What’s New in the Patient Safety World

April 2013


·        AHRQ Recommended Patient Safety Practices

·        Radiation Risk of CT Scans: Debate Continues

·        Safe Use of an Old Drug

·        Reminder: Hand Sanitizers Are Flammable

·        Chlorhexidine in the News

·        More Tips on Insulin Pen Safety





AHRQ Recommended Patient Safety Practices



AHRQ (the Agency for Healthcare Research and Quality) has updated its list of strategies to improve patient safety that are supported by research and clinical evidence (AHRQ 2013).


Ten of the strategies identified are "strongly encouraged" for adoption based on the strength and quality of evidence:


1.      Preoperative checklists and anesthesia checklists to prevent operative and postoperative events.

2.      Bundles that include checklists to prevent central line-associated bloodstream infections.

3.      Interventions to reduce urinary catheter use, including catheter reminders, stop orders, or nurse-initiated removal protocols.

4.      Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic-suctioning endotracheal tubes to prevent ventilator-associated pneumonia.

5.      Hand hygiene.

6.      "Do Not Use" list for hazardous abbreviations.

7.      Multicomponent interventions to reduce pressure ulcers.

8.      Barrier precautions to prevent healthcare-associated infections.

9.      Use of real-time ultrasound for central line placement.

10.  Interventions to improve prophylaxis for venous thromboembolisms.

Twelve other strategies are "encouraged" for adoption based on a slightly lesser strength and quality of evidence: 


1.      Multicomponent interventions to reduce falls.

2.      Use of clinical pharmacists to reduce adverse drug events.

3.      Documentation of patient preferences for life-sustaining treatment.

4.      Use of informed consent to improve patients' understanding of the potential risks of procedures.

5.      Team training.

6.      Medication reconciliation

7.      Practices to reduce radiation exposure from fluoroscopy and computed tomography scans.

8.      Use of surgical outcome measurements and report cards, such as the American College of Surgeons National Surgical Quality Improvement Program.

9.      Rapid response systems

10.  Utilization of complementary methods for detecting adverse events/medical errors to monitor for patient safety problems.

11.  Computerized provider order entry.

12.  Use of simulation exercises in patient safety efforts.

Summaries of several of the recommended practices and the evidence behind them are available in a special supplement to the Annals of Internal Medicine. Others will appear in an upcoming issue of BMJ Quality and Safety.






AHRQ. Making Health Care Safer II. An Updated Critical Analysis of the Evidence for Patient Safety Practices. March 2013




Making Health Care Safer: A Critical Review of Evidence Supporting Strategies to Improve Patient Safety. Annals of Internal Medicine 2013; 5 March 2013; 158(5 Part 2): 365-440







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Radiation Risk of CT Scans: Debate Continues



On several occasions we have talked about the Image Gently or Image Wisely campaigns, the purpose of which is to minimize the unnecessary exposure of patients to radiation (see our February 2, 2010 Patient Safety Tips of the Week “The Hazards of Radiation” and November 23, 2010 “Focus on Cumulative Radiation Exposure” and our What’s New in the Patient Safety World columns for March 2010 “More on Radiation Safety” and June 2011 “Progress in Reducing Radiation from CT Scans”).


For many years scientists have warned of the risk of radiation-induced cancers that might develop after exposure to radiation doses involved in medical tests such as CT scans. Those risks have been largely theoretical and based upon cancer rates in Japan following the nuclear bomb explosions in World War II. One of the first studies to actually demonstrate such an increased risk attributable to CT scanning was just published last year (Pearce 2012). That study showed that use of CT scans in children to deliver cumulative doses of about 50 mGy might almost triple the risk of leukaemia and doses of about 60 mGy might triple the risk of brain cancer. But the cumulative absolute risks were actually relatively small. In the 10 years after the first scan for patients younger than 10 years, one excess case of leukaemia and one excess case of brain tumor per 10 000 head CT scans were estimated to occur. The authors concluded that, although clinical benefits should outweigh the small absolute risks, radiation doses from CT scans ought to be kept as low as possible and alternative procedures, which do not involve ionizing radiation, should be considered if appropriate.


