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What’s New in the Patient Safety World

August 2019


·       Including Indications for Medications: We Are Failing

·       Tools for Reducing Sleep Meds in Hospitals

·       How Often Do Preventable Errors Occur?

·       More on the Cost of Rudeness




Including Indications for Medications: We Are Failing



In our December 18, 2018 Patient Safety Tip of the Week “Great Recommendations for e-Prescribing” and several other columns we’ve stressed the importance of including the indication for a medication when entering a prescription or order for a medication. Providing the indication for a prescription is important for more than one reason. First, there are many medications that are used for treating multiple conditions. For example, beta blockers may be used in the treatment of MI, CHF, migraine, essential tremor, hypertension, etc. Knowing the reason for the initial prescription, thus, is important when decisions about discontinuation are being pondered.


Second, seeing the indication may help a pharmacist recognize when a wrong drug has been prescribed. That is especially important when LASA (“look-alike, sound-alike”) errors are made. For example, if a prescriber erroneously clicked on “Dilaudid” instead of “Dilantin” but a pharmacist saw the indication was “for seizures”, the pharmacist would recognize a problem and contact the prescriber for clarification. The same concept should be used at the time of order entry to prevent prescribing the wrong medication. In the example above, if you looked for “seizures” as an indication under the erroneously chosen “Dilaudid” you’d realize you had chosen the wrong drug.


Third, seeing the indication can help avoid wrong-dosing errors. For example, we’ve discussed the methotrexate problem in multiple columns. That is when methotrexate is ordered for treating an autoimmune condition, like rheumatoid arthritis, rather than for oncologic conditions. For the former, once weekly dosing is used. So, if the pharmacist saw an order for daily methotrexate and the indication was “rheumatoid arthritis”, the pharmacist might recognize the dosing error.


Over 15 years ago, when we were doing introduction to patient safety for all incoming residents in the SUNY Buffalo system, we began including a slide stressing how inclusion of indication for a medication can help reduce medication errors. We’re, of course, not the only ones calling for this simple, yet frequently overlooked, patient safety intervention. ISMP (ISMP 2010) stressed this in its guidelines for standard order sets (see our March 23, 2010 Patient Safety Tip of the Week “ISMP Guidelines for Standard Order Sets”). And Schiff et al. made a plea to incorporate indication into medication ordering in a New England Journal of Medicine piece in 2016 (Schiff 2016). And it was one of the key elements in the article by Schiff et al. (Schiff 2018) that we highlighted in our December 18, 2018 Patient Safety Tip of the Week “Great Recommendations for e-Prescribing”.


So how are we doing in getting medication indication incorporated into medication orders or prescriptions? A recent study (Salazar 2019) says not so good. Salazar et al. extracted free-text sigs from all outpatient prescriptions generated by the computerized prescriber order entry system of a major academic institution during a 5-year period. They then used natural language processing to identify drug indications. In over 4 million prescriptions, they found indications were included in only 7.41%.


77.18% of those which included the indication were written for PRN orders. Somewhat surprisingly, the highest rate of including indication was by orthopedic surgery providers (33.41%), whereas the rate for internal medicine prescribers was only 6.26%. Pain was the most common indication, accounting for 30.35% of all documented indications. Non-PRN chronic medication prescriptions rarely included the indication.


So, we’re not doing so well. Since almost all prescribing and ordering medications today is via computer (through CPOE or ePrescribing systems), the solution needs to be a technological one. Those systems need to prompt all clinicians ordering medications for the indication. They should have drop-down lists of common reasons for ordering such medications but would also need an “other” category for entering free text if the indication is something other than the common ones presented. While you always like to avoid free text entries, you might not be able to predict what the entry might be. So, there need to be alerts for identifying mistakes in that latter circumstance. For example, in the scenario we mentioned above when the clinician mistakenly orders “Dilaudid” instead of “Dilantin”, the script for an alert would have to recognize “seizures” or “epilepsy” in the free text entered under “other”. Moreover, it would have to recognize typos, so it would have to employ natural language processing or similar tool to recognize those words. In addition, all the standing order sets in your system will need to be redone to include indications for any medications included.


So, you can see a lot of work needs to be done!


