidelines: Thoracic Society of Australia and NZ
August 4, 2015
Tip of the Week on Vacation
July 28, 2015
July 21, 2015
Avoiding Distractions in the OR
July 14, 2015
July 7, 2015
June 30, 2015
What Are Appropriate Indications for Urinary Catheters?
June 23, 2015
Again! Mistaking Antiseptic Solution for Radiographic Contrast
June 16, 2015
June 9, 2015
Add This to Your Fall Risk Assessment
June 2, 2015
May 26, 2015
May 19, 2015
May 12, 2015
More on Delays for In-Hospital Stroke
May 5, 2015
Errors with Oral Oncology Drugs
April 28, 2015
April 21, 2015
April 14, 2015
Using Insulin Safely in the Hospital
April 7, 2015
March 31, 2015
Clinical Decision Support for Pneumonia
March 24, 2015
Specimen Issues in Prostate Cancer
March 17, 2015
March 10, 2015
FDA Warning Label on Insulin Pens: Is It Enough?
March 3, 2015
Factors Related to Postoperative Respiratory Depression
February 24, 2015
More Risks with Long-Acting Opioids
February 17, 2015
Functional Impairment and Hospital Readmission, Surgical Outcomes
February 10, 2015
The Anticholinergic Burden and Dementia
February 3, 2015
CMS Hopes to Reduce Antipsychotics in Dementia
January 27, 2015
The Golden Hour for Stroke Thrombolysis
January 20, 2015
He Didn’t Wash His Hands After What!
January 13, 2015
January 6, 2015
Yet Another Handoff: The Intraoperative Handoff
December 30, 2014
Data Accumulates on Impact of Long Surgical Duration
December 23, 2014
Iatrogenic Burns in the News Again
December 16, 2014
More on Each Element of the Surgical Fire Triad
December 9, 2014
December 2, 2014
ANA Position Statement on Nurse Fatigue
November 25, 2014
Misdiagnosis Due to Lab Error
November 18, 2014
Handwashing Fades at End of Shift, ?Smartwatch to the Rescue
November 11, 2014
Early Detection of Clinical Deterioration
November 4, 2014
Progress on Fall Prevention
October 28, 2014
RF Systems for Retained Surgical Items
October 21, 2014
The Fire Department and Your Hospital
October 14, 2014
October 7, 2014
Our Take on Patient Safety Walk Rounds
September 30, 2014
More on Deprescribing
September 23, 2014
Stroke Thrombolysis: Need to Focus on Imaging-to-Needle Time
September 16, 2014
Focus on Home Care
September 9, 2014
The Handback
September 2, 2014
Frailty and the Trauma Patient
August 26, 2014
Surgeons’ Perception of Intraoperative Time
August 19, 2014
Some More Lessons Learned on Retained Surgical Items
August 12, 2014
Surgical Fires Back in the News
August 5, 2014
Tip of the Week on Vacation
July 29, 2014
The 12-Hour Nursing Shift: Debate Continues
July 22, 2014
More on Operating Room Briefings and Debriefings
July 15, 2014
Barriers to Success of Early Warning Systems
July 8, 2014
Update: Minor Head Trauma in the Anticoagulated Patient
July 1, 2014
Interruptions and Radiologists
June 24, 2014
Lessons from the General Motors Recall Analysis
June 17, 2014
SO2S Confirms Routine Oxygen of No Benefit in Stroke
June 10, 2014
Another Clinical Decision Support Tool to Avoid Torsade de Pointes
June 3, 2014
More on the Risk of Sedative/Hypnotics
May 27, 2014
A Gap in ePrescribing: Stopping Medications
May 20, 2014
May 13, 2014
Perioperative Sleep Apnea: Human and Financial Impact
May 6, 2014
Monitoring for Opioid-induced Sedation and Respiratory Depression
April 29, 2014
More on the Unintended Consequences of Contact Isolation
April 22, 2014
Impact of Resident Workhour Restrictions
April 15, 2014
Specimen Identification Mixups
April 8, 2014
FMEA to Avoid Breastmilk Mixups
April 1, 2014
Expensive Aspects of Sepsis Protocol Debunked
March 25, 2014
March 18, 2014
Systems Approach Improving Stroke Care
March 11, 2014
We Miss the Graphic Flowchart!
