What’s New in the Patient Safety World

January 2018



·       Can We Improve Barcoding?

·       Eliminating Vincristine Administration Events

·       What Happens After Delirium?

·       Transfusion in Cardiac Revision Surgery




Can We Improve Barcoding?



Bedside medication verification, using barcoding, is arguably our most successful patient safety intervention to reduce medication errors. Yet barcoding systems are not infallible and we likely have room for improvement in such systems.


We still vividly recall our first observation of a nurse administering medications as we implemented our first barcoding system. The label on the medication was smudged so the nurse simply copied and pasted the medication label from the CPOE system, totally bypassing the safety built into the barcoding system. There have been many other workarounds related to barcoding systems. Our June 17, 2008 Patient Safety Tip of the Week “Technology Workarounds Defeat Safety Intent”) discussed, among other studies, the seminal study by Koppel and colleagues (Koppel 2008) that identified 15 types of workarounds and 31 types of causes for the workarounds in barcoding medication administration systems.


Three recent studies show we still have considerable room for improvement in barcode medication administration (BCMA) systems. A review of 11 studies on the impact of BCMA on medication errors (Strudwick 2018) showed that most studies found BCMA significantly reduced the incidence of medication errors. Specifically, BCMA prevented wrong patient, medication, dose, time, and route errors, by ensuring that the medication administered correctly corresponded to that on the medication administration record.


Strudwick and colleagues were interested in identifying factors that helped or hindered the ability of BCMA to prevent medication errors. Being able to bring the technology closer to the point of care was identified as helping avoid medication errors. This was often accomplished by use of workstations on wheels (WOW’s). But in some cases the WOW’s could not be taken into patient rooms, so use of untethered barcode scanners or putting computer terminals within those rooms were solutions used.


Monitoring nurse scanning was identified as a way of identifying nurses and clinical areas that required more support, or where noncompliance with scanning might lead to a patient safety risk. Counting the number of times wristbands were printed for patients was a way of identifying potential “workarounds” (i.e. could be indicative that a nurse was scanning a printed copy of a wristband barcode, instead of the wristband that was supposed to be attached to the patient).


Systems that allow nurses to document deviations in medication administration were identified as improving medication safety. Examination of nurse workflows was considered important in identifying processes that need improvement. Nurse training and patient education were also identified as important to the successful use of BCMA in clinical practice And, no surprise, involvement of nurses in the planning and implementation of BCMA was an important success factor.


The second study was a Pennsylvania Patient Safety Authority study highlighting how Blue Mountain Health System reduced its barcode-workflow events by 53% between 2014 and 2016, using a near-miss event analysis (Magee 2017). The majority (81.3%) of events reported to the PA-PSRS (Pennsylvania Patient Safety Reporting System) involved the administration step of the medication use system but events were reported for the dispensing (27%), prescribing (1,6%), and transcribing (0.8%) steps as well (totals exceed 100% because sometimes multiple steps were involved). Of events reported to the PA-PSRS, failure to follow a policy or procedure or employing workarounds was identified in 40.3%. But 25.7% involved a problem related to equipment, including unreadable patient identification bracelets, uncharged scanners, missing or smudged barcode labels on medication, and lack of wireless connectivity. Equipment-related events sometimes also involved staff bypassing policy or procedure.


When Blue Mountain Health System's bedside barcode scanning software application was upgraded to allow for increased data capture and internal reporting capability, the system was able to recognize both actual adverse events related to barcoding and near-misses. That allowed them to focus on quality improvement activities that resulted in a 52.9% reduction in near-misses over a 3-year period. Those activities included review of actual events and near-misses, direct observations, and a FMEA (failure mode and effects analysis).


They found that their BCMA system allowed for variations in access to patient medication administration records and charting and that this variation created increased risk of near-miss events associated with barcode scanning workflow, such as potential wrong-patient selections. When they identified that increased rates of near-misses occurred in certain rooms, they identified lack of internet connectivity as a root cause and expanded the internet connectivity to those rooms. Also, when individual nurses were noted to have higher rates of events, those nurses were interviewed by the unit director and provided education.