But another study just published (Zondervan 2013) showed the risk of death from underlying morbidity is more than an order of magnitude greater than death from long-term radiation-induced cancer. They looked at the reasons for CT scans and the mortality rates of the underlying medical conditions. They found that young adults who have had 1 or more computed tomography (CT) scans earlier in life are at significantly greater risk of dying from underlying medical conditions than from radiation-induced cancer.


While we still have not seen a national system for tracking cumulative radiation doses, there appears to have been a slight reduction in the rate of growth of CT scanning in the past couple years. Whether that is due to the Image Gently or Image Wisely campaigns or due primarily to the economic slowdown remains unclear.


We don’t do a particularly good job of explaining the potential risks and benefits of CT scans to patients. A recent survey of patients undergoing CT scans showed that only 17% of patients said that the risks and benefits were explained and they were given the opportunity to participate in the decision with their physician about whether to order the scan (Caverly 2013). 62% felt that the decision to order the scan was mainly the physician’s. Only a small percentage were able to state what the risks of radiation were. Also, notably absent in the discussions before the exams were the potential risks that might be associated with incidental findings.


Audit and feedback may be helpful in reducing unnecessary CT scans. We’ve seen several emergency departments that significantly reduced the variation in CT ordering rates by individual physicians simply by providing the individual statistics at their monthly departmental meetings.


In our November 23, 2010 Patient Safety Tip of the Week “Focus on Cumulative Radiation Exposure” we noted that use of clinical decision support rules is a good way to minimize the number of unnecessary CT scans as well as reduce costs. We noted the multitude of such rules available for determining when to perform head CT scanning in patients with minor head injuries. Recently, a promising clinical decision support rule for deciding whether to perform abdominal CT scans in children presenting to the emergency department with blunt abdominal trauma was developed (Holmes 2013).


Conditional imaging strategies (see our August 2009 What’s New in the Patient Safety World column “Imaging for Acute Abdominal Pain”), such as performing ultrasound first in children with acute abdominal pain and only doing CT scans if the ultrasound does not provide a diagnosis, may help reduce unnecessary CT scans. However, a shortage of ultrasound techs has left many community and rural hospitals without ultrasound coverage at night. There remains great variation across hospitals in the rates of abdominal CT scans in children with abdominal pain. More and more we will see that appearing as a measurement parameter of quality and patient safety.


While the bulk of our efforts should really be directed at avoiding unnecessary scans it also makes sense to minimize the exposure to ionizing radiation when a scan is really necessary. One group used a multidisciplinary committee in a community hospital setting to reduce patient radiation dose, repeat rate, and variability in image quality (Siegelman 2013). The committee included radiologists, technologists, consultant medical physicists, and an administrator. This was really a proof-of-concept study that demonstrates it is possible to produce such improvements in quality and patient safety.


So the debate about the magnitude of the problem of unnecessary exposure to ionizing radiations continues. Nevertheless, continued efforts in that goal make sense. For those who are interested, Rebecca Smith-Bindman, MD of UCSF, an outspoken proponent of reducing unnecessary radiation exposure leads a host of authorities on radiation safety in a virtual symposium sponsored by UCSF on Radiation Safety and Computed Tomography that will be held on May 8-10, 2013.








Pearce MS, Salotti JA, Little MP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. The Lancet 2012; 380(9840): 499-505, 4 August 2012




Zondervan RL, Hahn PF, Sadow CA, et al. Body CT Scanning in Young Adults: Examination Indications, Patient Outcomes, and Risk of Radiation-induced Cancer. Radiology 2013; Published online February 5, 2013




Caverly TJ, Prochazka AV, Cook-Shimanek M. Weighing the Potential Harms of Computed Tomography: Patient Survey (Research Letter). JAMA Intern Med 2013; (): 1-2. published online first March 4, 2013




Holmes JF, Lillis K, Monroe D, et al. Identifying Children at Very Low Risk of Clinically Important Blunt Abdominal Injuries. Ann Emerg Med 2013; DOI: 10.1016/j.annemergmed.2012.11.009; Published online February 4, 2013




Siegelman JRQW, Gress DA. Radiology Stewardship and Quality Improvement: The Process and Costs of Implementing a CT Radiation Dose Optimization Committee in a Medium-Sized Community Hospital System.