March 4, 2014
Evidence-Based Prescribing and Deprescribing in the Elderly
February 25, 2014
Joint Commission Revised Diagnostic Imaging Requirements
February 18, 2014
February 11, 2014
Another Perioperative Handoff Tool: SWITCH
February 4, 2014
But What If the Battery Runs Low?
January 28, 2014
Is Polypharmacy Always Bad?
January 21, 2014
January 14, 2014
Diagnostic Error: Salient Distracting Features
January 7, 2014
Lessons From the Asiana Flight 214 Crash
December 24-31, 2013
Tip of the Week on Vacation
December 17, 2013
December 10, 2013
Better Handoffs, Better Results
December 3, 2013
Reducing Harm from Falls on Inpatient Psychiatry
November 26, 2013
Missed Care: New Opportunities?
November 19, 2013
Can We Improve Dilaudid/HYDROmorphone Safety?
November 12, 2013
More on Inappropriate Meds in the Elderly
November 5, 2013
Joint Commission Sentinel Event Alert: Unintended Retained Foreign Objects
October 29, 2013
PAD: The Pain, Agitation, and Delirium Care Bundle
October 22, 2013
How Safe Is Your Radiology Suite?
October 15, 2013
October 8, 2013
October 1, 2013
Fuels and Oxygen in OR Fires
September 24, 2013
Perioperative Use of CPAP in OSA
September 17, 2013
September 10, 2013
Informed Consent and Wrong-Site Surgery
September 3, 2013
Predicting Perioperative Complications: Slow and Simple
August 27 2013
Lessons on Wrong-Site Surgery
August 20 2013
Lessons from Canadian Analysis of Medical Air Transport Cases
August 13 2013
August 6, 2013
July 9-30, 2013
Tip of the Week on Vacation
July 2, 2013
June 25, 2013
June 18, 2013
DVT Prevention in Stoke – CLOTS 3
June 11, 2013
June 4, 2013
May 28, 2013
The Neglected Medications: IV Fluids
May 21, 2013
May 14, 2013
Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)
May 7, 2013
April 30, 2013
Photographic Identification to Prevent Errors
April 23, 2013
Plethora of Medication Safety Studies
April 16, 2013
April 9, 2013
Mayo Clinic System Alerts for QT Interval Prolongation
April 2, 2013
Absconding from Behavioral Health Services
March 26, 2013
Failure to Recognize Sleep Apnea Before Surgery
March 19, 2013
Dealing with the Violent Patient in the Emergency Department
March 12, 2013
More on Communicating Test Results
March 5, 2013
Underutilized Safety Tools: The Observational Audit
February 26, 2013
Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?
February 19, 2013
Practical Postoperative Pain Management
February 12, 2013
CDPH: Lessons Learned from PCA Incident
February 5, 2013
Antidepressants and QT Interval Prolongation
January 29, 2013
A Flurry of Activity on Handoffs
January 22, 2013
You Don’t Know What You Don’t Know
January 15, 2013
January 8, 2013
More Lessons Learned on Retained Surgical Items
January 1, 2013
Don’t Throw Away Those View Boxes Yet
December 25, 2012
Tip of the Week on Vacation
December 18, 2012
Unintended Consequences of the CAUTI Measure?
December 11, 2012
December 4, 2012
Unintentional Perioperative Hypothermia: A New Twist
November 27, 2012
November 20, 2012
Update on Perioperative Management of Obstructive Sleep Apnea
November 13, 2012
The 12-Hour Nursing Shift: More Downsides
November 6, 2012
Using LEAN to Improve Stroke Care
October 30, 2012
October 23, 2012
Latent Factors Lurking in the OR
October 16, 2012
What is the Evidence on Double Checks?
