Tips, Tools, Techniques, and Resources You Can Use in Your Patient Safety and Quality Improvement Initiatives

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Patient Safety Tip of the Week

January 3, 2012

Unintended Consequences of Restricted Housestaff Hours

This months Whats New in the Patient Safety World column Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety highlights the serious impact of provider fatigue on patient safety. Weve done numerous columns focusing on the impact of fatigue in both nurses and physicians, not only on patient care but on their personal health. (See our Patient Safety Tips of the Week for November 9, 2010 12-Hour Nursing Shifts and Patient Safety, April 26, 2011 Sleeping Air Traffic Controllers: What About Healthcare? and our Whats New in the Patient Safety World columns for February 2011 Update on 12-hour Nursing Shifts, September 2011 Shiftwork and Patient Safety, and November 2011 Restricted Housestaff Work Hours and Patient Handoffs.)

There is absolutely no doubt about the negative impact that fatigue has on patient safety and quality outcomes. However, equally disturbing is the fact that some of our interventions to minimize fatigue in healthcare workers may introduce unintended consequences that do not remedy the underlying threats to patient safety.

In our November 2011 Whats New in the Patient Safety World column Restricted Housestaff Work Hours and Patient Handoffs we discussed the mixed results of studies looking at the impact on patients of restrictions on housestaff work hours. And weve discussed the fact that our efforts to minimize errors due to fatigue of long working hours (for not only physicians but also nurses and others) must always be balanced against the errors that occur due to fumbled handoffs that increase when work hours are restricted.

In response to the ACGME duty-hour restrictions for housestaff a variety of schedules have been tried. At Childrens Hospital in Boston they moved from a night float system to one in which housestaff worked one straight week of nights during their 28-day rotations (compared to previously working every fourth night). Christopher Landrigan, director of the Sleep and Patient Safety Program at Harvard, and colleagues (Chua 2011) looked at the impact of this change and found some surprising results. Though mean shift length was reduced by almost 2 hours, the residents nightly sleep actually was reduced from 6.72 to 4.77 hours and total sleep reduced from 7.50 to 5.47 hours! The study did not assess impact on patient care.

Childrens Hospital of Boston subsequently reverted temporarily to a more traditional overnight call schedule and now has redesigned a night team schedule taking into account the results of this study. The article is a stark reminder that sometimes in our haste to correct one problem we inadvertently develop a solution that aggravates the original problem or creates new problems. And unless you actually measure the outcomes of the changes you make you may incorrectly assume that your changes created a desirable effect.

We had previously discussed some of Landrigans work in our September 2011 Whats New in the Patient Safety World column Shiftwork and Patient Safety. An audio interview (Henkel 2011a) with him in the August issue of The Hospitalist had some really good points about the effects of shiftwork on mistakes and patient safety. He stresses that you dont want to schedule someone to work too many nights in a row, citing literature from multiple industries that shows error rates go up with consecutive nights worked. Our November 9, 2010 Patient Safety Tip of the Week 12-Hour Nursing Shifts and Patient Safety cited a study on shift workers in fields other than healthcare (Folkard 2003) which showed that the risk of incidents increased each consecutive day worked. For example, on average for night shifts risk was 6% higher on the second night, 17% higher on the third night, and 36% higher on the fourth night (for morning/day shifts the corresponding risks were 2%, 7% and 17%). So Landrigan says that it is probably better to schedule hospitalists for only 3-4 days of night shifts rather than the more popular 7days on/7 days off pattern.

In the above interview Landrigan also discusses the biology of circadian rhythms and notes the importance of taking a 1.5-2.0 hour nap on the afternoon prior to working the first night shift and that working a day shift immediately after a night shift is not a good idea. He discusses how working consecutive night shifts adds to the burden of sleep deprivation, which ultimately has a role in the occurrence of mistakes and errors. When asked about nocturnists, he does note that some people have been able to alter their circadian rhythms to accommodate chronic night shift work. But he cautions that when such people take vacations their bodies return to a day circadian rhythm and there may be problems when they return to the night shift pattern.

Not only are too many consecutive night shifts potentially dangerous to patients, they are dangerous to the healthcare workers themselves. In the second article (Henkel 2011b) Landrigan notes We know that if hospitalists are driving home after night shifts, particularly multiple night shifts, that theyre at risk for motor vehicle crashes and at risk of sticking themselves with needles and scalpels toward the tail end of their shifts. None of us want that.

And the Journal of Neurosurgery has a series of articles on the impact of duty-hour restrictions on neurosurgery residents. Neurosurgery has been one discipline in which sentiment against the work hour restrictions has run heavy, both from attendings, educators and residents. One study (Dumont 2011) demonstrated an increase in complication rates for neurosurgical procedures after implementation of restricted work-hour rules. They postulate that the increased number of handoffs required probably plays a major role in the increase in morbidity and complications.

Another study (Ganju 2011) performed pre- and post-call simulation tests on neurosurgical residents and concluded there was a marginal decline in proficiency post-call. However, they noted that the decline was much less significant than the decline seen in general surgery residents post-call. That article and the accompanying editorial (Dacey 2011) seem to be touting neurosurgery residents are different were tougher and make a case that the same ACGME duty-hours restrictions should not apply equally to all specialties.

We dont buy that. Thats the same sort of Top Gun attitude that got many early fighter pilots killed. Fatigue is real and impairs our ability to respond no matter what professional or lifestyle activity we are engaged in. What we need to do is develop better ways to recognize when fatigue is occurring (because we ourselves are not good judges of our abilities when fatigued) and develop better systems to care for our patients when we need to excuse ourselves from patient care because we are fatigued.

But Landrigans message is clear - be careful that the solution you try is not worse than the problem itself!

References:

Chua K-P, Gordon MB, Sectish T, Landrigan CP. Effects of a Night-Team System on Resident Sleep and Work Hours. Pediatrics 2011; 128:6 1142-1147

http://pediatrics.aappublications.org/content/128/6/1142.abstract?sid=b1daf086-091b-43c7-8cf0-462317ca095b

Henkel G. ONLINE EXCLUSIVE: How to minimize the adverse affects of working night shifts. The Hospitalist. August 2011

http://www.the-hospitalist.org/details/article/1299087/ONLINE_EXCLUSIVE_How_to_minimize_the_adverse_affects_of_working_night_shifts.html

Henkel G. ONLINE EXCLUSIVE: Scheduling Rules of Thumb. Safety, equality should factor into HM groups coverage plans. The Hospitalist. August 2011

http://www.the-hospitalist.org/details/article/1309403/ONLINE_EXCLUSIVE_Scheduling_Rules_of_Thumb.html

Folkard S, Tucker P. Shift work, safety and productivity. Occupational Medicine 2003; 53: 95-101

http://occmed.oxfordjournals.org/content/53/2/95.full.pdf+html?sid=a10ee101-4552-4258-8490-8a6d91a2b925

Dumont TM, Rughani AI, Penar PL, Horgan MA, Tranmer BI, Jewell RP. Increased rate of complications on a neurological surgery service after implementation of the Accreditation Council for Graduate Medical Education work-hour restriction: Clinical article. Journal of Neurosurgery, epub ahead of print, December 2, 2011; DOI: 10.3171/2011.9.JNS116

http://thejns.org/doi/pdf/10.3171/2011.9.JNS116

Ganju A, Kahol K, Lee P, Simonian N, Quinn SJ, Ferrara JJ, Batjer HH. The effect of call on neurosurgery residents skills: implication for policy regarding resident call periods. Clinical article. Journal of Neurosurgery, epub ahead of print, December 2, 2011; DOI: 10.3171/2011.9.JNS101406

http://thejns.org/doi/pdf/10.3171/2011.9.JNS101406

Dacey RG. Resident Work Hours (editorial). Journal of Neurosurgery, epub ahead of print, December 2, 2011

Responses Batjer HH, Ganju A. and Dumont TM, Rughani AI.

http://thejns.org/doi/pdf/10.3171/2011.6.JNS11547

Print Unintended Consequences of Restricted Housestaff Hours

January 10, 2012

Verbal Orders

Problems related to verbal orders (including both orders given verbally in face-to-face encounters and those given via telephone) have received much attention from the Joint Commission, ISMP (ISMP 2001), and the Pennsylvania Patient Safety Authority (PPSA 2006) among others. A timely article surveying hospital policies on verbal orders appears in this months issue of The Joint Commission Journal on Quality and Patient Safety (Wakefield 2012). The Wakefield article highlights the extreme variability of verbal order policies across hospitals and even some inconsistencies within hospitals.

While we all have numerous anecdotal examples of adverse events related to verbal orders, there is actually almost no literature looking at verbal order related errors from a larger perspective (Wakefield 2009). We all assume, based on common sense and our own anecdotal experiences, that verbal and telephone orders are more error-prone than written or computerized orders. Yet one of the only systematic studies addressing the issue (West 1994) failed to demonstrate that. In fact, in their study verbal orders were actually less error-prone than written or computerized orders!! They did note, however, that verbal orders became more prone to error as the orders became more complex.

Could the prior study showing that verbal orders are actually less error-prone (West 1994) have been true? There are at least some theoretical and practical reasons that verbal orders might, in fact, be less error-prone. A nurse transcribing orders does not have to decipher the handwriting of a physician on written orders. Similarly, the artifacts often seen with faxed orders (eg. missing decimal points, etc.) dont come into play with verbal orders. And the nurse (or pharmacist) taking the verbal order has the opportunity to clarify the order more easily than with written orders. And the types of orders given verbally tend to be less complex. So maybe, despite our suspicions to the contrary, they could be less error-prone. That, of course, does not mean we should not have policies, procedures and practices for dealing with verbal/telephone orders to make sure that verbal/telephone orders are as safe as possible. Wed all like to think that with the widespread implementation of computerized physician order entry (CPOE) the need for verbal or telephone orders will be eliminated. That, however, is extremely unlikely. There are always likely to be situations in settings such as the OR, ER, ICU, sterile procedure rooms, etc. where a provider is tied up attending to one patients needs and an urgent order is needed on another patient. And even where we make CPOE available remotely to physicians not on site, there will be times when the systems are unavailable.

We all have our own examples of adverse patient events related to errors in the verbal/telephone order process. And the literature is replete with more examples: vitamin K being confused with potassium (Lesar 2003), morphine 2 mg IV misinterpreted as 10 mg IV (Koczmara 2006), 15 mg of hydralazine vs 50 mg IV (Koczmara 2006), Orgaran misinterpreted as argatroban (Koczmara 2006), azithromycin misinterpreted as erythromycin (PPSA 2006), Klonopin misinterpreted for clonidine (PPSA 2006), and multiple other examples.

