What’s New in the Patient Safety World


April 2008              More Neonatal Incubator Fires

More on Nosocomial UTI’s

More on 1000-Fold Heparin Overdoses




More Neonatal Incubator Fires



Our January 29, 2008  Patient Safety Tip of the Week “Thoughts on the Recent Neonatal Nursery Fire” discussed a fire in a neonatal nursery incubator in Minnesota and the ongoing investigation into the causes. We mentioned that we have always been somewhat surprised that fires in patient care areas other than surgical suites seem to be seldom reported. Well, last month within the space of two hours – in two separate hospitals in India – two infants died from incubator fires. So such occurrences may not be so rare. A short circuit was suspected in one of the cases but a full root cause analysis is not yet available. We still anxiously await the results of the investigation in the Minnesota case and these two cases to identify contributing factors and causes. In the interim, many of the components mentioned in our December 7, 2007 Patient Safety Tip of the Week on Surgical Fires should be emphasized, as well as all the excellent work done by ECRI on surgical fires.


And, again, given the risk of fires in incubators hospitals need to take a careful look at the clinical indications for use of concentrated oxygen and have evidence-based criteria not only for starting oxygen therapy but also for its continuation and discontinuation.


Update: See also our What’s New in the Patient Safety World column for March 2009 “Followup on the Minnesota Bassinet Fire”.



More on Nosocomial UTI’s



We discussed nosocomial urinary tract infections in our May 8, 2007 Tip of the Week “Doctor, when do I get this red rubber hose removed?” and our January 8, 2008 Patient Safety Tip of the Week “Urinary Catheter-Associated Infections”. In the latter, we focused on a paper by Sanjay Saint, M.D. and colleagues at the University of Michigan Preventing Hospital-Acquired Urinary Tract Infection in the United States: A National Study in the January issue of Clinical Infectious Diseases.


A related paper by Saint et al. discusses themes arising from their study. They found that even though preventing hospital-acquired UTI was a low priority for most hospitals, there was substantial recognition of the value of early removal of a urinary catheter for patients. Second, those hospitals that made UTI prevention a high priority also focused on noninfectious complications and had committed advocates, or “champions,” who facilitated prevention activities. Third, hospital-specific pilot studies were important in deciding whether or not to use devices such as antimicrobial-impregnated catheters. Finally, external forces, such as public reporting, influenced UTI surveillance and infection prevention activities.


Another article in that same journal (Raffaele 2008) found 30% of urinary catheters were clinically inappropriate. This article has a good discussion of the appropriate indications for urinary catheters and identifies some of the factors that were associated with inappropriate use.


Saint S, Kowalski CP, Forman J, Damschroder L, Hofer TP, Kaufman SR, Creswell JR, Krein SL. A Multicenter Qualitative Study on Preventing Hospital-Acquired Urinary Tract Infection in US Hospitals. Infect Control Hosp Epidemiol 2008;29:333–341 http://www.journals.uchicago.edu/doi/abs/10.1086/529589



Raffaele G, Bianco A, Aiello M, Pavia M. Appropriateness of Use of Indwelling Urinary Tract Catheters in Hospitalized Patients in Italy. Infect Control Hosp Epidemiol 2008;29:279–281 http://www.journals.uchicago.edu/doi/abs/10.1086/528814?prevSearch=%28raffaele%29+AND+%5Bjournal%3A+iche%5D






Update: See also Patient Safety Tip of the week for June 24, 2008 “Urinary Catheter-Related UTI’s: Bladder Bundles” and April 21, 2009 “Still Futzing with Foleys?” and our June 9, 2009 Patient Safety Tip of the Week “CDC Update to the Guideline for Prevention of CAUTI.







More on 1000-Fold Heparin Overdoses


Our December 2007 “What’s New in the Patient Safety World” column discussed the continued occurrence of 1000-fold heparin overdoses. This included discussion about the Cedars-Sinai incident involving, among others, the children of actor Dennis Quaid and the previous Indianapolis incident that resulted in death of 3 infants. We discussed many of the ISMP recommendations and listed multiple lessons learned.



Dennis Quaid did an interview on CBS’s “60 Minutes” recently to highlight this problematic issue. The 60 Minutes piece did a good job of keeping the issue of medical errors in front of the public and focused a great deal on the fact that the two different heparin solutions had come in vials that looked very much alike. The piece did not delve into many of the systems issues previously raised by ISMP or some of the system lessons learned we had in our December column. However, the Quaid family is apparently leading an effort to promote bar-coding initiatives more widely.



ISMP’s March 27, 2008 Newsletter has an excellent followup “There’s more to the 60 Minutes story on heparin errors”. It discusses the role that confirmation bias may have played in both the Cedars and Indianapolis incidents as well as in many other medical errors. And it really highlights the fact that human error will continue to occur so we need better systems in place to intercept those errors before harm comes to patients. They make a major case for implementation of systems such as bar-coding. Lastly, they discuss the importance of dissemination of lessons learned from incidents elsewhere and the issue of when to do recalls of products implicated in safety threats.





Update: See also our May 2008 What’s New in the Patient Safety World column  UK NPSA Alert on Heparin Flushes” and our July 15, 2008 Patient Safety Tip of the Week "Heparin Flushes.....Again!"


















Patient Safety Tip of the Week Archive


What’s New in the Patient Safety World Archive