Print “PDF version”

What’s New in the Patient Safety World

December 2021

·       Beta-Blockers Making a Comeback?

·       Maternal Morbidity Costly in Human and Fiscal Terms

·       Can AI Triage Postoperative Patients More Appropriately?

·       Midline Catheters vs PICC’s




Beta-Blockers Making a Comeback?



Perioperative use of beta-blockers engendered lots of controversy for several years. In our May 2013 What’s New in the Patient Safety World column “Beta Blocker Debate Just Won’t Go Away” we joked that one pro-beta-blocker article always engenders another anti-beta-blocker article and vice versa!


Most of you recall the history of the debate. After several years in which we pushed for almost universal use of beta-blockers perioperatively, publication of the POISE trial (Devereaux 2008) significantly changed things. The POISE trial showed that, though preoperative beta-blockers prevented 15 MI’s for every 1000 patients treated, there was an increased risk of stroke and an excess of 8 deaths per 1000 patients treated. Largely since that time recommendations have been to continue beta-blockers in the perioperative period in patients previously taking them but most no longer begin them perioperatively in patients not previously taking them.


Reserachers in 2020 reported on a cohort study that used data from the prospectively collected Swedish National Quality Registry for hip fractures to identify all patients over 40 years of age subjected to surgery for hip fractures between 2013 and 2017 in one Swedish county (Mohammad Ismail 2020). The found that beta-blocker therapy was associated with a significant reduction in 90-day postoperative mortality after hip fracture surgery.


The researchers expanded on this work with a restrospective cohort study of over 130,000 Swedish patients who underwent hip fracture surgery from 2008 to 2017 (Mohammad Ismail 2021). Patients who filled a prescription within the year before and after surgery were defined as having ongoing beta-blocker therapy. Because this was not a randomized trial, the researchers adjusted the data using the inverse probability of treatment weighting (IPTW). Beta-blocker therapy was associated with a 42% reduction the risk of mortality within the first postoperative year.after adjusting for age, sex, comorbidities, ASA physical status, fracture, and surgery type.


A previous report on that population by these authors (Ahl 2021) showed that beta-blocker therapy resulted in a 72% relative risk reduction in 30-day all-cause mortality and was independently associated with a reduction in deaths of cardiovascular, respiratory, and cerebrovascular origin and deaths due to sepsis or multiorgan failure. The current report (Mohammad Ismail 2021) showed that, after excluding patients who died within the first 30 days postoperatively, beta-blocker therapy was associated with a 27% reduction in the risk of mortality.


The authors conclude that the evidence presented emphasizes the importance of maintaining beta-blocker therapy in hip fracture patients but that beta-blocker therapy remains significantly underused for a large proportion of surgical patients. However, they are quick to point out that, with the evidence currently available, it is not possible to recommend initiating beta-blocker therapy in beta-blocker naive patients. They strongly recommend investigating this possibility using an interventional study design.


We, of course, agree that the results of this sort of retrospective observational study should simply be considered as hypothesis-generating. But the results are suggestive enough that it would seem a randomized controlled trial in this population would be worthwhile. Seems the perioperative beta-blocker debate is never-ending!



Our prior columns on perioperative use of beta blockers:


November 20, 2007    “New Evidence Questions Perioperative Beta Blocker Use”

November 4, 2008      “Beta Blockers Take More Hits”

December 2009           “Updated Perioperative Beta Blocker Guidelines”

November 2010          “More Perioperative Beta Blocker Controversy”

November 2012          “Beta Blockers Losing Their Luster?”

May 2013                     “Beta Blocker Debate Just Won’t Go Away”

September 2013           “More Perioperative Beta-Blocker Controversy”

November 2013          “Another Assault on Perioperative Beta-Blockers”






Devereaux PJ, Yang H, Yusuf S, et al for the POISE Study Group. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet 2008; 371(9627): 1839-1847



Mohammad Ismail A, Borg T, Sjolin G, et al. β-adrenergic blockade is associated with a reduced risk of 90-day mortality after surgery for hip fractures. Trauma Surg Acute Care Open 2020; 5: e000533.