There are lots of common sense reasons that verbal or telephone orders are vulnerable to error and misinterpretation. Accents and pronunciation are highly variable. There may be static on telephone lines. There may be considerable background noise on either end of a phone conversation (or even face-to-face verbal communication) that impedes communication.

Covering physicians may be relatively unfamiliar with the patient and not have access to the full medical information needed to prescribe medications (or order tests or procedures) safely. And weve previously talked about the chance of patient misidentification when orders are done remotely (see our Patient Safety Tips of the Week June 19, 2007 Unintended Consequences of Technological Solutions and May 20, 2008 CPOE Unintended Consequences - Are Wrong Patient Erors More Common?).

In many cases of verbal orders the ordering provider may be otherwise distracted (eg. they are busy attending to the urgent needs of another patient) or multi-tasking. Worse yet, in some of those scenarios the provider relays the verbal order via yet a third party (Lesar 2003).

And verbal or telephone orders are vulnerable to the same errors we see with look-alike sound-alike (LASA) drugs and dangerous abbreviations in written orders.

An especially vulnerable scenario occurs when a verbal or telephone order is taken by a nurse who not only transcribes the order but must then obtain the medication (eg. from an automated dispensing machine) and administer it to the patient without any other intervening safety steps. That is likely to happen at night in many hospitals when the physician is not in the hospital and pharmacists are unavailable.

About a year ago we were at a small hospital and observed a nurse taking a telephone order. We asked How do you know who that was on the phone?. The response was Were a small hospital. We know all the doctors voices. But during our stay we noted numerous new nurses working, who obviously did not know all the doctors on staff. And it turned out that there was a continuous turnover of both ER physicians and hospitalists, so new voices appeared regularly. Imagine how this issue could be more complex in our larger teaching hospitals and academic medical centers where there is a constant turnover of housestaff. It turns out that very few hospitals have any formal mechanism in their verbal order policies for verification of the prescriber on telephone orders. In the recent Wakefield article (Wakefield 2012) only around 10% of the smaller and community hospitals had any such mechanism, whereas about 64% of academic medical centers had some sort of mechanism to verify the identity of the caller. The latter usually included callbacks to physician offices or use of physician identification numbers.

There have been reports (ISMP 2008) of several instances of fraudulent orders. In one a teenager who worked at the hospital who began answering pages to on-call residents. He issued orders for 6 patients (lab tests, oxygen orders, heparin orders) that were not caught right away because the orders were medically appropriate. Another case involved a friend of a patient with AIDS calling in a verbal order for insulin in apparent attempt to end that patients life. And another case where someone posing as a physician ordered enemas on six different patients.

The ISMP article suggests several things you can do to avoid such fraudulent telephone orders. If you don't recognize the caller, request his or her telephone number, verify it in the medical staff directory, and call the prescriber back to take the order. You can also verify a cell phone number with the prescriber's office staff or answering service. Another identification method is asking for a doctor-specific number such as medical records dictation number, but you'd need a list of these numbers to verify the caller's identity. If the caller doesn't provide a telephone number or you can't verify it, ask the individual to call back to speak to a nursing supervisor.

One key factor in errors related to verbal/telephone orders is the situation in which the orders are given. Frequently they are given in response to a request from nursing. The physician (or other provider to whom the request goes) is often busy with other activities when the request comes in so he/she is multitasking and may be distracted by the other activities. Moreover, he/she typically does not have full access to the patients medical record when the request comes in. So orders are often given without full consideration of the patients other medications, allergies, comorbidities, renal function, lab values, etc. The 2006 Pennsylvania Patient Safety Authority article (PPSA 2006) has very good descriptions of the contextual errors encountered in incidents reported to the Pennsylvania Patient Safety Reporting System.

And any time you are ordering remotely, even if you have access to the electronic medical record, you have the potential to make mistakes (see our Patient Safety Tips of the Week June 19, 2007 Unintended Consequences of Technological Solutions and May 20, 2008 CPOE Unintended Consequences - Are Wrong Patient Erors More Common?). Moreover, the 2-item patient identification rule we use throughout our systems is frequently violated with verbal/telephone orders. How often have you heard a nurse call a physician and say Im calling about Doris Jones, DOB 03/11/56. Well bet never! The call is usually goes Im calling about Mrs. Jones in Room 712B. That, of course, would be unacceptable if we were planning to do a procedure on that patient. But is it any less safe to order medications on that patient? Not really.

The excellent paper from ISMP Canada (Koczmara 2006) also includes a description of how communication is handled in other high risk industries, such as conversations between railroad engineers and railway traffic controllers.

Often the verbal/telephone order is initiated by a request from nursing staff to the provider. In such cases, nurses should use a structured format like SBAR when initiating the request and provide the appropriate context for the request. If the provider is not onsite or does not have access to the patients medical record, it is important that the nurse provide as much information about the patient as is relevant to the request. That may include information about the patients current medications, allergies, medical conditions, lab values, etc.

Read back is the most critical communication technique to be used in the verbal/telephone order process, just as it is in aviation or other high risk industries. In read back the recipient reads back the message as he/she has heard it and interpreted it. The person giving the order then confirms that such recording and interpretation of the order is correct. Because drug names and doses may be prone to misinterpretation, often special techniques must be used. The drug name should be spelled out, for example using military-like terms such as C as in Charlie, A as in Alpha, etc. Certain doses, particularly those including a -teen (such as 16) may be misunderstood as having a -ty (such as 60). So spelling out the dose may be appropriate (for example, one-six).

So here are the important things pertinent to verbal and telephone orders you need to ensure take place via your policies, procedures and practices:

• Define in your policies what constitutes verbal or telephone orders
• Limit verbal or telephone orders to those circumstances in which it is not feasible to have the provider perform written or computer-entry orders (eg. when the provider is otherwise engaged in an urgent procedure elsewhere or is not on site)
• Encourage use of computerized physician order entry (CPOE) whenever a provider has access to the electronic medical record, whether in hospital or remotely
• Some facilities recommend that orders be written and faxed when the provider is outside the facility. However, we have concerns about that, given the problems identified with faxed orders and fact that there are no studies comparing safety of faxed orders vs. verbal or telephone orders.
• Specify who may give verbal or telephone orders
• Specify who may receive verbal or telephone orders
• Consider mechanisms to verify the identity of providers giving telephone orders (see above ISMP recommendations)
• When possible, medication orders should be called in to a pharmacistrather than allowing the possibility of an intermediary person (eg. nurse) mistranscribing or otherwise miscommunicating the order to pharmacy
• Where possible (and especially when high risk medications like insulin, anticoagulant, or narcotics are involved) have a second authorized person listen into confirm the verbal or telephone order
• Do not allow verbal or telephone orders for certain high risk medications, such as cancer chemotherapy agents
• Some organizations also do not allow verbal/telephone orders for non-formulary medications (but this restriction can be problematic in some facilities)
• If you usually require the ordering provider include a formula (eg. in pediatric dosing) when doing written or computerized order entry, have him/her also include the formula when doing verbal or telephone orders
• Always do read backto the ordering provider to confirm the orders are correct
• When giving verbal or telephone orders or doing read back when receiving such orders, always spell out doses (eg. sixteen, one six so that 16 is not misinterpreted as 60)
• Especially when the drug names are relatively unfamiliar or are one of the known sound alike drug pairs, the ordering provider or the recipient during read back should spell out the drug nameusing C as in Charlie, A as in Alpha, etc.
• Make sure the order does not include any of the do not use abbreviations or other dangerous practices (like trailing zeroes) in your dangerous abbreviations policy (and we strongly recommend ISMPs dangerous abbreviation list rather than the much briefer list from the Joint Commission that most hospitals use)
• Including the indication for the drugmay help prevent ordering drugs that are not appropriate for the patient
• Try to provide contextfor the ordering provider (allergies, lab values, other medications, medical conditions, etc.)
• The recipient should sign, date and time the order and indicate that it was a verbal order or telephone order
• Ensure verbal or telephone orders are promptly signed by the ordering provider
• Audit your facilitys use of verbal and telephone orders (frequency, appropriateness, errors, etc.), provide feedback to all staff, and include this in your quality improvement program

BTW, texted orders are not acceptable under any circumstance (Joint Commission 2011)!

In addition to the questions addressed in the recent Wakefield article (Wakefield 2012) about verbal order policies, the 2006 PPSA article (PPSA 2006) has a Verbal Orders Toolkit, a checklist for assessing verbal orders policies, a sample policy for verbal/telephone orders, and an audit tool to use in your quality improvement activities.

And dont just use some of these techniques for verbal/telephone orders. Some types of orders we often fail to consider being verbal are really in the same category. A very interesting study (Doyle 2006) on an academic pediatric unit assessed mediation errors. Typically orders were discussed on morning rounds and the interns later entered the orders. They found over 9% of all orders had errors (most often with doses but sometimes with other errors). So they changed their process so that the orders were input while the team was still rounding in the patient rooms and read back was used. The error rate after implementation of the new process dropped to zero!

