Healthcare Consulting Services
PO Box 1230
Grantham, NH 03753
ph: 716-550-1106
btruax
January 1, 2019
More on Automated Dispensing Cabinet (ADC) Safety
In our December 11, 2018 Patient Safety Tip of the Week “Another NMBA Accident” several issues arose about the role of the ADC (Automated Dispensing Cabinet) in the unfortunate accident in which a patient was inadvertently administered a fatal dose of the NMBA (neuromuscular blocking agent), vecuronium.
In that December 11, 2018 Patient Safety Tip of the Week “Another NMBA Accident”, the following ADC-related issues were discussed:
Since that column, another serious incident in which an ADC was a factor has been reported (CDPH 2018). A patient was given a fatal direct IV injection of concentrated Levophed (norepinephrine) rather than the diluted IV continuous drip infusion that had been ordered. The Levophed had been in a concentrated form in a vial in an ADC in the ICIU where the patient was hospitalized. It was removed from the ADC by a licensed nurse (LN1), even though a pharmacy premixed IV infusion of Levophed was stored in a refrigerator across from the ADC. It is not clear whether a formal double check was required for removal of this high alert medication from the ADC. The CDPH statement of deficiencies says that a second licensed nurse (LN2) was “cosigner” for LN1 but never looked at the medication and was unaware it was going to be given by IV push. LN1 noted she pushed the touch screen for each of the patient's meds and did not read the touch screen instructions written for Levophed to be diluted in 250 ml of D5 and given as a drip. LN1 stated she had never given Levophed and did not research it or double check with the co-signer about the medication administration,
In addition to training and education on a variety of issues related to this incident, the facility implemented several changes in processes and procedures related to the ADC and storage and dispensing of Levophed following the incident:
So these 2 cases got us wondering about other vulnerabilities and safety issues related to ADC’s. ADC’s, of course, have many valuable benefits. They certainly help get medications to patients in a more timely fashion. They also improve inventory functions, allow tracking of medications, and improve charge capture. We’re also glad to see they’re being used to manage certain non-medication medical supplies (Bourcier 2016).
We have advocated for that for over 10 years (see, for example our April 21, 2009 Patient Safety Tip of the Week “Still Futzing with Foleys?” where we suggested we treat Foley catheters like medications and use CPOE and barcoding to improve management).
A survey of nurses about their attitudes toward ADC’s (Rochais 2014) found that nursing staff considered the introduction of ADC made their work easier (level of agreement of 90%), helped to safely provide patients with care (91%), and helped to reduce medication incidents/accidents (81%). Nursing staff was particularly satisfied by the narcotic drugs management with the ADCs. Nursing staff were not satisfied with the additional delays in the preparation and administration of a medication dose and the inability to prevent a medication from being administered when stopped on the medication administration record (48%).
But, regarding medication safety, other than rates of wrong-time medication errors, results have been mixed (Grissinger 2012). ISMP (ISMP 2008) notes “ADCs can also reduce the risk of medication errors, but only when specific safeguards are consistently available and used.”
A significant problem with ADC’s is the override process. Note that the override process bypasses several medication safeguards. It often is the result of a verbal order and bypasses verification by a pharmacist and the bedside medication verification (barcoding) system.
As early as 2005 the Pennsylvania Patient Safety Reporting System (PA-PSRS 2005) began noting a role of ADC’s in medication errors. Nearly 15% of all medication error reports cited ADCs as the source of the medication, and 23% of these reports involved high-alert medications. Many of these reports described cases in which the design and/or use of ADCs contributed to the errors. The types of errors include wrong drug errors, stocking/storage errors, and medications being administered to patients with a documented allergy. They noted factors contributing to these errors:
The PA-PSRS report noted, in addition to overrides, other types of workarounds:
The PA-PSRS report also mentions the types of LASA (look-alike, sound-alike) errors and “picklist” errors that we discussed in our December 11, 2018 Patient Safety Tip of the Week “Another NMBA Accident”.
In 2008 ISMP (ISMP 2008) reported results of a survey on ADC’s. They found gaps in using double checks when stocking ADC’s or when withdrawing medications from ADC’s. They noted a case where an automated dispensing cabinet on the neonatal unit had been inadvertently stocked with heparin vials containing 10,000 units/ml. Nurses were used to drawing heparin from 10 units/mL vials from that cabinet and did not notice the difference (see our December 2007 What's New in the Patient Safety World column “1000-fold Heparin Overdoses Back in the News Again”). ISMP notes the importance of the interface between the pharmacy information system and ADCs so pharmacists can profile, screen, and approve medications before they are removed from the cabinet for administration. The override capability in ADC’s may short-circuit that safety feature. Stocking multiple concentrations of medications in the ADC’s can also be problematic. They also noted problems with ADC design, ADC locations (some locations may be more vulnerable to distractions), workflow issues, practice habits, and workarounds.
ISMP offered the following “12 Core Processes Associated with Safe ADC Use”:
ISMP has also recently re-surveyed hospitals and is in the process of revising its Guidelines for Safe Use of Automated Dispensing Cabinets (ISMP 2018a). Though the latter is yet in draft format, we hope you’ll read the guidelines that are far too numerous for today’s column. But here are a few highlights:
They have good recommendations about using biometrics for access to ADC’s, defining user privileges, strict management of usernames and passwords, timeframes for the ADC to time out, audits, procedures for addressing discrepancies, optimizing and maintaining ADC inventory, and many others.
They have excellent recommendations regarding overrides, including good planning for when overrides would be allowed and regular review of override reports by an interdisciplinary group. You should implement strategies that reduce the risk of error when an override is used:
a. Avoid the use of multi-dose containers.
b. Limit the quantity and number of drug concentrations available on override.
c. Use a process where the drug and dose are checked against the patient’s allergies and weight, if applicable, to determine if the drug and dose are appropriate.
d. Require documentation of override rationale.
e. Consider an independent double-check with another licensed healthcare provider when removing organization-identified high-alert medications on override.
They recommend you should limit overrides to the following situations:
a. When a licensed independent practitioner controls ordering, preparation, and administration of the medication.
b. When medications are required in emergent circumstances and waiting for a pharmacist to review the order could adversely impact the patient’s condition, such as the need for:
In our December 11, 2018 Patient Safety Tip of the Week “Another NMBA Accident” we discussed 2015 the Pennsylvania Patient Safety Authority advisory about overrides of healthcare technologies (Grisinger 2015). Over 75% of the overrides involved ADC’s. The most common type of event involving overrides of ADCs were unauthorized medications (e.g., obtaining a medication for a patient with no prescribed order for the patient), followed by wrong-drug events and wrong dosage form events (e.g., selecting a sustained-release product instead of the immediate-release form, selecting an oral formulation instead of the injection). A majority of the unauthorized medication events specifically stated there were no orders for the medication, and over 30% of the unauthorized medication events involved a high-alert medication. Many of the cases involved withdrawal of a medication from the ADC before pharmacist verification or when the pharmacy was closed.
An analysis of safety of nebulized medications (ISMP 2018b) found that trying to obtain a nebulizer medication via override from an ADC was a factor linked to numerous wrong drug/strength/form errors and wrong patient errors.. Many of the errors involved mix-ups when selecting albuterol, and the combination product, ipratropium and albuterol. In most of the reported events, a respiratory therapist had removed the medication via override prior to administering the treatment. In a few instances, nurses had obtained the medication via override and either administered it or gave it to a respiratory therapist who was not allowed to access the ADC.
The ISMP revised guideline draft (ISMP 2018a) provides good lists of which medications should not be included in ADC’s (examples: medications that require multiple dilutions or calculations, U-500 insulin vials and pens, vials/ampules of concentrated electrolytes, and medications that have been restricted from ADC storage based on organizational USP 800 Assessment of Risk).
They note that, if neuromuscular blocking agents are stocked in an ADC, ADC pockets or drawers containing neuromuscular blocking agents should include an auxiliary label to clearly communicate that respiratory paralysis will occur and ventilation is required (e.g., WARNING: CAUSES RESPIRATORY PARALYSIS—PATIENT MUST BE VENTILATED). Note that, while we endorse that label, it is not enough. The message that should appear on the ADC screen when an NMBA is selected should require confirmation that “the patient is intubated/ventilated or about to be intubated” before access is granted.
The ISMP revised guideline draft also discusses the need to define procedures for accurate ADC withdrawal and transfer to the bedside. Good practice would:
Drake and colleagues (Drake 2016) described a successful quality-improvement project in which CPOE was utilized to limit overrides in the emergency department. Before November 2012, the ADCs in the emergency department (ED) at Indiana University Health Methodist Hospital were programmed for “total override,” allowing nurses access to all medications in the machines independent of patient orders. At the time of CPOE implementation, ADC inventory for each area of the ED was evaluated in order to anticipate which medications should not be subject to override limitations. It was decided that these products should include life-saving, ED-specific medications (e.g., alteplase, activated charcoal), medications used for bedside procedures (e.g., bupivacaine injection, topical tetracaine), comfort care medications (e.g., acetaminophen tablets), and bulk items (e.g., magnesium citrate oral solution, oxymetazoline spray).
The nursing staff leadership were concerned over pharmacist turnaround time, ED nurses were accustomed to accessing medications from ADCs without delay. CPOE autoverification logic was implemented to allow for certain medications to be accessible from ADCs without pharmacist verification (i.e., immediately upon order placement by a provider, the status of certain orders was automatically changed to “verified” and the ordered medication could be removed from an ADC right away). It was decided that the autoverification list should include only medications considered to be emergently needed and those with a wide therapeutic index and minimal monitoring requirements and only if an ordered medication posed no threat of drug allergies or interactions.
After implementation of the limited override functionality, the proportion of ADC-stocked medications removed on override was reduced to 17.5%. Fifty-five percent of the orders entered in the ED qualified for autoverification. The mean total verification time, including autoverified orders, was 2.48 minutes. The mean pharmacist verification time, excluding autoverified orders, was 5.39 minutes. Two years after implementation of the new processes, all ADCs within the ED continued to operate on limited override. Subsequently, additional ADC’s in postoperative, labor and delivery, and procedural areas were removed from total override.
ADC’s are very valuable tools and are clearly here to stay. But careful attention is needed to ensure that they don’t inadvertently contribute to serious medical errors. It’s critical that you don’t just do perfunctory review of ADC overrides. You need to find out how often and why such overrides are used. We hope that the recommendations in today’s column and our December 11, 2018 Patient Safety Tip of the Week “Another NMBA Accident” about not only overrides but also the stocking, storage and dispensing issues, and the critical messaging functions for drugs like NMBA’s will help you identify vulnerabilities in your own organizations.
References:
CDPH (California Department of Public Health). Complaint lntalke Number: CA00424314; CDPH 8/16/18 accessed December 18, 2018
Bourcier E, Madelaine S, Archer V, et al Implementation of automated dispensing cabinets for management of medical devices in an intensive care unit: organisational and financial impact. Eur J Hosp Pharm 2016; 23 :86-90
https://ejhp.bmj.com/content/23/2/86
Rochais E, Atkinson S, Guilbeault M, Bussieres J-F. Nursing Perception of the Impact of Automated Dispensing Cabinets on Patient Safety and Ergonomics in a Teaching Health Care Center. Journal of Pharmacy Practice 2014; 27(2): 150-157
Grissinger M. Safeguards for Using and designing automated dispensing cabinets. Pharmacy & Therapeutics 2012; 37(9): 490-491, 530
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3462599/
ISMP (Institute for Safe Medication Practices). ADC Survey Shows Some Improvements, But Unnecessary Risks Still Exist. ISMP Medication Safety Alert Acute Care Edition 2008; January 17, 2008
https://www.ismp.org/resources/adc-survey-shows-some-improvements-unnecessary-risks-still-exist
PA-PSRS (Pennsylvania Patient Safety Reporting System). Problems Associated with Automated Dispensing Cabinets. PA-PSRS Patient Safety Advisory 2005; 2(3): September 2005
http://patientsafety.pa.gov/ADVISORIES/documents/200509_21.pdf
ISMP (Institute for Safe Medication Practices). Revised Guidelines for Safe Use of Automated Dispensing Cabinets (draft). ISMP 2018; July 23, 2018
https://www.ismp.org/sites/default/files/attachments/2018-07/ADC_Guidelines_PUBLICDRAFT.pdf
Grisinger M. Medication Errors Involving Overrides of Healthcare Technology. Pa Patient Saf Advis 2015; 12(4): 141-148
http://patientsafety.pa.gov/ADVISORIES/Pages/201512_141.aspx
ISMP (Institute for Safe Medication Practices). Safety with Nebulized Medications Requires an Interdisciplinary Team Approach. ISMP Medication Safety Alert Acute Care Edition 2018; February 22, 2018
https://www.ismp.org/resources/safety-nebulized-medications-requires-interdisciplinary-team-approach
Drake E, Srinivas P, Trujillo T. Using computerized prescriber order entry to limit overrides from automated dispensing cabinets. American Journal of Health-System Pharmacy 2016; 73(14): 1033-1035
https://academic.oup.com/ajhp/article/73/14/1033/5101547
Print “More on Automated Dispensing Cabinet (ADC) Safety”
January 8, 2019
Maternal Mortality in the Spotlight
Whenever we do a presentation on how we don’t get our money’s worth out of our healthcare system, one of the things we always mention is our relatively poor performance regarding infant mortality. But, much to our surprise, maternal mortality has quietly crept up over the past 2 decades and the US now ranks 30th out of the 31 OECD countries for maternal mortality (Lu 2018). Lu and colleagues reported that maternal mortality in the United States more than doubled between 2000 and 2014, from 9.8 to 21.5 maternal deaths per 100,000 live births. Every year in the United States, more than 700 women die of complications related to pregnancy and childbirth and more than 50,000 women experience a life-threatening complication (severe maternal morbidity).
Moreover, racial, ethnic, geographic, and socioeconomic disparities play a major role in maternal mortality. African American women are nearly 3 times as likely to die of complications related to pregnancy and childbirth compared with white women (Lu 2018).
And, it’s not just mortality. An AHRQ report shows that, from 2006 through 2015, the rate of deliveries involving any severe maternal morbidity increased 45 percent, from 101.3 to 146.6 per 10,000 delivery hospitalizations (Fingar 2018). This was especially driven by an increase in the rate of deliveries involving blood transfusion. Rates of acute renal failure, shock, ventilation, and sepsis at delivery also more than doubled between 2006 and 2015.
Propublica and NPR (Propublica Lost Mothers Series) actually began to raise attention about maternal mortality in 2017. Their report (Martin 2017) estimated 700 to 900 women in the U.S. died from pregnancy-related causes in 2016 and they began to tell the personal stories of those women.
In commenting on the AHRQ study, Fisher (Fisher 2018) notes there have been some changes in patient-related factors that contribute to the trend. Increases in maternal age, pre-existing medical conditions, and pre-pregnancy obesity are examples of such contributing factors. But they cannot account for all of the increases the AHRQ report describes. Specifically, over the decade of analysis the report indicates that rates of sepsis at delivery, acute renal failure, and shock all more than doubled.
Dalia Sofer highlights the disparities in two articles. In “The American Pregnancy: A Tale of Race, Class—and Zip Code” (Sofer 2018b) she notes that black women were the most likely to have births involving severe maternal morbidity, with in-hospital mortality three times higher than for whites. In the other (Sofer 2018a) she notes that, worldwide according to the WHO, high maternal mortality rates correlate with inadequate medical resources, particularly for women living in poor and rural areas. The picture is more complicated in the United States, where black women are three to four times more likely to die of pregnancy-related causes than white women, She does point out the dramatic improvement California made in reducing maternal mortality through the California Maternal Quality Care Collaborative (CMQCC 2018),
Rosindale (Rosindale 2018) notes a 2014 ACOG report that more than half of rural women have to drive over 30 minutes to receive perinatal services from the nearest hospital. We suspect that is even more problematic today. Given the financial strains that rural hospitals are experiencing, labor and delivery services are being dropped. Such services are very difficult to support, since you must have round-the-clock staffing even when the L&D census and newborn nursery census is low (or even zero). Mann et al. (Mann 2017) also suggest that linking such hospitals with tertiary care hospitals through telehealth services, quality-improvement aid, and transport may reduce morbidity and mortality. Note that some have also called for ACOG and the American Academy of Family Physicians to jointly develop an extra year of training for family medicine physicians who want to practice obstetrics in rural areas. (Mann 2018).
Katy Kozhimannil, in a recent Health Affairs article (Kozhimannil 2018), provides a longer time frame and outlines a number of factors contributing to the rising maternal mortality rate and offers strategies for reversing the trend. She notes that in 1955 the maternal mortality rate in the US was approximately 47.0 deaths per 100,000 live births. During the 1960s and 1970s access to health care and the quality of health services improved, and maternal mortality decreased, and by 1978 had dropped to 9.6 deaths per 100,000 live births. But, between 1987 and 2010 the rate more than doubled, reaching 16.0 deaths per 100,000 live births, and ultimately the 21.5 maternal deaths per 100,000 live births noted in the Lu study.
She outlines a number of factors contributing to the rising maternal mortality rate and offers the following strategic steps for reversing the trend:
Kozhimannil cites the California experience as evidence that reversing the trend is possible. From 2006 to 2013 California bucked the national trend, and maternal mortality declined by 57 percent, from 16.9 deaths to 7.3 deaths per 100,000 live births.
Regarding Kozhimannil’s first step, the U.S. House of Representatives recently unanimously approved a bill to fund state committees to review and investigate deaths of expectant and new mothers (Martin 2018). The bill, which awaits a Senate vote, authorizes $12 million a year in new funds for five years for states to create review committees to identify maternal deaths, analyze the factors that contributed to those deaths and translate the lessons into policy changes. (Update: the bill has passsd and has been signed by the President).
A recent “Perspective” in the New England Journal of Medicine (Mann 2018) outlined 4 steps that hospitals should be taking to begin to address the issue:
We discussed maternal safety bundles in detail in our February 7, 2017 Patient Safety Tip of the Week “Maternal Safety Bundles”. The Council on Patient Safety in Women’s Health Care sponsors the AIM (Alliance for Innovation on Maternal Health) Program that has links to the maternal patient safety bundles.
Note also that AHRQ has an excellent Toolkit for Improving Perinatal Safety (AHRQ 2017) that has some excellent resources for simulations of a variety of circumstances threatening infant or maternal safety.
In addition to the previously mentioned initiatives from Propublica and the state of California (CMQCC 2018) and AHRQ (AHRQ 2017), there are ongoing maternal safety initiatives from IHI (Institute for Healthcare Improvement) (IHI 2018), NY State (WKBW 2018), Washington State (Washington Statre. Department of Health 2018), and several other states.
.
We also hope you’ll go back to our February 7, 2017 Patient Safety Tip of the Week “Maternal Safety Bundles”. There we not only discussed programs using maternal safety bundles and simulations, but also discussed maternal safety issues such as RSI’s (retained surgical items), surgical fires, obstructive sleep apnea, epidural catheter mistaken infusions, unintentional hypothermia, the weekend effect, medication mixups, and other issues.
Some of our previous columns on maternal and ob/gyn issues:
February 5, 2008 “Reducing Errors in Obstetrical Care”
February 2010 “Joint Commission Sentinel Event Alert on Maternal Deaths”
April 2010 “RCA: Epidural Solution Infused Intravenously”
July 20, 2010 “More on the Weekend Effect/After-Hours Effect”
August 2010 “Surgical Case Listing Accuracy”
September 7, 2010 “Patient Safety in Ob/Gyn Settings”
January 2011 “Surgical Fires Not Just in High Risk Cases”
February 8, 2011 “Inducing Too Early”
April 2011 “Ob/Gyn Patient Safety Programs”
April 24, 2012 “Fire Hazard of Skin Preps Oxygen”
July 2012 “WHO Safe Childbirth Checklist”
December 4, 2012 “Unintentional Perioperative Hypothermia: A New Twist”
September 2013 “Full-Time Laborists Reduce C-Section Rates”
October 2013 “Challenging the 39-Week Campaign”
November 2013 “The Weekend Effect: Not One Simple Answer”
January 2014 “It MEOWS But Doesn’t Purr”
May 13, 2014 “Perioperative Sleep Apnea: Human and Financial Impact”
August 19, 2014 “Some More Lessons Learned on Retained Surgical Items”
November 3, 2015 “Medication Errors in the OR - Part 2”
February 7, 2017 “Maternal Safety Bundles”
January 23, 2018 “Unintentional Hypothermia Back in Focus”
References:
Lu MC. Reducing Maternal Mortality in the United States. JAMA 2018;3 20(12): 1237-1238
Fingar KR, Hambrick MM, Heslin KC, Moore JE. HCUP Statistical Brief #243. Trends and Disparities in Delivery Hospitalizations Involving Severe Maternal Morbidity, 2006-2015. AHRQ 2018; September 2018
Propublica. Lost Mothers series.
https://www.propublica.org/series/lost-mothers
Martin N, Cillekens E, Freitas A. Lost Mothers. Propublica 2017; July 17, 2017
https://www.propublica.org/article/lost-mothers-maternal-health-died-childbirth-pregnancy
Fisher N. Severe Complications Rise Sharply Among Women Giving Birth in Hospitals. Forbers 2018; September 10, 2018
Sofer D. The American Pregnancy: A Tale of Race, Class—and Zip Code. AJN The American Journal of Nursing 2018; 118(12): 12, December 2018
Sofer D. Why Are Women Still Dying of Pregnancy and Childbirth? AJN The American Journal of Nursing 2018; 118(9): 12, September 2018
CMQCC (California Maternal Quality Care Collaborative.), Accessed December 22, 2018
Rosindale L. Rural Maternal Mortality. AJN The American Journal of Nursing 2018; 118(12): 10
https://journals.lww.com/ajnonline/Citation/2018/12000/Rural_Maternal_Mortality.3.aspx
Mann S, McKay K, Brown H The Maternal Health Compact. N Engl J Med 2017; 376: 1304-1305
https://www.nejm.org/doi/full/10.1056/NEJMp1700485
Mann S, Hollier LM, McKay K, Brown H. What We Can Do about Maternal Mortality — And How to Do It Quickly. N Engl J Med 2018; 379: 1689-1691
https://www.nejm.org/doi/full/10.1056/NEJMp1810649
Kozhimannil KB. Reversing The Rise In Maternal Mortality. Health Affairs 2018; 37(11): 1901-1904 November 2018: Patient Safety
https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2018.1013
Martin N. “Landmark” Maternal Health Legislation Clears Major Hurdle. Propublica 2018; December 12, 2018
https://www.propublica.org/article/landmark-maternal-health-legislation-clears-major-hurdle
Council on Patient Safety in Women’s Health Care. Alliance for Innovation on Maternal Health Program. 2018
https://safehealthcareforeverywoman.org/aim-program/
Council on Patient Safety in Women’s Health Care. Patient Safety Bundles. 2018
https://safehealthcareforeverywoman.org/patient-safety-bundles.
AHRQ (Agency for Healthcsare Research and Quality). Toolkit for Improving Perinatal Safety. AHRQ 2017; June 2017
https://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/perinatal-care/index.html
IHI (Institute for Healthcare Improvement). Ihi Joining Efforts To Improve Outcomes, Reduce Disparities In Maternal Care. IHI 2018; August 14, 2018
http://www.ihi.org/about/news/Documents/IHI_Merck_for_Mothers_Press_Release_081418.pdf
WKBW. New York aims to reduce racial gap in maternal mortality. WKBW ABC News 7 (Buffalo, NY) 2018; Oct 01, 2018
https://www.wkbw.com/news/new-york-aims-to-reduce-racial-gap-in-maternal-mortality
Washington State. Department of Health. Maternal Mortality Review Panel. Accessed December 22, 2018
Print “Maternal Mortality in the Spotlight”
January 15, 2019
Another Plus for Prehabilitation
Seems like we’ve written many, many columns on the impact of frailty on a variety of medical outcomes but the impact on surgical outcomes has been most striking. Our surgical colleagues often say to us “Yes, I recognize when patients are frail. I tell them and their families that they are at greater risk for the surgery. What else am I supposed to do?”
Several studies have demonstrated that hospital multidisciplinary teams, usually led by geriatricians or other healthcare professionals who focus on those with frailty, may have a positive impact on outcomes for hospitalized frail patients. But the missing piece has always been whether doing anything preoperatively to ready frail patients for surgery makes a difference.
A systematic review (McIsaac 2017) found that few interventions have been tested to improve the outcomes of frail surgical patients, and most available studies are at substantial risk of bias.
Now a new study (Howard 2019) adds to a slowly growing body of evidence that “prehabilitation” does, indeed, have a positive impact on surgical outcomes. The Michigan Surgical and Health Optimization Program (MSHOP) is a formal prehabilitation program that engages patients in 4 activities before surgery: physical activity, pulmonary rehabilitation, nutritional optimization, and stress reduction. Patients were referred to the program at the discretion of their surgeon, with at least 2 weeks between referral and the surgery. The program focused on walking (patients receive a pedometer to track steps), breathing (patients receive an incentive spirometer), nutrition and stress management. They also received advice on smoking cessation, if appropriate. A DVD and brochure with instructions and resources for each domain was provided to patients, as well as a way to log their participation. During their involvement in the program, patients receive emails, phone messages, and text message-based reminders to
continue.
Overall, 70% of MSHOP patients complied with the program. MSHOP patients had better physiologic reserve (demonstrated by better systolic and diastolic blood pressures and lower heart rate compared to the other groups one hour into surgery). There was a significant reduction in class 3 to 4 complications in the MSHOP group (30%) compared with the nonprehabilitation (38%) and emergency (48%) groups. Total hospital charges averaged $75,494 for the MSHOP group, $97,440 for the nonprehabilitation group, and $166,085 for the emergency group. That translates to an average savings of $21,946 per patient. The authors note this represents a significant cost offset for a prehabilitation program. They conclude a prehabilitation program should be considered for all patients undergoing surgery.
