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What’s New in the Patient Safety World

April 2020




ECRI’s Top 10 Patient Safety Concerns for 2020



ECRI has published its annual “Top 10 Patient Safety Concerns” for 2020 (ECRI 2020). However, the download comes with a cover letter noting that the list was developed prior to the current coronavirus pandemic and that outbreak would clearly be one of the top patient safety concerns. Moreover, ECRI has established its COVID-19 (Coronavirus) Outbreak Preparedness Center that is loaded with very useful resources for everyone.


The Top 10 list for 2020:


  1. Missed and Delayed Diagnoses
  2. Maternal Health across the Continuum
  3. Early Recognition of Behavioral Health Needs
  4. Responding to and Learning from Device Problems
  5. Device Cleaning, Disinfection, and Sterilization
  6. Standardizing Safety across the System
  7. Patient Matching in the Electronic Health Record
  8. Antimicrobial Stewardship
  9. Overrides of Automated Dispensing Cabinets
  10. Fragmentation across Care Settings


Included in the document are links to resources for each of the 10 items. You’ll find those to be very helpful.


New to this year’s list is the focus on maternal health across the continuum. A year ago we did a column highlighting the frightening trend of increasing maternal mortality in the US (see our January 8, 2019 Patient Safety Tip of the Week “Maternal Mortality in the Spontlight”).


Another focus is early recognition of behavioral health needs. It states “Organizations can improve their recognition of and response to behavioral health needs by providing education, training and retraining, behavioral health assessment for patients, improving rapid response teams’ response times by conducting drills, and instituting a culture change that begins with the organization’s leadership.” It also focuses on the need to understand how to de-escalate situations dealing with aggressive, threatening, agitated, or violent behavior. Just last month we discussed how psychiatric and behavioral health problems have been recognized as a risk factor for preventable harm (see our March 2020 What's New in the Patient Safety World column “Risk Factor for Preventable Harm: Psychiatric Diagnosis”).


Item #4 Responding to and Learning from Device Problems reminds us that we often fail to learn valuable lessons following an event related to medical devices. It quotes the interesting statistic that patient harm from medical devices occurred in 84 of every 1,000 admissions in one hospital. It includes a downloadable poster for Device Incident Response that outlines the immediate action steps that should be undertaken when there is a device-related incident. Note that these elements have long been part of our own Serious Incident Response Checklist.


Item #9 Overrides of Automated Dispensing Cabinets is a problem we have highlighted in our January 1, 2019 Patient Safety Tip of the Week “More on Automated Dispensing Cabinet (ADC) Safety” and our multiple columns (listed below) related to a fatal incident involving a neuromuscular blocking agent (NMBA).



ECRI has done its usual great job of providing both emphasis on important patient safety issues and valuable resources to help you address them.



Our prior columns related to ADC’s (automated dispensing cabinets):

December 2007           1000-fold Heparin Overdoses Back in the News Again

August 23, 2016         ISMP Canada: Automation Bias and Automation Complacency

December 11, 2018     Another NMBA Accident

January 1, 2019           More on Automated Dispensing Cabinet (ADC) Safety

February 12, 2019       From Tragedy to Travesty of Justice

April 2019                   ISMP on Designing Effective Warnings

June 11, 2019              ISMP’s Grissinger on Overreliance on Technology






ECRI Institute. Top 10 Patient Safety Concerns 2020; ECRI Institute March 2020

(ECRI 2020)



ECRI Institute. COVID-19 (Coronavirus) Outbreak Preparedness Center. ECRI Institute March 2020






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Emergency Surgery in the Elderly: Easy with EASE



In our April 10, 2018 Patient Safety Tip of the Week “Prepping the Geriatric Patient for Surgery” we discussed many things to do before surgery on geriatric patients. Most of those presume you have some time prior to the surgery. But what about those elderly patients who need emergency surgery? They, too, can benefit from a comprehensive, integrative approach according to a new Canadian study.


