What’s New in the Patient Safety World

August 2010

·        Sedation Costs for Pediatric MRI

·        Surgical Case Listing Accuracy

·        ISMP Advice on Catheter Misconnections

·        Suicide Risk By Method Of First Attempt

·        SCIP: Disappointing Outcomes on SSI’s. What’s Next?




Sedation Costs for Pediatric MRI


In our May 25, 2010 Patient Safety Tip of the Week “Propofol Issues” we noted that propofol has quietly become the procedural sedating agent of choice in many venues, particularly when dealing with pediatric patients. In fact, at the recent Pediatric Academic Societies meeting research was presented on over 25, 000 cases using propofol sedation in areas outside the OR by emergency physicians. That abstract (Mallory et al 2010) presented data from the Pediatric Sedation Research Consortium. The vast majority of these (22,068) were performed in radiology. We discussed some of the safety issues in that column.


Now a new study (Vanderby 2010) addresses the financial impact of sedation for MRI scanning in pediatrics. They analyzed the workflow, personnel, and costs involved in MRI scanning of children at Hospital for Sick Children in Toronto, Ontario. They found that the average time spent in the MRI suite was 2 hours and 21 minutes for children scanned awake, 3 hours 38 minutes for those sedated, and 4 hours 7 minutes for those anesthetized. Corresponding average costs (in Canadian dollars) were $54.68, $177.27, and $522.73 respectively.


The Toronto group used their analyis to significantly redesign workflow and scheduling. This article has a good discsussion about those workflow and personnel issues and has some good lessons learned that you may apply in your organization. To their recommendations we would add that strong consideration needs to be given to the appropriateness of the MRI scan, in light of the patient safety and cost issues involved.





Smith M. PAS: Propofol Widely Used to Sedate Children. MedPageToday.com. May 3, 2010




Mallory MD, Baxter AL, Yanosky DJ,  Cravero. JP. Use of Propofol for Sedation of Pediatric Patients by Emergency Physicians: A Report from the Pediatric Sedation Research Consortium (abstract). Pediatric Academic Societies meeting May 1, 2010




Vanderby SA, Babyn PS, Carter MW, et al. Effect of Anesthesia and Sedation on Pediatric MR Imaging Patient Flow. Radiology 2010; 256(1): 229-237






Print “August 2010 Sedation Costs for Pediatric MRI





Surgical Case Listing Accuracy



Wrong site/wrong patient surgery continues to occur despite use of universal protocol, surgical timeouts, and various surgical checklists like the WHO Surgical Safety Checklist.


One opportunity for errors to occur that could lead to wrong site/wrong patient surgery is when surgical cases are “booked”. A new paper (Cima 2010) looked at the frequency of errors in the surgical case listing at a large academic medical center and found such errors in 1.38% of cases. Fortunately, there were no cases of wrong site/wrong patient surgery in their organization because the errors were picked up by a variety of healthcare workers preoperatively or in the OR. But the sheer number of cases with errors in booking highlights the serious potential during his step to set the stage for a wrong site surgery to occur.


They found that missing laterality was the most common error (66%), followed by incorrect laterality (14%) and incorrect listing besides laterality (11%). Such listing errors were found across the gamut of surgical specialties.


The findngs prompted the organization to revise its procedures for surgical case listing. They implemented an electronic surgical listing system using standardized case descriptions that required input of the laterality. Implementation of that system in ob/gyn surgery reduced the frequency of errors from 1.50% to 0.54% and in colorectal surgery from 2.06% to 0.49%.


We recommend you do this sort of audit in your organization to see what your potential vulnerability is during the booking process. Equally importantly, look at how your other “defenses” would pick up such potential problems prior to surgery. Are 100% of your cases reviewed the day prior to surgery by healthcare workers trained to identify such errors? Any case not reviewed until the day of surgery is one step closer to being a sentinel event. Who do you allow to book cases? Do you require formal designation of laterality at the time of booking? How do you ensure that all cases with imaging findings have laterality reconciliation prior to surgery?






The Joint Commisssion. Universal Protocol. Updated 2010.




WHO Surgical Safety Cheklist




Cima RR, Hale C, Kollengode A, et al. Surgical Case Listing Accuracy: Failure Analysis at a High-Volume Academic Medical Center. Arch Surg. 2010; 145(7): 641-646





Print “August 2010 Surgical Case Listing Accuracy





ISMP Advice on Catheter Misconnections



ISMP (Institute for Safe Medication Practices) reported two more cases of catheter misconnections last month but noted progress in initiatives to get industry to adopt standards that would render certain catheter fittings incompatible with tubing sets intended for other purposes.


One case involved administration of cholestyramine into an IV catheter and the other administration of barium into a central venous line. The article lists many other published examples of catheter misconnections and a link to a page with all their previous articles dealing with catheter misconnections.






ISMP. Preventing catheter/tubing misconnections: Much needed help is on the way.

