What’s New in the Patient Safety World
August 2017
·
Adverse Events in Hospitalized Neurological
Patients
·
Medication Errors Outside of Healthcare
Facilities
·
More on Pediatric Dosing Errors
·
ROI for a Second Victim Program
Adverse Events in
Hospitalized Neurological Patients
There has been a
relative paucity of studies on patient safety issues in neurological patients.
Neurological conditions that require hospitalization have a number of features
that predispose to a variety of potential adverse events. For example, many are
associated with neurogenic bladder dysfunction that may be a factor in high
rates of catheter-associated urinary tract infections (CAUTI’s). Many of the
conditions are associated with reduced mobility, increasing the risk for
pressure ulcers and DVT and venous thromboembolism. Some (eg.
stroke, Parkinson’s) may be associated with disordered sawallowing
that predisposes to aspiration and pneumonia. Impairment of balance and/or
righting reflexes may lead to falls. Those neurological conditions that impair
cognition may also predispose to delirium when other medical insults occur. And
several neurological conditions may be associated with obstructive sleep apnea,
which may increase the risk of respiratory depression in relation to opioids or
other drugs that depress respiration. So we would expect neurological
inpatients would have relatively high rates of adverse events while
hospitalized.
A new Canadian study
provides some perspective on adverse events in this population. Sauro and colleagues (Sauro 2017)
did a retrospective cohort study of
over 175,000 children and adults admitted to Alberta hospitals from 2009 to
2015 with 1 of 9 neurologic conditions (Alzheimer disease and related dementia,
brain tumor, epilepsy, motor neuron disease, multiple sclerosis,
parkinsonism/Parkinson disease, spinal cord injury, traumatic brain injury, and
stroke).
The mean age of the admitted
neurologic patients was 66.5 years and, as you’d expect, multiple comorbid
conditions were common. It’s not surprising that age and the presence of
comorbidities increased the odds of having an adverse event. The overall
proportion of admissions associated with an adverse events among those with a
neurologic condition was 11 per 100 admissions and, of those cases with adverse
events, 16.1% had more than one. The occurrence of
adverse events did vary by diagnosis, being highest for those patients with
spinal cord injuries (39.4 per 100 admissions). The most common adverse events
were infections and respiratory complications (32.0% and 16.7%, respectively). But
for those conditions where surgery was likely (eg.
brain tumor, spinal cord injury), surgery-related complications were more
common.
As in most studies
on adverse events, having an adverse event was associated with increased mortality
and increased length of hospital stay. Those experiencing an adverse event had
2.4 times the odds of mortality.
Length of stay was
35.4 days longer for those who had an adverse event compared to those who did
not. At first glance, we wondered whether that reported extremely large
increase in LOS was a typo because most studies on adverse events in
hospitalized patient reveal a more moderate increase in LOS related to adverse
events. But we must remember that the relationship between LOS and adverse
events is complicated. Not only do adverse events cause longer hospital stays,
but the chance of having an adverse event increases with each day of
hospitalization.
The most common
adverse events in this study were those related to infections and
respiratory-related adverse events, anesthesia-related adverse events,
CNS-related adverse events, and delirium accounted for a small proportion of adverse
events. The authors were somewhat surprised that falls did not rise to a higher
level in their ranking of adverse event rates, given that patients with many of
the neurological conditions studied are prone to falls. However, the authors
explain that this may be related to the difficulties in documenting falls by
using ICD-10 codes, which is how they identified most of the adverse events.
We’re also somewhat
surprised that adverse drug events were not more frequent in this population. They
found only 1.46% of the adverse events related to drugs, a proportion we would
have expected to be much higher in a population with this age and comorbidity
distribution.
Many of the adverse events seen in neurological inpatients
may be preventable. We’ve done numerous columns on CAUTI prevention, swallowing
assessment in stroke patients prior to initiating oral feeding, frequent
turning of immobile patients, fall prevention strategies, risk assessment for
obstructive sleep apnea, delirium prevention strategies, and VTE prophylaxis.
We’re glad to see this study by Sauro
and colleagues and hope this stimulates an interest by our neurological
colleagues to undertake more patient safety initiatives.
References:
Sauro KM, Quan
H, Sikdar KC, et al. Hospital safety among neurologic
patients. A population-based cohort study of adverse events. Neurology 2017; 89(3):
284-290
http://www.neurology.org/content/89/3/284.abstract?etoc
Print “August
2017 Adverse Events in Hospitalized Neurological Patients”
Medication Errors
Outside of Healthcare Facilities
Much of what we know about medication errors is derived from
inpatient studies and, to a lesser degree, long-term care studies. Medication
errors that occur in the home or other non-healthcare settings are less well
studied.