References:

Institute for Safe Medication Practices (ISMP). Instilling a measure of safety into those whispering down the lane verbal orders. Medication Safety Alert! Acute Care Edition 2001; 6(2): 1-2

http://search.ismp.org/cgi-bin/hits.pl?in=517791&fh=80&ph=1&tk=ujuCkqr juCkqrKX iCeuCX iCeuCKX iCeuC&su=okii:nAACCC.PFL:.brqApVCFwViiVrFA?WJiVW?rVA?riPWwVFA20010124.?F:&qy=miW:I-e L:&W:Q&pd=1

Pennsylvania Patient Safety Authority (PPSA). Improving the Safety of Telephone or Verbal Orders. PA PSRS Patient Saf Advis 2006; 3(2): 1,3-7

http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2006/Jun3(2)/Pages/01b.aspx

Wakefield DS, Wakefield BJ, Despins L, et al. A Review of Verbal Orders Policies in Acute Care Hospitals. The Joint Commission Journal on Quality and Patient Safety 2012; 38(1): 24-33

http://www.ingentaconnect.com/content/jcaho/jcjqs/2012/00000038/00000001/art00004

Wakefield DS, Wakefield BJ. Are verbal orders a threat to patient safety? BMJ Qual Saf Health Care 2009; 18: 165-168

http://qualitysafety.bmj.com/content/18/3/165.full.pdf+html

West DW, Levine S, Magram G, et al. Pediatric Medication Order Error Rates Related to the Mode of Order Transmission. Arch Pediatr Adolesc Med. 1994; 148(12): 1322-1326

http://archpedi.ama-assn.org/cgi/content/abstract/148/12/1322

Lessar TS. 40 of K. AHRQ Web M&M 2003; November 2003

http://webmm.ahrq.gov/case.aspx?caseID=36

Koczmara C, Jelincic V, Perri D. Communication of medication orders by telephone Writing it right. CACCN 2006; 17(1): 20-24 Spring 2006

http://www.ismp-canada.org/download/caccn/CACCN-Spring06.pdf

Institute for Safe Medication Practices (ISMP). Telephone orders. How do you know the caller is for real? ISMP Nurse Advise-ERR 2008; 6(7): 2 (July 2008)

http://www.ismp.org/newsletters/nursing/Issues/NurseAdviseERR200807.pdf

The Joint Commission. Standards FAQ Details. Texting Orders. November 10, 2011.

http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFAQId=401&ProgramId=39

Doyle E. To prevent ordering errors, one hospital is bringing read backs to the bedside. Cincinnati Childrens Hospital Medical Center found that the technique cut down on communication problems during rounds. Todays Hospitalist 2006; October 2006

http://todayshospitalist.com/index.php?b=articles_read&cnt=106

Print Verbal Orders

January 17, 2012

Delirium and Contact Isolation

In our March 25, 2008 Patient Safety Tip of the Week More on MRSA we noted that there are unintended consequences of contact isolation. Kirkland and Weinstein (Kirkland 1999) found that healthcare workers who treated patients in contact isolation entered their rooms less frequently and had significantly less direct contact with them. Saint et al. (2003) found that attending physicians in two teaching hospitals were about half as likely to examine patients in contact isolation. Another study (Stelfox et al. 2003) showed that isolated patients are twice as the likely as control patients to suffer an adverse event during hospitalization. The difference was primarily due to preventable adverse events and included event such as falls, decubiti, and fluid/electrolyte disorders. In fact, the latter events were 8 times more likely in isolated patients. They also had a cohort of congestive heart failure patients in isolation and these patients were much less likely to have certain interventions and evidence-based care than a control group of congestive heart failure patients. And we have all seen that patients in contact isolation often do not get services such as active rehabilitation that they might get were they not in isolation. A review of the literature (Morgan 2009) found 15 studies relating to adverse outcomes of contact isolation and identified these in four main themes: less patient-healthcare worker contact, changes in systems of care that produce delays and more noninfectious adverse events, increased symptoms of depression and anxiety, and decreased patient satisfaction with care.

The University of Maryland group (Morgan 2011) had previously looked at the impact of contact isolation on quality core measures. They found that performance on several core measures for pneumonia (typically those measures that take place after the emergency room) had lower adherence though those for CHF, AMI and SCIP were not impacted. Of note, some of the measures that typically require spending more time with the patient (smoking cessation counseling, flu and pneumonia vaccination) were the measures that had lower adherence. Smoking cessation counseling was also less frequent in the CHF and AMI cohorts that were in contact isolation. A good slide presentation by Daniel Morgan, M.D., author of several of the University of Maryland studies noted above, is also available online (Morgan 2011 slides).

Now a new study from the University of Maryland (Day 2012) found that delirium was 75% more common in patients who are put into contact isolation during admission (as opposed to those placed in contact isolation at the time of admission). Though the study was retrospective and utilized administrative data, from which accurate diagnosis of delirium is difficult, the results are nevertheless impressive. Because delirium is typically undercoded in administrative data the authors used a proxy that also included unexplained use of antipsychotic drugs or use of physical restraints, measures that have been validated as better than ICD-9 coding for delirium alone. Logically, wed say that patients put in isolation after admission likely had developed a hospital-acquired infection and are likely sicker so it is not surprising that delirium occurs more frequently in this population. To take that into consideration, the authors adjusted for comorbid conditions, ICU status, length of hospitalization, age, sex, etc. but there may still have been other confounding variables. Nevertheless, it certainly appears that we can add delirium as one of the untoward events associated with contact isolation.

Whether there is a causal relationship between contact isolation and delirium or not, the implications are clear. We must be extremely vigilant for delirium in patients we put in contact isolation and put in place the multimodality measures we use to prevent delirium or to help manage it once it has occurred. In many of our prior columns on delirium we have mentioned multimodality intervention programs that were promising in reducing the incidence or severity of delirium in hospitalized patients (see our Patient Safety Tips of the Week for October 21, 2008 Preventing Delirium, October 14, 2009 Managing Delirium, February 10, 2009 Sedation in the ICU: The Dexmedetomidine Study, March 31, 2009 Screening Patients for Risk of Delirium, January 26, 2010 Preventing Postoperative Delirium, August 31, 2010 Postoperative Delirium and our September 2011 Whats New in the Patient Safety World column Modified HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery).

One of those interventions is HELP, the Hospital Elder Life Program (see our October 21, 2008 Patient Safety Tip of the Week Preventing Delirium). Inouye et al (Inouye 1999) had shown in a landmark study of 852 medical patients aged 70 and older that management of 6 risk factors was able to reduce the incidence of delirium from 15% to 9.9%. The number of days with delirium and the number of episodes of delirium was also reduced by the intervention. The intervention targeted cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. This was strong evidence that a multicomponent intervention could be of benefit in reducing delirium.

Our August 31, 2010 Patient Safety Tip of the Week Postoperative Delirium had extensive recommendations from the 662-page guidance from NICE DELIRIUM: diagnosis, prevention and management that is probably the most comprehensive single-source document available on all aspects of delirium.

Some of those interventions are particularly difficult to implement when patients are in contact isolation. Those include things that promote familiarity and consistency, reassurance, reorientation, and others. Frequent assessment of hydration status and looking for potential sources of pain are often overlooked when patients are in contact isolation. Having family and friends have frequent contact with delirious patients is severely limited with contact precautions. Spending time using verbal or non-verbal de-escalation techniques with an agitated patient may be difficult when the patient is in contact isolation. And having a bunch of masked men sticking their heads into the room can be very distressing for such patients! This situation probably calls for interventions such as recording reassuring messages from loved ones for audio playback in the patients room.

And dont forget another risk seen in the delirious patient that is potentially more dangerous when in contact isolation the risk of suicide (see our Patient Safety Tips of the Week January 6, 2009 Preventing Inpatient Suicides and February 9, 2010 More on Preventing Inpatient Suicides and our December 2010 Whats New in the Patient Safety World column Joint Commission Sentinel Event Alert on Suicide Risk Outside Psych Units). There have been multiple cases of patients with delirium jumping from windows on med/surg inpatient units and ICUs. So make sure your contact isolation rooms have tamper-proof windows even if you have video surveillance into those rooms. Similarly, make sure there are no chemicals or other toxic substances that a delirious patient might get into while in a contact isolation room.

All the potential unintended consequences of contact isolation need to be closely monitored for and every attempt should be made to ensure they do not happen. But now we need to add assessment, prevention and management of delirium to the list of things we must consider when we put a patient in contact isolation.

References:

Kirkland KB, Weinstein JM. Adverse effects of contact isolation. The Lancet 1999; 354: 1177-1178 http://www.thelancet.com/journals/lancet/article/PIIS0140673699041963/abstract

Saint S, Higgins LA, Nallamothu BK, Chenoweth C. Do physicians examine patients in contact isolation less frequently? A brief report. Am J Infect Control 2003; 31: 354-356 http://www.ajicjournal.org/article/S0196-6553(02)48250-8/abstract

Stelfox HT, Bates DW, Redelmeier DA. Safety of Patients Isolated for Infection Control. JAMA. 2003;290:1899-1905

http://jama.ama-assn.org/cgi/content/abstract/290/14/1899 (abstract)

http://jama.ama-assn.org/cgi/reprint/290/14/1899 (pdf)

Morgan DJ, Diekema DJ, Sepkowitz K, Perencevich EN. Adverse outcomes associated with contact precautions: A review of the literature. Am J Infect Control 2009; 37(2): 8593

http://www.ajicjournal.org/article/S0196-6553(08)00685-8/abstract

Morgan DJ, Day HR, Harris AD, et al. The Impact of Contact Isolation on the Quality of Inpatient Hospital Care. PLoS One. 2011; 6(7): e22190

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3141007/

Morgan D. Adverse Outcomes and Contact Precautions (slide presentation). 6/8/2011

http://www.sf2h.net/congres-SF2H-productions-2011/the-global-threat-of-multidrug-resistant-microorganisms-in-healthcare_adverse-outcomes-and-contact-precautions.pdf

Day HR, Perencevich EN, Harris AD, et al. Association Between Contact Precautions and Delirium at a Tertiary Care Center. Infection Control and Hospital Epidemiology 2012; 33(1): 34-39

http://www.jstor.org/pss/10.1086/663340

Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM. A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients. NEJM 1999; 340: 669-676

http://content.nejm.org/cgi/reprint/340/9/669.pdf

NICE (National Institute for Clinical Excellence). National National Clinical Guideline Centre. DELIRIUM: diagnosis, prevention and management. Clinical Guideline 103. July 2010

full guidance:

http://www.nice.org.uk/nicemedia/live/13060/49908/49908.pdf

NICE (National Institute for Clinical Excellence). National National Clinical Guideline Centre. DELIRIUM: diagnosis, prevention and management. Clinical Guideline 103. July 2010

summary document:

http://www.nice.org.uk/nicemedia/live/13060/49909/49909.pdf

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January 24, 2012

Patient Safety in Ambulatory Care

Were always looking for studies on patient safety in the office or ambulatory setting but weve always been bothered by the relative paucity of high quality studies in the literature on patient safety issues and interventions in those settings. Now a special committee brought together by the AMA Center for Patient Safety has basically come to the same conclusion: research and initiatives in ambulatory safety have been remarkably limited over the past decade. That committee has summarized all the patient safety research done over the past decade in the ambulatory setting in a 192-page monograph (Lorincz 2011).

The new monograph begins with a good description of how features of care in the ambulatory setting differ significantly from that in the inpatient setting. That includes more diversity of patient population, wider range of conditions and severity of illness, more logistical and information challenges, more temporally and spatially dispersed care, and different infrastructures in the ambulatory setting. But importantly the role of the patient differs considerably. Patients themselves have a much greater role in their own care than they typically do while an inpatient.