And while we are talking about requiring an indication for all medications, we’d also like to take the opportunity once again to make our plea for including a “reason for discontinuation” when drugs are discontinued. It may be important to know whether a medication was discontinued because of:

-        Ineffectiveness

-        Side effects (dose-related or non-dose-related)

-        Allergy (true allergy)

-        Adverse event

-        Cost considerations

-        Other

For example, I might consider prescribing a beta blocker for migraine prophylaxis and the patient tells me that he/she was once on that medication. It would be important for me to know whether it had been discontinued because it was ineffective for the initial indication (other than migraine prophylaxis) or because of an untoward side effect or true allergy.


See also our August 6, 2019 Patient Safety Tip of the Week “Repeat Adverse Drug Events”.






ISMP (Institute for Safe Medication Practices). Guidelines for Standard Order Sets. January 12, 2010



Schiff GD, Seoane-Vazquez E, Wright A. Incorporating indications into medication ordering—time to enter the age of reason. N Engl J Med 2016; 375(4): 306-309



Schiff G, Mirica MM, Dhavle AA, Galanter WL, et al. A Prescription For Enhancing Electronic Prescribing Safety. Health Affairs 2018; 37(11): 1877-1883



Salazar A, Karmiy SJ, Forsythe KJ, et al. How often do prescribers include indications in drug orders? Analysis of 4 million outpatient prescriptions. American Journal of Health-System Pharmacy 2019; 76(13): 970-979





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Tools for Reducing Sleep Meds in Hospitals



We’ve done several columns discussing the problems inpatients encounter in achieving near-normal sleep patterns and ways for you to avoid use of sleep medications (see, for example, our Patient Safety Tips of the Week for August 6, 2013 “Let Me Sleep!”, May 15, 2018 “Helping Inpatients Sleep”, and November 6, 2018 “More on Promoting Sleep in Inpatients”).


There have been two recent good resources to help you avoid these in your inpatients.


Soong and colleagues published an implementation guide to promote sleep and reduce sedative-hypnotic initiation for noncritically ill inpatients (Soong 2019). They conducted a review summarizing effective interventions aimed at promoting sleep and reducing inappropriate sedative-hypnotic initiation. They then proposed an implementation strategy to guide quality improvement teams.


Many studies had described implementation of sleep hygiene protocols to reduce sedative-hypnotic use. Such have addressed modifiable factors associated with sleep disruption, reinforced premorbid healthy sleep habits and circadian rhythms, and promoted relaxation without pharmacologic means (examples: reduction of noise and light, modifying clinical monitoring and medication administration schedules where appropriate to maximize uninterrupted sleep time, and assisting patients with bedtime routines and relaxation techniques).


A second common approach involved structured medication reviews conducted by pharmacists. Soong et al. note studies showing successful reduction of sedative/hypnotic drugs when these programs are employed in acute care or long-term care settings.


Simple audit and feedback has been successful in reducing ordering of sleep meds in several studies. Computer-based interventions, like alerts and reminders have also been successful in a few studies. These work best not only when combined with educational information but also when they include suggestions for alternative non-pharmacologic interventions to promote natural sleep.


They did also include educational interventions, including counter-detailing, but results have been mixed. While we don’t discourage such educational endeavors, we recognize that education is one of the weakest interventions we do for almost any patient safety problem.


The authors go on to suggest several strategies to guide quality improvement initiatives to actively de-adopt sedative-hypnotic use for sleep use among inpatients.


Strategy 1: Create a Sleep-Promoting Inpatient Environment

A multidisciplinary team needs to help create such an environment using concepts like designated overnight periods of reduced noise, lighting, and interruptions for unnecessary clinical monitoring or nonessential medication administration. See our November 6, 2018 Patient Safety Tip of the Week “More on Promoting Sleep in Inpatients” for multiple examples of such programs.


Strategy 2: Interventions Targeting Prescribers

These include pharmacist-enabled medication reviews to flag new prescriptions, computer-based interventions, performance data feedback, and education. They also stress the role that nurses and nurse practitioners may have in promoting non-pharmacologic interventions.


Strategy 3: Rigorous Evaluation of Interventions

Like any good quality improvement program, these programs need to employ measurement to ensure that the goals of the programs are being met. These should include evaluation of not only sedative/hypnotic use but also clinical and patient-reported outcomes such as falls, delirium, and sleep quality.


The second recent contribution was publication of results of a sedative reduction bundle implemented among medical and cardiology inpatients (Fan-Lun 2019). They had analyzed data at their institution and found that over 15% of hospitalized older adults were prescribed sedative-hypnotics inappropriately. Of those prescriptions, 87% occurred at night to treat insomnia and almost 20% came from standard admission order sets. So, they implemented a multi-modal “bundle” to address the problem.