One method of identifying potential medication errors in
those latter facilities is analyzing data from our multiple poison control
centers. Such recent analysis of National Poison Database System (NPDS) data
from 2000 through 2012 showed a significant increase in errors that result in
serious medical outcomes (Hodges
2017). Those researchers found 67,603 exposures related to unintentional
therapeutic pharmaceutical errors that occurred outside of health care
facilities that resulted in serious medical outcomes (overall average rate 1.73
per 100,000 population). Most notably, there was a 100% rate increase over that
13-year study period. Increases were seen for all age groups except children
younger than 6 years of age.
Common types of medication errors included:
- incorrect dose
- wrong medication
- inadvertently
taking the medication twice.
The medication categories most frequently associated with
serious outcomes were:
- cardiovascular
drugs (20.6%)
- analgesics
(12.0%)
- hormones/hormone
antagonists (especially diabetes drugs like insulin and sulfonylurea)
(11.0%)
- sedative/hypnotics/antipsychotics
(9.6%)
- antidepressants
(8.6%)
The analgesic errors were dominated by three classes:
- opioids
(34%)
- acetaminophen
combination drugs (23.9%)
- acetaminophen
alone (20.5%)
Interestingly, serious medication errors were more frequent
among females in all age categories. Two-thirds of the errors involved solid
medications but 20% involved liquid medications, primarily in children.
Cough and cold medications were frequent offenders in
children under the age of 6 but a suspected reason for the lack of an increase
in overall errors in children under the age of 6 over the course of the study
was a reduction in the number due to cough and cold medications, attributable
to warnings from the FDA and numerous specialty societies.
And for children younger than 6 years, 10.9% of the errors
were classified as "ten-fold dosing error", a problem we’ve often
noted for pediatric patients (see list of columns on pediatric medication
errors below). But for children 6–12 years old, the percentage of medication
errors attributed to inadvertently taking/giving someone else’s medication was
nearly double that of any other age group. The authors speculate that some
children in this age group may be administering their own medication, and due
to their age, may be more likely to take another family member’s medication by
mistake.
Medical outcome was most commonly reported as moderate
effect (93.5%), followed by major effect (5.8%) and death (0.6%). A third of
exposures resulted in hospital admission. Not surprisingly, categories of
medications resulting in the highest proportion of admissions to a critical or
non-critical care unit were anticoagulants, analgesics, antineoplastics,
anticonvulsants, and cardiovascular medications.
The authors stress that most non-health care facility
medication errors are preventable, particularly those due to dosing errors,
taking or administering the wrong medication, and inadvertently taking or
administering the same medication twice. They also stress the growing body of
literature regarding use of proper dosing devices in children (see the list of
our prior columns below and another of this month’s What's
New in the Patient Safety World columns “More
on Pediatric Dosing Errors”).
But they also note that in young children the second most
common type of medication error was “health professional iatrogenic error”
(related to mistakes made by physicians, nurses, pharmacists, or other health
care professionals, and cases in which a contraindicated medication was given).
The authors offer many potential improvements that could
reduce the frequency of these medication errors, including:
- better product packaging,
labeling, and dosing instructions
- special consideration
given for patients with limited health literacy and numeracy
- prescription drug
monitoring (to identify contraindicated medications)
- physician and
patient/parent/caregiver education
- use of child-resistant
weekly pill organizers
- use of written records by
parents of young children to prevent another caregiver from
unintentionally administering the medication a second time
Some of our prior
columns on medication errors in other ambulatory settings:
June 12, 2007 “Medication-Related
Issues in Ambulatory Surgery”
August 14, 2007 “More
Medication-Related Issues in Ambulatory Surgery”
March 24, 2009 “Medication Errors in the OR”
October 16, 2007 “Radiology
as a Site at High-Risk for Medication Errors”
January 15, 2008 “Managing Dangerous Medications in the Elderly”
April 2010
“Medication
Incidents Related to Cancer Chemotherapy”
September 2010
“Beers
List and CPOE”
October 19, 2010 “Optimizing
Medications in the Elderly”
April 12, 2011 “Medication
Issues in the Ambulatory Setting”
June 2012 “Parents'
Math Ability Matters”
May 7, 2013 “Drug
Errors in the Home”
May 5, 2015 “Errors
with Oral Oncology Drugs”
September 15, 2015 “Another
Possible Good Use of a Checklist”
February 2016 “Avoiding
Methotrexate Errors”
April 19, 2016 “Independent
Double Checks and Oral Chemotherapy”
June 21, 2016 “Methotrexate
Errors in Australia”
Some of our other
columns on pediatric medication errors:
November 2007 “1000-fold
Overdoses by Transposing mg for micrograms”
December 2007 “1000-fold
Heparin Overdoses Back in the News Again”
September 9, 2008 “Less
is More and Do You Really Need that Decimal?”