A significant limitation of this study is that it was not specifically a study of a frail population and there were no specific inclusion criteria for frailty. But a retrospective comparison of frailty data between groups (using psoas muscle size as a proxy for frailty) did identify a higher incidence of frailty in the MSHOP group. Therefore, those patients would have been expected to do worse. But this study demonstrates that surgical prehabilitation is beneficial in that these patients do not have the inferior outcomes and patients who completed prehabilitation had superior outcomes in some cases.
This was also not a randomized, controlled trial. Rather patients were referred at the discretion of their surgeon (hence, some likely selection bias) and groups were chosen for comparison by propensity score matching.
In our April 10, 2018 Patient Safety Tip of the Week “Prepping the Geriatric Patient for Surgery” we discussed some other preoperative programs for frail elderly patients. The Perioperative Optimization of Senior Health (POSH) study (McDonald 2018) looked patients who were undergoing elective abdominal surgery and were considered at high risk for complications (ie, older than 85 years or older than 65 years with cognitive impairment, recent weight loss, multimorbidity, polypharmacy, visual or hearing loss, or simply deemed by their surgeons to be at higher risk). Intervention patients received a multidisciplinary comprehensive preoperative evaluation that focused on cognition, medications, comorbidities, mobility, functional status, nutrition, hydration, pain, and advanced care planning.
Despite higher mean age and morbidity burden, older adults who participated in this interdisciplinary perioperative care intervention had fewer complications, shorter hospitalizations, more frequent discharge to home, and fewer readmissions than a comparison group. Though this was not a randomized, controlled trial (it was a before/after study design) and did not include a formal frailty measure, it is quite clear that most or all the intervention group patients were frail.
One small randomized trial of “prehabilitation” in high-risk patients (age >70 years and/or American Society of Anesthesiologists score III/IV) undergoing elective major abdominal surgery has recently been completed (Barberan-Garcia 2018).The researchers randomized 71 patients to the control arm and 73 to intervention. Prehabilitation covered 3 actions: motivational interview; high-intensity endurance training, and promotion of physical activity. The intervention group enhanced aerobic capacity, reduced the number of patients with postoperative complications by 51%, and the rate of complications (P = 0.001).
A small randomized clinical trial in Canada (Minnella 2018) compared prehabilitation with a control group. Intervention consisted of preoperative exercise and nutrition optimization. Participants were adults awaiting elective esophagogastric resection for cancer. Compared with the control group, the prehabilitation group had improved functional capacity (measured by change in 6-minute walk distance) both before surgery and after surgery.
But a larger randomized study is ongoing (McIsaac 2018). This is a single-center, parallel-arm randomized controlled trial of home-based exercise prehabilitation versus standard care among consenting patients >60 years having elective cancer surgery (intra-abdominal and intrathoracic) and who are frail (Clinical Frailty Scale >4). The intervention consists of > 3 weeks of exercise prehabilitation (strength, aerobic and stretching). The primary outcome is the 6 min walk test at the first postoperative clinic visit. Secondary outcomes include the short physical performance battery, health-related quality of life, disability-free survival, complications and health resource utilization.
Hopefully the ongoing McIsaac study will provide definitive answers about utility of prehabilitation in preparing the frail geriatric patient for surgery.
One other program we’ve previously mentioned is the American College of Surgeons’ Strong for Surgery program. This program is intended to optimize patients’ overall status prior to surgery and provides a toolkit with checklists. “Strong for Surgery” empowers hospitals and clinics to integrate checklists into the preoperative phase of clinical practice for elective operations. The checklists are used to screen patients for potential risk factors that can lead to surgical complications, and to provide appropriate interventions to ensure better surgical outcomes.” The checklists in the Strong for Surgery Toolkit target eight areas known to be influential determinants of surgical outcomes:
It’s certainly logical that optimizing patients prior to surgery might improve outcomes. We are finally beginning to validate that concept and identifying the components of such “prehabilitation” programs that lead to success.
Some of our prior columns on preoperative assessment and frailty:
References:
McIsaac DI, Jen T, Mookerji N, et al. Interventions to improve the outcomes of frail people having surgery: A systematic review. PLOS One 2017; Published: December 29, 2017
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0190071
Howard R, Yin YS, McCandless L, et al. Taking Control of Your Surgery: Impact of a Prehabilitation Program on Major Abdominal Surgery. J Amer Coll Surg 2019; 228(1): 72-80 Published online: October 22, 2018
https://www.journalacs.org/article/S1072-7515(18)32073-8/fulltext
McDonald SR, Heflin MT, Whitson HE, et al. Association of Integrated Care Coordination With Postsurgical Outcomes in High-Risk Older AdultsThe Perioperative Optimization of Senior Health (POSH) Initiative. JAMA Surg 2018; Published online January 3, 2018
https://jamanetwork.com/journals/jamasurgery/article-abstract/2666836?redirect=true
Barberan-Garcia A, Ubré M, Roca J, et al. Personalised Prehabilitation in High-risk Patients Undergoing Elective Major Abdominal Surgery: A Randomized Blinded Controlled Trial. Ann Surg 2018; 267(1): 50-56
https://insights.ovid.com/pubmed?pmid=28489682
Minnella EM, Awasthi R Loiselle S-E, et al. Effect of Prehabilitation on Functional Capacity in Esophagogastric Cancer Surgery. JAMA Surgery 2018; Online First June 13, 2018
https://jamanetwork.com/journals/jamasurgery/fullarticle/10.1001/jamasurg.2018.1645
McIsaac DI, Saunders C, Hladkowicz E, et al. PREHAB study: a protocol for a prospective randomised clinical trial of exercise therapy for people living with frailty having cancer surgery. BMJ Open. 2018; 8(6): e022057. Published online 2018 Jun 22
https://bmjopen.bmj.com/content/8/6/e022057
American College of Surgeons. Strong for Surgery. Updated November 2018
https://www.facs.org/quality-programs/strong-for-surgery
Print “Another Plus for Prehabilitation”
January 22, 2019
Wandering Patients
In our July 28, 2009 Patient Safety Tip of the Week “Wandering, Elopements, and Missing Patients” we lumped together patient wandering and elopement or absconding. While the response each organization must take when a patient goes missing has similarities, there are definite differences between elopement/absconding and wandering.
Elopement implies intention. The term applies primarily to patients admitted to behavioral health facilities who leave the facility without notice. Wandering, on the other hand, is usually seen in patients with some degree of cognitive or executive impairment or impaired orientation, such as seen in patients with Alzheimer’s Disease or other dementias, head injuries, psychiatric disorders, developmental disabilities, acquired neurological disorders, etc. Today, our focus will be on the wandering patient.
A patient who had been reported as missing ended up in a New York hospital (Moore 2017). Police subsequently notified family where the patient was but when they arrived at the hospital, they were told he had disappeared again, wandering out in his white hospital gown, sky blue pajama pants and beige hospital socks.
A 50 y.o. disabled man walked out of an Atlanta hospital and was found 5 miles from the hospital more than 24 hours later bruised, still wearing a heart monitor and an IV, and confused (Jaquez 2018).
Last March a 71-year old man admitted to a Pittsburgh hospital with symptoms of a possible stroke went missing (KDKA2 2018) . He was believed to have walked out of the hospital at 9:20 p.m. and had not been seen since. His wife was about to pick him up just before he vanished. “She had gotten there around 9:50, and when she had gotten there, they said that he left around 9:20, took his IV out and left, and that’s the last time he’s been seen.” A search, including local police was initiated. His body was recovered from the Ohio River several days later (Luciew 2018). He apparently lived about 5 miles across the river from the hospital and some speculated he may have been trying to go home.
A patient with dementia and aggressive behavior was brought to a California hospital for psychiatric evaluation (CDPH 2017a). Disposition in the ER was planned admission as an inpatient, though he was housed in the ER Overflow area for several days. He was described as continuously attempting to walk out of the ER, anxious to go home, uncooperative some time, unable to follow simple directions, needing frequent redirection, agitated, wandering, and pacing. On the third day he was noted to be missing from the ER Overflow area. Two days later he was found dead, lying prone on a beach. The Medical Examiner determined death was the result of drowning.
At another California hospital (CDPH 2017b), an 81 y.o. man was admitted to a telemetry unit after a suspected MI. Because of a high fall risk score he had a bed alarm and was to receive hourly rounding. But because on the second hospital day he was ambulating without any difficulty and using the bathroom without any assistance, a nurse chose to disable the bed alarm. Sometime around 3AM a nurse was notified that the patient was no longer sending a telemetry signal. The nurse found the patient missing from his room and notified staff and security and a search was initiated by nursing and hospital security staff. The patient was found about an hour later at the bottom of an internal hospital stairwell, without a pulse, and could not be resuscitated.
At yet another California hospital, a 33 y.o. woman being held at the hospital on a 72-hour psychiatric hold (Van Derbeken 2018) (Montes 2018). She apparently was being treated on a bed in a hallway. She may have gone to the bathroom around 2AM but it is not clear whether anyone checked on her until she was found dead in a hallway at 6AM. This case is ironic in a couple regards. Just a week earlier, another dead body had been found in the power plant of this hospital (Newman 2018). That person was not a patient at this hospital but rather had gone missing from a Behavioral Health Center on the hospital’s 23-acre campus. And this was the same hospital where a wandering patient had been found dead in 2013 (see our October 15, 2013 Patient Safety Tip of the Week “Missing Patients” and our December 2013 What’s New in the Patient Safety World column “Lessons from the SFGH Missing Patient Incident”).
These cases are reminders that wandering patients are at significant risk of harm or death.
To prevent such disastrous outcomes there are three important steps:
The first step is identifying those patients at risk for wandering. We have been unable to find a validated risk assessment tool for wandering. A formal search for wandering instruments a few years ago yielded 34 instruments (White 2013). Of these, one wandering-specific measure and four measures of behavioral change in dementia met their inclusion criteria. The ability of these to confidently evaluate the risk of getting lost remains uncertain. They concluded that further research is required to more fully evaluate the psychometric properties of the retrieved instruments.
Probably the most widely known wandering risk assessment tool is the Dewing Wandering Risk Assessment Tool (Dewing 2008) but there are others as well (ECME14 Elopement Risk Decision Tree, NYSHFA 2005, Sheth 2014) and there are numerous factors that are often seen in patients who wander.
In our July 28, 2009 Patient Safety Tip of the Week “Wandering, Elopements, and Missing Patients” we noted that many of the risk factors for wandering and elopement are also risk factors for delirium. So if you have been following this column and begun screening for delirium risk factors, you are halfway there! Alzheimer’s disease or any dementia may predispose the patient to wandering. Most of you recognize the term “sundowning” which we apply to those patients with dementia who become more confused and disoriented in new unfamiliar settings such as the hospital. Such patients may be prone to wandering and elopement. But any patient with impaired cognition may be at risk. This includes patients with psychiatric disorders, developmental disabilities, and acquired neurological disorders. But there are other risk factors or contributing factors as well. Many of the drugs we’ve talked about under delirium (particularly sedating agents) may contribute. A prior history of wandering or elopement (eg. at a long-term care facility prior to admission) should be a red flag.
Some standardized questions that appear on most wandering assessment tools are:
But keep in mind: things change during a hospitalization. Therefore, a single assessment for elopement/wandering risk on admission is not sufficient. That risk assessment must be repeated after surgery, at internal transfers of care, and any time there has been a significant change in the patient’s mental status or overall medical status. The same patients should have formal risk assessments for delirium and falls.
Part of identifying patients at-risk for wandering also includes how you flag them as being high risk. Most EMR’s (electronic medical records) have a field that can be used to flag such patients. In the old days we used to put colored stickers on patients’ paper charts. But wandering patients don’t carry around their paper or electronic medical record! So you have to flag them in some other manner. Most facilities use some form of color-coded clothing or color-coded bracelets. But both have their faults. A patient who wanders may be on a unit where they typically do not wear gowns at all (eg. a behavioral health unit or a “memory” unit). Or they may change into street clothing before wandering. Color-coded bracelets are helpful but you need to be sure all your staff (including temporary ones) understand what the color means. For years we’ve pushed for universal (or at least regional) color coding schemes but we are not there yet. You may have staff that work in more than one hospital and a specific color may mean something different at each hospital. Also keep in mind that such patients, even though they may be cognitively impaired, may be quite good at ridding themselves of bracelets or other devices!
The second step is intervention to minimize wandering and minimize risk of wandering to dangerous areas inside or outside the hospital. It makes sense to put them in a room where staff would be more likely to see them exit the room (usually closer to the nurse’s station). Many floors have one or two rooms that are video monitored, a logical choice for such patients.
Consider having the patient wear a gown that is a different color than the usual gowns so that all staff would recognize such patient as being “lost” if encountered in other parts of the hospital. For example, Yale-New Haven Hospital (Yale-New Haven 2017) has adults at risk of wandering and elopement wear yellow gowns.
Potential exit doors on the unit should be fitted with appropriate alarms (that are functioning correctly) and with appropriate signage to keep the door closed. Consider keeping the patient in a room with a roommate or have family members stay in the room. Attention to the patient’s physical needs (food, water, warmth, pain management, toileting) are important. Letting the patient walk or exercise under supervision may be useful. The references below (VA Toolkit: Patients at Risk for Wandering, Spencer 2008, Rowe 2008) also contain excellent points on care management of the patient at risk for wandering.
Internal patient transports may also be vulnerable events. You’ve heard us talk on several occasions about the “Ticket to Ride” concept in which a formal checklist is completed for all transports (eg. to radiology). Such checklists typically contain information related to adequacy of any oxygen supplies and medications needed but should also include information about things like suicide risk and elopement or wandering risk. These all need to be conveyed to the caregiver who may be accepting the patient in the new area. Just as we’ve talked about cases where a patient may attempt suicide in a bathroom in the radiology suite that is not suicide-proofed, a patient at risk for elopement may wander off easily while waiting in the radiology suite if not appropriately supervised.
In this day and age, use of technology to track at-risk patients makes a lot of sense. There are a variety of RFID, Bluetooth, or GPS devices (eg. bracelets, anklets) that can be used for such tracking. Heck, I can track my car keys or my dog with these devices! The RFID and Bluetooth devices are limited in range. But, if you have receiving devices for these technologies spread throughout your facility, you should at least be able to find a patient who is still within your facility or to identify an exit the patient may have taken out of the facility. GPS tracking devices obviously are more expensive but would be useful for tracking patients who have left your facility. But keep in mind that such patients, even though they may be cognitively impaired, may be quite good at ridding themselves of bracelets or other devices. Such systems should never be relied on as the sole means of monitoring such patients. And each day the system/device should be checked to ensure it is functioning properly.
What about bed alarms? Our own experience with these is mixed. Bed alarms trigger when a patient gets up out of bed. So they can help identify when, particularly at night, a patient gets up out of bed. But we’ve seen that such alarms tend to trigger so often, particularly with patients already prone to wandering, that they simply contribute to alarm fatigue and often get ignored, manipulated or discontinued.
We’ve sometimes discussed the value of having photographs of patients in the medical record. This is one circumstance where having a digital photo is very important. If a patient goes missing, it can be important not only to broadcast an alert in your facility but also to be able to include a photo to help staff recognize the patient. Such photos can also be given to local police or other authorities outside your facility that may be involved in a search for a missing patient.
Training of staff is very important. This applies not only to all your healthcare professionals but to everyone who works in the hospital, whether they have clinical expertise or not. They must be trained both to recognize the wandering patient and then to understand techniques (de-escalation, re-direction, etc.) that need to be used with such patients.
Cognitive reminders are for hospital staff, not patients! The VA National Center for Patient Safety has a Toolkit: Patients at Risk for Wandering that includes cognitive reminders such as pocket cards or posters that help remind staff how to interact with wandering patients. These stress the following points when communicating with patients:
You also need to make your staff aware of “tailgating” behavior. This is where a wandering (or eloping) patient waits for someone to enter/exit through a door and then he/she uses that door to exit.
We should also mention staffing issues as factors contributing to wandering patients leaving the unit or the facility. In several of the incidents noted at the beginning of today’s column, there were times when staffing was short (eg. lunch breaks, etc.). Also, we’ve mentioned in some of our other columns on behavioral health issues that change of shift is also a vulnerable period.
Your facility should have exit cameras at all your entrances/exits. You’ll see below that one of the first things in your search for a missing patient is to look at the playback on those exit cameras to identify whether a patient has left the facility.
Robin Hattersley-Gray, in an excellent 2-part series on wandering patients (Hattersley-Gray 2018a) (Hattersley-Gray 2018b), discusses many of the other environmental considerations that can promote or prevent a patient from exiting the unit or facility. Some of those, however, are aimed more toward “memory” units rather than general med/surg floors. These recommendations might include bumpers on the walls, lighted paths, painting doors like the walls so they look like one continuous scene, or even having curved walls rather than right-angle walls.
We’d also like to make the observation that many of the fatal outcomes for wandering or eloping patients occur in hospital stairwells. Motion-activated security cameras that link via WiFi to a variety of systems are so inexpensive today that hospitals could put them in virtually all stairwells. While the threat of alarm fatigue would preclude their use much of the day, they could be activated during hours when “normal” stairwell traffic is minimal (eg. after evening visiting hours have ended). The alarms can be tied into your central security room and those on individual floors can also be programmed to alarm at the nursing station on those floors (or to designated smartphones).
The third step is having a plan for what to do if a patient goes missing. (And, we probably should emphasize a fourth step: practice or drill for that plan!).
The response to a missing patient is critical. It must be rapid, well-planned, and thorough in order to find the patient before he/she suffers any harm. Some facilities have chosen to merge their infant abduction policy with the elopement or missing patient policy since the procedures may be very similar. But be careful – you don’t want your staff searching for a newborn by mistake when they should be looking for a wandering geriatric patient.
Staff on the unit need to be notified as soon as a patient is missing. A very brief head count of patients and look in rooms on a unit is typically done but this should last no more than a couple minutes. At that point the hospital phone operator should be notified and “code yellow” (or whatever name you use at your facility) should be announced over the public address system. It should be announced with a brief description of the missing patient (age, sex, race, unit, etc.). Exits from the building need to be immediately locked (some doors may be locked from a central location) or manned by designated staff members. No one should be allowed to leave the building(s). The operator may notify visitors over the PA system that they are under no danger but need to avoid going near exits for the time being. Key assigned staff should immediately go to a designated “command center” from which they will direct the response. Each unit (clinical and nonclinical) will have a specific predetermined area they must search in a systematic fashion. The command center must have an overlay grid of the buildings and surrounding areas and be able to mark off areas on the grid that have been searched. The search teams must have keys to their search areas since sometimes patients lock themselves into rooms inadvertently. Don’t forget to look in all stairwells, parking lots, roofs, elevators, and closets.
We also recommend early outdoor search since a patient can easily stray far from the building (or into automobile traffic) in a very short period of time. We also recommend that the local police department be notified immediately by the operator when the “code yellow” is called (don’t forget to include them in your planning process). Many facilities also use many security video cameras that are monitored centrally. Security staff may be able to scan those quickly to look for a patient exiting the building.
In our October 15, 2013 Patient Safety Tip of the Week “Missing Patients” we noted a directive in the VA system regarding management of wandering and missing patients (VHA 2010). The VHA directive includes recommendations about assessing all patients for risk of wandering or becoming missing while in treatment. It then describes what should be done when a patient is found to be missing, including both preliminary and full searches. It discusses designation of persons to be responsible for various aspects of the response to a missing patient, including “off-hours” as well as during usual business hours. Particularly useful is the discussion of the full search. This includes superimposing a grid map over a site and facility plot to delineate the search sectors. One individual is assigned responsibility to ensure all search grid sector assignments are made, the times and by whom grid sectors are searched, times and by whom each building is searched, times and to whom notifications and requests are made, and results of the searches. The recommendations include a description of both the indoor search and the outdoor search. It describes that each search team has a leader and how members of the search teams are to conduct their searches.
Someone on the unit from which the patient disappeared should be designated to send out a general email to all staff, describing the missing patient and including a photograph if one is present on the information system. The patient’s physician should be notified by the operator or staff on the patient unit. Someone needs to be designated to be in communication with the family as well.
Also in our October 15, 2013 Patient Safety Tip of the Week “Missing Patients” we noted a good piece of advice from the Minnesota Hospital Association (MHA 2011). Most of you are aware of the movement to replace “codes” with plain language for paging emergencies in hospitals (and other healthcare settings). The MHA recommends that the plain language overhead page be: “Missing person (of any age) + descriptor (and as appropriate, action for staff/patient/visitors.)” We think that including something about the action to take is important for both staff and visitors.
Hattersley-Gray (Hattersley-Gray 2018b) also has a recommendation we had not previously thought about: placing some of the patient’s personal items and garments in a sealed plastic bag can be very beneficial because a search dog can quickly identify the patient’s scent.
To facilitate the response to a missing patient, we recommend you have a readily available checklist that has all the steps you need to take and includes items such as the phone numbers of police and local agencies you must contact.
What do you do when you find the patient? First, be aware they are likely confused and be careful not to frighten them. Do a brief assessment as to whether they may have been injured. Notify the command center you have found the patient and either return them to their unit or to the emergency department. They should be evaluated by a physician at that time to determine whether any injuries have occurred. In the unfortunate circumstance where the patient is found dead, the scene should be left undisturbed because the authorities will treat it as a crime scene.
Drills are critical for any event that is likely to be rare but critical when it occurs. Just as we’ve hammered home in our discussions about surgical fires, it is important that all staff know what to do during certain emergencies and the best way to prepare for those is with drills. Yes, you can and should include education and training on missing patient alerts during orientation and annual reorientation but you have to periodically run a drill to see whether the responses are adequate and timely. During drills one may also see various nooks and crannies and other areas (eg. ventilation ducts) that a patient could get into, perhaps leading to some physical improvements to prevent such dangerous access. You might also consider using a “secret wanderer” (person dressed as a patient in one of the special colored gowns) to see if staff identify them as a wanderer.
Staff education obviously is important but should be ongoing rather than just being delivered at annual orientation sessions. The Bay Pines (Florida) VA Hospital uses a creative reminder device on patient care areas that is shaped like a stop sign and uses the mnemonic “DON’T GET LOST” which stands for:
D Determine at-risk patients
O Observe for wandering triggers
N No-fall environment
T Teach staff/nonclinical support
G Get patient involved in activities
E Exit control
T Talk to patient and provide reassurance
L Low patient to staff ratio
O Offer food, drink and toileting
S Structure and routine
T TEAMWORK!!
Ongoing surveillance is also important. When we do patient safety walkrounds we also incorporate much of what traditionally has been termed environment of care rounds. We look to see that doors and other accesses to dangerous places are locked and appropriately alarmed. We also look at windows leading to rooftops and make sure no one could open them and exit onto a rooftop.
You probably will be unable to prevent every potential disappearance or elopement. When one does occur, do a debriefing session as soon as possible to identify potential missed clues and other useful lessons. Then do a formal root cause analysis within a short timeframe. There are always valuable lessons learned that hopefully can prevent other elopements in the future.
But don’t wait until you “lose” a patient. Review your current programs for wandering patients or those at risk for elopement. If need be, do a FMEA (Failure Mode and Effects Analysis) to determine your vulnerabilities and take steps to close the “cracks”.
See our previous columns on wandering, eloping, and missing patients:
References:
Moore T. City hospital allowed patient with dementia to wander off: family. NY Post 2017; December 6, 2017
https://nypost.com/2017/12/06/city-hospital-allowed-patient-with-dementia-to-wander-off-family/
Jaquez N. Disabled patient who left hospital unnoticed is found more than 24 hours later. WSB-TV (Atlanta) 2018; August 7, 2018
KDKA2. Police Seek Help Locating Missing Man After Walking Out Of Hospital. KDKA2 CBS (Pittsburgh) 2018; March 23, 2018
http://pittsburgh.cbslocal.com/2018/03/23/man-missing-walks-out-pittsburgh-hospital/
Luciew J. Man who checked himself out of hospital is found dead in Pa. river. Penn Live 2018; Mar 27, 2018
http://www.pennlive.com/daily-buzz/2018/03/man_who_walked_out_of_hospital.html
CDPH (California Department of Public Health). Complaint Intake Number CA00358774; 2017
CDPH (California Department of Public Health). Complaint Intake Number CA00513129; 2017
Van Derbeken J. SFPD Investigating After Another Body Found in San Francisco General Hallway. NBC Bay Area 2018; June 5, 2018
Montes D (Bay City News). Patient who died unexpectedly at SFGH last week id’ed. San Francisco Examiner 2018; January 12, 2018
http://www.sfexaminer.com/patient-died-unexpectedly-sfgh-last-week-ided/
Newman M. Resident of SFGH campus reported missing ten days before she was found in a SFGH stairwell. Mission Local News 2018; May 31, 2018
White EB, Montgomery P. A Review of “Wandering” Instruments for People With Dementia Who Get Lost. Research on Social Work Practice 2013; 24(4): 400–413 First Published November 27, 2013
https://journals.sagepub.com/doi/abs/10.1177/1049731513514116
Dewing J. Dewing Wandering Risk Assessment Tool. Version 2 (September 2008)
ECME14 Elopement Risk Decision Tree
NYSHFA (New York State Health Facilities Association). Risk Assessment Elopement Decision Tree. Elopement Resource Manual. May 2005
http://www.nccdp.org/ElopementManual.doc
Sheth HS, Krueger D, Bourdon S, Palmer RM. A New Tool to Asses Risk of Wandering in Hospitalized Patients. Journal of Gerontological Nursing 2014; 40(3): 1-6 February 2014
Yale-New Haven Hospital. Hospital issues new guidelines for elopement risk. The Bulletin (Yale-New Haven Hospital) 2017; February 2, 2017
VA National Center for Patient Safety. A Toolkit: Patients at Risk for Wandering. US Department of Veterans Affairs 2015; Last updated June 3, 2015
https://www.patientsafety.va.gov/A_Toolkit_Patients_At_Risk_for_Wandering.asp
Spencer E. Policy for Assessment and Care Management of Patients who are at risk of Wandering in the Acute Care Setting. University Hospitals of Leicester. August 2008
Rowe M. Wandering in Hospitalized Older Adults: Identifying risk is the first step in this approach to preventing wandering in patients with dementia. AJN, American Journal of Nursing 2008; 108(10): 62-70
Hattersley-Gray R. Preventing Elderly Patient Wandering and Elopement: Part 1. Campus Safety 2018; March 15, 2018
https://www.campussafetymagazine.com/hospital/elderly-patient-wandering-elopement/
Hattersley-Gray R. Responding to Elderly Patient Elopement and Wandering: Part 2. Campus Safety 2018; April 9, 2018
https://www.campussafetymagazine.com/news/elderly-patient-elopement-wandering/
VHA (Department of Veterans Affairs. Veterans Health Administration). VHA Directive 2010-052. MANAGEMENT OF WANDERING AND MISSING PATIENTS. VHA 2010; December 3, 2010
http://www.va.gov/VHAPUBLICATIONS/ViewPublication.asp?pub_ID=2340
MHA (Minnesota Hospital Association). Plain Language Overhead Emergency Paging. Implementation Toolkit. 2011
http://www.mnhospitals.org/Portals/0/Documents/ptsafety/overhead-paging-toolkit-2011.pdf
Print “Wandering Patients”
January 29, 2019
National Patient Safety Goal for Suicide Prevention
In our December 12, 2017 Patient Safety Tip of the Week “Joint Commission on Suicide Prevention” we highlighted The Joint Commission’s recommendations on suicide prevention (TJC 2017).