Journal of the American College of Radiology 2013; published online March 13, 2013




UCSF. The UCSF Virtual Symposium on Radiation Safety and Computed Tomography. May 8-10, 2013







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Safe Use of an Old Drug



ISMP Canada has just published a safety bulletin reminding us of the dangers of IV “pushes” of phenytoin (ISMP Canada 2013). They describe an index case of an elderly patient developing ventricular standstill during IV push of phenytoin at a rate of 50 mg/min. They then reviewed their medication incident database over the previous 10 years and identified 93 incidents, 9 of which were associated with harm.


Those of us who are old enough to recall phenytoin being used as a second line antiarrhythmic agent have a healthy respect for phenytoin used intravenously. Admittedly, the type of patient receiving IV phenytoin for arrhythmias was probably more vulnerable to the cardiac side effects but we commonly saw hypotension and bradyarrhythmias during phenytoin “pushes”. It’s not used very often any more for antiarrhythmic purposes but we continue to see it used frequently in the hospital inpatient or emergency department setting for treating seizure disorders and attention to the rate at which it is administered is often suboptimal.


The ISMP Canada safety bulletin has several good recommendations regarding IV use of phenytoin:

·        Is the IV route necessary at all? Yes, it obviously may be necessary if you are treating status epilepticus. But the patient in the ISMP Canada index case was receiving it as a daily maintenance dose. The oral or enteral route for administration of phenytoin in non-life threatening situations is preferred. Note that we continue to see use of IV “loading” doses of phenytoin used in patients not meeting the definition of status epilepticus.

·        If the IV route is necessary, use an infusion pump (smart pump) rather than an IV “push”.

·        The patient should be in an area where monitoring during IV phenytoin administration is ongoing (eg. ICU).

·        The maximum rate of IV phenytoin administration should be 25 mg/min in the elderly or those with a history of cardiac problems. (Note that product labeling in Canada already had a warning about not exceeding an IV rate of 25 mg/min in the elderly or those with a history of cardiac problems, whereas product labeling in the US just has the standard warning not to exceed a rate of 50 mg/min.)

·        A warning statement about the cardiovascular risks should be displayed prominently.

·        Guidance should be used regarding the IV flush rate following use of IV phenytoin whether the phenytoin was administered via “push” or infusion pump.


They also had two other very important observations:

1.      The practice of “flushing” IV tubing with 0.9% sodium chloride solution (whether following a “push” or infusion) may actually affect the rate of phenytoin administration.

2.      They cite a human factors study on high alert medications that showed the highest rate of interruptions per task was for medications being given by IV push (Trbovich 2010).


Some of the “sure bets” we’d make with a hospital CEO:

1.      Your facility is probably using IV phenytoin in some situations where it should be given via other route.

2.      When given IV its rate probably often exceeds 25 mg/min and probably also exceeds 50 mg/min in many cases.


You can probably do a pretty quick mini-audit by searching for all the doses of IV phenytoin dispensed and administered to get a feel for whether it is being used for appropriate indications and whether other routes of administration might be more appropriate.


Phenytoin is still a very good drug but you need to have a healthy respect for it.







ISMP Canada. Intravenous Phenytoin: Rate of Administration is Critical. ISMP Canada Safety Bulletin 2013; 13(1): 1-4




Trbovich P, Prakash V, Stewart J, Trip K, Savage P. Interruptions during the delivery of high-risk medications. J Nurs Adm. 2010; 40(5): 211-218






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Reminder: Hand Sanitizers Are Flammable



In our January 29, 2008 Patient Safety Tip of the Week “Thoughts on the Recent Neonatal Nursery Fire” we noted that during our research on operating room fires we wondered aloud “why don’t we see more fires elsewhere in hospitals?”. Given that the 3 key elements of the fire “triangle” (oxygen, a heat source, and flammable fuel) are present in many parts of the hospital it is surprising we don’t see more fires elsewhere.