October 9, 2012
Call for Focus on Diagnostic Errors
October 2, 2012
Test Results: Everyone’s Worst Nightmare
September 25, 2012
Preoperative Assessment for Geriatric Patients
September 18, 2012
September 11, 2012
In Search of the Ideal Early Warning Score
September 4, 2012
August 28, 2012
New Care Model Copes with Interruptions Better
August 21, 2012
More on Missed Followup of Tests in Hospital
August 14, 2012
August 7, 2012
Cognition, Post-Op Delirium, and Post-Op Outcomes
July 31, 2012
Surgical Case Duration and Miscommunications
July 24, 2012
FDA and Extended-Release/Long-Acting Opioids
July 17, 2012
July 10, 2012
Tip of the Week on Vacation
July 3, 2012
Recycling an Old Column: Dilaudid Dangers
June 26, 2012
Using Patient Photos to Reduce CPOE Errors
June 19, 2012
More Problems with Faxed Orders
June 12, 2012
Lessons Learned from the CDPH: Retained Foreign Bodies
June 5, 2012
Minor Head Trauma in the Anticoagulated Patient
May 29, 2012
Falls, Fractures, and Fatalities
May 22, 2012
Update on Preoperative Screening for Sleep Apnea
May 15, 2012
May 8, 2012
Importance of Nontechnical Skills in Healthcare
May 1, 2012
April 24, 2012
Fire Hazard of Skin Preps Oxygen
April 17, 2012
April 10, 2012
April 3, 2012
New Risk for Postoperative Delirium: Obstructive Sleep Apnea
March 27, 2012
March 20, 2012
Adverse Events Related to Psychotropic Medications
March 13, 2012
Medical Emergency Team Calls to Radiology
March 6, 2012
February 28, 2012
AACN Practice Alert on Delirium in Critical Care
February 21, 2012
Improving PCA Safety with Capnography
February 14, 2012
Handoffs More Than Battle of the Mnemonics
February 7, 2012
Another Neuromuscular Blocking Agent Incident
January 31, 2012
January 24, 2012
Patient Safety in Ambulatory Care
January 17, 2012
Delirium and Contact Isolation
January 10, 2012
January 3, 2012
Unintended Consequences of Restricted Housestaff Hours
December 20, 2011
December 13, 2011
December 6, 2011
Why You Need to Beware of Oxygen Therapy
November 29, 2011
November 22, 2011
Perioperative Management of Sleep Apnea Disappointing
November 15, 2011
November 8, 2011
WHOs Multi-professional Patient Safety Curriculum Guide
November 1, 2011
So Whats the Big Deal About Inserting an NG Tube?
October 25, 2011
October 18, 2011
October 11, 2011
October 4, 2011
Radiology Report Errors and Speech Recognition Software
September 27, 2011
The Canadian Suicide Risk Assessment Guide
September 20, 2011
When Practice Changes the Evidence: The CKD Story
September 13, 2011
Do You Use Fentanyl Transdermal Patches Safely?
September 6, 2011
August 30, 2011
Unintentional Discontinuation of Medications After Hospitalization
August 23, 2011
Catheter Misconnections Back in the News
August 16, 2011
August 9, 2011
Frailty and the Surgical Patient
August 2, 2011
July 26, 2011
July 19, 2011
Communication Across Professions
July 12, 2011
Psst! Pass it onHow a kids game can mold good handoffs
July 5, 2011
Sidney Dekker: Patient Safety. A Human Factors Approach
June 28, 2011
Long-Acting and Extended-Release Opioid Dangers
June 21, 2011
June 14, 2011
June 6, 2011
May 31, 2011
Book Review Human Factors and Team Psychology in a High Stakes Environment
May 24, 2011
May 17, 2011
Opioid-Induced Respiratory Depression Again!