Those have now been incorporated into a new National Patient Safety Goal NPSG.15.01.01: Reduce the risk for suicide (Lyons 2018). Effective July 1, 2019, there will be seven new and revised elements of performance (EPs) supporting this NPSG (TJC 2018). These are listed below for both the behavioral health care (BHC) and hospital (HAP) accreditation programs. There are also some elements important for non-psychiatric units in general hospitals.
NPSG.15.01.01.EP1: Environmental Risk Assessment
BHC: The organization conducts an environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide; the organization takes necessary action to minimize the risk(s) (for example, removal of anchor points, door hinges, and hooks that can be used for hanging).
HAP: For psychiatric hospitals and psychiatric units in general hospitals: The hospital conducts an environmental risk assessment that identifies features in the physical environment that could be used to attempt suicide; the hospital takes necessary action to minimize the risk(s) (for example, removal of anchor points, door hinges, and hooks that can be used for hanging).
As we noted in our December 12, 2017 Patient Safety Tip of the Week “Joint Commission on Suicide Prevention”, non-psychiatric units in general hospitals are not expected to be ligature-resistant. But that does not mean they are exempt from taking steps to reduce the risk of patient suicide. They are expected to implement procedures to mitigate the risk of suicide for patients at high risk for suicide, such as one-to-one monitoring, removing objects that pose a risk for self-harm if they can be removed without adversely affecting the patient’s medical care, assessing objects brought into a room by visitors, and using safe transportation procedures when moving patients to other parts of the hospital. (See also below for our own comments on areas, such as your radiology suite bathrooms, where you probably should make sure they are ligature-resistant). The Joint Commission elements do stress that each organization needs to assess how it will identify objects that could be used for self-harm and use this information in staff training.
We refer you back to our December 12, 2017 Patient Safety Tip of the Week “Joint Commission on Suicide Prevention” for details of The Joint Commission’s recommendations on the environmental risk assessment (TJC 2017), most of which rely heavily on many of the points from the VA’s Mental Health Environment of Care Checklist, which we’ve discussed in so many columns (most recently in our August 29, 2017 Patient Safety Tip of the Week “Suicide in the Bathroom”). In our February 14, 2017 Patient Safety Tip of the Week “Yet More Jumps from Hospital Windows” we mentioned 2 publications (Watts 2016, Mills 2016) showing sustained results from implementation of the Mental Health Environment of Care Checklist (MHEOCC). The checklist and program became mandated at all VA hospitals in 2007. Inpatient suicide rates in VA hospitals dropped from 4.2 per 100,000 admissions to 0.74 per 100,000 admissions from 2000 to 2015. The reduction in suicides coincided with introduction of the MHEOCC and has been sustained since implementation in 2007. The authors stress that the physical changes brought about by the MHEOCC likely have a bigger impact on inpatient suicide reduction than the numerous other interventions used.
Again, see our comments below regarding special issues for non-psychiatric units in general hospitals.
NPSG.15.01.01.EP 2: Use of a validated screening tool to assess patients at risk
BHC: Screen all individuals served for suicidal ideation using a validated screening tool.
HAP: Screen all patients for suicidal ideation who are being evaluated or treated for behavioral health conditions as their primary reason for care using a validated screening tool.
TJC provides examples of validated screening tools: the ED Safe Secondary Screener, the PHQ-9, the Patient Safety Screener, the TASR Adolescent Screener, and the ASQ Suicide Risk Screening Tool. The Columbia-Suicide Severity Rating Scale can be used for both screening and more in-depth assessment of patients who screen positive for suicidal ideation using another tool. There is more information on the use of the Columbia-Suicide Severity Rating Scale in the NPSG.15.01.01 Suicide Prevention Resources document. (We also discussed it in our December 2011 What’s New in the Patient Safety World column “Columbia Suicide Severity Rating Scale”).
TJC also provides a link to an article “Development and Implementation of a Universal Suicide Risk Screening Program in a Safety-Net Hospital System” (Roaten 2018).
NPSG.15.01.01.EP 3: Evidence-based process for conducting suicide risk assessments of patients screened positive for suicidal ideation
BHC: Use an evidence-based process to conduct a suicide risk assessment of individuals served who have screened positive for suicidal ideation. The assessment directly asks about suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors. Note: EPs 2 and 3 can be satisfied through the use of a single process or instrument that simultaneously screens individuals served for suicidal ideation and assesses the severity of suicidal ideation.
HAP: Use an evidence-based process to conduct a suicide risk assessment of patients who have screened positive for suicidal ideation. The assessment directly asks about suicidal ideation, plan, intent, suicidal or self-harm behaviors, risk factors, and protective factors.
Note: EPs 2 and 3 can be satisfied through the use of a single process or instrument that simultaneously screens patients for suicidal ideation and assesses the severity of suicidal ideation.
Here they again note that the Columbia-Suicide Severity Rating Scale can be used for both screening and more in-depth assessment of patients who screen positive for suicidal ideation using another tool. Another tool is SAMHSA’s SAFE-T Pocket Card: Suicide Assessment Five-Step Evaluation and Triage for Clinicians, which is now also available for download as an app on your mobile devices.
NPSG.15.01.01.EP 4: Documentation of patients’ risk and the plan to mitigate
BHC: Document individuals' overall level of risk for suicide and the plan to mitigate the risk for suicide.
HAP: Document patients’ overall level of risk for suicide and the plan to mitigate the risk for suicide.
Here they stress the importance that all clinicians who might come in contact with a patient at risk for suicide be aware of the level of risk and the mitigation plans to reduce that risk. Such information should be explicitly documented in the patient’s record.
NPSG.15.01.01.EP 5: Written policies and procedures addressing care of at-risk patients, and evidence they are followed
BHC: Follow written policies and procedures addressing the care of individuals served identified as at risk for suicide. At a minimum, these should include the following: - Training and competence assessment of staff who care for individuals served at risk for suicide - Guidelines for reassessment - Monitoring individuals served who are at high risk for suicide
HAP: Follow written policies and procedures addressing the care of patients identified as at risk for suicide. At a minimum, these should include the following:
Those written policies and procedures should include specifics about training and competence assessment of staff.
NPSG.15.01.01.EP 6: Policies and procedures for counseling and follow-up care for at-risk patients at discharge
BHC: Follow written policies and procedures for counseling and follow-up care at discharge for individuals served identified as at risk for suicide.
HAP: Follow written policies and procedures for counseling and follow-up care at discharge for patients identified as at risk for suicide.
A patient’s risk for suicide is high after discharge from the psychiatric inpatient or emergency department settings. Developing a safety plan with the patient and providing the number of crisis call centers can decrease suicidal behavior after the patient leaves the care of the organization. We would also stress the importance of scheduling the patient’s first followup visit and checking to see that the patient is compliant with such visit.
NPSG.15.01.01.EP 7: Monitoring of implementation and effectiveness, with action taken as needed to improve compliance
BHC: Monitor implementation and effectiveness of policies and procedures for screening, assessment, and management of individuals served at risk for suicide and take action as needed to improve compliance.
HAP: Monitor implementation and effectiveness of policies and procedures for screening, assessment, and management of patients at risk for suicide and take action as needed to improve compliance.
Your quality improvement program should monitor how often screening was done, the level of severity of risk assessed, how often specific items in the mitigation plan (eg. 1:1 monitoring) were followed, discharge arrangements made, and that all staff have had both initial training and reorientation as specified in your written policies.
There are a few points of our own we would like to stress about issues outside of behavioral health units. If you are a general hospital that has a behavioral health unit, there undoubtedly will be patients at risk for suicide in areas other than your behavioral health unit. One particularly important area is your radiology suite. In our August 25, 2015 Patient Safety Tip of the Week “Checklist for Intrahospital Transport” we stressed that suicide risk should be considered when patients are transported to Radiology (or other sites) whether the patient is on a behavioral health unit or medical unit (see our prior columns January 6, 2009 “Preventing Inpatient Suicides”, February 9, 2010 “More on Preventing Inpatient Suicides” and December 2010 “Joint Commission Sentinel Event Alert on Suicide Risk Outside Psych Units”). We’ve inspected bathrooms in radiology departments in several hospitals and uniformly found that not only do those bathrooms have numerous “loopable” items that could be used for hanging but also that they can be locked from the inside and there is typically no one readily available with a key to get in. In fact, that is one of the items we added to our patient safety scavenger hunt list (see our March 16, 2010 Patient Safety Tip of the Week “A Patient Safety Scavenger Hunt”). Bathrooms and other rooms in the radiology department also have many other tools and implements that could be used for suicide. So observation protocols for potentially suicidal patients on such units should ensure that doors are not locked (or, if they can be locked, that the “observer” has keys to access the bathroom). Having observers of the same gender as the patient also is recommended.
The other vulnerable area for patients at high risk for suicide is any of your acute care units in which you house psychiatric patients while their acute medical problems need attention. We’ve now done several columns on patients attempting or committing suicide by jumping from hospital windows. You should become familiar with the patient profile we’ve described for such patients (see, for example, our July 10, 2018 Patient Safety Tip of the Week “Another Jump from a Hospital Window”).
For those of you who frequently have such patients on your acute medical or surgical units, we suggest you actually consider making one or two rooms safer to be used for such patients. You could change the windows in such rooms to the type of windows used in behavioral health units. You could also minimize the number of “loopable” items in such rooms though, being realistic since you’ll more often be using these rooms for patients not at risk for suicide, some potentially loopable items will be needed in the rooms.
But there is much more than the physical environment that needs attention. In many, if not most, suicide incidents on med/surg units or ICU’s the staff have been inadequately trained to deal with behavioral health patients. Often, hospitals designate “sitters” to observe such at-risk patients but fail to ensure those “sitters” have adequate training for that task. The need training and testing for competency on how they would address the situation of a patient with serious suicidal ideation and 1:1 monitoring of patients with serious suicidal ideation. It would also include de-escalation techniques, conducting risk assessments for objects that could pose a risk for self-harm, identifying those objects that should be routinely removed from the immediate vicinity of patients with suicidal ideation, and plans for monitoring visitors (including what items visitors are allowed to bring with them). We also recommend you become familiar with the issue of bed positioning and furniture positioning we’ve discussed in our columns on jumps from windows.
Some of our prior columns on preventing hospital suicides:
References:
TJC (The Joint Commission). November 2017 Perspectives Preview: Special Report: Suicide Prevention in Health Care Settings. Recommendations Regarding Environmental Hazards for Providers and Surveyors. Joint Commission Online 2017; October 25, 2017
Lyons M. Joint Commission announces new National Patient Safety Goal to prevent suicide and improve at-risk patient care. Revisions effective July 1, 2019, for accredited hospitals and behavioral health programs. The Joint Commission 2018; December 5, 2018
TJC (The Joint Commission). R3 Report. National Patient Safety Goal for suicide prevention. The Joint Commission 2018; Issue 18: Nov. 27, 2018
https://www.jointcommission.org/assets/1/18/R3_18_Suicide_prevention_HAP_BHC_1_2_18_Rev2_FINAL.pdf
Mental Health Environment of Care Checklist (VA)
http://www.patientsafety.va.gov/docs/MHEOCCed092016508.xlsx
http://www.patientsafety.va.gov/professionals/onthejob/mentalhealth.asp
Watts BV, Shiner B, Young-Xu Y, Mills PD. Sustained Effectiveness of the Mental Health Environment of Care Checklist to Decrease Inpatient Suicide. Psychiatric Services 2016; Published Online Ahead of Print: November 15, 2016
http://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201600080
Mills PD. Use of the Mental Health Environment of Care Checklist to Reduce the Rate of Inpatient Suicide in VHA. TIPS (Topics in Patient Safety) 2016; 16(3): 3-4 July/August/September 2016
http://www.patientsafety.va.gov/professionals/publications/newsletter.asp
Suicide Prevention Resource Center, The Patient Safety Screener (PSS-3): A Brief Tool to Detect Suicide Risk in Acute Care Settings.
http://www.sprc.org/micro-learnings/patientsafetyscreener
PHQ-9, (Patient Health Care Questionnaire – 9).
https://www.phqscreeners.com/sites/g/files/g10049256/f/201412/PHQ-9_English.pdf
TASR Adolescent Screener, The Tool for Assessment of Suicide Risk for Adolescents (TASR-A): How to use the TASR – A.
http://teenmentalhealth.org/wp-content/uploads/2015/12/TASR-A_Package.pdf
ASQ Suicide Risk Screening Tool.
https://www.nimh.nih.gov/labs-at-nimh/asq-toolkit-materials/index.shtml
Columbia-Suicide Severity Rating Scale
TJC (The Joint Commission). NPSG.15.01.01 Suicide Prevention Resources document. November 15, 2018
https://www.jointcommission.org/npsg_150101_suicide_prevention_resources/
Roaten K, Johnson C, Genzel R, et al. Development and Implementation of a Universal Suicide Risk Screening Program in a Safety-Net Hospital System. Joint Commission Journal of Quality and Patient Safety, 2018; 44(1): 4-11
https://www.sciencedirect.com/science/article/abs/pii/S1553725017303343?via%3Dihub
SAMHSA (Substance Abuse and Mental Health Services Administration). SAFE-T Pocket Card: Suicide Assessment Five-Step Evaluation and Triage for Clinicians.
Print “National Patient Safety Goal for Suicide Prevention”
February 5, 2019
Flaws in Our Medication Safety Technologies
Over the last 2 decades we’ve implemented numerous technologies designed to improve medication safety. These have included barcoding, CPOE and e-prescribing, EMAR’s, automated dispensing cabinets, pharmacy IT systems, and pharmacy robots. These have helped us eliminate or reduce some of the errors we previously saw with handwritten or faxed medication orders. The new technologies have undoubtedly reduced many of the errors we saw in the pre-technology era. But, at the same time, they have introduced new error types or otherwise had unintended consequences. Patient Safety Tip of the Week is now in its 13th year and in every year we’ve had several columns on such unintended consequences related to healthcare IT (see full list at the end of today’s column).
A recent review of a database of pharmacist survey responses looked at both error prevented and errors observed in relation to e-prescribing and automated dispensing cabinets (Shaha 2019). The authors found the e-prescribing eliminated four error types but three new error types emerged (eg. duplicate prescriptions). Though e-prescribing eliminated many errors, wrong dose or wrong drug errors continued and either the prescriber or pharmacist might make wrong patient errors. Lack of required information also persisted.
Regarding automated dispensing cabinets (ADC’s), they found four error types were eliminated, three new error types emerged, and three error types persisted. Labelling errors were eliminated but wrong patient errors persisted and inaccuracies continued to be seen. Loading problems accounted for a large percentage of the “emerging” errors. (Note that we just did our January 1, 2019 Patient Safety Tip of the Week “More on Automated Dispensing Cabinet (ADC) Safety” after seeing another incident relating to ADC’s in our December 11, 2018 Patient Safety Tip of the Week “Another NMBA Accident”.)
Regarding source of the errors, Shaha and colleagues found that input errors accounted for about 3% of errors but that computer errors accounted for about 10%.
Ratwani and colleagues (Ratwani 2018) recently reviewed 9000 patient safety reports on medications errors that were likely related to EHR use in children from 3 different health care institutions. 3,243 (36 percent) had a usability issue that contributed to the medication event, and 609 (18.8 percent) of the 3,243 might have resulted in patient harm. The most common usability challenges were associated with system feedback and the visual display. The most common medication error was improper dosing. The general pattern of usability challenges and medication errors were the same across the three sites.
ISMP Canada recently did a column on electronic prescribing in primary care (ISMP Canada 2018), focusing on both the potential benefits and the unintended consequences. One the positive side they note:
But, on the negative side, they note the unintended introduction of risk:
They note that technology-related issues, such as automation complacency (over-reliance on technology) and incorrect selection from drop-down menus, have the potential to arise, similar to those that have been experienced with the introduction of computerized physician order entry in hospitals.
They highlight the risk that changes made in one component of the e-prescribing system may not be communicated to other components. As an example, they note the case where a prescriber makes a last-minute change to a previously transmitted e-prescription. Depending on the e-prescribing system, the revised prescription may override the initial one, or it may be necessary for the prescriber to cancel the initial prescription before transmitting the updated prescription. They note one study (Allen 2012) found 1.5% of e-prescriptions discontinued by the prescriber were dispensed, and about 12% of these improperly dispensed prescriptions were potentially harmful. (We highlighted the problem of discontinuation of medications in our March 2017 What's New in the Patient Safety World column “Yes! Another Voice for Medication e-Discontinuation!” and our Patient Safety Tips of the Week for August 28, 2018 “Thought You Discontinued That Medication? Think Again” and December 18, 2018 “Great Recommendations for e-Prescribing”.)
They also note one problem we were not familiar with. With some e-prescribing systems, prescriptions for multiple patients, from various prescribers, arrive in the pharmacy sequentially in the order of prescription submission rather than being “bundled” for the individual patient. This lack of prescription bundling can create confusion for the pharmacy team and may result in patients leaving the pharmacy without receiving all their prescriptions or with prescriptions intended for another person.
Free-text fields within electronic prescriptions are another source of errors. In a US study involving review of more than 3 million prescriptions (Dhavle 2016), it was found that 15% of e-prescriptions contained free-text data. About two-thirds of these free-text entries captured unnecessary information already present in other fields of the prescription. Notably, for 19% of the prescriptions with free-text entries, the information provided in the free-text field conflicted with directions included in the designated standard field intended for this purpose. Moreover, 9.6% were prescription cancellation requests for which a separate e-prescribing message currently exists but is not widely supported by software vendors or used by prescribers.
Lastly, the ISMP Canada column notes that e-prescribing systems often remove the patient from the process of conveying the prescription to the pharmacy, bypassing a patient’s potential safety check. They note that prescribers should engage the patient in
discussion at the time prescriptions are entered and provide patients with a printed summary of their prescribed medications. And better use should be made of “patient-facing applications” (e.g., patient portals) to support patient-based safety checks.
Abramson (Abramson 2015), in a literature review of errors in community pharmacies, found many new types of errors, such as provider order entry errors, transcription errors, and dispensing errors, resulting from e-prescribing.
On the provider ordering side she found some of the errors we’ve often talked about:
While a major benefit of e-prescribing is avoidance of transcription errors, many times there are interface problems, connectivity problems, or incompatibilities with pharmacy software that result in the need for manual input of the e-prescription into the pharmacy system. Errors may then be made during that manual transcription into the pharmacy system.
Dispensing errors were often associated with modified prescriptions. For example, once a prescription is sent by most e-prescribing systems, it may no longer be modified so the ordering provider inputs a new prescription. This may result in dispensing of more than one prescription. And, because the orders arrive at the pharmacy without “bundling”, a patient may not receive all his/her prescriptions or get someone else’s prescription intermixed with his/her prescriptions. Pharmacies also might fill a prescription twice if it was sent both via e-prescribing and fax. And, as we’ve so often discussed, pharmacies are often not notified when a provider discontinues a prescription, resulting in continued dispensing of discontinued drugs.
Abramson found that such errors often led to work inefficiency and rework for pharmacists, delays for patients, and increased costs to the pharmacies.
All these serve as a reminder that, as we implement new technologies intended to improve patient safety, we need to remain vigilant for introduction of unintended consequences.
See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:
References:
Shaha SR, Galtbc KA, Fuji KT. Error types with use of medication-related technology: A mixed methods research study. Research in Social and Administrative Pharmacy 2019; Available online 16 January 2019
https://www.sciencedirect.com/science/article/pii/S1551741119300233
Ratwani RM, Savage E, Will A, et al. Identifying Electronic Health Record Usability And Safety Challenges In Pediatric Settings. Health Affairs 2018; 37(11): Published online November 1, 2018
https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2018.0699?journalCode=hlthaff
ISMP Canada. Electronic Prescribing in Primary Care: Effects on Medication Safety. ISMP Canada Safety Bulletin 2018; 18(10): December 18, 2018
https://www.ismp-canada.org/download/safetyBulletins/2018/ISMPCSB2018-i10-ePrescribing.pdf
Allen AS, Sequist TD. Pharmacy dispensing of electronically discontinued medications. Ann Intern Med 2012; 157(10 ):700-705
http://annals.org/aim/article-abstract/1391698
Dhavle AA, Yang Y, Rupp MT, et al. Analysis of prescribers' notes in electronic prescriptions in ambulatory practice. JAMA Intern Med 2016; 176(4): 463-470
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2498845
Abramson EL. Causes and consequences of e-prescribing errors in community pharmacies. Integr Pharm Res Pract 2015; 4: 31-38
Print “Flaws in Our Medication Safety Technologies”
February 12, 2019
2 ER Drug Studies: Reassurances and Reservations
In the past month we came across two drug studies done in emergency departments that gave us both reassurance and reservations.
The first was a study of a clinical decision rule about how long you need to observe patients following opiate overdoses (Clemency 2019). The researchers did a validation study of St. Paul's Early Discharge Rule, developed in 2000 at St. Paul’s Hospital in Vancouver, BC but apparently not yet validated elsewhere. The rule was derived to determine which patients could be safely discharged from the emergency department after a 1‐hour observation period following naloxone administration for opiate overdose (Christenson 2000). The rule suggested that, one hour after the administration of naloxone for presumed opioid overdose, patients can be safely discharged from the ED if they meet all six criteria:
In the current study by Clemency and colleagues, a total of 538 patients received at least one administration of prehospital naloxone, were transported to the study hospital, and had a 1‐hour evaluation performed by a provider. Adverse events (AE’s) occurred in 15.4% of patients. The rule exhibited a sensitivity of 84.1%, a specificity of 62.1%, and a negative predictive value of 95.6%. Only one patient with a normal 1‐hour evaluation subsequently received additional naloxone following a presumed heroin overdose.
There were no deaths. The most frequent adverse events were:
Both provider judgement and the clinical prediction rule were predictive of adverse outcomes. Among the 10 cases in which both provider judgment and the rule failed to predict an AE, two patients received a repeat dose of naloxone after the 1‐hour evaluation and one patient was treated with artificial ventilation (bilevel positive airway pressure).
The authors attribute the expanded availability of intranasal naloxone as one of the key differences between the derivation study and the current study (85.4% of patients in the current study received IN naloxone). Also, 64.3% of patients in this study had actual ED lengths of stays greater than 4 hours, compared to 28.8% of patients whom had hospital stays of greater than 4 hours in the derivation study.
The one patient who received naloxone following a heroin overdose and had a normal 1‐hour evaluation was given another dose of naloxone 5 hours 30 minutes after her first dose in the field. In that case, the repeat naloxone administration occurred beyond the 4‐hour window they typically observe such patients.
This validation study did not include information on the route or type of opioid involved in the exposure when determining the performance characteristics of the rule.
Our reservations about the study have to do with long-acting and extended-release forms of opioids that have become so widely available. The problem arises when the half life of the administered naloxone is exceeded by the half life of the opioid taken or when there is delayed absorption of the opioid that allows “re-emergence” of opioid toxicity when blood levels rise after the naloxone effect has disappeared. We’ve done several columns on these drugs (see full list below). In our May 10, 2016 Patient Safety Tip of the Week “Medical Problems in Behavioral Health” we mentioned we’ve seen patients who have taken such drugs and been alert in the ED with low levels of drug in their urine screen yet become obtunded due to opioid intoxication the following day due to the delayed absorption of these drugs.
And, as one of the cases in the Clemency study demonstrated, pulse oximetry does not provide a good prediction of impending respiratory depression.
The Clemency study is reassuring that the majority of opioid overdose patients may be safely discharged after an hour if they meet the St. Paul's Early Discharge Rule criteria. However, we’d be very reluctant to discharge such patients that early if there is any doubt about the type of opioid (and route of administration) that led to the overdose.
The second study we came across compared 4 different pharmacologic agents (and 5 regimens) for treatment of acute agitation in the emergency department (Klein 2018). Medications were administered according to an a priori protocol in which the initial medication given was predetermined in the following 3-week blocks: haloperidol 5 mg, ziprasidone 20 mg, olanzapine 10 mg, midazolam 5 mg, and haloperidol 10 mg (all doses administered intramuscularly).
A total of 737 patients were included in the study. The proportion of patients adequately sedated at 15 minutes (assessed by the Altered Mental Status Scale) was greater for patients treated with midazolam than with haloperidol, olanzapine, and ziprasidone. Olanzapine also resulted in a greater proportion of patients adequately sedated at 15 minutes compared with haloperidol and ziprasidone.