Recently there was a very unusual hospital fire injuring a young girl in Oregon (Budnick 2013). It was suspected that an alcohol-based hand sanitizer from a wall-mounted dispenser was the key fuel in this fire. The fire began on the shirt of an 11 y.o. girl, who suffered third degree burns over multiple parts of her body.


The report of the fire marshal who investigated the fire determined through discovery and analysis of circumstantial evidence and elimination of other ignition sources that static electricity had likely been the ignition source. The girl had apparently been scuffing her feet and rubbing her bed linens in attempt to create sparks on her sheets. The fuel source was determined to be an alcohol-based hand sanitizer, which the girl had apparently spread on her bedside table and shirt. The alcohol content of the hand sanitizer was 50-70%. In addition, there was olive oil on the girl’s shirt and hair. This apparently had been used to remove glue from EEG electrodes that had been used for monitoring. It was noted that some olive oil dripped on her shirt while it was combed through her hair and that the girl also wiped her hands on her shirt after touching her hair. The fire marshal tested the hypothesis regarding the oil and hand sanitizer on her shirt and the ignition source and confirmed burn patterns that matched those in the actual case. Notably, he determined that ignition source would not have been adequate to ignite just the olive oil without the presence of the hand sanitizer.


Those who are familiar with surgical fires know that the alcohol-based skin preps used in the OR are commonly identified as the fuel in surgical fires. But this is the first time we’ve heard of the hand sanitizers found in most hospital rooms as a potential fuel. But they certainly have the same types of volatile alcohols in high concentrations that we see in the surgical skin preps that have been associated with surgical fires. This fire did not even require an oxygen-rich environment. But static electricity is ubiquitous and the fumes from the alcohol-based hand sanitizer obviously were enough to generate this fire.


It’s not clear what role the olive oil actually played here. Perhaps the hand sanitizer was only being used because of the presence of the olive oil. However, in addition to making your nursing and other staff aware of this unusual case you probably want your EEG technicians to also be aware of it.



Our prior columns on surgical fires:


Patient Safety Tips of the Week:

·        December 4, 2007 “Surgical Fires

·        April 29, 2008 “ASA Practice Advisory on Operating Room Fires

·        December 13, 2011 “Surgical Fires Again

·        April 24, 2012 “Fire Hazard of Skin Preps Oxygen


What’s New in the Patient Safety World columns:

·        November 2009 “ECRI: Update to Surgical Fire Prevention

·        January 2011 “Surgical Fires Not Just in High-Risk Cases

·        March 2011 “APSF Fire Safety Video

·        November 2011 “FDA Initiative on Preventing Surgical Fires









Budnick N. Portland hospital fire investigated; hand sanitizer link suspected in girl's injuries. The Oregonian February 18, 2013




State of Oregon. Office of the Fire Marshal. Fire and Life Safety Supplemental Investigation Report. February 5, 2013






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Chlorhexidine in the News



In the column above (our April 2013 What’s New in the Patient Safety World column “Reminder: Hand Sanitizers Are Flammable”) we mentioned that many of the surgical skin preps used in the OR are potentially flammable. Chlorhexidine preps typically have high concentrations of alcohol and have often been implicated as the fuel in surgical fires. There are less flammable surgical skin preps (eg. povidone-iodine) and there are certain circumstances where povidone-iodine might be the preferred prep (see our April 24, 2012 “Fire Hazard of Skin Preps, Oxygen”). However, we are always balancing the risk of surgical fires vs. the risk of surgical site infections (SSI’s).