They go on to discuss various definitions and taxonomies of errors, adverse events, harm, injury, etc., classifications of severity and potential preventability. They conclude that the taxonomies are not consistent or standardized. In particular, they noted that most studies on errors in ambulatory care do not distinguish between those that cause harm and those that do not. Also, most studies have been done in primary care settings and there is little data on other settings or across settings. And, while they note the potential of electronic medical records to improve safety, they acknowledge that EHRs may introduce errors of their own and that their net effect on patient safety is not yet known. It notes that current EHRs often encourage cutting and pasting and automatic behavior like filling out checklists and templates that tend to take away from the more thoughtful reasoning process that should be part of the history taking and physical examination. They also discuss clumsy user interfaces and fact that computers sometimes fail to fit into the usual flow of work and may also cause information overload and alert fatigue.

The best-studied area of patient safety in ambulatory care is medication safety. They note that there remains a need for large-scale studies on the incidence and types of ambulatory medication errors, adverse drug events (ADEs), potential ADEs, ameliorable ADEs, and the harms they cause. They cite studies on high-risk medications and patient risk factors for ADEs and errors (eg. advanced age, impaired renal function, polypharmacy, etc.) and the importance of medication reconciliation. They note that some medication errors are under control of the ambulatory practice but others may be only indirectly under their control (eg. dispensing errors, nonadherence, etc.).

Diagnostic error is the next major category. They discuss the difficulties in even identifying diagnostic errors and note that much of the research has utilized malpractice claims, which certainly underrepresent the scope of the problem. Their section on the risk factors for diagnostic error is excellent and covers most of the factors we discussed in our Patient Safety Tips of the Week for September 28, 2010 Diagnostic Error and November 29, 2011 More on Diagnostic Error plus our multiple columns on failure to follow up on tests ordered. They note a dearth of research on interventions to prevent diagnostic error and note that approaches taken, including using IT and decision support tools or cognition-focused approaches, have yet to demonstrate significant evidence of effectiveness. Note that another paper just published (Singh 2012) reviewed 6 tested interventions and 37 suggestions for possible interventions to reduce diagnostic error and found that empirical studies, while somewhat positive, lacked rigorous methodology. They also highlighted the need for improved research on interventions to reduce diagnostic error.

A section in the monograph on office-based surgery and anesthesia notes that adverse events tend to occur in elective cosmetic procedures more often than in medically indicated procedures and that a disproportionate number of cases with patient harm involved general anesthesia. Much of the research in this area comes from Florida, which has had more oversight of office-based surgery than other states. Since this publication, there has been another review of complications of office-based surgery reported in Florida and Alabama (Starling 2011). It confirms that cosmetic procedures and those done under general anesthesia tend to be more problematic but that certification by independent accrediting bodies and surgeon board certification did not seem to make a difference.

There is a whole section on the patients role in patient safety. This includes patient adherence to advice or directions, follow up with appointments, health literacy, and communication issues.

Just as we see in RCAs of hospital adverse events, communication errors are involved in a great many adverse events on the ambulatory side. Problems at transitions of care, including issues with discharge summaries and test results pending at the time of discharge, have had a fair amount of research. Highlighted are problems in communication between primary care physicians and specialists and discontinuity that takes place at discharge or other transitions of care. The problem of communication of abnormal tests results is again stressed. Included under communication errors is the phenomenon of alert fatigue that we see with EHRs and decision support systems.

While the overall conclusions of this monograph may seem discouraging, this is a very well-researched document and incredibly well-referenced. It contains a great annotated bibliography of published research on patient safety in the ambulatory setting. It certainly highlights the need for us to focus our energies and resources on patient safety issues in ambulatory care.

The report obviously calls for greater research into the prevalence and nature of errors and patient safety issues in the ambulatory setting and focused research on interventions to mitigate those problems. Note that the NQFs recently updated list of serious reportable events has begun to include events occurring in the ambulatory setting.

One area not really discussed in the AMA monograph is infection control in the office setting. Fortunately, the CDC recently published a helpful guide to infection prevention for outpatient settings (CDC 2011).

There are a few validated tools out there for assessing patient safety in primary care offices. The best known are the MGMA Physician Practice Patient Safety Assessment and the European Practice Assessment tool. The latter was shown in a recent article to lead to improvements in complaint management, analysis of critical incidents, and quality development/quality policy in primary care practices (Szecsenyi 2011).

We reviewed our site and were actually pleasantly surprised at how many columns weve done focusing on topics pertinent to patient safety in the ambulatory setting.

Some of our prior Patient Safety Tips of the Week on diagnostic error:

• September 28, 2010 Diagnostic Error
• May 29, 2008 If You Do RCAs or Design Healthcare ProcessesRead Gary Kleins Work)
• August 12, 2008 Jerome Groopmans How Doctors Think)
• August 10, 2010 Its Not Always About The Evidence
• November 29, 2011 Patient Safety Tip of the Week More on Diagnostic Error

Some of our prior Patient Safety Tips of the Week on medication safety in ambulatory care:

• April 12, 2011 Medication Issues in the Ambulatory Setting
• August 2, 2011 Hazards of ePrescribing

Some of our prior columns on communicating significant results:

• May 1, 2007 The Missed Cancer
• February 12, 2008 More on Tracking Test Results
• October 13, 2009 Slipping Through the Cracks
• July 2009 Failure to Inform Patients of Clinically Significant Outpatient Test Results
• March 9, 2010 Communication of Urgent or Unexpected Radiology Findings
• March 1, 2011 Tests Pending at Discharge
• June 14, 2011 Failure to Follow Up

Some of our prior columns on wrong site procedures in the ambulatory setting:

• June 6, 2011 Timeouts Outside the OR

References:

Lorincz CY, Drazen E, Sokol PE, Neerukonda KV, Metzger J, Toepp MC, Maul L, Classen DC, Wynia MK. Research in Ambulatory Patient Safety 20002010: A 10-Year Review. American Medical Association, Chicago IL 2011

http://www.ama-assn.org/resources/doc/ethics/research-ambulatory-patient-safety.pdf

Singh H, Graber ML, Kissam SM, et al. System-related interventions to reduce diagnostic errors: a narrative review. BMJ Qual Saf 2012; 21: 160-170

http://qualitysafety.bmj.com/content/21/2/160.abstract

Starling J, Thosani MK, Coldiron BM. Determining the safety of office-based surgery: what 10 years of Florida data and 6 years of Alabama data reveal. Dermatol Surg. 2011; Oct 19; [Epub ahead of print].

http://onlinelibrary.wiley.com/doi/10.1111/j.1524-4725.2011.02206.x/abstract

NQF (National Quality Forum). Serious Reportable Events In Healthcare2011 Update: A CONSENSUS REPORT. 2011

http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=69573

CDC (Centers for Disease Control and Prevention). Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care. May 2011

http://www.cdc.gov/HAI/settings/outpatient/outpatient-care-guidelines.html

MGMA. Physician Practice Patient Safety Assessment (PPPSA), a self-assessment tool.

http://www.mgma.com/pppsahome/

European Practice Assessment Program.

http://www.epa-qm.de/epa/upload/CONTENT/Download/epa_flyer_en_11-11_web.pdf

Szecsenyi J, Campbell S, Broge B, et al. Effectiveness of a quality-improvement program in improving management of primary care practices. CMAJ 2011; 183: E1326-E1333

http://www.cmaj.ca/content/183/18/E1326.full.pdf+html

Print Patient Safety in Ambulatory Care

January 31, 2012

Medication Safety in the OR

The OR is a setting at risk for medication errors for a variety of reasons (and note that when we use the term OR here we also include all the other areas collectively making up the perioperative setting). These reasons include the complexity of the cases, the increasing number of comorbidities, the pace of activity, the distractions and interruptions, the changing of personnel at various times, hand-printed labels that can get smudged, multiple patient IV lines and catheters of various types, and fact that many high-alert drugs and look-alike/sound-alike (LASA) drugs are used in the OR. In addition, many of the safety checks and balances we use in other parts of the hospital are often absent in the OR. We often have one person (the anesthesiologist) obtaining, mixing or preparing, administering, documenting in the record, and monitoring the effects of the medications. So the double checks we use elsewhere (eg. by pharmacists or nurses or the patient himself) are often not used in the OR. Similarly, many ORs do not yet have IT integration with the hospitals other IT systems so safety measures such as bedside medication verification (BMV aka barcoding) may not be usable in the OR. In addition, the physical constraints of the OR often result in syringes, medication vials, basins with fluids, etc. being in a position that someone could inadvertently use the wrong item in the midst of a rapidly progressing situation. Clutter (ever looked at an anesthesiologists work station!) is often a contributing factor to errors. Add to that the multi-tasking that the anesthesiologist must do and you can see how our systems make this setting so potentially prone to errors.

In fact, medication errors do occur frequently in the OR. In malpractice claims against anesthesiologists, medication errors are considered the most preventable and tend to lead to higher payouts than other types of claims.

This month two new valuable resources on medication errors in the OR became available: a medication safety video from the Anesthesia Patient Safety Foundation (APSF 2012) and the 2012 edition of the Perioperative Standards and Recommended Practice from the Association of periOperative Registered Nurses (AORN 2012).

The new AORN standards address medication safety at each of the phases of medication use (procuring, prescribing, transcribing, dispensing, administering, monitoring, and disposal). They really focus on a multidisciplinary approach and note that monitoring compliance with medication safety practices is critical, yet seldom done in a rigorous fashion in most ORs,

One of their key new recommendations is not to use multidose vials. While most facilities use multidose vials, primarily as a cost-saving measure, they give rise to two problems. First, they introduce the risk of cross-contamination. Second, they increase the risk that a patient may be given too much of a medication. Another recommendation that has caused some controversy is to puncture intravenous solution containers as close to time of use as possible. In some ORs, to improve efficiency, multiple medications and solutions that are expected to be used are prepared in advance. While that may improve efficiency the tradeoff is on the safety side (see our September 15, 2009 Patient Safety Tip of the Week ETTOs: Efficiency-Thoroughness Trade-Offs). They also stress the importance of maintaining sterility. That is important not only when transferring newly prepared medications to the sterile field but also when one syringe might be used for incremental injections. Another key recommendation is to include a pharmacist in perioperative medication management, if not physically during actual cases at least being involved in the planning and oversight of OR medication safety programs.