Adverse events were uncommon: cardiac arrest (0), extrapyramidal adverse effects (2; 0.3%), hypotension (5; 0.5%), hypoxemia (10; 1%), and intubation (4; 0.5%), and occurred at similar rates in each group. Many patients required more than one dose or more than one medication and this occurred more often when midazolam used.
The results sound like a resounding endorsement of use of IM midazolam for acutely agitated patients. But we have a few reservations. The median age of the patients was 40, and the underlying etiology was thought to be acute alcohol intoxication in 88%.
We are surprised at the relative infrequency of serious adverse events. We suspect that we’d see more AE’s in older patients or those with multiple comorbidities.
So we’d probably say the real conclusion of this study is that IM midazolam in safe and effective for management of relatively young males with acute alcohol intoxication. The generalizability to other populations is certainly suspect. And we would emphasize that even in the currently studied population, the potential for respiratory depression due to the combined effects of alcohol and midazolam merits close monitoring.
A second question is whether adequate sedation at 15 minutes is the most appropriate outcome measure. That certainly might help you get bloodwork done and perhaps some other interventions. But probably more important would be parameters like time to disposition or time to discharge.
So you have 2 studies that statistically provide some reassurance on strategies for managing certain patients in the ED setting but leave enough questions that make it difficult to generalize about their use at this time.
Our prior articles pertaining to long-acting and/or extended release preparations of opioids:
References:
Clemency BM, Eggleston W, Shaw EW, et al. Hospital Observation Upon Reversal (HOUR) With Naloxone: A Prospective Clinical Prediction Rule Validation Study. Academic Emergency Medicine 2019; 26(1): 7-15
https://onlinelibrary.wiley.com/doi/10.1111/acem.13567
Christenson J, Etherington J, Grafstein E, et al. Early discharge of patients with presumed opioid overdose: development of a clinical prediction rule. Acad Emerg Med 2000; 7(10): 1110-1118
https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1553-2712.2000.tb01260.x
Klein LR; Driver BE; Miner JR; Martel ML et al. Intramuscular Midazolam, Olanzapine, Ziprasidone, or Haloperidol for Treating Acute Agitation in the Emergency Department. Ann Emerg Med 2018; 72(4): 374-385
https://www.annemergmed.com/article/S0196-0644(18)30373-1/abstract
Print “2 ER Drug Studies: Reassurances and Reservations”
February 12, 2019
From Tragedy to Travesty of Justice
In our December 11, 2018 Patient Safety Tip of the Week “Another NMBA Accident” we discussed a tragic case where a patient was administered a fatal dose of the NMBA (neuromuscular blocking agent) vecuronium instead of the ordered Versed. We discussed a whole cascade of errors, root causes, and contributing factors that were important in leading to the unfortunate outcome.
At the end of that column we noted that the nurse who administered the fatal dose had been terminated from the hospital. While acknowledging that the nurse made several egregious errors, we noted that there were multiple system issues that put her in position to be at the “sharp end” of the error cascade. Now that nurse has been charged with reckless homicide and impaired adult abuse in Tennessee (Kelman 2019).
Clearly, the nurse who was charged made the following errors:
Though the prosecutors apparently were barred from publicly discussing the merits of the case, a spokesman for the District Attorney’s Office said in a brief statement that overriding the safeguards of the ADC (automated dispensing cabinet) was central to the charge of reckless homicide (Kelman 2019b).
The nurse did override the warning on the ADC screen. But we identified two system issues regarding ADC overrides. First, hospital policy and ADC settings apparently did not require an independent double check for the override.
Second, even more importantly, the warning on the ADC screen was inadequate. The nurse may well have considered this a “STAT” order since she was told to go down to the PET suite now or they will send the patient back here without doing the scan. A proper warning would have said something like “Verify that the patient is intubated and mechanically ventilated or that this drug is being used for an intubation procedure”.
Note that ISMP (ISMP 2019), in its own review of the issue following this case, agrees with us and recommends “Display an interactive warning (e.g., “Patient must be intubated to receive this medication”) on ADC screens that interrupts all attempts to remove a neuromuscular blocker via a patient’s profile or on override. The warning should require the user to enter or select the purpose of the medication removal (“other” should not be a choice) and verify that the patient is (or will be) manually or mechanically ventilated. This type of warning provides an opportunity to specify why the user is being interrupted and requires the user to document a response.”
The CMS inspection report (CMS 2018) also does not mention whether overriding an ADC alert was an issue unique to this nurse or whether ADC overrides had become a routine part of the culture of the unit (i.e. “normalization of deviance”).
We refer you back to our December 11, 2018 Patient Safety Tip of the Week “Another NMBA Accident” for discussion of all the system issues we identified as root causes or contributing factors. But, to summarize, we can identify at least 19 points where interventions or different decisions could have prevented this tragic death:
It is conceivable that a different action or decision at any one of the above 19 points might have prevented this tragic accident. Yes, several of these relate directly and solely to the nurse. But the majority are enabling factors that can allow a human error to break through multiple defense systems and lead to patient harm.
In our December 11, 2018 Patient Safety Tip of the Week “Another NMBA Accident” we concluded that it was quite conceivable that another nurse might have made similar errors given the same set of circumstances and contributing factors. That is, the many system issues actually put that nurse in a position where human error would leave her at the “sharp end” of the error cascade. As such, we would not have recommended terminating the nurse. And we think that charging this individual with reckless homicide is an outrageous travesty of justice. This nurse will undoubtedly live with the memory of this terrible accident the rest of her life. But to put her through the rigors of a homicide trial, even if she is ultimately acquitted, is simply wrong.
Some of our prior columns on neuromuscular blocking agents (NMBA’s):
June 19, 2007 “Unintended Consequences of Technological Solutions”
July 31, 2007 “Dangers of Neuromuscular Blocking Agents”
November 2007 “FMEA Related to Neuromuscular Blocking Agents”
May 20, 2008 “CPOE Unintended Consequences - Are Wrong Patient Errors More Common?”
January 31, 2012 “Medication Safety in the OR”
February 7, 2012 “Another Neuromuscular Blocking Agent Incident”
October 22, 2013 “How Safe Is Your Radiology Suite?”
December 9, 2014 “More Trouble with NMBA’s”
December 11, 2018 “Another NMBA Accident”
January 1, 2019 “More on Automated Dispensing Cabinet (ADC) Safety”
References:
Kelman B. Vanderbilt ex-nurse indicted on reckless homicide charge after deadly medication swap. Nashville Tennessean 2019; Published February 4, 2019
Kelman B. Vanderbilt nurse: Safeguards were ‘overridden’ in medication error, prosecutors say. Nashville Tennessean 2019; Published February 7, 2019
ISMP (Institute for Safe Medication Practices). Safety Enhancements Every Hospital Must Consider in Wake of Another Tragic Neuromuscular Blocker Event. ISMP Medication Safety Alert! Acute Care Edition 2019; January 17, 2019
CMS (Centers for Medicare and Medicaid Services). Statement of Deficiences. Complaint #TN00045852. CMS 2018; Date of survey 11/08/2018
Print “From Tragedy to Travesty of Justice”
February 19, 2019
Focus on Pediatric Patient Safety
The pediatric literature this past month has had an intense focus on patient safety for children. The American Academy of Pediatrics issued a Policy Statement “Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care” (Mueller 2019). And a consortium of Children’s Hospitals compiled a prioritized list of research topics for pediatric patient safety (Hoffman 2019).
The AAP policy statement (Mueller 2019) begins with an excellent review of the literature on pediatric patient safety issues. It then goes into the safety culture, which includes human factors concepts, and discusses the concepts of human fallibility, organizational culture, reporting culture, learning culture, flexible culture, and just culture. It goes on to discuss many of the strategies and approaches to patient safety and the roles of leadership, healthcare information technology, and goals set not only by The Joint Commission but also by a variety of other professional organizations. The appendices and reference list provide excellent links to useful information and tools.
It ends with a set of recommendations:
See the AAP paper for details on each of these recommendations.
The second paper comes from the Children’s Hospitals Solutions for Patient Safety Network, a network of >100 children’s hospitals working together to eliminate harm due to health care. They engaged key stakeholders (importantly, including parents) in an iterative process to identify and prioritize topics on pediatric patient safety (Hoffman 2019). They developed a final list of 24 topics. Top-priority research topics concerned high reliability, safety culture, open communication, and early detection of patient deterioration and sepsis. Further discussion with health system executives put the following at the top of their list as priority areas: diagnostic error, medication safety, deterioration, and ambulatory patient safety.
For years, our pediatric colleagues have been reminding us that “kids are not just little adults”. And that does ring true when it comes to patient safety. There are clearly vulnerabilities in infants and children that render them at risk for a variety of patient safety hazards. So we went back and reviewed our own patient safety columns related to children over the years, and we clearly see the impact of those vulnerabilities. We noted several key contributing factors:
Medication safety would have been at the top of our list and many of the vulnerabilities unique to children lead to adverse medication events. Compared to adults, where “standardized” doses are typically used, children have different body weights and surface areas that lead to the need to calculate their medication doses. Any time you have to perform a calculation, you’ve added an additional threat layer (see our many columns on dosing errors and dose rounding issues). Moreover, someone else is usually making medical decisions or management and they may be prone to error (see our columns on parental “numeracy” issues). Genetically-determined vulnerabilities are often first brought to light in children (for example, the “rapid metabolizer” issue that renders children at risk from use of codeine). The fact that children are often excluded from clinical trials may preclude them from benefiting from certain drugs but may also put them in harm’s way when someone uses those drugs in a population where they have not been adequately assessed for safety and efficacy.
Because they may not be able to communicate with us, they cannot tell us “hey, you’ve got the wrong patient!”. They may not be able to communicate to us that they are having an adverse reaction to a medication we’ve given them. And inability to communicate may impede our ability to recognize early clinical deterioration in patients with sepsis or other conditions.
Infants and children can’t be expected to hold still for diagnostic studies like CT or MRI or for therapeutic interventions like dental work. Therefore, they are given sedation for such events and are put at risk for the unwanted consequences of sedation (respiratory depression, aspiration, etc.).
Kids are inquisitive and like to play. That puts them at risk for finding things like discarded opioid transdermal patches, which can lead to disaster if they put these in their mouths or attach them to their skin. They can get into medicine cabinets (or other places where medications intended for their parents or siblings are kept) and ingest medications that will harm them. We’ve also noted cases where kids had ingested magnets and underwent MRI with consequent burning of GI tissues.
Most of our columns on the effects of unnecessary radiation exposure have focused on children. The carcinogenic risks from ionizing radiation often depend upon cumulative doses and children obviously have a much longer lifespan that allows for more total radiation exposure.
While we listed “similarity of names” in neonatal units, there are actually many factors that contribute to misidentification issues in newborns. Our numerous columns on this topic are listed below.
And we’ve not even touched upon the many other safety hazards for children that are not directly related to medical care but should be addressed by healthcare professionals when they interact with infants and children and their families. These include topics like gun safety, bicycle and automobile (or other vehicles) safety, sports safety, drugs, smoking, bullying, and other topics. We pointed to some good references for those topics in our January 2019 What's New in the Patient Safety World column “Pediatric Health and Safety Guide”.
Some of our other columns on pediatric medication errors:
November 2007 “1000-fold Overdoses by Transposing mg for micrograms”
December 2007 “1000-fold Heparin Overdoses Back in the News Again”
June 28, 2011 “Long-Acting and Extended-Release Opioid Dangers”
September 13, 2011 “Do You Use Fentanyl Transdermal Patches Safely?”
September 2011 “Dose Rounding in Pediatrics”
April 17, 2012 “10x Dose Errors in Pediatrics”
May 2012 “Another Fentanyl Patch Warning from FDA”
June 2012 “Parents’ Math Ability Matters”
September 2012 “FDA Warning on Codeine Use in Children Following Tonsillectomy”
May 7, 2013 “Drug Errors in the Home”
May 2014 “Pediatric Codeine Prescriptions in the ER”
November 2014 “Out-of-Hospital Pediatric Medication Errors”
January 13, 2015 “More on Numeracy”
April 2015 “Pediatric Dosing Unit Recommendations”
September 2015 “Alert: Use Only Medication Dosing Cups with mL Measurements”
November 2015 “FDA Safety Communication on Tramadol in Children”
October 2016 “Another Codeine Warning for Children”
January 31, 2017 “More Issues in Pediatric Safety”
May 2017 “FDA Finally Restricts Codeine in Kids; Tramadol, Too”
August 2017 “Medication Errors Outside of Healthcare Facilities”
August 2017 “More on Pediatric Dosing Errors”
September 2017 “Weight-Based Dosing in Children”
Some of our previous columns on opioid safety issues in children:
Some of our previous columns on sedation issues in children:
Some of our prior columns related to identification issues in newborns:
Some of our prior columns related to radiation issues in children:
Miscellaneous columns on other pediatric patient safety topics:
References:
Mueller BU, Neuspiel DR, Stucky ER, Fisher S, Council on Quality Improvement and Patient Safety. American Academy of Pediatrics. Policy Statement.
Principles of Pediatric Patient Safety: Reducing Harm Due to Medical Care. Pediatrics 2019; 143(2): e20183649 February 2019
http://pediatrics.aappublications.org/content/early/2019/01/18/peds.2018-3649
Hoffman JM, Keeling NJ, Forrest CB, et al. Priorities for Pediatric Patient Safety Research. Pediatrics 2019; Jan 2019: e20180496 January 23, 2019
Print “Focus on Pediatric Patient Safety”
February 26, 2019
Vascular Access Device Dislodgements
It’s staring us right in the face. It’s so common, we never think about it as a patient safety issue. But the latest under-the-radar patient safety topic: dislodgement of catheters and vascular access devices! But it really shouldn’t be a surprise. Dislodgement of vascular access devices and other devices is important for “the 3 C’s”: comfort, complications, and cost.
When vascular access devices are dislodged, delays in treatment occur. Intravenous fluid replacement falls behind and intravenous medication administration is delayed. And, in some cases where peripheral sites are scarce, the need for vascular access may result in the patient getting a more invasive procedure (central line, subclavian line, etc.). Complications include bleeding, skin tears, air embolism, hematoma, phlebitis, thrombus formation, infiltration, extravasation, and infection.
Patient comfort is impacted, both by the above mentioned complications and by pain and anxiety during restarts or need for a more invasive procedure for vascular access.
Very few hospitals even know the impact of catheter/device dislodgement. They seldom record a reason when such devices are changed or discontinued. But maybe if they break out spending on such devices, the problem of dislodgement might garner some attention. And those cost considerations do not include the cost of additional time required for care provided by nursing and other healthcare professionals. Requirements to attend to dislodged catheters and restarts can take time away from other nursing tasks and even result in some “missed care” (see our many columns on the impact of missed care).
A web-based survey of clinicians (Moureau 2018) found that 68% of respondents reported often, daily, or multiple times daily occurrence of accidental dislodgement affecting intravenous (IV) devices. 96.5% identified peripheral intravenous catheters as most common device experiencing accidental dislodgement.
The most commonly reported contributing factors were:
80% Confused patient
74% Patient physically removes catheter
65% IV catheter tape or securement loose
60% Patient moving around in bed with tangled tubing
51% Any forceful pull by patient or other
48% Patient going to bathroom forgetting IV is attached
47% Patient hair growth or perspiration lifting dressing
38% Bed transfer of patient
33% Hospital staff assisting patient when IV dislodged
3% Tubing too long and gets caught when ambulating
Moureau gives a conservative projection of accidental dislodgement incidence at 19 million events per year in the United States.
She also notes that, regarding time for PIV replacement, most clinicians responding to the survey estimated a range of 6-30 minutes (depending on patient-related factors and type of hospital setting among other factors).
A study of peripheral intravenous catheters (PIV’s) in a tertiary hospital in Australia (Marsh 2018) followed 1000 patients until catheter removal. Catheter failure occurred in 32% of 1578 PIV’s. Phlebitis occurred in 17%. Factors associated with occlusion/infiltration risk included intravenous (IV) flucloxacillin, 22-gauge PIV’s, and female patients. Phlebitis was associated with female patients, bruised insertion sites, IV flucloxacillin, and dominant side insertion. Paramedic insertion was a risk for dislodgement. Each increase by 1 in the average number of daily PIV accesses was associated with occlusion/infiltration, phlebitis and dislodgement. On the other hand, additional securement products were associated with less occlusion/infiltration, phlebitis and dislodgement.
The authors note that their findings regarding the 22-guage PIV’s question international guidelines, which currently recommend the smallest gauge peripheral catheter possible. They also note that they did not have good data on the impact of multiple insertion attempts because they did not witness the insertions.
They note that their PIV failure rate of 32% is actually lower than rates in most published studies.
They used a mean cost of PIV replacement cost of US $51.92 per episode of IV treatment (Tuffaha 2014) to calculate the financial impact of PIV failures. For their hospital, which uses 200,000 PIV’s per year, the current level of PIV failure suggests almost US $4.1 million in waste annually at this site alone.
Another Australian study (Wallis 2014) performed a secondary data analysis from a randomized controlled trial of PIVC (peripheral intravenous catheter) dwell time. They found these potentially modifiable risk factors for occlusion: hand, antecubital fossa, or upper arm insertion compared with forearm. Larger diameter PIVC was a risk factor for phlebitis. PIVC’s inserted by the operating and radiology suite staff had lower occlusion risk than ward insertions. Modifiable risks for accidental removal included hand or antecubital fossa insertion compared with forearm, clinical staff insertion compared with intravenous service, and smaller PIVC diameter. Female sex was a nonmodifiable factor associated with an increased risk of both phlebitis and occlusion. The authors conclude that PIVC survival is improved by preferential forearm insertion, selection of appropriate PIVC diameter, and insertion by intravenous teams and other specialists.
So how do you minimize the risk of device dislodgement and many of these other complications of peripheral IV catheters?
Czajka et al. (Czajka 2018) show that proper primary and secondary securement can reduce complications, increase patient comfort, and save money. In fact, they make a case that decisions related to securement of vascular access devices should be considered equally as important as the choice of the catheter itself.
“Primary” catheter securement directly holds the catheter in place on the skin. “Secondary” securement acts as an additional anchor for the infusion set tubing or extension set to reduce any force the primary securement receives when energy is applied to the tubing by accident or rapid patient movement. They stress that secondary securement is as important as the primary. Primary stabilization cannot withstand the forces applied, for example, when IV tubing becomes trapped in the bed rail during a patient transfer. Without the secondary securement “shock absorber,” the primary stabilization can fail, resulting in a lost catheter.
They note that all lines, whether PVC’s (peripheral venous catheters) or CVC’s (central venous catheters), should be secured. Proper securement is particularly important when placing an infusion line in anatomic areas of greater movement (eg. antecubital veins or saphenous veins in the foot), and for patients at greater risk of unintentional dislodgment (eg., those who are confused, combative, or developmentally challenged, or have changes in mental status) and neonates, infants, and toddlers.
Multiple catheter securement choices are available, including several types of tape, transparent dressings, sutures, engineered securement devices (ESD’s), subcutaneous ESD’s, and medical cyanoacrylate tissue adhesives. Factors influencing choice of the most appropriate method for securement include patient age, skin turgor and integrity, previous adhesive skin reactions or injuries, and any type of drainage at the insertion site. They cite studies showing engineered securement devices (ESD’s) have advantages over the old standard of suture and tape. But the ESD must be available in a wide variety of sizes for all populations. It should be gentle to the skin and should not impede vascular circulation or delivery of the prescribed therapy, damage the catheter, or be a source of needlestick injuries. Obviously, the ESD should not interfere with assessing and monitoring the access site.
Before replacing an ESD, it is important to remove all old adhesive to allow for appropriate skin antisepsis. Watch for adhesive–related injuries associated with the use of or removal of adhesive- based ESD’s.
They stress that a dislodged or displaced vascular access device should never be re-advanced into a vein. Peripheral catheters that become dislodged should be removed. Dislodged central catheters should be assessed for tip position, infusion therapies, and other influencing factors. Then stabilize that PICC at the current position; in some cases, a new catheter insertion may be warranted.
The ECRI Institute PSO (ECRI 2018) has a nice review on device dislodgement (not only vascular access devices but also devices like feeding tubes, nephrostomy tubes, and others) and includes a staff handout pointing out the importance of avoiding such dislodgements and the steps to prevent them.
So far we’ve been talking primarily about regular peripheral IV’s rather than peripherally inserted central catheters (PICC lines). We refer you back to our multiple columns on PICC lines (listed below) that call into question the often misperceived relative safety of PICC lines. In addition, a new study (Krein 2019) analyzed PICC-related complications from the perspective of the patient, both during and after hospitalization. This included 438 consecutive patients with PICC’s at four US hospitals between 2015 and 2017. During the 70-day follow-up period, 61.4% of patients reported signs of at least one complication, including potentially serious complications, such as bloodstream infection (17.6%) and deep vein thrombosis (30.6%). Correspondence of these reported events with medical record documentation of the complication was generally low. More than one-quarter (27.9%) of patients reported minor complications, such as insertion site redness, discomfort or difficult removal. While the PICC was in place, 26.0% reported restrictions in activities of daily living, 14.4% social activity restrictions and 19.2% had difficulty with flushing or operating the PICC. The exact incidence of catheter dislodgement is not clear because it was lumped together in a category “Discomfort, inadvertent removal, migration or difficulty when removed” that was seen in 8.4% of patients.
Have your fiscal analysts take a look at your supply costs for vascular access devices. Then add in an estimated cost for the time your nurses or other healthcare professionals spend dealing with dislodged vascular access sites. Now that you have everyone’s attention, do an audit of peripheral IV’s and PICC lines (either specified consecutive cases or a “convenience” sample) so you can determine rates of dislodgement and complications. Better yet, take one of those unused customizable fields in your EMR and use it to record a reason for every new IV insertion or change or removal. Make sure you readily identify the risk factors in the Moureau, Marsh, and Wallis papers. Then make sure you are using some of the techniques and best practices in the Czajka and ECRI papers. And make review of your vascular access device experiences a regular part of your quality improvement program.
Some of our other columns on central venous catheters and PICC lines:
January 21, 2014 “The PICC Myth”
December 2014 “Surprise Central Lines”
July 2015 “Reducing Central Venous Catheter Use”
October 2015 “Michigan Appropriateness Guide for Intravenous Catheters”
March 27, 2018 “PICC Use Persists”
References:
Moureau N. Impact and Safety Associated with Accidental Dislodgement of Vascular Access Devices: A Survey of Professions, Settings, and Devices. Journal of the Association for Vascular Access 2018; 23(4): 203-215
https://www.sciencedirect.com/science/article/pii/S1552885518300734#!
Marsh N, Webster J, Larsen E, et al. Observational Study of Peripheral Intravenous Catheter Outcomes in Adult Hospitalized Patients: A Multivariable Analysis of Peripheral Intravenous Catheter Failure. J Hosp Med 2018; 13(2): 83-89. Published online first October 18, 2017
Tuffaha HW, Rickard CM, Webster J, et al. Cost-effectiveness analysis of clinically indicated versus routine replacement of peripheral intravenous catheters. Appl Health Econ Health Policy 2014; 12(1): 51-58
https://link.springer.com/article/10.1007/s40258-013-0077-2
Wallis MC, McGrail M, Webster J, et al. Risk factors for peripheral intravenous catheter failure: a multivariate analysis of data from a randomized controlled trial. Infect Control Hosp Epidemiol 2014; 35(1): 63-68
Czajka C, Frey AM, Schears G. Vascular Access Device Stabilization and Line Securement. Am Nurs Today 2018; 13(12): 22-24
https://www.americannursetoday.com/vascular-access-device-stabilization-and-line-securement/
ECRI Institute PSO. Device dislodgements: common but sometimes harmful event. PSO Navigator. November 2018; 10[4]
https://www.ecri.org/components/PSOCore/Pages/PSONav1118.aspx
ECRI PSO staff handout on device dislodgements
Krein SI, Saint S, Trautner BW, et al. Patient-reported complications related to peripherally inserted central catheters: a multicentre prospective cohort study. BMJ Qual Saf 2019; Published Online First: 25 January 2019
https://qualitysafety.bmj.com/content/early/2019/01/25/bmjqs-2018-008726
Print “Vascular Access Device Dislodgements”
March 5, 2019
Infusion Pump Problems
We recently discussed problems associated with several of our medication safety technologies in our Patient Safety Tips of the Week for February 5, 2019 “Flaws in Our Medication Safety Technologies”, December 11, 2018 “Another NMBA Accident”, and January 1, 2019 “More on Automated Dispensing Cabinet (ADC) Safety”. However, one we did not yet discuss was smart pump infusion technologies. Smart pumps are used for administering IV medications, IV fluids, patient-controlled analgesia, parenteral nutrition, blood, and even MRI infusions. They are also used for other types of infusions, like epidural infusions, nerve blocks, and syringe infusions and enteral feedings. These devices have been used now for several decades and have a significant impact on reducing medication infusion errors. But there are still problems associated with smart infusion pumps.
A patient at a hospital in Singapore inadvertently received a dose of lignocaine (lidocaine) that was 10 times the intended dose, possibly contributing to her death (Lam 2018). A nurse had accidentally keyed in 41.7 ml/hr instead of 4.17 ml/hr. Smart infusion pumps allow you to key in under dose selection or rate selection. In this case, she should have keyed in either 41.7 mg per hour using dose selection or 4.17 ml per hour using rate selection. But she accidentally keyed in 41.7 ml in the rate selection instead. She apparently was unfamiliar with the smart pump due to her limited exposure to it, and there was no independent double check performed.