Mohammad Ismail A, Ahl R, Forssten MP, et al. Beta-Blocker Therapy Is Associated With Increased 1-Year Survival After Hip Fracture Surgery: A Retrospective Cohort Study. Anesthesia & Analgesia 2021; 133(5): 1225-1234




Ahl R, Mohammad Ismail A, Borg T, et al. A nationwide observational cohort study of the relationship between beta-blockade and survival after hip fracture surgery. Eur J Trauma Emerg Surg 2021; Published online January 28, 2021. doi:10.1007/s00068-020-01588-7






Print “December 2021 Beta-Blockers Making a Comeback?”






Maternal Morbidity Costly in Human and Fiscal Terms



We often give talks on what is wrong with the US healthcare system and highlight areas in which our healthcare system has outcomes that are far worse than those in other OECD countries. One such area is maternal mortality and morbidity. In fact, the US maternal mortality ratio of 20 maternal deaths per 100,000 live births is worst among developed countries (Hoyert 2020). We discussed this in detail in our Patient Safety Tips of the Week for January 8, 2019 “Maternal Mortality in the Spotlight” and December 8, 2020 “Maternal Mortality: Looking in All the Wrong Places?”. The latter column focused not only on maternal mortality but also discussed many maternal morbidities.


A new study from the Commonweatlh Fund notes that maternal morbidity is not just of concern from a human standpoint, but also has significant fiscal implications (O’Neil 2021).


The Commonwealth study analyzed nine maternal morbidities (amniotic fluid embolism, cardiac arrest, gestational diabetes mellitus, hemorrhage, hypertensive disorders, maternal mental health conditions, renal disease, sepsis, venous thromboembolism) and considered not only direct medical costs but also societal costs (eg. loss of productivity, use of social services, etc.).


The estimated total costs of these nine maternal morbidity conditions for all US births in 2019 reached $32.3 billion from conception through the child’s fifth birthday. This amounts to roughly $8,624 in additional costs to society for each maternal–child pair associated with 6.3 million pregnancies and 3.7 million births in the U.S. annually. Two-thirds of these costs occurred within the first year postpartum.


The largest costs included maternal mental health conditions ($18.1 billion), hypertensive disorders ($7.5 billion), gestational diabetes ($4.8 billion), and postpartum hemorrhage ($1.8 billion).


The health care system bore more than half these costs (58%), with the rest shouldered by employers, public social services programs, and other nonmedical sectors. These nonmedical costs included losses in productivity ($6.6 billion), costs associated with behavioral and developmental disorders in children ($6.5 billion), and increased use of social programs like SNAP, WIC, Medicaid, and TANF ($239 million).


The authors note these data likely underestimate the true societal costs of maternal morbidity, because data on the many nonmedical costs associated with the nine conditions is lacking in the research literature.


A word of caution is necessary when we discuss either the US infant mortality and maternal mortality/morbidity standing. Social issues, socioeconomic issues, access to healthcare insurance, access to healthcare provision, and societal disparities clearly impact those outcomes. The US spends proportionately far less on social programs than many of the OECD countries.


But the Commonwealth study makes it clear that greater focus on maternal morbidities may well result in savings to US society.


Our December 8, 2020 Patient Safety Tip of the Week “Maternal Mortality: Looking in All the Wrong Places?” and several of the other columns listed below describe maternal safety bundles and other interventions that we, on the healthcare side of the equation, can focus on addressing the problem of maternal morbidity and mortality.