May 10, 2011
Preventing Preventable Readmissions: Not As Easy As It Sounds
May 3, 2011
April 26, 2011
Sleeping Air Traffic Controllers: What About Healthcare?
April 19, 2011
DVT Prophylaxis in Acute Stroke: Controversy Reappears
April 12, 2011
Medication Issues in the Ambulatory Setting
April 5, 2011
March 29, 2011
The Silent Treatment:A Dose of Reality
March 22, 2011
An EMR Feature Detrimental to Teamwork and Patient Safety
March 15, 2011
March 8, 2011
Yes, Physicians Get Interrupted Too!
March 1, 2011
February 22, 2011
February 15, 2011
Controversies in VTE Prophylaxis
February 8, 2011
February 1, 2011
January 25, 2011
Procedural Sedation in Children
January 18, 2011
More on Medication Errors in Long-Term Care
January 11, 2011
NPSA (UK) How to Guide: Five Steps to Safer Surgery
January 4, 2011
December 28, 2010
HAIs: Looking In All The Wrong Places
December 21, 2010
More Bad News About Off-Hours Care
December 14, 2010
NPSA (UK): Preventing Fatalities from Medication Loading Doses
December 6, 2010
More Tips to Prevent Wrong-Site Surgery
November 30, 2010
SURPASS: The Mother of All Checklists
November 23, 2010
Focus on Cumulative Radiation Exposure
November 16, 2010
November 9, 2010
12-Hour Nursing Shifts and Patient Safety
November 2, 2010
Insulin: Truly a High-Risk Medication
October 26, 2010
Confirming Medications During Anesthesia
October 19, 2010
Optimizing Medications in the Elderly
October 12, 2010
October 5, 2010
September 28, 2010
September 21, 2010
September 14, 2010
Wrong-Site Craniotomy: Lessons Learned
September 7, 2010
Patient Safety in Ob/Gyn Settings
August 31, 2010
August 24, 2010
The BP Oil Spill Analogies in Healthcare
August 17, 2010
Preoperative Consultation Time to Change
August 10, 2010
Its Not Always About The Evidence
August 3, 2010
Tip of the Week on Vacation
July 27, 2010
EMRs Still Have A Long Way To Go
July 20, 2010
More on the Weekend Effect/After-Hours Effect
July 13, 2010
Postoperative Opioid-Induced Respiratory Depression
July 6, 2010
Book Reviews: Pronovost and Gawande
June 29, 2010
Torsade de Pointes: Are Your Patients At Risk?
June 22, 2010
Disclosure and Apology: How to Do It
June 15, 2010
Dysphagia in the Stroke Patient: the Scottish Guideline
June 8, 2010
Surgical Safety Checklist for Cataract Surgery
June 1, 2010
May 25, 2010
May 18, 2010
Real-Time Random Safety Audits
May 11, 2010
May 4, 2010
More on the Impact of Interruptions
April 27, 2010
April 20, 2010
HITs Limited Impact on Quality To Date
April 13, 2010
April 6, 2010
March 30, 2010
Publicly Released RCAs: Everyone Learns from Them
March 23, 2010
ISMPs Guidelines for Standard Order Sets
March 16, 2010
A Patient Safety Scavenger Hunt
March 9, 2010
Communication of Urgent or Unexpected Radiology Findings
March 2, 2010
Alarm Sensitivity: Early Detection vs. Alarm Fatigue
February 23, 2010
Alarm Issues in the News Again
February 16, 2010
Spin/HypeKnowing It When You See It
February 9, 2010
More on Preventing Inpatient Suicides
February 2, 2010
January 26, 2010
Preventing Postoperative Delirium
January 19, 2010
January 12, 2010
Patient Photos in Patient Safety
January 5, 2010
December 29, 2009
Recognizing Deteriorating Patients
December 22, 2009
December 15, 2009
December 8, 2009
December 1, 2009
Patient Safety Doesnt End at Discharge
November 24, 2009
Another Rough Month for Healthcare IT
November 17, 2009
November 10, 2009
Conserving ResourcesBut Maintaining Patient Safety
November 3, 2009
Medication Safety: Frontline to the Rescue Again!
