Patient Safety Tip of the Week
July 19, 2016 Infants and Wrong
Site Surgery
A mother was
dumbfounded when nurses brought her newborn back from what she thought was a
routine physical examination and instead was listening to instructions about
aftercare for her newborn’s frenulectomy (CBS
News 2016). The newborn had no reason to have a frenulectomy.
Apparently a pediatrician had mistaken this newborn for another newborn who was
to have the frenulectomy.
No details about the events leading to that
misidentification error are available. The newborn, of course, could not
communicate to staff that he did not need a frenulectomy.
Was there an appropriate consent in the chart? Certainly, the hospital should
have had in place Universal Protocol or its equivalent to ensure correct patient
and procedure. The reports don’t mention where the procedure was done.
Sometimes minor procedures don’t require an operating room and are simply done
in a procedure room. However, even bedside procedures should have an
appropriate timeout to ensure correct patient, correct procedure, and correct
laterality (see our June 6, 2011 Patient Safety Tip of the Week “Timeouts
Outside the OR”).
We’ve done multiple columns on misidentification errors in
newborns and infants. See our Patient Safety Tips of the Week for November 17,
2009 “Switched
Babies”,
September 4, 2012 “More
Infant Abductions”, December 11, 2012 “Breastfeeding
Mixup Again”, April 8, 2014 “FMEA
to Avoid Breastmilk Mixups” and our August 2015
What's New in the Patient Safety World column “Newborn
Name Confusion”.
So just how frequent
are newborn misidentification errors? The Pennsylvania Patient Safety Authority
recently published an advisory on patient identification issues in newborns (Wallace
2016). They found 1234 such misidentification errors in newborns over a 2
year period, an average of almost 2 misidentification errors in Pennsylvania
hospitals and birthing centers per day. That may even be an underestimate since
many misidentification errors impact 2 patients (for example, one patient gets
a medication intended for someone else and the other patient does not get
his/her intended medication) and the reports to the PPSA may have each only
included 1 patient.
The good news from
the PPSA report, though, is that very few of the misidentification errors
actually reached the patient and caused harm. Of the 1234 reports, harm
occurred in only 5 cases and was serious in only one. The majority of errors
were intercepted by interventions like double checks, barcoding, ID tags, etc.
In our Patient Safety
Tips of the Week November 17, 2009 “Switched
Babies” and December 11, 2012 “Breastfeeding
Mixup Again” we noted that one of the risk
factors for these mixups are similar sounding names. Similar
names are always an issue when it comes
to wrong patient events but neonates may be even more at risk. In our May 20,
2008 Patient Safety Tip of the Week “CPOE
Unintended Consequences – Are Wrong Patient Errors More Common?” we noted
you would be surprised to see how often patients with the same or very similar
names may be hospitalized at the same time. Shojania (2003) described a near-miss related to
patients having the same last name and noted that a survey on his medical
service over a 3-month period showed patients with the same last names on 28%
of the days. The problem is even more significant on neonatal units, where
multiple births often lead to many patients with the same last name being
hospitalized at the same time and medical record numbers being similar except
for one digit. Gray et al
(2006) found multiple patients with the same last names on 34% of all NICU
days during a full calendar year, and similar sounding names on 9.7% of days.
When similar-appearing medical records numbers were also included, not a single
day occurred where there was no risk for patient misidentification. Both these
studies were on relatively small services so one can anticipate that the risks
of similar names is much higher when the entire hospitalized patient population
is in the database.
So it is common for
newborns to have similar last names, similar dates of birth, and even similar
medical record numbers (since most hospitals assign medical record numbers
sequentially). The inability of the newborn to participate in the
identification verification process is another obvious contributing factor.
And, though we’re trying to not sound politically incorrect, newborns look
alike! Keep in mind that a mother who just delivered may have seen her newborn
for only a short time and her cognition might be clouded by medications
received during or after the labor and delivery. So even a mom might have
difficulty identifying her own newborn.
