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October 6, 2020
Successfully Reducing Opioid-Related Adverse Events
Opioid-induced respiratory depression (OIRD) is a significant issue in hospital inpatients, as well as in post-anesthesia care patients. Many of our initial columns on OIRD focused on post-surgical patients. But in our January 2020 What's New in the Patient Safety World column “Opioids and Apnea: Not Just Surgical Patients” we pointed out that over half of non-surgical inpatients receive opioids, often in high doses. And high percentages of both medical and surgical patients have undiagnosed obstructive sleep apnea (OSA) that is a major risk factor for OIRD.
Our many columns on OIRD have emphasized several key elements to consider in order to avoid OIRD:
Patient selection includes both asking whether use of opioids is necessary and assessment for risk factors for OIRD. Foremost is assessment for possible obstructive sleep apnea (OSA), using a tool such as the STOP-BANG questionnaire. But you also need to consider whether there are other medical comorbidities (eg. COPD) that might predispose to OIRD and whether the patient is also receiving other medications that might depress respiration.
Once you have determined that an opioid is necessary, you need to decide which one to use and proper dosing. That includes determination as to whether the patient is opioid naïve or opioid tolerant. We recommend that you avoid providing too many choices for specific opioids, since issues of equipotency always come into play. In particular, we recommend avoiding HYDROmorphone (Dilaudid) because clinicians often underestimate the potency on a milligram basis (see our multiple columns on Dilaudid dangers listed below). We encourage standardization on a few products and incorporation of those into standardized order sets. And, if you are going to use PCA (patient-controlled analgesia), we recommend you use our PCA Pump Audit Tool and PCA Pump Criteria tools or the PCA Safety Checklist put out by the Physician-Patient Alliance for Health & Safety (PPAHS 2012).
Proper monitoring is essential. Monitoring end-tidal carbon dioxide (ETCO2) by capnography is now the accepted gold standard. We’d like to see every patient on opioids monitored with capnography. Realistically, some hospitals may not have the resources to use capnography on all patients receiving opioids. But clearly those at high risk for OIRD should be on capnography. Monitoring with only pulse oximetry is inadequate and often leads to a false sense of security. Hypoxemia occurs relatively late in opioid-induced respiratory depression. Much earlier, pCO2 begins to rise and leads to obtundation and eventually respiratory arrest. Patients usually don’t become hypoxemic until substantial reduction in respiration has occurred. Hence, the need for monitoring for hypercapnia by using continuous capnography to monitor end-tidal carbon dioxide (ETCO2).
One hospital recently published its results from implementation of a comprehensive program aimed at avoiding OIRD incidents (Steele 2020). A midwest medical center found that it continued to experience frequent opioid-related adverse events despite introduction of some interventions intended to reduce them. Most of those consisted primarily of educational interventions (aimed at both clinicians and patient/families) but we’ve pointed out so many times that educational interventions are in the lowest tier of effectiveness for any interventions. So, they introduced a number of measures, including staff education, sleep apnea risk assessment documentation and communication, revisions to PCA policies and procedures, and revisions to preprinted PCA orders. In addition, a smart infusion pump system with continuous capnography to monitor end-tidal carbon dioxide (ETCO2) was introduced for use with all PCA patients, epidural patients, and patients considered at high risk of respiratory depression. (Prior to 2010, monitoring of at-risk patients receiving opioids had been done primarily by pulse oximetry.) The smart infusion pump system incorporated a PCA pause functionality automatically stopping opioid delivery to those patients who are identified as compromised.
They measured opioid-related adverse reactions (ADR’s) before and after those interventions. Compared with the pre-implementation period, the post-implementation period the number of severe adverse reactions dropped from 3.08 to 0.64 per 10,000 patients treated with opioid, a statistically significant 79.2% reduction. The relative proportion of code blue events decreased from approximately 40% before the introduction of capnography monitoring to just more than 10% per year after introduction, to nearly 0% by the end of the study period. Moreover, there was also a reduction in the duration of opioid treatment (average 2.05 vs 1.37 days).
Rates of mild and moderate ADR’s actually increased in the post-capnography period, but that should not be surprising. The addition of capnography monitoring likely led to earlier recognition of respiratory depression and intervention before serious respiratory depression had occurred.
This is a good example of how a multi-pronged plan can be successfully implemented and deliver the outcomes desired.
Other Patient Safety Tips of the Week pertaining to opioid-induced respiratory depression and PCA safety:
Our prior columns on patient safety issues related to Dilaudid/HYDROmorphone:
References:
PPAHS (Physician-Patient Alliance for Health & Safety). PCA Safety Checklist.
PPAHS 2012
Steele T, Eidem L, Bond J. Impact of Adoption of Smart Pump System With Continuous Capnography Monitoring on Opioid-Related Adverse Event Rates: Experience From a Tertiary Care Hospital, Journal of Patient Safety: September 2020; 16(3): e194-e198
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October 13, 2020
Night-Time Surgery
Some studies have shown that morbidity and mortality rates are higher for “after-hours” surgery or “night” surgery. It’s easy to think “that should be obvious since patients having surgery at night are sicker and need emergency surgery”. But is that the case? In fact, many surgeries done at “night” or “after-hours” were actually elective cases that just got scheduled or pushed to later times. Do those cases also have higher morbidity and mortality rates?
A recent study (Althoff 2020) analyzed data on over 300,000 patients undergoing non-cardiac surgery at 2 tertiary care hospital networks, 8% of whom underwent night surgery. Night surgery was defined as a surgical incision time between 17:00 and 07:00 hours. They found that, indeed, night surgery was associated with an increased risk of postoperative mortality and morbidity and that the effect was independent of case acuity. Moreover, at least some of the effect was mediated by potentially preventable factors: higher blood transfusion rates and more frequent anesthesia handovers.
The 30-day mortality rate was 0.9% after day surgery and 3.4% after night surgery (adjusted odds ratio for increased risk of mortality after night surgery = 1.26, p<0.001). In secondary analyses, night surgery was also associated with increased 30-day morbidity, defined as a composite outcome including renal, cardiovascular, bleeding, infection, intestinal/digestive, and pulmonary complications (adjusted odds ratio 1.41, p<0.001).
Among patients undergoing non-emergency surgery, night surgery was associated with 1.35-fold higher adjusted odds for 30-day mortality compared with day surgery. For patients undergoing emergency surgery, morbidity and mortality were higher for those undergoing night surgery but did not reach statistical significance. These findings suggest that the increased risk of mortality and morbidity after night surgery was not driven by a higher case acuity.
They also extended their analyses to examine whether transfusion rates and handovers were associated with the outcomes of 30-day mortality and morbidity. The proportion of patients receiving intraoperative blood transfusions was 5.5% during night surgeries and 2.8% during day surgeries. Night surgery was significantly associated with higher transfusion rates after adjustment (adjusted odds ratio 1.25) and the association remained robust in a subgroup of cases where data on intraoperative estimated blood loss and preoperative hemoglobin levels were available, after additional adjustment for blood loss, mild anemia, and moderate to severe anemia within 30 days prior to surgery. They estimated that the higher intraoperative transfusion rates mediated about 5% of the effect on morbidity and mortality.
Anesthesia handovers occurred in 22.6% of night surgeries, compared to 8.8% in day surgeries. Anesthesia handovers were significantly associated with an increased risk of morbidity (adjusted odds ratio 1.10) They estimated that the higher rate of anesthesia handovers mediated about 4.1% of the effect of night surgery on morbidity.
In our October 4, 2016 Patient Safety Tip of the Week “More on After-Hours Surgery” we noted a Canadian study which showed that surgical mortality does vary by time of day (WFSA 2016). They evaluated all surgical procedures for the past 5 years, including all elective and emergent surgical cases except ophthalmic and local anesthesia cases. After adjustment for age and ASA scores, patients operated at night (11:30 PM-7:29 AM) were 2.17 times more likely to die within 30 days than those operating on during regular daytime working hours (7:30 AM-3:29 PM). Those operated on in the late day (3:30 PM-11:29 PM) were 1.43 times more likely to die than those operated on during regular daytime working hours.
Of course, it is logical that patients operated on after-hours are likely to be sicker and thus have a higher mortality. The Canadian authors tried to adjust for that using age and ASA scores but those likely are imperfect adjusters. Other potential factors contributing to the higher after-hours mortality as noted by the authors include provider fatigue during anesthesia and surgery, overnight hospital staffing issues, delays in treatment, or the patient being too sick to be postponed prior to treatment.
We’ve done several prior columns pointing out some of the downsides of after-hours surgery. In our What's New in the Patient Safety World columns for September 2009 “After-Hours Surgery – Is There a Downside?” and October 2014 “What Time of Day Do You Want Your Surgery?” we discussed studies that showed for certain types of orthopedic surgery after hours there was an increased need for reoperations for removal of painful fracture hardware (Ricci 2009) and laparoscopic cholecystectomies done at night compared to daytime were associated with a higher conversion rate to open cholecystectomy (11% vs 6%) (Wu 2014). We also noted previous studies by Kelz and colleagues that showed increased morbidity in non-emergent surgical cases done “after hours”, one in the VA system (Kelz 2008) and another in a private hospital setting (Kelz 2009). And our January 2015 What's New in the Patient Safety World column “Emergency Surgery Also Very Costly” suggested, in addition to the human costs of after-hours surgery there may also be financial costs.
Why should “after hours” surgery be more prone to adverse outcomes than regularly scheduled elective surgery? There are many reasons aside from the fact that patients needing emergency and after-hours surgery are generally sicker. For surgery, in particular, the impact of time of day on teamwork is important. You are often operating with a team that is likely different from your daytime team. All members of that team (physicians, nurses, anesthesiologists, techs, etc.) may not have the same level of expertise or experience as your regular daytime team (because many hospitals have “seniority” policies, you may have less experienced personnel on your OR “on-call” teams) and the team dynamics between members is likely to be different. The post-surgery recovery unit is likely to be staffed much differently after-hours as well. The staff may be more likely to be unfamiliar with things like location of equipment. And some of the other hospital support services (eg. radiology, laboratory, sterile processing, etc.) may have lesser staffing after-hours. Just as importantly, many or all of the “on-call” staff that make up the after-hours surgical team have likely worked a full daytime shift that day, so fatigue enters as a potential contributory factor. And there are always time pressures after hours as well. In addition, one of the most compelling reasons surgery is done at night rather than deferred to the next morning is the schedule of the surgeon or other physician for that next morning (either in surgery or the cath lab or his/her office). Because the surgeon does not want to disrupt that next day schedule, he/she often prefers to go ahead with the current case at night. Similarly, many hospitals run very tight OR schedules and adding a case from the previous night can disrupt the schedule of many other cases.
In our October 24, 2017 Patient Safety Tip of the Week “Neurosurgery and Time of Day” we highlighted a study which looked at neurosurgical procedures at the University of Michigan Health System (Linzey 2017). Noting that reported outcomes are worse at night for things like coronary angioplasty, orthopedic surgery, and colorectal surgery, Linzey and colleagues reviewed their own experience in neurosurgery. There was a higher percentage of more minor procedures late in the day. As you’d expect, complications were more frequent in those cases done as “emergent” and in those patients with more comorbidities (likelihood of complications increasing 10% for each comorbidity). But after adjusting for all patient and procedure characteristics, the odds of a complication were increased by more than 50% for start times between 21:01 and 07:00 (OR 1.53). The odds ratio was even higher when severe complications were considered (OR 1.61).
Linzey and colleagues have some thoughtful comments on why a “night effect” might not have been seen in some reported series of transplant surgery. They noted that transplant surgery is done by teams who are used to working together and who frequently perform surgery at night. Transplant teams are also less reliant on housestaff. And transplant teams are typically doing one type of surgery, compared to other specialties which may be performing multiple different types of surgery at night.
The current Althoff study would seem to add to the concept of the importance of team continuity in that it showed how anesthesia handovers contributed to the higher morbidity and mortality of night surgery. The Althoff study is important in that it found the “night effect” applies even more to non-emergency surgery and identified both the anesthesia handover issue and transfusion issue as contributory factors. Althoff et al. also speculated that prolonged fasting might be a factor contributing to the higher mortality and morbidity in patients having night surgery.
Clearly, there are multiple factors that likely contribute to worse outcomes when surgery is done at night or after-hours. As in our several prior columns, we highly recommend hospitals take a hard look at surgical cases done “after-hours”. You need to look at the morbidity and mortality statistics of such cases. You especially need to look at issues like team continuity and intraoperative handovers. In particular, you need to determine which cases truly needed to be done after hours and, perhaps more importantly, which ones could have and should have been done during “regular hours”. If the latter are significant, you need to consider system changes such as reserving some “regular hours” for such cases to be done the following morning. You may have to alter the scheduling of cases for individual surgeons as well. For example, perhaps the surgeon on-call tonight should not have elective cases scheduled tomorrow morning. That way, if a case comes in tonight that should be done tomorrow morning you will have both a “free” OR room and a “free” surgeon. And you would need to develop a list of criteria to help you triage cases into “regular” or “after-hours” time slots.
Some of our previous columns on “after-hours” surgery:
References:
Althoff FC, Wachtendorf LJ, Rostin P, et al. Effects of night surgery on postoperative mortality and morbidity: a multicentre cohort study. BMJ Quality & Safety 2020; Published Online First: 07 October 2020
https://qualitysafety.bmj.com/content/early/2020/10/07/bmjqs-2020-011684
WFSA (World Federation of Societies of Anaesthesiologists). Five-year study reveals patients operated on at night twice as likely to die as patients who have daytime operations. Science Daily 2016; August 29, 2016
Regarding:
Wang N, et al. Retrospective analysis of time of day of surgery and its 30 day in-hospital postoperative mortality rate at a single Canadian institution. Poster presentation 601. World Congress of Anaesthesiologists 2016
https://www.sciencedaily.com/releases/2016/08/160829192642.htm
Ricci WM, Gallagher B, Brandt A, Schwappach J, Tucker M, Leighton R. Is After-Hours Orthopaedic Surgery Associated with Adverse Outcomes? A Prospective Comparative Study. J Bone Joint Surg Am. 2009; 91: 2067-2072
http://www.ejbjs.org/cgi/content/abstract/91/9/2067
Wu JX, Nguyen AT, de Virgilio C, et al. Can it wait until morning? A comparison of nighttime versus daytime cholecystectomy for acute cholecystitis. Amer J Surg 2014; published online first September 20, 2014
http://www.americanjournalofsurgery.com/article/S0002-9610%2814%2900438-3/abstract
Kelz, R.R., Freeman, K.M., Hosokawa, P.W. et al. Time of day is associated with postoperative morbidity: an analysis of the national surgical quality improvement program data. Annals of Surgery 2008; 247: 544–552
http://www.ncbi.nlm.nih.gov/pubmed/18376202?dopt=Abstract
Kelz RR, Tran TT, Hosokawa P, et al. Time-of-day effects on surgical outcomes in the private sector: a retrospective cohort study. J Am Coll Surg 2009; 209(4): 434-445.e2.
http://www.journalacs.org/article/S1072-7515%2809%2900507-9/abstract
Linzey JR, Burke JF, Sabbagh A, et al. The Effect of Surgical Start Time on Complications Associated With Neurological Surgeries. Neurosurgery 2017; Published online 13 October 2017
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October 20, 2020
More on Post-Operative Risks for Patients with OSA
It’s been over 10 years since our August 17, 2010 Patient Safety Tip of the Week “Preoperative Consultation – Time to Change” in which we recommended screening for obstructive sleep apnea (OSA) as one of the 3 most important preoperative considerations (the other 2 being screening for delirium risk and frailty). OSA is, of course, one of the biggest risk factors for opioid-induced respiratory depression (OIRD), which may occur in both surgical and medical patients. This month there were several key studies published in Anesthesia and Analgesia on OSA in the perioperative period.
The Society of Anesthesia and Sleep Medicine partnered with the Anesthesia Closed Claims Project to create an international registry of unexpected critical events occurring in patients with OSA. Bolden et al. published a comprehensive analysis of 66 cases submitted to the “OSA Death and Near Miss Registry” who had procedures under general anesthesia or combined general plus regional anesthesia (Bolden 2020). Most patients (83%) had a confirmed diagnosis of OSA and the rest had been screened as high risk for OSA. Sixty-five percent of patients died or had brain damage; the remaining 35% experienced other critical events.
Fifty-six percent of events occurred on the hospital ward and 21% occurred at home after discharge. The majority of events occurred within the first 24 postoperative hours. Inadequate respiratory monitoring, no supplemental oxygen, lack of personnel closely observing the patient, and coadministration of sedatives and opioids were all associated with worse outcomes.
Of the events that occurred at home, half occurred within 24 hours of procedure end. Notably, these patients were ASA physical status III or IV, and all had received opioids within 24 hours of the event.
Lack of monitoring was an important contributing factor. Whereas most patients in the PACU, stepdown unit, or ICU were monitored, only 57% on the ward and none at home were monitored. Monitoring consisted of intermittent or continuous pulse oximetry. There were no reports of chest impedance or end-tidal carbon dioxide monitoring (capnography).
52% of the patients were receiving supplemental oxygen at the time of the event. But only 7.5% had a positive airway pressure (PAP) device at the time of the event. Nearly all PACU or ICU/step-down unit events were witnessed, with most ward or at-home cases not witnessed.
Ninety-seven percent received opioids within 24 hours before the event, with a wide MME (morphine milligram equivalent) range (0 to 423 MME, median = 122,). Sedative medications were co-administered with opioids in 62%.
As you’d expect, death or brain damage was less common when the event was witnessed. It was also less common when patients were receiving supplemental oxygen or when patients had respiratory monitoring.