The APSF medication safety video (APSF 2012) is about 15 minutes long and includes some clips you may have previously seen in ISMP videos highlighting testimonials from some providers at the sharp end of unfortunate medication incidents in the OR. It is largely based on STPC paradigm published in their Spring 2010 Newsletter (APSF 2010). STPC stands for:

• Standardization
• Technology
• Pharmacy/Prefilled/Premixed
• Culture

The video begins with the oft-quoted statistic that a significant medication error will occur in one of every 133 cases where anesthesia is administered and that 4% of closed malpractice claims for anesthesiologists involve medication errors. It points out many of the high-risk drugs used in the OR. That includes not only the usual suspects we see in other parts of the hospital (eg. opiates, anticoagulants, insulin, benzodiazepines) but also drugs more unique to the OR such as neuromuscular blocking agents (NMBAs) and epinephrine or vasopressors. They point out a variety of the common errors in the OR, including syringe swaps, labeling errors, substitution errors, and injection into wrong ports. A full quarter of the errors involved in the claims involve substituting the wrong drug for an intended drug (eg. giving a NMBA instead of epinephrine or vice versa) and almost a third are due to giving incorrect doses.

Recurrent themes in OR cases with medication errors are lack of standardization and lack of protocols in the setting of production pressures and other distractions. Drug labeling errors and syringe swaps are often implicated as causes of OR medication errors.

The video highlights the importance of labeling all medications and syringes and reading those labels before administering the drugs. They also talk about making drug labels distinctive. They mention color-coding of labels to help recognition of high-alert drugs (though this remains somewhat controversial where statewide or national standards for color-coding have not been established). But they note that APSF says this is not enough and has failed to prevent medication errors so more is needed.

Standardization is a fundamental patient safety concept. This applies not only to things like drug dosages and drug concentrations but also to drug preparation, workplace design, equipment models, and clinical protocols. They describe all the Joint Commisssion requirements for appropriate labeling for all drugs and syringes (and dont forget you need to also label any liquids you put in sterile containers or basins on the sterile field). Having drugs in standardized concentrations prevents someone from inadvertently giving a patient a dose that is 100- or 1000-times higher than the intended dose. That is especially important with high-alert drugs like epinephrine, phenylephrine, heparin, etc. Lots of anesthesiologists like to have their room in the OR and not have to switch from room to room. If you standardize the workspace in each room that becomes less a barrier at the same time it helps prevent errors. Admittedly, the medication needs are quite different for cardiac and intracranial cases than, say, for orthopedic cases. So sometimes the standardized items need to be standardized by case type. If you dont have some of the technology safeguards mentioned below, consider requiring verification of high-risk medications by a second person prior to administration. And use read-back and hear-back to facilitate understanding in all your OR communications.

Pharmacy/Premixed/Prefilled refers not only to having pharmacists involved in your program but also to using premixed solutions and prefilled syringes so that your anesthesiologist is not trying to prepare those things while attending to multiple other things. Let someone else do that preparation, whether it is a pharmacist in an OR satellite pharmacy or pre-packaged drugs and solutions purchased from commercial vendors. As in the AORN resource, they strongly recommend a pharmacist being physically part of the OR but, if that is not feasible, at least being involved in the planning and oversight of OR medication safety programs.

Technology is a key component of patient safety systems in preventing medication errors in most other parts of the hospital and should also be used in the OR. Barcoding (BMV) is a critical component of that but feedback and clinical decision support tools are also important. Ideally, your OR computer systems should be integrated with your hospital electronic health record so that information exchange is facilitated in both directions. Documentation of drug administration on EHRs theoretically should improve efficiency, though the clunkiness of some current user interfaces may actually detract from OR efficiencies. Undoubtedly these will improve in the future. The video optimistically looks to voice recognition technology to help with that efficiency. And use of standardized infusion pumps with standardized drug libraries (smart pumps) are used in other parts of the hospital and should be used in the OR and perioperative area as well. Make sure that the pumps and the concentrations of the drugs used are standardized so that these pumps can go with the patient when they go from the PACU to the ICU, etc.

Culture, of course, refers to developing the culture characteristics that are hallmarks of the culture of patient safety. This includes adoption of a Just Culture approach, recognition that most bad outcomes typically involve multiple system errors rather just human error, having a non-punitive system for reporting errors and near-misses, and learning from adverse events or near-misses and sharing those lessons learned. In the APSF video, Michael Cohen from ISMP stresses that good people make errors and points out that there is usually a cascade of multiple errors or contributing factors in every case where there is a bad outcome. Focusing on fixing systems rather than people leads to more success in safety in any industry (not to mention that systems are easier to fix than people!).

Changing some aspects of culture can be difficult, particularly since so many anesthesiologists have prided themselves in their autonomy and independence and abilities to think fast and improvise. So getting them to buy into standardization, use of protocols, checklists, etc. may be met with some resistance. Using the technique of stories, not statistics (see our December 2009 Whats New in the Patient Safety World column Stories, Not Statistics) may be helpful. The APSF video does include reference to the well-known unfortunate case in which a young boy died after inadvertent injection of concentrated epinephrine. In the consensus conference that led to development of the STPC paradigm, multiple speakers provided such real-life examples of errors that led to deaths or other serious outcomes. Those included cases of injection of wrong drugs or injection of drugs into the wrong (eg. epidural) catheters or other injection ports. Using such stories or real-life examples, particularly if you can also tell the story from the point of the second victim (the provider involved) is a very useful way to get buy-in from not just your anesthesiologists, but every one involved in perioperative care (including administrators and especially CFOs!).

The APSF video should be part of mandatory training for all your personnel involved in perioperative care. Its short but to the point and makes a compelling case for the need to change our ways and our culture in the OR. That video and the Spring 2010 APSF Newsletter plus the new AORN standards are very valuable resources to help you ensure medication safety in your OR and perioperative environment. For those of you who happen to be in Canada, ISMP Canada has a collaborative that uses their Operating Room Medication Safety Checklist (ISMP Canada 2009), another very valuable tool. At least the last time we checked its use is still restricted to the Canadian hospitals participating in the collaborative but we expect it will be further refined and eventually made available to everyone.

If you havent yet adopted the recommendations from these resources, we expect that you will soon. But dont forget the other critical piece: you need to audit and monitor compliance with any of these safety interventions you put in place. Make it part of your Patient Safety Walk Rounds, part of your regular OR Committee agenda and part of your Medication Safety Committee or Patient Safety Committee agenda.

References:

APSF (Anesthesia Patient Safety Foundation). Medication Safety In The Operating Room: Time For A New Paradigm (video). 2012

http://apsf.org/resources_video2.php

AORN (Association of periOperative Registered Nurses). Perioperative Standards and Recommended Practice. 2012

http://www.aorn.org/Books_and_Publications/Perioperative_Standards_and_Recommended_Practices/Perioperative_Standards_and_Recommended_Practices.aspx

APSF (Anesthesia Patient Safety Foundation). APSF Newsletter. Spring 2010

http://apsf.org/newsletters/pdf/spring_2010.pdf

ISMP Canada. Operating Room Medication Safety Checklist. Version 2. 2009

https://www.ismp-canada.org/operatingroomchecklist/index.php

Print Medication Safety in the OR

February 7, 2012

Another Neuromuscular Blocking Agent Incident

In our January 31, 2012 Patient Safety Tip of the Week Medication Safety in the OR we mentioned neuromuscular blocking agents (NMBAs) as being high-alert medications in the OR. Most hospitals keep NMBAs on their list of high-alert medications for the entire hospital but many took action steps years ago after an ISMP Safety Alert (ISMP 2005) to limit access to these drugs outside the OR and have not paid as much attention to them since. Its been almost 5 years since we first did a column on NMBA risks (see our July 31, 2007 Patient Safety Tip of the Week Dangers of Neuromuscular Blocking Agents and our November 2007 Whats New in the Patient Safety World column FMEA Related to Neuromuscular Blocking Agents). Other than an excellent review by the Pennsylvania Patient Safety Authority in 2009 (PPSA 2009) the news and literature have been relatively quiet on NMBAs.

But a recent incident in a hospital in Florida (ABC News 2011) has rekindled concern about NMBAs. In the Florida case an order was written for 20 mg famotidine IV but a nurse gave by mistake 20 mg IV pancuronium. The patient subsequently became paralyzed and had a respiratory arrest. Though resuscitated, he suffered severe brain damage and eventually died. We dont know the details of the case but apparently some safety steps such as barcoding verification, independent double checks, and monitoring were not done. In addition, the drug was available on the unit on which it was administered and perhaps should not have been (see below for recommendations about restricting access for these drugs to only certain units). The hospital apparently has subsequently removed the drugs from all areas other than the OR.

The PPSA review (PPSA 2009) noted that they had received 154 reports dealing with NMBAs over a 5-year period. Most importantly, the percentage of cases where patient harm occurred was nearly 13 times higher than the percentage of harm seen in their overall drug-related incident database. Harm came to the patient in over 9% of cases, a figure similar to that found in a 2006 report from the MedMarx database. The vast majority of the PPSA reports involved either the wrong medication being given, i.e. an NMBA was given rather than a different intended drug, or an incorrect dose of an NMBA. Of course, the former is the most serious category because this usually involved patients who were not being mechanically ventilated and were at the greatest risk for respiratory arrest from NMBA administration.

But again stories, not statistics! All the above statistics wont help you remember the importance of safety regarding NMBAs. But a few stories will!

A patient is in need of an emergency CT scan one night. There is no nurse available in the radiology suite so the ER resident accompanies the patient for the CT scan. The patient is in need of sedation for the scan and the resident inadvertently administers vecuronium IV to the patient, resulting in respiratory arrest necessitating rescuscitation.

A patient is undergoing a surgical procedure in the OR and the physician asks the CRNA to give IV antibiotic. The CRNA reaches into the anesthesia medicine drawer, where all the medications are kept, and pulls out a vial of vecuronium thinking it was the antibiotic and adds it to the IV bag. Shortly thereafter its noted that the patient is not breathing well and she requires intubation (PPSA 2009).

A syringe filled with an NMBA is not properly disposed of. It is later mistaken for a syringe full of normal saline and used as a saline flush on an infant who suffered a respiratory arrest as a result (ISMP 2005).

