What’s New in the Patient Safety World

January 2011


·        Surgical Fires Not Just in High-Risk Cases

·        ECRI’s Top 10 Health Technology Hazards for 2011

·        No Improvement in Patient Safety: Why Not?

·        Joint Commission Proposed New National Patient Safety Goals for 2012






Surgical Fires Not Just in High-Risk Cases



While the risk of a surgical fire exists any time the elements of the “fire triangle” are present (fuel, heat source, and oxidizer), we generally think of those cases at high risk as being cases done on head and neck cases or procedures near the airway or involving the chest (see our Patient Safety Tips of the Week for December 4, 2007 “Surgical Fires” and April 29, 2008 “ASA Practice Advisory on Operating Room Fires” as well as all the excellent work done by ECRI on surgical fires and our November 2009 What’s New in the Patient Safety World column “ECRI: Update to Surgical Fire Prevention”). But fires can occur even in cases that might be considered low risk. One such case occurred in Israel during a C-section. The patient had been prepped prior to the planned surgery and allowed to dry off. However, in the OR the surgeon requested the field again be prepped with an alcohol-based prep. This was done and then he began an incision using a diathermy needle and a spark caused the resultant fire. The fire was extinguished and a healthy baby was delivered but the patient suffered severe burns and later required skin grafting to her buttocks and thighs. The Israeli health ministry noted the risk of fire is particularly dangerous in cases where the legs are elevated, promoting pooling of the alcohol-based prep under the buttocks (Even 2010). They also noted the sheets were flammable, which further complicated the case.


We have long advocated that the surgical fire risk be discussed as part of the pre-op huddle (or pre-op briefing) and, if the case is considered high-risk, respective roles of all OR participants are called out during the surgical timeout. As part of an effort to promote fire safety in the OR (Murphy 2010), the San Francisco VA has developed a checklist “The Surgical Fire Assessment Protocol”. This checklist/protocol is actually printed on the reverse side of their larger preoperative checklist. This is really a very good tool! The fire risk is assessed by a simple numerical scale. If the score is 3 (high risk) the rest of the form is filled out, which basically delineates the respective roles of all those participants. That’s a really good way to remind all about their responsibilities if a fire occurred.


But even that tool would probably not have flagged the above case as high-risk. It remains crucial that any time an alcohol-based skin prep is used, sufficient time be allowed for drying and a search for possible pooling be done. We know of some organizations that employ stop watches or timers in the OR to ensure adequate drying of alcohol-based preps.


Search for the ideal skin disinfectant that prevents surgical site infections but is not flammable is still ongoing. Several studies have now demonstrated that chlorhexadine/alcohol is a better disinfectant than providone-iodine. Unfortunately, the fire risk is much higher for the chlorhexadine/alcohol preparation. So careful attention to the drying time remains most important.






Woman Accidentally Set On Fire During C-Section

FoxNews.com  Published December 01, 2010




Even D. Operating theater accident sets pregnant woman alight. Hospital staff delivered a healthy baby, but the woman later needed plastic surgery for burns sustained in fire started by diathermic needle. Haaretz.com  December 1, 2010




Murphy J. A New Effort to Promote Fire Safety in the OR.

Topics In Patient Safety (TIPS) 2010; 10(6): 3




SF VAMC Surgical Fire Risk Assessment Protocol





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ECRI’s Top 10 Health Technology Hazards for 2011



ECRI  Institute has published its annual list of its Top 10 Health Technology Hazards for 2011. The reprint can be downloaded for free from the ECRI site but you must register for that download. We won’t tell you all the items in the ECRI top 10 – you need to download the reprint and read it. But you won’t be sorry. They detail the risks of each of the technologies and make very useful recommendations on what your organization should be doing to minimize those risks.


Number one on their list is radiation therapy hazards. Note that we have previously discussed hazards of radiation therapy on several occasions (see our February 2, 2010 Patient Safety Tip of the Week “The Hazards of Radiation” and our March 2010 What’s New in the Patient Safety World column “More on Radiation Safety”). Also note that the New York Times has just done another article on errors related to radiation therapy, specifically stereotactic radiosurgery delivered via linear accelerators. This is another extremely disconcerting story about how an industry largely avoids oversight and regulation, where pieces of equipment are mixed or retrofitted to save costs, and training and quality control leave a lot to be desired. The scariest feature is that the only body collecting information on the scores of errors occurring with these devices is the New York Times!!! The ECRI paper has very useful recommendations on the training and competencies of staff specific to the devices and equipment being used, proper use of testing and monitoring, validation of treatment plans, and many others.


Number 4 on the ECRI list is the high radiation dose of CT scans. In our own two columns we mentioned above we discussed not only the risk of radiation exposure from single studies but also the cumulative radiation exposure risk and the fact that currently no one is tracking that for our patients – not we as physicians, not health systems, and not the patients themselves. We expounded on this in our November 23, 2010 Patient Safety Tip of the Week “Focus on Cumulative Radiation Exposure”. The ECRI paper has recommendations for monitoring radiation levels used in routine CT scanning and optimizing protocols.