Such mistaken input of dose or dose rate instead of flow rate or vice versa (so called “wrong-field programming error”) has long been recognized as a major problem with smart pumps. ISMP (Institute for Safe Medication Practices), PPSA (Pennsylvania Patient Safety Authority), ASHP (American Society of Health-System Pharmacists), and other professional organizations have pointed out wrong-field programming errors as a danger for many years. And this problem made ECRI Institute’s Top 10 List of Health Technology Hazards for 2019 (ECRI 2019). Number 6 on the list is “Confusing Dose Rate with Flow Rate Can Lead to Infusion Pump Medication Errors”. ECRI notes that entering the intended flow rate into an infusion pump’s dose rate field can lead to dangerous medication administration errors. And ECRI notes that such wrong-field programming errors occur relatively frequently (and many go unreported).
Also, the inverse relationship between concentration and volume is counterintuitive (ISMP 2018a) That is, more concentrated drugs require less volume to deliver a specified dose, and less concentrated drugs require more volume to deliver a specified dose. So, if the programmed concentration is lower than the actual concentration in the infusion bag or syringe, the pump will deliver an overdose. If the programmed concentration is higher than the actual concentration in the bag or syringe, the pump will deliver an underdose.
Enter the need for the “hard” minimum concentration limit to prevent the overdose scenario. When pumps issue a “soft” low concentration alert that can be overridden, a nurse may override the warning, mistakenly believing the “low concentration” warning is inconsequential.
ISMP (ISMP 2018a) also highlighted a problem when using “custom” concentrations in smart pumps and stressed the importance of setting hard stops (requires reprogramming) for minimum concentration limits when programming custom concentrations. Programming a custom concentration entails selecting a drug from the library but then manually entering the concentration. The ISMP article notes that sometimes practitioners may unnecessarily select a custom concentration option, then enter the wrong concentration, even though a standard concentration option for the drug was available in the pump library. In such cases, programming errors would have resulted in a hard stop had the standard concentration pathways been employed but no hard stops appear when the custom concentration route is used.
ISMP makes the following recommendations:
See the ISMP article (ISMP 2018a) for details on each of those recommendations.
The Pennsylvania Patient Safety Authority (PPSA 2007) provides some great examples of how smart pumps prevented (or could have prevented) errors. But it also includes examples of errors that did occur with smart pumps. They categorized smart pump errors as wrong rate, wrong dose, wrong drug, wrong unit of measure, and override problems.
Examples included entering a rate for the standard drug concentration when the infusion dispensed by the pharmacy used a non-standard concentration. Also noted were cases of transposition of IV lines after temporary disconnection, resulting in infusions from two pumps being at the wrong rate. And an old nemesis, basing a dosage on the wrong weight (eg. pounds rather than kg), can also be seen with smart pumps (see our many columns on errors related to wrong weight listed at the end of today’s column).
They also had examples of using the wrong unit of measure. In once case, a drug was intended to be infused at a ml/hr rate but the smart pump’s library was set for a mg/minute rate. In another, an intended rate to be infused over 24 hours was misprogrammed to infuse over one hour.
We discussed problems with overrides in our Patient Safety Tips of the Week for December 11, 2018 “Another NMBA Accident” and January 1, 2019 “More on Automated Dispensing Cabinet (ADC) Safety”. Well, smart pumps are no different. The PPSA study gave numerous examples of errors where the smart pump libraries or alerts were overridden. They also noted the following reasons (from the literature) why practitioners bypass these safety measures:
Some earlier versions of smart pumps had a problem with “key bounce” or “double bounce” where, during input, pressing a key once often led to a value entered twice. For example, a nurse thought she entered a flow rate of 36 ml/h but the second keystroke "bounced" and 366 ml/h was programmed into the pump (ISMP Canada 2006). While newer smart pumps seem to have encountered this problem less often, ISMP Canada’s recommendations are still logical:
Another problem is not specifically a problem with the pump per se but rather a problem when multiple infusion pumps are being used and the lines are temporarily disconnected during, for example, a patient transport or patient transfer to another unit. The danger here is that, when re-hooking up the lines to the pumps, the lines get transposed and the medications now get infused at the wrong rates.
A recent ISMP survey (ISMP 2018b) confirmed high usage of smart pumps in most hospitals. But bi-directional interoperability between their smart pumps and electronic health record (EHR) that facilitates pump programming and documentation of the infusion in the EHR is still not widely implemented. There is also a size/geography disparity in that and in wireless connectivity for transfering data to and from smart pumps (with lesser implementation in rural and small hospitals).
The most common types of errors reported included:
Survey respondents also noted many challenges:
Review of data analytics and compliance data should be part and parcel of the quality improvement program at every hospital. Of survey respondents, Of all respondents who review compliance data, review occurs monthly (33%), quarterly (35%), weekly or daily (11%), or yearly (10%). But, of concern, whereas most manager/director/administrator-level practitioners were aware of smart pump compliance rates, over half of staff-level practitioners were unaware of smart pump compliance rates.
Your quality improvement program should be tracking not only pump overrides but also looking at all alerts. Most newer smart pumps have the capability of logging all alerts. Following up on a survey of its readers, ISMP has some great recommendations on what metrics related to smart pumps should be part of your quality improvement program and how often these should be reviewed (ISMP 2018c).
One of our own most important warnings applies to any sort of infusion pump, smart or otherwise: never put a potentially lethal amount of a medication in a bag/bottle/syringe, lest some sort of error leads to infusion of the entire amount over too short a period. We have done several columns in which fatal or near-fatal overdoses of chemotherapy agents have been infused inadvertently over several hours when they had been intended to infuse over several days (see our Patient Safety Tips of the Week for September 11, 2007 “Root Cause Analysis of Chemotherapy Overdose” and April 6, 2010 “Cancer Chemotherapy Accidents” and September 15, 2015 “Another Possible Good Use of a Checklist”).
And dosing errors are not the only problems with infusion pumps. An FDA alert (FDA 2019) has just issued about problems with air-in-line alarms and the risk of air embolism with infusion pumps (the warning also applies to fluid warmers and rapid infusers). The warning notes one problem is balancing the sensitivity of the air-in-line sensor with the risk of clinically significant air embolism. It notes that, with a false alarm, the device may generate an air-in-line alarm when air is not present, or the amount of air detected is so small that it would not present a risk to the patient. When the device alarms, it stops the infusion, which may cause delays or an interruption of therapy.
It notes that some infusion devices offer different ranges or thresholds of air-in-line detection, which can be adjusted depending on the patient population. For example, an infusion pump air-in-line sensor setting used in a neonatal or pediatric patient population would likely be more sensitive than an adult patient population due to the patient size differences. In general, the setting of the air-in-line detector should be considered so that it is sensitive enough to help prevent a harmful amount of air reaching the patient, but not so sensitive that it generates false alarms too frequently.
The FDA notes that clinically significant air embolism depends on several factors including:
The FDA alert includes recommendations for healthcare professionals, biomedical engineers, and for those patients/families using infusion pumps at home. For healthcare professionals they note the importance of training and education on the risk of air embolism, ways to reduce the risk, and how to appropriately use infusion devices. They need to know whether the devices have an air-in-line sensor and whether they have programmable settings for air-in-line sensors that allow changing of the threshold of the sensor depending on the patient population being treated (for example, neonates, adults). Those settings should always be checked to ensure they are appropriate for the patient population using the devices.
Devices should always be inspected before use, and damaged devices should not be used. IV tubing should be free from damage such as cuts, kinks, or disconnections before and during use, as these can be a source of air in the tubing. Healthcare professionals should know what to do when an air-in-line alarm occurs so that delays of therapy do not occur. The FDA stresses the need to follow the manufacturer’s instructions for use to ensure the air is completely removed from the system when priming accessory devices (such as IV tubing).
The alert stresses that, if a patient is receiving a high-risk medication like epinephrine, you need to have a backup plan in place (for example, having spare devices and accessories readily available).
Recognition of the signs and symptoms of an air embolism (eg, a sudden onset of chest pain or tightness, difficulty breathing or shortness of breath, lightheadedness, fainting, or confusion, other neurologic symptoms) should lead to prompt intervention.
If the air-in-line sensor on your device is not working properly (for example, false alarms or failure to alarm), the device should be removed from service.
We suggest you go to the FDA alert to review the recommendations for biomedical engineers and for those patients/families using infusion pumps at home.
Back in 2010 the FDA had an initiative on infusion pump safety. We did 2 columns related to that (see our May 2010 What's New in the Patient Safety World column “FDA's Infusion Pump Safety Initiative” and our April 27, 2010 Patient Safety Tip of the Week “Infusion Pump Safety”). In the latter column we had some recommendations that still look pretty good today:
Other good resources include ISMP’s “Guidelines for Safe Implementation and Use of Smart Pumps” in 2008 (ISMP 2008). The Guidelines are currently being updated by ISMP. In the meantime, you can download the old ones here. ISMP also has a good resource “Building a Smart Infusion System Drug Library” (ISMP 2017).
Now that we’ve scared you about the potential pitfalls of smart infusion pumps, take a look at a recent study that details a successful system-wide smart pump implementation (Lehr 2019). Lehr and colleagues addressed the challenge of integrating 1327 smart pumps into clinical practice across 45 departments within an aggressive 3-month timeline. Read about the multidisciplinary structure they used for workgroups and their use of LEAN principles in guiding the project but pay special attention to how they went about building and refining their drug libraries.
Two months following implementation they achieved 100% compliance using the drug library across all 6 ICU’s. But compliance on other nursing units was not as good, with bypassing the drug library 34% of the time. Secondary infusions were often programmed outside the drug library because the staff perceived these infusions to be low risk. Some infusion limits were perceived as too restrictive so drug library dosing limits were adjusted to minimize potential alert fatigue improve compliance. That, along with ongoing education and skills training, resulted in a continual improvement in library compliance and reduction of pump alerts.
This is a very good read, not only for those organizations rolling out a smart pump program, but also for helping those with existing programs improve their compliance rates, reduce unhelpful alerts, and reduce errors.
Note, also, that we’ve not discussed problems with PCA (patient-controlled analgesia) pumps but we’ve listed below our many columns on PCA issues.
Our prior columns related to infusion pump issues:
Our prior columns related to chemotherapy safety:
Some of our other columns on errors related to patient weights:
March 23, 2010 “ISMP Guidelines for Standard Order Sets”
September 2010 “NPSA Alert on LMWH Dosing”
August 2, 2011 “Hazards of ePrescribing”
January 2013 “More IT Unintended Conseequences”
December 8, 2015 “Danger of Inaccurate Weights in Stroke Care”
May 2016 “ECRI Institute’s Top 10 Patient Safety Concerns for 2016”
September 2017 “Weight-Based Dosing in Children”
January 2018 “Can We Improve Barcoding?”
June 2018 “Incorrect Weights in the EMR”
Other Patient Safety Tips of the Week pertaining to PCA safety:
References:
Lam L. Elderly woman accidentally given 10 times prescribed drug dose at SGH. Channel NewsAsia 2018; December 19, 2018
ECRI Top 10 Health Technology Hazards for 2019
https://www.ecri.org/top-ten-tech-hazards
ISMP (Institute for Safe Medication Practices). Smart Pump Custom Concentrations without Hard “Low Concentration” Alerts Can Lead to Patient Harm. ISMP Medication Safety Alert! Acute Care Edition 2018; May 31, 2018
PPSA (Pennsylvania Patient Safety Authority). Smart Infusion Pump Technology: Don’t Bypass the Safety Catches. PA PSRS Patient Saf Advis 2007; 4(4): 139-143
http://patientsafety.pa.gov/ADVISORIES/Pages/200712_139.aspx
ISMP Canada. ALERT: Potential for “Key Bounce” with Infusion Pumps. ISMP Canada Safety Bulletin 2006; 6(6): September 7, 2006
https://www.ismp-canada.org/download/safetyBulletins/ISMPCSB2006-06KeyBounce.pdf
ISMP (Institute for Safe Medication Practices). Smart Pumps in Practice: Survey Results Reveal Widespread Use, but Optimization Is Challenging. ISMP Medication Safety Alert! Acute Care Edition 2018; April 5, 2018
ISMP (Institute for Safe Medication Practices). Survey Results: Smart Pump Data Analytics Pump Metrics that Should Be Monitored to Improve Safety. ISMP Medication Safety Alert! Acute Care Edition 2018; July 12, 2018
FDA (US Food and Drug Administration). Safety Communication. Intravascular Air-in-Line and Air Embolism Risks Associated with Infusion Pumps, Fluid Warmers, and Rapid Infusers: FDA Safety Communication. FDA January 31, 2019
ISMP (Institute for Safe Medication Practices). Smart Pumps Are Not Smart on Their Own. ISMP Medication Safety Alert! Acute Care Edition 2007; April 19, 2007
https://www.ismp.org/resources/smart-pumps-are-not-smart-their-own
FDA (US Food and Drug Administration). Infusion Pump Risk Reduction Strategies for Patients Using Infusion Pumps at Home. FDA 2017; Last Updated: 12/13/2017
FDA (US Food and Drug Administration). Brochure - Home Healthcare Medical Devices: Infusion Therapy - Getting the Most Out of Your Pump. FDA 2017; Last Updated: 12/17/2017
https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/HomeHealthandConsumer/ucm070208.htm
ISMP (Institute for Safe Medication Practices). Guidelines for Safe Implementation and Use of Smart Pumps . ISMP Medication Safety Alert! Acute Care Edition 2008; March 7, 2008
https://www.ismp.org/guidelines/safe-implementation-and-use-smart-pumps
ISMP (Institute for Safe Medication Practices). Building a Smart Infusion System Drug Library. ISMP Medication Safety Alert! Acute Care Edition 2017; January 30, 2017
https://www.ismp.org/resources/building-smart-infusion-library
Lehr J, Vitoux RR, Evanovich Zavotsky K, et al. Achieving Outcomes With Innovative Smart Pump Technology: Partnership, Planning, and Quality Improvement. Journal of Nursing Care Quality 2019; 34(1): 9-15, January/March 2019
Print “Infusion Pump Problems”
March 12, 2019
Update on Overlapping Surgery
Our regular readers know we are not fans of overlapping surgery. Nevertheless, we always try to present all sides of any controversial issue. In our December 19, 2017 Patient Safety Tip of the Week “More on Overlapping Surgery” we noted at least 8 retrospective cohort studies supporting the safety of overlapping surgery and a single one noting an increased risk of complications with overlapping surgery. Since our last column on the topic, there have been several more studies concluding that overlapping surgery is not associated with increased mortality or morbidity.
The most recent study was just published in JAMA (Sun 2019). Sun and colleagues did a retrospective cohort study of over 66,000 surgeries at 8 centers. They found that, for adults undergoing common operations, overlapping surgery was not significantly associated with differences in in-hospital mortality or postoperative complication rates. As seen in multiple other studies, overlapping surgery was associated with significantly longer case duration.
The study used administrative data and included adults undergoing total knee or hip arthroplasty, spine surgery, coronary artery bypass graft (CABG) surgery, and craniotomy. Overlapping surgery was defined as ≥2 operations performed by the same surgeon in which ≥1 hour of 1 case, or the entire case for those <1 hour, occurs when another procedure is being performed.
In addition to in-hospital mortality, the major complications assessed included thromboembolic events, pneumonia, sepsis, stroke, or myocardial infarction and the minor complications included urinary tract or surgical site infection. Data were adjusted for confounders.
In-hospital mortality was 1.9% in overlapping cases vs 1.6% in nonoverlapping cases (difference non-significant). Complications occurred in 12.8% of overlapping cases vs 11.8% of nonoverlapping cases (also a non-significant difference).
However, overlapping surgery was significantly associated with increased mortality and increased complications in 2 pre-specified subgroups. Among patients having a high preoperative predicted risk for mortality and complications, overlapping surgery was significantly associated with increased mortality and increased complications compared with low-risk patients (mortality 5.8% vs 4.7% and complications 29.2% vs 27.0%). Similarly, for patients undergoing CABG, in-hospital mortality rates were significantly higher for the overlapping surgery group (4.0% versus 2.2%) and complication rates were also significantly higher in the overlapping surgery group (34.5% versus 30.2%).
Overlapping surgery was associated with a significant increased surgery length (average 204 vs 173 minutes). That is consistent with multiple other studies, which generally show overlapping surgery cases to be about a half hour longer than non-overlapping cases. That’s always been somewhat of an enigma for us because previous studies on surgical case duration have shown higher rates of infection as case duration increases. We often cite the statistic that infection rates increase by 2.5% for every half hour of surgery (Procter 2010). One previous Canadian study (Ravi 2017) on hip fracture patients and patients undergoing total hip replacement did find a higher rate of infectious complications in those undergoing overlapping surgery. After matching, overlapping hip fracture procedures had a statistically significant greater risk for a complication (hazard ratio 1.85), as did overlapping THA procedures (hazard ratio 1.79). Moreover, for the overlapping hip fracture operations, increasing duration of operative overlap was associated with increasing risk for complications (adjusted odds ratio, 1.07 per 10-minute increase in overlap). For hip fracture patients the complications in the overlapping group were primarily infections and revisions.
We suspect the lack of more infectious complications in the Sun study and most of the other studies may reflect that most of the excess duration in overlapping cases is related simply to wound closure (the prior studies assessed total surgical length without breaking down individual components contributing to duration).
Nevertheless, the longer case duration of overlapping surgery should catch the interest of those interested in optimizing OR efficiency.
Ponce et al (Ponce 2018) analyzed over 26,000 cases done over a 2-year period at a large tertiary academic center by surgeons who performed at least 10% of their cases as overlapping cases. Overlapping procedure patients had an average case length of 2.18 hours compared with 1.64 hours among non-overlapping patients (P < 0.0001), a decreased risk of mortality (RR 0.42), a decreased risk of readmission (RR 0.92), and a decreased risk of experiencing any patient safety indicator (RR 0.67).
Hyder et al. (Hyder 2018) compared their experience with overlapping surgery vs. non-overlapping surgery on pediatric patients at a single children’s hospital. They used various methods to match patients in the non-overlapping cases to those in the overlapping cases. They found no significant difference in mortality between the two groups nor significant differences in length of stay (LOS). They do note that, because mortality rates were very low, that mortality may not be a good parameter to assess. Rather, LOS or intraoperative measures may be more appropriate.
Orthopedics is probably the area in which overlapping surgery is most often practiced. There have been several studies comparing orthopedic procedures done in overlapping vs. non-overlapping fashion. Goldfarb et al. (Goldfarb 2018) looked at over 22,000 orthopedic cases performed in a single ambulatory surgery center, 23% of which were overlapping. Complications were logged into a database monthly by surgeons. The median duration of surgery overlap was 8 minutes. After propensity score weighting, there were only minor differences between groups in operative time, anesthesia time, and tourniquet time and no significant differences in surgical site infection, noninfectious surgical complications, hospitalization, or morbidity.
Dy et al. (Dy 2018) looked at all inpatient orthopedic surgical procedures performed at 5 academic institutions over a one year period. Overlapping surgery was defined as 2 skin incisions open simultaneously for 1 surgeon. There were 14,135 cases, with overlapping surgery in 40%. The frequencies of perioperative complications were 1% in the overlapping surgery group and 2% in the non-overlapping surgery group. There was no difference in mortality and the overlapping group had reduced odds of perioperative complications (OR, 0.61), a lower chance of all-cause 30-day readmission (OR, 0.67), and shorter length of stay.
So, there are now multiple retrospective cohort studies supporting the safety of overlapping surgery and very few noting an increased risk of complications with overlapping surgery.
But, here’s the rub. As we’ve pointed out before, there are 2 basic problem with interpretation of all these studies. First, untoward events related to overlapping surgery, particularly serious ones, are not common. In fact, the vast majority of overlapping surgeries are accomplished without any problems. The serious events therefore get “buried” or “diluted out” in any large series. In fact, the bigger the series, the less likely we are to identify cases in which the overlap contributed to an adverse outcome. Given that a randomized controlled trial is not likely to ever take place, the only real way to determine whether overlapping surgery caused or contributed to such events is to perform root cause analysis of all cases with adverse events, a time- and resource-intensive process.
A second problem is that, even in those studies that used propensity score adjustments to minimize bias, there is likely an element of selection bias. There is really no way from administrative data or even chart review to fully understand why non-overlapping surgery was chosen over overlapping surgery or vice versa. It is quite likely that surgeons may avoid overlapping surgery in patients they consider to be at more risk. Note that the subgroup analysis in the Sun study does indicate that complications may be more common with overlapping surgery in more complex cases. So, when we see a retrospective cohort study that says patients undergoing overlapping surgery do better than those with non-overlapping surgery, we are not at all surprised. If they are less at risk, they should have fewer complications.
We’ll also speculate there might be an element of publication bias as well. Most of the studies come from venues in which the practice of overlapping surgery has been well ingrained.
Those of us involved in patient safety have all seen instances in which overlapping surgery was a contributing factor to or root cause of an adverse event. And just because the population-based studies seem to show a relative safety of overlapping surgery, it does not mean we don’t need to pay attention to the dangers. Wrong-site surgery and retained surgical items are also relatively rare events. Yet we strive to prevent all such cases of those. Why should events related to overlapping surgery be treated differently?
The one thing that is reassuring from these studies is that, with the exception of the Ontario study, there does not seem to be an increased rate of surgical site infections in cases of overlapping surgery. That is somewhat surprising to us, given that virtually all the studies have shown that procedure durations are longer in overlapping surgery. We’ve actually done several columns on prolonged surgical duration and you’ve heard us often use the statistic that infection rates increase by 2.5% for every half hour of surgery (Procter 2010). Many of the above studies showed mean surgical durations on the order of 30 minutes longer in overlapping cases. Thus, we would have predicted we’d see increased infection rates in such cases. But note that those are mean durations. Quite likely there are many cases with prolonged durations of, say, 10 minutes and then other cases with more prolonged durations that raise the mean. Perhaps the latter ones are associated with increased infection rates. That cannot be determined from the currently published studies. It is interesting that in the Canadian study the complication rate did increase incrementally as the duration of overlap increased.
We hope you will go back to our December 19, 2017 Patient Safety Tip of the Week “More on Overlapping Surgery” to see our detailed comments on the following considerations for overlapping surgery:
In our December 19, 2017 Patient Safety Tip of the Week “More on Overlapping Surgery” we noted that views of overlapping surgery are largely in the eye of the beholder. We noted studies showing the perception of overlapping surgery differed between surgeons and patients. Another recent pediatric study (Choe 2018) found a significant mismatch between parents' expectations and those of pediatric surgeons about the role of the surgeon on the day of operation, with parents consistently expecting more direct involvement by the attending surgeon.
We hope that you’ll heed the concerns and recommendations from today’s column and our previous columns listed below. If your organization does allow overlapping surgery, we hope you’ll use our “Overlapping Surgery Checklist” to help guide you in planning for safe implementation.
See our previous columns on double-booked, concurrent, or overlapping surgery:
And our “Overlapping Surgery Checklist”
References:
Sun E, Mello MM, Rishel CA, et al. Association of Overlapping Surgery With Perioperative Outcomes. JAMA 2019; 321(8): 762-772
https://jamanetwork.com/journals/jama/article-abstract/2725689
Procter LD, Davenport DL, Bernard AC, Zwischenberger JB. General Surgical Operative Duration Is Associated with Increased Risk-Adjusted Infectious Complication Rates and Length of Hospital Stay, Journal of the Amercican College of Surgeons 2010; 210: 60-65
http://www.journalacs.org/article/S1072-7515%2809%2901411-2/abstract
Ravi B, Pincus D, Wasserstein D, et al. Association of Overlapping Surgery With Increased Risk for Complications Following Hip SurgeryA Population-Based, Matched Cohort Study. JAMA Intern Med 2017; Published online December 4, 2017
Ponce BA, Wills BW, Hudson PW, et al. Outcomes With Overlapping Surgery at a Large Academic Medical Center. Annals of Surgery 2018; Publish Ahead of Print - February 1, 2018
Hyder JA, Hanson KT, Storlie CB, et al. Assessing the Safety of Overlapping Surgery at a Children's Hospital. Annals of Surgery 2018; Publish Ahead of Print – January 25, 2018
Goldfarb CA, Rizzo MG, Rogalski BL, et al. Complications Following Overlapping Orthopaedic Procedures at an Ambulatory Surgery Center. The Journal Of Bone And Joint Surgery 2018; 100(24): 2118-2124
Dy CJ, Osei DA, Maak TG, et al. Safety Of Overlapping Inpatient Orthopaedic Surgery. The Journal Of Bone And Joint Surgery 2018; 100(22): 1902-1911
Choe JK, Ibarra C, Feinn RS, et al. Concurrent Surgery and the Role of the Pediatric Attending Surgeon: Comparing Parents' and Surgeons' Expectations. J Amer Coll Surg 2018; 226(6): 1022-1029
https://www.journalacs.org/article/S1072-7515(18)30257-6/fulltext
Our own “Overlapping Surgery Checklist”.
http://www.patientsafetysolutions.com/docs/Overlapping_Surgery_Checklist.htm
Print “Update on Overlapping Surgery”
March 19, 2019
Updated Beers Criteria
There are a variety of medications that are particularly prone to be problematic in older adults. In our June 21, 2011 Patient Safety Tip of the Week “STOPP Using Beers’ List?” we discussed the STOPP and START tools and our October 2018 What's New in the Patient Safety World column “STOPP/START/STRIP” discussed the STRIP tool. But the granddaddy of all tools for inappropriate prescribing in older adults is Beers List (aka “Beers Criteria”) which we’ve discussed in many columns over the years (listed below). With the last several updates, Beers Criteria have become much more evidence-based. The American Geriatrics Society (AGS) updates Beers Criteria roughly every 3 years since 2011. The last update had been in 2015. But the American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults has now been published (AGS 2019).
The AGS notes that a panel of 13 experts reviewed more than 1,400 clinical trials and research studies published between 2017 and the last update in 2015. Across its five lists, the 2019 AGS Beers Criteria® includes:
The Beers Criteria update was developed by a consensus expert panel who reviewed the evidence base developed since the last update and used a Delphi process to arrive at the current recommendations. Recommendations are grouped into several tables which include with each drug a rationale for the recommendation, the recommendation itself, and the quality of the evidence and strength of recommendation. It is important to remember that PIM’s (potentially inappropriate medications) are not absolutely to be avoided. Sound clinical judgement must be used in weighing potential benefits of any drug against potential adverse effects. A companion article “How to Use the Beers Criteria” (Steinman 2019) published along with the update emphasizes this point.