Khadaroo et al. developed and implemented the Elder-Friendly Approaches to the Surgical Environment (EASE) model in an emergency surgical setting in Alberta, Canada. EASE study initiatives include: co-locating patients over the age of 65 years to a single unit; having an interdisciplinary care team that includes a Geriatrician; initiating confusion prevention strategies; getting patients moving earlier in their recovery; and optimizing nutrition. Also included (Khadaroo 2020) were use of a standardized order set (including intentional “comfort” rounds and delirium screening by nursing staff; proactive mobilization; early withdrawal of tubes, lines, urethral catheters, and drains; and elder-friendly appropriate medication use); promoting patient-orientated rehabilitation activities with the BE FIT (Bedside Reconditioning for Functional Improvements) program; and early discharge planning, which encouraged the team to identify the day of discharge at time of admission with the involvement of the care coordinator.


Results were recently reported (Khadaroo 2020). The study was conducted at 2 tertiary hospitals and included patients age 65 and older who underwent emergency general surgery. It was a nonrandomized before/after study that compared patients receiving the EASE protocol to those managed in usual ways. Just over 20% of patients met criteria for frailty. The most frequent diagnoses included cholecystitis (25.9%), intestinal obstruction (18.7%), hernia (14.5%), and appendicitis (12.0%).


In the pre-EASE and post-EASE comparison at the intervention site, a statistically significant 19% decrease occurred in a composite primary outcome of in-hospital major complication or death and a 19% decrease in all complications. There was also a statistically significant decrease in the mean Comprehensive Complication Index. They also noted a significant decrease in minor complications at the intervention site, compared with an increase at the control site. Notably, the incidence of delirium was reduced by half (25.5% to 12.9%) with EASE, whereas no significant change was found at the control site.


At the intervention site, the median length of stay decreased by 3 days, whereas there was no change at the control site. And the number of participants requiring an alternative level of care at discharge decreased by almost half at the intervention site, compared with no change at the control site. Death or readmission was unchanged at 30 days.


Note that transfers from other medical services, patients undergoing elective surgery or with trauma, and nursing home residents were excluded.


Most of you will recognize that EASE draws heavily on concepts from HELP, the Hospital Elder Life Program (Inouye 1999). We’ve discussed many of those concepts in prior columns (September 2011 “Modified HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery”, April 10, 2018 “Prepping the Geriatric Patient for Surgery, September 17, 2019 “American College of Surgeons Geriatric Surgery Verification Program”).


The Khadaroo study adds to our understanding of the usefulness of comprehensive approaches to management of older patients, particularly those with frailty.



Some of our prior columns on preoperative assessment and frailty:






EASE. Alberta’s Strategic Clinical Networks. Elder-friendly Approaches to the Surgical Environment (EASE).



Khadaroo RG, Warkentin LM, Wagg AS, et al. Clinical Effectiveness of the Elder-Friendly Approaches to the Surgical Environment Initiative in Emergency General Surgery. JAMA Surg 2020; Published online February 12, 2020



Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM. A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients. NEJM 1999; 340: 669-676





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More Gems from ISMP


ISMP has come out with its biweekly medication safety alerts and other valuable resources for many years. But 2 recent ISMP resources have been particularly valuable. ISMP’s Targeted Medication Safety Best Practices for Hospitals was published last month. Here are the best practices (the ISMP document has extensive details for each best practice):



Dispense vinCRIStine and other vinca alkaloids in a minibag of a compatible solution and not in a syringe.



a)     Use a weekly dosage regimen default for oral methotrexate in electronic systems when medication orders are entered.

b)     Require a hard stop verification of an appropriate oncologic indication for all daily oral methotrexate orders.

c)     Provide specific patient and/or family education for all oral methotrexate discharge orders.



a)     Weigh each patient as soon as possible on admission and during each appropriate outpatient or emergency department encounter. Avoid the use of a stated, estimated, or historical weight.

b)     Measure and document patient weights in metric units only.



Ensure that all oral liquid medications that are not commercially available in unit dose packaging are dispensed by the pharmacy in an oral syringe or an enteral syringe that meets the International Organization for Standardization (ISO) 80369 standard, such as ENFit.



Purchase oral liquid dosing devices (oral syringes/cups/droppers) that only display the metric scale.

