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.
References:
AHRQ. Making Health Care Safer II. An Updated Critical Analysis of the Evidence for Patient Safety Practices. March 2013
http://www.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
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
http://annals.org/issue.aspx?journalid=90&issueid=926462
Print “April
2013 AHRQ Recommended Patient Safety Practices”
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.
References:
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
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2960815-0/fulltext
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
http://archinte.jamanetwork.com/article.aspx?articleid=1657757
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
http://www.annemergmed.com/article/S0196-0644%2812%2901743-X/abstract
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
http://www.jacr.org/article/S1546-1440%2812%2900741-7/abstract
UCSF. The UCSF Virtual Symposium on Radiation Safety and Computed Tomography. May 8-10, 2013
http://rorl.radiology.ucsf.edu/symposiumRegistration/Home
Print “April
2013 Radiation Risk of CT Scans: Debate Continues”
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.
References:
ISMP Canada. Intravenous Phenytoin: Rate of Administration is Critical. ISMP Canada Safety Bulletin 2013; 13(1): 1-4
http://www.ismp-canada.org/download/safetyBulletins/2013/ISMPCSB2013-01_Intravenous_Phenytoin.pdf
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
Print “April
2013 Safe Use of an Old Drug”
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”
References:
Budnick N. Portland hospital fire investigated; hand sanitizer link suspected in girl's injuries. The Oregonian February 18, 2013
http://www.oregonlive.com/health/index.ssf/2013/02/portland_hospital_fire_investi.html
State of Oregon. Office of the Fire Marshal. Fire and Life Safety Supplemental Investigation Report. February 5, 2013
http://media.oregonlive.com/health_impact/other/OHSU%20Feb%2002%20Report%20Final.pdf
Print “April
2013 Reminder: Hand Sanitizers Are Flammable”
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.
References:
Keller DM. Preoperative Chlorhexidine Wash Superior to Povidone-Iodine.
Medscape News. September 30, 2011
http://www.medscape.com/viewarticle/750716
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
http://www.nejm.org/doi/full/10.1056/NEJMoa1113849
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
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2961687-0/abstract
Print “April
2013 Chlorhexidine in the News”
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?”.
References:
McIntosh BA, Trettin KW. Beyond insulin pen sharing: hospital systems issues. Topics in Patient Safety 2013; 13(2): 2-3
http://www.patientsafety.gov/TIPS/Docs/TIPS_MarApr13.pdf
Print “April
2013 More Tips on Insulin Pen Safety”
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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