There was no evidence for an association between the outcome and sex, age, body mass index (BMI), ASA physical status, OSA diagnosed versus suspected, presence of cardiovascular or pulmonary comorbidities, or hours between anesthesia end and the event. There was also no evidence for an association between severity of OSA and outcome. There was no evidence for an association between MME and outcome.
There was, however, a strong association of death or brain damage with use of sedatives in addition to opioids compared to patients receiving opioids without sedatives (OR = 4.133).
Timing appears to be very important. The majority of events occurred within the first 24 postoperative hours. Note that a previous systematic review of opioids and OSA (Cozowicz 2018) also found the initial 24 hours after opioid administration appear to be most critical with regard to life-threatening OIRD.
Bolden and colleagues called for special attention to the fact that 21% of these events occurred at home. They stress that, with the trend toward ambulatory rather than inpatient surgery, OSA patients will increasingly have ambulatory surgery and potentially be at risk for catastrophic outcomes after discharge. They also note that, despite use of CPAP, patients may still experience postoperative hypoxic events.
Though they found no statistically significant association between severity of OSA and outcome, they note that lack of an association might be attributed to the small sample size. They cite two large studies which demonstrated that patients with severe OSA had higher risk for postoperative adverse outcomes. They also note the lack of an association between MME and outcome might be attributable to the small sample size.
The Postoperative Vascular Complications in Unrecognized OSA (POSA) study (Chan 2019) was a large, multicenter, prospective observational cohort study designed to evaluate the association between the results of preoperative sleep testing for OSA and 30-day postoperative cardiovascular outcomes among patients undergoing noncardiac surgery. Rates of undiagnosed OSA were high. 37.1% of patients had mild OSA, 19.3% moderate OSA, and 11.2% severe OSA. Postoperative cardiovascular events occurred in 19.3% of patients. Severe OSA was significantly associated with a higher rate of postoperative cardiovascular events (adjusted hazard ratio 2.23) but the associations for mild or moderate OSA did not reach statistical significance.
They found a higher risk for postoperative cardiovascular events with longer duration of postoperative oxygen desaturation less than 80%. No significant association was observed between the type of anesthesia or supplemental oxygen therapy and perioperative outcomes. Somewhat surprisingly, they found no significant association with postoperative opioids.
In an editorial accompanying the Chan study, Auckley and Memtsoudis (Auckley 2019) state “Although the effectiveness of these interventions is poorly studied, some suggested strategies may include enhanced monitoring (oximetry, CO2 monitoring), conservative measures (elevating the head of the bed, avoiding supine sleep position, minimizing opioids), and specific OSA therapies such as the perioperative use of positive airway pressure.”
Since the vast majority of patients with OSA are undiagnosed at the time of surgery, we rely heavily on screening tools to identify patients at high risk for OSA. Multiple screening tools are available, including the ASA Check List, the Berlin Questionnaire, the STOP and STOP-Bang Questionnaires, the BOSTN tool, and the P-SAP Score.
The most frequently used tool is the STOP-Bang questionnaire. Sequin et al. (Seguin 2020) note that STOP-Bang has a high sensitivity at scores ≥3, but its specificity is moderate, particularly for scores of 3-4. So, they prospectively studied 115 surgical patients with preoperative STOP-Bang scores of 3–8. Patients were categorized into 2 subgroups: patients with an intermediate (STOP-Bang 3–4) or a high risk of OSA (STOP-Bang 5–8). Patients had a portable polygraph study at their homes (recording blood oxygen saturation (Spo2), electrocardiogram, movements of the chest and abdomen, and breathing events via a nasal cannula overnight).
After adjustment for age, sex, BMI, history of hypertension, diabetes, and major adverse cardiac and cerebrovascular events, patients with a STOP-Bang score of 5–8 had a significantly higher risk of an apnea-hypopnea index (AHI) >15 than those with a STOP-Bang score of 3–4 (odds ratio 2.9).
They concluded that the STOP-Bang questionnaire detected moderate-to-severe OSA patients when scores reached 5–8. However, STOP-Bang scores of 3–4 and alternative scoring models with specific combinations of factors failed to improve the screening of these patients.
They suggest that using the lower STOP-Bang cutoff may result in unnecessary referrals for sleep studies. As an example, they note that a 55-year old man with a history of hypertension scores a 3 on STOP-Bang, even though he has no OSA symptoms or obesity.
One alternative screening tool we have previously highlighted is the BOSTN tool (see our April 2019 What's New in the Patient Safety World column “New Simple OSA Screening Tool: BOSTN”). Raub et al. (Raub 2020) recently assessed use of the BOSTN score and a perioperative pathway for management of patients with suspected obstructive sleep apnea (OSA) in patients undergoing noncardiac surgery. Their results were somewhat surprising. Patients at high risk of OSA required postoperative mechanical ventilation less frequently and were hospitalized for shorter periods of time, despite higher odds of early post-extubation oxygen desaturation.
Those authors note that some previous studies have shown lower perioperative mortality rates for patients at high risk for OSA but others have shown higher rates. In attempt to explain the seeming paradox that lower mortality rates might be seen, they note that, in OSA, intermittent hypoxia and ischemic preconditioning have been postulated as potential mechanisms underlying the protective effects of obesity on mortality.
Our January 2020 What's New in the Patient Safety World column “Opioids and Apnea: Not Just Surgical Patients” noted that opioid-induced respiratory depression is not just a problem in surgical patients. The OpiatesHF Study (Niroula 2019) showed that a large percentage of inpatients with acute heart failure and sleep disordered breathing received opioids. Among those with an AHI greater than or equal to 10/h, escalation of care occurred in 26% of those who received opiates versus 4% of those who did not.
Khanna et al. (Khanna 2020) recently reported the results of the PRODIGY trial, a prospective, observational trial of blinded continuous capnography and oximetry conducted at 16 sites in the United States, Europe, and Asia aimed at prediction of opioid-induced respiratory depression on inpatient wards. Over 1300 patients on general care floors were receiving parenteral opioids (note: patients enrolled in the US were non-surgical patients and those enrolled elsewhere were postsurgical).
46% had one or more episodes of respiratory depression. Patients with ≥1 episode of respiratory depression were 2.5 times more likely to require some rescue intervention, including activation of a rapid response team. They also experienced 3 days longer mean hospital length of stay, which adds to costs.
A prediction model was developed using 5 independent variables: age ≥60 (in decades), sex, opioid naivety, sleep disorders, and chronic heart failure. The resultant PRODIGY score accurately predicted 74% of patients who would have episodes of respiratory depression and allowed separation of 3 groups (low-, medium-, and high-risk). Patients in the high-risk group by PRODIGY score were >6 times more likely to experience OIRD than the patients in the low-risk group.
The authors suggest that implementation of the PRODIGY score could determine the need for continuous monitoring and may be a first step to reduce the incidence and consequences of respiratory compromise in patients receiving opioids on the general care floor. This could certainly be welcome in those facilities that are resource-poor and cannot afford to do universal continuous monitoring with these modalities.
In the editorial accompanying the Khanna study, Prielipp et al. (Prielipp 2020) note that, although OIRD can occur at any time, the highest incidence has been reported in the first 6–24 postoperative hours and that a majority of fatalities due to OIRD occur at night (midnight to 6 am), underscoring the likely contribution of decreased vigilance and availability of night shift staff. They also note other risk factors for development of OIRD: age >65 years, ASA PS ≥III, presence of OSA, cardiac or neurologic disease, diabetes mellitus, hypertension, use of PCA, concomitant use of sedative drugs, different routes of opioid administration, and multiple prescribers of opioids. They also note that, although OIRD can occur following any surgical procedure, the highest incidence appears to be in orthopedic patients, likely reflecting their older age.
Prielipp et al. acknowledge the potential utility of stratifying such patients by risk. However, they also point out the “sobering statistic” that 26% of patients who experience respiratory depression were not identified.
The Society of Anesthesia and Sleep Medicine has published guidelines on preoperative screening and assessment of adult patients with obstructive sleep apnea (Chung 2016) and the intraoperative management of adult patients with obstructive sleep apnea (Memtsoudis 2018). A recent overview of OSA diagnosis and management (Gottlieb 2020) has limited discussion on OSA patients undergoing surgery. But it does state that patients with known OSA should inform all clinicians involved in their perioperative care, including their surgeon and anesthesiologist, of their OSA diagnosis. It recommends patients using PAP should continue this therapy in the perioperative period and those with known or suspected OSA should be monitored closely during the perioperative period, and the use of opiate analgesics should be minimized or avoided if possible.
Our prior columns on obstructive sleep apnea in the perioperative period and other acute settings:
June 10, 2008 “Monitoring the Postoperative COPD Patient”
August 18, 2009 “Obstructive Sleep Apnea in the Perioperative Period”
August 17, 2010 “Preoperative Consultation – Time to Change”
July 2010 “Obstructive Sleep Apnea in the General Inpatient Population”
July 13, 2010 “Postoperative Opioid-Induced Respiratory Depression”
November 2010 “More on Preoperative Screening for Obstructive Sleep Apnea”
February 22, 2011 “Rethinking Alarms”
November 22, 2011 “Perioperative Management of Sleep Apnea Disappointing”
March 2012 “Postoperative Complications with Obstructive Sleep Apnea”
May 22, 2012 “Update on Preoperative Screening for Sleep Apnea”
February 12, 2013 “CDPH: Lessons Learned from PCA Incident”
February 19, 2013 “Practical Postoperative Pain Management”
March 26, 2013 “Failure to Recognize Sleep Apnea Before Surgery”
June 2013 “Anesthesia Choice for TJR in Sleep Apnea Patients”
September 24, 2013 “Perioperative Use of CPAP in OSA”
May 13, 2014 “Perioperative Sleep Apnea: Human and Financial Impact”
March 3, 2015 “Factors Related to Postoperative Respiratory Depression”
August 18, 2015 “Missing Obstructive Sleep Apnea”
June 7, 2016 “CPAP for Hospitalized Patients at High Risk for OSA”
October 11, 2016 “New Guideline on Preop Screening and Assessment for OSA”
November 21, 2017 “OSA, Oxygen, and Alarm Fatigue”
July 17, 2018 “OSA Screening in Stroke Patients”
April 2019 “New Simple OSA Screening Tool: BOSTN”
January 2020 “Opioids and Apnea: Not Just Surgical Patients”
October 6, 2020 “Successfully Reducing Opioid-Related Adverse Events”
Other Patient Safety Tips of the Week pertaining to opioid-induced respiratory depression and PCA safety:
References:
Bolden N, Posner K, Domino KB, et al. Postoperative Critical Events Associated With Obstructive Sleep Apnea: Results From the Society of Anesthesia and Sleep Medicine Obstructive Sleep Apnea Registry. Anesthesia & Analgesia 2020; 131(4): 1032-1041
Cozowicz C, Chung F, Doufas AG, et al. Opioids for Acute Pain Management in Patients With Obstructive Sleep Apnea: A Systematic Review. Anesthesia & Analgesia 2018; 127(4): 988-1001
Chan MTV, Wang CY, Seet E, et al. Association of Unrecognized Obstructive Sleep Apnea With Postoperative Cardiovascular Events in Patients Undergoing Major Noncardiac Surgery. JAMA 2019; 321(18): 1788-1798
https://jamanetwork.com/journals/jama/fullarticle/2733209
Auckley D, Memtsoudis S. Unrecognized Obstructive Sleep Apnea and Postoperative Cardiovascular Complications: A Wake-up Call. JAMA 2019; 321(18): 1774-1776
https://jamanetwork.com/journals/jama/article-abstract/2733190
Seguin L, Tamisier R, Deletombe B, et al. Preoperative Screening for Obstructive Sleep Apnea Using Alternative Scoring Models of the Sleep Tiredness Observed Pressure-Body Mass Index Age Neck Circumference Gender Questionnaire: An External Validation. Anesthesia & Analgesia 2020; 131(4): 1025-1031
Raub D, Santer P, Nabel S, et al. BOSTN Bundle Intervention for Perioperative Screening and Management of Patients With Suspected Obstructive Sleep Apnea: A Hospital Registry Study, Anesthesia & Analgesia 2020; 130(5): 1415-1424
Niroula A, Garvia V, Rives-Sanchez M, et al. Opiate Use and Escalation of Care in Hospitalized Adults with Acute Heart Failure and Sleep-disordered Breathing (OpiatesHF Study). Ann Am Thorac Soc 2019; 16(9): 1165-1170
https://www.atsjournals.org/doi/abs/10.1513/AnnalsATS.201902-100OC
Khanna AK, Bergese SD, Jungquist CR, et al. on behalf of the PRODIGY Group Collaborators. Prediction of Opioid-Induced Respiratory Depression on Inpatient Wards Using Continuous Capnography and Oximetry: An International Prospective, Observational Trial, Anesthesia & Analgesia 2020; 131(4): 1012-1024
Prielipp, Richard C. MD, MBA, FCCM*; Fulesdi, Bela MD, PhD†; Brull, Sorin J. MD, FCARCSI (Hon)‡ Postoperative Opioid-Induced Respiratory Depression: 3 Steps Forward, Anesthesia & Analgesia: October 2020 - Volume 131 - Issue 4 - p 1007-1011
Chung F, Memtsoudis SG, Ramachandran SK, et al. Society of Anesthesia and Sleep Medicine guidelines on preoperative screening and assessment of adult patients with
obstructive sleep apnea. Anesth Analg 2016; 123: 452-473
Memtsoudis SG, Cozowicz C, Nagappa M, et al. Society of Anesthesia and Sleep Medicine guideline on intraoperative management of adult patients with obstructive sleep apnea. Anesth Analg 2018; 127: 967-987
Gottlieb DJ, Punjabi NM. Diagnosis and Management of Obstructive Sleep Apnea: A Review. JAMA 2020;3 23(14):1389-1400
https://jamanetwork.com/journals/jama/fullarticle/2764461
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October 27, 2020
Conflicting Studies on Technology to Reduce RSI's
We’ve been discussing use of tracking technologies to avoid retained surgical items (RSI’s) for many years now. But we continue to see conflicting reports on outcomes with use of these technologies.
There are 2 types of technologies. In one, data-matrix codes (barcodes) are embedded in the surgical sponges. In the other, radiofrequency (RF) chips are embedded. Each can be used to scan in the number of sponges introduced to a case and scan the number of sponges taken out at the end. The RF technologies may have the additional advantage of using of a handheld device or mat to scan the patient for the presence of a sponge if one is missing from the final count.
Gunnar and colleagues (Gunnar 2020) looked at retained surgical item (RSI) rates for 137 Veterans Health Administration surgery programs and compared rates between those with and without surgical count technology. Retained surgical item rates were calculated by the sum of events (sharp, soft good, instrument) divided by the total procedures performed. One hundred twenty-four RSI events occurred in 2,964,472 procedures for an overall RSI rate of 1/23,908 procedures. The RSI rates for 46 programs with surgical count technology were significantly higher in comparison with 91 programs without a surgical count technology system (1/18,221 versus 1/30,593). Moreover, RSI rates before and after acquiring the surgical count technology were not significantly different (1/17,508 versus 1/18,673). Root cause analyses for 42 soft good RSI events found that human factors (n = 24), failure of policy/procedure (n = 21), and communication (n = 19) accounted for 65% of the 98 root causes identified.
On the other hand, recent studies published in the AORN Journal found that such tracking technologies were successful in reducing RSI rates. Primiano et al. (Primiano 2020) did a retrospective evaluation of incident reports before and after implementing the use of an RF system for retained surgical sponges at one facility. They found that using RF technology was associated with fewer retained sponges and improved outcomes. Mortality rates before and after RF technology implementation were similar. They also estimated that the hospital's costs were reduced.
The potential benefits of such RF tracking systems have other potential benefits. Steelman et al. (Steelman 2019a) reported an observational study evaluating the effect of a radiofrequency (RF) surgical‐sponge detection system on time spent searching for surgical sponges. The study included 27,637 procedures during nine months before and after implementing an RF surgical‐sponge detection system. Though they had no RSI’s in either the pre- or post-implementation period studies, after implementation the RF system detected eight missing sponges that were in patients and removed. After implementation of the system, time spent searching for sponges was reduced by 79.58%, the percentage of unreconciled counts was reduced by 71.28%, and time spent using radiography to rule out a retained sponge was reduced by 46.31%. This resulted in a reduction of costs. The estimated cost savings of x-rays and OR time obtaining the x-rays was $38,218.40 for a hospital performing 15,000 procedures per year. The estimated total annual cost savings related to searching for sponges and using radiography to rule out the presence of a sponge to be $6,350.93 per 1,000 procedures or $95,263.95 for a hospital performing 15,000 procedures per year. So, there may well be benefits to surgical sponge-counting systems even if they did not reduce the actual rate of RSI’s.
Statistics we’ve cited before are that the sensitivity of the surgical count is only 77.2% and that more than 80% of retained surgical sponges occur when the count has been recorded as “correct”. Previous work by Steelman et al. (Steelman 2012) had shown 100% sensitivity of the RF wand and the 98.1% sensitivity of the RF mat, compared to only 67% sensitivity of intraoperative radiographs.
Back in 2011, Cima et al. (Cima 2011) first reported on use of a data-matrix-coded sponge counting system at the Mayo Clinic to reduce RSI’s. In their pre-implementation period, the overall incidence of RSI’s was 0.178 RSIs/1,000 operations, or approximately 1 RSI per 5,500 cases, 68% of which were retained sponges. After implementation of the data-matrix-coded sponge count system they had no RSI’s after 18 months.
