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July 13, 2021
The Skinny on Rapid Response Teams
Failure to rescue (FTR) is a fairly frequent claim in malpractice and wrongful death suits. And one of the biggest reasons for failure to rescue is failure to recognize signs of clinical deterioration in a patient at a time when an intervention could be beneficial. So, health systems have often looked to early warning systems (EWS) and rapid response teams (RRT’s) as an answer to this problem. But keep in mind that a good early warning scoring system is only as good as what you do with any alerts generated. The literature on early warning scoring systems and rapid response teams has shown mixed and inconsistent results in terms of actual patient outcomes. Our many columns on both those issues (listed below) have demonstrated our ambiguity and uncertainty about the value of these systems.
Our December 1, 2020 Patient Safety Tip of the Week “An Early Warning System and Response System That Work” discussed one successful implementation at the 21-hospital Kaiser Permanente Northern California (KPNC) system (Escobar 2020).
Fischer et al. (Fischer 2021) recently published a review on rapid response teams as a patient safety practice for failure to rescue. They acknowledge that the evidence to determine if RRT’s decrease mortality or intensive care unit (ICU) transfer rate is inconclusive. Their review is based on a paper from the Agency for Healthcare Research and Quality (AHRQ 2020).
Two meta-analyses demonstrated decreased hospital mortality rates after RRT implementation: 1.93% vs 1.95% (Maharaj 2015) and 1.56% vs 1.62% (Solomon 2016) but a 2010 meta-analysis of 15 studies (Chan 2010) found no overall difference in mortality associated with RRT implementation. The heterogeneity and some methodological issues of prior studies have also clouded the interpretations. Fischer et al. note there is moderate evidence that RRT’s are associated with reduced secondary outcomes, such as ICU transfer rate and non-ICU cardiac arrests.
Barriers included inadequate activation mechanisms, poor institutional culture, and lack of leadership support.
Facilitators included having physicians as RRT members. Also, because improvements were often delayed for a year or more after implementation, they felt this implies that education and time are necessary to achieve cultural change for meaningful use of an RRT system. Having staff members feel empowered to activate RRT’s without concern for retribution was also considered a positive.
Are there unintended consequences of RRT’s? Fatigue of RRT members due to overuse is one potential unwanted unintended consequence. Another is potential loss of non-RRT clinician skill to handle unstable patients. On the positive side, at least one study showed increased rates of DNR orders after RRT implementation, suggesting that earlier goals of care discussions had taken place.
One potential unintended consequence almost never looked at in studies on RRT’s is whether activation of an RRT results in other adverse events due to focus on the case needing the RRT. Our February 2017 What's New in the Patient Safety World column “BOGO Applies to Adverse Events, Too” noted a study from the University of Chicago on 13 med-surg wards where rapid response teams were used (Volchenboum 2016). The researchers looked at cardiac arrests and urgent transfers to ICU’s. They found that in the 6-hour window following a cardiac arrest or urgent transfer to ICU, the likelihood of a second similar event increased 18%. And if 2 events occurred the likelihood of a third event on that ward increased 53%. These results remained statistically significant when the time window was changed to 3 hours or 12 hours after the first event.
The authors explained the findings by likely diversion of resources to critically ill patients, resulting in less attention to other patients on the ward. Anyone who has observed all the events taking place on a ward when a patient has a cardiac arrest or other critical event would not be surprised that less attention gets paid to other patients on the ward. But this is the first time, to our knowledge, that anyone has formally quantified this phenomenon. The authors stress that although the absolute increased risk was small, these events were associated with high morbidity and mortality.
So, when key personnel from the unit are needed to work with the Rapid Response Team, you should always designate someone to maintain surveillance over the remaining patients on the unit. And that should be an element covered in your training for Rapid Response Teams.
It is highly unlikely that we will ever see a randomized clinical trial (RCT) on RRT’s, so they are likely here to stay. They certainly make sense in theory and in practical terms. We suggest you go back to our December 1, 2020 Patient Safety Tip of the Week “An Early Warning System and Response System That Work” and use the lessons from the Kaiser Permanente Northern California (KPNC) implementation of both an early warning system and rapid response team system (Escobar 2020).
Cullinane et al. (Cullinane 2021) recently added another component connecting the early warning system and the rapid response team – the surgical safety huddle. The researchers introduced the surgical safety huddle to an acute general surgical ward in March 2019. A multidisciplinary team (physiotherapists, staff nurses and clinical nurse managers of the ward, the on-call surgical registrar) plus the “deteriorating patient team” would “huddle” in front of the ward whiteboard. Huddles lasted no longer than 15 minutes. The primary focus was identification of the deteriorating patient to intervene early and prevent “failure to rescue.” Huddles began with a formalized script and a checklist-style “huddle observation tool” was used.
Their surgical safety huddle program was fine-tuned by multiple iterations of the PDSA cycle. A full 5 iterations were required before the full cooperation and attendance of the surgical registrar was achieved (see the full Cullinane article for details about the barriers involved). Similarly, 3 PDSA cycles occurred before the clinical nurse manager became fully committed. And 3 PDSA cycles resulted in refinement of the early warning system (as the study was done in the UK, the National Early Warning Score (NEWS) was used) and establishment of the “deteriorating patient service” to assist and educate nursing and medical staff with the management of acutely unwell patients.
Prior to the introduction of the surgical huddle, 110 patients with NEWS >7 were audited. Twenty-eight of these patients (25%) had a poor outcome at 72 hours. Three patients had a delayed transfer to the intensive care unit (ICU) and 25 patients had persistently elevated NEWS after 72 hours. A Pareto chart was used to show the main factors contributing to poor outcomes. Lack of compliance with NEWS recording by nursing staff and lack of escalation to the appropriate medical team, as well as delays in medical review, were some of the factors leading to a poor outcome for patients.
After introduction of the surgical huddle and the deteriorating patient team, the interval between cardiac arrests increased more than sixfold. Six months after introduction of the surgical huddle, 64 patients with NEWS >7 were reviewed, and only 3 of these patients (4.7%) had a poor outcome at 72 hours. That reduction from 25% to 4.7% more than surpassed their original target reduction of poor outcomes of 50%.
Changes or concerns in patients’ clinical conditions were voiced at the huddle and interventions were proactive rather than reactive. The “watcher” concept was introduced to highlight patients at risk of deterioration that might not be reflected in their NEWS score (such as high risk of falls, preoperative patients, or patients for whom their family had expressed significant concern). Preemptive postoperative chest physiotherapy and identification of patients at risk of venous thromboembolism were other proactive measures adopted. If there was a clinical concern regarding a deteriorating patient, a medical review and/or sepsis screen were usually warranted. A management plan was conveyed to the intern and the primary team responsible for the patient. The initial concerns and recommended outcomes were recorded using the huddle observation tool. Later in the day, the deteriorating patient team would review the patient to ensure those clinical actions were implemented and the patient was responding accordingly. Data recorded in the huddle observation tool and deviations or noncompliance with the recommended actions were used in monthly reviews by a member of the deteriorating patient team and shared with relevant stakeholders.
Though no formal cost-effectiveness analysis was done, the researchers predicted it would be very cost effective because of likely reductions in both hospital LOS and ICU LOS.
This was not an easy project to carry out. Cullinane et al. detail the many barriers encountered along the way. But their results are pretty impressive and the concept of the “surgical safety huddle” is worthy of your consideration.
Our other columns on rapid response teams:
Some of our other columns on MEWS or recognition of clinical deterioration:
References:
Escobar GJ, Liu VX, Schuler A, et al. Automated Identification of Adults at Risk for In-Hospital Clinical Deterioration. N Engl J Med 2020; 383: 1951-1960
https://www.nejm.org/doi/full/10.1056/NEJMsa2001090
Fischer CP, Bilimoria KY, Ghaferi AA. Rapid Response Teams as a Patient Safety Practice for Failure to Rescue. JAMA 2021; Published online June 24, 2021
https://jamanetwork.com/journals/jama/fullarticle/2781594
AHRQ (Agency for Healthcare Research and Quality). Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices. AHRQ; 2020. March 2020
Maharaj R, Raffaele I,Wendon J. Rapid response systems: a systematic review and meta-analysis. Crit Care 2015; 19(1): 254
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4489005/
Solomon RS, Corwin GS, Barclay DC, et al. Effectiveness of rapid response teams on rates of in-hospital cardiopulmonary arrest and mortality. J Hosp Med 2016; 11(6): 438-445
https://www.journalofhospitalmedicine.com/jhospmed/article/127418/rapid-response-team-meta-analysis
Chan PS, Jain R, Nallmothu BK, et al. Rapid response teams: a systematic review and
meta-analysis. Arch Intern Med 2010; 170(1): 18-26
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/481530
Volchenboum SL, Mayampurath A, Göksu-Gürsoy G, et al. Association between In-Hospital Critical Illness Events and Outcomes in Patients on the Same Ward (Research Letter). JAMA 2016; 316(24): 2674-2675 Published online December 27, 2016
https://jamanetwork.com/journals/jama/article-abstract/2594707
Cullinane C, Healy C, Doyle M, et al. The Surgical Safety Huddle: A Novel Quality Improvement Patient Safety Initiative. Patient Safety 2021; 3(2), 66-77
https://patientsafetyj.com/index.php/patientsaf/article/view/surgical-safety-huddle-ireland
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July 20, 2021
FDA Warning: Magnets in Consumer Electronics May Affect Medical Devices
The FDA has raised concerns that magnets in some consumer electronics, such as cell phones and smartwatch wristbands, may affect pacemakers, implantable defibrillators, and other medical devices (FDA 2021a). The FDA states “We believe the risk to patients is low and the agency is not aware of any adverse events associated with this issue at this time. However, the number of consumer electronics with strong magnets is expected to increase over time. Therefore, we recommend people with implanted medical devices talk with their health care provider to ensure they understand this potential risk and the proper techniques for safe use.”