There had been some data suggesting that alcohol-based chlorhexidine preparations may be superior to povidone-iodine in preventing SSI’s (Keller 2011) and recently there have been multiple other studies touting the benefits of chlorhexidine in preventing infection.


A recent study performed in ICU’s or bone marrow transplant units (Climo 2013) showed that daily bathing with chlorhexidine-impregnated washcloths significantly reduced the risks of acquisition of multiple drug-resistant organisms (MDRO’s) and development of hospital-acquired bloodstream infections.


Similarly, in a multicenter randomized crossover trial in PICU’s critically ill children receiving daily CHG bathing had a lower incidence of bacteraemia compared with those receiving a standard bathing routine (Milstone 2013).


So the evidence seems to be accumulating that preps are very useful in preventing a variety of infections in the hospital. Where the risk of fires is low it probably makes sense to use chlorhexidine as the preferred skin prep.







Keller DM. Preoperative Chlorhexidine Wash Superior to Povidone-Iodine.

Medscape News. September 30, 2011


51st Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC): Abstract K-480. Presented September 18, 2011



Climo MW, Yokoe DS, Warren DK, et al. Effect of Daily Chlorhexidine Bathing on Hospital-Acquired Infection. N Engl J Med 2013; 368: 533-542




Milstone AM, Elward A, Song X, et al. Daily chlorhexidine bathing to reduce bacteraemia in critically ill children: a multicentre, cluster-randomised, crossover trial. The Lancet 2013; Early Online Publication, 28 January 2013






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More Tips on Insulin Pen Safety



Our February 26, 2013 Patient Safety Tip of the Week “Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?” highlighted the occurrence of insulin pens being used on multiple patients, potentially causing cross-contamination of patients with blood-borne pathogens. The focus of our column was as much on how organizations are made aware of unsafe practices discovered elsewhere as it was on the insulin pens themselves. We did provide some recommendations and referred readers to several articles by ISMP.


Both ISMP and the VA Health System have discouraged use of insulin pens (or multi-dose pen injectors for other drugs).


Since then the VA Health System has done a nice job summarizing many other issues that can arise when using insulin pens on inpatients (McIntosh 2013). This has some very practical examples of other system problems that may pertain to insulin pens and recommendations for hospitals continuing to use them on inpatient units.


For example, they note that several factors may result in improper dosing. The “tip and roll” method may result in incomplete mixing of the insulin suspension, resulting in inaccurate doses. Failure to “prime” the pen correctly may result in lower than intended doses. The pen’s dose display may be read upside down during administration, potentially leading to incorrect doses. Other technical factors that might lead to incorrect dosing are failure to leave the pen in place for the required time, unintentionally lifting the pen from the injection site due to difficulty pressing the pen button, or thinking the a full dose was not given because a wet spot (from priming) or not recognizing the plunger movement is gradual, leading to potentially re-dosing the patient.


They also discuss issues related to needle attachment and disposal and the risks of needle stick injuries to staff. They note several reasons why adding labeling to pen barrel is difficult and note that the lack of a tamper-evident cap might lead staff to think the pen had not been used and return it to pharmacy stock.


Read the McIntosh article. It has many good recommendations you’ll need to add to your educational and inservicing programs for nurses and pharmacists and practical recommendations for system changes you’ll need if you continue to stock insulin pens for inpatient use. And read the references in our February 26, 2013 Patient Safety Tip of the Week “Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?”.







McIntosh BA, Trettin KW. Beyond insulin pen sharing: hospital systems issues. Topics in Patient Safety 2013; 13(2): 2-3






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Print “April 2013 What's New in the Patient Safety World (full column)

Print “April 2013 AHRQ Recommended Patient Safety Practices

Print “April 2013 Radiation Risk of CT Scans: Debate Continues

Print “April 2013 Safe Use of an Old Drug

Print “April 2013 Reminder: Hand Sanitizers Are Flammable

Print “April 2013 Chlorhexidine in the News

Print “April 2013 More Tips on Insulin Pen Safety




Print “March 2013 What's New in the Patient Safety World (full column in PDF version)











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