One interesting workaround was identified during observation and discussion of workflows. The policy expectation was that the patient is scanned first, then the medication. However, in practice, some nurses in certain circumstances (such as when the same medication, e.g., acetaminophen, was ordered for multiple patients) would first scan the medication. This workaround contributed to some of the wrong-patient scan totals. So in addition to re-education on the policy, nursing directors affixed a STOP sign-shaped visual reminder to the mobile computers, which reinforced the proper scanning sequence:

S scan the patient, then the medication

C close the screen

A advance to the next patient

N next patient


There were multiple success factors involved in the Blue Mountain project. Involving front line staff and obtaining support of administration were important first steps. Promoting event reporting, especially reporting of near misses, was a key element. And the organization used both root cause analyses (RCA’s) and failure mode and effects analysis (FMEA) to better understand vulnerabilities. A point we have always stressed, they conducted direct observations of staff workflows. That often identified deviations from policy and highlighted workarounds that had evolved. It also helped identify problems with equipment. Conducting simulation exercises was also seen as useful.


In the third article, ISMP has highlighted some problematic issues with barcode labels on medications (ISMP 2017). Barcodes on some products have been repositioned in ways that may render them unreadable. For example, horizontally oriented barcodes on the FLOVENT HFA (fluticasone) inhaler and Teva’s enoxaparin injection now round the circumference of the canister or barrel, respectively, making them difficult to be read by barcode scanners. To further complicate matters, there are multiple different types of barcodes, including the linear (1 dimensional) barcode, the 2D (two dimensional) data matrix barcode, and the Quick Response (QR) barcode, and OTC products have a Universal Product Code (UPC). Not all barcode scanners are capable of capturing all these barcodes. The presence of two barcodes on medications has led to confusion about which barcode to scan.


Since there is a new requirement (as of November 27, 2017) to include a 2D data matrix barcode on certain product labels, ISMP recommends organizations alert all practitioners to the new requirement and ensure that practitioners understand which barcode to scan for verification during the drug preparation, dispensing, and administration processes. ISMP also recommends organizations should have a process in place to program new medication barcodes into information technology databases and ensure that they are linked to the correct product and operational before use. ISMP requests organizations report any barcode scanning problems to ISMP so they can alert the manufacturer and FDA.


ISMP also highlights the American Society of Health-System Pharmacists Foundation tool kit for pharmacists (ASHP 2016) as an excellent resource on implementing barcoding systems.


Yes, barcoding has been a wonderful patient safety tool. But these three studies show that we always have room for further improvement.



See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:







Koppel R, Tosha Wetterneck T, Telles JL, Karsh B-T. Workarounds To Barcode Medication Administration Systems: Their Occurrences, Causes, And Threats To Patient Safety. JAMIA 2008; 15(4): 408-423




Strudwick G, Reisdorfer E, Warnock C, et al. Factors Associated With Barcode Medication Administration Technology That Contribute to Patient Safety: An Integrative Review. Journal of Nursing Care Quality 2018; 33(1): 79-85




Magee MC. Near-Miss Event Analysis Enhances the Barcode Medication Administration Process. Pa Patient Saf Advis 2017; 14(4): 1-17




ISMP (Institute for Safe Medication Practices). Unreadable barcodes and multiple barcodes on packages can lead to errors. ISMP Medication Safety Alert! Acute Care Edition. October 19, 2017




ASHP Foundation. Pharmacist’s tool kit for implementing barcode medication administration. 2016






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Eliminating Vincristine Administration Events



We highlighted NCCN’s “Just Bag It!” campaign in our What's New in the Patient Safety World columns for December 2016 “Standardize 4 Safety and Just Bag It!” and June 2017 “Just Bag It Campaign Success Story”. Now the Joint Commission has jumped on board, recommending similar measures to reduce vincristine administration errors (TJC 2017).


You’ll recall that the “Just Bag It!” campaign was launched in 2016 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.


The Just Bag It! campaign calls 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.


Our June 2017 What's New in the Patient Safety World column “Just Bag It Campaign Success Story” highlighted how Johns Hopkins nurses successfully implemented the “Just Bag It!” campaign (Olsen 2017, NCCN 2017). Understanding the rationale for the new practice and becoming familiar with the technique were critical. Nurses received training that included background on the reasons for the switch, watched a video of the technique, and had hands-on training in a skills lab to ensure proper technique before going live with this practice change.


The new Joint Commission “Quick Safety Issue” (TJC 2017) cites a 2015 international survey of oncology pharmacy practitioners that was conducted to determine how vincristine is administered and the strategies in place for preventing accidental intrathecal administration of vincristine. That survey (Gilbar 2015) revealed that intravenous vincristine was dispensed in minibags in 77.4 percent of centers, though some also used syringes. Syringes were used in 31.1 percent of centers, with half these doses prepared undiluted. The most common reasons for still using syringes were perceived risk of extravasation and faster infusion time. Despite numerous vincristine administrations, extravasation was very rare.