October 27, 2009
Co-Managing Patients: The Good, The Bad, and The Ugly
October 20, 2009
Radiology AgainBut This Time Its Really Radiology!
October 13, 2009
October 6, 2009
Oxygen Safety: More Lessons from the UK
September 29, 2009
Perioperative Peripheral Nerve Injuries
September 22, 2009
Psychotropic Drugs and Falls in the SNF
September 15, 2009
ETTOs: Efficiency-Thoroughness Trade-Offs
September 8, 2009
Barriers to Medication Reconciliation
September 1, 2009
The Real Root Causes of Medical Helicopter Crashes
August 25, 2009
Interruptions, Distractions, InattentionOops!
August 18, 2009
Obstructive Sleep Apnea in the Perioperative Period
August 11, 2009
August 4, 2009
July 28, 2009
Wandering, Elopements, and Missing Patients
July 21, 2009
Medication Errors in Long Term-Care
July 14, 2009
Is Your Do Not Use Abbreviations List Adequate?
July 7, 2009
Nudge: Small Changes, Big Impacts
June 30, 2009
iSoBAR: Australian Clinical Handoffs/Handovers
June 23, 2009
June 16, 2009
Disclosing Errors That Affect Multiple Patients
June 9, 2009
CDC Update to the Guideline for Prevention of CAUTI
June 2, 2009
Why Hospitals Should FlyJohn Nance Nails It!
May 26, 2009
Learning from Tragedies. Part II
May 19, 2009
May 12, 2009
May 5, 2009
Adverse Drug Events in the ICU
April 28, 2009
Ticket Home and Other Tools to Facilitate Discharge
April 21, 2009
April 14, 2009
More on Rehospitalization After Discharge
April 7, 2009
March 31, 2009
Screening Patients for Risk of Delirium
March 24, 2009
March 17, 2009
March 10, 2009
Prolonged Surgical Duration and Time Awareness
March 3, 2009
Overriding AlertsLike Surfin the Web
February 24, 2009
Discharge Planning: Finally Something That Works!
February 17, 2009
Reducing Risk of Overdose with Midazolam Injection
February 10, 2009
Sedation in the ICU: The Dexmedetomidine Study
February 3, 2009
NTSB Medical Helicopter Crash Reports: Missing the Big Picture
January 27, 2009
Oxygen Therapy: Everything You Wanted to Know and More!
January 20, 2009
The WHO Surgical Safety Checklist Delivers the Outcomes
January 13, 2009
January 6, 2009
December 30, 2008
Unintended Consequences: Is Medication Reconciliation Next?
December 23, 2008
December 16, 2008
Joint Commission Sentinel Event Alert on Hazards of Healthcare IT
December 9, 2008
December 2, 2008
Playing without the ballthe art of communication in healthcare
November 25, 2008
November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
November 11, 2008
November 4, 2008
October 28, 2008
More on Computerized Trigger Tools
October 21, 2008
October 14, 2008
October 7, 2008
Lessons from Falls....from Rehab Medicine
September 30, 2008
September 23, 2008
Checklists and Wrong Site Surgery
September 16, 2008
More on Radiology as a High Risk Area
September 9, 2008
Less is More.and Do You Really Need that Decimal?