Number 7 on the ECRI list is oversedation during use of PCA infusion pumps. Our May 12, 2009 Patient Safety Tip of the Week “Errors With PCA Pumps” dealt with a number of errors that may occur during use of patient controlled analgesia (PCA) and our April 27, 2010 Patient Safety Tip of the Week “Infusion Pump Safety” dealt with infusion pump issues in general. And we’ve discussed the issue of postoperative respiratory depression due to opioids in our Patient Safety Tips of the Week for July 13, 2010 “Postoperative Opioid-Induced Respiratory Depression” and September 21, 2010 “Dilaudid Dangers”. The ECRI paper notes that the true prevalence of respiratory depression in patients on PCA is much higher than previously suspected since better monitoring has been implemented and may be as high as 41%. The ECRI recommendations are for monitoring not just vital signs but also mental status, pulse oximetry and capnography. They also discuss how to correctly assess the patients, use double checks for both orders and pump programming, and consider alternatives to PCA. In our multiple prior articles we have discussed identification of high-risk patients, correct use of sedation scales, and the dangers of oxygen in patients at risk for hypercapnia. We’ll be doing some updates on PCA pump issues in the near future as well.


No more hints on ECRI’s top 10! Download the reprint for yourselves As usual, ECRI’s evaluations are always thorough with very useful recommendations.






ECRI. ECRI Institute’s 2011 Top 10 Health Technology Hazards. Health Devices 2010; 39(11): 386-398




Bogdanich W, Rebelo K. A Pinpoint Beam Strays Invisibly, Harming Instead of Healing.

NY Times December 28, 2010





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No Improvement in Patient Safety: Why Not?



The landmark 1999 Institute of Medicine paper “To Err is Human” is considered by many to have launched the “new era” of patient safety. That paper set a challenge goal of 50% reduction in harm due to medical care over the next 5 years. No formal measurements have been available to determine the exact progress made to date but most in the patient safety field think any nation-wide gains have been modest despite our ever-increasing knowledge of individual and bundled interventions that have proven efficacy.


A recent 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.


Now a new study (Landrigan 2010) confirms that there has been little improvement overall over a long time frame. That study, done on data from 10 North Carolina hospitals used IHI’s global trigger tool (see our October 30, 2007 Patient Safety Tip of the Week “Using IHI's Global Trigger Tool”) to estimate rates of patient harm and preventable harm over a 6-year period. They found essentially no reduction in harm over that period. They had chosen North Carolina because many hospitals there had participated in patient safety collaboratives and North Carolina had a much higher percentage of hospitals participating in IHI’s patient safety programs.


While the IHI global trigger tool measures events somewhat different than in the studies that formed the basis of the IOM report, the global trigger tool methodology is “doable” with limited resources and provides a more reliable comparison over time.


Editorials by BobWachter and Michael Millenson offer some insight into the reasons why we have not. Wachter had previously always felt that, despite the lack of adequate measurement in patient safety, significant progress was being made. However, he now acknowledges that the methodology used by Landrigan et al really shows that our progress in patient safety has been disappointing. Millenson spares no words and attributes the lack of progress to the “three I’s”: invisibility, inertia and income. He argues that the widespread occurrence of adverse events and medical errors still seems to largely fly under everyone’s radar and that inertia continues to keep healthcare workers from doing things for which there is good evidence. He highlights the national average 40% compliance with hand hygiene guidelines as evidence of lack of commitment on the part of healthcare workers.


Landrigan et al. note that patient safety interventions such as CPOE (computerized physician order entry) and reductions in resident work hours should have resulted in improvements in harm due to medical treatment. But both of those interventions also have downsides. With the exception of a few hospitals that have developed their own CPOE systems in-house and integrated them with patient safety programs, most CPOE systems are still very rudimentary, lack sophisticated clinical decision support, and have been associated with unintended consequences that have largely cancelled out any improvements (see our multiple columns dealing with unintended consequences). And another new study on the impact of healthcare IT systems on quality (Jones 2010) has also shown mixed and modest results.


And the reduction in housestaff hours has the downside of increasing the number of handoffs that occur. We’ve often asked ourselves “Would I rather be cared for by a sleepy resident who knows me or by a wide awake floating resident who knows nothing about me?”. Fatigue is a major concern, not just among housestaff, but among all healthcare workers. But too many of our interventions reduce the critical communication that must take place between healthcare workers of all types.


Technological advances have also been double-edged swords. While promising significant improvements in various aspects of patient care, they also have their downsides. Our column above “ECRI’s Top 10 Health Technology Hazards for 2011”includes among ECRI’s list of technology hazards many of the technologies we have introduced to improve patient safety (eg. healthcare IT, various alarms, PCA pumps, etc.).