Many medical devices are designed with a “magnet mode” to allow for safe operation during certain medical procedures, such as undergoing an MRI scan. These safety features are typically initiated with the use of a high field strength magnet that is placed near the implanted device placing it into a “magnet mode.” But there have been recent case reports where magnets in certain cell phones or smartwatches or fitness bands have deactivated devices such as implantable cardioverter-defibrillators (ICD’s).
The FDA also provides information for patients on this issue (FDA 2021b), stating “People with implanted medical devices may want to take some simple precautions, including:
The FDA patient advisory goes on to say that, when near high strength magnets, devices with a magnetic safe mode could stop working or change how the device works. An example is that a cardiac defibrillator may be unable to detect tachycardia events, or it may change the operational mode of the devices such as turning on asynchronous (i.e., two or more events not happening at the same time) mode in a pacemaker.
FDA emphasizes the following for patients: “to avoid interference between cell phones and smart watches and your heart device, keep them at least six inches (15 centimeters) away from implanted medical devices. Also, do not place cell phones, smart watches, and other consumer electronics close to your implanted medical device.”
Based on concerns that the new magnet in the iPhone 12 with MagSafe compatible cases might affect implantable cardioverter-defibrillators (ICD’s), researchers at Henry Ford Heart & Vascular Institute tested the hypothesis on a patient with a Medtronic ICD (Greenberg 2021). Once the iPhone was brought close to the ICD over the left chest area, immediate suspension of ICD therapies was noted and persisted for the duration of the test. This result was reproduced multiple times with different positions of the phone over the pocket.
Asher et al. (Asher 2021) found that a patient’s ICD had reverted to magnet mode after she slept wearing an Apple Watch. They subsequently conducted tests and found both Fitbit and Apple Watch wristband magnets could deactivate the ICD up to distances of 2.4 and 2.0 centimeters, respectively.
Apple recently published a list of its devices that patients should keep away from their pacemaker or other medical devices (Apple 2021). It is surprising how many Apple products have magnets. The list includes not only the iPhone 12 and its MagSafe accessories, but also Apple Watches, AirPods and their charging cases, various iPads, Beats, various Mac models and accessories, and HomePods.
Apple notes “Under certain conditions, magnets and electromagnetic fields might interfere with medical devices. For example, implanted pacemakers and defibrillators might contain sensors that respond to magnets and radios when in close contact. To avoid any potential interactions with these types of medical devices, keep your Apple product a safe distance away from your medical device (more than 6 inches / 15 cm apart or more than 12 inches / 30 cm apart if wirelessly charging). Consult with your physician and your device manufacturer for specific guidelines. If you suspect that your Apple product is interfering with your medical device, stop using your Apple product and consult your physician and your medical-device manufacturer.”
More and more consumer electronic products are using magnets and it is not always obvious to people that their device has a magnet that could potentially interfere with a medical device.
While the FDA advisory says it believes “the risk to patients is low and the agency is not aware of any adverse events associated with this issue at this time”, we found the case described by Asher et al. (Asher 2021) to be particularly bothersome. That case involved a 55-year-old woman with a dual-chamber ICD because of a history of sustained ventricular tachycardia secondary to arrhythmogenic right ventricular dysplasia. Because of a recommendation to avoid strenuous exercise, she purchased an Apple Watch with fitness tracking capabilities to monitor her heart rate. She sometimes wore the watch overnight. While asleep one night, she was awoken by several beeps emanating from her implanted cardiac device. Subsequent interrogation of the device showed no alerts or abnormal parameters, but it was found that the device had reverted to magnet mode, owing to magnetic interference from the fitness watch’s wristband. No other possible sources of interference were identified. This was replicated in the office, where interrogation of the ICD confirmed magnetic reversion when placed in proximity to the wristband. The watch itself did not have magnetic interference.
Had not that patient heard the beeps from her ICD, she might not have realized her ICD would not be active if she had an episode of ventricular tachycardia. Pretty scary!
References:
FDA (US Food and Drug Administration). FDA In Brief: FDA Continues to Monitor the Effects of Magnets in Consumer Electronics on Implanted Medical Devices. FDA 2021; May 13, 2021
FDA (US Food and Drug Administration). Magnets in Cell Phones and Smart Watches May Affect Pacemakers and Other Implanted Medical Devices. FDA 2021
Greenberg JC, Altawil MR, Singh G. Lifesaving therapy inhibition by phones containing magnets (Letter to the Editor). HeartRhythm 2021;18(6): 1040-1041, June 01, 2021
https://www.heartrhythmjournal.com/article/S1547-5271(20)31227-3/fulltext
Asher EB, Panda N, Tran CT, Wu M. Smart wearable device accessories may interfere with implantable cardiac devices. HeartRhythm Case Reports 2021; 7: 167-169 Published online December 12, 2020
https://www.heartrhythmcasereports.com/article/S2214-0271(20)30274-8/fulltext
Apple. About potential magnetic interference with medical devices. Apple Support 2021; June 25, 2021
https://support.apple.com/en-us/HT211900
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July 27, 2021
Sustainability
We’ve all seen it. We implement a quality improvement or patient safety project and get the results we desire. But 6 months later, we’ve fallen back to old practices and our gains are lost. This failure to sustain improvement is frustrating, since a lot of work, people resources, and often political capital usually went into the project(s).
Silver et al. (Silver 2016) cited one study which noted about 70% of all change initiatives fail (Nohria 2000) and another which reported that 33% of QI projects are not sustained upon evaluation 1 year after completion (Maher 2010).
From our perspective, there are 5 keys to any change management project:
Some might ask “Aren’t the last 2 items the same?”. The answer is no. In many change projects the overall intended effect is positive, but there may well be specific groups that are impacted negatively, and those groups can scuttle the whole project. We’ve always stressed that you must encounter “noise” during your planning stages prior to implementation. Silence during these stages usually means you are likely to encounter resistance and barriers once you begin roll out your project implementation. That silent resistance is also a major reason that initial success of such projects fails to be sustained.
Note also our comment about the meaningfulness of the goals. In our June 8, 2021 Patient Safety Tip of the Week “Cut OR Traffic to Cut Surgical Site Infections” we emphasized that point. Reduction in OR traffic is not a meaningful goal in itself. Rather, the meaningful goal is reduction of surgical site infections. (Reduction in OR traffic might also produce a desirable reduction in interruptions and distractions, but even that is an intermediary goal. The ultimate goal from that would be a reduction in errors that impact the patient.) The same reasoning may explain why hand hygiene rates are abysmally low in most facilities and why initial improvement in those rates with QI projects fails to be sustained. Handwashing rate is not itself the meaningful goal. The meaningful goal is a reduction in infections. Unless clinicians (and other healthcare workers) can visually see that infection rates are improving, they don’t make the connection that their individual hand hygiene practices are important.
Add to those factors above the importance of adequate support and resources from senior leadership and a culture of safety and continuous learning.
Silver et al. (Silver 2016) used the NHS (UK) Sustainability Model (Maher 2010) in a quality improvement project aimed at increasing the number of dialysis patients on home dialysis. Silver et al. note that the NHS model has also informed several other sustainability models, including the Institute for Healthcare Improvement model (Scoville 2016).
They stress that planning for sustainability must begin early. Ten factors are considered in the NHS Sustainability model, related to process, staff, and organizational issues:
Recognizing when a quality improvement project is ready to be sustained or implemented can be challenging, but they point out that several signs exist, including the following:
Silver et al. note the importance of “visual management”. While they note use of process control boards and performance boards, our take on it is that you need to make the progress toward and sustenance of your goals readily visible to all relevant stakeholders.
They also stress use of “improvement huddles”. These are regular (daily to weekly) 10- to 15-minute meetings among all unit staff to anticipate problems and review current performance. These allow for problems to be corrected quickly, which shifts efforts from problem troubleshooting to problem prevention.
In a section “Context Eats Strategy for Breakfast”, Silver et al. note that the success of the same improvement intervention may differ on the basis of the local environment in which it is applied. Contextual factors occur at all levels, including the external environment, macrosystem, mesosystem, and microsystem.