Steelman et al. (Steelman 2018) identified factors contributing to over 300 occurrences of retained surgical sponges (RSS’s) that had been reported to the Joint Commission. 52.2% of the items were laparotomy sponges, which are radiopaque. The second most frequently identified RSS (34.0%) was a 4 in. by 4 in. or 4 in. by 8 in. sponge (81% of which were radiopaque). 6.9% were of the retained towels. 50.2% of items were left in the abdomen or pelvis, 23.9% in the vagina, and 8.5% in the chest or mediastinum. Other sites included the throat, breast, or the pocket made to insert an internal pacemaker/defibrillator.
A sponge count was performed in 77.4%, and when the count was performed, it was reported as being correct in 80.6% of cases. The latter is consistent with other reports on the percentage of RSI’s that had correct counts. (Note: there were higher percentages of counts done and correct counts for general surgery cases than Ob/Gyn cases).
They found that, in some cases where RF technology was used, RF did identify the retained item. However, in one case where the RF did alarm for a likely RSS, the alarm was ignored. In several other cases, RF technology was available but not used. In another case, RF did not identify kerlix, not surprising since kerlix does not contain an RF chip or radiopaque marker.
In the 319 cases, they identified 1430 contributing factors, clustered into 13 categories with 63 subcategories. You should go to the article itself for full details of these contributing factors. Some of the more frequent contributing factors were related to policies and procedures, communication, and human factors.
The had several recommendations:
Sponges identified and removed after the incision is closed/procedure completed, prior to transfer from the operating/procedure room, should be considered either a sentinel event, or a near miss. These events should be reported internally and investigated.
The authors go on to state “Because of the multitude of contributing factors that have led to a RSS, and the published accuracy and potential benefit of the RF sponge detection, we recommend that this technology be seriously considered in areas where surgery is performed and in Labor and Delivery.” They note that laparotomy, episiotomy, 4 X 4 s and towels should all include a RF chip, and that small sponges unavailable with a RF chip (cottonoids, peanuts, and kittners) should be counted.
Victoria Steelman, in a review of the evidence for preventing retained surgical items (Steelman 2019b), reiterated the recommendation of using RF surgical sponge identification systems since the collective evidence suggests that the sensitivity and specificity of manual counting and radiograph screening is insufficient to prevent RSI’s.
She included a section on guidewires, another item often inadvertently left behind. She notes other researchers have recommended education and training with simulation and forced error, using checklists during insertion of guidewires, and having two people present during the insertion for verification purposes.
Weprin et al. (Weprin 2020) note that there has been a significant shift from retained soft surgical items to retained hard surgical items over the last decade. While reported retained soft items (primarily sponges, packs and towels) have indeed decreased, retained hard items have increased. The latter include things like needles, blades, instrument fragments, guidewires and an incredible variety of “hard” surgical items that we’ve described in several columns. Weprin et al. note that most retained “hard” items are radiopaque but radiographs are usually only ordered when there is an unreconciled count. Moreover, many of the items are very small and may be easily missed on radiographs.
While sponge accounting systems are at the top of everyone’s list of tools to prevent RSI’s because surgical sponges are far and away the most commonly retained surgical items, our previous columns warn you not to lose sight of the fact that all sorts of other RSI’s have been appearing more and more. In our August 20, 2019 Patient Safety Tip of the Week “Yet Another (Not So) Unusual RSI” we noted the following items that have been retained: blue towels, Kerlix, cautery tips, Glassman viscera container, KOH cup, instrument labeling tape, Jackson Pratt drain bulbs, Rainey clips, and, yes, a cell phone, and others. Other unusual RSI’s reported since our last column include a fetal scalp monitor (Marchitelli 2019) and the bulb from a Toomey bulb syringe (CDPH 2016). Even the newest radiofrequency identification and tracking systems would miss most of those items.
Victoria Steelman (Steelman 2019b) also notes a variety of “other URFO’s” (unintentionally retained foreign objects), including instruments, catheters or drains, needles and blades, packing, implants, specimens, and a variety of other items. She notes that some of these were retained during minimally invasive surgery, previously felt by some to have had a low risk of RSI’s.
Recommendations to avoid URFO’s have included team training, managing disruptive behavior, conducting a proactive risk assessment, using a white board to communicate
insertion of devices discussing packing during handovers, methodologically exploring the incision before closure, verbally acknowledging the removal of objects, and verifying the integrity of objects removed.
It’s worth your reviewing the root cause analyses (RCA’s) in our August 20, 2019 Patient Safety Tip of the Week “Yet Another (Not So) Unusual RSI” that identified factors contributing to many of these “other” RSI’s. These included communications breakdowns, failure to maintain a “sterile cockpit”, personnel changes, time of day, distractions and interruptions, unanticipated events, time pressures, and in some cases unfamiliarity with the particular device involved. In addition, cognitive biases such as “seeing what we expect to see” and the related cognitive bias “inattentional blindness” were contributory factors.
So, maybe studies aren’t really contradictory after all. It’s highly likely that technological solutions do reduce retained surgical sponges and “soft” products, but more and more “hard” and unusual items have been being reported and these are not detected by the newer technologies.
We agree with Steelman et al. that it makes sense to use RF technology as an adjunct to help avoid RSI’s. But, don’t just rely on high-tech solutions to help you avoid RSI’s. Some simple things can also help reduce RSI’s. Vaginal packing is often used to stop bleeding after Ob/Gyn procedures and sometimes those packs are inadvertently left in place. One hospital began using bright orange wristbands with the word "packing" printed on them to alert providers and patients that packing has been used (McDonald 2020). A single band is applied to the patient for each packing that's placed, and it remains in place until the packing is removed per physicians' orders. Since they implemented this system they have had no instances of vaginal packing inadvertently left behind.
Yet another “low-tech” intervention is the “visualize and verify” process. One facility instituted this process after 2 cases of retained sponges that occurred after the final count was completed and was documented as correct, despite being incorrect (Patel 2020). After the final count is conducted at the incision closure, all sponges are removed from the surgical field, bagged, and laid out for the third verification process. The RN circulator and the surgeon then visualize and verify the sponge count together. This process is not initiated unless the final count is correct. The authors describe the initial barriers and challenges to implementation, including difficulties co-opting surgeons and other OR staff, but eventually convinced all of the usefulness of the process. Compliance with “visualize and verify” eventually rose to 75-80%.
Avoiding RSI’s requires good planning, good systems, good teamwork and communication, adherence to policies and protocols, technological solutions, and, most of all, a good culture of safety that appreciates the “sterile cockpit” concept and respects the voices of the whole OR team.
In addition to our many prior columns on RSI’s/RFO’s listed below, there are many good resources available to help prevent these. NoThing Left Behind® (NoThing Left Behind®) is the preeminent resource. Others include AORN (AORN 2020), the American College of Surgeons (ACS 2016), The Joint Commission (TJC 2017, TJC 2013), Pennsylvania Patient Safety Authority (Wallace 2017). Verna Gibbs, founder and director of NoThing Left Behind®, also has provided some great tips for surgeons, nurses, and all OR staff for avoiding RSI’s (Gibbs 2019). And Victoria Steelman, author of so many publications on RSI’s, and her colleagues have also published recent articles on RSI’s (Steelman 2018, Steelman 2019a, Steelman 2019b). A recent webinar from the University of Michigan School of Nursing had a nice review on retained surgical items and described how one surgical sponge tracking system works (University of Michigan 2020).
Our prior columns on retained surgical items/retained foreign objects (RSI’s/RFO’s):
References:
Gunnar W, Soncrant C, Lynn MM, et al. The Impact of Surgical Count Technology on Retained Surgical Items Rates in the Veterans Health Administration, Journal of Patient Safety 2020; Publish Ahead of Print March 24, 2020
Primiano M, Sparks D, Murphy J, et al. Using radiofrequency technology to prevent retained sponges and improve patient outcomes. AORN Journal 2020; 112(4): 345-352
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13171
Steelman VM, Schaapveld AG, Storm HE, et al. The Effect of Radiofrequency Technology on Time Spent Searching for Surgical Sponges and Associated Costs. AORN Journal 2019: 109(6): 718-727
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12698
Steelman VM, Alasagheirin MH. Assessment of Radiofrequency Device Sensitivity for the Detection of Retained Surgical Sponges in Patients With Morbid Obesity. Arch Surg 2012; 147(10): 955-960
https://jamanetwork.com/journals/jamasurgery/fullarticle/1380459
Cima RR, Kollengode A, Clark J, et al. Using a data-matrix-coded sponge counting system across a surgical practice: impact after 18 months. Jt Comm J Qual Patient Saf 2011; 37(2): 51-58
Steelman, V.M., Shaw, C., Shine, L. et al. Retained surgical sponges: a descriptive study of 319 occurrences and contributing factors from 2012 to 2017. Patient Saf Surg 2018; 12, 20
https://pssjournal.biomedcentral.com/articles/10.1186/s13037-018-0166-0#citeas
Steelman VM. Retained Surgical Items: Evidence Review and Recommendations for Prevention. AORN Journal 2019; 110(1): 92-96
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12740
Weprin SA, Moore RH, Meyer D, Autorino R. Retained Surgical Items. A Changing Landscape. Journal of Patient Safety 2020; Publish Ahead of Print September 8, 2020
Marchitelli R. Medical device used during labour falls out of patient 10 weeks later. CBC News 2019; November 6, 2019
https://www.cbc.ca/news/health/fetal-monitor-left-inside-surgical-medical-error-1.5349111
CDPH (California Department of Public Health). Complaint Intake Number CA00405547; 2016
McDonald J. Ideas That Work: Visual Alert. Wristbands Identify Patients With Vaginal Packing. Outpatient Surgery 2020; XXI(7): July 2020
Patel R, White J. Implementing a “visualize and verify” process for the surgical sponge count. AORN Journal 2020; 111(2): P11-P13
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12971
AORN (Association of periOperative Registered Nurses). Retained Surgical Items. AORN 2020; Accessed October 25, 2020
NoThing Left Behind®: A National Surgical Patient Safety Project to Prevent Retained Surgical Items. Prevention of Retained Surgical Items.
http://nothingleftbehind.org/Home_Page.html
NoThing Left Behind®: A National Surgical Patient Safety Project to Prevent Retained Surgical Items
ACS (American College of Surgeons). Revised statement on the prevention of unintentionally retained surgical items after surgery. October 1, 2016
TJC (The Joint Commission). New Sentinel Event Alert video: Preventing Unintended Retained Foreign Objects. Joint Commission Online 2017; October 25, 2017
TJC (The Joint Commission). Sentinel Event Alert. Preventing unintended retained foreign objects. Issue 51 October 17, 2013
http://www.pwrnewmedia.com/2013/joint_commission/urfo/downloads/SEA_51_URFOs.pdf
Wallace SC. PPSA (Pennsylvania Patient Safety Authority). Retained Surgical Items: Events and Guidelines Revisited. Pennsylvania Patient Safety Advisory 2017; 14(1): 27-35
http://patientsafety.pa.gov/ADVISORIES/Pages/201703_RSI.aspx
Gibbs V. 5 Keys to Preventing Retained Surgical Items. Use these strategies so there's nothing left behind. Outpatient Surgery 2019; XX(4): April 2019
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November 3, 2020
Reminder: Infant Abduction Risk
A recent infant abduction is a stark reminder that your organization can be vulnerable even when it thinks it has all appropriate preventive measures in place. A 35-year old man abducted a newborn infant in a back pack from a Louisiana hospital (Segura 2020a, Segura 2020b, Cole 2020, Onken 2020). The baby was found safe a few hours later and the man was subsequently arrested.
The hospital had multiple measures in place for infant safety. Visitors are required to have a photo ID at arrival when check-in. The “Safe Place” infant security system was in place with sensors in place throughout the organization that track the baby as it moves from one place to the next. That system sends alerts and there are panels at the nurses' station as well as the security department that trigger alerts to the staff, Security bracelets are put on the babies until they’re discharged. According to arrest records, an alarm did sound notifying the hospital staff that the security bracelet had been removed, but the baby was gone by the time staff arrived. Records state that the bracelet was found in the trashcan. The mother was not cooperative, according to authorities. Records said the suspected abductor entered the hospital room just after 11 p.m. He left the room with a book bag about 10 minutes later. The baby was taken from the hospital just after 11:20 PM and state police issued a Level II Endangered/ Missing Child Advisory and the baby was found safe a few hours later and the man, who was the father of the newborn, was subsequently arrested.
According to court records, the baby’s mother had tested positive for THC and amphetamines and there was a possibility the baby would be taken by the Department of Children and Family Services (Segura 2020b).
The hospital had a similar newborn infant abduction four years earlier (KNOE News 2016). That led to implementation of the “Safe Place” infant security system. The hospital also provides ongoing education and training drills to all team members to ensure the safety of all patients.
SAFE PLACE® is an RFID-based infant security system (and can also be used for older patients who might be at risk for elopement). Patients wear small, lightweight transmitters that continuously “check-in” with the system. If a patient is too close to a monitored exit, doors lock, an alarm sounds and staff members are instantly notified, all via their wireless devices. It is the type of tracking system we advocate, not only to protect against infant abductions, but also to identify wandering patients with dementia or delirium, or detect elopement in patients on behavioral health units (see our June 16, 2020 Patient Safety Tip of the Week “Tracking Technologies”).
But the current Louisiana case shows there are important considerations beyond just implementation of such systems. While removal of the bracelet triggers an alarm, the delay in responding to the alarm could allow enough time for the abductor to leave with the infant, as happened in this case. Fortunately, hospital video monitoring identified the perpetrator and staff was able to tell authorities who had been visiting the mother.
A second consideration is that such systems often rely upon Wi-Fi systems to broadcast the alarms and alerts to staff. Theoretically, an abductor could take advantage of malfunction of the Wi-Fi system to carry out an abduction. Hospitals doing a FMEA (failure mode and effects analysis) on risk of infant abduction or missing patient should ask what would happen if the Wi=Fi system happened to be down or whether someone could intentionally disable the Wi-Fi system.
Another question to ask is “What happens if a fire alarm has gone off?”. We’ve mentioned in several columns on patient elopements use of fire alarms to both serve as a distraction and to automatically unlock doors. For that reason, we recommend that hospitals occasionally perform drills where they tie a “Code Pink” (or whatever you call your infant abduction alert code) or “Code Yellow” (or whatever you call your alert for missing patients) to your fire drills.
The abductor in this case does not fit the profile of the “typical” infant abductor. The National Center for Missing & Exploited Children (NCMEC 2018) describes the characteristic of the “typical” infant abductor:
For those infants abducted from healthcare facilities, the abductor most often impersonates a nurse or other healthcare worker (72.53%), or a relative, friend or acquaintance (14.29%), someone involved in business-related interactions with the mother (i.e. advertising, selling, or purchasing) (4.40%), or someone from Social Services, INS or other government entity (2.20%).
But NCMEC notes that not all infant abductor fit that profile. Only 7 of 325 infant abductors in the NCMEC analysis were male. The unique circumstance in this case (threat of potentially losing the infant to the Department of Children and Family Services likely had a role in the motivation for the abduction by the infant’s father.
The 2016 newborn infant abduction at that Louisiana hospital (KNOE News 2016) better fit with the “typical” pattern. A 24-year old woman entered a hospital room occupied by a mom and her three-day old infant. She told the mother a mutual friend sent her there with a baby bag. The two talked for a little while, and when the mother got up to use the bathroom, she returned to find the baby gone. Hospital staff, security, and police were notified, and began investigating. A hospital employee recalled dealing with a patient earlier in the day, talking about pregnancy issues. Police would later connect that person to that conversation, after finding out she had been treated in the hospital several hours prior to receiving the initial kidnapping call. Investigators contacted the suspect's mother at her home. Shortly after, an unknown woman came to the suspect's mother's home and surrendered the baby. Police say the child appeared in good health and unharmed, and afterwards, was reunited with his mom. Video footage from the hospital showed that suspect leaving with the child, which led to a warrant being issued for aggravated kidnapping.
A 2007 article (Miller 2007) still provides some very practical recommendations:
It also had recommendations to tell the parents:
The Miller article also had recommendations from a since-retired Joint Commission Sentinel Event Alert:
Our December 20, 2011 Patient Safety Tip of the Week “Infant Abduction” also had examples of cases where infant abductions took place despite hospitals having in place similar bracelet-based alert systems. We hope you will go back to that column and also our September 4, 2012 Patient Safety Tip of the Week “More Infant Abductions” for our multiple recommendations on prevention of infant abductions.
But we also recommend you do a FMEA (failure mode and effects analysis) on infant abduction. A FMEA gets you to always consider “what if…?” scenarios to help you identify areas of vulnerability:
The whole point of a FMEA is to identify areas where unexpected circumstances might occur that could breach your safety processes.
As we said in our September 4, 2012 Patient Safety Tip of the Week “More Infant Abductions” “First and foremost don’t get complacent!” All too often we hear “that could never happen here” and people assume that the infant security bracelet system is failsafe. Well it’s not, as evidenced in this case and our prior columns.