July 2009 “NPSA
Review of Patient Safety for Children and Young People”
June 28, 2011 “Long-Acting
and Extended-Release Opioid Dangers”
September 13, 2011 “Do
You Use Fentanyl Transdermal Patches Safely?”
September 2011 “Dose
Rounding in Pediatrics”
April 17, 2012 “10x
Dose Errors in Pediatrics”
May 2012 “Another
Fentanyl Patch Warning from FDA”
June 2012 “Parents’
Math Ability Matters”
September 2012 “FDA
Warning on Codeine Use in Children Following Tonsillectomy”
May 7, 2013 “Drug
Errors in the Home”
May 2014 “Pediatric
Codeine Prescriptions in the ER”
November 2014 “Out-of-Hospital
Pediatric Medication Errors”
January 13, 2015 “More
on Numeracy”
April 2015 “Pediatric
Dosing Unit Recommendations”
September 2015 “Alert:
Use Only Medication Dosing Cups with mL Measurements”
November 2015 “FDA
Safety Communication on Tramadol in Children”
October 2016 “Another
Codeine Warning for Children”
January 31, 2017 “More
Issues in Pediatric Safety”
May 2017 “FDA
Finally Restricts Codeine in Kids; Tramadol, Too”
August 2017 “More
on Pediatric Dosing Errors”
References:
Hodges NL, Spiller HA, Casavant
MJ, et al. Non-health care facility medication errors resulting in serious
medical outcomes. Journal of Clinical Toxicology 2017; Published online: 10 Jul
2017
http://www.tandfonline.com/doi/full/10.1080/15563650.2017.1337908
Print “August
2017 Medication Errors Outside of Healthcare Facilities”
More on Pediatric
Dosing Errors
Medication errors in children, particularly for liquid
medications, have numerous contributing factors. Health literacy and “numeracy”
issues in the parents or caregivers administering the medications clearly
contribute. But there are also contributions related to the dosing instruments
used (eg. syringe vs. cup vs. teaspoon) and to the
way instructions are provided with the medications.
Several of our columns have focused on the sorts of dosing
errors made by parents or other caregivers for children (see the full list at
the end of today’s column). Proper dosing devices, labels, and parent/caregiver
education are critical in attempts to reduce such errors.
A recent randomized controlled trial attempted to determine
which components of such programs are most effective in reducing pediatric
dosing errors. Yin and colleagues (Yin
2017) randomly assigned English- and Spanish-speaking parents of children 8
years old or younger to 1 of 4 groups and given labels and dosing tools that
varied in label instruction format (text and pictogram, or text only) and units
(“mL" or "mL/tsp").
83.5% of parents made one or more dosing errors and 12.1% of
all errors involved overdosing. And 29.3% of parents made one or more “large”
errors (greater than double dose). The dosing tools provided did make a
difference. When the tool was more closely matched to the prescribed dose
volumes, there were fewer errors. For example, when a 2 mL dose was prescribed
there were fewer errors when a 5 mL syringe was used compared to a 10 mL syringe. And for a 7.5 mL prescribed dose there were fewer
errors with a 10 mL syringe than a 5 mL syringe (the 5 mL syringe would require
multiple fills, whereas the 10 mL syringe did not).
Using “mL” only also led to fewer errors than using
“mL/teaspoon”. More “large” errors were also made when parents received
“mL/teaspoon” instructions than just “mL”. Fewer “large” errors were also seen
when parents were given both text and pictogram instructions than text only
instructions.
The impact of these errors is unknown because this was a
simulation study (the parents were given several scenarios and asked to
demonstrate how they would provide the medication for the child). But it
clearly confirms that optimal use of dosing tools and instructions can have a
positive impact on reducing pediatric medication errors.
We’ve previously
described how parental health literacy, numeracy in particular,
can render children vulnerable to medication errors (see our What’s New in the Patient Safety World columns
for June 2012 “Parents'
Math Ability Matters” and November 2014 “Out-of-Hospital
Pediatric Medication Errors” and our January 13, 2015 Patient Safety Tip of
the Week “More
on Numeracy”).