Some of our previous columns on maternal and ob/gyn issues:

February 5, 2008         “Reducing Errors in Obstetrical Care”

February 2010             “Joint Commission Sentinel Event Alert on Maternal Deaths”

April 2010                   “RCA: Epidural Solution Infused Intravenously”

July 20, 2010              “More on the Weekend Effect/After-Hours Effect”

August 2010               “Surgical Case Listing Accuracy”

September 7, 2010      “Patient Safety in Ob/Gyn Settings”

January 2011               “Surgical Fires Not Just in High Risk Cases”

February 8, 2011         “Inducing Too Early”

April 2011                   “Ob/Gyn Patient Safety Programs”

April 24, 2012             “Fire Hazard of Skin Preps Oxygen”

July 2012                    “WHO Safe Childbirth Checklist”

December 4, 2012       “Unintentional Perioperative Hypothermia: A New Twist”

September 2013          “Full-Time Laborists Reduce C-Section Rates”

October 2013              “Challenging the 39-Week Campaign”

November 2013          “The Weekend Effect: Not One Simple Answer”

January 2014               “It MEOWS But Doesn’t Purr”

May 13, 2014              “Perioperative Sleep Apnea: Human and Financial Impact”

August 19, 2014         “Some More Lessons Learned on Retained Surgical Items”

November 3, 2015      “Medication Errors in the OR - Part 2”

February 7, 2017         “Maternal Safety Bundles”

January 23, 2018         “Unintentional Hypothermia Back in Focus”

January 8, 2019           “Maternal Mortality in the Spotlight”

December 8, 2020       “Maternal Mortality: Looking in All the Wrong Places?”

August 3, 2021           “Obstetric Patients More At-Risk for Wrong Patient Orders”

November 16, 2021    “Cognitive Biases and Heuristics in the Delivery Room”






Hoyert DL. Maternal Mortality Rates in the United States, 2019. Centers for Disease Control and Prevention 2020; Apr. 1, 2020



O’Neil S, Platt I, Vohra D, et al. The High Costs of Maternal Morbidity Show Why We Need Greater Investment in Maternal Health. The Commonwealth Fund 2021;






Print “December 2021 Maternal Morbidity Costly in Human and Fiscal Terms”






Can AI Triage Postoperative Patients More Appropriately?



We’ve written many columns on postoperative complications and attempts to identify clinical deterioration early enough for clinical intervention to make a difference in patient outcomes. Various early warning systems (EWS’s) have been devised, using both clinical and physiological data and data residing in the electronic medical record. Those EWS’s are designed to identify patients who need to be moved to a higher level of care. But how about a system that more appropriately triages postop patients to that higher level of care?


Loftus et al. (Loftus 2021) have developed a developed a real-time machine-learning model to identify undertriage to hospital wards among patients after surgical procedures.


Their machine-learning algorithms analyze preoperative and intraoperative data and estimate patients’ risk of postoperative complications. Data found to be important for these algorithms included primary procedure, scheduled postoperative location, intraoperative minimum alveolar anesthetic concentration measurements, and duration of inhalation anesthetic. These were the best predictors of mortality and prolonged ICU stay.


Patients identified by these algorithms as being at increased risk for postoperative complications who were undertriaged to hospital wards had increased mortality and morbidity compared with a risk-matched control group of admissions to ICUs.


The authors conclude that real-time machine-learning models are valuable in identifying postoperative undertriage.


In an accompanying commentary, Ko and Wren (Ko 2021) note that some early warning systems, like MEWS, when used for postoperative triage have been associated with a significantly decreased rate of ICU admissions without a difference in mortality rate, suggesting the tool’s utility in preventing overtriage to the ICU. They suggest that, with more sophisticated machine-learning models like thaat developed by Loftus and associates, “one could anticipate not only avoiding undertriage to wards, which may be wrought with increased mortality and morbidity, but also preventing overtriage to the ICU in the setting of increased health care costs and overuse of resources.” They do go on, however, to discuss the continued importance of clinical judgement, and conclude that data-driven, patient-level risk assessment models seem promising, not in substitution for clinical judgment, but in supplementation of it.