The type of interventions in your QI project are also important for ensuring sustainability. In our March 27, 2012 Patient Safety Tip of the Week “Action Plan Strength in RCA’s” we discuss the hierarchy of strength of interventions. We also provide a Power Point presentation to visually show the relative strengths of various interventions. Though these were discussed in the context of root cause analyses, they also apply to interventions in any form of quality improvement process. Education and training always rank low in our hierarchy of effective interventions. The strongest actions are forcing functions and constraints. For example, educational or training sessions on avoiding CLABSI’s (central line–associated bloodstream infections) will get you only so far. But, if you force staff to do a time out to complete a checklist before they can open a central line kit, you’ll likely get better results.
One barrier to sustaining improvement is staff turnover. It is especially important when bringing new staff into a system that they fully understand the reasons for your project and the importance of maintaining the improvements you’ve made.
Another barrier to sustainability is failure to identify what elements in a QI project are actually important. That’s particularly relevant since we often implement “bundles” containing multiple interventions at the same time. When we can’t separate out the impact of individual components in those bundles, it’s pretty easy for staff to begin slacking off on compliance with some of those components.
Burke and Marang-van de Mheen (Burke 2021) recently did an editorial on sustaining quality improvement efforts to accompany a study (Schechter 2021) that showed an initial improvement in pediatric asthma guideline adherence across 43 community hospitals was associated with concerning declines in guideline adherence over time.
They note that QI interventions are more likely to be sustainable if if they simplify clinical workflows. Alexander et al. (Alexander 2021) also note that changes in work processes must be “hard-wired” into the day-to-day work including ongoing surveillance to ensure sustained improvement.
Burke and Marang-van de Mheen also discuss a barrier we mentioned above – identifying which components of a QI project are important. They stress the importance of using PDSA cycles to allow for careful isolation and refinement of the ‘active ingredient(s)’ and the resources necessary for the intervention to be effective. The PDSA cycles also are important in identifying barriers. In our August 2021 What's New in the Patient Safety World column “Antibiotic Stewardship in Pediatrics” discusses a study by Frost et al. (Frost 2021) on improving delayed antibiotic prescribing for acute otitis media. You should read the Frost study to see the multiple barriers that were encountered and identified in the reiterative PDSA cycles.
Burke and Marang-van de Mheen suggest 3 keys to sustainability:
The very successful Michigan Keystone ICU Project significantly reduced central line–associated bloodstream infection (CLABSI) rates and was able to sustain these improvements. Pronovost et al. (Pronovost 2016) found several factors that aided the sustainability of the project. The QI teams integrated the intervention into staff orientation, and active involvement of hospital leaders and the Keystone Center as well as ongoing monitoring and feedback of performance were important in sustaining results. And we will add another real key to the sustainability – the goal was incredibly meaningful to all.
We mentioned above that many (or most) hand hygiene improvement programs fail to produce sustained results because the “meaningful” focus should be on infections rather than on hand hygiene per se. Well, we know of at least one hand hygiene program that got sustained results when the focus was on hand hygiene itself. McLean et al at Duke University Medical Center (Mclean 2017) implemented their program on 2 inpatient pediatric units that already had quite impressive hand hygiene rates. Hand hygiene compliance rates improved from an average of 87% to ≥95% within 9 months, and this improvement has been sustained for >2 years on both pediatric inpatient units. They progressively added interventions in multiple iterations of the PDSA cycle to achieve these amazing results. Interventions included: (1) increasing awareness, (2) providing timely feedback, (3) empowering patients and families to participate in mitigation, (4) providing focused education, and (5) developing interdisciplinary HH champions. Obviously, those units already had a high culture of safety that facilitated sustainability. But the fact that each successive PDSA iteration further improved their outcomes reinforces the importance of not becoming complacent once you’ve achieved good results.
Sometimes you need to keep plugging away over the long haul to achieve desired goals and sustain them. Alexander et al. (Alexander 2021) conducted a quality improvement initiative over a 36-month period to improve the efficiency and reduce the variation in the patient handoff process during high-risk, low-volume transfers from the outpatient setting. The most significant improvement effect occurred in the third year with a 50% reduction in transfer time. We encourage you to read the Alexander article for details of the important components that went into their successful program. And in our August 2021 What's New in the Patient Safety World column “Antibiotic Stewardship in Pediatrics” we describe a study (Frost 2021) that required a total of 27 PDSA (plan-do-study-act) cycles to overcome barriers and improve delayed antibiotic prescribing for acute otitis media.
Achieving an improvement in a quality improvement project is the easy part. Sustaining it is the hard part.
Some of our prior columns on RCA’s, FMEA’s, response to serious incidents, etc:
July 24, 2007 “Serious Incident Response Checklist”
March 30, 2010 “Publicly Released RCA’s: Everyone Learns from Them”
April 2010 “RCA: Epidural Solution Infused Intravenously”
March 27, 2012 “Action Plan Strength in RCA’s”
March 2014 “FMEA to Avoid Breastmilk Mixups”
July 14, 2015 “NPSF’s RCA2 Guidelines”
July 12, 2016 “Forget Brexit – Brits Bash the RCA!”
May 23, 2017 “Trolling the RCA”
October 2019 “Human Error in Surgical Adverse Events”
January 2020 “ISMP Canada: Change Management to Prevent Recurrences”
October 2020 “Common Cause Analysis”
References:
Silver SA, McQuillan R,Weizman AV, et al. How to sustain change and support continuous quality improvement. Clin J Am Soc Nephrol 2016; 11(5): 916-924
https://cjasn.asnjournals.org/content/clinjasn/11/5/916.full.pdf
Nohria N, Beer M. Cracking the Code of Change. Harvard Business Review 2000 ; May-June 2000
https://hbr.org/2000/05/cracking-the-code-of-change
Maher L, Gustafson D, Evans A: Sustainability model and guide. NHS Institute for Innovation and Improvement 2010
https://ktpathways.ca/system/files/resources/2019-11/nhs_sustainability_model_-_february_2010_1_.pdf
Scoville R, Little K, Rakover J, Luther K, Mate K. Sustaining Improvement. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2016
http://www.ihi.org/resources/Pages/IHIWhitePapers/Sustaining-Improvement.aspx
Burke RE, Marang-van de Mheen PJ. Sustaining quality improvement efforts: emerging principles and practice. BMJ Quality & Safety 2021; Published Online First: 17 May 2021
https://qualitysafety.bmj.com/content/early/2021/05/16/bmjqs-2021-013016
Schechter S, Jaladanki S, Rodean J, et al. Sustainability of paediatric asthma care quality in community hospitals after ending a national quality improvement collaborative. BMJ Quality & Safety 2021; Published Online First: 19 January 2021
https://qualitysafety.bmj.com/content/early/2021/01/18/bmjqs-2020-012292
Alexander C; Rovinski-Wagner C, Wagner S, et al. Building a Reliable Health Care System: A Lean Six Sigma Quality Improvement Initiative on Patient Handoff. Journal of Nursing Care Quality 2021; 36(3): 195-201
Frost, HM, Monti JD, Andersen LM, et al. Improving Delayed Antibiotic Prescribing for Acute Otitis Media. Pediatrics 2021; 147(6): e2020026062
https://pediatrics.aappublications.org/content/147/6/e2020026062
Pronovost PJ, Watson SR, Goeschel CA, et al. Sustaining reductions in central line-associated bloodstream infections in Michigan intensive care units: a 10-year analysis. Am J Med Qual 2016; 31: 197-202
https://journals.sagepub.com/doi/10.1177/1062860614568647
Mclean HS, Carriker C, Bordley WC. Good to great: quality improvement initiative increases and sustains pediatric health care worker hand hygiene compliance. Hosp Pediatr 2017; 7(4): 189-196
https://hosppeds.aappublications.org/content/7/4/189.long
Print “Sustainability”
August 3, 2021
Obstetric Patients More At Risk for Wrong Patient Orders
We’ve done many columns on patient misidentification and wrong patient orders. There are, of course, some patient-related factors that put patients at greater risk of wrong patient events – such as having very common last names. But we’ve always presumed that patients would be equally at risk for wrong patient orders regardless of site in the healthcare system. A new study shows that may not be the case.
Kern-Goldberger and colleagues (Kern-Goldberger 2021) used the “retract-and-reorder” method (see our July 17, 2012 Patient Safety Tip of the Week “More on Wrong-Patient CPOE”) to identify near-miss wrong patient orders and compared rates of such orders among patients on obstetric units to those for reproductive-aged women admitted to medical–surgical units. They found the rate of such orders on obstetric patients was nearly double that seen on general med-surg units. The rate of retract-and-reorder events per 100,000 order sessions in obstetric units was 79.5, compared to 42.3 in the general medical–surgical population (OR 1.98). The obstetric retract-and-reorder event rate was significantly higher for attending physicians and house staff compared with advanced practice clinicians. There were no significant differences in error rates between day and night shifts.