We are also to blame in that many of the patient safety interventions we have implemented have turned out to adversely affect patient outcomes. In retrospect, the evidence for some of these interventions was “soft”. We hyped perioperative beta blockers for just about anyone undergoing surgery. Now we’ve learned that they may actually increase mortality. We overdid it on prophylactic use of agents for gastric acid suppression. Now we realize they may have played a role in development of C. difficile infections and may even have increased the risk for ventilator-associated pneumonia (VAP), the very condition for which they were commonly being used. We made antibiotics within 4 hours for community-acquired pneumonia a quality and pay-for-performance standard, only to see many patients who turned out not to have pneumonia being unnecessarily treated with antibiotics. Even the SCIP (Surgical Care Improvement Project) showed little impact of adherence to individual practices on patient outcomes (see our August 2010 What’s New in the Patient Safety World column “SCIP: Disappointing Outcomes on SSI’s. What’s Next?”).


But we still go back to the basic premise of John Nance’s “Why Hospitals Should Fly” (see our June 2, 2009 Patient Safety Tip of the Week “Why Hospitals Should Fly…John Nance Nails It!”) that healthcare has failed to produce significant patient safety improvement because we have failed to change the culture. Perhaps the biggest reason we have failed to truly develop a culture of safety is that many of the very interventions we espouse actually take away from face-to-face time with patients. That clearly is the case with many of the healthcare IT initiatives. The Jones paper notes that IT-related initiatives often compete with other quality improvement initiatives for resources. And many of the other administrative burdens we place on healthcare workers compete for their most valuable asset: time.


Wachter, in his editorial above, also stresses we need to focus more on culture change. Lori Paine and Peter Pronovost and colleagues at Johns Hopkins (Paine 2010) have demonstrated how a number of patient safety programs may lead to rapid improvements in the culture of safety. But the next critical step remains demonstrating that such improvements in culture actually translate to improvement in patient outcomes.


We’ve still made only limited initiatives at introducing patient safety and culture of safety into our professional school training. How often do you see nursing, medical and pharmacy students actually working together as teams in any significant fashion until much later in their training?


While the IOM report is often referred to as “seminal” or “eye opening”, the Landrigan report is really a wake-up call. We clearly are not making the impact we should be.






Christopher P. 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




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




Wachter R. Could It Be That Patients Aren’t Any Safer? Wachter’s World (blog)

Nov. 25, 2010




Millenson M. Why We Still Kill Patients: Invisibility, Inertia, And Income. Health Affairs Blog December 6th, 2010




Jones SS, Adams JL, Schneider EC, Ringel JS, McGlynn EA. American Journal of Electronic Health Record Adoption and Quality Improvement in US Hospitals.

Managed Care 2010; 16(12 Spec No.): SP64-SP71  Published Online: December 22, 2010




Nance, John J. Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care. Bozeman MT: Second River Healthcare Press. 2008



Paine LA, Rosenstein BJ, Sexton JB, et al. Assessing and improving safety culture throughout an academic medical centre: a prospective cohort study.

Qual Saf Health Care 2010; 19: 547-554





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Joint Commission Proposed New National Patient Safety Goals for 2012



The Joint Commission has proposed two new National Patient Safety Goals (NPSG’s) for 2012. The 2 new NPSG’s address prevention of ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infections (CAUTI’s). Both utilize the consensus guidelines published jointly in 2008 by SHEA (the Society for Healthcare Epidemiology in America) and IDSA (Infectious Diseases Society of America).


For VAP prevention, the focus is on hand hygiene before and after contact, maintaining patients in the semirecumbent position, regular antiseptic oral care, daily assessment for readiness to wean, and daily sedation interruption.


For CAUTI prevention, the focus is on limiting use and duration of indwelling catheters, using aseptic techniques for catheter insertion and maintenance, and proper management of catheter drainage systems.


Both proposed NPSG’s also contain provisions for surveillance, monitoring and measurement.


The proposals are requesting comments from the field, with comments due by January 27, 2011.


Meanwhile, you can find the 2011 National Patient Safety Goals here.






The Joint Commission. Proposed National Patient Safety Goals addressing ventilator-associated pneumonia (VAP) and catheter-associated urinary tract infections (CAUTI)

Start Date: December 2, 2010
End Date: January 27, 2011





The Joint Commission. 2011 National Patient Safety Goals.




SHEA/IDSA. Compendium of Strategies to Prevent Healthcare-Associated

Infections in Acute Care Hospitals. Infect Control Hosp Epidemiol 2008; 29(10): 901-994





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Print “January 2011 What's New in the Patient Safety World (full column)

Print “January 2011 Surgical Fires Not Just in High-Risk Cases

Print “January 2011 ECRI’s Top 10 Health Technology Hazards for 2011

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

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