The bundle consisted of education, removal of benzodiazepines and sedative hypnotics from available admission order sets, and use of non-pharmacological strategies to improve sleep. From the mean baseline benzodiazepine and sedative/hypnotic prescription rate of 15.8%, the postintervention period saw an absolute reduction of 8.0%. Adjusted for temporal trends, the intervention produced a 5.3% absolute reduction in the proportion of patients newly prescribed benzodiazepines and sedative hypnotics. Prescription rates on the control ward remained stable. There was no change in the patient-reported measure of sleep quality, falls, and use of other sedating medications throughout the study duration.



Some of our previous columns on safety issues associated with sleep meds and promoting sleep in inpatients:


August 2009               “Bold Experiment: Hospitals Saying No to Sleep Meds

March 23, 2010           “ISMP Guidelines for Standard Order Sets

May 2012                    “Safety of Hypnotic Drugs

November 2012          “More on Safety of Sleep Meds

March 2013                 “Sedative/Hypnotics and Falls

June 2013                    “Zolpidem and Emergency Room Visits

August 6, 2013           “Let Me Sleep!

June 3, 2014                 “More on the Risk of Sedative/Hypnotics

May 15, 2018              “Helping Inpatients Sleep

June 2018                    “Deprescribing Benzodiazepine Receptor Agonists

November 6, 2018      “More on Promoting Sleep in Inpatients

June 2019                    “FDA Boxed Warning on Sleep Meds






Soong C, Burry L, Cho HJ, et al. An Implementation Guide to Promote Sleep and Reduce Sedative-Hypnotic Initiation for Noncritically Ill Inpatients. JAMA Intern Med 2019; 179(7): 965-972 Published online June 03, 2019

(Soong 2019)



Fan-Lun C, Chung C, Lee EHG, et al. Reducing unnecessary sedative-hypnotic use among hospitalised older adults. BMJ Quality & Safety 2019; Published Online First: 03 July 2019





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How Often Do Preventable Errors Occur?



The 1999 Institute of Medicine (IOM) report “To Err is Human: Building a Safer Health System” has widely been recognized as opening the eyes of the public and the medical profession about the enormity of the issue of medical errors. It estimated that up to 98,000 patients might die each year as the result of their medical care rather than from their underlying medical conditions. While some criticized the study as overestimating the numbers or noted many of the patients may have died anyway, most of us who have been hospital medical directors or been involved in quality improvement and patient safety felt the numbers were likely underestimates.


Since then there have been numerous studies looking at the frequency of medical errors, but most have focused on total errors rather than those errors that are truly preventable.


A new systematic review and meta-analysis in the BMJ concludes that around one in 20 patients are exposed to preventable harm in medical care (Panagioti 2019). Moreover, 12% of such cases result in permanent disability or death.


The authors reviewed 70 studies, with over 300,000 patients, that reported on preventable harm. The pooled prevalence for preventable patient harm was 6%. And the pooled prevalence of overall harm (preventable and non-preventable) was 12%. A pooled proportion of 12% of preventable patient harm was severe or led to death. The highest percentage of incidents with preventable harm were related to drugs (25%) and other treatments (24%), followed by surgical procedures (23%), healthcare infections (16%,), and diagnosis (16%).


Since the authors found preventable patient harm occurs in 6% of patients across medical care settings and the pooled prevalence of overall harm was 12%, the authors conclude that half of patient harm is preventable.


Compared with general hospitals (where most evidence originated), preventable patient harm was more prevalent in advanced specialties (intensive care or surgery). The highest pooled prevalence estimate of preventable patient harm was reported in intensive care (18%) and surgery (10%) and the lowest in obstetrics (2%).


In addition to the human costs, the authors note that preventable harm results in about $9.3 billion in extra health care costs in the United States. That comes from a study by Zhan et al. (Zhan 2003) which studied excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. From their data, they extrapolated to infer that the 18 types of medical injuries studied may add to a total of 2.4 million extra days of hospitalization, $9.3 billion excess charges, and 32,591 attributable deaths in the United States annually.


Two accompanying editorials (Abbasi 2019, Papanicolas 2019) discuss the heterogeneity of definitions of preventable harm across studies and call for better measures of preventable harm.