By definition, instances found by the retract-and-reorder method did not result in actual wrong patient errors (because the error was rapidly identified and corrected). Nevertheless, they do provide a reasonable estimate of the comparable frequency of actual wrong patient order errors.
Medications most frequently subject to error in the obstetric population in this study were non-oxytocin uterotonics, nifedipine, antibiotics, opioid and non-opioid analgesics, and tocolytics. While the confidence intervals were too wide to make firm conclusions about the risks for these medication categories, they are similar to those found in other studies showing higher error rates for antibiotics, opioid analgesics, tocolytics, and magnesium sulfate in the obstetric population.
The authors discuss potential factors contributing to the higher frequency of wrong patient orders on obstetrics units. One is that the patients are similar in terms of age, sex, and reason for admission. Another is the rapidly changing clinical status of patients in labor and delivery settings. And clinicians are often entering orders for multiple patients at the same order entry sitting. Also, their order entry may be interrupted by obstetric emergencies or imminent deliveries.
In attempt to explain the disparity in wrong patient orders between physicians (attendings and residents) and advanced practice clinicians, the authors note that the physicians are more likely to be entering orders on busy labor and delivery units, whereas the advanced practice clinicians are more likely entering orders in triage, antepartum, and postpartum settings (which might be less hectic).
The study is not clear on one item – the impact of babies having the same last name as the moms. Our multiple columns on misidentification of newborns points out that newborns usually have the same last name as the moms and often share a last name with their twin or other multiple birth sibling. But given the types of medications most frequently involved, it is unlikely that those were being ordered for newborns. So, we doubt much of an impact due to babies having the same last names as moms here.
The authors suggest helping clinicians place orders without disturbance, such as adopting a mandated “no disruption” culture while orders are being placed or other safety tools to
protect physicians and advanced practice clinicians from distraction and interruption. They also suggest better balancing clinical responsibilities for all obstetric clinicians, especially house staff, to ensure adequate time and attention to enter orders safely.
They discuss other factors that frequently contribute to patiens safety issues, such as workload and clinician/patient ratio, crossover coverage and covering multiple services simultaneously, and handoffs.
They also discuss many of the interventions we’ve discussed to avoid wrong patient errors, such as requiring electronic confirmation of patient identity before signing an order, EMR-generated warnings about patients with similar names, use of patient photographs, and CDS alerts regarding high alert or common medications.
Your EMR/CPOE system should always include patient identification information on every page (fixed, so it is not lost when scrolling) and we advocate use of patient photographs in addition to the names and other identifiers. In addition, a good EMR/CPOE system will prevent drop-down lists of patients from stopping at the first search name or at least use some sort of mechanism to alert the clinician that there are more patients with the same search name. And we again caution against allowing multiple patient records to be open at the same time (that also means you need to synchronize records if you have more than one IT program running at the same time, such as CPOE and a separate radiology system).
We also strongly advocate use of the retract-and-reorder” tool as a means of identifying your vulnerabilities to wrong patient orders.
Our March 26, 2019 Patient Safety Tip of the Week “Patient Misidentification” has many recommendations on avoiding wrong patient orders, as do the multiple other columns listed below.
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”
June 19, 2018 “More EHR-Related Problems”
November 2018 “More on Hearing Loss”
March 26, 2019 “Patient Misidentification”
May 21, 2019 “Mixed Message on Number of Open EMR Records”
September 10, 2019 “Joint Commission Naming Standard Leaves a Gap”
December 17, 2019 “Tale of Two Tylers”
March 24, 2020 “Mayo Clinic: How to Get Photos in Your EMR”
June 16, 2020 “Tracking Technologies”
November 17, 2020 “A Picture Is Worth a Thousand Words”
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”
March 26, 2019 “Patient Misidentification”
September 10, 2019 “Joint Commission Naming Standard Leaves a Gap”
June 16, 2020 “Tracking Technologies”
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”
January 8, 2019 “Maternal Mortality in the Spotlight”
December 8, 2020 “Maternal Mortality: Looking in All the Wrong Places?”
References:
Kern-Goldberger AR, Kneifati-Hayek J, Fernandes Y, et al. Wrong-Patient Orders in Obstetrics. Obstetrics & Gynecology 2021; Published online July 8, 2021
https://journals.lww.com/greenjournal/Fulltext/9900/Wrong_Patient_Orders_in_Obstetrics.235.aspx
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August 24, 2021
More Home Infusion Safety Issues
More and more medication infusions are being done in the home, due to both convenience and economic reasons. Often these are for chemotherapy drugs. But there have been problems with home infusion of other drugs as well. Our August 2016 What's New in the Patient Safety World column “Home Infusion Therapy Pitfalls” highlighted a case related to home infusion of vancomycin. And, increasingly, we are seeing home infusion of biologic drugs used for treating immune-mediated disorders.
Baker et al. (Baker 2021) recently analyzed data on over 750,000 biologic infusions in over 57,000 patients, 4.5% of which were administered at home vs. 95.5% administered in facilities. They found that home infusions were associated with 25% increased odds of ED or hospital admission on the same or next day after the infusion (odds ratio 1.25) and 28% increased odds of discontinuation of the biologic after the ED or hospital admission (OR, 1.28). There was no difference in mortality rates between the two sites.
68% of patients were female, likely reflecting the increased incidence of immune-mediated disorders in women, and mean age of patients receiving infusions was 50.1 years. However, those receiving biologic infusions at home were younger, more likely to be male, and had lower Charlson Comorbidity scores than those receiving infusions in facilities.
The top 3 biologics administered at home were infliximab (60.6%), natalizumab (19.6%), and vedolizumab (7.9%), and the top 3 biologics administered at a facility were infliximab (52.1%), abatacept (15.4%), and natalizumab (13.3%).
Note that 25.5% of home infusion patients actually received their first infusion at a facility, followed by subsequent infusions of the same biologic at home.
The raw data showed that 4.4% of the home infusions were associated with ED or hospital admission on the same or next day, compared to 3.5% of those receiving facility infusions. This disparity occurred despite the home infusion patients being younger and having fewer comorbidities. After adjustment for multiple factors, infusions administered at home were associated with 25% increased odds of ED or hospital admission on the same or next day after the infusion compared with infusions administered at a facility (OR 1.25). Home infusions were also associated with 28% increased odds of discontinuation of the biologic after an ED or hospital admission (OR 1.28).
Infusion reactions most commonly occur after the first infusion of a biologic. In this study, the highest proportion of ED or hospital admissions occurred after the first infusion of a given biologic when administered at home, with 4.9% occurring after the first infusion, 4.3% after the second infusion, and 3.9% after the third infusion of the same biologic. Corresponding rates for facility infusions were 3.7%, 3.7%, and 3.9%. Remember that 25% of home infusion patients had received their first dose in a facility, so the relative risks of an adverse event after home infusion might even be greater.
Baker et al. hypothesize that administration of biologics at home involves less intensive monitoring, less physician oversight, and lack of immediate access to urgent medical treatment in the event of an acute infusion reaction and that this can result in delayed care and a more frequent need for escalation of care.
Although permanent discontinuation of a biologic after ED or hospital admission was a rare outcome, it occurred more also frequently after home infusions compared with facility infusions.
In the editorial accompanying the Baker study, Calip et al. (Calip 2021) point out numerous methodological problems and biases inherent in the Baker study. They caution that one cannot conclude causal attribution in such a study. But they acknowledge the evidence provided in the Baker study is highly relevant to understanding the risks and benefits of these disease-altering biologic therapies in different treatment settings.
It is probably no accident that the American College of Rheumatology recently released a position statement on patient safety and site of service for biologics (ACR 2021). It contains the following 3 position statements pertinent to infusion of biologics:
The ACR position statement notes that adverse drug reactions associated with biologics occur in up to 30% of patients in clinical trials and, although injection site reactions caused by subcutaneous biologics are generally easily managed, infusion reactions associated with IV biologics are often more serious. These reactions range in severity from a mild rash and myalgia to hypertension, shortness of breath, headaches, and even life-threatening anaphylaxis, and can occur during or after the infusion. It points out the importance of monitoring for infusion reactions because some must be promptly evaluated and treated. It notes that, for a mild reaction, the infusion rate can often be slowed potentially allowing the patient to complete the infusion. But moderate reactions require cessation of the infusion and either oral or IV medications to prevent clinical decline. And severe reactions can involve multiple organ systems and lead to respiratory and cardiovascular collapse, so these are medical emergencies requiring immediate therapy with medications such as epinephrine and IV glucocorticoids. It warns that such interventions are often beyond the scope of home health providers and delays waiting for emergency services further jeopardize patients’ lives. Experienced providers, available on site, are most capable of deciding whether it is safe to continue therapy in the setting of mild reactions and providing prompt treatment for moderate or severe reactions.