Our June 26, 2012 Patient Safety Tip of the Week “Using
Patient Photos to Reduce CPOE Errors”) highlighted an intervention developed
by Children’s Hospital of Colorado (Hyman
2012) in which a patient verification prompt accompanied by photos of the
patient reduced the frequency of wrong patient order entry errors. That may be
helpful for older children and adults but, frankly, is not of much benefit in
neonates.
In our August 2015 What's New in the Patient Safety World column “Newborn
Name Confusion” we noted researchers have applied the retract-and-reorder or RAR tool to assess the
impact of a change in naming conventions
for newborns (Adelman
2015). Hospitals need to create a name for each newborn promptly on
delivery because the families often have not yet decided on a name for their
baby. Most hospitals have used the nonspecific convention “Baby Boy” Jones or
“Baby Girl” Jones. A suggested alternative uses a more specific naming
convention. It uses the first name of the mother. For example, it might be “Wendysgirl Jones”. Montefiore Medical Center switched to
this new naming convention in its 2 NICU’s in July 2013 and the RAR tool was
used to measure the impact on wrong patient errors. Wrong patient error rates measured in the one year after
implementation of the new more specific naming protocol were 36% fewer than in the year prior to
implementation. For reasons not immediately clear, error rates were reduced
even more for orders placed by housestaff (52%
reduction) and orders placed on male patients (61% reduction).
Switch to the more specific neonatal naming convention was
simple and effective and done without significant financial or labor cost and
done with technology already present in most NICU’s. Though the Montefiore
study was not blinded and was potentially subject to the Hawthorne effect, the
more specific naming convention is very promising. Validation at other NICU’s
would be the next logical step before adopting this convention in a more
widespread fashion.
The authors note that they only studied the impact on order
entry. They point out that mixing up names is also a potentially serious for
reading imaging studies or pathology specimens, giving blood products, and may
also be a factor in breastmilk mixups. So the
potential for this new naming convention to avert wrong patient errors is
substantial.
In the PPSA advisory
(Wallace
2016) misidentification errors were most commonly related to procedures,
treatment, or tests (80%). Another 8.3% were medication errors. Some errors
were related to identification bands missing (eg.
might be taped on the bassinet rather than infant) but others were related to
having the wrong identification band. Sometimes the errors were related to
labeling errors on blood or urine specimens or on breastmilk. The PPSA advisory
on misidentification errors in newborns noted breastfeeding the wrong infant or
breast milk administration mishaps were also common. We’ve addressed those in
our Patient Safety Tips of the Week November 17, 2009 “Switched
Babies” and December 11, 2012 “Breastfeeding
Mixup Again” and April 8, 2014 “FMEA
to Avoid Breastmilk Mixups”. We refer you to
those columns for details. If your organization does obstetrics and cares for
newborns or young infants, we highly recommend you do your own FMEA
(failure mode and effects analysis) to assess your risk for breastmilk mixups. We suspect you will be very surprised at the
potential vulnerabilities you identify.
The PPSA advisory
offers recommendations for risk reduction strategies to reduce labeling errors,
registration issues, documentation practices, and issues related to
identification bands and band design. In addition to the baby naming convention
we noted above, the PPSA advisory also suggests daily huddles to acknowledge
and discuss newborns with similar names, and try not to place newborns with
similar names in the same location where possible. They also suggest using some
visual flag (like a star, or “stop” sign, or color-coding) to visually alert
workers that a newborn with a similar name may be present in the unit. (How
many of you even do a daily printout, by unit, of patients so you can flag
instances where patients have similar names?) Use of technologies that assist
correct identification (barcoding, radiofrequency ID, etc.) should be used and
might also reduce labeling errors. One important point is having bedside label
printers to generate labels for specimens at the point of care (so
phlebotomists and others don’t arrive at the bedside with a slew of pre-printed
labels from which they might select the wrong one).
In several of our
columns, most recently in our January 19, 2016 Patient Safety Tip of the Week “Patient
Identification in the Spotlight” we’ve discussed many of the reasons that
CPOE (computerized physician order entry) may lead to wrong patient errors.
