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Some of our prior columns on neuromuscular blocking agents (NMBA’s):
June 19, 2007 “Unintended Consequences of Technological Solutions”
July 31, 2007 “Dangers of Neuromuscular Blocking Agents”
November 2007 “FMEA Related to Neuromuscular Blocking Agents”
January 31, 2012 “Medication Safety in the OR”
February 7, 2012 “Another Neuromuscular Blocking Agent Incident”
October 22, 2013 “How Safe Is Your Radiology Suite?”
December 9, 2014 “More Trouble with NMBA’s”
December 11, 2018 “Another NMBA Accident”
January 1, 2019 “More on Automated Dispensing Cabinet (ADC) Safety”
February 12, 2019 “From Tragedy to Travesty of Justice”
April 2019 “ISMP on Designing Effective Warnings”
This time of year is when all the “Top 10” lists on patient safety issues come out. Three big ones have come out from ISMP (Institute for Safe Medication Practices), ECRI Institute, and Becker’s Hospital Review.
ISMP’s “Start the Year Off Right by Preventing These Top 10 Medication Errors and Hazards from 2020” (ISMP 2021) has its list Top 10 Medication Errors and Hazards from 2020:
ECRI Institute’s “Top 10 Health Technology Hazards for 2021” (ECRI 2021)
Becker’s 10 top patient safety issues for 2021 (Carbajal 2021
Even though the themes of these lists are slightly different for each organization, you can see there is still considerable overlap and issues related to COVID-19, directly or indirectly, dominate the lists. We refer you to the original articles for details of each item on the respective lists.
ISMP (Institute for Safe Medication Practices). Start the Year Off Right by Preventing These Top 10 Medication Errors and Hazards from 2020. ISMP Medication Safety Alert! Acute Care Edition 2011; 26(2): January 27, 2021
ECRI Institute. Top 10 Health Technology Hazards for 2021. ECRI Institute 2021; January 2021
December 30th, 2020M. Becker’s 10 top patient safety issues for 2021; Becker’s Hospital Review 2021;
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We’ve done many columns on the dangers of intrahospital transports and the need to do careful planning to avoid those dangers. But we’ve focused primarily on temporary transports to areas such as radiology or the OR. But there is a different sort of intrahospital transfer that is also problematic – the transfer of patients from beds on one unit to beds on another unit.
A recent study from the UK (Boncea 2021) found that intrahospital transfers are associated with increased odds of developing a healthcare-associated infection (HAI). The authors suggest that strategies for minimizing intrahospital transfers should be considered, and further research is needed to identify unnecessary transfers. Their reduction may diminish spread of contagious pathogens in the hospital environment.
The frequency of such intrahospital transfers should probably not surprise you. Only 27.8% of patients did not undergo any intrahospital transfers. 44.2% of patients underwent one intrahospital transfer, 17.1% underwent two transfers, and 11.0% underwent three or more transfers. Overall, 11.9% of patients developed an HAI. C. difficile infection accounted for almost a third of the HAI’s, but many other pathogens were implicated as well.
The accompanying editorial (Escobar 2021) notes that cases and controls were well matched, and the statistical modelling provided very compelling results. But it notes the study did not adjust for the indication for transfer (eg, transfer to or from the intensive care unit based on patient acuity, transfer for isolation precautions or transfer due to bed capacity or staffing issues) to determine if the patient care needs, isolation status or hospital strain modify the observed risk. It therefore recommends, as do Boncea et al., that prospective studies are needed to better identify the clinical, administrative and systems factors that contribute to more frequent intrahospital transfers.
Boncea et al. note several factors that could underlie a possible association between HAIs and intrahospital transfers:
Especially in the COVID-19 era, where hospital bed shortages are rampant, we often move patients from one site to another, The Boncea study suggests we not simply act reflexly in such intrahospital transfers, but rather carefully consider the implications before carrying out such transfers. The 9% increased risk of an HAI associated with each transfer is a substantial consideration. There are, of course, other unwanted consequences of intrahospital transfers. For example, one study (Goldberg 2015) found that room transfers amongst hospitalized elderly medical patients substantially increased the risk of development of delirium (OR 9.69).