ISMP Medication Safety Alert (Acute Care Edition) 2010; 15(14): 1-2  July 15, 2010




ISMP. Collection of all their catheter misconnection articles.





Print “August 2010 ISMP Advice on Catheter Misconnections





Suicide Risk By Method Of First Attempt



Most studies show about a 10% risk of suicide in a patient who has previously attempted suicide and that the risk is highest in the year following the attempt. Therefore, most assessments of patients after a suicide attempt focus on identification of risk factors for current and future suicide. Such assessments focus on known risk factors like male sex, older age in women, presence of a psychiatric disorder, and level of suicidal intent (considering things like “was there a well-thought out plan?”).


Now a new study (Runeson 2010), using data from linked databases in Sweden, has captured long-term data on the risk of successful suicide after a prior attempted suicide. In this study, 12% of patients committed suicide after a prior attempted suicide during a followup period of 21-31 years.


The most important finding, however, was that the risk varied significantly by the method used during the first attempted suicide. Whereas poisoning (overdoses) and cutting are far and away the most common methods of attempted suicide, the highest relative risk for successful suicide was for those whose index attempt was by hanging, strangulation, or suffocation/drowning and 87% of these suicides occurred within one year of the initial attempt. The risks were also higher for those whose index attempt involved firearms or explosives, gassing, or jumping from heights. Most successful suicides also used the same method that had been tried in the index attempted suicide.


The presence of a psychotic or affective disorder were additional independent risk factors for suicide. So a patient with such a severe psychiatric disorder and a suicide attempt by a method such as hanging, drowning or firearms would be at particularly high risk.


The implications of this study are that method of attempted suicide should be included in the overall risk assessment and that those patients deemed to be at the highest risk merit close followup, especially during the first year. The editorial accompanying the study (Hawton 2010) points out that the study was unable to determine whether the method used in the index attempt may have simply reflected the degree of lethality or intent on the part of the patient. It also notes that while these statistics accurately describe a population, it is still difficult to apply them in individual cases. Would you followup a patient who had attempted suicide by overdose any less rigorously than one who attempted suicide by hanging? Probably not. But you can expect the key points of this study to probably be incorporated into some existing suicide risk assessment tools.






Runeson B, Tidemalm D, Dahlin M, et al. Method of attempted suicide as predictor of subsequent successful suicide: national long term cohort study.

BMJ  2010; 341: c3222




Hawton K. Completed suicide after attempted suicide. BMJ  2010; 341:c3064






Print “August 2010 Suicide Risk By Method Of First Attempt





SCIP: Disappointing Outcomes on SSI’s. What’s Next?



Most of us read with a certain degree of disappointment the recent publication (Stulberg 2010) of outcomes using the SCIP (Surgical Care Improvement Project) measures. Adherence reported on individual SCIP measures was not associated with a significantly lower probability of infection, though adherence to the global all-or-none composite infection prevention score was associated with a lower incidence of SSI’s (surgical site infections).


But some empirical observations have led to another possible approach for reducing SSI’s: selection of anesthesia type. A new population-based study (Chang 2010) showed that patients having total hip or total knee replacement surgery done under general anesthesia are 2.21 times more likely to develop an SSI within 30 days of surgery compared to those done under epidural or spinal anesthesia.


The authors propose several potential biological explanations for the findings, all of which should be considered hypotheses at this time. Because this was a retrospective analysis and not a randomized controlled trial, one cannot be sure that there was not patient selection bias or some confounding variable that led to these results. Nevertheless, this empirical observation is striking and should lead to a randomized controlled trial.


The accompanying editorial (Sessler 2010) notes that the magnitude of difference here is similar to that seen with timely use of prophylactic antibiotics. He points out that other promising interventions, such as potential use of supplemental oxygen, did not hold up when assessed under the scrutiny of randomized controlled trials.





Stulberg JJ, Delaney CP, Neuhauser DV, et al. Adherence to Surgical Care Improvement Project Measures and the Association With Postoperative Infections
JAMA 2010; 303: 2479-2485 June 23/30, 2010




Chang C-C, Lin H-C; Lin H-W, Lin H-C. Anesthetic Management and Surgical Site Infections in Total Hip or Knee Replacement: A Population-based Study. Anesthesiology 2010; 113(2): 279-284 August 2010




Sessler, DI. Neuraxial Anesthesia and Surgical Site Infection. Anesthesiology 2010; 113(2) :265-267  August 2010






Print “August 2010 SCIP: Disappointing Outcomes on SSI’s. What’s Next?






Print “August 2010 What's New in the Patient Safety World (full column)

Print “August 2010 Sedation Costs for Pediatric MRI

Print “August 2010 Surgical Case Listing Accuracy

Print “August 2010 ISMP Advice on Catheter Misconnections

Print “August 2010 Suicide Risk By Method Of First Attempt

Print “August 2010 SCIP: Disappointing Outcomes on SSI’s. What’s Next?














Patient Safety Tip of the Week Archive


What’s New in the Patient Safety World Archive