Dosing errors related to the vehicles used for
administration of medications to
children have also been problematic. In our What's New in the Patient Safety
World columns for April 2015 “Pediatric
Dosing Unit Recommendations” and September 2015 “Alert:
Use Only Medication Dosing Cups with mL Measurements” we discussed use of
metric units for liquid medications administered to pediatric patients (AAP
2015). Use of measures such as
“teaspoon” and “tablespoon” should no longer be used. Moreover, the correct
abbreviation for milliliters is “mL” (rather than “ml”, “ML”, or “cc”).
Dispensing devices are also critical. Pharmacies, hospitals, and healthcare
centers should distribute appropriate-volume milliliter-based dosing devices
such as syringes. And the syringe (or other dosing device) should not be
significantly larger than the dose prescribed. And a national alert
recommended hospitals replace medication dosage cups that use units other than
mL (NAN 2015).
The 2015 AAP
statement also recommends that manufacturers avoid labeling, instructions or
dosing devices that contain units other than metric units. But poorly designed
labels and packaging continue to contribute to errors. A recent study in 3
urban pediatric clinics (Yin
2016) randomly assigned parents to 1 of 5 study arms and given labels and
dosing tools that varied in unit pairings. 84.4% of parents made 1 or more
dosing errors and 21.0% made 1 or more large error. More errors were seen with
cups than syringes, especially for smaller doses. Use of a teaspoon-only label
(with a milliliter and teaspoon tool) was associated with more errors than when
milliliter-only labels and tools were used. The authors recommend that use of oral
syringes over cups, particularly for smaller doses, should be part of a
comprehensive pediatric labeling and dosing strategy to reduce medication
errors.
Children are also more vulnerable to 10-fold dosing errors,
primarily because dose calculations often result in results with decimal
points. The decimal points can be overlooked, resulting in administration of a
dose that is 10 times (or 100 times if there are two digits following the
decimal point) higher than intended. In our September 2011 “Dose
Rounding in Pediatrics” we discussed under which circumstances it might be
appropriate to keep a decimal point and when the dose should simply be rounded
to eliminate the need for a decimal point.
More information on pediatric medication errors outside the
hospital can be found in our What's New
in the Patient Safety World columns for November 2014 “Out-of-Hospital
Pediatric Medication Errors” and August 2017 “Medication
Errors Outside of Healthcare Facilities” and our May 7, 2013 Patient Safety Tip of the Week “Drug
Errors in the Home”.
We’ve also discussed the problems often seen with opioids in children, particularly those
related to use of codeine (see columns listed below). These columns described the
original cases of death and serious adverse effects in children treated with
codeine following adenotonsillectomy for obstructive
sleep apnea. The problem originally noted for codeine was that there are
genetic variations that cause some people to be “ultra-rapid metabolizers” of
codeine, which leads to higher concentrations of morphine in the blood earlier.
But recommendations have now gone further than just avoiding codeine after adenotonsillectomy and it is now recommended that codeine
not be used for pain or cough in children. And children are often the victims
of accidental ingestion of discarded transdermal patches of fentanyl or other
dangerous medications.
Some of our other
columns on pediatric medication errors:
November 2007 “1000-fold
Overdoses by Transposing mg for micrograms”
December 2007 “1000-fold
Heparin Overdoses Back in the News Again”
September 9, 2008 “Less
is More and Do You Really Need that Decimal?”
July 2009 “NPSA
Review of Patient Safety for Children and Young People”
June 28, 2011 “Long-Acting
and Extended-Release Opioid Dangers”
September 13, 2011 “Do
You Use Fentanyl Transdermal Patches Safely?”