Seven infants receive subcutaneous doses of atracurium instead of hepatitis B vaccine. All developed respiratory distress. Five recovered but one suffered permanent injury and one died. An anesthesiologist had placed a vial of atracurium in the refrigerator of the nursery that had a similar appearance to vaccine vials (Koczmara 2007).

Obviously, the biggest risk of NMBAs is in patients who are not being mechanically ventilated. There are a couple circumstances where NMBAs may be inadvertently ordered and given in non-ventilated patients. We previously mentioned a case (see our June 19, 2007 Patient Safety Tip of the Week Unintended Consequences of Technological Solutions) where an unintended consequence of CPOE led to inadvertent administration of a neuromuscular blocking agent to a patient who was not being mechanically ventilated (ISMP 2007). In that case the physician was ordering from a remote site and inadvertently entered orders on the wrong patient. The other circumstance is when a patient in an ICU is extubated and weaned from a respirator and transferred to a regular floor and someone writes continue all previous orders not recognizing that such might include orders for NMBAs in a now unventilated patient.

Look-alike/sound-alike (LASA) issues are root causes in many NMBA incidents. Very often the vials closely resemble vials of other more common medications and solutions. How and where drugs are stored is an important contributing factor in many of the adverse NMBA incidents. Many of the reported incidents involving NMBAs being confused with another intended drug have involved NMBAs that were stored in refrigerators, especially in refrigerators where such are not usually stored. The vials have been confused with vials of other substances like normal saline, heparin, and vaccines. The 2005 ISMP alert (ISMP 2005) had several examples. In one instance an anesthesiologist put a vial of an NMBA in a refrigerator on a different unit that does not usually stock NMBAs and the vial was mistaken for hepatitis B vaccine and was inadvertently given to seven infants. In others, vials of NMBAs looked similar to vials of either vaccines or the diluents used with those vaccines, resulting in multiple patients being exposed to the NMBAs.

The sound-alike issues are also problematic. Norcuron (vecuronium) has been mistaken for Narcan, vecuronium for vancomycin, atracurium for Ativan, etc. In other cases, look-alike packaging has been a major contributing factor.

Limiting access to NMBAs is arguably the most import intervention to prevent incidents. Many hospitals restrict them to the OR and pharmacy. In those areas where they might be needed emergently (eg. in the ER or ICU where they may be needed for emergent intubations) the drugs can be sequestered or sealed in the intubation kits so that they are available only at the time of intubation.

But while restricting access is important, keep in mind those incidents above where NMBAs popped up in areas where they were not supposed to be. So there clearly must be other safety measures taken and you need to be ever vigilant to items showing up where they are not supposed to be.

Storage of NMBAs in automated dispensing machines can be especially problematic. Probably most important is only storing them in areas where they are clearly needed. Where needed, they should be kept in single access drawers. But there needs to be a special warning that the NMBA should not be used in patients who are not intubated/mechanically ventilated. Such a message could be delivered in those automated systems having the capability of messaging when an NMBA is selected for removal from a drawer. Similarly, the type of CPOE error noted earlier might be avoided by programming in an alert ensuring the patient is intubated/ventilated when the physician enters an order for an NMBA.

Most important are warning labels for vials, syringes, bags, or storage boxes containing NMBAs. Both ISMP and the PPSA recommend using fluorescent red labels that state Warning: Paralyzing Agent Causes Respiratory Arrest.

The ISMP Canada review (Koczmara 2007) notes that a form of confirmation bias often is a contributing factor. Specifically, because the vials and labels may look similar to those of the expected medication, we tend to see what we expect to see rather than what we actually see. The phenomenon is also sometimes known as inattentional blindness (ISMP 2009).

Part of your medication safety program should include education and communication about NMBAs. They should never be referred to as muscle relaxants and should never be allowed to be ordered on a prn basis (PPSA 2009). Similarly, the phrase renew all previous orders should never be allowed. Rather, when patients are transferred from one unit to another, the physician should write out each of the orders as if they were brand new orders. The same applies when the physician is using CPOE. While some CPOE systems have functions (or workarounds) that facilitate renewal of a large number of orders, beware that such can give rise to unintended consequences.

Prompt disposal of unused NMBAs is also essential. Several of the previously mentioned incidents involved use of NMBA preparations that had been poorly labeled and left behind from use with one patient, then were inadvertently administered to other patients. ISMP recommends that unused NMBAs (whether in vials, bags, or syringes) be placed in a sequestered bin for immediate pickup by pharmacy

Obviously, use of traditional medication safety measures, such as barcoding, are important and NMBAs, being high-alert drugs, should require independent double checks before being dispensed and before being administered.

Lastly, you may find 2 other resources on NMBAs helpful. In our July 31, 2007 Patient Safety Tip of the Week Dangers of Neuromuscular Blocking Agents we recommended this is a good issue to address in FMEA (Failure Mode and Effects Analysis) in your organization. Susan Paparella (Paparella 2007), from ISMP, did exactly that in the Journal of Emergency Nursing (see our November 2007 Whats New in the Patient Safety World column FMEA Related to Neuromuscular Blocking Agents). The ED staff had recognized NMBAs as high-alert drugs and were contemplating their removal from ED stores, to be replaced in kits prepared for rapid-sequence intubation. FMEA is especially useful in such situations where change is to take place, because it helps identify potential unintended consequences. The article nicely describes how you do a FMEA exercise and provides examples for scoring probability and severity and use of a hazard scoring matrix. Lastly, one of the AHRQ M&M Conference cases (Weinger 2003) on an NMBA incident had 2 terrific downloadable videos addressing some of the communications issues in that case. It is well worth reading and watching the videos.

Again, consider adding NMBA Safety to your list of things you look for in your Patient Safety Walk Rounds and consider doing a FMEA on NMBA use in your organization.

References:

ISMP (Institute for Safe Medication Practices). Paralyzed by mistakes. Preventing errors with neuromuscular blocking agents. ISMP Medication Safety Alert Acute Care Edition 2005; September 22, 2005 issue

http://www.ismp.org/Newsletters/acutecare/articles/20050922.asp

PPSA (Pennsylvania Patient Safety Authority). Patient Safety Advisory.

Neuromuscular Blocking Agents: Reducing Associated Wrong-Drug Errors

Pa Patient Saf Advis 2009; 6(4): 109-14.

http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/Dec6(4)/Pages/109.aspx

ABC News (Caron C.) Nurse Gives Patient Paralytic Instead of Antacid. November 21, 2011

http://abcnews.go.com/Health/nurse-patient-paralytic-antacid/story?id=14997244#.Ty1FOvlLuSo

Koczmara C, Jelincic V. Neuromuscular blocking agents: Enhancing safety by reducing the risk of accidental administration. ISMP Canada 2007 in the Spring 2007 publication of the Canadian Association of Critical Care Nurses (CACCN).

http://www.ismp-canada.org/download/CACCN-Spring07.pdf

ISMP (Institute for Safe Medication Practices). Remote CPOE error-a situation that's more than remotely possible. ISMP Medication Safety Alert Acute Care Edition 2007; May 31, 2007

http://www.ismp.org/Newsletters/acutecare/articles/20070531.asp

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

Paparella, Susan RN, MSN Failure Mode and Effects Analysis: A Useful Tool for Risk Identification and Injury Prevention. Journal of Emergency Nursing. 33(4):367-371, August 2007

http://www.jenonline.org/article/S0099-1767(07)00190-0/fulltext

Weinger MB, Blike GT. Intubation Mishap. AHRQ Web M&M. September 2003
http://www.webmm.ahrq.gov/case.aspx?caseID=29&searchStr=paralytic

Print Another Neuromuscular Blocking Agent Incident

February 14, 2012

Handoffs - More Than Battle of the Mnemonics

Weve probably done more columns on the problems associated with handoffs in healthcare than any other topic (see the listing and links at the end of todays column). Handoffs are among the most common transactions in transitions at all levels of the healthcare system and are also among the processes most prone to error. We know that breakdowns in communication are contributing factors in roughly 70% of all Sentinel Events in Joint Commissions Sentinel Event database and many of those breakdowns occur during handoffs. We had been intending for some time now to do a column on an excellent Australian initiative on improving handoffs. But in just the last couple months several more initiatives on improving handoffs have also been published. Importantly, each points out that the tools and formats used are really situation-dependent. That is, a tool or format used in one setting may not work well in another.

There are a number of key features of to successful handoffs in any situation (adequate time, minimal distraction, adequate allowance for interactive discussion where the recipient is able to review all relevant material and has ample opportunity to ask questions, using language that is clearly understood by all parties, use of read-back, repeat-back and hear-back to ensure that communication is understood by all parties, etc.) The most successful handoffs utilize both a written/computerized component and a verbal component and need to meet confidentiality standards. And dont forget that during a handoff you are not only passing on information but also passing on responsibility for care of the patient.

But another key feature of handoffs is use of some sort of a tool with a standardized format to remind staff of all the important elements to cover during a handoff. Mnemonics may be very helpful in that regard. Over the course of all those previous columns weve covered handoff tools and formats that go by a variety of acronyms and mnemonics: SBAR, ISBAR, iSoBAR, I PASS the BATON, PACE, the 5 Ps, SHARED and others.

An ongoing project by several pediatric organizations, the I-PASS Study, perhaps best puts the issue in perspective (Starmer 2012). This collaborative project is looking at improving the handoff process and reducing errors and improving patient outcomes. But they are going about it in the right way. First, they recognized that the format of some handoff tools may not be optimal for other handoffs. An example they use is SBAR. Dont get us wrong SBAR is a great format for many handoffs. We use it frequently in demonstrating how communication across professions may be facilitated. For instance, after an RCA showed that a nurse was reluctant (probably for a variety of reasons) to ask a physician to physically come see a patient, we noted that SBAR could have been very helpful:

Situation Patient X is becoming increasingly diaphoretic and nauseous.

Background She was admitted with a non-ST elevation MI.

Assessment I think she is extending her MI.

Recommendation: I think you should come to see her immediately.

But the leaders of the pediatric collaborative recognized that the SBAR format does not work very well for resident-to-resident handoffs, etc. because the situations are much more complex. They note that SBAR is ideal for situations where a brief summary suffices and less than 5 key points need to be communicated, and is especially suited for communications across hierarchical boundries.

So, even though adoption of SBAR has been shown to reduce adverse events in hospitals, they looked at other formats. They first piloted a tool/format and analyzed both the benefits and the downsides of the tool. The tool/format they started with was the SIGNOUT tool but when they analyzed the handoffs during the pilot they recognized that most did not adhere well to that format. Moreover, the residents involved in that pilot said that a tool/format needed to be short, easy to remember, and not have elements that overlapped each other. They also recognized that it would have to integrate with the increasing use of computerized tools for handoffs and other communication.

