What’s New in the Patient Safety World

December 2016



·         Standardize 4 Safety and Just Bag It!

·         Update on Ambulatory Antibiotic Stewardship

·         The Joint Commission NPSG for CAUTI’s

·         ECRI’s Top 10 Health Technology Hazards for 2017




Standardize 4 Safety and Just Bag It!



A couple nationwide medication safety campaigns have been in the news lately. Earlier this year ASHP (American Society of Health-System Pharmacists) was awarded a 3-year contract by the FDA to develop standardized concentrations for intravenous and oral liquid medications. ASHP has partnered with ISMP (Institute for Safe Medication Practices), AAMI (Association for the Advancement of Medical Instrumentation), and PPAG (Pediatric Pharmacy Advocacy Group) in this endeavor, the Standardize 4 Safety initiative. The coalition just announced one of its Phase 1 (of 3 Phases) outcomes: a list of recommended standardized concentrations for adult continuous IV infusions. The list includes the standardized concentration(s), dosing units, status of commercial availability, and comments for over 30 of the most commonly infused drugs in adults.


Other activities in Phase 1 will be development and implementation of concentrations and dosing units for compounded oral liquids for adults. Phase II addresses concentrations and dosing units for pediatric continuous IV infusions and standard doses for oral liquid medications. Phase III addresses intermittent IV medications, PCA (patient-controlled analgesia) pumps, epidurals, and standard doses for oral chemotherapy agents.


Another collaborative medication safety campaign, the Just Bag It Campaign, was just launched by the National Comprehensive Cancer Network (NCCN 2016). Vincristine is a chemotherapy agent intended for intravenous use. Yet since the 1960’s there have been numerous incidents where it has been administered intrathecally or via Omaya reservoirs. The results are disastrous, with patients developing quadriplegia, encephalopathy, and usually death. In 2013 ISMP summarized the literature (ISMP 2013) and noted that virtually all cases involved vincristine being prepared in a syringe and that there were no cases when vincristine was prepared in an IV bag. There are, of course, other contributing factors in such incidents. ISMP noted the following contributing factors: mislabeling of syringes; bringing IV and intrathecal medications into a treatment area together; failing to administer vinca alkaloids in a specialty oncology unit or with only experienced, oriented staff familiar with current operational and clinical standards, procedures, or protocols; administering chemotherapy outside of normal hours; not conducting an independent double check or “time out” before intrathecal medication administration; and incomplete or missing warning labels. But, given that all reported incidents occurred when vincristine was in a syringe, ISMP recommended that vincristine instead by diluted in a minibag for infusion and syringes be avoided.


Now the NCCN Just Bag It Campaign has been launched for the safe handling of vincristine, calling for health care professionals to always dilute vincristine in a 50ml mini-IV drip bag and never in a syringe. The campaign comes with Christopher’s Story, the sad story of a patient who died as the result of one of the above vincristine errors. All NCCN member institutions have already adopted this best practice for handling vincristine but the campaign calls on all other oncology providers to do the same.






ASHP (American Society of Health-System Pharmacists). Standardize 4 Safety website.




ASHP (American Society of Health-System Pharmacists). ASHP IV ADULT CONTINUOUS INFUSION GUIDELINES. October 2016




NCCN (National Comprehensive Cancer Network). Just Bag It: The NCCN Campaign for Safe Vincristine Handling. NCCN 2016; accessed November 14, 2016




ISMP (Institute for Safe Medication Practices). Death and neurological devastation from intrathecal vinca alkaloids: Prepared in syringes = 120; Prepared in minibags = 0. ISMP Medication Safety Alert! Acute Care Edition. September 5, 2013








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Update on Ambulatory Antibiotic Stewardship



In our November 2015 What's New in the Patient Safety World column “Medications Most Likely to Harm the Elderly Are…” we noted the paucity of evidence in the literature about antibiotic stewardship programs in ambulatory care or other outpatient settings. CDC had previously published on the core elements for hospitals (CDC 2014) and nursing homes (CDC 2015). Now CDC has published the “Core Elements of Outpatient Antibiotic Stewardship” (Sanchez 2016).


The Core Elements of Outpatient Antibiotic Stewardship are:

  1. Commitment: Demonstrate dedication to and accountability for optimizing antibiotic prescribing and patient safety.
  2. Action for policy and practice: Implement at least one policy or practice to improve antibiotic prescribing, assess whether it is working, and modify as needed.
  3. Tracking and reporting: Monitor antibiotic prescribing practices and offer regular feedback to clinicians, or have clinicians assess their own antibiotic prescribing practices themselves.
  4. Education and expertise: Provide educational resources to clinicians and patients on antibiotic prescribing, and ensure access to needed expertise on optimizing antibiotic prescribing.


Regarding commitment, CDC notes that declaring commitment to antibiotic stewardship in a public fashion (eg. posters in examination rooms) has been shown to reduce inappropriate prescription of antibiotics. In larger practices and healthcare organizations, designating a leader for antibiotic stewardship programs is recommended. CDC also recommends not only educating all staff on antibiotic stewardship but also making it part of their job descriptions and evaluation. CDC stresses that all members of the healthcare team have an important role in antibiotic stewardship.


Under Action for policy and practice they recommend adherence to the evidence-based practices recommended in specialty society guidelines. They note that use of delayed prescribing practices or watchful waiting, when appropriate, may be successful strategies. This requires good communication skills and consistent messages. Systems should provide clinical decision support tools for clinicians and have informational printouts available for patients and families. Various triage systems (eg. nurse call lines) should also reinforce principles of appropriate antibiotic prescribing and may help reduce unnecessary office/clinic/ER visits. They also recommend documentation in the medical record of rationale for decisions not to prescribe antibiotics.