High on the list of drugs to avoid in the elderly are those with strong anticholinergic properties. The update has added two such drugs to that list, pyrilamine and methscopolamine.
Changes to criteria on cardiovascular drugs include minor updates to the rationale and a minor change to clarify the recommendation for avoiding digoxin as first-line therapy for atrial fibrillation and heart failure.
The rationale to avoid sliding scale insulin was revised to clarify its meaning and intent and glimepiride was added to the list of sulfonylureas with a greater risk of severe prolonged hypoglycemia.
The duration of use of metoclopramide was added to be consistent FDA labeling.
Serotonin-norepinephrine reuptake inhibitors (SNRIs) have been added to the list of drugs to avoid in patients with a history of falls or fractures.
While we usually refer to inappropriate prescribing for a population, such as those age 65 and older, don’t forget that there is also inappropriate prescribing based upon certain conditions a patient may have. A classic one is Parkinson’s Disease (see our prior columns for August 2011 “Problems Managing Medications in Parkinson’s Disease”, December 2012 “More on Hospitalized Parkinson’s Disease Patients”, June 2015 “More Risks for Parkinson Inpatients” and our November 27, 2018 Patient Safety Tip of the Week “Focus on Deprescribing”). Beers Criteria has also looked at Parkinson’s Disease. After reviewing and discussing the evidence on antipsychotics to treat psychosis in patients with Parkinson disease, the panel decided to remove aripiprazole as preferred and add pimavanserin. Thus, the 2019 Beers Criteria recognize quetiapine, clozapine, and pimavanserin as exceptions to the general recommendation to avoid all antipsychotics in older adults with Parkinson disease. Note that the Beers Criteria also recommend avoiding benztropine and trihexyphenidyl for prevention or treatment of available for treatment of Parkinson’s.
The Beers Criteria has a nice table with recommendations on PIM use in older adults due to drug-disease or drug-syndrome interactions that may exacerbate the disease or syndrome. That table includes Parkinson’s Disease but also includes heart failure, syncope, dementia/cognitive impairment, delirium, history of falls or fractures, chronic kidney disease, urinary incontinence, and lower urinary tract symptoms.
The update also contains a table with medications “to be used with caution” in older adults with heart failure who are asymptomatic (ie, excellent control of heart failure signs and symptoms). The NOAC’s dabigatran and rivaroxaban make that list to use with caution table for adults 75 years or older. The list also notes that trimethoprim-sulfamethoxazole should be used with caution when used concurrently with an ACEI or ARB in the presence of decreased creatinine clearance because of an increased risk for hyperkalemia.
Two of the tables we find most useful are those for “Drug-Drug Interactions” and for “PIM’s Based on Kidney Function”. These recommendations really need to be wired into your CPOE and e-Prescribing systems so that useful alerts can make you aware of the PIM’s.
So, what do you do when you come across a PIM or a drug to be used with caution on Beers List in an elderly patient? As pointed out in the companion article (Steinman 2019), presence of a drug on Beers List is not an absolute contraindication to using that drug in a specific patient. You need to assess both the risks and potential benefits of the drug and consider whether safer alternatives are available. So, you need a system in place to alert you at the time of initial prescribing. If your patient is already taking a medication on Beers List, you need to consider deprescribing. See our numerous columns, listed below, on deprescribing.
Endsley (Endsley 2018) notes that deprescribing can be accomplished in four steps:
Farrell (Farrell 2019) notes five steps to individualize deprescribing practices to each patient:
(1) to identify potentially inappropriate medications
(2) to determine if the medication dosage can be reduced or the medication stopped
(3) to plan tapering
(4) to monitor (for discontinuation symptoms or the need to restart) and support the patient
(5) to document outcome
Years ago, we set up an alert for prescribers about avoiding use of amitriptyline in the elderly (amitriptyline has both anticholinergic side effects and may cause orthostatic hypotension and may cause drowsiness and increase the risk of falling in the elderly). New starts of amitriptyline dropped substantially. But we found that the prescribers almost never stopped the drug in patients for whom they had already prescribed it.
Why is it so difficult to get healthcare professionals to deprescribe? One is an inherent cognitive bias to continue doing something one started. In human factors research, continuation bias is the unconscious cognitive bias to continue with the original plan in spite of changing conditions. There’s an equivalent of this often taught in executive leadership training. That is where a simulated exercise shows people seldom back off a position they have previously declared publicly – like the problem leading to the Challenger disaster.
One very important point when advising how to avoid PIM’s on Beers List or to facilitate deprescribing is to be able to suggest alternatives. Keep in mind that those alternatives are not always pharmacological ones. Nonpharmacological alternatives may be very important, particularly to facilitate deprescribing. That’s especially true for conditions like insomnia, where promotion of good sleep hygiene may obviate the need for any sleep medications. Our numerous columns on prevention and management of delirium have also emphasized nonpharmacological approaches. The 2015 Beers Criteria update was accompanied by an article suggesting both pharmacological and nonpharmacological alternatives (Hanlon 2015). Though that article has not yet been updated to include changes in the 2019 Beers Criteria update, it still has very useful suggestions.
Of course, Beers Criteria also includes drugs that may be inappropriately continued beyond the recommended durations, such as proton pump inhibitors (PPI’s). In our November 27, 2018 Patient Safety Tip of the Week “Focus on Deprescribing” we discussed the problem of "legacy prescribing", which refers to the prescribing of drugs for a longer period than is typically needed to treat a condition. Canadian researchers (Mangin 2018) noted that commonly prescribed drugs with legacy prescribing potential include antidepressants, bisphosphonates, and proton pump inhibitors (PPIs),
In our November 27, 2018 Patient Safety Tip of the Week “Focus on Deprescribing” we noted that, fortunately, there are evidence-based algorithms available for deprescribing many medications. One website, deprescribing.org, has links to algorithms for deprescribing several drugs, including PPI’s, benzodiazepine receptor agonists, antipsychotics, cholinesterase inhibitors and memantine, and antihyperglycemics. In addition to the algorithm for deprescribing PPI’s available on that website, there is also a toolkit for deprescribing PPI’s on the Choosing Wisely Canada website (Wintemute 2017).
There have also been several recent guidelines and/or algorithms for deprescribing benzodiazepine receptor agonists (Croke 2019, Pottie 2018, Scrandis 2018), deprescribing antipsychotics for behavioral and psychological symptoms of dementia and insomnia (Croke 2018), and deprescribing cholinesterase inhibitors and memantine in patients with dementia (Reeve 2018a, Reeve 2018b). A systematic review also identified many tools for deprescribing in frail older persons and those with limited life expectancy (Thompson 2018). The Farrell article noted above (Farrell 2019) also contains links to good resources for deprescribing.
While you are focusing on deprescribing, that is also an opportunity to determine whether patients are missing medications they should be taking (for their comorbidities). We addressed “optimizing” medications in our October 19, 2010 Patient Safety Tip of the Week “Optimizing Medications in the Elderly”.
And, lastly, don’t forget that sometimes medications are inadvertently continued when we think we have discontinued them. See our columns listed below on this problem.
Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:
Some of our past columns on deprescribing:
Some of our other columns on failed discontinuation of medications:
March 2017 “Yes! Another Voice for Medication e-Discontinuation!”
February 2018 “10 Years on the Wrong Medication”
August 28, 2018 “Thought You Discontinued That Medication? Think Again”
December 18, 2018 “Great Recommendations for e-Prescribing”
References:
2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Amer Geriatr Soc 2019; First published: 29 January 2019
https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.15767
Steinman MA, Fick DM. Using Wisely: A Reminder on the Proper Use of the American Geriatrics Society Beers Criteria®. J Amer Geriatr Soc 2019; First published: 29 January 2019
https://onlinelibrary.wiley.com/doi/10.1111/jgs.15766
Endsley S. Deprescribing Unnecessary Medications: A Four-Part Process. Fam Pract Manag 2018; 25(3): 28-32
https://www.aafp.org/fpm/2018/0500/p28.html
Farrell B, Mangin D. Deprescribing Is an Essential Part of Good Prescribing. Am Fam Physician 2019; 99(1): 7-9
https://www.aafp.org/afp/2019/0101/p7.html
Hanlon JT, Semla TP, Schmader KE. Alternative Medications for Medications in the Use ofHigh-Risk Medications in the Elderly and Potentially HarmfulDrug–Disease Interactions in the Elderly Quality Measures. J Amer Geriatr Soc 2015; 63(12): e8-e18 First published October 8, 2015
https://onlinelibrary.wiley.com/doi/10.1111/jgs.13807
Mangin D, Lawson J, Cuppage, J, et al. Legacy Drug-Prescribing Patterns in Primary Care. Ann Fam Med 2018; 16(6): 515-520
http://www.annfammed.org/content/16/6/515.full
Deprescribing.org
Wintemute K. Bye, bye, PPI: a toolkit for deprescribing proton pump inhibitors in EMR-enabled primary care settings. Version 1.2. Toronto, Ontario: Choosing Wisely Canada; July 2017.
https://choosingwiselycanada.org/wp-content/uploads/2017/07/CWC_PPI_Toolkit_v1.2_2017-07-12.pdf
Croke LM. AFP Practice Guideline. Deprescribing Benzodiazepine Receptor Agonists for Insomnia in Adults. Am Fam Physician 2019; 99(1): 57-58
https://www.aafp.org/afp/2019/0101/p57.html
Pottie K, Thompson W, Davies S, et al. Deprescribing benzodiazepine receptor agonists. Evidence-based clinical practice guideline. Canadian Family Physician 2018, 64 (5) 339-351
http://www.cfp.ca/content/64/5/339
Scrandis DA, Duarte AC. Deprescribing benzodiazepines. The Nurse Practitioner 2019; 44(2): 12-14
https://journals.lww.com/tnpj/Fulltext/2019/02000/Deprescribing_benzodiazepines.3.aspx
Croke LM. AFP Practice Guideline. Deprescribing Antipsychotics for Behavioral and Psychological Symptoms of Dementia and Insomnia. Am Fam Physician 2018; 98(6): 394-395
https://www.aafp.org/afp/2018/0915/p394.html
Linda Brookes L. Deprescribing Cholinesterase Inhibitors and Memantine in People With Dementia. A Sensitive Issue. Medscape 2018; March 06, 2018
https://www.medscape.com/viewarticle/893256
Reeve E, Farrell B, Thompson W, et al. Evidence-based Clinical Practice Guideline for Deprescribing Cholinesterase Inhibitors and Memantine. Sydney: The University of Sydney; 2018
http://sydney.edu.au/medicine/cdpc/documents/resources/deprescribing-guideline.pdf
Reeve E, Farrell B, Thompson W, et al. Evidence-based Clinical Practice Guideline for Deprescribing Cholinesterase Inhibitors and Memantine: Recommendations. Sydney: The University of Sydney; 2018
http://sydney.edu.au/medicine/cdpc/documents/resources/deprescribing-recommendations.pdf
Thompson W, Lundby C, Graabæk T, et al. Tools for Deprescribing in Frail Older Persons and Those With Limited Life Expectancy. A Systematic Review. J Am Geriatr Soc 2019; 67(1): 172-180
https://onlinelibrary.wiley.com/doi/10.1111/jgs.15616
Print “Updated Beers Criteria”
March 26, 2019
Patient Misidentification
A patient label affixed to a tube of blood lying in an ER room from a prior patient results in a fatal transfusion error (Hixenbaugh 2019).
A newborn is given to the wrong mother for breastfeeding (Peel 2018).
Cancer treatment is given to the wrong patient (Schulmeister 2018).
An anesthesiologist leaves a patient’s EMR open, orders fentanyl for what he thinks is his current patient. The other patient gets fentanyl and aspriates (Minion 2018).
The wrong patient was taken from CT scan for x-rays. No double check of ID band and request was done and patient could not communicate because of medical condition. The exam was completed before they realized it was the wrong patient (Field 2018).
Two women with the same name go in for mammograms on the same day at the same hospital (Arndt 2018). One mammogram shows potential cancer. The other shows no sign of cancer. One patient gets unnecessary tests. The other gets a delay in correct diagnosis and the tumor may advance during the delay.
A near-miss occurs when two patients have the same name and same date of birth (Frost 2018)
These are just a few recent examples of patient misidentification that did, or had the potential to, result in patient harm. Patient misidentification may lead to:
We did a webinar on patient misidentification for Patient Safety & Quality Healthcare (PSQH) last August. It is still available on the PSQH website (https://www.psqh.com/resource/upcoming-patient-misidentification-minimizing-the-risks/). Today’s column expands upon the material in that webinar and highlights what continues to be a significant patient safety problem. We’ve discussed it in the numerous columns listed at the end of today’s column. We particularly point you to our January 19, 2016 Patient Safety Tip of the Week “Patient Identification in the Spotlight” for some in-depth analysis.
Both low-tech and high-tech factors contribute to patient misidentification and interventions to prevent such events are also both low-tech and high-tech. When we did our first electronic medical record implementation we actually predicted we would see an increase in wrong patient events (see our May 20, 2008 “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?”).
The oncology case (Schulmeister 2018) illustrates how a series of factors can contribute to a patient misidentification incident. A cancer patient arrived at busy outpatient registration area. The registration clerk copied the name from a driver’s license to a computer search screen and chose the first name from list and printed a wristband. The clerk asked the patient if the information was correct and he nodded “yes” (he was not wearing glasses). The patient was then sent to busy infusion center for his second chemotherapy treatment. An RN there asked him if his name is <blank> and if his birthday is the date that she read from his wristband. He nodded yes. He didn’t notice she gave wrong birthday because she had a “heavy accent” and “rattled off numbers” and the infusion room was loud and busy and that he “didn’t hear well.” As a result, the patient received the chemotherapy intended for another patient who had the same name but a different birthdate. There was no apparent harm, but the incident resulted in a lawsuit anyway.
This case illustrates several factors that commonly contribute to patient misidentification incidents. First, it illustrates the “picklist” error (also variously known as the cursor error, menu error, juxtaposition error, etc.) or the “first option” error. There is a tendency, when choosing from a list on a computer screen, to select the first option presented. Unfortunately, many IT systems may truncate lists so that the user does not scroll down to see if there are more options (the “truncated scroll syndrome”). You need to ensure that your computer systems don’t allow such truncation when there are more than one patient with the same name.
But it also illustrates a very fundamental error in patient identification: failure to use active, rather than passive, identification. Joint Commission requires at least 2-factor identification of patients and most organizations use name (first and last) plus date of birth. But, do not ask the patient if he/she is “John Jones” and is “xx/xx/xxxx” your date of birth. Rather ask the patient to provide his/her name & DOB “What is your name?” What is your date of birth?”. But issues like hearing impairment, language problems, accents, speech problems, and things like dementia or other cognitive impairments may complicate the issue. And what if there are two patients with the same name and DOB? When your system identifies the occurrence of 2 (or more) patients with the same name and DOB you must do at least 2 things. First, you must somehow flag in your IT systems that there are more than one patient with this name and DOB. Second, you must let both patients know about the duplication so they can be on the alert any time they interact with the health system.
The Australian case (Minion 2018) occurred shortly after a new EMR (electronic medical record) was implemented. An anesthesiologist forgot to order something on prior patient so opened the prior patient’s chart in the EMR and entered an order. But he forgot to close that prior patient’s chart. Then, thinking he is in chart of patient currently in OR, he entered an order for fentanyl. He also overrode multiple alerts. The prior patient received the fentanyl intended for current patient. That patient died of aspiration pneumonia resulting from mixed drug toxicity.
This illustrates the “failure to log off” issue. This occurs when a physician leaves the order entry screen temporarily without logging off. Sometimes, a second physician comes by and leaves orders on another patient (without logging on separately). The first physician then returns to the screen and assumes that he/she is still entering orders on the original patient. In this case, the same physician returned after failing to log off. Your IT systems need to have strict timeout rules so that records are closed after a specified period of inactivity.
We don’t know whether that EMR had the patient name and identifying information on every screen. But it also raises the issue of how important it is to have in place a way of forcing the user to make sure they have the correct patient. In several of our columns, we’ve discussed some of the tools developed by Adelman and colleagues to minimize the chances of such occurring (Adelman 2013). The intervention tools they developed were simple yet elegant. The “ID-verify alert” was triggered by opening an order entry screen and prompted the physician with the patient name, gender and age and the physician was required to acknowledge that was the correct patient before being allowed to proceed with order entry. The “ID-reentry function” prevents the provider from accessing the order entry screen until he/she re-enters the patient’s initials, gender and age. These interventions were piloted in a randomized fashion. While the “ID-verify alert” reduced errors by 16%, the “ID-reentry function” reduced them by 41%.
The case of the fatal transfusion error (Hixenbaugh 2019) points out vulnerabilities in specimen mixups that we’ve discussed in columns listed below, most recently in our October 9, 2018 Patient Safety Tip of the Week “More on Lab Specimen Mixups”. Though there were numerous errors and contributing factors in this case, the two most glaring errors were:
Obviously, both of those should never happen.
Whereas for biopsy and surgical specimens, labeling should be done after specimen collection, the procedure for labeling blood specimens is not as clearcut. Various organizations and regulating bodies around the world have differing policies. The Joint Commission simply states that all containers for blood or other specimens be labelled in the presence of the patient. Lippi and Plebani, who have done much quality and safety work related to lab specimens, make a case that tubes for collecting blood specimens should be pre-labeled (Lippi 2017a). That labeling can still take place in the presence of the patient. It just means the labels are affixed to tubes before venipuncture. They make that recommendation based upon evidence that post-collection labeling of tubes carries a higher risk of identification errors (Lippi 2011).
The majority of “lab errors” actually occur in the pre-analytic phase and are often related to problems with specimen collection and identification. Lab errors can lead to:
Causes of patient identification errors in medical laboratories (Lippi 2017b):
See our numerous columns on laboratory errors listed below.
The breastfeeding mixup (Peel 2018) highlights a problem that is probably a lot more frequent than you’d realize. We discussed it in our December 11, 2012 Patient Safety Tip of the Week “Breastfeeding Mixup Again” and went on to do a FMEA (Failure Mode and Effects Analysis) that demonstrates the multiple factors that may contribute to such mixups (see our April 8, 2014 Patient Safety Tip of the Week “FMEA to Avoid Breastmilk Mixups”).
So, how often do such patient misidentification incidents happen? No one knows for sure. There are no good statistics. Probably the best estimate is that there are about 60 to 100 wrong patient orders per 100,000 electronic orders (Adelman 2015, Adelman 2013). A survey by the Ponemon Institute (Ponemon Institute 2016) found that 86 percent of respondents have witnessed or know of a medical error that was the result of patient misidentification.
Some of the most salient factors contributing to patient misidentification are:
You would be surprised to see how often patients with the same or very similar names may be hospitalized at the same time. Shojania (Shojania 2003) described a near-miss related to patients having the same last name and noted that a survey on his medical service over a 3-month period showed patients with the same last names on 28% of the days. The problem is even more significant on neonatal units, where multiple births often lead to many patients with the same last name being hospitalized at the same time and medical record numbers being similar except for one digit. Gray et al. (Gray 2006) found multiple patients with the same last names on 34% of all NICU days during a full calendar year, and similar sounding names on 9.7% of days. When similar-appearing medical records numbers were also included, not a single day occurred where there was no risk for patient misidentification. Both these studies were on relatively small services so one can anticipate that the risks of similar names is much higher when the entire hospitalized patient population is in the database. And in one hospital district in Texas, 2488 patients were named Maria Garcia, and 231 of these (9.3%) also shared the same date of birth! (Lippi 2017b).
Problems with our IT systems and computer workflow issues today are major contributors to patient identification errors. In our May 20, 2008 “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?”) we noted the following factors that contribute to wrong patient errors:
See that 2008 column and our several other columns below for details of each of those factors.
We included the case of the patient getting x-rays that were not ordered (Field 2018) because it illustrates the problem of the patient not being able to be an active participant in the identification verification process. This patient could not communicate because of a medical condition. You’d be surprised how often active patient participation is not possible. The following are common barriers to communication:
In such cases you may need to use interpreters or verify identification with some other reliable source (eg. family). This is also where use of biometrics may be especially valuable.
So, what are the interventions we can use to reduce the risk of patient misidentification? Some of them are listed below:
Timeouts are one of our principle tools to verify correct patient identification (as well as procedure, laterality, etc.) and these should not only be done in OR’s but also in any other area where procedures are being done. We actually developed one of the first timeout protocols in the mid-1990’s after a case in which 2 consecutive patients received the wrong intraocular lenses. New York State a year later adopted the protocol almost verbatim and Joint Commission’s Universal Protocol followed shortly thereafter with most of the same features. But timeouts are not infallible. Why do timeouts fail?
IT solutions include the above mentioned tools developed by Adelman and colleagues to minimize the chances of such occurring (Adelman 2013), including the “ID-verify alert” and the “ID-reentry function”. You also need to ensure that the patient’s name and key identification information appear on every screen on your IT systems and that you avoid the scrolling and truncation problems discussed above. And you need good procedures for automatic timeouts after periods of computer inactivity.
As of January 1, 2019 Joint Commission has a new requirement for newborn naming (TJC 2018a). You must use two distinct methods of identification for newborn patients. You need distinct naming conventions using the mother's first and last names and the newborn's sex (for example, "Smith, Judy Girl" or "Smith, Judy Girl A" and "Smith, Judy Girl B" for multiples). You also need standardized practices for identification banding (for example, two body-site identification and bar coding). You also need to establish identification-specific communication tools among staff (for example, visually alerting staff with signage noting newborns with similar names)
In our August 2015 What's New in the Patient Safety World column “Newborn Name Confusion” we discussed another study by Adelman and colleagues in which they applied their “retract and reorder” (RAR) tool to assess the impact of a change in naming conventions for newborns (Adelman 2015). Hospitals need to create a name for each newborn promptly on delivery because the families often have not yet decided on a name for their baby. Most hospitals had used the nonspecific convention “Baby Boy” Jones or “Baby Girl” Jones. They suggested an alternative naming convention. It uses the first name of the mother. For example, it might be “Wendysgirl Jones”. Montefiore Medical Center switched to this new naming convention in its 2 NICU’s in July 2013 and the RAR tool was used to measure the impact on wrong patient errors. Wrong patient error rates measured in the one year after implementation of the new more specific naming protocol were 36% fewer than in the year prior to implementation.
Barcoding is arguably our most important patient safety intervention. Barcoding is used most often as a medication safety tool but you should be using barcoding for multiple other things. For example, you can match barcodes between the patient’s bracelet and a radiology requisition or with medical devices. Barcoding can also be used during procurement of blood samples to reduce wrong blood in tube errors (Kaufman 2019). But barcode workarounds have been used since barcoding was first implemented. Koppel et al (Koppel 2008) identified 15 types of workarounds and 31 causes for workarounds. Though workarounds may improve efficiency and sometimes improve safety, more often they put patient safety in jeopardy.
Biometrics are gaining in importance to help prevent patient misidentification. Examples include:
Biometrics are very accurate but you need a fallback because sometimes they may not work. For example, my fingerprint access on my iPhone may not work when I come out of the shower. Facial recognition access to my laptop sometimes does not work in dim light. Retinal or iris scans could get obscured by some eye pathologies. In the ideal world we’d have a National Unique Patient ID paired with biometrics but even that raises some privacy/fraud issues.
We are also advocates for patient photographs. Digital photos are easy enough to obtain and most EMR’s have a field in which you can place a photo. See our April 30, 2013 Patient Safety Tip of the Week “Photographic Identification to Prevent Errors” for examples of how photos can help prevent identification errors. But you need to be wary that circumstances may make use of photos unhelpful. For example, they may not be useful in patients with facial trauma. And you have to have a system to ensure your photos are not outdated. Butler (Butler 2018), in an article on best practices for accurate patient identification, also strongly endorses use of patient photographs. She also points out that requiring a photo ID, such as a driver’s license or state identification card, is a preferred practice but isn’t always available for populations such as children and seniors and others who don’t drive.
Independent double checks can be important tools. You already use them when administering transfusions or high alert drugs. But keep in mind they are not infallible. We often quote the statistic that an inspector errs 10% of the time when inspecting someone else’s work. So your double checks need to be truly independent double checks (see our October 16, 2012 Patient Safety Tip of the Week “What is the Evidence on Double Checks?”).
And we often forget an old tried and true way of ensuring we have the correct patient: look at their handwriting! Most patients admitted to hospitals or undergoing a procedure have signed a consent form or other document and usually have on file an older signed document for comparison. Just keep in mind that some conditions may cause a change in handwriting. For example, in Parkinson’s Disease we typically see patient’s handwriting become progressively smaller (micrographia) and in other cases tremor may alter signatures. And today’s signatures obtained on digital pads often bear little resemblance to handwritten signatures (Butler 2018).
We included “scheduling” on our list of interventions. Scheduling is of great importance in avoiding wrong site surgery (see our October 30, 2012 Patient Safety Tip of the Week “Surgical Scheduling Errors”). But scheduling may also be important in avoiding other cases of patient misidentification. For example, you could use IT algorithms to avoid scheduling two patients with similar names for clinic on the same day. If you must schedule two such patients on the same day, set up a flag that there will be more than one patient with similar names. Simply scheduling them at different times is not adequate since patients often show up early in hopes of getting seen sooner. We also recommend the daily “huddle” as a good time to identify potential misidentification opportunities. When you meet with your clinical and front office staff in the morning of a clinic/office session, simply look through the schedule for patients with similar sounding names. Also, beware of last minute scheduling changes. These have often been a factor in many cases of wrong patient surgery. Any time you make late changes, make sure all involved are aware that such changes have been made.