So after considering other tools (such as I PASS the BATON from the TeamSTEPPS program) and brainstorming, they came up with the I-PASS format (and note that even though it sounds like the I PASS the BATON format it is a totally different format):

I: Illness Severity

P: Patient Summary

A: Action List

S: Situation Awareness and Contingency Planning

S: Synthesis by Receiver

The final S emphasizes a key feature of all successful communication: it ensures that the message is fully understood by the person receiving the handoff, including asking questions then summarizing the key steps and restating the key actions/to-do steps.

The Starmer article includes a nice example of use of the I-PASS format in a clinical handoff.

The article also summarizes some of the key elements that make a mnemonic successful. It needs to be catchy, symbolic, parsimonious, utilitarian, and somehow link a visual image to a process or subject. The I-PASS mnemonic certainly accomplishes that.

The I-PASS Study collaborative is now ongoing at 10 pediatric institutions, utilizing a resident handoff bundle that includes not only the I-PASS format but also team training and a template for the written or computerized portion of handoffs. We look forward to seeing the impact this collaborative has on reducing errors and improving patient safety.

The Australian Commission on Safety and Quality in Health Care (ACSQHC) recently updated its Clinical Handover program that was launched in 2007 to improve handover communication across a range of healthcare settings (ACSQHC 2011).

The ACSQHC Clinical Handover pilot program had numerous lessons learned. Perhaps most surprising was the need to convince clinicians that the current way of doing business was simply not adequate and that change was necessary. So developing a compelling case for change was essential. Potential benefits they considered for clinicians include decreased duplication of effort, concise communication with other staff, clear allocation of staff roles, higher staff morale and more confidence in giving and receiving patient handovers, and a reduction in errors and adverse events caused by miscommunication at handovers.

Their toolkit includes a suggested project plan that includes conventional advice about a change management project (support from top leadership, involvement of strong clinical champions, stakeholder engagement, input from staff at all levels and from patients, adequate allocation of resources, identification of barriers and facilitators of change, etc.). They then describe piloting the project, flowcharting current practices, doing a PDSA style rapid improvement project, and sustaining a project. Establishing clear cut goals and measures is critical in demonstrating that any performance improvement project actually leads to improvement. The tools provided are excellent, not only for a clinical handover project but for almost any improvement project. Links to reference materials are excellent and they even provide a host of presentations for various clinical settings.

They point out that, through use of handover mnemonics such as SBAR, ISBAR, ISOBAR, iSoBAR, SHARED, handovers may be facilitated but that there is no evidence that any mnemonic is better than another in terms of improving patient safety and that the choice of handover mnemonic must be considered in the local context.

An external evaluation found that overall the Pilot Program has:

• raised the profile of clinical handover as a key safety and quality issue and established a national impetus for change
• fostered expertise and clinical handover champions for change
• embedded improved handover in a number of Australian health services
• developed a range of tools for improving different types of handover across different settings
• reinforced the need for effective approaches to change, spread and sustainability
• contributed to jurisdictional handover priorities and policies
• created a body of published work on pilot processes, outcomes and lessons learned
• identified gaps in handover knowledge and practice for further investment and development.

Perhaps the most important lesson from the ACSQHC project is that there is no one handoff mnemonic that is ideal for all handoff situations. There are advantages and disadvantages of each mnemonic in different settings.

The emergency department presents yet another unique situation for handoffs. A UK project came up with the ABC of handover tool for ED handoffs (Farhan 2012). They noted that some mnemonics commonly used in the UK, such as JUMP (Jobs outstanding, Unseen patients, Medical contacts, Patients to be aware of) and ANTICipate (Administrative data, New information, Tasks, Illness, Contingency planning), were better suited for ward handovers than for ED handovers. Rather than focusing on just the transfer of information and responsibility for single patients, they focused on the transfer of responsibility of a whole department, the ED, at change of shift. That includes knowledge of all the patients in the ED, prioritization of risks, pending tests and other issues, patient flow and waiting time issues, staffing patterns, equipment issues, planned patient dispositions (admissions, transfers, discharges), and even events taking place in the community that might impact the ED. And, since the project was done at an academic medical center, teaching responsibilities were considered as well. They recognized that poor handovers were not only associated with potentially bad patient outcomes but also added a considerable amount of unnecessary work for ED providers (some estimated they lost 1-3 hours per shift catching up after a poor handover). Using direct observation of handoffs, a series of semi-structured interviews with ED participants of all levels, and consensus building they were able to develop a tool called the ABC of handover though it really has the elements ABCDE:

A Areas and Allocation

B Beds, Bugs, Breaches

C Colleagues, Consultant on Call

D Deaths, Disasters, Deserters

E Equipment, External Events

Note that the ED practices in the UK allow for a one hour overlap at change of shift that is dedicated for handovers. In addition, they recommend that another brief review of progress take place halfway through a shift.

They have formalized a template for this tool and developed laminated cards and posters to facilitate its use. They also recommend keeping a written record of the handovers. Though the tool might seem to violate the parsimonious characteristic desired in the I-PASS collaborative, it does have an easy to use format that clearly reminds all participants to discuss a host of important ED issues at each handover and still takes less than 5 minutes to complete. The article provides some good examples of issues that might be discussed during handovers using the tool.

A follow up study on the impact of the ABC of handover tool (Farhan 2011) showed that discussion of the items considered to be essential increased from a mean of 34% at each handover to 86% and staff felt that the tool improved their situational awareness and made them more proactive on operational issues such as staffing and equipment shortages.

Also in February ACOG released its updated committee opinion on Communication Strategies for Patient Handoffs (ACOG 2012). Note that they advocate the I PASS the BATON format from the TeamSTEPPS program as their structured communication tool and also discuss SBAR. But their document also discusses things like barriers to effective handoffs and ways to facilitate good handoffs.

Note that ACOG does consider e-mail to be an appropriate form of handoff as long as receipt of the e-mail can be acknowledged. But they stress that voice mail or other messages for which receipt cannot be acknowledged are not acceptable formats. We personally would discourage use of e-mail as the sole component of handoffs since it limits at least to some degree the ability of the recipient to ask questions, which is a core component of good interactive handoffs, and lacks the body language that is such an important part of any communication. The document does, however, have good discussion about the physical environment for handoffs and is quite good in pointing out the language and cultural aspects of communication and styles of communication.

We think the information youll find in the pediatric I-PASS project, ACSQHC project, the ABC of handover, the ACOG opinion, and the AORN toolkit we noted in our December 2011 Whats New in the Patient Safety World column AORN Perioperative Handoff Toolkit will be valuable to help you improve your handoff processes in multiple venues.

Mnemonics and the tools or format that they denote may be very helpful in your handoffs. The key message is that you need to implement tools that address the needs of each particular type of handoff that occurs in your organization.

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 CommunicationCommunicationCommunication

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, InattentionOops!

April 13, 2010 Update on Handoffs

July 12, 2011 Psst! Pass it onHow a kids 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

References:

Starmer AJ, Spector ND, Srivastava R, et al. and the I-PASS Study Group. I-PASS, a Mnemonic to Standardize Verbal Handoffs.

Pediatrics 2012; 129(2): 201 -204

http://pediatrics.aappublications.org/content/129/2/201.extract

ACSQHC (Austrailian Commission on Safety and Quality in Health Care) Clinical Handover. October 25, 2011

http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/content/PriorityProgram-05#Tools

Farhan M, Brown R, Woloshynowych M, Vincent C. The ABC of handover: a qualitative study to develop a new tool for handover in the emergency department. Emerg Med J 2012; Published Online First: 3 January 2012 http://emj.bmj.com/content/early/2012/01/03/emermed-2011-200199.full.pdf+html?sid=4b3509fa-c354-42cb-a27c-b80721ddeec5

Farhan M, Brown R, Vincent C, Woloshynowych M. The ABC of Handover: impact on shift handover in the emergency department. Emerg Med J 2011; published online 28 December 2011

http://emj.bmj.com/content/early/2011/12/28/emermed-2011-200201.abstract

ACOG. Committee on Patient Safety and Quality Improvement. Committee Opnion Number 517. Communication Strategies for Patient Handoffs. February 2012

http://www.acog.org/~/media/Committee Opinions/Committee on Patient Safety and Quality Improvement/co517.ashx?dmc=1&ts=20120202T0354210086

AORN. Perioperative Patient 'Hand-Off' Tool Kit.

http://www.aorn.org/PracticeResources/ToolKits/PatientHandOffToolKit/

Print Handoffs More Than Battle of the Mnemonics

February 21, 2012

Improving PCA Safety with Capnography

Weve stressed on numerous occasions the difficulties monitoring patients on PCA pumps or receiving postoperative opioids by other routes. The primary danger is development of respiratory failure. Some patients may be at greater risk because of concomitant conditions (eg. obstructive sleep apnea, massive obesity, COPD, various neuromuscular disorders) or because of concomitant medications (benzodiazepines or other sedating agents).

Use of pulse oximetry to monitor such patients can give rise to a false sense of security (see our December 6, 2011 Patient Safety Tip of the Week Why You Need to Beware of Oxygen Therapy). Patients with respiratory depression secondary to opioids or sedatives typically develop CO₂ retention well before they develop oxygen desaturation. So a good monitoring strategy would utilize capnography.

One organization recently shared its experience with adoption of capnography for all patients on PCA pumps (Maddox 2012). They use the capnography apparatus to monitor both the respiratory rate and the end-tidal CO₂.

Their initial experience led to adjustment of their monitoring parameters. They started with alerts programmed for respiratory rates of 10 or less or no breath for 30 seconds and an end-tidal CO₂ level of 50. However, they found too many nuisance alarms at those levels so reprogrammed their alert targets to respiratory rates of 6 and end-tidal CO₂ to 60.

The article nicely describes all the steps they went through to plan and implement the system and the daily mechanics involved. Since 2004 they have used the system for virtually all patients on PCA and have also begun using it on patients receiving epidural PCA or opioids via other routes. In over 5000 patients they have had no serious respiratory complications of PCA. They also calculated an estimated ROI (based on potentially avoided intubations, transfers to ICU, etc.) and felt that the 5-year ROI was about $2.5 million for their organization. Plus all the ROI in human terms! Pretty impressive!