Other considerations pointed out by the ACR are that home infusions do not allow for rigorous maintenance of conditions such as recommended temperature, storage away from sunlight, and proper reconstitution or dosing.
It further cautions that financial considerations related to potential cost savings of home infusions should not override patient safety and standards of care. The position of the ACR is that “proper administration of biologics should take place under the close supervision of a physician in a provider’s office, infusion center or hospital rather than in a patient’s home, unless the patient and provider decide that home infusion is in the patient’s best interest.“ It also suggests that forcing patients to receive infusions at home or in facilities not supervised by a trained provider may reduce access to these critical therapies.
The ACR opposes policies that require home infusion of biologics. “In the absence of an
agreement between the provider and the patient that home infusion is the best option due to extenuating circumstances (i.e., lack of transportation or medical comorbidities) and that the risks of home infusion are outweighed by the benefits, required home infusion is an unnecessary risk to patients and violates current clinical standards of practice.”
It is important that we balance reasons for recommending home infusion therapies against the patient safety issues related to home infusions. While there are likely legitimate reasons for doing such infusions in the home, it is important to recognize what can go wrong and take steps to ensure that any adverse reactions will be recognized promptly and appropriately managed.
Some of our prior columns on patient safety issues in the home:
References:
Baker MC, Weng Y, Fairchild R, Ahuja N, Rohatgi N. Comparison of Adverse Events Among Home- vs Facility-Administered Biologic Infusions, 2007-2017. JAMA Netw Open 2021; 4(6): e2110268
Calip GS, Yerram P, Ascha MS. Nonrandomized Comparison of Adverse Events Following Facility- and Home-Infused Biologics Using Real-World Data. JAMA Netw Open 2021; 4(6): e2111156
ACR (American College of Rheumatology). Position Statement. Patient Safety and Site of Service for Biologics. American College of Rheumatology 2021; June 2021
https://www.rheumatology.org/Portals/0/Files/Biologics-Patient-Safety-and-site-of-Service.pdf
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August 31, 2021
The Community Pharmacy and Patient Safety
One venue we’ve largely ignored in our many columns on patient safety over the years is the community pharmacy. We have discussed how community pharmacies are often left out of the loop when medications are discontinued, often leading to unintended dispensing of those medications (see columns listed below). And we’ve noted a few other examples where patients were given the wrong medications at their pharmacy. But perhaps because we lack a dedicated data repository for errors related to community pharmacies, we have little knowledge of the scope of patient safety issues related to them.
Frankly, we’re surprised we haven’t heard more about patient safety events related to community pharmacies. All you have to do is stand in a long line at a community pharmacy and watch the pharmacists and assistants taking phone calls and incoming orders and scrambling to get all their prescriptions filled and dispensed to patients. In that hectic and stressful environment, we’d expect errors to occur. Tradeoffs between safety and efficiency have been a topic of many of our columns (see, for example, our Patient Safety Tip of the Week “ETTO’s: Efficiency-Thoroughness Trade-Offs”). ISMP Canada (ISMP Canada 2021) saw the same vulnerabilities and recently published a bulletin on balancing safety and efficiency in the community pharmacy.
ISMP Canada queried several databases over roughly 2 years and identified 192 incidents related to community pharmacies, 94 of which were included in their final analysis. They identified 6 areas where measures intended to expedite prescription processing contributed to medication incidents in 3 phases of the medication process:
Under prescription order entry the old “copy and paste” error appeared, just as we have often seen it in errors related to other facets of the electronic medical record. The example given is where the pharmacist copies a previous prescription for the same medication, with the intention of editing it to include the new information (such as a dose change or frequency change). The staff member then overlooks changing the intended information and the patient is dispensed the wrong prescription. ISMP Canada notes that the safe practice is to create a new entry for all new prescriptions and limit the copy function to new prescriptions that are unchanged from the previous prescription in the patient’s profile.
A second theme under prescription order entry relates to delay in patient profile updates. For example, in their hurry to dispense a change in previously used medication or a new medication for the same problem, a pharmacist may fail to delete the old medication from the patient profile. This may result in the discontinued prescriptions remaining on the profile, possibly leading to duplicate therapy or other error. (That is similar to the issue we have previously raised where a clinician discontinues a medication but that never gets conveyed to the community pharmacy and the discontinued medication remains on the patients “active medication” profile.)
Under prescription filling, one of the errors is related to a workaronnd we have seen in hospitals – repeat scanning of bar codes on one item to represent multiple items. For example, this might involve scanning the bar code on 1 item multiple times, rather than scanning the bar code on each item separately, when more than 1 package of a medication is needed to fill a single prescription. An example is provided where one of 3 items had a different dosage that was missed because only the first item was scanned 3 times.
Another problem occurred when patients’ medications are in blister packs but there is a change in recommended dose before the next blister packs are dispensed. ISMP Canada recommends that, when possible, the existing blister pack should be repackaged to reflect the modified regimen. Alternatively, collaborate with the prescriber to determine whether a medication change can be initiated with the next blister pack to be dispensed.
Not surprisingly, under the prescription pickup category, patient misidentification was a major concern. ISMP Canada notes pharmacies should follow strict procedures for patient identification at pickup, such as asking for 2 patient identifiers and having the patient and pharmacy staff member double check the containers in the bag together before leaving the pharmacy.
And perhaps the biggest drawback in the busy community pharmacy is failure to take time to counsel patients who are picking up their prescriptions. ISMP Canada notes that the pharmacy IT systems often show alerts that could or should be discussed with patients, but the busy pharmacist often does not take the time to do so. Or someone other than the patient is picking up the medication so there is no opportunity for discussion.
For the former problem, ISMP Canada suggests the pharmacist should identify and document discussion points during the verification process and attach the documentation to the filled prescription as an alert for the pharmacist to engage in patient dialogue before the prescription is released. For the latter, it suggests use of technology to communicate with those patients not picking up the medication themselves.
All the best practices often get skipped or shortcut when the pharmacy staff is too busy. The obvious solution is better staffing for community pharmacies. Economic factors and workforce issues undoubtedly contribute to understaffing. Ironically, most “pharmacies” do not make the bulk of their profits on drug dispensing (they make it on selling many items other than medications). The per prescription dispensing fees paid to pharmacies are generally very low, so payers need to reconsider their practices.
Difficulty finding workers, both professional and non-professional is a major problem. In a recent survey of independent community pharmacists (NCPA 2021), 80 percent said they are having a difficult time filling open positions. Nearly 90 percent of respondents say they can’t find pharmacy technicians and nearly 60 percent can’t find front-end employees to run the cash register, track inventory, and manage other basic store operations. More than 13 percent are having difficulty trying to hire staff pharmacists to handle prescriptions and patients.
We’ve for years said that the community pharmacist is the most underutilized component of our healthcare system. If you think about it, the community pharmacist is often the healthcare professional with the most frequent opportunities to interact with our patients. Many patients still go to their pharmacy monthly (though mail order has changed this considerably). So, aside from medication counselling, things like blood pressure monitoring and many preventive services could be delivered during those visits to the pharmacy.
It’s high time that health policy makers consider how to make better use of these valuable assets.
Some of our other columns on failed discontinuation of medications:
May 27, 2014 “A Gap in ePrescribing: Stopping 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”
August 2019 “Including Indications for Medications: We Are Failing”
August 6, 2019 “Repeat Adverse Drug Events”
Some of our other columns on medication errors:
December 2007 “1000-fold Heparin Overdoses Back in the News Again”
May 2008 “UK NPSA Alert on Heparin Flushes”
July 15, 2008 “Heparin Flushes.....Again!”
March 24, 2009 “Medication Errors in the OR”
May 20, 2014 “Ophthalmology: Blue Dye Mixup”
September 2014 “Another Blue Dye Eye Mixup”
November 3, 2015 “Medication Errors in the OR - Part 2”
December 1, 2015 “TALLman Lettering: Does It Work?”
May 2016 “Name Confusion in the Pharmacy”
May 24, 2016 “Texting Orders – Is It Really Safe?”
July 2016 “ISMP Updates TALLman Lettering List”
August 23, 2016 “ISMP Canada: Automation Bias and Automation Complacency”
December 2016 “Standardize 4 Safety and Just Bag It!”
March 2017 “Loading Doses Again”
March 2017 “Yes! Another Voice for Medication e-Discontinuation!”