September 2, 2008
August 26, 2008
August 19, 2008
August 12, 2008
Jerome Groopmans How Doctors Think
August 5, 2008
July 29, 2008
Heparin-Induced Thrombocytopenia
July 22, 2008
Lots New in the Anticoagulation Literature
July 15, 2008
July 8, 2008
July 1, 2008
WHOs New Surgical Safety Checklist
June 24, 2008
Urinary Catheter-Related UTIs: Bladder Bundles
June 17, 2008
Technology Workarounds Defeat Safety Intent
June 10, 2008
Monitoring the Postoperative COPD Patient
June 3, 2008
UK Advisory on Chest Tube Insertion
May27, 2008
If You Do RCAs or Design Healthcare ProcessesRead Gary Kleins Work
May20, 2008
CPOE Unintended Consequences Are Wrong Patient Errors More Common?
May13, 2008
Medication Reconciliation: Topical and Compounded Medications
May 6, 2008
Preoperative Screening for Obstructive Sleep Apnea
April 29, 2008
ASA Practice Advisory on Operating Room Fires
April 22, 2008
CMS Expanding List of No-Pay Hospital-Acquired Conditions
April 15, 2008
April 8, 2008
April 1, 2008
Pennsylvania PSAs FMEA on Telemetry Alarm Interventions
March 25, 2008
March 18, 2008
Is Desmopressin on Your List of Hi-Alert Medications?
March 11, 2008
March 4, 2008
Housestaff Awareness of Risks for Hazards of Hospitalization
February 26, 2008
Nightmares.The Hospital at Night
February 19, 2008
February 12, 2008
February 5, 2008
Reducing Errors in Obstetrical Care
January 29, 2008
Thoughts on the Recent Neonatal Nursery Fire
January 22, 2008
More on the Cost of Complications
January 15, 2008
Managing Dangerous Medications in the Elderly
January 8, 2008
Urinary Catheter-Associated Infections
January 1, 2008
December 25, 2007
December 18, 2007
December 11, 2007
CommunicationCommunicationCommunication
December 4, 2007
November 27,2007
November 20, 2007
New Evidence Questions Perioperative Beta Blocker Use
November 13, 2007
AHRQ's Free Patient Safety Tools DVD
November 6, 2007
October 30, 2007
Using IHIs Global Trigger Tool
October 23, 2007
Medication Reconciliation Tools
October 16, 2007
Radiology as a Site at High-Risk for Medication Errors
October 9, 2007
October 2, 2007
Taking Off From the Wrong Runway
September 25, 2007
Lessons from the National Football League
September 18, 2007
Wristbands: The Color-Coded Conundrum
September 11, 2007
Root Cause Analysis of Chemotherapy Overdose
September 4, 2007
August 28, 2007
Lessons Learned from Transportation Accidents
August 21, 2007
Costly Complications About To Become Costlier
August 14, 2007
More Medication-Related Issues in Ambulatory Surgery
August 7, 2007
Role of Maintenance in Incidents
July 31, 2007
Dangers of Neuromuscular Blocking Agents
July 24, 2007
Serious Incident Response Checklist
July 17, 2007
Falls in Patients on Coumadin or Other Anticoagulants
July 10, 2007
Catheter Connection Errors/Wrong Route Errors
July 3, 2007
June 26, 2007
Pneumonia in the Stroke Patient
June 19, 2007
Unintended Consequences of Technological Solutions
June 12, 2007
Medication-Related Issues in Ambulatory Surgery
June 5, 2007
Patient Safety in Ambulatory Surgery
May 29, 2007
Read Anything & Everything Written by Malcolm Gladwell!
May 22, 2007
May 15, 2007
Communication, Hearback and Other Lessons from Aviation
May 8, 2007
Doctor, when do I get this red rubber hose removed?
May 1, 2007
April 23, 2007
April 16, 2007
April 9, 2007
Make Your Surgical Timeouts More Useful
April 2, 2007
March 26, 2007
Alarms Should Point to the Problem
March 19, 2007
Put that machine back the way you found it!
March 12, 2007
March 5, 2007
February 26, 2007
Copyright 2012 The Truax Group Healthcare Consulting Patient Safety Solutions Tools Tips & Resources. All rights reserved.
PO Box 1230
Grantham, NH 03753
ph: 716-550-1106
btruax