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Patient Safety Tip
of the Week
December 15, 2020
Our
Perennial Pre-Holiday Warning: “Be Careful Out There!”
Since
this is our last column prior to the holidays, it’s
time for our annual warning: “Be careful out there!”. Be very wary about patient
safety vulnerabilities during the holidays. We don’t
have statistics to verify that medical errors and incidents are more frequent
around the holidays. But anecdotes abound. We have had two dear friends suffer
serious incidents while inpatients on Christmas Day. In each case there was lack
of attention to critical events during evolving clinical situations, likely due
to coverage issues or other distractions related to the holiday. In one case,
lack of consultant availability led to lack of appropriate intervention in a
patient with colonic pseudo-obstruction (Ogilvie’s syndrome) after an
orthopedic procedure. That patient developed sepsis and died. In the other
case, a several hour period of inattention to serum electrolytes led to rapid overcorrection
of hyponatremia and consequent osmotic demyelination syndrome.
Staffing
issues, coverage issues, and distractions are more common on holidays and are
potential factors contributing to incidents. And it’s
not just the day of the holiday that is important. Sometimes the time pressures
created by a holiday may be contributing factors to incidents on the following
day(s). In our December 11, 2018 Patient Safety Tip of the Week “Another NMBA Accident” we speculated about the impact of such time
pressures contributing to the patient being sent for a PET scan late in the day,
during which a fatal mistake took place.
There
has been at least one study that looked systematically at mortality related to
public holidays. Smith et al. (Smith
2014) found that adjusted public holiday
mortality in the all public holidays versus all other
days analysis was 48% higher at 7 days (OR 1.48) and 27% higher at 30 days
(OR 1.27). Interactions between the weekend variable and the public holiday
variable were not statistically significant. They concluded that patients
admitted as emergencies to medicine on public holidays had significantly higher
mortality at 7 and 30 days compared with patients admitted on other days
of the week.
We
have, of course, done multiple columns on the “weekend effect” and the impact of
time of day or “after hours” care (see columns listed below). And we’ve described a host of factors that are different in
hospitals on weekends, evenings and nights, and holidays compared to daytime.
But
one factor that hasn’t received very much attention is
the impact of distractions during those periods of vulnerability. To try to
focus on that factor among so many others, Kato and
colleagues (Kato 2020) recently took an innovative approach – they
looked at mortality for patients operated on by surgeons on the surgeons’ birthdays!
They looked at mortality in Medicare beneficiaries aged 65 to 99 years who
underwent one of 17 common emergency surgical procedures. Of almost a million
cases, 0.2% were performed by surgeons on the surgeons’ birthday.
The
overall unadjusted 30-day mortality on the operating surgeon’s birthday was
7.0% and that on other days was 5.6%. After adjustment for patient
characteristics and other potential confounders, patients who underwent surgery
on a surgeon’s birthday exhibited higher mortality compared with patients who
underwent surgery on other days (adjusted mortality rate, 6.9% v 5.6%; P=0.03).
They interpreted these findings as suggesting that surgeons might be distracted
by life events that are not directly related to work. They
note that, while that hypothesis is intuitive, it has been otherwise difficult
to assess, owing to lack of detailed information on events that are potentially
distracting to an individual surgeon.
The authors
go on to discuss several potential mechanisms that might explain these
findings. First, and foremost, are the time pressures that might be operative
on a surgeon’s birthday (eg. need to be at a scheduled
family event). But other distractions could be related to simple things like conversations
with other OR staff about birthdays or receiving text/phone messages with
birthday wishes. They speculate that perhaps surgeons are more likely to
delegate parts of the procedures to residents and fellows, and that perhaps
post-operative care decisions might be impacted (as an example, they speculate
a surgeon might be less likely to return to the hospital to see their patients
who show signs of deterioration if they are having dinner with family and
friends, compared with regular evenings).
We were originally going to title this column “OMG! Don’t Tell Me Your Stats. Tell Me Your Date of
Birth!” Is it more important to ask your surgeon about his/her birthday than his/her
surgical outcome statistics? And what about his/her anniversary or his/her
children’s birthdays? Or his/her tee time? Those questions are, of course,
absurd. But it does remind us that certain life events may make us more
vulnerable to distractions and subsequent errors. Perhaps we need to be more
careful in on-call scheduling to avoid being put in vulnerable positions on
such days. But, most of all, we need to recognize that certain occasions and
events increase the possibility we will be distracted and take special care on
those days to avoid those distractions.
The Kato
study makes a very important point that we are all more
vulnerable to distraction at certain times. But we don’t
want to take away from our focus on reminding everyone of the need for extra
vigilance and care during the holidays.
Happy
holidays to all! Stay safe and practice safely!
Some of our previous columns on the “weekend effect”:
·
February 26, 2008 “Nightmares….The
Hospital at Night”
·
December 15, 2009 “The Weekend Effect”
·
July 20, 2010 “More on the Weekend Effect/After-Hours Effect”
·
October 2008 “Hospital at Night Project”
·
September 2009 “After-Hours Surgery – Is There a Downside?”
·
December
21, 2010 “More
Bad News About Off-Hours Care”
· June 2011 “Another
Study on Dangers of Weekend Admissions”
· September 2011 “Add
COPD to Perilous Weekends”
· August 2012 “More
on the Weekend Effect”
· June 2013 “Oh
No! Not Fridays Too!”
· November 2013 “The
Weekend Effect: Not One Simple Answer”
· August 2014 “The
Weekend Effect in Pediatric Surgery”
· October 2014 “What
Time of Day Do You Want Your Surgery?”
· December 2014 “Another
Procedure to Avoid Late in the Day or on Weekends”
· January 2015 “Emergency
Surgery Also Very Costly”
· May 2015 “HAC’s
and the Weekend Effect”
· August 2015 “More
Stats on the Weekend Effect”
· September 2015 “Surgery
Previous Night Does Not Impact Attending Surgeon Next Day”
· February 23, 2016 “Weekend Effect Solutions?”
· June 2016 “Weekend Effect Challenged”
· October 4, 2016 “More on After-Hours Surgery”
· July 25, 2017
“Can We Influence the “Weekend Effect”?”
· August 15, 2017 “Delayed Emergency Surgery and Mortality Risk”
· September 2020 “Care Processes and the Weekend Effect”
· October 13, 2020 “Night-Time
Surgery”
Some of our previous columns on “after-hours” surgery:
·
September 2009 “After-Hours Surgery – Is There a Downside?”
· October 2014 “What
Time of Day Do You Want Your Surgery?”
· January 2015 “Emergency
Surgery Also Very Costly”
· September 2015 “Surgery
Previous Night Does Not Impact Attending Surgeon Next Day”
· October 4, 2016 “More on After-Hours Surgery”
· August 15, 2017 “Delayed Emergency Surgery and Mortality Risk”
· October 24, 2017 “Neurosurgery and Time of Day”
· December 2019 “Surgeon On-Call Shifts”
· October 13, 2020 “Night-Time
Surgery”
References:
Smith
S, Allan A, Greenlaw N, Finlay S, Isles C. Emergency medical
admissions, deaths at weekends and the public holiday effect. Cohort study. Emerg Med J 2014; 31: 30-34
https://emj.bmj.com/content/31/1/30
Kato
H, Jena AB, Tsugawa Yusuke T. Patient mortality after
surgery on the surgeon’s birthday: observational study BMJ 2020; 371: m4381
https://www.bmj.com/content/371/bmj.m4381
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