June 2017 “Just Bag It Campaign Success Story”
August 2017 “Medication Errors Outside of Healthcare Facilities”
September 2017 “Safe Medication Use in the ICU”
January 2018 “Eliminating Vincristine Administration Events”
February 2018 “10 Years on the Wrong Medication”
May 8, 2018 “Heparin Overdose”
August 28, 2018 “Thought You Discontinued That Medication? Think Again”
September 2018 “ISMP Updates List of High-Alert Medications”
December 4, 2018 “Don’t Use Syringes for Topical Products”
December 11, 2018 “Another NMBA Accident”
December 18, 2018 “Great Recommendations for e-Prescribing”
January 1, 2019 “More on Automated Dispensing Cabinet (ADC) Safety”
February 5, 2019 “Flaws in Our Medication Safety Technologies”
February 12, 2019 “From Tragedy to Travesty of Justice”
March 5, 2019 “Infusion Pump Problems”
April 2019 “ISMP on Designing Effective Warnings”
June 11, 2019 “ISMP’s Grissinger on Overreliance on Technology”
July 9, 2019 “Spinal Injection of Tranexamic Acid”
August 2019 “Including Indications for Medications: We Are Failing”
August 6, 2019 “Repeat Adverse Drug Events”
November 19, 2019 “An Astonishing Gap in Medication Safety”
February 4, 2020 “Drugs and Chronic Kidney Disease”
May 2020 “PPSA on IV Vancomycin Safety”
June 16, 2020 “Tracking Technologies”
July 2020 “Medication Dosage Miscalculations”
July 21, 2020 “Is This Patient Allergic to Penicillin?”
August 4, 2020 “Intravenous Issues”
April 27, 2921 “Errors Common During Thrombolysis for Acute Ischemic Stroke”
References:
ISMP Canada (Institute for Safe Medication Practices Canada). Balancing Safety and Efficiency in Community Pharmacy. ISMP Canada Safety Bulletin 2021; 21(7): June 30, 2021
https://www.ismp-canada.org/download/safetyBulletins/2021/ISMPCSB2021-i7-Safety-Efficiency.pdf
NCPA (National Community Pharmacists Association). Tight Labor Market Squeezing Local Pharmacies, Survey Shows. NCPA Press Release June 2, 2021
Print “The Community Pharmacy and Patient Safety”
September 7, 2021
The Vanderbilt Tragedy Gets Uglier
We have done several columns on the tragic incident at Vanderbilt in which a patient died after being inadvertently administered a neuromuscular blocking agent (see our Patient Safety Tips of the Week for December 11, 2018 “Another NMBA Accident”, January 1, 2019 “More on Automated Dispensing Cabinet (ADC) Safety” and February 12, 2019 “From Tragedy to Travesty of Justice”).
The nurse involved in that incident was charged with criminal homicide. That trial has not yet taken place. The Tennessee Board of Nursing recently revoked her nursing license, fined her, and ordered her to pay an inordinate amount to cover prosecution costs (Warick 2021). Perhaps the word “persecution” would be more appropriate than “prosecution”.
While we do not defend the errors and deviations from practice that she made (and she did make multiple ones), when we review a serious incident we always ask “Could another nurse/physician/pharmacist make similar errors, given the set of circumstances this individual acted in?” Our answer to that question in those prior columns was “yes”. Once again, a healthcare worker has been placed at the “sharp end” of a cascade of errors, left with the “smoking gun” and bearing the brunt of blame for a catastrophic event that had multiple root causes and contributing factors.
It's worth reiterating here the findings in our February 12, 2019 Patient Safety Tip of the Week “From Tragedy to Travesty of Justice” and our other previous columns on this incident:
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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.
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And the current revocation of here nursing license, especially in view of the upcoming criminal trial, is particularly bothersome.
ISMP (Institute for Safe Medication Practices) recently expressed a stance similar to ours (ISMP 2021). They also stressed a few important considerations. First, they note there was undoubtedly significant outcome bias in the Board’s decision, noting that “the Board has not filed disciplinary action against all TN nurses who have not read a medication label carefully, obtained a nonurgent medication from an ADC via override, drawn an incorrect conclusion, failed to monitor a sedated patient, or failed to document a medication error in the patient’s record.” In this case, the patient died, so the decision was likely biased because of that outcome.
A second important consideration deals with the concept of Just Culture. ISMP notes that the Board apparently has a policy that differentiates between human error, at-risk behavior, reckless behavior, and bad intent. Apparently, the prosecutor noted that the nurse did not act with bad intent but alleged that she did act recklessly. ISMP argues that her actions were either unintentional (human error) or at-risk behaviors, not reckless behaviors. ISMP notes that conscious disregard of a substantial and unjustifiable risk is a requirement for reckless behavior, and notes that this nurse had no idea that she had made a mistake. Failure to read the front of the medication label was either due to a momentary distraction (error) or an unsafe practice habit (at-risk behavior). ISMP argues that the Board did not determine whether the nurse saw the risk(s). They also note that, while she made a conscious decision to not monitor the patient or scan the medication’s barcode, she was told that monitoring was not required, and barcode scanning technology was not available in the radiology suite.
ISMP further argues that the Board relied on an incomplete investigation of the event, particularly related to the question, “What normally happens in similar circumstances?” ISMP would have wanted to know what happens “normally” for patients who were anxious about radiology scans due to claustrophobia. It would have asked whether they were given oral anxiolytics or IV sedatives, and whether they were monitored and by whom and for how long? ISMP also notes the Board failed to consider all the system deficiencies that they have outlined, most of which we have discussed in our prior columns.
ISMP also notes this nurse was contrite and honest in admitting errors she made and was devastated about the tragic patient outcome.
The ISMP column has a useful table outlining the nurse’s alleged failures, with comments about each specific “charge”, noting that several were “disputed” failures and others “undisputed failures” but adds comments as to whether the latter were due to reckless behavior or due to human error or at-risk behavior in accord with Just Culture principles. It is worth your taking time to read the full ISMP column and our prior columns listed below.
Every day in every hospital, healthcare workers make some of the mistakes or deviations noted in this incident. Fortunately, in most cases, harm does not come to patients. But when systems fail, adding contributing factors and lacking safety defenses, bad outcomes ensue. Did the Tennessee Board of Nursing, the hospital, and the prosecutors in the upcoming trial really consider that fundamental question “Could another nurse/physician/pharmacist make similar errors, given the set of circumstances this individual acted in?” We think anyone considering the totality of circumstances in this case would agree with both our view and ISMP’s view that the actions against this nurse (now by multiple parties) have been unjust.
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”
February 12, 2019 “From Tragedy to Travesty of Justice”
April 2019 “ISMP on Designing Effective Warnings”
February 2021 “ISMP: 2 Alerts on NMBA’s”
References:
Warick S. Former nurse accused of giving fatal dose of wrong medicine to patient loses nursing license. News 4 Nashville 2021; Jul 26, 2021
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
ISMP (Institute for Safe Medication Practices). TN Board of Nursing’s Unjust Decision to Revoke Nurse’s License: Travesty on Top of Tragedy! ISMP Medication Safety Alert! Acute Care Edition 2021; 26(16): August 12, 2021
Print “The Vanderbilt Tragedy Gets Uglier”
September 14, 2021
Wrong Eye Injections
It was ophthalmology that actually introduced us to wrong site surgery. Our initial interest in surgical timeouts and checklists stemmed from a root cause analysis on an ophthalmology incident. That incident led to the development of one of the first formal surgical timeout policies, which later became a model for New York State’s first foray into surgical timeout policies. Also, during a lull at one of the meetings of the statewide NYPORTS (New York Patient Occurrence and Report Tracking System) committee we asked attendees if they had ever seen implantation of incorrect lenses during cataract surgery. One hand after another shot up! Probably a third of attendees had experienced this at their hospital. John Simon and his colleagues at Albany Medical College subsequently analyzed all such cases in the NYPORTS database and an ophthalmology malpractice claims database. His work and the references are summarized in our March 11, 2008 Patient Safety Tip of the Week “Lessons from Ophthalmology”.
Note that we use the term ”wrong site surgery” to include not only a procedure on the wrong body part but also procedures on the wrong patient, wrong side, or wrong procedure.
But it’s not just ophthalmologic surgery that runs the risk of wrong site errors. Intravitreous injections have become a very frequent ophthalmologic procedure and a recent report described several cases of errors related to such injections (Vora 2021). While the overall incidence of errors in such cases was very low, Vora et al. identified some important lessons from the four cases they found. Two cases involved injections in the wrong eye, one injection of the wrong medication, and one the wrong dose of the correct medication.
The 2 cases of wrong eye injection involved failure to use (or failure to review) a surgical checklist and failure to perform a pre-procedure timeout. Timeouts and surgical safety checklists should be required not only for “surgery”, but also for any procedure being performed regardless of site of service. See our June 6, 2011 Patient Safety Tip of the Week “Timeouts Outside the OR” for a good discussion on that issue. And, of course, this also raises the question of how organizations that do have policies for use of timeouts and checklists for non-OR procedures actually audit adherence to those checklist and timeout procedures.
Also, in both cases, a new consent form was not obtained because the EMR contained an “active” consent form. Since age-related macular degeneration is commonly bilateral, it is not surprising that a patient might be scheduled for injections in each eye at one time or other. So, the presence in the EMR of consents for injections in both eyes may be a factor contributing to wrong eye errors. Also, since patients are likely to need recurrent injections, the issue of how long a consent should be “active” in the EMR is a serious consideration. How many of you have a process for “closing” a consent once the patient has the first procedure for which that consent was obtained? We’ll bet probably none of you. We really need to develop a standard for somehow flagging in the EMR those consents that are no longer valid because the patient has already had the procedure for which that consent pertained. Just because a patient consented to a procedure the first time does not automatically mean they have consented to the repeat procedure.