Some of our prior columns related to newborn infant abductions:
December 20, 2011 “Infant Abduction”
September 4, 2012 “More Infant Abductions”
June 16, 2020 “Tracking Technologies”
See our previous columns on wandering, eloping, and missing patients:
References:
Segura M. Baby found safe after being taken; Monroe, La. hospital releases statement. KNOE News 2020; October 23, 2020
https://www.knoe.com/2020/10/23/missing-child-alert-issued-after-baby-taken-from-monroe-hospital/
Segura M. Father of baby taken from Monroe hospital arrested. KNOE News 2020; October 26, 2020
https://www.knoe.com/2020/10/26/father-of-baby-taken-from-monroe-hospital-arrested/
Cole C. St. Francis Medical Center shares infant security measures after baby was taken from hospital. KNOE News 2020; October 26, 2020
Onken A, Gibson K. Newborn baby taken from Louisiana hospital found safe. WALB News 2020; October 23, 2020
https://www.walb.com/2020/10/23/newborn-baby-taken-louisiana-hospital-found-safe/
KNOE News Staff. Suspect accused of stealing baby turns herself in to police. KNOE News 2016; updated April 25, 2016
RFT. SAFE PLACE® Keeping Newborns Safe and Your Reputation Secure. RFT 2020; accessed October 29, 2020
https://www.rft.com/brands/safe-place/
NCMEC (National Center for Missing & Exploited Children). Analysis of Infant Abduction Trends. Data Collected: 1965 through September 2018. National Center for Missing & Exploited Children 2018; Revised 09/15/2018
https://pnce.org/documents/57315-156_AdditionalResource.pdf
Miller RS. Preventing infant abduction in the hospital, Nursing2007 2007; 37(10): 20,22
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November 10, 2020
More on Infusion Pump Errors
The tragic death of a prominent cancer researcher serves as a stark reminder of things that can go wrong with infusion pumps (Evans 2020). The 61-year-old man was admitted to the hospital with a stroke. Over the next two days his condition stabilized and he began speech, physical and occupational therapies. His diet was advanced to solid foods. But, as plans were being made for his move to a rehab facility, his condition took a turn for the worse and he failed a swallowing test. His breathing became labored and a feeding tube was inserted due to his difficulty swallowing. During the procedure, he apparently aspirated a large piece of food from his stomach. It lodged in his airway and he suffered acute respiratory arrest and was placed on a ventilator.
To sedate him while he was on the ventilator, he was given four small doses of fentanyl, ranging from 25 to 75 micrograms. At that time he was responsive and able to follow simple commands. It was anticipated he would come off the ventilator soon.
A little after 11 PM, a nurse covering for his primary nurse responded to an alarm going off on a medication pump next to his bed. An IV bag of Lactated Ringer's solution needed to be replaced. The nurse obtained a new bag of the solution and hung it on the pole along with other medications also attached to the pump. One of those bags contained the fentanyl, which had been discontinued 12 hours earlier. The nurse scanned the bag of Lactated Ringer's solution and a barcode that came up on the pump before restarting it at 11:24 p.m. She had attached the Lactated Ringer's solution to one channel on the pump, but mistakenly pushed the start button for another channel — the one attached to a bag of fentanyl. As soon as she pushed the start button on the module that was actually going to give the fentanyl, the alarm went off. But, instead of checking the alarm and reading the alarm code, the nurse just hit a silence button. A few minutes later, another nurse who checked the pump also missed the error.
Because the mix-up went unnoticed, over the next 69 minutes he received 1119.4 mcg of fentanyl. The error was finally discovered at 12:33 AM. Narcan was not given then or when a doctor came to his bedside around 2 AM, when he was profoundly hypotensive. He never regained consciousness and was subsequently removed from life support. The family apparently was not made aware of the mistakes until details were revealed during a medical record review done as part of a malpractice investigation.
We, of course, do not know details about the hospital’s own root cause analysis (RCA) or incident investigation but it should have focused on at least the following issues:
Our March 2020 What's New in the Patient Safety World column “ISMP Smart Infusion Pump Guidelines” discussed ISMP’s “Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps” (ISMP 2020). The hospital violated two of the most important recommendations in that guideline.
One point that was emphasized in those guidelines was performance of double checks at certain points. When starting selected facility-defined high-alert medication infusions and at additional facility-defined steps (e.g., change of shift/handoffs, change in the rate/dose of infusion, change in bag/bottle/syringe) hospitals should require that a double check be performed and documented to verify the following before starting the infusion:
ISMP noted that technology (eg. barcoding) is the preferred method for double checking most of these items but use of a second practitioner is necessary to perform and document an independent double check for line attachment. (Keep in mind that we also always recommend that, when multiple lines are connected to multiple different sources, it is critical that good labeling be placed not only on the sources but also on the lines themselves).
It also emphasized another often overlooked point: “Immediately discard all continuous IV medications and epidural infusions (e.g., continuous infusions of magnesium, neuromuscular blocking agents, and opioids) after discontinuation (i.e., do not leave hanging on an IV pole or at the bedside).”
While those 2 issues provide, arguably, the most important lessons learned from this tragic incident, keep in mind that the cascade of errors in this case is typical of most adverse events where there is a bad patient outcome. Almost each of the issues above represented an opportunity to intervene and stop the cascade before an unfortunate outcome occurred.
In our March 5, 2019 Patient Safety Tip of the Week “Infusion Pump Problems” we did an extensive review of safety issues related to infusion pumps. We hope you’ll go back to that column to review our many recommendations.
There was also another recent review of human-based errors involving smart infusion pumps (Kirkendal 2020). The authors classified five main categories: undocumented orders, drug library errors, programming errors, administration errors, and ancillary equipment errors. Within these five main categories of errors, the investigative team identified specific types and even more granular subtypes.
While they discussed issues like programming errors and drug library errors, they also stressed several other important issues: misunderstanding or misinterpreting pump alerts, forgetting to close tube clamps, and bag misalignment with multiple infusions. And they acknowledged that some errors may be the result of workarounds performed by clinicians to intentionally bypass safety features.
Lastly, we are strong believers in transparency and disclosure and apology Not only is that the right thing to do, but one can only wonder if prompt disclosure and apology might have prevented the details of this tragic case from being splashed in the headlines. Our many columns and resources on disclosure and apology and communication and resolution programs are also listed below.
Our prior columns related to infusion pump issues:
Some of our prior columns on Disclosure & Apology:
July 24, 2007 “Serious Incident Response Checklist”
June 16, 2009 “Disclosing Errors That Affect Multiple Patients”
June 22, 2010 “Disclosure and Apology: How to Do It”
September 2010 “Followup to Our Disclosure and Apology Tip of the Week”
November 2010 “IHI: Respectful Management of Serious Clinical Adverse Events”
April 2012 “Error Disclosure by Surgeons”
June 2012 “Oregon Adverse Event Disclosure Guide”
December 17, 2013 “The Second Victim”
July 14, 2015 “NPSF’s RCA2 Guidelines”
June 2016 “Disclosure and Apology: The CANDOR Toolkit”
August 9, 2016 “More on the Second Victim”
January 3, 2017 “What’s Happening to “I’m Sorry”?”
October 2017 “More Support for Disclosure and Apology”
April 2018 “More Support for Communication and Resolution Programs”
August 13, 2019 “Betsy Lehman Center Report on Medical Error”
September 2019 “Leapfrog’s Never Events Policy”
Other very valuable resources on disclosure and apology:
References:
Evans T. Drug error at Eskenazi Hospital killed prominent cancer researcher. Here's how it happened. Indianapolis Star 2020; October 30, 2020
ISMP (Institute for Safe Medication Practices). Guidelines for Optimizing Safe Implementation and Use of Smart Infusion Pumps. ISMP 2020; February 10, 2020
https://www.ismp.org/guidelines/safe-implementation-and-use-smart-pumps
Kirkendal, ES., Timmons K., Huth H, et al. Human-Based Errors Involving Smart Infusion Pumps: A Catalog of Error Types and Prevention Strategies. Drug Saf 2020;
https://link.springer.com/article/10.1007/s40264-020-00986-5#citeas
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November 17, 2020
A Picture is Worth a Thousand Words
Ever since our first electronic health record (EHR) implementation in 2007, we’ve been advocates of including patient photographs in the EHR as a means of avoiding wrong patient events. It’s a common sense solution, but evidence confirming that it actually does reduce such wrong patient errors has been slow to demonstrate. Our March 24, 2020 Patient Safety Tip of the Week “Mayo Clinic: How to Get Photos in Your EMR” showed how the Mayo Clinic was able to get patient photographs in to the HER (Aseem 2020). But that study did not measure the ultimate goal: reduction in patient misidentification errors. In that column we suggested that, if you were to implement such a project in your organization, you might use the RAR (Retract-and-Reorder) methodology (see our July 17, 2012 Patient Safety Tip of the Week “More on Wrong-Patient CPOE”) to identify instances where a user initially entered an order on the wrong patient. Now a new study does just that.
Salmasian and colleagues (Salmasian 2020) compared wrong-patient order entry (WPOE) errors between patients visiting the ED who had a photograph in their EHR with those who did not. They found that the risk of WPOE errors was significantly lower when the patient’s photograph was displayed in the EHR (odds ratio 0.72). Moreover, this simple intervention was noninterruptive and had minimal risk of alert fatigue.
Many other clinical decision support tools to help avoid wrong patient orders rely on presentation of alerts that can interrupt clinician workflow and lead to alert fatigue. In the current study, inclusion of patient photographs was a passive intervention. Though the study was not a truly randomized controlled study (patients were encouraged to get their photographs taken and included in the EHR as a potential patient safety issue), retrospective comparison of the two cohorts was reasonable.
Wrong patient order errors were measured using the wrong-patient retract-and-reorder (RAR) measure, which is a validated measure endorsed by the National Quality Forum. We’ve discussed the RAR measure in numerous columns on patient misidentification listed below (see, for example, our July 17, 2012 Patient Safety Tip of the Week “More on Wrong-Patient CPOE”).
The hospital instituted a multi-pronged quality improvement campaign to encourage capture of patient photographs into the EHR. Components included educating the ED registration staff of the importance of patient photographs for patient identification and patient safety and educating patients by using posters placed in the waiting area of the ED that explained the importance of patient photographs and inviting them to participate in the campaign. The registration team was provided with equipment to facilitate capture of those patient photographs. To facilitate photograph capture they switched from desktop computers equipped with webcams to mobile devices. Feedback to registration staff showed trends in photograph capture rates.
The researchers looked at over 2.5 million orders on 71,851 patients, of which 23.3% were placed on patients who had a photograph in their EHR. The unadjusted odds ratio (OR) of RAR events in the photograph group vs the no photograph group was 0.72. The odds ratio was even better after adjustment for covariates (OR, 0.57). The authors note that the effect size associated with this strategy was larger than in previously published interventions aimed at reducing WPOE errors, and this strategy has the advantage of being noninterruptive in nature.
The authors did acknowledge some of the barriers encountered in obtaining patient photographs. They note that this can be difficult in the ED setting because of time pressures and because severely ill patients may not be amenable to being asked for or consenting to capturing their photographs. But they note that photographs captured in other settings (at ambulatory clinics, at inpatient admitting offices, or by scanning the patient’s identification card at the time of creating a record) are then available and displayed in the EHR when patients are in the ED as well. Many patient portals and mobile apps also allow patients to upload their own photographs. They also acknowledge, as we have often expressed, there is a need for organizations to have a policy of when photographs should be updated to ensure the photographs accurately reflect the patients.
Interestingly, they found that the sickest patients, who were less likely to end up in the photograph group, also had notably lower odds of wrong-patient errors. The authors felt that this could be attributable to the higher level of attention these patients receive from their practitioners, reducing the chances of a wrong-patient error. Or it might be the type of orders placed for critically ill patients being different from orders placed for other patients, such that practitioners are more likely to catch these errors before placing those orders for the wrong patient.
The authors attribute much of the success to high levels of engagement by the registration staff and the patients. They note that this whole process is relatively inexpensive to implement. The costs include the time used to train the staff on taking photographs, time spent by managers of the patient registration team to monitor photograph capture adherence and troubleshoot issues as they arose, and the cost of the equipment used for capturing photographs, and equipment costs. For the study, they only had to purchase 6 handheld devices and supporting accessories for a total of less than $1600, plus estimated annual operating costs for maintenance and replacement of equipment of approximately $1000. They speculate that the expected savings from improved safety would far outweigh those costs.
Our March 24, 2020 Patient Safety Tip of the Week “Mayo Clinic: How to Get Photos in Your EMR” showed how the Mayo Clinic was able to get patient photographs in to the EHR (Aseem 2020). They did encounter some barriers and it took several PDSA cycles to accomplish their goal but, ultimately, they also concluded that the intervention can be implemented inexpensively and without significant impact on workflow.
The ED is an area particularly prone to wrong-patient order entry errors because clinicians are often caring for multiple patients simultaneously, are multitasking, and often have more than one patient record open at a time. Having more than one record open simultaneously is a significant risk factor for WPOE errors (see our May 21, 2019 Patient Safety Tip of the Week “Mixed Message on Number of Open EMR Records”).
The ability to reduce wrong patient orders in a nonobtrusive manner is important. Some interventions that have been successful use alerts that pop up during order entry requiring the clinician to verify the patient’s identity. These could contribute to alert fatigue. Our June 26, 2012 Patient Safety Tip of the Week “Using Patient Photos to Reduce CPOE Errors” described how Children’s Hospital of Colorado successfully implemented use of patient photographs to reduce CPOE errors (Hyman 2012). Beginning with a nice review of the literature on patient-note mismatches, they implemented tools to help avoid such mismatches during CPOE. First, they modified their CPOE workflow to include a verification screen asking the provider to verify that this is the patient on whom he/she intends to enter orders. They then began taking photographs of patients at admission or registration and including these on the above noted verification screen. They found a dramatic reduction in the number of events of actual ordering on the wrong patient or near-misses. And when such events or near-misses did occur, it was usually in charts that did not have a photograph of the patient. While they could not separate out the impact of the verification screen from that of the photograph, they felt that the photographs played a large role in reducing the number of orders placed in the records of wrong patients. They noted that, unlike other CPOE alerts that have a high likelihood of being ignored, the presence of the large centrally placed photograph is effective in capturing the attention of the CPOE user. They did note that photographs have limitations, particularly for newborns and when pictures are poorly exposed. And they note that photographs need to be updated at appropriate times.
Our December 17, 2019 Patient Safety Tip of the Week “Tale of Two Tylers” showed a glaring example of how patient photographs in the EMR might prevent a wrong patient error. It also described the mechanical steps another hospital uses to get patient photographs into the EMR. In a study by Blanchfield et al. (Blanchfield 2019) the patient photographs were taken when the patient presented to the ED. The ease with which we can today take a digital photograph today and upload it to the EHR enables the use of up-to-date patient photos. In the Blanchfield study, they created a new standard of care and implemented a new workflow for ED registration staff. Using iPod touch devices, ED registration staff took photos of consenting patients either at the front desk when patients check-in, or at the end of the registration process.
We refer you back to our March 24, 2020 Patient Safety Tip of the Week “Mayo Clinic: How to Get Photos in Your EMR” for a discussion of several other benefits of patient photographs in the EHR. The time has clearly come for healthcare organizations to include patient photographs in their electronic health records.
Some of our prior columns on use of patient photographs in patient safety:
December 2008 “Patient Photographs Improve Radiologists’ Performance”
January 12, 2010 “Patient Photos in Patient Safety”
June 26, 2012 “Using Patient Photos to Reduce CPOE Errors”
April 30, 2013 “Photographic Identification to Prevent Errors”
January 19, 2016 “Patient Identification in the Spotlight”
March 26, 2019 “Patient Misidentification”
November 12, 2019 “Patient Photographs Again Help Radiologists”
December 17, 2019 “Tale of Two Tylers”
March 24, 2020 “Mayo Clinic: How to Get Photos in Your EMR”
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”
References:
Aseem S, Ratrout BM, Litin SC, et al. A Process of Acceptance of Patient Photographs in Electronic Medical Records to Confirm Patient Identification. Mayo Clinic Proceedings: Innovations, Quality & Outcomes 2020; 4(1): 99-104
https://mcpiqojournal.org/article/S2542-4548(19)30152-3/fulltext
Salmasian H, Blanchfield BB, Joyce K, et al. Association of Display of Patient Photographs in the Electronic Health Record With Wrong-Patient Order Entry Errors. JAMA Netw Open 2020; 3(11): e2019652
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2772798?resultClick=3
Hyman D, Laire M, Redmond D, Kaplan DW. The use of patient pictures and verification screens to reduce computerized provider order entry errors. Pediatrics 2012; 130(1): e211-e219
https://pediatrics.aappublications.org/content/130/1/e211?download=true
Blanchfield BB, Salmaisian H, Landman A. Abstract #56. Adding Patient Photos to the Electronic Health Record to Improve Patient Identification and Reduce Wrong Patient Order Errors. Ann Emerg Med 2019; 74(4s): S22-23 October 2019
https://www.annemergmed.com/article/S0196-0644(19)30733-4/fulltext
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November 24, 2020
Specimen Management
Our multiple previous columns on errors in specimen management have highlighted the devastating impact of mixed-up specimens and lost specimens. In this month’s AORN Journal, Lisa Croke (Croke 2020) provides a preview of the pending update of AORN’s Guideline for Specimen Management, expected out in December. Topics in the update included transferring specimens off the sterile field, handling, containing, labeling, requisition forms, preserving, transporting, temporarily storing them, policies and procedures, documentation, quality, and education.
We’re glad to see they included a point we have long been making: your preop huddle or preprocedure briefing should specifically include discussion of anticipated specimens. (Likewise, we recommend your post-procedure debriefing should include note of any specimens taken and sent.) And many organizations include anticipated specimens as an item on their Surgical Safety Checklist.
The guideline stresses the importance of using the read-back method for communication between OR staff members to review the specimens that are anticipated, but not yet excised; and the name, type, and location of specimens on the sterile field, in the OR, or that have been sent to the pathology laboratory. The guideline also says the pathologist should communicate directly with the physicians regarding the diagnosis or other information about the specimen.