In addition, if patients are taking an oral liquid medication after discharge, educate patients to request appropriate oral dosing devices to measure oral liquid volumes in milliliters (mL) only.



Eliminate glacial acetic acid from all areas of the hospital.

While still important as a Best Practice, compliance with recommendations for an archived Best Practice signal that focus can be directed toward new and other existing Best Practices with lower adoption rates. Archived Best Practices maintain their original Best Practice number but will be listed after the unarchived Best Practices.



Segregate, sequester, and differentiate all neuromuscular blocking agents (NMBs) from other medications, wherever they are stored in the organization.



a)     Administer medication infusions via a programmable infusion pump utilizing dose error-reduction systems.

b)     Maintain a 95% or greater compliance rate for the use of dose error-reduction systems.

c)     Monitor compliance with use of smart pump dose error-reduction systems on a monthly basis.

d)     If your organization allows for the administration of an IV bolus or a loading dose from a continuous medication infusion, use a smart pump that allows programming of the bolus (or loading dose) and continuous infusion rate with separate limits for each.



Ensure all appropriate antidotes, reversal agents, and rescue agents are readily available. Have standardized protocols and/or coupled order sets in place that permit the emergency administration of all appropriate antidotes, reversal agents, and rescue agents used in the facility. Have directions for use/administration readily available in all clinical areas where the antidotes, reversal agents, and rescue agents are used.



Eliminate all 1,000 mL bags of sterile water (labeled for “injection,” “irrigation,” or “inhalation”) from all areas outside of the pharmacy.



When compounding sterile preparations, perform an independent verification to ensure that the proper ingredients (medications and diluents) are added, including confirmation of the proper amount (volume) of each ingredient prior to its addition to the final container.



Eliminate the prescribing of fentaNYL patches for opioid-naïve patients and/or patients with acute pain.



Eliminate injectable promethazine from the formulary.



Seek out and use information about medication safety risks and errors that have occurred in other organizations outside of your facility and take action to prevent similar errors.



Verify and document a patient’s opioid status (naïve versus tolerant) and type of pain (acute versus chronic) before prescribing and dispensing extended-release and long-acting opioids.



a)     Limit the variety of medications that can be removed from an automated dispensing cabinet (ADC) using the override function.

b)     Require a medication order (e.g., electronic, written, telephone, verbal) prior to removing any medication from an ADC, including those removed using the override function.

c)     Monitor ADC overrides to verify appropriateness, transcription of orders, and documentation of administration.

d)     Periodically review for appropriateness the list of medications available using the override function.



Earlier this year, ISMP released its Top 10 Medication Errors and Hazards (ISMP 2020). Here is the list:

  1. Selecting the wrong medication after entering the first few letters of the drug name
  2. Daily instead of weekly oral methotrexate for non-oncologic conditions
  3. Errors and hazards due to look-alike labeling of manufacturers’ products
  4. Misheard drug orders/recommendations during verbal/telephone communication
  5. Unsafe “overrides” with automated dispensing cabinets
  6. Unsafe practices associated with adult IV push medications
  7. Wrong route (intraspinal injection) errors with tranexamic acid
  8. Unsafe labeling of prefilled syringes and infusions by 503b compounders
  9. Unsafe use of syringes for vinca alkaloids
  10. 1,000-fold overdoses with zinc


We’re pleased that we have covered virtually all these topics over the years, but ISMP has done a superb job of putting this all together in a concise, informative format. Download the documents from the ISMP site and make sure your hospital or other healthcare facility is following these best practices.






ISMP (Institute for Safe Medication Practices). Targeted Medication Safety Best Practices for Hospitals. ISMP 2020; February 21, 2020



ISMP (Institute for Safe Medication Practices). Start the New Year Off Right by Preventing These Top 10 Medication Errors and Hazards. ISMP 2020; January 16, 2020





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More on Inappropriate Medications in Parkinson’s



Most of our prior columns on medication errors in patients with Parkinson’s Disease (PD) have focused on the difficulties hospitals have meeting the necessary timing of medication doses for inpatients. But we’ve also noted that many patients with PD get prescribed medications that may worsen symptoms of PD or be otherwise contraindicated. Most often those are medications having significant anti-dopaminergic activity, such as butyrophenones and phenothiazines.