The case in which the wrong medication was injected was interesting. This was a patient who had received previous injections of 3 anti-VEGF agents. There had been successful response to only one of those agents. “Active” consents for all 3 agents were present in the electronic medical record. Instead of reviewing the most recent medical record, the surgeon reviewed a past note where the patient received one of the failed medications. He then ordered that medication rather than the one that had been successful. Once again, the procedure team had not relied on a surgical checklist and it is unclear if a pre-procedure timeout was completed.
The fourth case involved injection of the wrong concentration of an anti-VEGF agent. At this site, all anti-VEGF agents were stored together in a refrigerator. The medical assistant, who was new to the service, erroneously pulled a box containing the higher concentration of the intended anti-VEGF agent and the surgeon injected that higher dose. As in the other cases, no checklist was used and there was no pre-procedure timeout performed.
The Vora study does not comment on two significant factors we’ve seen in ophthalmologic “wrong site” cases in the past – daily volume of cases and throughput pressures. Some of those cases involved ophthalmologic surgeons performing many procedures during a session and unexpected changes in the schedules on the day of the procedures. Distractions and interruptions are other factors leading to wrong-site errors. Since many of these procedures are being performed in the office, one wonders how often the surgeon gets interrupted or distracted by other activities in the office setting (phone calls, other patients, requests from other staff, etc.). In one of these cases, where the decision to inject an eye was made during a “routine” appointment, it was noted that the surgeon “re-entered” the room. Was he/she distracted by whatever he/she was doing outside that room?
Apparently, none of these patients suffered harm from these errors. But the authors note these errors did have the potential to cause substantial ocular morbidity, particularly if a complication such as endophthalmitis might occur. They also comment on how such errors can diminish trust in the treating physician and harm the physician-patient relationship.
The authors propose that retina surgeons standardize the injection pathway, with the following considerations:
One of the most important facets in avoiding “wrong site” errors is a strong scheduling policy and procedure (see our October 30, 2012 Patient Safety Tip of the Week “Surgical Scheduling Errors”). At the time of scheduling a procedure, the appropriate primary source documents (including any relevant imaging studies) and current consent forms should be submitted along with a request delineating the exact procedure to be performed and laterality if appropriate. Requests for special equipment or supplies required should also be part of the scheduling process. We also recommend that the scheduling process include a comment or checkbox as to whether a surgical specimen for pathological examination is anticipated. That should be the process when a procedure is scheduled for an OR or facility-based procedure room. But many or most of these intravitreous injections are performed in the office. We suspect that such a formal scheduling process is not routinely performed for office-based procedures like these.
One problem we see during timeouts, whether they are in the OR or elsewhere, is failure of all staff to review primary source documents. All too often, staff merely nod agreement to items on the timeout checklist without themselves reviewing those documents.
Two other important opportunities to avoid wrong-site procedures are the pre-procedure “huddle” and the site marking. In cases being done in a hospital OR or an ambulatory surgery center, the pre-op huddle is done prior to the team entering the OR or procedure room. But we doubt such “huddles” are being done in most office-based procedures. The Vora study does not indicate whether site marking was used in any of these cases or whether it is routinely used during intravitreous injections in their organization. Our May 14, 2019 “Wrong-Site Surgery and Difficult-to-Mark Sites” had comments about site marking in eye procedure cases.
One important consideration in avoiding wrong-site procedures is involvement of the patient in the processes. But, since the majority of patients receiving intravitreous injections are elderly, problems with hearing, eyesight, and/or cognition may preclude full participation by the patient in those processes.
Lastly, how the anti-VEGF agents are stored may be important. Each office (or other site) should have a process in place to clearly segregate these medications to minimize the risk that the wrong one will be procured for a procedure. In the Vora paper there is a photo of the similar appearance of the medication-filled syringes for the two different doses of one of the anti-VEGF agents. Note that this is a similar problem to primary care practices storing multiple vials of different vaccines in their refrigerators.
While the incidence of such “wrong-site” procedures was low in this study, the increasing frequency of intravitreous injections will likely lead to occurrence of similar cases. The Vora study provides valuable lessons to avoid such incidents.
Some of our previous patient safety columns involving ophthalmology issues:
June 5, 2007 “Patient Safety in Ambulatory Surgery”
March 11, 2008 “Lessons from Ophthalmology”
June 8, 2010 “Surgical Safety Checklist for Cataract Surgery”
June 2012 “Tailored Timeouts for Ophthalmologists”
May 20, 2014 “Ophthalmology: Blue Dye Mixup”
September 2014 “Another Blue Dye Eye Mixup”
May 17, 2016 “Patient Safety Issues in Cataract Surgery”
December 5, 2017 “Massachusetts Initiative on Cataract Surgery”
Some of our prior columns related to wrong-site surgery:
September 23, 2008 “Checklists and Wrong Site Surgery”
June 5, 2007 “Patient Safety in Ambulatory Surgery”
July 2007 “Pennsylvania PSA: Preventing Wrong-Site Surgery”
March 11, 2008 “Lessons from Ophthalmology”
July 1, 2008 “WHO’s New Surgical Safety Checklist”
January 20, 2009 “The WHO Surgical Safety Checklist Delivers the Outcomes”
September 14, 2010 “Wrong-Site Craniotomy: Lessons Learned”
November 25, 2008 “Wrong-Site Neurosurgery”
January 19, 2010 “Timeouts and Safe Surgery”
June 8, 2010 “Surgical Safety Checklist for Cataract Surgery”
December 6, 2010 “More Tips to Prevent Wrong-Site Surgery”
June 6, 2011 “Timeouts Outside the OR”
August 2011 “New Wrong-Site Surgery Resources”
December 2011 “Novel Technique to Prevent Wrong Level Spine Surgery”
October 30, 2012 “Surgical Scheduling Errors”
January 2013 “How Frequent are Surgical Never Events?”
January 1, 2013 “Don’t Throw Away Those View Boxes Yet”
August 27, 2013 “Lessons on Wrong-Site Surgery”
September 10, 2013 “Informed Consent and Wrong-Site Surgery”
July 2014 “Wrong-Sided Thoracenteses”
March 15, 2016 “Dental Patient Safety”
May 17, 2016 “Patient Safety Issues in Cataract Surgery”
July 19, 2016 “Infants and Wrong Site Surgery”
September 13, 2016 “Vanderbilt’s Electronic Procedural Timeout”
May 2017 “Another Success for the Safe Surgery Checklist”
May 2, 2017 “Anatomy of a Wrong Procedure”
June 2017 “Another Way to Verify Checklist Compliance”
March 26, 2019 “Patient Misidentification”
May 14, 2019 “Wrong-Site Surgery and Difficult-to-Mark Sites”
May 2020 “Poor Timeout Compliance: Ring a Bell?”
References:
Vora RA, Patel A, Seider MI, Yang S. Evaluation of a Series of Wrong Intravitreous Injections. JAMA Ophthalmol. Published online August 26, 2021.
https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2783398
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September 21, 2021
Repeat CT in Anticoagulated Patients After Minor Head Trauma Not Cost-Effective
One topic that has remained controversial over the years is how often delayed intracranial hemorrhage occurs in anticoagulated patients who suffer blunt head trauma. In several of our columns we have described cases where patients did develop subdural hematomas after they had an initially negative CT scan. But most case series have demonstrated that the overall risk is quite low.
A new study (Borst 2021) identified patients in a trauma registry who were on antithrombotic (anticoagulant and antiplatelet) medications during a 5-y period and who underwent a head computed tomography for blunt trauma. Per their institution protocol, patients with an initial negative head computed tomography underwent repeat imaging 6 hours after their initial head computed tomography. All patients were admitted to the trauma service and observed for 12 to 24 hours with neurologic checks every 2 hours.
The initial head computed tomography was negative in 82% of 1,377 patients. Of those with an initial negative head computed tomography, 12 patients (0.9%) developed an intracranial hemorrhage that was identified on the second head computed tomography (6 had intraventricular hemorrhage, 3 had subdural hematoma, 2 had subarachnoid hemorrhage, and 1 had an intraparenchymal hemorrhage). None of the patients with delayed intracranial hemorrhage developed a change in neurologic status, required an intracranial pressure monitor, or underwent neurosurgical intervention.
Although delayed intracranial hemorrhage was more common in patients on anticoagulants than on antiplatelet agents, the study was not powered to detect a difference between these two groups. The authors also note that, given the small percentage of patients with known INR’s in the supratherapeutic range, their results may not apply to patients with supratherapeutic INR levels.
The estimated total direct cost of the negative head computed tomography scans was $926,247. Applying their findings to a hypothetical case where a delayed intracranial hemorrhage is missed, they estimated the ICER per QALY at $132,321, not meeting the generally accepted criteria for cost-effectiveness.