In an upcoming column we will discuss the recent analysis by the Betsy Lehman Center for Patient Safety in Massachusetts of the financial costs of medical errors and the behavioral, physical, emotional, and financial harms to those who suffered the errors (Betsy Lehman Center 2019). Overall, they identified almost 62,000 preventable harm events that resulted in over $617 million in excess health care insurance claims. That accounts for about 1% of the total Massachusetts expenditures on healthcare in 2017.


Landrigan et al (Landrigan 2010) found lethal adverse events due to medical errors in 0.6% of hospital admissions in North Carolina hospitals, 63.1% of which were deemed to be preventable.


Other studies put the estimates for patient harm resulting from healthcare at much higher rates. In our May 2011 What’s New in the Patient Safety World column “Just How Frequent Are Hospital Medical Errors?” we noted a study (Classen 2011), using IHI’s Global Trigger Tool to identify hospital adverse events, that found that the numbers may be 10-fold higher than what was noted in the IOM report. Potentially avoidable adverse events occurred in a third of hospital admissions. Another study by Levinson (Levinson 2012) found that hospital incident reporting systems do not capture most patient harm.


James (James 2013) utilized the Global Trigger Tool (GTT) methodology to identify cases of potentially preventable medical errors. Using a weighted average of 4 studies utilizing the GTT, he estimated that the lower limit of deaths per year associated with preventable harms in hospitals is 210,000 deaths per year. And, given the limitations of the GTT and fact that these studies did not include deaths related to diagnostic errors which may not show up for years, he further estimated that the number of deaths associated with preventable harm may be more than 400,000 per year. He also noted that the frequency of serious harm may be 10- to 20-fold higher than that for lethal harm.


Makary and Daniel (Makary 2016) declared medical errors as the third leading cause of death in the US but pointed out the great difficulties in accurately measuring this problem.


How dangerous is a day in the hospital? For many years, we have used the numbers from a study done by Lori Andrews et al. (Andrews 1997) that found you have a 6% chance per inpatient day of having an adverse event that could impact your health. And, of course, a 2010 report (Levinson 2010) showed that one in every seven Medicare patients who is hospitalized experienced adverse events during their hospital stays, up to 44% being potentially preventable. A study (Hauck 2011) quantified the risk even further. Using a large database from public hospitals in Australia, the authors calculated that the average hospital stay carries a 5.5% risk of adverse drug reaction, 17.6% risk of infection, and 3.1% risk of pressure ulcers. Moreover, each additional night in the hospital increases the risk by 0.5% for adverse drug reactions, 1.6% for infections, and 0.5% for pressure ulcers.



So, got all those numbers? You’ll forget them shortly. You’ve often heard us use the phrase “Stories, Not Statistics” (see our December 2009 What’s New in the Patient Safety World column “Stories, Not Statistics”). When we first began doing presentations on patient safety in the early 1990’s we often began with some of the statistics on medical error from Lucien Leape’s work. But we began to notice physicians and medical students begin to zone out when we talked about statistics on medical error. What got their attention were the anecdotes we would tell about cases that really happened. So, we changed our focus. While we still often show statistics on medical error to put things in context, we no longer highlight them. Instead, we really rely on the stories. That’s what makes people say “I wonder if that could happen here?” and what makes them go back to look at the systems in their health care systems. It is those stories that hit home hard and make people remember. Who cannot remember their own reactions when they first heard the Josie King story, or the story about the nurse who administered Bicillin intravascularly, or the little boy who died from concentrated epinephrine injection during a simple surgical procedure, or any nurse who inadvertently administered concentrated potassium solutions?


In fact, the lack of compelling stories like these is the prime reason we feel IOM’s “To Err is Human: Building a Safer Health System” failed to gain traction despite considerable initial media attention. Everyone focused on the statistics from that report. It lacked the stories about real people you need to tell in order to get people and systems to change.


The new Panagioti study will undoubtedly suffer the same fate. Yes, it does reinforce the magnitude of the problem. But telling stories about real people experiencing such problems is what will get your healthcare colleagues to perk up and take notice that many of those problems could happen in their hospital or their practice.




See some of our prior columns on the frequency of harmful medical errors:


May 2011                    “Just How Frequent Are Hospital Medical Errors?

February 2012             “OIG: Hospitals Fail to Recognize Most Cases of Harm

March 2012                 “How Dangerous is a Day in the Hospital?

October 2013              “How Many Deaths Result from Medical Errors?







Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press, 1999



Panagioti M, Khan K, Keers RN, et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ 2019; 36: l4185



Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA 2003; 290: 1868-1874



Abbasi K. First do no harm: the impossible oath.  BMJ 2019; 366: l4734



Papanicolas I, Figueroa JF. Preventable harm: getting the measure right. BMJ 2019; 366 : l4611



Betsy Lehman Center for Patient Safety. The Financial and Human Cost of Medical Error... and how Massachusetts can lead the way on patient safety. Betsy Lehman Center 2019; June 2019



Landrigan CP, Parry GJ, Bones CB, et al. Temporal Trends in Rates of Patient Harm Resulting from Medical Care. N Engl J Med 2010; 363: 2124-2134



Classen D, Resar R, Griffin F, et al. ‘Global Trigger Tool’ Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured. Health Affairs 2011; 30(4): 581-589



Levinson DR. OIG (Office of the Inspector General. Department of Health and Human Services). Hospital Incident Reporting Systems Do Not Capture Most Patient Harm. January 2012



James JT. A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. Journal of Patient Safety 2013; 9(3): 122–128,_Evidence_based_Estimate_of_Patient_Harms.2.aspx



Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ 2016; 353: i2139



Andrews LB, Stocking C, Krizek T, et al. An alternative strategy for studying adverse events in medical care. Lancet 1997; 349: 309–313



Levinson DR. Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2010. Report No. OEI-06-09-00090



Hauck K, Zhao X. How Dangerous is a Day in Hospital?: A Model of Adverse Events and Length of Stay for Medical Inpatients. Medical Care 2011; 49(12): 1068-1075, December 2011






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More on the Cost of Rudeness



Our July 2012 What’s New in the Patient Safety World column “A Culture of Disrespect” summarized what Lucian Leape considers to be the number one problem in patient safety today: we have a culture of disrespect. Leape noted that the problem is not just that of the obvious disruptive physician who yells at people, throws things, etc. Rather, there are much more subtle behaviors that are equally disrespectful, and all are threats to teamwork and patient safety.


Then, in our September 22, 2015 Patient Safety Tip of the Week “The Cost of Being Rude”, we highlighted a study by Riskin et al. (Riskin 2015).that demonstrated the negative impact of rudeness on diagnostic and procedural performance in a very clever randomized controlled trial in a simulated environment.


Once again, Riskin et al. (Riskin 2019) conducted a study of primarily nurses in a general hospital which explored the impact of rudeness on patient safety performance, “state depletion” (that is, exhaustion of mental energy for reflective behavior), and team processes (for example, information sharing). A total of 231 rudeness incidents were reported in 98 shifts (out of 480 shifts analyzed). Most rudeness incidents stemmed from a patient or family. After a rudeness exposure, compliance with hand hygiene was significantly lower (for up to 24 hours following the exposure). Rudeness also led to decreased information sharing and increased team member’s state depletion. The adverse indirect effect of shifts’ temporal proximity to rudeness on poor compliance with medication preparation and team members’ information sharing via state depletion was significant. Rudeness exposure was also associated with increased rate of adverse events in the subsequent 24 hours, although this association was not statistically significant.


Another recent study in a simulated operating room scenario demonstrated that incivility had a negative impact on performance (Katz 2019). Katz et al. randomly assigned anesthesiology residents to either a normal or ‘rude’ environment and subjected them to a validated simulated operating room crisis. The “rude” environment included an impatient surgeon-actor in a simulated OR hemorrhage scenario. They measured both technical and non-technical performance domains including vigilance, diagnosis, communication and patient management. Those exposed to incivility scored lower on every performance metric, including a binary measurement of overall performance with 91.2% (control) versus 63.6% (rude) obtaining a passing score (p=0.009). It was particularly stroking that multiple areas were impacted including vigilance, diagnosis, communication and patient management even though participants were not aware of these effects (self-reported performance assessment was similar between groups).


They note that incivility doesn’t have to mean ranting and raving behavior. It can involve much more subtle behaviors, such as failure to use someone’s name (instead, calling them out by their function). You’ll recall from our July 2012 What’s New in the Patient Safety World column “A Culture of Disrespect” that Lucian Leape had also stressed the more subtle ways that disrespect is conveyed. Indeed, a new study (Torres 2019) shows that “microaggressions” in medicine and surgery can create stresses that are worse than those caused by overt behaviors. Microaggressions are subtle forms of prejudice and discrimination. The authors categorize them as microassaults, microinsults, microinvalidations, and environmental microaggressions. Examples include slights, humiliation, snubs, dismissals, general disrespect, devaluation, and exclusion. Microaggressions are often directed at minorities and women. The authors go on to describe ways to recognize microaggressions and how to respond to them.


