What’s New in the Patient Safety World


July 2009


Editorial on Medicare Nonpayment for Falls

NPSA Review of Patient Safety for Children and Young People

Failure to Inform Patients of Clinically Significant Outpatient Test Results

Unintended Consequences of a DVT Prevention Strategy




Editorial on Medicare Nonpayment for Falls


In the June 4, 2009 issue of the New England Journal of Medicine, Sharon Inouye and colleagues authored an editorial about the Medicare policy of nonpayment for falls and its potential for unintended consequences. They make the argument that there really is not a good evidence base for interventions that prevent falls or prevent injuries from falls. They do note that their own multimodality intervention for delirium prevention, the Hospital Elder Life Program or HELP (see our October 21, 2008 Patient Safety Tip of the Week “Preventing Delirium”) has also been successful in reducing falls, though that data has not been published.


Their major concern is that hospitals may inappropriately intervene by using restraints in an ill-advised attempt to reduce falls (use of restraints, in fact, increases the likelihood of injury from falls). That may have the unintended consequence of reducing patient mobility. They even point out that the new Medicare policy has spurred an industry manufacturing devices intended to circumvent guidelines against traditional restraints.


We share their concerns about such unintended consequences. However, the CMS policy has caused hospitals to renew their focus on fall prevention. Most of the interventions in the HELP program (such as scheduled toileting, avoidance of restraints, avoiding psychoactive medications in the elderly, etc.) just make common sense and should be encouraged even without a more definitive evidence base, particularly since the cost of such implementation is relatively inexpensive.




Inouye SK, Brown CJ, Tinetti ME. Medicare Nonpayment, Hospital Falls, and Unintended Consequences. NEJM 2009; 360:2390-2393






NPSA Review of Patient Safety for Children and Young People


The National Patient Safety Agency in the UK has published its report “Review of patient safety for children and young people”. This summarizes learnings from data reported in the NPSA’s Reporting and Learning System (RLS). Of almost a million incidents now in that system, 2% relate to neonates and 5% to children. They acknowledge that reporting of incidents from primary care areas has been suboptimal so most of the incidents in the database come from hospitals.


The most commonly reported safety incident involving children or neonates related to “medication incidents”. In fact, the age group 0-4 had the second highest incidence of medication errors, surpassed only by the over 75 age group. Incorrect dose or strength was a big problem, including multiple examples of erroneous calculations and problems with decimal points (leading to 10-fold dosing errors). Note that a recent study in Austrailia also pointed out deficiencies in drug dose calculation skills, particularly of housestaff and less experienced physicians.


The report also highlights problems with recognition of severity of illness and continued problems with communication as issues of concern. Interestingly, the third most common type of incident was “slips, trips and falls”. Actually that should not be so surprising since in the age group of concern, slips trips and falls are very common amongst those healthy children who are not hospitalized. It does, however, emphasize the need to consider fall risk in our assessments of children as well as adults during hospitalization.





NPSA (UK). Review of patient safety for children and young people. 2009




Simpson CM, Keijzers GB, Lind JF. A survey of drug-dose calculation skills of Australian tertiary hospital doctors. Med J Aust 2009; 190 (3): 117-120






Failure to Inform Patients of Clinically Significant Outpatient Test Results


One of our continuing hot buttons is results of significant clinical findings slipping through the cracks. We discussed these extensively in our May 1, 2007 Patient Safety Tip of the Week “The Missed Cancer” and our February 12, 2008 Patient Safety Tip of the Week “More on Tracking Test Results”.


A new paper sheds some light on the frequency with which such failures to inform patients about clinically significant tests occur. Casalino et al reviewed charts from both community and academic primary care practices to find documentation of followup of abnormal results of 11 common blood tests and 3 common preventive tests. They found apparent failure to inform patients of such abnormal test results 7.1% of the time. Perhaps the most interesting finding is that those practices using a combination of paper and electronic records (so called “partial EMR”) had higher failure rates than those having either a full EMR or full paper-based systems. They found that very few practices had explicit rules or systems for managing test results and usually relied on the individual physician to devise his/her own system. Unfortunately, some were still telling patients to rely on the old “no news is good news” concept, which obviously is very flawed and unsafe.


This entire issue remains problematic and better systems are needed to ensure such abnormal test results do not slip through the cracks. Further research is needed to develop the evidence base for best practices in this regard.



Update: See also our October 13, 2009 Patient Safety Tip of the Week “Slipping Through the Cracks”.





Casalino LP, Dunham D, Chin MH et al. Frequency of Failure to Inform Patients of Clinically Significant Outpatient Test Results. Arch Intern Med. 2009;169(12):1123-1129.






Unintended Consequences of a DVT Prevention Strategy


Often we implement quality improvement or patient safety strategies without considering all the possible unintended consequences (or we simply do not know what unintended consequences to look for!). For years, graduated compression stockings have been used as a strategy to prevent DVT in patients with stroke. Though in the US we have felt that the evidence for use of these (as opposed to pneumatic compression stockings) in stroke patients was scant, they have been used extensively in other countries. And, while we were skeptical about their effectiveness, most of us took an attitude that “it can’t hurt”. Well, now a new study published in Lancet (CLOTS trial 1) shows that not only do thigh-high graduated stockings not prevent DVT in stroke patients, they actually cause harm. Skin breaks, ulcers, blisters, and skin necrosis were significantly more common in patients allocated to GCS than in those allocated to avoid their use.


The same group is now looking at both the efficacy and safety of pneumatic compression stockings in stroke patients (in the CLOTS-3 trial).


Whereas there is evidence to support use of graduated compression stockings in surgical patients, there will now undoubtedly also be studies now looking at the overall efficacy and unintended consequences of graduated compression stockings in other conditions.





The CLOTS Trials Collaboration. Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial. The Lancet 2009; 373:1958 - 1965, 6 June 2009

















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