Tracking and reporting consists of audit and feedback, which has been shown to reduce inappropriate antibiotic prescribing. Items to track should include whether antibiotics were appropriate, whether the correct antibiotic was prescribed, and whether the duration of therapy recommended was appropriate. Some systems or practices might choose a high priority condition, like acute bronchitis, to monitor. Others might look at percentage of overall visits at which antibiotics are prescribed. Feedback to individual prescribers can be compared to peers. Some systems may also track adverse drug events related to antibiotics.


Education applies both to prescribers and patients. Communication with patients or families should take into account health literacy issues. Continuing educational activities should be available for healthcare providers and timely access to persons with expertise (eg. pharmacists, infectious disease staff) should be made available.


See also our November 2015 What's New in the Patient Safety World column “Medications Most Likely to Harm the Elderly Are…” for other recommendations and links to some of the other studies on antibiotic stewardship in the outpatient setting.



Some of our prior columns on antibiotic stewardship:






CDC. Core elements of hospital antibiotic stewardship programs [Internet]. Atlanta, GA: US Department of Health and Human Services, CDC; 2014; last updated May 25, 2016




CDC. Core elements of antibiotic stewardship for nursing homes [Internet]. Atlanta, GA: US Department of Health and Human Services, CDC; 2015; last updated August 18, 2016




Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core Elements of Outpatient Antibiotic Stewardship. Recommendations and Reports. MMWR 2016; 65(6): 1-12







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The Joint Commission NPSG for CAUTI’s



The Joint Commission has revised for 2017 NPSG.07.06.01, its national patient safety goal for prevention of CAUTI’s (catheter-associated urinary tract infections).


The elements of performance for NPSG.07.06.01 are:

  1. Educate staff and licensed independent practitioners involved in the use of indwelling urinary catheters about CAUTI and the importance of infection prevention. Education occurs upon hire or granting of initial privileges and when involvement in indwelling catheter care is added to an individual’s job responsibilities. Ongoing education and competence assessment occur at intervals established by the organization.
  2. Educate patients who will have an indwelling catheter, and their families as needed, on CAUTI prevention and the symptoms of a urinary tract infection.
  3. Develop written criteria, using established evidence-based guidelines, for placement of an indwelling urinary catheter. Written criteria are revised as scientific evidence changes. (Examples are provided in the document and we’ve provided them in our many columns on CAUTI prevention listed below).
  4. Follow written procedures based on established evidence-based guidelines for inserting and maintaining an indwelling urinary catheter. The procedures address the following:

-          Limiting use and duration

-          Performing hand hygiene prior to catheter insertion or maintenance care

-          Using aseptic techniques for site preparation, equipment, and supplies

-          Securing catheters for unobstructed urine flow and drainage

-          Maintaining the sterility of the urine collection system

-          Replacing the urine collection system when required

-          Collecting urine samples
(The NPSG acknowledges that there are certain medical conditions, predominantly neurological ones, that require a prolonged use of an indwelling urinary catheter in order to avoid adverse events and promote patient safety.)

  1. Measure and monitor catheter-associated urinary tract infection prevention processes and outcomes in high-volume areas by doing the following:

-          Selecting measures using evidence-based guidelines or best practices

-          Having a consistent method for medical record documentation of indwelling urinary catheter use, insertion, and maintenance.

-          Monitoring compliance with evidence-based guidelines or best practices

-          Evaluating the effectiveness of prevention efforts
(The NPSG notes that surveillance may be targeted to areas with a high volume of patients using in-dwelling catheters, as identified through the hospital’s risk assessment.)


Of course, we are advocates of incorporating your evidence-based criteria into your CPOE system. That can help ensure appropriate use of catheters and may help you meet some of the documentation requirements. Innovative hospitals will also use barcoding to help create documentation for things like time of insertion, review for continuation, etc.


This NPSG and all the other 2017 National Patient Safety Goals are now available on The Joint Commission website (TJC 2016).




Our other columns on urinary catheter-associated UTI’s:








The Joint Commission. Hospital Accreditation Program. National Patient Safety Goals Effective January 2017. Accessed November 18, 2016







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ECRI’s Top 10 Health Technology Hazards for 2017



ECRI Institute has published its annual list of its Top 10 Health Technology Hazards for 2017 (ECRI 2016). The full report details the risks of each of the technologies and makes very useful recommendations on what your organization should be doing to minimize those risks. Their 2017 list:

  1. Infusion errors
  2. Inadequate cleaning of complex reusable instruments
  3. Missed ventilator alarms
  4. Undetected opioid-induced respiratory depression
  5. Infection risks with heater-cooler devices used in cardiothoracic surgery
  6. Software management gaps
  7. Occupational radiation hazards in hybrid ORs
  8. Automated dispensing cabinets setup and use errors
  9. Surgical stapler misuse and malfunction
  10. Device failures caused by cleaning products and practices


As is our usual practice we don’t go into detail about items on their list because we encourage you to go right to their excellent resources on these topics. We’re happy to see that under alarm management they have highlighted failures to communicate alarms effectively to staff, a topic we discussed in detail in our February 9, 2016 Patient Safety Tip of the Week “It was just a matter of time…”.


Go to the ECRI site to download the full report. It is a free download but you’ll need to register to receive it.







ECRI Institute. Top 10 Health Technology Hazards for 2017.






Print “December 2016 ECRI’s Top 10 Health Technology Hazards for 2017




Print “December 2016 What's New in the Patient Safety World (full column)

Print “December 2016 Standardize 4 Safety and Just Bag It!

Print “December 2016 Update on Ambulatory Antibiotic Stewardship

Print “December 2016 The Joint Commission NPSG for CAUTI’s

Print “December 2016 ECRI’s Top 10 Health Technology Hazards for 2017




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