The Joint Commission urges hospitals and other health care organizations that provide chemotherapy services to promote the safe administration of intravenous vincristine and other vinca alkaloids by:


Inadvertent intrathecal administration of vincristine or vinca alkaloids has devastating results. The interventions described above are extremely important in your efforts to avoid such accidents.



Our prior columns related to chemotherapy safety:







TJC (The Joint Commission). Quick Safety Issue 37: Eliminating vincristine administration events. October 2017




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




Olsen M, Benani D, Przybylski A, Carrol S, Szabo K. Putting an Old Oncology Nursing Practice to Bed: A Hospital-Wide Initiative Using Evidence-Based Practice to Standardize the Administration of Vinca Alkaloids Using a Minibag, Side-Arm Technique. Oncology Nursing Society 42nd Annual Congress. Poster 187. May 5, 2017




NCCN (National Comprehensive Cancer Network). In Oncology Nursing, One Small Change Can Potentially Prevent Deadly Medical Error in Thousands of Patients. Press Release May 1, 2017




Gilbar P, Chambers CR, Larizza M, et al. Medication safety and the administration of intravenous vincristine: International survey of oncology pharmacists. Journal of Oncology Pharmacy Practice 2015; 21(1): 10-18







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What Happens After Delirium?



A much needed study on delirium has recently been published. We and others have done multiple columns on preventing and managing delirium but one question has largely been ignored: “What happens to patients who have been started on antipsychotics for delirium?”.


The new study addresses that question. Johnson and colleagues (Johnson 2017) wanted to know how many inpatients begun on antipsychotic medications for delirium had a clear discontinuation plan after discharge. They conducted a retrospective chart review identifying geriatric inpatients in their health system started on a new antipsychotic during admission and in those discharged from the hospital on a new antipsychotic, they examined the discharge summary for a discontinuation treatment plan. Of patients started on a new antipsychotic (82% of whom had a diagnosis of delirium), 30.2% were discharged on the antipsychotic. Only 12.4% of those patients discharged on an antipsychotic with a diagnosis of delirium had included in their discharge summaries instructions for discontinuation of the antipsychotic. Of those patients who were discharged with instructions for discontinuation, 80% had received a psychiatric or geriatric medicine consult.


Antipsychotic drugs have significant potential adverse consequences. Anticholinergic effects, sedation, sexual dysfunction, movement disorders, postural hypotension, cardiac arrhythmia, and sudden cardiac death are well-known consequences. Metabolic syndrome has also been associated with many of the newer antipsychotics. Increased mortality rates are seen in nursing home patients treated with antipsychotic drugs, and falls are frequent in the nursing home patient on antipsychotics. So it’s really important that we don’t continue antipsychotic drugs any longer than necessary in this population.


Good medication reconciliation at discharge (and, for that matter, at all transitions of care) is essential. Even when an antipsychotic is intended to be continued temporarily following discharge, there should be a clear plan and instructions for how long it should be continued, whether it should be tapered or abruptly discontinued, and for what symptoms it should be restarted. Consultation by a geriatrician or geropsychiatrist may be very beneficial in this regard.



Some of our prior columns on delirium assessment and management:

·       October 21, 2008 “Preventing Delirium”

·       October 14, 2008 “Managing Delirium”

·       February 10, 2009 “Sedation in the ICU: The Dexmedetomidine Study”

·       March 31, 2009 “Screening Patients for Risk of Delirium”

·       June 23, 2009  “More on Delirium in the ICU”

·       January 26, 2010 “Preventing Postoperative Delirium”

·       August 31, 2010 “Postoperative Delirium”

·       September 2011 “Modified HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery”

·       December 2010 “The ABCDE Bundle”

·       February 28, 2012 “AACN Practice Alert on Delirium in Critical Care”

·       April 3, 2012 “New Risk for Postoperative Delirium: Obstructive Sleep Apnea”

·       August 7, 2012 “Cognition, Post-Op Delirium, and Post-Op Outcomes”

·       February 2013 “The ABCDE Bundle in Action”

·       September 2013 “Disappointing Results in Delirium”

·       October 29, 2013 “PAD: The Pain, Agitation, and Delirium Care Bundle”

·       February 2014 “New Studies on Delirium”

·       March 25, 2014 “Melatonin and Delirium”

·       May 2014 “New Delirium Severity Score”

·       August 2014 “A New Rapid Screen for Delirium in the Elderly”

·       August 2014 “Delirium in Pediatrics”

·       November 2014 “The 3D-CAM for Delirium”

·       December 2014 “American Geriatrics Society Guideline on Postoperative Delirium in Older Adults”

·       June 16, 2015 “Updates on Delirium”

·       October 2015 “Predicting Delirium”

·       April 2016 “Dexmedetomidine and Delirium”

·       April 2016 “Can Antibiotics Lead to Delirium?”