Some of our other columns on MEWS or recognition of clinical deterioration:




Our other columns on rapid response teams:







Loftus TJ, Ruppert MM, Ozrazgat-Baslanti T, et al. Association of Postoperative Undertriage to Hospital Wards With Mortality and Morbidity. JAMA Netw Open 2021; 4(11): e2131669



Ko A, Wren SM. Advances in Appropriate Postoperative Triage and the Role of Real-time Machine-Learning Models: The Goldilocks Dilemma. JAMA Netw Open 2021; 4(11): e2133843







Print “December 2021 Can AI Triage Postoperative Patients More Appropriately?”






Midline Catheters vs PICC’s



PICC’s (peripherally inserted central catheters) have an important place in our ability to deliver necessary treatments to patients. But they also have some downsides that we’ve highlighted in our multiple prior columns listed below.


A new study looked at the comparative safety of PICC’s vs. midline catheters in patients who had a PICC vs midline catheter placed for the indication of difficult vascular access or antibiotic therapy for 30 or fewer days (Swaminathan 2021). Perhaps somewhat surprisingly, PICC’s were associated with almost twice the risk of major complication compared to midline catheters (odds ratio, 1.99). The reduction in complications was primarily due to lower rates of occlusion (2.1% vs 7.0%; P < .001) and bloodstream infection (0.4% vs 1.6%; P < .001) in midlines vs PICC’s.


The results regarding DVT, however, were less clear. After adjusting for patient, device, and hospital characteristics, there was no statistically significant difference between the overall risk of DVT or PE. However, when examining time-to-event models, midline catheters appeared to be associated with greater daily hazard of DVT, potentially owing to a similar number of events occurring within a shorter catheter dwell time associated with these devices. The authors caution that this finding serves as a reminder to not dismiss the risk of thrombosis associated with midlines, especially in patients with hypercoagulability or preexisting risk factors for DVT, such as cancer.


The authors note that MAGIC (the Michigan Appropriateness Guide for Intravenous Catheters) (Chopra 2015) recommends midlines as the preferred vascular access in patients with difficult vascular access, for treatment thatwill likely exceed 6 days, and for patients requiring infusions including antibiotics for up to 14 days and that the results of their study support the MAGIC guideiines.



Some of our other columns on IV access, central venous catheters and PICC lines:


January 21, 2014         “The PICC Myth”

December 2014           “Surprise Central Lines”

July 2015                    “Reducing Central Venous Catheter Use”

October 2015              “Michigan Appropriateness Guide for Intravenous Catheters”

March 27, 2018           “PICC Use Persists”

February 26, 2019       “Vascular Access Device Dislodgements”

July 16, 2019              “Avoiding PICC’s in CKD”

March 2, 2021             “Barriers to Timely Catheter Removal”







Swaminathan L, Flanders S, Horowitz J, Zhang Q, O’Malley M, Chopra V. Safety and Outcomes of Midline Catheters vs Peripherally Inserted Central Catheters for Patients With Short-term Indications: A Multicenter Study. JAMA Intern Med 2021; Published online November 29, 2021



Chopra V, Flanders SA, Saint S, et al; Michigan Appropriateness Guide for Intravenouse Catheters (MAGIC) Panel. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): results from a multispecialty panel using the RAND/UCLA appropriateness method. Ann Intern Med 2015; 163(6)(suppl): S1-S40





Print “December 2021 Midline Catheters vs PICC's”



Print “December 2021 What's New in the Patient Safety World (full column)”

Print “December 2021 Beta-Blockers Making a Comeback?”

Print “December 2021 Maternal Morbidity Costly in Human and Fiscal Terms”

Print “December 2021 Can AI Triage Postoperative Patients More Appropriately?”

Print “December 2021 Midline Catheters vs PICC's”




Print “PDF version”





Tip of the Week Archive


What’s New in the Patient Safety World Archive