And yet recent another study (Cooper 2019) found that patients whose surgeons had higher numbers of coworker reports about unprofessional behavior in the 36 months before the patient’s operation appeared to be at increased risk of surgical and medical complications. The researchers were able to use data from medical centers that participated in the National Surgical Quality Improvement Program (NSQIP) and recorded and acted on electronic reports of safety events from coworkers describing unprofessional behavior by surgeons. The adjusted complication rate was 14.3% higher for patients whose surgeons had 1 to 3 reports and 11.9% higher for patients whose surgeons had 4 or more reports compared with patients whose surgeons had no coworker reports. Despite the higher complication rate for surgeons with more reports, there was no difference between groups for mortality, need for second operations, or readmission within 30 days.


In the accompanying editorial Emerel et al. (Emerel 2019) use the analogy to the #MeToo movement to make the point we can no longer tolerate workplace hostility. Hospitals can no longer “look the other way” and let unprofessional behavior go unaddressed. Medicine and surgery, in particular, is a “team sport” and any negative interactions within the team can lead not only to poor team function, turnover, and burnout, but also to poor patient outcomes.



Some of our prior columns on the impact of “bad behavior” of healthcare workers:


January 2011               “No Improvement in Patient Safety: Why Not?

March 29, 2011           “The Silent Treatment: A Dose of Reality

July 2012                    “A Culture of Disrespect

July 2013                    “"Bad Apples" Back In?

July 7, 2015                “Medical Staff Risk Issues

September 22, 2015    “The Cost of Being Rude

April 2017                   “Relation of Complaints about Physicians to Outcomes

October 2, 2018          “Speaking Up About Disruptive Behavior



Some of our prior columns related to the “culture of safety”:


April 2009                   “New Patient Safety Culture Assessments

June 2, 2009                “Why Hospitals Should Fly...John Nance Nails It!

January 2011               “No Improvement in Patient Safety: Why Not?

March 2011                 “Michigan ICU Collaborative Wins Big”).

March 29, 2011           “The Silent Treatment: A Dose of Reality

May 24, 2011              “Hand Hygiene Resources

March 2012                 “Human Factors and Operating Room Safety

July 2012                    “A Culture of Disrespect

July 2013                    “"Bad Apples" Back In?

July 22, 2014              “More on Operating Room Briefings and Debriefings

October 7, 2014          “Our Take on Patient Safety Walk Rounds

July 7, 2015                “Medical Staff Risk Issues

September 22, 2015    “The Cost of Being Rude

May 2016                    “ECRI Institute’s Top Ten Patient Safety Concerns for 2016

June 28, 2016             “Culture of Safety and Catheter-Associated Infections

April 2017                   “Relation of Complaints about Physicians to Outcomes

April 2017                   “Joint Commission Sentinel Event Alert on Safety Culture

October 2, 2018          “Speaking Up About Disruptive Behavior







Riskin A, Erez A, Foulk TA, et al. The Impact of Rudeness on Medical Team Performance: A Randomized Trial. Pediatrics 2015; 136: 487-495



Riskin A, Bamberger P, Erez A, et al. Incivility and Patient Safety: A Longitudinal Study of Rudeness, Protocol Compliance, and Adverse Events. Joint Commission Journal on Quality and Patient Safety 2019; 45(5): 358-367



Katz D, Blasius K, Isaak R, et al. Exposure to incivility hinders clinical performance in a simulated operative crisis. BMJ Quality & Safety Published Online First: 31 May 2019



Torres MB, Salles A, Cochran A. Recognizing and Reacting to Microaggressions in Medicine and Surgery. JAMA Surg. Published online July 10, 2019



Cooper WO, Spain DA, Guillamondegui O, et al. Association of Coworker Reports About Unprofessional Behavior by Surgeons With Surgical Complications in Their Patients. JAMA Surg 2019; Published online June 19, 2019



Emerel LV, Kent T, Chu D. Time for Changes in the Surgical Community—Promoting Professionalism as #MeToo 2.0. JAMA Surg. Published online June 19, 2019





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Print “August 2019 Including Indications for Medications: We Are Failing

Print “August 2019 Tools for Reducing Sleep Meds in Hospitals

Print “August 2019 How Often Do Preventable Errors Occur?

Print “August 2019 More on the Cost of Rudeness




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