That column also includes some of the tools that have been adapted to CPOE to
reduce the risk of those errors.
Another issue related to infant identification is infant
abductions from hospitals. Think you are not at risk for infant abductions at
your facility? Watch
this man attempt to abduct an infant in a shopping bag (Urbanski
2015). See our Patient Safety Tips of the Week for December 20, 2011
“Infant
Abduction” and September 4, 2012 “More
Infant Abductions” for details about how infant abductions occur and ways
to identify your vulnerabilities to these. In those we’ve described some of the
characteristic scenarios by which infant abductions occur. Another infant
abduction in Canada two years ago also illustrates a rather typical scenario seen
(Schwartz
2014). And the excellent NCMEC resources
for healthcare professionals includes descriptions of typical abductors and
scenarios.
Also timely is this month’s ECRI Institute’s PSO Monthly
Brief, which has an article on faulty infant security systems. It has
descriptions of several scenarios in which infant alarms will not work properly
and other vulnerabilities. It has good recommendations on what you should be
doing to ensure your system is functioning properly, including daily testing
and regular drills. We've discussed infant abduction drills in several of our
prior columns and even recommend you consider doing one coincident with a fire
alarm drill to make sure your system does not become disabled during such
events. Note that the monthly brief is one of several free newsletters provided
by ECRI Institute. You are missing out if you don’t subscribe to any of these
very valuable free resources. You can subscribe at: https://www.ecri.org/Pages/eNews.aspx.
Doing drills is important. But you need to do them the right
way. In our December 20, 2011 Patient
Safety Tip of the Week “Infant
Abduction” we noted that the hospital at which an abduction occurred had
done 4 such “Code Pink” drills in the two prior years and that in each of those
drills the “abductor” had been able to exit the facility. So when you do drills
you need to be sure your observer/evaluators know what to look for. Then you
need to be sure you follow up on items that need correction. The NCMEC resources
for healthcare professionals includes a good drill critique form with a
list of items to evaluate during drills and provides a good bibliography to
other resources about doing drills. One item you would evaluate is whether
during the “Code Pink” appropriate people were stopped and interrogated or
prevented from exiting. Even though NCMEC has developed a profile of a typical
abductor, we would caution against “profiling” during a Code Pink and recommend
every person be considered a potential abductor. Also, given our comments about
doors during fire alerts you might even consider doing a “Code Pink” drill
immediately following a fire alert drill.
So see our Patient Safety Tips of the Week for December 20,
2011 “Infant
Abduction” and September 4, 2012 “More
Infant Abductions” and the NCMEC resources
for healthcare professionals to see what you should be doing to protect
against infant abductions from your facilities. But we also highly
recommend those facilities taking care of newborns and children do a FMEA
(failure mode and effects analysis) to assess their potential vulnerabilities
to infant abductions. Doing a FMEA gets you to always consider “what if…?”
scenarios to help you identify areas of vulnerability.
- What
if…the bracelet security system failed?
- What
if…the exit doors unlocked automatically during a fire alert?
- What
if…staffing was low due to an unexpected absence and we now get an
emergency C-section?
- What
if…an infant has to go to radiology for a study?
- What
if…an infant has to go to the OR or a procedure
room for a procedure?
- What
if…a doctor tells us “it’s okay to let the father carry the infant to
radiology”?
The whole point of a FMEA is to identify areas where
unexpected circumstances might occur that could breach your safe processes.
Newborns can’t fend for themselves very well from a medical
standpoint. We can’t afford to also expose them to a host of threats from a
variety of other sources.
Some of our prior
columns related to identification issues in newborns:
November 17, 2009 “Switched
Babies”,
December 20, 2011 “Infant
Abduction”
September 4, 2012 “More
Infant Abductions”.
December 11, 2012 “Breastfeeding
Mixup Again”.