There is a discussion on the vacuum sealing method of containment and refrigeration issues, including processes for cleaning and disinfecting the vacuum sealing containment device. A new section on highly infectious specimens, such as from patients with COVID-19 or Ebola, has been added to the guideline. It also contains a new section on handling specimens from patients with known or suspected prion disease, including Creutzfeldt-Jakob disease. It stresses the critical importance of communication among all parties when handling such specimens that might pose a risk to the healthcare workers.
That same issue of AORN Journal also provides a graphic example of proper labeling for specimen containers (AORN 2020b).
One of the biggest impediments we see to safe specimen management is lack of error reporting that is available to all who need to know. You can’t fix what you don’t know about! Your quality improvement/patient safety dashboard should specifically track and report specimen errors.
Another barrier to safe specimen management is that, in many healthcare organizations, there are different IT systems in the OR and the pathology lab. That was mentioned in the Lim (Lim 2020) study and the Temple University Hospital (AORN 2019) and the Hospital of the University of Pennsylvania (Morris 2020) that we discuss below. The Temple article describes how special computer script was written to get info from both systems to create a specimen tracking capability.
Steelman et al. (Steelman 2016) reviewed 648 surgical specimen events. Though events were reported at all stages of the lab process (pre-analytic, analytic, and post-analytic), events most commonly occurred during the pre-analytic phase and, specifically, with specimen labeling, collection/preservation, and transport. The most common contributing factors were failures in handoff communication, staff inattention, knowledge deficit, and environmental issues. Eight percent of the events resulted in either the need for additional treatment or temporary or permanent harm to the patient. That study served as a call to attention for healthcare organizations to conduct proactive risk analyses of specimen handling procedures and to design safer processes. It recommended particular attention should be paid to effective communication and handoffs, consistent processes across care areas, and staff training. It also recommended organizations consider the use of technology-based identification and tracking systems.
In the Steelman study (Steelman 2016) almost one-half of the surgical specimen events involved a specimen labeling issue. In 30% of those, the specimen container was not labeled, or the requisition form was not sent with the specimen. In the other 70%, the specimen was labeled or had a requisition, but the information was incomplete, inaccurate, or illegible.
Nearly one-quarter of the errors occurred during specimen collection. Issues were related to specimen solution (43%), placement into containers (33%), and collection technique (15%). Solution/preservative errors involved not adding any solution, adding the incorrect, solution, or adding solution when it should not have been added. Often specimens were not immediately placed into the specimen container, resulting in temporarily misplaced or lost specimens. Some specimens were left on the surgical field or were accidentally discarded. There were also issues with collection technique (eg. insufficient biopsy sample size, margins, or contents) or incorrect specimen handling (eg, discarding a portion of specimen). Other collection issues included placing the specimen in the wrong container or type of container.
Almost 40% of the reported events involved issues in specimen transport to the laboratory and/or storage before receipt in the laboratory. 40% of these involved delays in transporting specimens and in 31% specimens were misplaced or lost and did not reach the lab or pathology department. Sometimes, OR personnel set specimens aside or stored them temporarily on a counter, in collection boxes, in a refrigerator, or under a stretcher, or the specimen was held until the end of the case (individual or batched specimens) rather than taking or sending them directly to the laboratory. Sometimes specimens were transported to the wrong location or area and had to be rerouted or were temporarily lost. In some cases, the specimen was not stored properly in the refrigerator and, in others, the preservative/solution leaked during transport when container lids were not sealed securely, or breakage/compromise of the container occurred.
6% of the specimen events involved orders. In some events, orders were not entered or were cancelled because of a software programming issue and the laboratory staff did not receive the order. Other errors occurred when the order was entered incorrectly, or the incorrect order was delivered to the laboratory. Rarely, orders were entered into the wrong patient’s electronic health record, wrong encounter, or an inactive record.
Contributing factors were identified in 51% of the event reports, the most common being failures in communication or handoffs (52%), staff inattention (49%), inadequate knowledge, training, or experience (38%), and environmental issues (17%), including distractions, interruptions, emergencies, and poor lighting.
Steelman et al. also noted errors in the laboratory and post-laboratory phases of specimen management, but those are not the focus of today’s column.
Several published quality improvement projects have highlighted the importance of communication issues and handoffs as factors contributing to specimen errors. After finding over 30 specimen error issues per month at their facility, Lim and colleagues (Lim 2020) undertook a quality improvement project in which they did fishbone diagrams and process mapping. They found that handoff communication and specimen handling processes were the main issues that led to mishandling and mislabeling of specimens. They also found that, while nurses were utilizing the electronic health record (EHR), the pathology department was using a different system to track specimens. Other issues noted related to shift changes, staff attitude, personality conflicts, and distractions.
Interventions developed and implemented included distributing a monthly specimen error report, requiring the attending surgeon to sign-off on requisition, and improving the specimen SBAR handoff. Within the first three months of implementation, the average number of errors dropped from 30.9 to 18 events per month.
The article from Temple University Hospital (AORN 2019) noted that many individuals were looking at specimen management errors on single cases and there was no overall coordinated effort. So the Temple group put together a multidisciplinary team to look at the big picture. One of the first problems they identified was that there was not an adequate space to collect and label specimens in the OR. So, they created a mobile specimen table for each OR. Each table is labeled with a brightly colored decal to identify it as the dedicated specimen table. The decal on the table also outlines their standardized specimen management protocol. The tables receive appropriate cleaning and can be wheeled from near the sterile field to the computer workstation for documentation. (Another hospital (Liston 2018) standardized specimen carts for each OR. When nurses move from room to room, they know that the cart is stocked and has everything they need to collect a specimen. The carts are positioned in the same spot in each OR — near the sub-sterile door so when the surgeon breaks scrub, he can look at the specimen and sign the order.)
Temple also created the position of “specimen nurse” That nurse works 9AM to 3PM, when most specimens are generated. The specimen nurse responds to the text alerts by going into the OR when specimens are being generated to ensure proper labeling and documentation, provide guidance to the staff members, and solicit their feedback on the process. The specimen nurse also meets the transporter when the transporter is removing specimens from the OR refrigerator and taking them to the laboratory. Together, the transporter and specimen nurse verify correct labeling on the specimen containers and laboratory requisitions.
They also got their computer programmers to create from the 2 different IT systems a run-time report that would show location and status of each specimen confirm when it was received in the lab.
They also, as we recommended above, began to incorporate discussion of specimens in their post-op debriefing. And they used TeamSTEPPS® and Just Culture principles to facilitate communication amongst all staff.
They reported that, as a result of these efforts, their rate of “high risk” specimen errors was reduced by 50%.
An IHI Improvement Story highlighted a project done at the Carle Foundation Hospital and Carle Clinic Association (Urbana, Illinois) to improve specimen management that resulted in a significant reduction in specimen errors (IHI 2020). Their multidisciplinary team developed standardized processes for specimen handling and labeling and transport and actions to be taken by the Histology lab when a specimen arrives with any errors or deficiencies. Order entry screens and requisitions were standardized. It required the proceduralist to verify correct specimen(s) is/are in the correct container(s) and information on label and requisition are complete and correct prior to leaving procedure area. Second person double-checks all of the information. Specimens cannot be sent without these verifications. Label printers were installed in all relevant locations, with barcode capability. They created secure holding areas for specimens while waiting for transport. They adopted regular reporting of specimen errors for review by all levels of the organization and instituted educational programs for all impacted parities on the topic of specimen management.
Another quality improvement project at the Hospital of the University of Pennsylvania (Morris 2020) did process mapping and found there were over 30 steps in specimen management and that there was variation depending on the specimen type, time of day, day of the week, surgical specialty, and OR location. Lack of interoperability between the lab IT system and the nursing IT system precluded use of computer-generated specimen labels that could reduce the risk for misspellings, illegibility, and transcription errors that often occur with handwritten labels. That precluded implementation of barcode technology for surgical specimen labeling. So perioperative nurses had to type the specimen description into the electronic record plus handwrite the specimen’s description on both the label used on the specimen container and the label used in the logbook hand over to laboratory staff members.
Chain of custody is critical in specimen management. They identified that labeling is the first step in establishing the chain of custody. Read-back is key to confirming specimen identification verbally and documenting it accurately, legibly, and completely. That must include patient identifiers, source of the specimen, and laterality and avoid using any confusing abbreviations. Read-back may also need to include spelling out specific words to avoid errors.
One key process change that they (and other hospitals) made was to have the specimen handed over directly to a pathology clerk in the OR. That eliminates the need for the RN circulator to leave the OR during the procedure to deliver the specimen to a refrigerator. It also ensures the chain of custody is maintained and provides the opportunity to engage the surgeon and identify any inaccuracies in specimen description or testing requests immediately before the specimen leaves the OR. Moreover, it eliminates the need for a logbook and the subsequent duplication of illegible documentation. We like that idea since it potentially eliminates at least one handoff. In our November 16, 2010 Patient Safety Tip of the Week “Lost Lab Specimens” we described how a pathology department decided that it would take ownership of the transport process from the OR to the lab. That effectively reduced the number of handoffs. Handoffs are always opportunities for errors to occur so anything that reduces the number of handoffs generally improves safety.
One other interesting feature is used at Geisinger, where OR nurses suggested that when they were doing the count, that would be a perfect time to have a conversation about specimens before they go out to pathology. That led to development of the "Specimen Safety Pause" (Neufer 2019). As the surgeon begins to close, they all review with the surgeon the specimens they've obtained and read the label back to the surgeon. And that leads right into the count, which is another time where everybody needs to be participating.
Steelman et al. (Steelman 2016) also recommended organizations consider the use of technology-based identification and tracking systems. Yu et al. (Yu 2019) investigated the use of barcode technology in a Taiwanese hospital as a method to improve the accuracy of pathology specimen labeling and patient safety. They found fewer specimen management errors after implementation of the barcode system and found that use of this technology significantly enhanced nurses’ satisfaction. Our June 16, 2020 Patient Safety Tip of the Week “Tracking Technologies” discussed multiple technologies used for tracking things. The postal service and companies like UPS and Fedex scan barcodes at every step along the way to track where your packages are at any point in time. Hospitals should be able to do the same. Conceivably you could use RFID technology for tracking specimens as well.
Specimen management errors often result in devastating consequences for patients. Every organization needs to be monitoring the occurrence of such errors and sharing them with all stakeholders. Pay careful attention to the recommendations in that AORN guideline expected out this December.
Some of our other columns on errors related to laboratory studies:
References:
Croke L. Guideline for specimen management. AORN Journal 2020; 112(5): P8-P10
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13258
AORN (Association of periOperative Registered Nurses), Guideline for specimen management. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2021. In press
AORN (Association of periOperative Registered Nurses), Correctly labeling surgical specimen containers. AORN Journal 2020; 112(5): P25-P25
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13263
Lim, K., Maghanoy, E., Juarez, A., Garay, R., Jacob, R. and Segal, C. (2020), Eliminating Mistakes One Specimen at a Time. AORN Journal 2020; 112(5): 545-545
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13204
AORN. Reducing Specimen Errors. AORN Journal 2019; 109(4): 496-499
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12658
Morris AM. Reducing Lost Surgical Specimens. AORN Journal 2020; 111(6): 691-698
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13061
Steelman VM, Williams TL, Szekendi MK, et al. Surgical specimen management: a descriptive study of 648 adverse events and near Misses. Arch Pathol Lab Med. 2016; 140(12): 1390-1396
Liston J. Ideas That Work: Pathology. Standardize Your Specimen Management Carts. Outpatient Surgery 2018; XIX(11): November 2018
IHI (Institute for Healthcare Improvement). Eliminating Pathology Specimen Handling and Labeling Errors/Deficiencies. IHI Accessed November 19, 2020
Neufer L. Ideas That Work: Doing Zero Harm. Take a Specimen Safety Pause. Outpatient Surgery 2019; XX(7): July 2019
Yu M-H, Lee T-T, Mills ME. The Effect of Barcode Technology Use on Pathology Specimen Labeling Errors. AORN Journal 2019; 109(2): 183-191 First Published:29 January 2019
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12585
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December 1, 2020
An Early Warning System and Response System That Work
Early warning scoring systems to identify patients at risk of clinical deterioration make a lot of sense in theory. 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. But a new study moves the needle toward adoption of a new integrated program.
Clinicians and researchers at Kaiser Permanente Northern California (KNPC), a 21-hospital system, previously developed an automated early warning system based on data obtained from the electronic medical record (EMR) (Kipnis 2016). The scoring system they derived, called the Advanced Alert Monitor (AAM) compared favorably to 2 other early warning scores (NEWS and eCART) in predicting events (unplanned transfers to the intensive care unit from a general med/surg floor). Predictors of events included laboratory tests, individual vital signs, neurologic status, severity of illness and longitudinal indexes of coexisting conditions, care directives, and health services indicators (e.g., length of stay). A score is generated and a threshold level was ascertained for prediction of events. For all three scores, about half of alerts occurred within 12 hours of the event, and almost two thirds within 24 hours of the event. The AAM system is monitored remotely by nurses who then communicate alerts to rapid-response teams at hospitals. An AAM score of 5 (alert threshold) indicates a 12-hour risk of clinical deterioration of 8% or more. At this threshold, the model generates one new alert per day per 35 patients. Notably, the alerts provide 12-hour warnings and do not require an immediate response from clinicians.
After a successful pilot at 2 of the KNPC hospitals, the program was subsequently deployed in a staggered fashion at the other 19 hospitals in the KPNC system between August 1, 2016, and February 28, 2019 (Escobar 2020). To assess the impact, they looked at adult patients admitted to those hospitals after the intervention. A comparison cohort that included all the patients who had been admitted to any of the study hospitals in the 1 year before the introduction of the intervention in the first hospital was used as a historical control. A nontarget population included all the patients whose condition did not reach the alert threshold.
Patients in the intervention cohort, as compared with those in the comparison cohort, had a lower incidence of ICU admission (17.7% vs. 20.9%), a shorter length of stay among survivors (6.5 days vs. 7.2 days), and lower mortality within 30 days after an event reaching the alert threshold (15.8% vs. 20.4%).
They also did adjusted analyses, which estimated an absolute difference of 3.8 percentage
points in mortality within 30 days after an event reaching the alert threshold between the intervention cohort and the comparison cohort. That difference translated into 3.0 deaths avoided per 1000 eligible patients or to 520 deaths per year over the 3.5-year study period among approximately 153,000 annual hospitalizations. The intervention was also associated with a lower incidence of ICU admission, a higher percentage of patients with a favorable status 30 days after the alert, a shorter length of stay, and longer survival. Results were reasonably similar across the hospitals in the system.
There are several advantages the AAM system coupled with this specific response system have over prior early warning scoring systems and rapid response teams. The AAM is fully automated, takes advantage of detailed EHR data, and does not require an immediate response by hospital staff. The authors point out that these factors facilitated its incorporation into a rapid-response system that uses remote monitoring, thus shielding providers from alert fatigue. That you have almost a 12-hour window in which to respond is a major advantage over systems that immediately trigger a Code Blue or other rapid response.
Though this was not a randomized, controlled trial (RCT) it had the advantage of being assessed in a very large population and the results seemed consistent across hospitals.
We love the concept of a system that relies on readily available data and works relatively unseen in the background and does not disrupt clinical workflows. Yet we lament somewhat that clinical judgement is not part of this system. Our February 2015 What's New in the Patient Safety World column “Detecting Clinical Deterioration: Don’t Neglect Clinical Impression” reminded us not to neglect the value of the clinical impression a nurse or physician has about the patient’s status. In that column we noted a study that added the question “How likely is this patient to suffer a cardiac arrest or require emergent transfer to the ICU in the next 24 hours?” improved the predictive value of at least one early warning system tool (Patel 2015).
Our latter concern aside, this work by the clinicians and researchers at KPNC makes one of the strongest cases we’ve ever seen for an integrated response system tied to an early warning scoring system. Kudos to KPNC!
Some of our other columns on MEWS or recognition of clinical deterioration:
Our other columns on rapid response teams:
References:
Kipnis P, Turk BJ, Wulf DA, et al. Development and validation of an electronic medical record-based alert score for detection of inpatient deterioration outside the ICU. J Biomed Inform 2016; 64: 10-19
https://www.sciencedirect.com/science/article/pii/S1532046416301265
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
Patel AR, Zadravecz FJ, Young RS, et al. The Value of Clinical Judgment in the Detection of Clinical Deterioration. JAMA Intern Med 2015; 175(3): 456-458 Published online January 05, 2015
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2087874
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December 8, 2020
Maternal Mortality: Looking in All the Wrong Places?
Our January 8, 2019 Patient Safety Tip of the Week “Maternal Mortality in the Spotlight” highlighted the dire status of maternal mortality in the US. The US “rank” in maternal mortality varies between 55th and 65th depending upon which source you go to for statistics. But clearly, compared to 10 “peer” industrialized OECD countries, the US ranks dead last, with a maternal mortality rate at least double the next highest country (Tikkanen 2020). The U.S. maternal mortality rate was 17.4 deaths per 100,000 births in 2018 (CDC 2020). The persistently high maternal mortality rates in the US have garnered the attention of many US media entities (USA Today, Bloomberg, Vox, US News & World Report).
Our January 8, 2019 Patient Safety Tip of the Week “Maternal Mortality in the Spotlight” also highlighted the disparities in maternal mortality in the US. The maternal mortality rate for 2018 was 17.4 deaths per 100,000 live births, and the rate for non-Hispanic black women (37.1) was 2.5 to 3.1 times the rates for non-Hispanic white (14.7) and Hispanic (11.8) women (Hoyert 2020).