But one has to weigh the benefits of transfer against the risks. There are risks of keeping a patient on a unit not used to caring for such patients. We cohort patients on floors with special expertise in care for patients with certain conditions. A patient being followed by one service (eg. neurology) who is temporarily housed on a non-neurology floor gets less attention from the neurology staff than he would were he housed on the neurology floor. In addition, the nursing care on the specialty unit is much more attuned to the problems that neurology patient is likely to have. So, decisions about transferring patients from one location in the hospital to another can’t simply be based on the risk of HAI. Nevertheless, the substantial risk of HAI pointed out in the Boncea study should make us recognize that decisions about transfer of patients should not be made rashly.
Some of our prior columns on intrahospital transports and the “Ticket to Ride” concept:
Boncea E, Expert P, Honeyford K. Association between intrahospital transfer and hospital-acquired infection in the elderly: a retrospective case-control study in one urban UK Hospital network. BMJ Qual Saf 2021; Published Online First: 25 January 2021
Escobar D, Pegues D. Healthcare-associated infections: where we came from and where we are headed. BMJ Quality & Safety 2021; Published Online First: 08 January 2021
Goldberg A, Straus SE, Hamid JS, Wong CL. Room transfers and the risk of delirium incidence amongst hospitalized elderly medical patients: a case-control study. BMC Geriatr 2015; 15: 69. Published 2015 Jun 25
We’ve done many columns on potentially inappropriate medications (PIM’s) in older adults (see list below). We’ve often focused on drugs with prominent anticholinergic actions, sedative/hypnotic drugs, benzodiazepines, gabapentinoids, and others. But there is one class of PIM’s that has largely flown “under the radar”: skeletal muscle relaxants. And there has been a disturbing trend in prescribing patterns for drugs in this class.
The 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults (AGS 2019) notes that most muscle relaxants are poorly tolerated by older adults because some have anticholinergic adverse effects, sedation, increased risk of fractures; and their effectiveness at dosages tolerated by older adults questionable. Examples of skeletal muscle relaxants they note are: Carisoprodol, Chlorzoxazone, Cyclobenzaprine, Metaxalone, Methocarbamol, and Orphenadrine.
A recent analysis (Soprano 2020) found that skeletal muscle relaxant (SMR) use increased rapidly between 2005 and 2016. During the study period, office visits with a prescribed SMR nearly doubled. Actually, visits for new SMR prescriptions remained stable, but office visits with continued SMR drug therapy tripled. Older adults accounted for 22.2% of visits with an SMR prescription. Concomitant use of an opioid was recorded in 67.2% of all visits with a continuing SMR prescription.
So, what’s driving this trend? SMR’s have been increasingly used in long-term pain management, despite lack of data on efficacy and safety. It’s likely that the opioid epidemic and the resultant push to reduce opioid prescribing has made clinicians look for alternatives to opioids in management of chronic pain.
The major indication for SMR use is for acute low back pain. There is little evidence of SMR efficacy in managing chronic low back pain. And the use of SMR’s for all other types of chronic pain is “off-label” and based largely on anecdotal data.
That SMR use was associated with concomitant opioid use in 67% of visits is particularly bothersome. One study identified an elevated risk of overdose with concomitant use of opioids and skeletal muscle relaxants (Li 2020).
We, personally, have never been fans of skeletal muscle relaxants, even for acute low back pain. So, we were quite taken aback to see this disturbing trend in SMR prescribing. This is probably a situation in which use of clinical decision support tools in ePrescribing applications or CPOE might be useful. Clinical decision support tools could alert clinicians about dangers prescribing them to older adults, suggest long-term use of SMR’s is not appropriate, and to particularly flag issues with concomitant use of opioids.
Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:
2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. J Amer Geriatr Soc 2019; First published: 29 January 2019
Soprano SE, Hennessy S, Bilker WB, Leonard CE. Assessment of Physician Prescribing of Muscle Relaxants in the United States, 2005-2016. JAMA Netw Open 2020; 3(6): e207664
Li Y, Delcher C, Wei YJ, et al. Risk of opioid overdose associated with concomitant use of opioids and skeletal muscle relaxants: a population-based cohort study. Clin Pharmacol Ther 2020; Published online February 5, 2020
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