All your heathcare workers need to have education and training about patient identification issues. That includes not only your clinical staff but all your front office and back office staff and even your cleaning and maintenance workers. You can do some limited audit and feedback. But we always go back to our mantra “Stories, not statistics!“. You are not likely to change anyone’s behavior with statistics. You need to tell a story. It’s best if you can use a story of an untoward event that occurred in your organization. Or use an event that happened to a family member. Or use an example from an event you found elsewhere. The most powerful way is to have a healthcare worker who made an error tell how that affected their own life.
And don’t forget to educate and empower your patients. At select opportunities (eg. registrations, first visits, checking into hospital, etc.) explain to patients both the reason(s) for verification of identity and the procedure(s). We use scripts such as “It may seem silly or annoying to you that we do this every time you interact with a healthcare worker, but this is to prevent serious errors that could occur if we mix you up with another patient.” “You should also speak up if a healthcare worker fails to ask you these questions!”
The other problem related to patient identification has to do with our medical records and other patient databases. As health entities merge, we need a way to integrate medical records into one system and avoid duplicate medical records. As we import data from multiple sources, we need to ensure the data goes into the correct record. Patient demographic information may also change (marriage, new address, etc.). So, we end up with a large number of duplicate patient records in our databases. Average duplicate rate within healthcare organizations is 18% and about a third of insurance denials are related to patient identification issues (Black Book Research 2018). A discussion about enterprise master patient index (EMPI) technologies and tools like “referential matching” are beyond the scope of today’s column but your organization should be keeping abreast of work being done to reduce such duplication.
A good resource for patient identification issues is SAFER (Safety Assurance Factors for EHR Resilience) (ONC 2016). This includes good guidelines and has a very useful checklist for ensuring correct patient identification. The survey by the Ponemon Institute (Ponemon Institute 2016) also has information about root causes of patient misidentification issues. ECRI Institute’s Partnership for Health IT Patient Safety also produced a very helpful Toolkit for the Safe Use of Health IT for Patient Identification (ECRI 2017). The Joint Commission (TJC 2018b) also lists numerous steps that organizations can and should be taking to minimize the risk of patient misidentification, including use of the National Quality Forum (NQF)-endorsed “retract and reorder” algorithm noted above.
What else should you be doing? Review any RCA’s (root cause analyses) you have done on cases with patient misidentification. Do a FMEA (Failure Mode and Effects Analysis) on some procedure prone to patient misidentification incidents (see, for example, our April 8, 2014 Patient Safety Tip of the Week “FMEA to Avoid Breastmilk Mixups”). Make sure you track and monitor issues related to patient ID in your Quality Improvement activities. That should include:
Patient misidentification often has dire consequences. We also need to learn from our own experiences and those of others and adopt best practices as they are discovered.
Some of our prior columns related to patient identification issues:
May 20, 2008 “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?”
November 17, 2009 “Switched Babies”
July 17, 2012 “More on Wrong-Patient CPOE”
June 26, 2012 “Using Patient Photos to Reduce CPOE Errors”
April 30, 2013 “Photographic Identification to Prevent Errors”
August 2015 “Newborn Name Confusion”
January 12, 2016 “New Resources on Improving Safety of Healthcare IT”
January 19, 2016 “Patient Identification in the Spotlight”
August 1, 2017 “Progress on Wrong Patient Orders”
Some of our prior columns related to identification issues in newborns:
November 17, 2009 “Switched Babies”
December 20, 2011 “Infant Abduction”
September 4, 2012 “More Infant Abductions”
December 11, 2012 “Breastfeeding Mixup Again”
April 8, 2014 “FMEA to Avoid Breastmilk Mixups”
August 2015 “Newborn Name Confusion”
January 19, 2016 “Patient Identification in the Spotlight”
July 19, 2016 “Infants and Wrong Site Surgery”
August 1, 2017 “Progress on Wrong Patient Orders”
Some of our other columns on errors related to laboratory studies:
References:
Hixenbaugh M, Ornstein C. Numerous Mistakes Led to Fatal Blood Transfusion at St. Luke’s in Houston, Report Finds. Houston Chronicle and ProPublica 2019; February 26, 2019
Peel C. Newborn given to wrong mother for breastfeeding at hospital. Hours after giving birth, Joii Brown says son mistakenly given to another woman. WJXT 2018; September 27, 2018
Schulmeister L. Cancer Treatment to the Wrong Patient: Why Does This Still Happen?
Oncology Nursing News 2018; March 08, 2018
Minion L. Electronic prescribing error in month-old EHR responsible for death of NSW man, State Coroner finds. Healthcare IT News 2018; 06 April 2018
Field C. Adapting Verification Processes to Prevent Wrong Radiology Events. Pa Patient Saf Advis 2018; 15(3): 1-13
http://patientsafety.pa.gov/ADVISORIES/Pages/201809_WrongSiteRadiology.aspx
Arndt RZ. Fail-Safe Patient ID Matching Remains Just Out of Reach. Modern Healthcare 2018; July 14, 2018
Frost S. Patient ‘lucky’ to avoid disaster after hospital’s identity mistake. Mercury (UK) 2019; 07 April 2018
Truax BT. On-demand (webinar): Patient Misidentification – Minimizing the Risks
PSQH (Patient Safety & Quality Healthcare) 2018; August 30, 2018
https://www.psqh.com/resource/upcoming-patient-misidentification-minimizing-the-risks/
Adelman JS, Kalkut GE, Schechter CB, et al. Understanding and preventing wrong-patient electronic orders: a randomized controlled trial. J Am Med Inform Assoc 2013; 20(2): 305-310 Published online 29 June 2012
http://jamia.oxfordjournals.org/content/20/2/305
Lippi G, Plebani M. Blood tubes should be labeled before drawing blood. Annals of Blood 2017; Published: 25 November 2017
http://aob.amegroups.com/article/view/4171/4902
Lippi G, Sonntag O, Plebani M. Appropriate labelling of blood collection tubes: a step ahead towards patient's safety. Clin Chem Lab Med 2011; 49(12): 1921-1923
https://www.degruyter.com/view/j/cclm.2011.49.issue-12/cclm.2011.736/cclm.2011.736.xml
Lippi G, Chiozza L, Mattiuzzi C, Plebani M. Patient and Sample Identification. Out of the Maze? J Med Biochem 2017; 36(2): 107-112. Published online 2017 Apr 22
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5471642/
TJC (The Joint Commission). Distinct newborn identification requirement. R3 Report 2018; Issue 17, June 25, 2018
https://www.jointcommission.org/assets/1/18/R3_17_Newborn_identification_6_22_18_FINAL.pdf
Adelman J, Aschner J, Schechter C, et al. Use of Temporary Names for Newborns and Associated Risks. Pediatrics 2015; Published online July 13, 2015
http://pediatrics.aappublications.org/content/early/2015/07/08/peds.2015-0007.full.pdf+html
Ponemon Institute. 2016 National Patient Misidentification Report. Sponsored by Imprivata. Publication Date: December 2016
https://pages.imprivata.com/rs/imprivata/images/Ponemon-Report_121416.pdf
Shojania KG. AHRQ Web M&M Case and Commentary. Patient Mix-Up. February 2003
http://www.webmm.ahrq.gov/case.aspx?caseID=1&searchStr=shojania
Gray JE, Suresh G, Ursprung R, Edwards WH, et al. Patient Misidentification in the Neonatal Intensive Care Unit: Quantification of Risk. Pediatrics 2006; 117: e43-e47
http://pediatrics.aappublications.org/content/pediatrics/117/1/e43.full.pdf
Kaufman RM, Dinh A, Cohn CS, et al. Electronic patient identification for sample labeling reduces wrong blood in tube errors. Transfusion 2019 Mar;5 9(3): 972-980
https://onlinelibrary.wiley.com/doi/abs/10.1111/trf.15102
Koppel R, Wetterneck T, Telles JL, Karsh B-T. Workarounds to Barcode Medication Administration Systems: Their Occurrences, Causes, And Threats To Patient Safety. JAMIA 2008; 15(4): 408-423 First published online 1 July 2008
http://jamia.oxfordjournals.org/content/15/4/408
Butler, Mary. Show Me Some ID: Tips for Trusting Identity in the Era of Cybercrime and Fraud. Journal of AHIMA 2018; 89(6): 24-27
http://bok.ahima.org/doc?oid=302514#.W3sfy7gnZPZ
Black Book Research. Improving Provider Interoperability Congruently Increasing Patient Record Error Rates, Black Book Survey. Cision PR Newswire 2018; April 10, 2018
ONC. SAFER. Safety Assurance Factors for EHR Resilience. Self-Assessment. Patient Identification. Office of the National Coordinator for Health Information Technology 2016; September 2016
https://www.healthit.gov/sites/default/files/safer/guides/safer_patient_identification.pdf
(ONC 2016)
ECRI Institute. Partnership for Health IT Patient Safety. Health IT Safe Practices: Toolkit for the Safe Use of Health IT for Patient Identification. ECRI Institute February 2017
https://www.ecri.org/Resources/HIT/Patient%20ID/Patient_Identification_Toolkit_final.pdf
The Joint Commission. People, processes, health IT and accurate patient identification. The Joint commission 2018; Quick Safety 45; October 01, 2018
Print “Patient Misidentification”
Click here to leave a comment on any of these tips.
To get "Patient Safety Tip of the Week "emailed to you, click here and enter "subscribe" in the subject field.
Click on the "Contact Us" button at the left to send us your comments on our "Patient Safety Tip of the Week" cases.
To get "Patient Safety Tip of the Week "emailed to you, click here and enter "subscribe" in the subject field.
January 31, 2023
January 24, 2023
January 17, 2023
Patient Safety with NOAC’s and DOAC’s
January 10, 2023
January 3, 2023
Helping Inpatients Sleep – Failing Grades
December 27, 2022
Tip of the Week on Vacation
December 20, 2022
Amazing Results from I-PASS Implementation
December 13, 2022
Surgical Teams – the “Consistency Score”
December 6, 2022
Rare Risk – Defibrillator Fires
November 29, 2022
November 22, 2022
The Apple Watch and Patient Safety
November 15, 2022
November 8, 2022
November 1, 2022
APSF on Criminalization of Medical Error
October 25, 2022
October 18, 2022
Methotrexate Again, With a Twist
October 11, 2022
Good Intentions, Unintended Consequences
October 4, 2022
Successfully Reducing OR Traffic
September 27, 2022
September 20, 2022
September 13, 2022
Smart Socks and Robots for Fall Prevention?
September 6, 2022
AORN and Others on Retained Surgical Items
August 30, 2022
August 23, 2022
Yes, There is a Proper Way to Assess Orthostatic Hypotension
August 16, 2022
August 9, 2022
Tip of the Week on Vacation
August 2, 2022
Tip of the Week on Vacation
July 26, 2022
More Risks in the Radiology Suite
July 19, 2022
Sucked Out of the Plane at 17,000 Feet
July 12, 2022
Radiologists Racked by Interruptions
July 5, 2022
Tip of the Week on Vacation
June 28, 2022
Pneumonia in Nervous System Injuries
June 21, 2022
June 14, 2022
June 7, 2022
May 31, 2022
NHS Serious Incident Response Framework
May 24, 2022
Requiring Indication for Antibiotic Prescribing
May 17, 2022
Patient Harm in Medicare Inpatients
May 10, 2022
May 3, 2022
April 26, 2022
Challenges with Early Warning Systems
April 19, 2022
April 12, 2022
A Healthcare Worker’s Worst Fear
April 5, 2022
Follow-up on Incidental Findings
March 29, 2022
Disturbing Stats on Perioperative Benzodiazepine Use in Elderly Patients
March 22, 2022
Not Just Politicians That Behave Badly
March 15, 2022
Medication Errors in Home Care
March 8, 2022
Update on Retained Surgical Items
March 1, 2022
Including the Indication on Prescriptions
February 22, 2022
Medication Reconciliation at ICU Exit
February 15, 2022
February 8, 2022
ED to Inpatient Delays Increase Mortality
February 1, 2022
Perioperative Delirium is Not Just Postoperative
January 25, 2022
More on Dental Patient Safety Issues
January 18, 2022
January 11, 2022
Documenting Distractions in the OR
January 4, 2022
Spin or Not: A Useful Secondary Finding in a Study
December 28, 2021
Tip of the Week on Vacation
December 21, 2021
December 14, 2021
Delayed Hemorrhage After Head Trauma in Anticoagulated Patients
December 7, 2021
November 30, 2021
November 23, 2021
The Perils of Hypertonic Sodium Chloride
November 16, 2021
Cognitive Biases and Heuristics in the Delivery Room
November 9, 2021
November 2, 2021
Adverse Drug Events After Hospitalization
October 26, 2021
Opioid-Induced Respiratory Depression Costly in Fiscal as Well as Human Terms
October 19, 2021
COVID-19 Vaccine/ Flu Vaccine Mixups
October 12, 2021
FDA Approval of Concussion Tool – Why Not a Fatigue Detection Tool?
October 5, 2021
September 28, 2021
Barcoding Better? Not So Fast!
September 21, 2021
Repeat CT in Anticoagulated Patients After Minor Head Trauma Not Cost-Effective
September 14, 2021
September 7, 2021
The Vanderbilt Tragedy Gets Uglier
August 31, 2021
The Community Pharmacy and Patient Safety
August 24, 2021
More Home Infusion Safety Issues
August 17, 2021
Tip of the Week on Vacation
August 10, 2021
Tip of the Week on Vacation
August 3, 2021
Obstetric Patients More At-Risk for Wrong Patient Orders
July 27, 2021
July 20, 2021
FDA Warning: Magnets in Consumer Electronics May Affect Medical Devices
July 13, 2021
The Skinny on Rapid Response Teams
July 6, 2021
Tip of the Week on Vacation
June 29, 2021
June 22, 2021
Remotely Monitoring Suicidal Patients in Non-Behavioral Health Areas
June 15, 2021
What’s Happened to Your Patient Safety Walk Rounds?
June 8, 2021
Cut OR Traffic to Cut Surgical Site Infections
June 1, 2021
Stronger Magnets, More MRI Safety Concerns
May 25, 2021
Yes, Radiologists Have Handoffs, Too
May 18, 2021
Medical Overuse Is Not Just An Economic Problem
May 11, 2021
How Are Alerts in Ambulatory CPOE Doing?
May 4, 2021
More 10x Dose Errors in Pediatrics
April 27, 2021
Errors Common During Thrombolysis for Acute Ischemic Stroke
April 20, 2021
Taser “Slip and Capture Error” Again!
April 13, 2021
Incidental Findings – What’s Your Strategy?
April 6, 2021
March 30, 2021
Need for Better Antibiotic Stewardship
March 23, 2021
Nursing Staffing and Sepsis Outcomes
March 16, 2021
Sleep Program Successfully Reduces Delirium
March 9, 2021
Update: Disclosure and Apology: How to Do It
March 2, 2021
Barriers to Timely Catheter Removal
February 23, 2021
February 16, 2021
New Methods for QTc Monitoring
February 9, 2021
February 2, 2021
MGH Protocols Reduce Risk of Self-Harm in ED
January 26, 2021
This Freezer Accident May Cost Lives
January 19, 2021
Technology to Identify Fatigue?
January 12, 2021
January 5, 2021
Dilaudid/HYDROmorphone Still Problematic
December 29, 2019
Tip of the Week on Vacation
December 22, 2019
Tip of the Week on Vacation
December 15, 2020
Our Perennial Pre-Holiday Warning: “Be Careful Out There!”
December 8, 2020
Maternal Mortality: Looking in All the Wrong Places?
December 1, 2020
An Early Warning System and Response System That Work
November 24, 2020
November 17, 2020
A Picture Is Worth a Thousand Words
November 10, 2020
November 3, 2020
Reminder: Infant Abduction Risk
October 27, 2020
Conflicting Studies on Technology to Reduce RSI’s
October 20, 2020
More on Post-operative Risks for Patients with OSA
October 13, 2020
October 6, 2020
Successfully Reducing Opioid-Related Adverse Events
September 29, 2020
September 22, 2020
VA RCA’s: Suicide Risks Vary by Site
September 15, 2020
September 8, 2020
Follow Up on Tests Pending at Discharge
September 1, 2020
NY State and Nurse Staffing Issues
August 25, 2020
The Off-Hours Effect in Radiology
August 18, 2020
August 11, 2020
Above-Door Alarms to Prevent Suicides
August 4, 2020
July 28, 2020
July 21, 2020
Is This Patient Allergic to Penicillin?
July 14, 2020
A Thesis on Intrahospital Transports
July 7, 2020
Another Patient Found Dead in a Stairwell
June 30, 2020
What Happens after Hospitalization?
June 23, 2020
June 16, 2020
June 9, 2020
Perioperative Medication Safety
June 2, 2020
May 26, 2020
May 19, 2020
Reminder on Telephone or Verbal Orders
May 12, 2020
May 5, 2020
COVID-19 and the Dental Office
April 28, 2020
April 21, 2020
Parenteral Nutrition Safety Issues
April 14, 2020
Patient Safety Tidbits for the COVID-19 Pandemic
April 7, 2020
From Preoperative Assessment to Preoperative Optimization
March 31, 2020
Intrahospital Transport Issues in Children
March 24, 2020
Mayo Clinic: How to Get Photos in Your EMR
March 17, 2020
March 10, 2020
Medication Harm in the Elderly
March 3, 2020
Opportunities to Reduce Unnecessary Contact Precautions
February 25, 2020
More on Perioperative Gabapentinoids
February 18, 2020
February 11, 2020
February 4, 2020
Drugs and Chronic Kidney Disease
January 28, 2020
January 21, 2020
Disruptive Behavior and Patient Safety: Cause or Effect?
January 14, 2020
January 7, 2020
Even More Concerns About MRI Safety
December 31, 2019
Tip of the Week on Vacation
December 14, 2019
Tip of the Week on Vacation
December 17, 2019
December 10, 2019
December 3, 2019
Overlapping Surgery Back in the News
November 26, 2019
Pennsylvania Law on Notifying Patients of Test Results
November 19, 2019
An Astonishing Gap in Medication Safety
November 12, 2019
Patient Photographs Again Help Radiologists
November 5, 2019
October 29, 2019
Tip of the Week on Vacation
October 22, 2019
Tip of the Week on Vacation
October 15, 2019
October 8, 2019
October 1, 2019
Electronic Medication Reconciliation: Glass Half Full or Half Empty?
September 24, 2019
EHR-related Malpractice Claims
September 17, 2019
American College of Surgeons Geriatric Surgery Verification Program
September 10, 2019
Joint Commission Naming Standard Leaves a Gap
September 3, 2019
Lessons from an Inpatient Suicide
August 27, 2019
August 20, 2019
Yet Another (Not So) Unusual RSI
August 13, 2019
Betsy Lehman Center Report on Medical Error
August 6, 2019
July 30, 2019
Lessons from Hospital Suicide Attempts
July 23, 2019
Order Sets Can Nudge the Right Way or the Wrong Way
July 16, 2019
July 9, 2019
Spinal Injection of Tranexamic Acid
July 2, 2019
Tip of the Week on Vacation
June 25, 2019
June 18, 2019
June 11, 2019
ISMP’s Grissinger on Overreliance on Technology
June 4, 2019
Medication Errors in the OR – Part 3
May 28, 2019
May 21, 2019
Mixed Message on Number of Open EMR Records
May 14, 2019
Wrong-Site Surgery and Difficult-to-Mark Sites
May 7, 2019
Simulation Training for OR Fires
April 30, 2019
Reducing Unnecessary Urine Cultures
April 23, 2019
In and Out the Door and Other OR Flow Disruptions
April 16, 2019
AACN Practice Alert on Alarm Management
April 9, 2019
Handoffs for Every Occasion
April 2, 2019
Unexpected Events During MRI
March 26, 2019
March 19, 2019
March 12, 2019
Update on Overlapping Surgery
March 5, 2019
Infusion Pump Problems
February 26, 2019
Vascular Access Device Dislodgements
February 19, 2019
Focus on Pediatric Patient Safety
February 12, 2019
From Tragedy to Travesty of Justice
February 12, 2019
2 ER Drug Studies: Reassurances and Reservations
February 5, 2019
Flaws in Our Medication Safety Technologies
January 29, 2018
National Patient Safety Goal for Suicide Prevention
January 22, 2019
Wandering Patients
January 15, 2019
Another Plus for Prehabilitation
January 8, 2019
Maternal Mortality in the Spotlight
January 1, 2019
More on Automated Dispensing Cabinet (ADC) Safety
December 25, 2018
Happy Holidays!
December 18, 2018
Great Recommendations for e-Prescribing
December 11, 2018
December 4, 2018
Don’t Use Syringes for Topical Products
November 27, 2018
November 20, 2018
November 13, 2018
Antipsychotics Fail in ICU Delirium
November 6, 2018
More on Promoting Sleep in Inpatients
October 30, 2018
October 23, 2018
Lessons From Yet Another Aviation Incident
October 16, 2018
October 9, 2018
October 2, 2018
Speaking Up About Disruptive Behavior
September 25, 2018
Foley Follies
September 18, 2018
September 11, 2018
September 4, 2018
The 12-Hour Nursing Shift: Another Nail in the Coffin
August 28, 2018
Thought You Discontinued That Medication? Think Again
August 21, 2018
Delayed CT Scan in the Anticoagulated Patient
August 14, 2018
ISMP Canada’s Updated “Do Not Use” Abbreviation List
August 7, 2018
Tip of the Week on Vacation
July 31, 2018
Surgery and the Opioid-Tolerant Patient
July 24, 2018
More on Speech Recognition Software Errors
July 17, 2018
OSA Screening in Stroke Patients
July 10, 2018
Another Jump from a Hospital Window
July 3, 2018
Tip of the Week on Vacation
June 26, 2018
Infection Related to Colonoscopy
June 19, 2018
June 12, 2018
Adverse Events in Cancer Patients
June 5, 2018
Pennsylvania Patient Safety Authority on Iatrogenic Burns
May 29, 2018
More on Nursing Workload and Patient Safety
May 22, 2018
Hazardous Intrahospital Transport
May 15, 2018
May 8, 2018
May 1, 2018
April 24, 2018
April 17, 2018
More on Tests Pending at Discharge
April 10, 2018
Prepping the Geriatric Patient for Surgery
April 3, 2018
March 27, 2018
March 20, 2018
Minnesota Highlights Lost Tissue Samples
March 13, 2018
March 6, 2018
February 27, 2018
Update on Patient Safety Walk Rounds
February 20, 2018
February 13, 2018
February 6, 2018
Adverse Events in Inpatient Psychiatry
January 30, 2018
January 23, 2018
Unintentional Hypothermia Back in Focus
January 16, 2018
January 9, 2018
More on Fire Risk from Surgical Preps
January 2, 2018
Preventing Perioperative Nerve Injuries
December 26, 2017
Tip of the Week on Vacation
December 19, 2017
December 12, 2017
Joint Commission on Suicide Prevention
December 5, 2017
Massachusetts Initiative on Cataract Surgery
November 28, 2017
More on Dental Sedation/Anesthesia Safety
November 21, 2017
OSA, Oxygen, and Alarm Fatigue
November 14, 2017
Tracking C. diff to a CT Scanner
November 7, 2017
Perioperative Neuropathies
October 31, 2017
Target Drugs for Deprescribing
October 24, 2017
Neurosurgery and Time of Day
October 17, 2017
Progress on Alarm Management
October 10, 2017
More on Torsade de Pointes
October 3, 2017
Respiratory Compromise: One Size Does Not Fit All
September 26, 2017
Tip of the Week on Vacation
September 19, 2017
Tip of the Week on Vacation
September 12, 2017
Can You Hear Me Now?
September 5, 2017
Another Iatrogenic Burn
August 29, 2017
Suicide in the Bathroom
August 22, 2017
August 15, 2017
Delayed Emergency Surgery and Mortality Risk
August 8, 2017
Sedation for Pediatric MRI Rising
August 1, 2017
Progress on Wrong Patient Orders
July 25, 2017
Can We Influence the “Weekend Effect”?
July 18, 2017
Another Hazard from Alcohol-Based Hand Gels
July 11, 2017
The 12-Hour Shift Takes More Hits
July 4, 2017
Tip of the Week on Vacation
June 27, 2017
June 20, 2017
June 13, 2017
June 6, 2017
NYS Mandate for Sepsis Protocol Works
May 30, 2017
Errors in Pre-Populated Medication Lists
May 23, 2017
May 16, 2017
Are Surgeons Finally Ready to Screen for Frailty?
May 9, 2017
Missed Nursing Care and Mortality Risk
May 2, 2017
Anatomy of a Wrong Procedure
April 25, 2017
April 18, 2017
Alarm Response and Nurse Shift Duration
April 11, 2017
Interruptions: The Ones We Forget About
April 4, 2017
Deprescribing in Long-Term Care
March 28, 2017
More Issues with Dental Sedation/Anesthesia
March 21, 2017
Success at Preventing Delirium
March 14, 2017
More on Falls on Inpatient Psychiatry
March 7, 2017
February 28, 2017
February 21, 2017
Yet More Jumps from Hospital Windows
February 14, 2017
February 7, 2017
January 31, 2017
More Issues in Pediatric Safety
January 24, 2017
Dexmedetomidine to Prevent Postoperative Delirium
January 17, 2017
January 10, 2017
The 26-ml Applicator Strikes Again!
January 3, 2017
What’s Happening to “I’m Sorry”?
December 27, 2016
Tip of the Week on Vacation
December 20, 2016
End-of-Rotation Transitions and Mortality
December 13, 2016
More on Double-Booked Surgery
December 6, 2016
Postoperative Pulmonary Complications
November 29, 2016
Doubling Down on Double-Booked Surgery
November 22, 2016
Leapfrog, Picklists, and Healthcare IT Vulnerabilities
November 15, 2016
November 8, 2016
Managing Distractions and Interruptions
November 1, 2016
CMS Emergency Preparedness Rule
October 25, 2016
Desmopressin Back in the Spotlight
October 18, 2016
Yet More Questions on Contact Precautions
October 11, 2016
New Guideline on Preop Screening and Assessment for OSA
October 4, 2016
September 27, 2016
September 20, 2016
Downloadable ABCDEF Bundle Toolkits for Delirium
September 13, 2016
Vanderbilt’s Electronic Procedural Timeout
September 6, 2016
August 30, 2016
Can You Really Limit Interruptions?