They do note that patient mobility is limited when hooked up to the pumps and capnography equipment. However, they also note that most patients who are mobile no longer have the need for the PCA pumps.

Continuous capnography may not be the complete answer to patient safety in patients on PCA. Note that several times we have quoted the excellent article by Lynn and Curry (Lynn 2011) that discussed several mechanisms for unexpected deaths in hospitalized patients (see our February 22, 2011 Patient Safety Tip of the Week Rethinking Alarms). That article nicely outlines the multiple problems involved in developing the ideal monitoring system. Our September 6, 2011 Patient Safety Tip of the Week More Tips on PCA Safety also noted a unique apnea prevention device (Zornow 2011) that uses inputs from multiple modalities to create a system for alerting providers to impending respiratory disasters.

We also came across some excellent informal discussions on PCA safety through the Beckers ASC Review website (www.beckerasc.com). One was an interview with Bryanne Patail of the VAs National Center for Patient Safety (Wong 2012) who noted that more than 50 percent of these events events related to infusion pumps, suggesting that incidents with PCA pumps are about 10 times more frequent than with general-purpose pumps. That, of course, reflects that occurrence of respiratory depression related to the opioid infusions. The VA has also reduced its PCA events by integrating capnography into its PCA systems. The second was about the Physician-Patient Alliance for Health & Safety (PPAHS) putting together a working group to create a checklist targeted towards PCA (Kurtz 2011). It has interviews with multiple healthcare providers who have excellent suggestions for items to be included on such a checklist. On the Physician-Patient Alliance for Health & Safety website are some heart-wrenching stories about patients who died during PCA, likely as a result of inadequate monitoring. We look forward to seeing that checklist when it is ready.

In our May 17, 2011 Patient Safety Tip of the Week Opioid-Induced Respiratory Depression Again! we encouraged hospitals to perform their own FMEA (Failure Mode and Effects Analysis) on the PCA process and provided links to two tools we use when doing FMEAs of the PCA pump process: the PCA Pump Audit Tool and the PCA Pump Criteria. And we hope that youll go back and look at the string of recommendations we made in our September 6, 2011 Patient Safety Tip of the Week More Tips on PCA Safety. We think you will find them extremely helpful.

Understanding the complexities of respiration as it relates not only to various medications but also to underlying patient conditions is extremely important in managing the postoperative patient. Implementing a PCA safety program is one of the most important things your organization can do to improve the perioperative care of patients and avoid unnecessary morbidity and mortality.

Other Patient Safety Tips of the Week pertaining to opioid-induced respiratory depression and PCA safety:

• January 4, 2011 Patient Safety Tip of the Week Safer Use of PCA
• July 13, 2010 Patient Safety Tip of the Week Postoperative Opioid-Induced Respiratory Depression
• May 12, 2009 Patient Safety Tip of the Week Errors With PCA Pumps
• September 21, 2010 Patient Safety Tip of the Week Dilaudid Dangers
• November 2010 Whats New in the Patient Safety World column More on Preoperative Screening for Obstructive Sleep Apnea
• February 22, 2011 Patient Safety Tip of the Week Rethinking Alarms
• May 17, 2011 Patient Safety Tip of the Week Opioid-Induced Respiratory Depression Again!
• September 6, 2011 Patient Safety Tip of the Week More Tips on PCA Safety
• December 6, 2011 Patient Safety Tip of the Week Why You Need to Beware of Oxygen Therapy

• February 21, 2012 Patient Safety Tip of the Week Improving PCA Safety with Capnography

• Tools: PCA Pump Audit Tool and the PCA Pump Criteria

Prior columns pertaining to oxygen safety:

• April 8, 2008 Patient Safety Tip of the Week Oxygen as a Medication
• June 10, 2008 Patient Safety Tip of the Week Monitoring the Postoperative COPD Patient
• January 27, 2009 Patient Safety Tip of the Week Oxygen Therapy: Everything You Wanted to Know and More!
• April 2009 Whats New in the Patient Safety World column Nursing Companion to the BTS Oxygen Therapy Guidelines.

References:

Maddox RR, Williams CK. Clinical Experience with Capnography Monitoring for PCA Patients. APSF Newsletter 2012; 26(3: 47-50 Winter 2012

http://www.apsf.org/newsletters/pdf/winter_2012.pdf

Lynn LA, Curry JP. Patterns of unexpected in-hospital deaths: a root cause analysis. Patient Safety in Surgery 2011, 5:3 (11 February 2011)

http://www.pssjournal.com/content/pdf/1754-9493-5-3.pdf

Zornow MH. Clinical Testing of the Apnea Prevention Device: Proof of Concept Data. Anesth Analg 2011; 112:;582-586

http://www.anesthesia-analgesia.org/content/112/3/582.abstract

Wong M. Reducing Errors With Patient-Controlled Analgesia Pumps: Q&A With Bryanne Patail of the National Center for Patient Safety. Physician-Patient Alliance for Health & Safety. February 09, 2012

http://www.beckersasc.com/asc-accreditation-and-patient-safety/reducing-errors-with-patient-controlled-analgesia-pumps-qaa-with-bryanne-patail-of-the-national-center-for-patient-safety.html?A_With_Bryanne_Patail_of_the_National_Center_for_Patient_Safety=

Kurtz R. How to Prevent 'Dead-in-Bed' Syndrome With Patients After Surgery: Q&A With Physician Experts & PPAHS. November 09, 2011

http://www.beckersasc.com/asc-accreditation-and-patient-safety/how-to-prevent-dead-in-bed-syndrome-with-patients-after-surgery-qaa-with-physician-experts-a-ppahs.html

Physician-Patient Alliance for Health & Safety

http://ppahs.wordpress.com/

Print Improving PCA Safety with Capnography

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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

Medication Safety in the OR

January 24, 2012

Patient Safety in Ambulatory Care

January 17, 2012

Delirium and Contact Isolation

January 10, 2012

Verbal Orders

January 3, 2012

Unintended Consequences of Restricted Housestaff Hours

December 20, 2011

Infant Abduction

December 13, 2011

Surgical Fires Again

December 6, 2011

Why You Need to Beware of Oxygen Therapy

November 29, 2011

More on Diagnostic Error

November 22, 2011

Perioperative Management of Sleep Apnea Disappointing

November 15, 2011

Rethinking Colonoscopy

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

Renewed Focus on MRI Safety

October 18, 2011

High-Risk Surgical Patients

October 11, 2011

LEAN in the Lab

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

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Do You Use Fentanyl Transdermal Patches Safely?

September 6, 2011

More Tips on PCA Safety

August 30, 2011

Unintentional Discontinuation of Medications After Hospitalization

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Catheter Misconnections Back in the News

August 16, 2011

Crisis Checklists for the OR

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Frailty and the Surgical Patient

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Hazards of e-Prescribing

July 26, 2011

Hourly Rounding

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

STOPP Using Beers List?

June 14, 2011

Failure to Follow Up

June 6, 2011

Timeouts Outside the OR

May 31, 2011

Book Review Human Factors and Team Psychology in a High Stakes Environment

May 24, 2011

Hand Hygiene Resources

May 17, 2011

Opioid-Induced Respiratory Depression Again!

May 10, 2011

Preventing Preventable Readmissions: Not As Easy As It Sounds

May 3, 2011

Its All in the Timing

April 26, 2011

Sleeping Air Traffic Controllers: What About Healthcare?

April 19, 2011

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April 12, 2011

Medication Issues in the Ambulatory Setting

April 5, 2011

More Aviation Principles

March 29, 2011

The Silent Treatment:A Dose of Reality

March 22, 2011

An EMR Feature Detrimental to Teamwork and Patient Safety

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Early Warnings for Sepsis

March 8, 2011

Yes, Physicians Get Interrupted Too!

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Rethinking Alarms

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Controversies in VTE Prophylaxis

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Procedural Sedation in Children

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Ticket Home and Other Tools to Facilitate Discharge

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Ticket to Ride: Checklist, Form, or Decision Scorecard?

November 11, 2008

Probiotics and VAP Prevention

November 4, 2008

Beta Blockers Take More Hits

October 28, 2008

More on Computerized Trigger Tools

October 21, 2008

Preventing Delirium

October 14, 2008

Managing Delirium

October 7, 2008

Lessons from Falls....from Rehab Medicine

September 30, 2008

Hot Topic: Handoffs

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

Updates on VAP Prevention

August 26, 2008

Pattern Recognition and CPOE

August 19, 2008

Arterial Line Issues

August 12, 2008

Jerome Groopmans How Doctors Think

August 5, 2008

Tip of the Week on Vacation

July 29, 2008

Heparin-Induced Thrombocytopenia

July 22, 2008

Lots New in the Anticoagulation Literature

July 15, 2008

Heparin Flushes.....Again!

July 8, 2008

Medical Helicopter Crashes

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

Computerizing Trigger Tools

April 8, 2008

Oxygen as a Medication

April 1, 2008

Pennsylvania PSAs FMEA on Telemetry Alarm Interventions

March 25, 2008

More on MRSA

March 18, 2008

Is Desmopressin on Your List of Hi-Alert Medications?

March 11, 2008

Lessons from Ophthalmology

March 4, 2008

Housestaff Awareness of Risks for Hazards of Hospitalization

February 26, 2008

Nightmares.The Hospital at Night

February 19, 2008

MRI Safety

February 12, 2008

More on Tracking Test Results

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

Fall Prevention

December 25, 2007

Happy Holidays

December 18, 2007

Bed Rails

December 11, 2007

CommunicationCommunicationCommunication

December 4, 2007

Surgical Fires

November 27,2007

More on Rapid Response Teams

November 20, 2007

New Evidence Questions Perioperative Beta Blocker Use

November 13, 2007

AHRQ's Free Patient Safety Tools DVD

November 6, 2007

Don Norman Does It Again!

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

Errors in the Laboratory

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

Workarounds as a Safety Issue

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

Tip of the Week on Vacation

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

More on TeamSTEPPS

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

The Missed Cancer

April 23, 2007

Predictable Errors

April 16, 2007

Falls with Injury

April 9, 2007

Make Your Surgical Timeouts More Useful

April 2, 2007

More Alarm Issues

March 26, 2007

Alarms Should Point to the Problem

March 19, 2007

Put that machine back the way you found it!

March 12, 2007

10x Overdoses

March 5, 2007

Disabled Alarms

February 26, 2007

Unintended Consequences