·       July 2016 “New Simple Test for Delirium”

·       September 20, 2016 “Downloadable ABCDEF Bundle Toolkits for Delirium”

·       January 24, 2017 “Dexmedetomidine to Prevent Postoperative Delirium”

·       March 21, 2017 “Success at Preventing Delirium”

·       July 2017 “HELP Program Reduces Delirium Rate and LOS”






Johnson KG, Fashoyin A, Madden-Fuentes R, et al. Discharge Plans for Geriatric Inpatients With Delirium: A Plan to Stop Antipsychotics? J Am Geriatr Soc 2017; 65(10): 2278-2281







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Transfusion in Cardiac Revision Surgery



We’ve done many columns supporting more restrictive transfusion policies. Our most recent column (see our December 2017 What's New in the Patient Safety World column “Study Confirms Safety of Restrictive Transfusion Policy”) showed that even for cardiac surgery these more restrictive policies should apply. But maybe that does not apply to all cardiac surgery. A new study shows that the transfusion requirement for cardiac revision surgery may be considerably higher than previously reported.


Previous studies had shown transfusion requirements were about 75% higher in cardiac revision surgeries. But a new study shows that, when compared with first-time cardiac surgery, blood product utilization for revision cases was two to four times greater. Analyzing cases between January 2009 and June 2016, researchers at Johns Hopkins (Hensley 2017a, Doyle 2017) found that with CAB (coronary artery bypass) surgeries, the mean transfusion requirements for redo patients were two- to fourfold greater than the non-redo CAB patients. For non-CAB cardiac surgeries the mean transfusion requirements for redo cases were two times greater.


Dr. Hensley noted that microvascular bleeding, when layers of scar tissue from a primary sternotomy are dissected, is common in revision cases but is not easily seen or repaired by surgeons. Revision cases also showed significant increases in bypass or aortic cross-clamping time, which has been linked to increased blood transfusion requirements.


So anesthesiologists must be prepared for the increased transfusion need in revision cases. Blood conservation strategies are important and “these patients should also be targeted ahead of surgery, when there is time to increase hemoglobin with erythropoietin or iron supplementation, or by correcting coagulopathies.”


Hensley and colleagues had also published some of their findings separately (Hensley 2017b). They note that prior studies comparing these cohorts were performed before patient blood management (PBM) and blood conservation measures were commonplace. Compared to the primary cardiac surgery patients, revision surgery patients required approximately twofold more transfused units intraoperatively and approximately two- to threefold more transfused units for the whole hospital stay. Moreover, intraoperative massive transfusion (>10 RBC units) was substantially more frequent with revision versus primary cardiac surgery (2.6% vs. 0.1% for isolated CAB or valve surgery and 6.1% vs. 1.9% for all other cardiac surgeries). Revision surgery was an independent risk factor for both moderate (6-10 RBC units) and massive intraoperative transfusion.


With all our attention to restrictive transfusion policies, this is an important wake-up call that such restrictive approaches do not apply to revision surgeries (at least cardiac revisions).



Prior columns on potential detrimental effects related to red blood cell transfusions:







Hensley NB, Gupta PB, Yang WW, Frank SM, Brown C. Blood Product Utilization in Revision vs. First-Time Cardiac Surgery: An Update in The Era Of Patient Blood Management. International Anesthesia Research Society 2017 annual meeting (abstract 1879)


As discussed in:

Doyle C. Transfusion Requirements Significantly Increased in Revision Cardiac Surgery

Anesthesiology News 2017; December 15, 2017




Hensley NB, Kostibas MP, Yang WW, et al. Blood utilization in revision versus first-time cardiac surgery: an update in the era of patient blood management. Transfusion 2017; Epub ahead of print 8 October 2017






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Print “January 2018 What's New in the Patient Safety World (full column)”

Print “January 2018 Can We Improve Barcoding?”

Print “January 2018 Eliminating Vincristine Administration Events”

Print “January 2018 What Happens After Delirium?”

Print “January 2018 Transfusion in Cardiac Revision Surgery”





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