August 23, 2016
ISMP Canada: Automation Bias and Automation Complacency
August 16, 2016
How Is Your Alarm Management Initiative Going?
August 9, 2016
August 2, 2016
Drugs in the Elderly: The Goldilocks Story
July 26, 2016
Confirmed: Keep Your OR Doors Closed
July 19, 2016
Infants and Wrong Site Surgery
July 12, 2016
Forget Brexit – Brits Bash the RCA!
July 5, 2016
Tip of the Week on Vacation
June 28, 2016
Culture of Safety and Catheter-Associated Infections
June 21, 2016
Methotrexate Errors in Australia
June 14, 2016
Nursing Monitoring of Patients on Opioids
June 7, 2016
CPAP for Hospitalized Patients at High Risk for OSA
May 31, 2016
More Frailty Measures That Predict Surgical Outcomes
May 24, 2016
Texting Orders – Is It Really Safe?
May 17, 2016
Patient Safety Issues in Cataract Surgery
May 10, 2016
Medical Problems in Behavioral Health
May 3, 2016
Clinical Decision Support Malfunction
April 26, 2016
Lots More on Preventing Readmissions But Where's the Beef?
April 19, 2016
Independent Double Checks and Oral Chemotherapy
April 12, 2016
April 5, 2016
Workarounds Overriding Safety
March 29, 2016
March 22, 2016
Radiology Communication Errors May Surprise You
March 15, 2016
March 8, 2016
Tip of the Week on Vacation
March 1, 2016
February 23, 2016
February 16, 2016
February 9, 2016
February 2, 2016
January 26, 2016
More on Frailty and Surgical Morbidity and Mortality
January 19, 2016
Patient Identification in the Spotlight
January 12, 2016
New Resources on Improving Safety of Healthcare IT
January 5, 2016
Lessons from AirAsia Flight QZ8501 Crash
December 29, 2015
More Medical Helicopter Hazards
December 22, 2015
The Alberta Abbreviation Safety Toolkit
December 15, 2015
Vital Sign Monitoring at Night
December 8, 2015
Danger of Inaccurate Weights in Stroke Care
December 1, 2015
TALLman Lettering: Does It Work?
November 24, 2015
Door Opening and Foot Traffic in the OR
November 17, 2015
Patient Perspectives on Communication of Test Results
November 10, 2015
Weighing in on Double-Booked Surgery
November 3, 2015
Medication Errors in the OR - Part 2
October 27, 2015
Sentinel Event Alert on Falls and View from Across the Pond
October 20, 2015
Updated Beers List
October 13, 2015
Dilaudid Dangers #3
October 6, 2015
Suicide and Other Violent Inpatient Deaths
September 29, 2015
More on the 12-Hour Nursing Shift
September 22, 2015
The Cost of Being Rude
September 15, 2015
Another Possible Good Use of a Checklist
September 8, 2015
TREWScore for Early Recognition of Sepsis
September 1, 2015
August 25, 2015
Checklist for Intrahospital Transport
August 18, 2015
Missing Obstructive Sleep Apnea
August 11, 2015
New Oxygen Guidelines: Thoracic Society of Australia and NZ
August 4, 2015
Tip of the Week on Vacation
July 28, 2015
July 21, 2015
Avoiding Distractions in the OR
July 14, 2015
July 7, 2015
June 30, 2015
What Are Appropriate Indications for Urinary Catheters?
June 23, 2015
Again! Mistaking Antiseptic Solution for Radiographic Contrast
June 16, 2015
June 9, 2015
Add This to Your Fall Risk Assessment
June 2, 2015
May 26, 2015
May 19, 2015
May 12, 2015
More on Delays for In-Hospital Stroke
May 5, 2015
Errors with Oral Oncology Drugs
April 28, 2015
April 21, 2015
April 14, 2015
Using Insulin Safely in the Hospital
April 7, 2015
March 31, 2015
Clinical Decision Support for Pneumonia
March 24, 2015
Specimen Issues in Prostate Cancer
March 17, 2015
March 10, 2015
FDA Warning Label on Insulin Pens: Is It Enough?
March 3, 2015
Factors Related to Postoperative Respiratory Depression
February 24, 2015
More Risks with Long-Acting Opioids
February 17, 2015
Functional Impairment and Hospital Readmission, Surgical Outcomes
February 10, 2015
The Anticholinergic Burden and Dementia
February 3, 2015
CMS Hopes to Reduce Antipsychotics in Dementia
January 27, 2015
The Golden Hour for Stroke Thrombolysis
January 20, 2015
He Didn’t Wash His Hands After What!
January 13, 2015
January 6, 2015
Yet Another Handoff: The Intraoperative Handoff
December 30, 2014
Data Accumulates on Impact of Long Surgical Duration
December 23, 2014
Iatrogenic Burns in the News Again
December 16, 2014
More on Each Element of the Surgical Fire Triad
December 9, 2014
December 2, 2014
ANA Position Statement on Nurse Fatigue
November 25, 2014
Misdiagnosis Due to Lab Error
November 18, 2014
Handwashing Fades at End of Shift, ?Smartwatch to the Rescue
November 11, 2014
Early Detection of Clinical Deterioration
November 4, 2014
Progress on Fall Prevention
October 28, 2014
RF Systems for Retained Surgical Items
October 21, 2014
The Fire Department and Your Hospital
October 14, 2014
October 7, 2014
Our Take on Patient Safety Walk Rounds
September 30, 2014
More on Deprescribing
September 23, 2014
Stroke Thrombolysis: Need to Focus on Imaging-to-Needle Time
September 16, 2014
Focus on Home Care
September 9, 2014
The Handback
September 2, 2014
Frailty and the Trauma Patient
August 26, 2014
Surgeons’ Perception of Intraoperative Time
August 19, 2014
Some More Lessons Learned on Retained Surgical Items
August 12, 2014
Surgical Fires Back in the News
August 5, 2014
Tip of the Week on Vacation
July 29, 2014
The 12-Hour Nursing Shift: Debate Continues
July 22, 2014
More on Operating Room Briefings and Debriefings
July 15, 2014
Barriers to Success of Early Warning Systems
July 8, 2014
Update: Minor Head Trauma in the Anticoagulated Patient
July 1, 2014
Interruptions and Radiologists
June 24, 2014
Lessons from the General Motors Recall Analysis
June 17, 2014
SO2S Confirms Routine Oxygen of No Benefit in Stroke
June 10, 2014
Another Clinical Decision Support Tool to Avoid Torsade de Pointes
June 3, 2014
More on the Risk of Sedative/Hypnotics
May 27, 2014
A Gap in ePrescribing: Stopping Medications
May 20, 2014
May 13, 2014
Perioperative Sleep Apnea: Human and Financial Impact
May 6, 2014
Monitoring for Opioid-induced Sedation and Respiratory Depression
April 29, 2014
More on the Unintended Consequences of Contact Isolation
April 22, 2014
Impact of Resident Workhour Restrictions
April 15, 2014
Specimen Identification Mixups
April 8, 2014
FMEA to Avoid Breastmilk Mixups
April 1, 2014
Expensive Aspects of Sepsis Protocol Debunked
March 25, 2014
March 18, 2014
Systems Approach Improving Stroke Care
March 11, 2014
We Miss the Graphic Flowchart!
March 4, 2014
Evidence-Based Prescribing and Deprescribing in the Elderly
February 25, 2014
Joint Commission Revised Diagnostic Imaging Requirements
February 18, 2014
February 11, 2014
Another Perioperative Handoff Tool: SWITCH
February 4, 2014
But What If the Battery Runs Low?
January 28, 2014
Is Polypharmacy Always Bad?
January 21, 2014
January 14, 2014
Diagnostic Error: Salient Distracting Features
January 7, 2014
Lessons From the Asiana Flight 214 Crash
December 24-31, 2013
Tip of the Week on Vacation
December 17, 2013
December 10, 2013
Better Handoffs, Better Results
December 3, 2013
Reducing Harm from Falls on Inpatient Psychiatry
November 26, 2013
Missed Care: New Opportunities?
November 19, 2013
Can We Improve Dilaudid/HYDROmorphone Safety?
November 12, 2013
More on Inappropriate Meds in the Elderly
November 5, 2013
Joint Commission Sentinel Event Alert: Unintended Retained Foreign Objects
October 29, 2013
PAD: The Pain, Agitation, and Delirium Care Bundle
October 22, 2013
How Safe Is Your Radiology Suite?
October 15, 2013
October 8, 2013
October 1, 2013
Fuels and Oxygen in OR Fires
September 24, 2013
Perioperative Use of CPAP in OSA
September 17, 2013
September 10, 2013
Informed Consent and Wrong-Site Surgery
September 3, 2013
Predicting Perioperative Complications: Slow and Simple
August 27 2013
Lessons on Wrong-Site Surgery
August 20 2013
Lessons from Canadian Analysis of Medical Air Transport Cases
August 13 2013
August 6, 2013
July 9-30, 2013
Tip of the Week on Vacation
July 2, 2013
June 25, 2013
June 18, 2013
DVT Prevention in Stoke – CLOTS 3
June 11, 2013
June 4, 2013
May 28, 2013
The Neglected Medications: IV Fluids
May 21, 2013
May 14, 2013
Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)
May 7, 2013
April 30, 2013
Photographic Identification to Prevent Errors
April 23, 2013
Plethora of Medication Safety Studies
April 16, 2013
April 9, 2013
Mayo Clinic System Alerts for QT Interval Prolongation
April 2, 2013
Absconding from Behavioral Health Services
March 26, 2013
Failure to Recognize Sleep Apnea Before Surgery
March 19, 2013
Dealing with the Violent Patient in the Emergency Department
March 12, 2013
More on Communicating Test Results
March 5, 2013
Underutilized Safety Tools: The Observational Audit
February 26, 2013
Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?
February 19, 2013
Practical Postoperative Pain Management
February 12, 2013
CDPH: Lessons Learned from PCA Incident
February 5, 2013
Antidepressants and QT Interval Prolongation
January 29, 2013
A Flurry of Activity on Handoffs
January 22, 2013
You Don’t Know What You Don’t Know
January 15, 2013
January 8, 2013
More Lessons Learned on Retained Surgical Items
January 1, 2013
Don’t Throw Away Those View Boxes Yet
December 25, 2012
Tip of the Week on Vacation
December 18, 2012
Unintended Consequences of the CAUTI Measure?
December 11, 2012
December 4, 2012
Unintentional Perioperative Hypothermia: A New Twist
November 27, 2012
November 20, 2012
Update on Perioperative Management of Obstructive Sleep Apnea
November 13, 2012
The 12-Hour Nursing Shift: More Downsides
November 6, 2012
Using LEAN to Improve Stroke Care
October 30, 2012
October 23, 2012
Latent Factors Lurking in the OR
October 16, 2012
What is the Evidence on Double Checks?
October 9, 2012
Call for Focus on Diagnostic Errors
October 2, 2012
Test Results: Everyone’s Worst Nightmare
September 25, 2012
Preoperative Assessment for Geriatric Patients
September 18, 2012
September 11, 2012
In Search of the Ideal Early Warning Score
September 4, 2012
August 28, 2012
New Care Model Copes with Interruptions Better
August 21, 2012
More on Missed Followup of Tests in Hospital
August 14, 2012
August 7, 2012
Cognition, Post-Op Delirium, and Post-Op Outcomes
July 31, 2012
Surgical Case Duration and Miscommunications
July 24, 2012
FDA and Extended-Release/Long-Acting Opioids
July 17, 2012
July 10, 2012
Tip of the Week on Vacation
July 3, 2012
Recycling an Old Column: Dilaudid Dangers
June 26, 2012
Using Patient Photos to Reduce CPOE Errors
June 19, 2012
More Problems with Faxed Orders
June 12, 2012
Lessons Learned from the CDPH: Retained Foreign Bodies
June 5, 2012
Minor Head Trauma in the Anticoagulated Patient
May 29, 2012
Falls, Fractures, and Fatalities
May 22, 2012
Update on Preoperative Screening for Sleep Apnea
May 15, 2012
May 8, 2012
Importance of Nontechnical Skills in Healthcare
May 1, 2012
April 24, 2012
Fire Hazard of Skin Preps Oxygen
April 17, 2012
April 10, 2012
April 3, 2012
New Risk for Postoperative Delirium: Obstructive Sleep Apnea
March 27, 2012
March 20, 2012
Adverse Events Related to Psychotropic Medications
March 13, 2012
Medical Emergency Team Calls to Radiology
March 6, 2012
February 28, 2012
AACN Practice Alert on Delirium in Critical Care
February 21, 2012
Improving PCA Safety with Capnography
February 14, 2012
Handoffs More Than Battle of the Mnemonics
February 7, 2012
Another Neuromuscular Blocking Agent Incident
January 31, 2012
January 24, 2012
Patient Safety in Ambulatory Care
January 17, 2012
Delirium and Contact Isolation
January 10, 2012
January 3, 2012
Unintended Consequences of Restricted Housestaff Hours
December 20, 2011
December 13, 2011
December 6, 2011
Why You Need to Beware of Oxygen Therapy
November 29, 2011
November 22, 2011
Perioperative Management of Sleep Apnea Disappointing
November 15, 2011
November 8, 2011
WHOs Multi-professional Patient Safety Curriculum Guide
November 1, 2011
So Whats the Big Deal About Inserting an NG Tube?
October 25, 2011
October 18, 2011
October 11, 2011
October 4, 2011
Radiology Report Errors and Speech Recognition Software
September 27, 2011
The Canadian Suicide Risk Assessment Guide
September 20, 2011
When Practice Changes the Evidence: The CKD Story
September 13, 2011
Do You Use Fentanyl Transdermal Patches Safely?
September 6, 2011
August 30, 2011
Unintentional Discontinuation of Medications After Hospitalization
August 23, 2011
Catheter Misconnections Back in the News
August 16, 2011
August 9, 2011
Frailty and the Surgical Patient
August 2, 2011
July 26, 2011
July 19, 2011
Communication Across Professions
July 12, 2011
Psst! Pass it onHow a kids game can mold good handoffs
July 5, 2011
Sidney Dekker: Patient Safety. A Human Factors Approach
June 28, 2011
Long-Acting and Extended-Release Opioid Dangers
June 21, 2011
June 14, 2011
June 6, 2011
May 31, 2011
Book Review Human Factors and Team Psychology in a High Stakes Environment
May 24, 2011
May 17, 2011
Opioid-Induced Respiratory Depression Again!
May 10, 2011
Preventing Preventable Readmissions: Not As Easy As It Sounds
May 3, 2011
April 26, 2011
Sleeping Air Traffic Controllers: What About Healthcare?
April 19, 2011
DVT Prophylaxis in Acute Stroke: Controversy Reappears
April 12, 2011
Medication Issues in the Ambulatory Setting
April 5, 2011
March 29, 2011
The Silent Treatment:A Dose of Reality
March 22, 2011
An EMR Feature Detrimental to Teamwork and Patient Safety
March 15, 2011
March 8, 2011
Yes, Physicians Get Interrupted Too!
March 1, 2011
February 22, 2011
February 15, 2011
Controversies in VTE Prophylaxis
February 8, 2011
February 1, 2011
January 25, 2011
Procedural Sedation in Children
January 18, 2011
More on Medication Errors in Long-Term Care
January 11, 2011
NPSA (UK) How to Guide: Five Steps to Safer Surgery
January 4, 2011
December 28, 2010
HAIs: Looking In All The Wrong Places
December 21, 2010
More Bad News About Off-Hours Care
December 14, 2010
NPSA (UK): Preventing Fatalities from Medication Loading Doses
December 6, 2010
More Tips to Prevent Wrong-Site Surgery
November 30, 2010
SURPASS: The Mother of All Checklists
November 23, 2010
Focus on Cumulative Radiation Exposure
November 16, 2010
November 9, 2010
12-Hour Nursing Shifts and Patient Safety
November 2, 2010
Insulin: Truly a High-Risk Medication
October 26, 2010
Confirming Medications During Anesthesia
October 19, 2010
Optimizing Medications in the Elderly
October 12, 2010
October 5, 2010
September 28, 2010
September 21, 2010
September 14, 2010
Wrong-Site Craniotomy: Lessons Learned
September 7, 2010
Patient Safety in Ob/Gyn Settings
August 31, 2010
August 24, 2010
The BP Oil Spill Analogies in Healthcare
August 17, 2010
Preoperative Consultation Time to Change
August 10, 2010
Its Not Always About The Evidence
August 3, 2010
Tip of the Week on Vacation
July 27, 2010
EMRs Still Have A Long Way To Go
July 20, 2010
More on the Weekend Effect/After-Hours Effect
July 13, 2010
Postoperative Opioid-Induced Respiratory Depression
July 6, 2010
Book Reviews: Pronovost and Gawande
June 29, 2010
Torsade de Pointes: Are Your Patients At Risk?
June 22, 2010
Disclosure and Apology: How to Do It
June 15, 2010
Dysphagia in the Stroke Patient: the Scottish Guideline
June 8, 2010
Surgical Safety Checklist for Cataract Surgery
June 1, 2010
May 25, 2010
May 18, 2010
Real-Time Random Safety Audits
May 11, 2010
May 4, 2010
More on the Impact of Interruptions
April 27, 2010
April 20, 2010
HITs Limited Impact on Quality To Date
April 13, 2010
April 6, 2010
March 30, 2010
Publicly Released RCAs: Everyone Learns from Them
March 23, 2010
ISMPs Guidelines for Standard Order Sets
March 16, 2010
A Patient Safety Scavenger Hunt
March 9, 2010
Communication of Urgent or Unexpected Radiology Findings
March 2, 2010
Alarm Sensitivity: Early Detection vs. Alarm Fatigue
February 23, 2010
Alarm Issues in the News Again
February 16, 2010
Spin/HypeKnowing It When You See It
February 9, 2010
More on Preventing Inpatient Suicides
February 2, 2010
January 26, 2010
Preventing Postoperative Delirium
January 19, 2010
January 12, 2010
Patient Photos in Patient Safety
January 5, 2010
December 29, 2009
Recognizing Deteriorating Patients
December 22, 2009
December 15, 2009
December 8, 2009
December 1, 2009
Patient Safety Doesnt End at Discharge
November 24, 2009
Another Rough Month for Healthcare IT
November 17, 2009
November 10, 2009
Conserving ResourcesBut Maintaining Patient Safety
November 3, 2009
Medication Safety: Frontline to the Rescue Again!
October 27, 2009
Co-Managing Patients: The Good, The Bad, and The Ugly
October 20, 2009
Radiology AgainBut This Time Its Really Radiology!
October 13, 2009
October 6, 2009
Oxygen Safety: More Lessons from the UK
September 29, 2009
Perioperative Peripheral Nerve Injuries
September 22, 2009
Psychotropic Drugs and Falls in the SNF
September 15, 2009
ETTOs: Efficiency-Thoroughness Trade-Offs
September 8, 2009
Barriers to Medication Reconciliation
September 1, 2009
The Real Root Causes of Medical Helicopter Crashes
August 25, 2009
Interruptions, Distractions, InattentionOops!
August 18, 2009
Obstructive Sleep Apnea in the Perioperative Period
August 11, 2009
August 4, 2009
July 28, 2009
Wandering, Elopements, and Missing Patients
July 21, 2009
Medication Errors in Long Term-Care
July 14, 2009
Is Your Do Not Use Abbreviations List Adequate?
July 7, 2009
Nudge: Small Changes, Big Impacts
June 30, 2009
iSoBAR: Australian Clinical Handoffs/Handovers
June 23, 2009
June 16, 2009
Disclosing Errors That Affect Multiple Patients
June 9, 2009
CDC Update to the Guideline for Prevention of CAUTI
June 2, 2009
Why Hospitals Should FlyJohn Nance Nails It!
May 26, 2009
Learning from Tragedies. Part II
May 19, 2009
May 12, 2009
May 5, 2009
Adverse Drug Events in the ICU
April 28, 2009
Ticket Home and Other Tools to Facilitate Discharge
April 21, 2009
April 14, 2009
More on Rehospitalization After Discharge
April 7, 2009
March 31, 2009
Screening Patients for Risk of Delirium
March 24, 2009
March 17, 2009
March 10, 2009
Prolonged Surgical Duration and Time Awareness
March 3, 2009
Overriding AlertsLike Surfin the Web
February 24, 2009
Discharge Planning: Finally Something That Works!
February 17, 2009
Reducing Risk of Overdose with Midazolam Injection
February 10, 2009
Sedation in the ICU: The Dexmedetomidine Study
February 3, 2009
NTSB Medical Helicopter Crash Reports: Missing the Big Picture
January 27, 2009
Oxygen Therapy: Everything You Wanted to Know and More!
January 20, 2009
The WHO Surgical Safety Checklist Delivers the Outcomes
January 13, 2009
January 6, 2009
December 30, 2008
Unintended Consequences: Is Medication Reconciliation Next?
December 23, 2008
December 16, 2008
Joint Commission Sentinel Event Alert on Hazards of Healthcare IT
December 9, 2008
December 2, 2008
Playing without the ballthe art of communication in healthcare
November 25, 2008
November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
November 11, 2008
November 4, 2008
October 28, 2008
More on Computerized Trigger Tools
October 21, 2008
October 14, 2008
October 7, 2008
Lessons from Falls....from Rehab Medicine
September 30, 2008
September 23, 2008
Checklists and Wrong Site Surgery
September 16, 2008
More on Radiology as a High Risk Area
September 9, 2008
Less is More.and Do You Really Need that Decimal?
September 2, 2008
August 26, 2008
August 19, 2008
August 12, 2008
Jerome Groopmans How Doctors Think
August 5, 2008
July 29, 2008
Heparin-Induced Thrombocytopenia
July 22, 2008
Lots New in the Anticoagulation Literature
July 15, 2008
July 8, 2008
July 1, 2008
WHOs New Surgical Safety Checklist
June 24, 2008
Urinary Catheter-Related UTIs: Bladder Bundles
June 17, 2008
Technology Workarounds Defeat Safety Intent
June 10, 2008
Monitoring the Postoperative COPD Patient
June 3, 2008
UK Advisory on Chest Tube Insertion
May27, 2008
If You Do RCAs or Design Healthcare ProcessesRead Gary Kleins Work
May20, 2008
CPOE Unintended Consequences Are Wrong Patient Errors More Common?
May13, 2008
Medication Reconciliation: Topical and Compounded Medications
May 6, 2008
Preoperative Screening for Obstructive Sleep Apnea
April 29, 2008
ASA Practice Advisory on Operating Room Fires
April 22, 2008
CMS Expanding List of No-Pay Hospital-Acquired Conditions
April 15, 2008
April 8, 2008
April 1, 2008
Pennsylvania PSAs FMEA on Telemetry Alarm Interventions
March 25, 2008
March 18, 2008
Is Desmopressin on Your List of Hi-Alert Medications?
March 11, 2008
March 4, 2008
Housestaff Awareness of Risks for Hazards of Hospitalization
February 26, 2008
Nightmares.The Hospital at Night
February 19, 2008
February 12, 2008
February 5, 2008
Reducing Errors in Obstetrical Care
January 29, 2008
Thoughts on the Recent Neonatal Nursery Fire
January 22, 2008
More on the Cost of Complications
January 15, 2008
Managing Dangerous Medications in the Elderly
January 8, 2008
Urinary Catheter-Associated Infections
January 1, 2008
December 25, 2007
December 18, 2007
December 11, 2007
CommunicationCommunicationCommunication
December 4, 2007
November 27,2007
November 20, 2007
New Evidence Questions Perioperative Beta Blocker Use
November 13, 2007
AHRQ's Free Patient Safety Tools DVD
November 6, 2007
October 30, 2007
Using IHIs Global Trigger Tool
October 23, 2007
Medication Reconciliation Tools
October 16, 2007
Radiology as a Site at High-Risk for Medication Errors
October 9, 2007
October 2, 2007
Taking Off From the Wrong Runway
September 25, 2007
Lessons from the National Football League
September 18, 2007
Wristbands: The Color-Coded Conundrum
September 11, 2007
Root Cause Analysis of Chemotherapy Overdose
September 4, 2007
August 28, 2007
Lessons Learned from Transportation Accidents
August 21, 2007
Costly Complications About To Become Costlier
August 14, 2007
More Medication-Related Issues in Ambulatory Surgery
August 7, 2007
Role of Maintenance in Incidents
July 31, 2007
Dangers of Neuromuscular Blocking Agents
July 24, 2007
Serious Incident Response Checklist
July 17, 2007
Falls in Patients on Coumadin or Other Anticoagulants
July 10, 2007
Catheter Connection Errors/Wrong Route Errors
July 3, 2007
June 26, 2007
Pneumonia in the Stroke Patient
June 19, 2007
Unintended Consequences of Technological Solutions
June 12, 2007
Medication-Related Issues in Ambulatory Surgery
June 5, 2007
Patient Safety in Ambulatory Surgery
May 29, 2007
Read Anything & Everything Written by Malcolm Gladwell!
May 22, 2007
May 15, 2007
Communication, Hearback and Other Lessons from Aviation
May 8, 2007
Doctor, when do I get this red rubber hose removed?
May 1, 2007
April 23, 2007
April 16, 2007
April 9, 2007
Make Your Surgical Timeouts More Useful
April 2, 2007
March 26, 2007
Alarms Should Point to the Problem
March 19, 2007
Put that machine back the way you found it!
March 12, 2007
March 5, 2007
February 26, 2007
Copyright 2012 The Truax Group Healthcare Consulting Patient Safety Solutions Tools Tips & Resources. All rights reserved.
PO Box 1230
Grantham, NH 03753
ph: 716-550-1106
btruax