The Annals of Internal Medicine recently devoted a whole supplement to maternal mortality. But it was an article for the Commonwealth Fund that caught our attention (Tikkanen 2020). It focused attention on the timing of the maternal deaths as reported by Petersen et al. (Petersen 2019) and this somewhat surprised us. About a third of U.S. pregnancy-related deaths occur during pregnancy. Seventeen percent of deaths occur on the day of delivery. But 52 percent occur after delivery:
Petersen et al. (Petersen 2019) also looked at causes of maternal death. They noted that approximately sixty percent of pregnancy-related deaths from state MMRC’s (maternal mortality review committees) were determined to be preventable and did not differ significantly by race/ethnicity or timing of death. Causes of death did vary by timing of death related to the pregnancy. Most deaths caused by amniotic fluid embolism occurred on the day of delivery or within 6 days postpartum. Approximately 60% of deaths caused by hypertensive disorders of pregnancy occurred 0–6 days postpartum, whereas those caused by cerebrovascular accidents occurred most frequently 1-42 days postpartum. Deaths caused by cardiomyopathy most commonly occurred 43-365 days postpartum; deaths caused by other cardiovascular conditions occurred most commonly during pregnancy and within 42 days postpartum. Multiple factors contributed to pregnancy-related deaths and they categorized contributing factors and prevention strategies at the community, health facility, patient, provider, and system levels and include improving access to, and coordination and delivery of, quality care.
Between 2003 and 2016, inpatient maternal mortality fell by 20%. There was a similar (24%) decline in maternal deaths in outpatient facilities and emergency departments. But, there was a significant increase in mortality in other settings, particularly within the descendant’s home with a doubling in maternal mortality rate over this time period (Burgess 2020). These numbers and trends are especially bothersome since so many maternal deaths are potentially preventable. The authors suggest that future progress in lowering maternal mortality in the US will require successfully addressing social, cultural, and financial issues beyond the direct control of the medical community.
We do many presentations on the fact that the high cost of healthcare in the US does not result in better health outcomes compared to other countries. We often highlight the high infant mortality and maternal mortality rates in the US as examples. But we also point out that statistics on infant and maternal mortality are somewhat misleading, since social and economic issues are as important as the strictly medical ones. Other countries spend significantly more on social issues that we do in the US.
Tikkanen and colleagues point out the US has a relative undersupply of maternity care providers, especially midwives, and lacks comprehensive postpartum supports. Ob/Gyn’s are overrepresented in the US maternity care workforce relative to midwives, but there is an overall shortage of maternity care providers (both Ob/Gyn’s and midwives) relative to births. In most other countries, midwives outnumber Ob/Gyn’s by severalfold, and primary care plays a central role in the health system. They also note that, although a large share of its maternal deaths occur post-birth, the US is the only country not to guarantee access to provider home visits or paid parental leave in the postpartum period. Tikkanen et al. note that home visits give providers an opportunity to address mental health concerns and allow them to assess social determinants of health, including needs for food, housing, financial security, and protection from domestic violence. They also note that the US is the only high-income country that does not guarantee paid leave to mothers after childbirth.
Tikkanen et al. point out a number of features of the Affordable Care Act (ACA) that have been beneficial to maternal care (expanded access to insurance coverage, expanded Medicaid, covered preventive services, better reimbursement rates for some providers, etc). But they also point out that the COVID-19 pandemic is likely to exacerbate the disparities, given that the pandemic has disproportionately impacted minorities economically.
Most quality improvement and patient safety efforts have focused on prenatal care and inpatient care. But the statistics noted above would suggest, as emphasized by Tikkanen et al., that we need to be focusing much more on what happens after the mothers and infants leave the hospital.
Petersen et al. in a separate paper (Petersen 2019b) addressed factors contributing to racial/ethnic disparities in pregnancy-related mortality, identified at multiple levels, including community, health facility, patient/family, provider, and system. Differences in access to care, quality of care, and prevalence of chronic diseases are among the leading factors. Chronic diseases associated with increased risk for pregnancy-related mortality, particularly hypertension, are more prevalent and less well controlled in black women. They note that ensuring access to quality care, including specialist providers, during preconception, pregnancy, and the postpartum period is crucial for all women to identify and manage those chronic medical conditions. Systemic factors, such as gaps in health care coverage and preventive care, lack of coordinated health care, and social services, and community factors, like securing transportation for medical visits and inadequate housing, are also contributors to pregnancy-related deaths.
But they also note that quality of care likely has a role in pregnancy-related deaths and associated racial disparities. They note a previous study (Tucker 2007) found a similar prevalence of 5 specific complications among black and white women, but a significantly higher case-fatality rate among black women. They also note that some studies have suggested that black women are more likely than are white women to receive obstetric care in hospitals that provide lower quality of care.
ACOG recognized the role of cardiovascular disease as a leading cause of maternal mortality in a 2019 Practice Bulletin (ACOG 2019). In a discussion of that ACOG Practice Bulletin, it was pointed out that a key barrier to adequate care is that 40% of women do not return for post-partum visits (Nackerdien 2019).
Our January 8, 2019 Patient Safety Tip of the Week “Maternal Mortality in the Spotlight” discussed many of the social issues related to maternal mortality and disparities in care. But there we also mentioned the plight of women living in rural areas. Over 100 rural hospitals have closed since 2010 and about a quarter of rural hospitals are at risk of closing today. Rural hospitals have great difficulty recruiting doctors, nurses, and other healthcare professionals. As these hospitals hemorrhage financially, many cannot afford to staff labor & delivery units 24x7 when there are few actual deliveries, so this service is often dropped and women are forced to seek their obstetrical care elsewhere. That often leads to discontinuity between their obstetrical care and their overall medical care.
Though inpatient maternal mortality rates have been improving, Joint Commission this past summer introduced 13 new elements of performance (EP’s) related to maternal safety (TJC 2019), though Joint Commission has suspended regular hospital surveys during the current COVID-19 pandemic. The new EP’s focus on maternal harm related to hypertension/eclampsia and to maternal hemorrhage. They also stress the importance of multidisciplinary teams and use of drills and simulations.
Standard PC.06.01.01: Reduce the likelihood of harm related to maternal hemorrhage
EP 1: Complete an assessment using an evidence-based tool for determining maternal hemorrhage risk on admission to labor and delivery and on admission to postpartum.
EP 2: Develop written evidence-based procedures for stage-based management of pregnant and postpartum patients who experience maternal hemorrhage that includes the following:
Note: The written procedures should be developed by a multidisciplinary team that includes representation from obstetrics, anesthesiology, nursing, laboratory, and blood bank
EP 3: Each obstetric unit has a standardized, secured, dedicated hemorrhage supply kit that must be stocked per the organization’s defined process and, at a minimum, contains the following:
EP 4: Provide role-specific education to all staff and providers who treat pregnant and postpartum patients about the organization’s hemorrhage procedure. At a minimum, education occurs at orientation, whenever changes to the processes or procedures occur, or every two years.
EP 5: Conduct drills at least annually to determine system issues as part of on-going quality improvement efforts. Drills include representation from each discipline identified in the organization’s hemorrhage response procedure and include a team debrief after the drill.
EP 6: Review hemorrhage cases that meet criteria established by the organization to evaluate the effectiveness of the care, treatment, and services provided by the hemorrhage response team during the event.
EP 7: Provide education to patients (and their families including the designated support person whenever possible). At a minimum, education includes:
Standard PC.06.01.03: Reduce the likelihood of harm related to maternal severe hypertension/preeclampsia
EP 1: Develop written evidence-based procedures for measuring and remeasuring blood pressure. These procedures include criteria that identify patients with severely elevated blood pressure.
EP 2: Develop written evidence-based procedures for managing pregnant and postpartum patients with severe hypertension/preeclampsia that includes the following:
Again, the written procedures should be developed by a multidisciplinary team
EP 3: Provide role-specific education to all staff and providers who treat pregnant/ postpartum patients about the hospital’s evidence-based severe hypertension/ preeclampsia procedure. At a minimum, education occurs at orientation, whenever changes to the procedure occur, or every two years. (Note that this requirement for education applies to to staff and providers in emergency departments regardless of the hospital’s ability to provide labor and delivery services.)
EP 4: Conduct drills at least annually to determine system issues as part of ongoing quality improvement efforts. Severe hypertension/preeclampsia drills include a team debrief.
EP 5: Review severe hypertension/preeclampsia cases that meet criteria established by the hospital to evaluate the effectiveness of the care, treatment, and services provided to the patient during the event.
EP 6: Provide printed education to patients (and their families including the designated support person whenever possible). At a minimum, education includes:
Note that the EP’s for both maternal hemorrhage and hypertension/eclampsia include performance of multidisciplinary drills. Most organizations that provide labor and delivery services do simulation exercises (see our February 7, 2017 Patient Safety Tip of the Week “Maternal Safety Bundles”).
And, of course, we are always big fans of drills and exercises that help prepare teams for emergencies. Fortunately, ob/gyn has been a pioneer in simulation programs that use team-based interdisciplinary training for events like post-partum hemorrhage and other obstetrical emergencies. Many academic medical centers put on such simulation programs for interested parties to attend. We are familiar with the one put on by the University of Rochester Medical Center. These simulations can be quite comprehensive. There’s even one module in which there is simulation of the expectant father fainting in the delivery room!
We also hope you’ll go back to our February 7, 2017 Patient Safety Tip of the Week “Maternal Safety Bundles”. There we not only discussed programs using maternal safety bundles and simulations, but also discussed maternal safety issues such as RSI’s (retained surgical items), surgical fires, obstructive sleep apnea, epidural catheter mistaken infusions, unintentional hypothermia, the weekend effect, medication mix ups, and other issues. In that column we also discussed the Patient Safety Bundles developed by the National Partnership for Maternal Safety (NPMS) and Council on Patient Safety in Women’s Healthcare and supported by ACOG and the Anesthesia Patient Safety Foundation (Banayan 2020).
One way to address the inpatient portion of obstetrical care has been introduction of obstetrical hospitalist programs. Internal medicine hospitalist and Ob/Gyn laborist programs have been around for a couple decades. OB hospitalist programs have been envisioned as a potential way to address issues such as physician burnout, unpredictable work schedules, fragmentation of care, lack of standardization, and patient safety. Decesare and colleagues (Decesare 2020) recently reported that implementation of an OB hospitalist program significantly reduced patient safety events.
So, we have, in fact, been doing a better job at reducing maternal mortality in hospitalized patients. But the real message in today’s column is that much maternal mortality occurs after the pregnancy has ended and is potentially preventable. We clearly need better focus on those system features that could address factors contributing to those deaths.
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”
References:
USA Today. Deadly Deliveries. USA Today 2020
https://www.usatoday.com/series/deadlydeliveries/
Flam F. American Mothers Are Dying Because of the U.S. Health Care System. The U.S. has an inexcusably high maternal mortality rate. Bloomberg 2020; February 9, 2020
Belluz J. We finally have a new US maternal mortality estimate. It’s still terrible.
Among 10 similarly wealthy countries, “the US would rank 10th.” Vox 2020; Jan 30, 2020
https://www.vox.com/2020/1/30/21113782/pregnancy-deaths-us-maternal-mortality-rate
Galvin G. The U.S. Has a Maternal Mortality Rate Again. Here’s Why That Matters. US News & World Report 2020; January 30, 2020
Tikkanen R, Gunja MZ, FitzGerald M, Zephyrin L. Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries. The Commonwealth Fund 2020; November 18, 2020
Petersen EE, Davis NL, Goodwin D, et al. Vital signs: Pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017. MMWR 2019; 68(18): 423-429 Published May 10, 2019
https://www.cdc.gov/mmwr/volumes/68/wr/mm6818e1.htm
Hoyert DL, Miniño AM. Maternal Mortality in the United States: Changes in Coding, Publication, and Data Release, National Vital Statistics Report 2020; 69(2): 1-18
https://pubmed.ncbi.nlm.nih.gov/32510319/
CDC (Centers for Disease Control and Prevention). National Center for Health Statistics. Maternal Mortality. CDC 2020; Page last reviewed: November 9, 2020
https://www.cdc.gov/nchs/maternal-mortality/index.htm
Burgess A, Clark S, Dongarwar D, SalihuH. Hospital maternal mortality rates are falling,overall maternal mortality still rises: Implications forforward movement. Amer J Obstet Gyn 2020; 222(1): Supplement S5
https://www.ajog.org/article/S0002-9378(19)31391-2/fulltext#sec2
Annals of Internal Medicine. Maternal Health in the United States: Findings From the Health Resources and Services Administration and Partners. Annals of Internal Medicine 2020’ 173(11): Supplement
https://www.acpjournals.org/toc/aim/173/11_Supplement
Petersen EE, Davis NL, Goodman D, et al. Racial/ethnic disparities in pregnancy-related deaths—United States, 2007–2016. MMWR Morb Mortal Wkly Rep. 2019; 68: 762-765
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6730892/
Tucker MJ, Berg CJ, Callaghan WM, Hsia J. The Black-White disparity in pregnancy-related mortality from 5 conditions: differences in prevalence and case-fatality rates. Am J Public Health 2007; 97: 247-251
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1781382/
ACOG (American College of Obstetricians and Gynecologists). ACOG Practice Bulletin No. 212 Summary: Pregnancy and Heart Disease. Obstetrics & Gynecology 2019; 133(5): 1067-1072
Nackerdien Z. ACOG Plan Addresses Cardiovascular Disease as Top Killer of Pregnant Women in U.S. MedPage Today 2019; May 12, 2019
TJC (The Joint Commission). R3 Report. Provision of Care, Treatment, and Services standards for maternal safety. The Joint Commission R3 Report 2019; Issue 24: August 21, 2019
URMC (University of Rochester Medical Center). Center for Obstetrics and Gynecology Simulation (COGS).
https://www.urmc.rochester.edu/ob-gyn/education/simulation.aspx
Decesare JZ, Bush SY, Morton AN. Impact of an Obstetrical Hospitalist Program on the Safety Events in a Mid-Sized Obstetrical Unit. Journal of Patient Safety 2020; 16(3): e179-e181
Council on Patient Safety in Women’s Healthcare. Patient Safety Bundles. 2020
https://safehealthcareforeverywoman.org/
Banayan JM, Scavone BM. National Partnership for Maternal Safety—Maternal Safety Bundles. APSF Newsletter 2020; 35(3): 96-97 October 2020
https://www.apsf.org/article/national-partnership-for-maternal-safety-maternal-safety-bundles-2/
Print “Maternal Mortality: Looking in All the Wrong Places?”
December 15, 2020
Our Perennial Pre-Holiday Warning: "Be Careful Out There!"
Since this is our last column prior to the holidays, it’s time for our annual warning: “Be careful out there!”. Be very wary about patient safety vulnerabilities during the holidays. We don’t have statistics to verify that medical errors and incidents are more frequent around the holidays. But anecdotes abound. We have had two dear friends suffer serious incidents while inpatients on Christmas Day. In each case there was lack of attention to critical events during evolving clinical situations, likely due to coverage issues or other distractions related to the holiday. In one case, lack of consultant availability led to lack of appropriate intervention in a patient with colonic pseudo-obstruction (Ogilvie’s syndrome) after an orthopedic procedure. That patient developed sepsis and died. In the other case, a several hour period of inattention to serum electrolytes led to rapid overcorrection of hyponatremia and consequent osmotic demyelination syndrome.
Staffing issues, coverage issues, and distractions are more common on holidays and are potential factors contributing to incidents. And it’s not just the day of the holiday that is important. Sometimes the time pressures created by a holiday may be contributing factors to incidents on the following day(s). In our December 11, 2018 Patient Safety Tip of the Week “Another NMBA Accident” we speculated about the impact of such time pressures contributing to the patient being sent for a PET scan late in the day, during which a fatal mistake took place.
There has been at least one study that looked systematically at mortality related to public holidays. Smith et al. (Smith 2014) found that adjusted public holiday mortality in the all public holidays versus all other days analysis was 48% higher at 7 days (OR 1.48) and 27% higher at 30 days (OR 1.27). Interactions between the weekend variable and the public holiday variable were not statistically significant. They concluded that patients admitted as emergencies to medicine on public holidays had significantly higher mortality at 7 and 30 days compared with patients admitted on other days of the week.
We have, of course, done multiple columns on the “weekend effect” and the impact of time of day or “after hours” care (see columns listed below). And we’ve described a host of factors that are different in hospitals on weekends, evenings and nights, and holidays compared to daytime.
But one factor that hasn’t received very much attention is the impact of distractions during those periods of vulnerability. To try to focus on that factor among so many others, Kato and colleagues (Kato 2020) recently took an innovative approach – they looked at mortality for patients operated on by surgeons on the surgeons’ birthdays! They looked at mortality in Medicare beneficiaries aged 65 to 99 years who underwent one of 17 common emergency surgical procedures. Of almost a million cases, 0.2% were performed by surgeons on the surgeons’ birthday.
The overall unadjusted 30-day mortality on the operating surgeon’s birthday was 7.0% and that on other days was 5.6%. After adjustment for patient characteristics and other potential confounders, patients who underwent surgery on a surgeon’s birthday exhibited higher mortality compared with patients who underwent surgery on other days (adjusted mortality rate, 6.9% v 5.6%; P=0.03). They interpreted these findings as suggesting that surgeons might be distracted by life events that are not directly related to work. They note that, while that hypothesis is intuitive, it has been otherwise difficult to assess, owing to lack of detailed information on events that are potentially distracting to an individual surgeon.