September 2011 “Dose
Rounding in Pediatrics”
April 17, 2012 “10x
Dose Errors in Pediatrics”
May 2012 “Another
Fentanyl Patch Warning from FDA”
June 2012 “Parents’
Math Ability Matters”
September 2012 “FDA
Warning on Codeine Use in Children Following Tonsillectomy”
May 7, 2013 “Drug
Errors in the Home”
May 2014 “Pediatric
Codeine Prescriptions in the ER”
November 2014 “Out-of-Hospital
Pediatric Medication Errors”
January 13, 2015 “More
on Numeracy”
April 2015 “Pediatric
Dosing Unit Recommendations”
September 2015 “Alert:
Use Only Medication Dosing Cups with mL Measurements”
November 2015 “FDA
Safety Communication on Tramadol in Children”
October 2016 “Another
Codeine Warning for Children”
January 31, 2017 “More
Issues in Pediatric Safety”
May 2017 “FDA
Finally Restricts Codeine in Kids; Tramadol, Too”
August 2017 “Medication
Errors Outside of Healthcare Facilities”
References:
Yin HS, Parker RM, Sanders LM, et al. Pictograms, Units and
Dosing Tools, and Parent Medication Errors: A Randomized Study. Pediatrics 2017;
Published Ahead of Print June 27, 2017
Print “August
2017 More on Pediatric Dosing Errors”
ROI for a Second
Victim Program
Our multiple columns on “the
second victim” (see list at the end of today’s column) discuss the evolution of
the approach to helping second victims. Back in the early 1990’s as we began
dealing with investigations on serious events we recognized that those
healthcare workers involved in serious events, either directly or indirectly,
often had difficulty coping in the aftermath of such events. But while
we recognized the issue of the second victim in those early days of patient
safety, we didn’t really know how to best help them. We often simply made
available to them professional assistance (employee assistance programs or
psychological counselling). Over the years, helping the “second victim” has
evolved considerably and such referral for professional help is not a good
first line strategy and may even be counterproductive. Support from peers is
extremely important if such programs are to be successful.
Some healthcare
organizations have been reluctant to help fund the resources needed to have
successful second victim programs. At Johns Hopkins, where Albert Wu
originally coined the term “second victim” to describe such individuals and
their plight (Wu
2000), its RISE (Resilience
In Stressful Events) program is an emotional
peer support structure to support “second victims” who were emotionally
impacted by a stressful patient-related event or unanticipated adverse event. A
multidisciplinary peer responder team who have volunteered to support second
victims responds when an unanticipated patient-related event occurs. Researchers
there recently did a cost benefit analysis of their program as it pertains to
nursing staff, modeling the cost of running the RISE program, nurse
turnover, and nurse time off (Moran
2017).
Their model predicted the RISE program has a net monetary
benefit savings of US $22,576.05 per nurse who initiated a RISE call. They
estimated that a hospital could save US $1.81 million each year because of the
RISE program. The annual cost of the RISE program per nurse was roughly $656
but the expected annual cost saved from nurse time off or nurse turnover was
$23,232, for the estimated net cost savings of $22,576. The authors conclude
that hospitals should be encouraged by these findings to implement
institution-wide support programs for staff, based on a high demand for this
type of service and the potential for cost savings.
As an aside, while the Moran study focuses preferentially on
nurses as second victims, don’t forget that any healthcare worker may be a second
victim. Another recent study (Han
2017) looked at surgeons involved in intraoperative adverse events (iAE’s). They surveyed surgeons at 3 major teaching
hospitals. They found the emotional
toll of iAE’s was significant, with 84% of
respondents reporting a combination of anxiety (66%), guilt (60%), sadness
(52%), shame/embarrassment (42%), and anger (29%). Colleagues constituted the
most helpful support system (42%) rather than friends or family; a few surgeons
needed psychological therapy/counseling.
We refer you to our
previous columns on the second victim for descriptions of good programs to help
address the issues impacting second victims. We don’t doubt that the sort of
ROI on such programs would apply to all healthcare workers, though the relative
dollar amounts as seen in the Moran study may vary by type of worker.
Some of our prior
columns on “the second victim”:
- December 17, 2013 “The
Second Victim”
- July 14, 2015 “NPSF’s
RCA2 Guidelines”
- June 2016 “Disclosure
and Apology: The CANDOR Toolkit”
- August 9, 2016 “More
on the Second Victim”
References:
Wu AW. Medical error: the second victim. The doctor
who makes the mistake needs help too.
BMJ 2000; 320: 726–727
Moran D, Wu AW, Connors C, et al. Cost-Benefit Analysis of a
Support Program for Nursing Staff. Journal of Patient Safety 2017; Post Author
Corrections: April 27, 2017
Han K, Bohnen JD, Peponis T, et al. The Surgeon as the Second Victim? Results
of the Boston Intraoperative Adverse Events Surgeons' Attitude (BISA) Study. J Amer Coll Surg
2017; 224(6): 1048-1056 Published online: January 14, 2017
http://www.journalacs.org/article/S1072-7515(17)30035-2/fulltext
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2017 ROI for a Second Victim Program”
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2017 What's New in the Patient Safety World (full
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2017 Adverse Events in Hospitalized Neurological Patients”
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2017 Medication Errors Outside of Healthcare Facilities”
Print “August
2017 More on Pediatric Dosing Errors”
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2017 ROI for a Second Victim Program”
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