But patients with PD also have a high incidence of psychosis. Symptoms may include visual hallucinations, delusions, and systemized hallucinations that are often severe enough to merit treatment. Patients with PD also have a high incidence of dementia and depression, which may put them further at risk for psychosis.


In our November 27, 2018 Patient Safety Tip of the Week “Focus on Deprescribing” we noted a study (Mantri 2018) which looked at patterns of dementia treatment and frank prescribing errors in older adults with Parkinson Disease. 27.2% were given a prescription for at least 1 antidementia medication. Of those receiving an acetylcholinesterase inhibitor (ACHEI), 44.5% experienced at least 1 high-potency anticholinergic–ACHEI event. They did find variation in such prescribing by race/ethnicity, sex, and geography.


In our March 19, 2019 Patient Safety Tip of the Week “Updated Beers Criteria” we noted the American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults (AGS 2019) specifically commented on Parkinson’s Disease. After reviewing and discussing the evidence on antipsychotics to treat psychosis in patients with Parkinson disease, the panel decided to remove aripiprazole as preferred and add pimavanserin. Thus, the 2019 Beers Criteria recognize quetiapine, clozapine, and pimavanserin as exceptions to the general recommendation to avoid all antipsychotics in older adults with Parkinson disease. Note that the Beers Criteria also recommend avoiding the anticholinergic drugs benztropine and trihexyphenidyl for prevention or treatment of Parkinson’s, since more effective agents are available.


A new study of patients with PD and comorbid depression living in nursing homes (Chekani 2020) examined incidence of inappropriate atypical antipsychotics, namely asenapine, brexpiprazole, iloperidone, lurasidone, olanzapine, paliperidone, risperidone, or ziprasidone as specified in the 2015 AGS Beers criteria. Appropriate atypical antipsychotic included aripiprazole, clozapine, or quetiapine. (Note that they used the 2015 AGS Beers criteria rather than the updated 2019 criteria, which would have considered aripiprazole to be inappropriate. It also did not note the use of pimavanserin.) The incidence of atypical antipsychotic use was 17.50% among PD patients over a 2-year follow-up. The percentage of inappropriate use among atypical antipsychotic users was 36.32%. The likelihood of inappropriate antipsychotic use was higher for patients who had dementia or COPD. However, patients who were taking levodopa, dopamine agonists, Catechol-O-methyltransferase (COMT) inhibitors, Monoamine Oxidase (MAO) inhibitors type B, or amantadine were less likely to receive inappropriate antipsychotics.

There is a point we are trying to emphasize with all of this. Parkinson’s Disease, probably more so than any other condition, is frequently associated with features that call for medications that are often contraindicated because of other features. We find it hard to believe that anyone could conceivably remember all the ramifications without assistance. This is a situation desperately calling for a sophisticated clinical decision support system to help guide appropriate medication management whether the patient is an outpatient, inpatient, or LTC patient.



Our prior columns on problems related to Parkinson’s Disease patients as inpatients:







Mantri S, Fullard M, Gray SL, et al. Patterns of Dementia Treatment and Frank Prescribing Errors in Older Adults With Parkinson Disease. JAMA Neurol 2018; Published online October 1, 2018



2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Amer Geriatr Soc 2019; First published: 29 January 2019



Chekani F, Holmes HM, Johnson ML, Chen H, Sherer JT, Aparasu RR. Use of Atypical Antipsychotics in Long-Term Care Residents with Parkinson’s Disease and Comorbid Depression. Drug Healthc Patient Saf 2020; 12: 23-30






Print “April 2020 More on Inappropriate Medications in Parkinson’s



Print “April 2020 What's New in the Patient Safety World (full column)

Print “April 2020 ECRI’s Top 10 Patient Safety Concerns for 2020

Print “April 2020 Emergency Surgery in the Elderly: Easy with EASE

Print “April 2020 More Gems from ISMP

Print “April 2020 More on Inappropriate Medications in Parkinson’s



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