We’ll note that the methodology used likely overestimated the potential cost savings. The authors estimated the cost of negative head CT’s by multiplying the average charge for a noncontrast head CT scan ($2,179) by the Healthcare Cost and Utilization Project cost-to-charge ratio. If you are a trauma center (the study institution was a Level 1 Trauma Center) and have round-the-clock radiology staffing, your actual marginal cost for doing that second non-contrast CT scan is actually quite small. Even if you have to call in a radiology tech, the marginal cost is probably considerably lower than their calculated value. Nevertheless, we all like to avoid any study that adds little value.
Based on the findings of their study, the institutional protocol at the study institution was updated. Repeat head CT scans are no longer performed unless the patient has an INR
>3.5 or a mental status decline on neuro checks performed every 2 hours during their 12- to 24-hour admission for observation.
The results of the study are reassuring. One question still unanswered is the optimal timing of the initial CT scan. Perhaps it might make sense to delay the initial scan in patients who are alert, not drowsy, and having no neurological signs to 6 hours. But a key to clinical management of these patients was that they did observe the patients for 24 hours, with neuro checks performed every 2 hours.
We should also note that the many clinical decision rules on deciding which patients with minor head trauma should get CT scans do not apply to patients on anticoagulants.
Some of our previous columns on head trauma in the anticoagulated patient:
April 16, 2007 “Falls With Injury”
July 17, 2007 “Falls in Patients on Coumadin or Heparin or Other Anticoagulants”
June 5, 2012 “Minor Head Trauma in the Anticoagulated Patient”.
July 8, 2014 “Update: Minor Head Trauma in the Anticoagulated Patient”
August 21, 2018 “Delayed CT Scan in the Anticoagulated Patient”
Some of our previous columns on CT scans in minor head trauma:
April 16, 2007 “Falls With Injury”
July 17, 2007 “Falls in Patients on Coumadin or Heparin or Other Anticoagulants”
March 2010 “CATCH: New Clinical Decision Rule for CT in Pediatric Head Trauma”
November 23, 2010 “Focus on Cumulative Radiation Exposure”
June 5, 2012 “Minor Head Trauma in the Anticoagulated Patient”.
July 8, 2014 “Update: Minor Head Trauma in the Anticoagulated Patient”
January 2017 “Still Too Many CT Scans for Pediatric Appendicitis”
March 2017 “Update on CT Scanning after Minor Head Trauma”
September 2017 “Clinical Decision Rule Success”
August 21, 2018 “Delayed CT Scan in the Anticoagulated Patient”
References:
Borst J, Godat LN, Berndtson AE, et al. Repeat head computed tomography for anticoagulated patients with an initial negative scan is not cost-effective. Surgery 2021; 170(2): 623-627 Published online: March 26, 2021
https://www.surgjournal.com/article/S0039-6060(21)00117-3/fulltext
Print “Repeat CT in Anticoagulated Patients After Minor Head Trauma Not Cost-Effective”
September 28, 2021
Barcoding Better? Not So Fast!
Barcoding, for bedside medication verification and other uses, has arguably been our most effective medication safety intervention. Yet barcoding has always had a bumpy road. One of our earliest patient safety columns discussed the many workarounds that were being used during barcoding (see our June 17, 2008 Patient Safety Tip of the Week “Technology Workarounds Defeat Safety Intent”). Our very first observation of a nurse administering medications as we implemented our first barcoding system was eye opening. The label on the medication was smudged so the nurse simply copied and pasted the medication label from the CPOE system, totally bypassing the safety built into the barcoding system. In that column we discussed, among other studies, the seminal study by Koppel and colleagues (Koppel 2008) that identified 15 types of workarounds and 31 types of causes for the workarounds in barcoding medication administration systems.
So, how is barcoding going? Have we worked out all the kinks? A recent observational study found that issues related to barcode medication administration (BCMA) remain rampant. Mulac et al. (Mulac 2021) used a mixed-methods design comprising structured observation, field notes, and nurses’ comments on use of BCMA use at two medical wards at a 700-bed hospital in Norway. They observed 44 nurses administering 884 medications to 213 patients and identified BCMA policy deviations for more than half of the observations.
They observed task-related policy deviations in 140 patients (66%) during dispensing and 152 patients (71%) during administration. Organizational deviations included failure to scan 29% of medications and 20% of patient’s wristbands. Policy deviations also arose due to technological factors (eg, low laptop battery, system freezing), as well as environmental factors (eg, medication room location, patient drawer size). Most deviations were caused by policies that interfere with proper and safe BCMA use and suboptimal technology design.
Policy deviations were observed fairly frequently during the dispensing process. These included:
That last item is one we suspect happens in other hospitals. The facility policy was that the patients’ own medication should be stored in the COW (computer on wheels) or the medication room, yet they found a 96% deviation rate from this policy. It’s rare that a patient needs to use his/her own medication brought from home. But, occasionally, a hospital formulary may not have a certain medication required by the patient and use of the patient’s own supply is necessary. But it is critical in such cases that those medications be handled and barcoded just as you’d barcode medications in your hospital pharmacy. And they should be stored in either the pharmacy or in the patient’s drawer in the COW (or other medication cabinet) rather than elsewhere in the patient’s room. There are other potential problems with patients’ own medications. In our September 2021 What's New in the Patient Safety World column “Another Unusual Cause for a 10-Fold Overdose” we described a case where a 10-fold dosing error was made during the transition from use of the home medication to use of the pharmacy’s formulary product.
Technology-related factors were found in 18% of observations. These included:
Software problems included slow response and the need for multiple clicking after scanning each medication.
Environmental factors included both facility layout and equipment issues, such as:
Nurse-related factors also led to deviations:
Most importantly, as our many columns dealing with workarounds have noted, every time you see a workaround you need to look for the root cause(s) that led to that workaround. The Mulac study did delve into those root causes.
The “big picture” causes to policy deviations are that there is a complex dispensing process, the BCMA procedure can be slow or cumbersome, technology design is often suboptimal. and policy description is often non-specific.
Hardware and connectivity problems were common causes. Sometimes laptops were not charged. Scanners often had to be borrowed across wards and some of the scanners were not wireless. And that the scanner was not mobile but attached to the laptop further restricted their use. The authors felt these factors might explain why 20% of patient ID wristbands were not scanned during observation.
Interestingly, the COW (computer on wheels) shows up in several places where causes are discussed. The lack of standardized delivery of dispensed doses lead to several variations in how the medications were dispensed in the COW. As a result, the nurses found it difficult to take for granted that the medications dispensed were correct. To compensate for the uncertainty, the nurses had to manually reconfirm doses before administering to patients. This practice undermines the purpose of BCMA. The COW was also described as being “bulky”. Because of that “bulk” nurses often avoided bringing the COW into the patient room when administering few or one single medication. When the scanner was connected to the COW, that meant the patient’s wrist ID band was not scanned. The COW also contained medications for all patients, which when combined with scanning not being used increased the risk of a patient being given the wrong medication. And, in cases where medications were missing from the COW (often because the COW drawers were too small), the distance a nurse had to travel to obtain the medication was too long. The small size of patient drawers led to deviations because voluminous medications had to be retrieved during administration. And, as above, the work surfaces of the COW’s were often untidy.
The Mulac study demonstrates the power of a tool we underutilize – the observational audit. We’ve discussed that previously in our Patient Safety Tips of the Week for March 5, 2013 “Underutilized Safety Tools: The Observational Audit” and May 18, 2010 “Real-Time Random Safety Audits”. But you need to be careful in performing these that you let your staff understand this is a learning exercise and not intended to be used in any punitive way. You need to use the opportunity to ask staff why they are doing things a certain way. That is what leads you to identify root causes that you can act upon. Sometimes you even need to ask “Would you have done it that way if I were not observing?” In the Mulac study one nurse admitted to not using the BCMA on regular basis but used it during observation period. Again, that question needs to be asked in an entirely nonjudgmental manner.
Here we are – 13 years after the Koppel study that found so many workarounds during BCMA – and we are still seeing significant deviations in use of this technology that is otherwise so valuable in ensuring medication safety. How many of you have done an audit on the BCMA process like that done by the Mulac group? We’ll bet your observations probably won’t be much different.
We also refer you to our January 2018 What's New in the Patient Safety World column “Can We Improve Barcoding?” that described several other studies demonstrating gaps in our use of barcoding in medication safety.
See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:
References:
Koppel R, Tosha 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
Mulac A, Mathiesen L, Taxis K, et al. Barcode medication administration technology use in hospital practice: a mixed-methods observational study of policy deviations. BMJ Quality & Safety 2021; Published Online First: 20 July 2021
https://qualitysafety.bmj.com/content/early/2021/07/19/bmjqs-2021-013223
Print “Barcoding Better? Not So Fast!”
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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
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PO Box 1230
Grantham, NH 03753
ph: 716-550-1106
btruax