April 8, 2014 “FMEA
to Avoid Breastmilk Mixups”
August 2015 “Newborn
Name Confusion”
January 19, 2016 “Patient
Identification in the Spotlight”
Some of our prior columns
related to wrong-site surgery:
September 23, 2008 “Checklists
and Wrong Site Surgery”
June 5, 2007 “Patient
Safety in Ambulatory Surgery”
July 2007 “Pennsylvania
PSA: Preventing Wrong-Site Surgery”
March 11, 2008 “Lessons
from Ophthalmology”
July 1, 2008 “WHO’s
New Surgical Safety Checklist”
January 20, 2009 “The
WHO Surgical Safety Checklist Delivers the Outcomes”
September 14, 2010 “Wrong-Site
Craniotomy: Lessons Learned”
November 25, 2008 “Wrong-Site
Neurosurgery”
January 19, 2010 “Timeouts
and Safe Surgery”
June 8, 2010 “Surgical
Safety Checklist for Cataract Surgery”
December 6, 2010 “More
Tips to Prevent Wrong-Site Surgery”
June 6, 2011 “Timeouts
Outside the OR”
August 2011 “New
Wrong-Site Surgery Resources”
December 2011 “Novel
Technique to Prevent Wrong Level Spine Surgery”
October 30, 2012 “Surgical
Scheduling Errors”
January 2013 “How
Frequent are Surgical Never Events?”
January 1, 2013 “Don’t
Throw Away Those View Boxes Yet”
August 27, 2013 “Lessons
on Wrong-Site Surgery”
September 10, 2013 “Informed
Consent and Wrong-Site Surgery”
July 2014 “Wrong-Sided
Thoracenteses”
May 17, 2016 “Patient
Safety Issues in Cataract Surgery”
References:
CBS News. Mix-up leads to surgical procedure on wrong baby.
CBS News February 5, 2016
http://www.cbsnews.com/news/mix-up-leads-to-surgical-procedure-on-wrong-baby/
Wallace SC. Newborns
Pose Unique Identification Challenges. Pa Patient Saf
Advis 2016; 13(2): 42-49
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2016/jun;13(2)/Pages/42.aspx
Shojania KG. AHRQ Web M&M Case
and Commentary. Patient Mix-Up. February 2003
http://www.webmm.ahrq.gov/case.aspx?caseID=1&searchStr=shojania
Gray JE, Suresh G, Ursprung R, et
al. Patient Misidentification in the Neonatal Intensive Care Unit:
Quantification of Risk. Pediatrics 2006; 117: e43-e47
http://pediatrics.aappublications.org/cgi/reprint/117/1/e43
Hyman D, Laire M, Redmond D, Kaplan DW. The Use of Patient Pictures
and Verification Screens to Reduce Computerized Provider Order Entry Errors. Pediatrics 2012; 130: 1-9 Published online June 4, 2012 (10.1542/peds.2011-2984)
http://pediatrics.aappublications.org/content/early/2012/05/29/peds.2011-2984.abstract
Adelman J, Aschner J, Schechter C,
et al. Use of Temporary Names for Newborns and Associated Risks. Pediatrics 2015;
Published online July 13, 2015
http://pediatrics.aappublications.org/content/early/2015/07/08/peds.2015-0007.full.pdf+html
Urbanski D. When You Realize Who’s Inside the Bag He’s Trying to Sneak Out of a
Hospital, You Will Be One Step Ahead of the Staffers. The Blaze 2015; March 12,
2015
Schwartz D. Baby Victoria abduction: What hospitals can do
to boost security. Educating nurses, moms most important safety measure, expert says after Trois-Rivières incident. CBC News 2014; Posted: May 28, 2014
NCMEC (National Center for Missing & Exploited
Children). For health care professionals: Guidelines on prevention of and response
to infant abductions. 10th edition. 2014
http://www.missingkids.com/en_US/publications/NC05.pdf
ECRI Institute PSO. Babies and Buzzers: Faulty Infant
Security Systems. ECRI Institute's PSO Monthly Brief 2016; July 2016
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