The authors go on to discuss several potential mechanisms that might explain these findings. First, and foremost, are the time pressures that might be operative on a surgeon’s birthday (eg. need to be at a scheduled family event). But other distractions could be related to simple things like conversations with other OR staff about birthdays or receiving text/phone messages with birthday wishes. They speculate that perhaps surgeons are more likely to delegate parts of the procedures to residents and fellows, and that perhaps post-operative care decisions might be impacted (as an example, they speculate a surgeon might be less likely to return to the hospital to see their patients who show signs of deterioration if they are having dinner with family and friends, compared with regular evenings).
We were originally going to title this column “OMG! Don’t Tell Me Your Stats. Tell Me Your Date of Birth!” Is it more important to ask your surgeon about his/her birthday than his/her surgical outcome statistics? And what about his/her anniversary or his/her children’s birthdays? Or his/her tee time? Those questions are, of course, absurd. But it does remind us that certain life events may make us more vulnerable to distractions and subsequent errors. Perhaps we need to be more careful in on-call scheduling to avoid being put in vulnerable positions on such days. But, most of all, we need to recognize that certain occasions and events increase the possibility we will be distracted and take special care on those days to avoid those distractions.
The Kato study makes a very important point that we are all more vulnerable to distraction at certain times. But we don’t want to take away from our focus on reminding everyone of the need for extra vigilance and care during the holidays.
Happy holidays to all! Stay safe and practice safely!
Some of our previous columns on the “weekend effect”:
Some of our previous columns on “after-hours” surgery:
References:
Smith S, Allan A, Greenlaw N, Finlay S, Isles C. Emergency medical admissions, deaths at weekends and the public holiday effect. Cohort study. Emerg Med J 2014; 31: 30-34
https://emj.bmj.com/content/31/1/30
Kato H, Jena AB, Tsugawa Yusuke T. Patient mortality after surgery on the surgeon’s birthday: observational study BMJ 2020; 371: m4381
https://www.bmj.com/content/371/bmj.m4381
Print “Our Perennial Pre-Holiday Warning: “Be Careful Out There!””
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July 23, 2019
Order Sets Can Nudge the Right Way or the Wrong Way
July 16, 2019
July 9, 2019
Spinal Injection of Tranexamic Acid
July 2, 2019
Tip of the Week on Vacation
June 25, 2019
June 18, 2019
June 11, 2019
ISMP’s Grissinger on Overreliance on Technology
June 4, 2019
Medication Errors in the OR – Part 3
May 28, 2019
May 21, 2019
Mixed Message on Number of Open EMR Records
May 14, 2019
Wrong-Site Surgery and Difficult-to-Mark Sites
May 7, 2019
Simulation Training for OR Fires
April 30, 2019
Reducing Unnecessary Urine Cultures
April 23, 2019
In and Out the Door and Other OR Flow Disruptions
April 16, 2019
AACN Practice Alert on Alarm Management
April 9, 2019
Handoffs for Every Occasion
April 2, 2019
Unexpected Events During MRI
March 26, 2019
March 19, 2019
March 12, 2019
Update on Overlapping Surgery
March 5, 2019
Infusion Pump Problems
February 26, 2019
Vascular Access Device Dislodgements
February 19, 2019
Focus on Pediatric Patient Safety
February 12, 2019
From Tragedy to Travesty of Justice
February 12, 2019
2 ER Drug Studies: Reassurances and Reservations
February 5, 2019
Flaws in Our Medication Safety Technologies
January 29, 2018
National Patient Safety Goal for Suicide Prevention
January 22, 2019
Wandering Patients
January 15, 2019
Another Plus for Prehabilitation
January 8, 2019
Maternal Mortality in the Spotlight
January 1, 2019
More on Automated Dispensing Cabinet (ADC) Safety
December 25, 2018
Happy Holidays!
December 18, 2018
Great Recommendations for e-Prescribing
December 11, 2018
December 4, 2018
Don’t Use Syringes for Topical Products
November 27, 2018
November 20, 2018
November 13, 2018
Antipsychotics Fail in ICU Delirium
November 6, 2018
More on Promoting Sleep in Inpatients
October 30, 2018
October 23, 2018
Lessons From Yet Another Aviation Incident
October 16, 2018
October 9, 2018
October 2, 2018
Speaking Up About Disruptive Behavior
September 25, 2018
Foley Follies
September 18, 2018
September 11, 2018
September 4, 2018
The 12-Hour Nursing Shift: Another Nail in the Coffin
August 28, 2018
Thought You Discontinued That Medication? Think Again
August 21, 2018
Delayed CT Scan in the Anticoagulated Patient
August 14, 2018
ISMP Canada’s Updated “Do Not Use” Abbreviation List
August 7, 2018
Tip of the Week on Vacation
July 31, 2018
Surgery and the Opioid-Tolerant Patient
July 24, 2018
More on Speech Recognition Software Errors
July 17, 2018
OSA Screening in Stroke Patients
July 10, 2018
Another Jump from a Hospital Window
July 3, 2018
Tip of the Week on Vacation
June 26, 2018
Infection Related to Colonoscopy
June 19, 2018
June 12, 2018
Adverse Events in Cancer Patients
June 5, 2018
Pennsylvania Patient Safety Authority on Iatrogenic Burns
May 29, 2018
More on Nursing Workload and Patient Safety
May 22, 2018
Hazardous Intrahospital Transport
May 15, 2018
May 8, 2018
May 1, 2018
April 24, 2018
April 17, 2018
More on Tests Pending at Discharge
April 10, 2018
Prepping the Geriatric Patient for Surgery
April 3, 2018
March 27, 2018
March 20, 2018
Minnesota Highlights Lost Tissue Samples
March 13, 2018
March 6, 2018
February 27, 2018
Update on Patient Safety Walk Rounds
February 20, 2018
February 13, 2018
February 6, 2018
Adverse Events in Inpatient Psychiatry
January 30, 2018
January 23, 2018
Unintentional Hypothermia Back in Focus
January 16, 2018
January 9, 2018
More on Fire Risk from Surgical Preps
January 2, 2018
Preventing Perioperative Nerve Injuries
December 26, 2017
Tip of the Week on Vacation
December 19, 2017
December 12, 2017
Joint Commission on Suicide Prevention
December 5, 2017
Massachusetts Initiative on Cataract Surgery
November 28, 2017
More on Dental Sedation/Anesthesia Safety
November 21, 2017
OSA, Oxygen, and Alarm Fatigue
November 14, 2017
Tracking C. diff to a CT Scanner
November 7, 2017
Perioperative Neuropathies
October 31, 2017
Target Drugs for Deprescribing
October 24, 2017
Neurosurgery and Time of Day
October 17, 2017
Progress on Alarm Management
October 10, 2017
More on Torsade de Pointes
October 3, 2017
Respiratory Compromise: One Size Does Not Fit All
September 26, 2017
Tip of the Week on Vacation
September 19, 2017
Tip of the Week on Vacation
September 12, 2017
Can You Hear Me Now?
September 5, 2017
Another Iatrogenic Burn
August 29, 2017
Suicide in the Bathroom
August 22, 2017
August 15, 2017
Delayed Emergency Surgery and Mortality Risk
August 8, 2017
Sedation for Pediatric MRI Rising
August 1, 2017
Progress on Wrong Patient Orders
July 25, 2017
Can We Influence the “Weekend Effect”?
July 18, 2017
Another Hazard from Alcohol-Based Hand Gels
July 11, 2017
The 12-Hour Shift Takes More Hits
July 4, 2017
Tip of the Week on Vacation
June 27, 2017
June 20, 2017
June 13, 2017
June 6, 2017
NYS Mandate for Sepsis Protocol Works
May 30, 2017
Errors in Pre-Populated Medication Lists
May 23, 2017
May 16, 2017
Are Surgeons Finally Ready to Screen for Frailty?
May 9, 2017
Missed Nursing Care and Mortality Risk
May 2, 2017
Anatomy of a Wrong Procedure
April 25, 2017
April 18, 2017
Alarm Response and Nurse Shift Duration
April 11, 2017
Interruptions: The Ones We Forget About
April 4, 2017
Deprescribing in Long-Term Care
March 28, 2017
More Issues with Dental Sedation/Anesthesia
March 21, 2017
Success at Preventing Delirium
March 14, 2017
More on Falls on Inpatient Psychiatry
March 7, 2017
February 28, 2017
February 21, 2017
Yet More Jumps from Hospital Windows
February 14, 2017
February 7, 2017
January 31, 2017
More Issues in Pediatric Safety
January 24, 2017
Dexmedetomidine to Prevent Postoperative Delirium
January 17, 2017
January 10, 2017
The 26-ml Applicator Strikes Again!
January 3, 2017
What’s Happening to “I’m Sorry”?
December 27, 2016
Tip of the Week on Vacation
December 20, 2016
End-of-Rotation Transitions and Mortality
December 13, 2016
More on Double-Booked Surgery
December 6, 2016
Postoperative Pulmonary Complications
November 29, 2016
Doubling Down on Double-Booked Surgery
November 22, 2016
Leapfrog, Picklists, and Healthcare IT Vulnerabilities
November 15, 2016
November 8, 2016
Managing Distractions and Interruptions
November 1, 2016
CMS Emergency Preparedness Rule
October 25, 2016
Desmopressin Back in the Spotlight
October 18, 2016
Yet More Questions on Contact Precautions
October 11, 2016
New Guideline on Preop Screening and Assessment for OSA
October 4, 2016
September 27, 2016
September 20, 2016
Downloadable ABCDEF Bundle Toolkits for Delirium
September 13, 2016
Vanderbilt’s Electronic Procedural Timeout
September 6, 2016
August 30, 2016
Can You Really Limit Interruptions?
August 23, 2016
ISMP Canada: Automation Bias and Automation Complacency
August 16, 2016
How Is Your Alarm Management Initiative Going?
August 9, 2016
August 2, 2016
Drugs in the Elderly: The Goldilocks Story
July 26, 2016
Confirmed: Keep Your OR Doors Closed
July 19, 2016
Infants and Wrong Site Surgery
July 12, 2016
Forget Brexit – Brits Bash the RCA!
July 5, 2016
Tip of the Week on Vacation
June 28, 2016
Culture of Safety and Catheter-Associated Infections
June 21, 2016
Methotrexate Errors in Australia
June 14, 2016
Nursing Monitoring of Patients on Opioids
June 7, 2016
CPAP for Hospitalized Patients at High Risk for OSA
May 31, 2016
More Frailty Measures That Predict Surgical Outcomes
May 24, 2016
Texting Orders – Is It Really Safe?
May 17, 2016
Patient Safety Issues in Cataract Surgery
May 10, 2016
Medical Problems in Behavioral Health
May 3, 2016
Clinical Decision Support Malfunction
April 26, 2016
Lots More on Preventing Readmissions But Where's the Beef?
April 19, 2016
Independent Double Checks and Oral Chemotherapy
April 12, 2016
April 5, 2016
Workarounds Overriding Safety
March 29, 2016
March 22, 2016
Radiology Communication Errors May Surprise You
March 15, 2016
March 8, 2016
Tip of the Week on Vacation
March 1, 2016
February 23, 2016
February 16, 2016
February 9, 2016
February 2, 2016
January 26, 2016
More on Frailty and Surgical Morbidity and Mortality
January 19, 2016
Patient Identification in the Spotlight
January 12, 2016
New Resources on Improving Safety of Healthcare IT
January 5, 2016
Lessons from AirAsia Flight QZ8501 Crash
December 29, 2015
More Medical Helicopter Hazards
December 22, 2015
The Alberta Abbreviation Safety Toolkit
December 15, 2015
Vital Sign Monitoring at Night
December 8, 2015
Danger of Inaccurate Weights in Stroke Care
December 1, 2015
TALLman Lettering: Does It Work?
November 24, 2015
Door Opening and Foot Traffic in the OR
November 17, 2015
Patient Perspectives on Communication of Test Results
November 10, 2015
Weighing in on Double-Booked Surgery
November 3, 2015
Medication Errors in the OR - Part 2
October 27, 2015
Sentinel Event Alert on Falls and View from Across the Pond
October 20, 2015
Updated Beers List
October 13, 2015
Dilaudid Dangers #3
October 6, 2015
Suicide and Other Violent Inpatient Deaths
September 29, 2015
More on the 12-Hour Nursing Shift
September 22, 2015
The Cost of Being Rude
September 15, 2015
Another Possible Good Use of a Checklist
September 8, 2015
TREWScore for Early Recognition of Sepsis
September 1, 2015
August 25, 2015
Checklist for Intrahospital Transport
August 18, 2015
Missing Obstructive Sleep Apnea
August 11, 2015
New Oxygen Guidelines: Thoracic Society of Australia and NZ
August 4, 2015
Tip of the Week on Vacation
July 28, 2015
July 21, 2015
Avoiding Distractions in the OR
July 14, 2015
July 7, 2015
June 30, 2015
What Are Appropriate Indications for Urinary Catheters?
June 23, 2015
Again! Mistaking Antiseptic Solution for Radiographic Contrast
June 16, 2015
June 9, 2015
Add This to Your Fall Risk Assessment
June 2, 2015
May 26, 2015
May 19, 2015
May 12, 2015
More on Delays for In-Hospital Stroke
May 5, 2015
Errors with Oral Oncology Drugs
April 28, 2015
April 21, 2015
April 14, 2015
Using Insulin Safely in the Hospital
April 7, 2015
March 31, 2015
Clinical Decision Support for Pneumonia
March 24, 2015
Specimen Issues in Prostate Cancer
March 17, 2015
March 10, 2015
FDA Warning Label on Insulin Pens: Is It Enough?
March 3, 2015
Factors Related to Postoperative Respiratory Depression
February 24, 2015
More Risks with Long-Acting Opioids
February 17, 2015
Functional Impairment and Hospital Readmission, Surgical Outcomes
February 10, 2015
The Anticholinergic Burden and Dementia
February 3, 2015
CMS Hopes to Reduce Antipsychotics in Dementia
January 27, 2015
The Golden Hour for Stroke Thrombolysis
January 20, 2015
He Didn’t Wash His Hands After What!
January 13, 2015
January 6, 2015
Yet Another Handoff: The Intraoperative Handoff
December 30, 2014
Data Accumulates on Impact of Long Surgical Duration
December 23, 2014
Iatrogenic Burns in the News Again
December 16, 2014
More on Each Element of the Surgical Fire Triad
December 9, 2014
December 2, 2014
ANA Position Statement on Nurse Fatigue
November 25, 2014
Misdiagnosis Due to Lab Error
November 18, 2014
Handwashing Fades at End of Shift, ?Smartwatch to the Rescue
November 11, 2014
Early Detection of Clinical Deterioration
November 4, 2014
Progress on Fall Prevention
October 28, 2014
RF Systems for Retained Surgical Items
October 21, 2014
The Fire Department and Your Hospital
October 14, 2014
October 7, 2014
Our Take on Patient Safety Walk Rounds
September 30, 2014
More on Deprescribing
September 23, 2014
Stroke Thrombolysis: Need to Focus on Imaging-to-Needle Time
September 16, 2014
Focus on Home Care
September 9, 2014
The Handback
September 2, 2014
Frailty and the Trauma Patient
August 26, 2014
Surgeons’ Perception of Intraoperative Time
August 19, 2014
Some More Lessons Learned on Retained Surgical Items
August 12, 2014
Surgical Fires Back in the News
August 5, 2014
Tip of the Week on Vacation
July 29, 2014
The 12-Hour Nursing Shift: Debate Continues
July 22, 2014
More on Operating Room Briefings and Debriefings
July 15, 2014
Barriers to Success of Early Warning Systems
July 8, 2014
Update: Minor Head Trauma in the Anticoagulated Patient
July 1, 2014
Interruptions and Radiologists
June 24, 2014
Lessons from the General Motors Recall Analysis
June 17, 2014
SO2S Confirms Routine Oxygen of No Benefit in Stroke
June 10, 2014
Another Clinical Decision Support Tool to Avoid Torsade de Pointes
June 3, 2014
More on the Risk of Sedative/Hypnotics
May 27, 2014
A Gap in ePrescribing: Stopping Medications
May 20, 2014
May 13, 2014
Perioperative Sleep Apnea: Human and Financial Impact
May 6, 2014
Monitoring for Opioid-induced Sedation and Respiratory Depression
April 29, 2014
More on the Unintended Consequences of Contact Isolation
April 22, 2014
Impact of Resident Workhour Restrictions
April 15, 2014
Specimen Identification Mixups
April 8, 2014
FMEA to Avoid Breastmilk Mixups
April 1, 2014
Expensive Aspects of Sepsis Protocol Debunked
March 25, 2014
March 18, 2014
Systems Approach Improving Stroke Care
March 11, 2014
We Miss the Graphic Flowchart!
March 4, 2014
Evidence-Based Prescribing and Deprescribing in the Elderly
February 25, 2014
Joint Commission Revised Diagnostic Imaging Requirements
February 18, 2014
February 11, 2014
Another Perioperative Handoff Tool: SWITCH
February 4, 2014
But What If the Battery Runs Low?
January 28, 2014
Is Polypharmacy Always Bad?
January 21, 2014
January 14, 2014
Diagnostic Error: Salient Distracting Features
January 7, 2014
Lessons From the Asiana Flight 214 Crash
December 24-31, 2013
Tip of the Week on Vacation
December 17, 2013
December 10, 2013
Better Handoffs, Better Results
December 3, 2013
Reducing Harm from Falls on Inpatient Psychiatry
November 26, 2013
Missed Care: New Opportunities?
November 19, 2013
Can We Improve Dilaudid/HYDROmorphone Safety?
November 12, 2013
More on Inappropriate Meds in the Elderly
November 5, 2013
Joint Commission Sentinel Event Alert: Unintended Retained Foreign Objects
October 29, 2013
PAD: The Pain, Agitation, and Delirium Care Bundle
October 22, 2013
How Safe Is Your Radiology Suite?
October 15, 2013
October 8, 2013
October 1, 2013
Fuels and Oxygen in OR Fires
September 24, 2013
Perioperative Use of CPAP in OSA
September 17, 2013
September 10, 2013
Informed Consent and Wrong-Site Surgery
September 3, 2013
Predicting Perioperative Complications: Slow and Simple
August 27 2013
Lessons on Wrong-Site Surgery
August 20 2013
Lessons from Canadian Analysis of Medical Air Transport Cases
August 13 2013
August 6, 2013
July 9-30, 2013
Tip of the Week on Vacation
July 2, 2013
June 25, 2013
June 18, 2013
DVT Prevention in Stoke – CLOTS 3
June 11, 2013
June 4, 2013
May 28, 2013
The Neglected Medications: IV Fluids
May 21, 2013
May 14, 2013
Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)
May 7, 2013
April 30, 2013
Photographic Identification to Prevent Errors
April 23, 2013
Plethora of Medication Safety Studies
April 16, 2013
April 9, 2013
Mayo Clinic System Alerts for QT Interval Prolongation
April 2, 2013
Absconding from Behavioral Health Services
March 26, 2013
Failure to Recognize Sleep Apnea Before Surgery
March 19, 2013
Dealing with the Violent Patient in the Emergency Department
March 12, 2013
More on Communicating Test Results
March 5, 2013
Underutilized Safety Tools: The Observational Audit
February 26, 2013
Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?
February 19, 2013
Practical Postoperative Pain Management
February 12, 2013
CDPH: Lessons Learned from PCA Incident
February 5, 2013
Antidepressants and QT Interval Prolongation
January 29, 2013
A Flurry of Activity on Handoffs
January 22, 2013
You Don’t Know What You Don’t Know
January 15, 2013
January 8, 2013
More Lessons Learned on Retained Surgical Items
January 1, 2013
Don’t Throw Away Those View Boxes Yet
December 25, 2012
Tip of the Week on Vacation
December 18, 2012
Unintended Consequences of the CAUTI Measure?
December 11, 2012
December 4, 2012
Unintentional Perioperative Hypothermia: A New Twist
November 27, 2012
November 20, 2012
Update on Perioperative Management of Obstructive Sleep Apnea
November 13, 2012
The 12-Hour Nursing Shift: More Downsides
November 6, 2012
Using LEAN to Improve Stroke Care
October 30, 2012
October 23, 2012
Latent Factors Lurking in the OR
October 16, 2012
What is the Evidence on Double Checks?
October 9, 2012
Call for Focus on Diagnostic Errors
October 2, 2012
Test Results: Everyone’s Worst Nightmare
September 25, 2012
Preoperative Assessment for Geriatric Patients
September 18, 2012
September 11, 2012
In Search of the Ideal Early Warning Score
September 4, 2012
August 28, 2012
New Care Model Copes with Interruptions Better
August 21, 2012
More on Missed Followup of Tests in Hospital
August 14, 2012
August 7, 2012
Cognition, Post-Op Delirium, and Post-Op Outcomes
July 31, 2012
Surgical Case Duration and Miscommunications
July 24, 2012
FDA and Extended-Release/Long-Acting Opioids
July 17, 2012
July 10, 2012
Tip of the Week on Vacation
July 3, 2012
Recycling an Old Column: Dilaudid Dangers
June 26, 2012
Using Patient Photos to Reduce CPOE Errors
June 19, 2012
More Problems with Faxed Orders
June 12, 2012
Lessons Learned from the CDPH: Retained Foreign Bodies
June 5, 2012
Minor Head Trauma in the Anticoagulated Patient
May 29, 2012
Falls, Fractures, and Fatalities
May 22, 2012
Update on Preoperative Screening for Sleep Apnea
May 15, 2012
May 8, 2012
Importance of Nontechnical Skills in Healthcare
May 1, 2012
April 24, 2012
Fire Hazard of Skin Preps Oxygen
April 17, 2012
April 10, 2012
April 3, 2012
New Risk for Postoperative Delirium: Obstructive Sleep Apnea
March 27, 2012
March 20, 2012
Adverse Events Related to Psychotropic Medications
March 13, 2012
Medical Emergency Team Calls to Radiology
March 6, 2012
February 28, 2012
AACN Practice Alert on Delirium in Critical Care
February 21, 2012
Improving PCA Safety with Capnography
February 14, 2012
Handoffs More Than Battle of the Mnemonics
February 7, 2012
Another Neuromuscular Blocking Agent Incident
January 31, 2012
January 24, 2012
Patient Safety in Ambulatory Care
January 17, 2012
Delirium and Contact Isolation
January 10, 2012
January 3, 2012
Unintended Consequences of Restricted Housestaff Hours
December 20, 2011
December 13, 2011
December 6, 2011
Why You Need to Beware of Oxygen Therapy
November 29, 2011
November 22, 2011
Perioperative Management of Sleep Apnea Disappointing
November 15, 2011
November 8, 2011
WHOs Multi-professional Patient Safety Curriculum Guide
November 1, 2011
So Whats the Big Deal About Inserting an NG Tube?
October 25, 2011
October 18, 2011
October 11, 2011
October 4, 2011
Radiology Report Errors and Speech Recognition Software
September 27, 2011
The Canadian Suicide Risk Assessment Guide
September 20, 2011
When Practice Changes the Evidence: The CKD Story
September 13, 2011
Do You Use Fentanyl Transdermal Patches Safely?
September 6, 2011
August 30, 2011
Unintentional Discontinuation of Medications After Hospitalization
August 23, 2011
Catheter Misconnections Back in the News
August 16, 2011
August 9, 2011
Frailty and the Surgical Patient
August 2, 2011
July 26, 2011
July 19, 2011
Communication Across Professions
July 12, 2011
Psst! Pass it onHow a kids game can mold good handoffs
July 5, 2011
Sidney Dekker: Patient Safety. A Human Factors Approach
June 28, 2011
Long-Acting and Extended-Release Opioid Dangers
June 21, 2011
June 14, 2011
June 6, 2011
May 31, 2011
Book Review Human Factors and Team Psychology in a High Stakes Environment
May 24, 2011
May 17, 2011
Opioid-Induced Respiratory Depression Again!
May 10, 2011
Preventing Preventable Readmissions: Not As Easy As It Sounds
May 3, 2011
April 26, 2011
Sleeping Air Traffic Controllers: What About Healthcare?
April 19, 2011
DVT Prophylaxis in Acute Stroke: Controversy Reappears
April 12, 2011
Medication Issues in the Ambulatory Setting
April 5, 2011
March 29, 2011
The Silent Treatment:A Dose of Reality
March 22, 2011
An EMR Feature Detrimental to Teamwork and Patient Safety
March 15, 2011
March 8, 2011
Yes, Physicians Get Interrupted Too!
March 1, 2011
February 22, 2011
February 15, 2011
Controversies in VTE Prophylaxis
February 8, 2011
February 1, 2011
January 25, 2011
Procedural Sedation in Children
January 18, 2011
More on Medication Errors in Long-Term Care
January 11, 2011
NPSA (UK) How to Guide: Five Steps to Safer Surgery
January 4, 2011
December 28, 2010
HAIs: Looking In All The Wrong Places
December 21, 2010
More Bad News About Off-Hours Care
December 14, 2010
NPSA (UK): Preventing Fatalities from Medication Loading Doses
December 6, 2010
More Tips to Prevent Wrong-Site Surgery
November 30, 2010
SURPASS: The Mother of All Checklists
November 23, 2010
Focus on Cumulative Radiation Exposure
November 16, 2010
November 9, 2010
12-Hour Nursing Shifts and Patient Safety
November 2, 2010
Insulin: Truly a High-Risk Medication
October 26, 2010
Confirming Medications During Anesthesia
October 19, 2010
Optimizing Medications in the Elderly
October 12, 2010
October 5, 2010
September 28, 2010
September 21, 2010
September 14, 2010
Wrong-Site Craniotomy: Lessons Learned
September 7, 2010
Patient Safety in Ob/Gyn Settings
August 31, 2010
August 24, 2010
The BP Oil Spill Analogies in Healthcare
August 17, 2010
Preoperative Consultation Time to Change
August 10, 2010
Its Not Always About The Evidence
August 3, 2010
Tip of the Week on Vacation
July 27, 2010
EMRs Still Have A Long Way To Go
July 20, 2010
More on the Weekend Effect/After-Hours Effect
July 13, 2010
Postoperative Opioid-Induced Respiratory Depression
July 6, 2010
Book Reviews: Pronovost and Gawande
June 29, 2010
Torsade de Pointes: Are Your Patients At Risk?
June 22, 2010
Disclosure and Apology: How to Do It
June 15, 2010
Dysphagia in the Stroke Patient: the Scottish Guideline
June 8, 2010
Surgical Safety Checklist for Cataract Surgery
June 1, 2010
May 25, 2010
May 18, 2010
Real-Time Random Safety Audits
May 11, 2010
May 4, 2010
More on the Impact of Interruptions
April 27, 2010
April 20, 2010
HITs Limited Impact on Quality To Date
April 13, 2010
April 6, 2010
March 30, 2010
Publicly Released RCAs: Everyone Learns from Them
March 23, 2010
ISMPs Guidelines for Standard Order Sets
March 16, 2010
A Patient Safety Scavenger Hunt
March 9, 2010
Communication of Urgent or Unexpected Radiology Findings
March 2, 2010
Alarm Sensitivity: Early Detection vs. Alarm Fatigue
February 23, 2010
Alarm Issues in the News Again
February 16, 2010
Spin/HypeKnowing It When You See It
February 9, 2010
More on Preventing Inpatient Suicides
February 2, 2010
January 26, 2010
Preventing Postoperative Delirium
January 19, 2010
January 12, 2010
Patient Photos in Patient Safety
January 5, 2010
December 29, 2009
Recognizing Deteriorating Patients
December 22, 2009
December 15, 2009
December 8, 2009
December 1, 2009
Patient Safety Doesnt End at Discharge
November 24, 2009
Another Rough Month for Healthcare IT
November 17, 2009
November 10, 2009
Conserving ResourcesBut Maintaining Patient Safety
November 3, 2009
Medication Safety: Frontline to the Rescue Again!
October 27, 2009
Co-Managing Patients: The Good, The Bad, and The Ugly
October 20, 2009
Radiology AgainBut This Time Its Really Radiology!
October 13, 2009
October 6, 2009
Oxygen Safety: More Lessons from the UK
September 29, 2009
Perioperative Peripheral Nerve Injuries
September 22, 2009
Psychotropic Drugs and Falls in the SNF
September 15, 2009
ETTOs: Efficiency-Thoroughness Trade-Offs
September 8, 2009
Barriers to Medication Reconciliation
September 1, 2009
The Real Root Causes of Medical Helicopter Crashes
August 25, 2009
Interruptions, Distractions, InattentionOops!
August 18, 2009
Obstructive Sleep Apnea in the Perioperative Period
August 11, 2009
August 4, 2009
July 28, 2009
Wandering, Elopements, and Missing Patients
July 21, 2009
Medication Errors in Long Term-Care
July 14, 2009
Is Your Do Not Use Abbreviations List Adequate?
July 7, 2009
Nudge: Small Changes, Big Impacts
June 30, 2009
iSoBAR: Australian Clinical Handoffs/Handovers
June 23, 2009
June 16, 2009
Disclosing Errors That Affect Multiple Patients
June 9, 2009
CDC Update to the Guideline for Prevention of CAUTI
June 2, 2009
Why Hospitals Should FlyJohn Nance Nails It!
May 26, 2009
Learning from Tragedies. Part II
May 19, 2009
May 12, 2009
May 5, 2009
Adverse Drug Events in the ICU
April 28, 2009
Ticket Home and Other Tools to Facilitate Discharge
April 21, 2009
April 14, 2009
More on Rehospitalization After Discharge
April 7, 2009
March 31, 2009
Screening Patients for Risk of Delirium
March 24, 2009
March 17, 2009
March 10, 2009
Prolonged Surgical Duration and Time Awareness
March 3, 2009
Overriding AlertsLike Surfin the Web
February 24, 2009
Discharge Planning: Finally Something That Works!
February 17, 2009
Reducing Risk of Overdose with Midazolam Injection
February 10, 2009
Sedation in the ICU: The Dexmedetomidine Study
February 3, 2009
NTSB Medical Helicopter Crash Reports: Missing the Big Picture
January 27, 2009
Oxygen Therapy: Everything You Wanted to Know and More!
January 20, 2009
The WHO Surgical Safety Checklist Delivers the Outcomes
January 13, 2009
January 6, 2009
December 30, 2008
Unintended Consequences: Is Medication Reconciliation Next?
December 23, 2008
December 16, 2008
Joint Commission Sentinel Event Alert on Hazards of Healthcare IT
December 9, 2008
December 2, 2008
Playing without the ballthe art of communication in healthcare
November 25, 2008
November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
November 11, 2008
November 4, 2008
October 28, 2008
More on Computerized Trigger Tools
October 21, 2008
October 14, 2008
October 7, 2008
Lessons from Falls....from Rehab Medicine
September 30, 2008
September 23, 2008
Checklists and Wrong Site Surgery
September 16, 2008
More on Radiology as a High Risk Area
September 9, 2008
Less is More.and Do You Really Need that Decimal?
September 2, 2008
August 26, 2008
August 19, 2008
August 12, 2008
Jerome Groopmans How Doctors Think
August 5, 2008
July 29, 2008
Heparin-Induced Thrombocytopenia
July 22, 2008
Lots New in the Anticoagulation Literature
July 15, 2008
July 8, 2008
July 1, 2008
WHOs New Surgical Safety Checklist
June 24, 2008
Urinary Catheter-Related UTIs: Bladder Bundles
June 17, 2008
Technology Workarounds Defeat Safety Intent
June 10, 2008
Monitoring the Postoperative COPD Patient
June 3, 2008
UK Advisory on Chest Tube Insertion
May27, 2008
If You Do RCAs or Design Healthcare ProcessesRead Gary Kleins Work
May20, 2008
CPOE Unintended Consequences Are Wrong Patient Errors More Common?
May13, 2008
Medication Reconciliation: Topical and Compounded Medications
May 6, 2008
Preoperative Screening for Obstructive Sleep Apnea
April 29, 2008
ASA Practice Advisory on Operating Room Fires
April 22, 2008
CMS Expanding List of No-Pay Hospital-Acquired Conditions
April 15, 2008
April 8, 2008
April 1, 2008
Pennsylvania PSAs FMEA on Telemetry Alarm Interventions
March 25, 2008
March 18, 2008
Is Desmopressin on Your List of Hi-Alert Medications?
March 11, 2008
March 4, 2008
Housestaff Awareness of Risks for Hazards of Hospitalization
February 26, 2008
Nightmares.The Hospital at Night
February 19, 2008
February 12, 2008
February 5, 2008
Reducing Errors in Obstetrical Care
January 29, 2008
Thoughts on the Recent Neonatal Nursery Fire
January 22, 2008
More on the Cost of Complications
January 15, 2008
Managing Dangerous Medications in the Elderly
January 8, 2008
Urinary Catheter-Associated Infections
January 1, 2008
December 25, 2007
December 18, 2007
December 11, 2007
CommunicationCommunicationCommunication
December 4, 2007
November 27,2007
November 20, 2007
New Evidence Questions Perioperative Beta Blocker Use
November 13, 2007
AHRQ's Free Patient Safety Tools DVD
November 6, 2007
October 30, 2007
Using IHIs Global Trigger Tool
October 23, 2007
Medication Reconciliation Tools
October 16, 2007
Radiology as a Site at High-Risk for Medication Errors
October 9, 2007
October 2, 2007
Taking Off From the Wrong Runway
September 25, 2007
Lessons from the National Football League
September 18, 2007
Wristbands: The Color-Coded Conundrum
September 11, 2007
Root Cause Analysis of Chemotherapy Overdose
September 4, 2007
August 28, 2007
Lessons Learned from Transportation Accidents
August 21, 2007
Costly Complications About To Become Costlier
August 14, 2007
More Medication-Related Issues in Ambulatory Surgery
August 7, 2007
Role of Maintenance in Incidents
July 31, 2007
Dangers of Neuromuscular Blocking Agents
July 24, 2007
Serious Incident Response Checklist
July 17, 2007
Falls in Patients on Coumadin or Other Anticoagulants
July 10, 2007
Catheter Connection Errors/Wrong Route Errors
July 3, 2007
June 26, 2007
Pneumonia in the Stroke Patient
June 19, 2007
Unintended Consequences of Technological Solutions
June 12, 2007
Medication-Related Issues in Ambulatory Surgery
June 5, 2007
Patient Safety in Ambulatory Surgery
May 29, 2007
Read Anything & Everything Written by Malcolm Gladwell!
May 22, 2007
May 15, 2007
Communication, Hearback and Other Lessons from Aviation
May 8, 2007
Doctor, when do I get this red rubber hose removed?
May 1, 2007
April 23, 2007
April 16, 2007
April 9, 2007
Make Your Surgical Timeouts More Useful
April 2, 2007
March 26, 2007
Alarms Should Point to the Problem
March 19, 2007
Put that machine back the way you found it!
March 12, 2007
March 5, 2007
February 26, 2007
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