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What’s New in the Patient Safety World

July 2022



·       Five-Character Drug Search Has Problems, Too

·       Outcomes OK When Surgeon Operated the Night Before

·       C. diff Success Story

·       Asymptomatic Bacteriuria Still Problematic




Five-Character Drug Search Has Problems, Too



In our April 12, 2022 Patient Safety Tip of the Week “A Healthcare Worker’s Worst Fear” we mentioned that, after the Vanderbilt neuromuscular blocking agent (NMBA) case, ISMP began recommending the entry of a minimum of five characters of a drug name during searches in ADC’s. ISMP’s “Guidelines for Safe Electronic Communication of Medication Information” also include that requirement for medication searches on other forms of electronic communication.


But ISMP also has seen reports where even entry of 5 letters has been associated with errors (ISMP 2021). For example:

·       You can still make a misspelling error in the first 5 characters of a drug’s name.

·       Some people have entered spaces or symbols to meet the 5-character requirement.

·       Combination drugs or parenteral fluids have been difficult to locate.

·       Some drugs are known by several different names.

·       In an emergency, some have forgotten the new requirement and entered fewer than 5 characters and been unable to promptly retrieve the emergency drug.

·       Some practitioners, unable to find their intended product, may scroll through an entire list of drugs using the inventory function rather than searching for a specific drug, a practice considered unsafe and time-consuming by ISMP.


ISMP offers some potential solutions:

·       For drug names with the same beginning characters beyond five letters, you might want to consider adding the therapeutic class to the drug name listing to help avoid drug selection errors (e.g., methylPREDNISolone [corticosteroid], methylphenidate [stimulant], methylnaltrexone [gastrointestinal agent], methylergonovine [ergot derivative]).

·       It is also reasonable to consider creating an alias/synonym for certain drugs on the override list that are commonly known by an alias/synonym. For example, NSS <space> <space> may be created as an alias for 0.9% sodium chloride solution. But each synonym created should be reviewed against other aliases/synonyms to ensure they are not too similar. 

·       ISMP also notes it might be safest to allow simultaneous drug name searches by the current brand and generic name. You’ll recall in the Vanderbilt NMBA incident, letters of a brandname drug were entered when the ADC only had the generic name.


There have also been suggestions that vendor functionality should be more tailored and specific to individual, problematic drugs that require the five-character search via override, rather than requiring an all-inclusive change for all drug name searches via override. Another suggestion is to allow users to “opt out” certain drugs from the five-character search rule but ISMP notes that could be confusing to require two different levels of drug name searches. ISMP also suggests that vendors might develop algorithms that would allow users to enter the exact number of characters to get only one unique drug name to appear on the screen, making emergency kits and key emergency drugs always accessible (ISMP notes that a separate code cart should always be maintained for emergency equipment and drugs to use during a cardiac and/or respiratory arrest).


As a precaution, ISMP recommends that before implementing the five-character search requirement for medications obtained from an ADC via override, hospitals should analyze the workflow, especially the searchability of emergency medications, and conduct a failure mode and effects analysis (FMEA) to identify and manage potential challenges (the ISMP article has some nice examples of risk points to consider during the FMEA). Prior to implementation, organizations must develop a robust and effective communication plan, and obtain feedback from frontline staff. After any changes, collect data to assess whether unintended consequences are occurring and make appropriate adjustments if needed.


And ISMP strongly recommends that, whenever possible, orders should be entered and verified by a pharmacist to allow medication or product removal within the patient’s profile, bypassing the requirement to enter five characters and limiting the necessity for ADC overrides.


The 5-letter entry requirement for drug searches on ADC’s or CPOE or any electronic medication system is certainly a step in the right direction. ISMP has done its usual great job of identifying barriers, challenges, and potential unintended consequences to implementing this important patient safety intervention.



Our prior columns related to ADC’s (automated dispensing cabinets):

December 2007           “1000-fold Heparin Overdoses Back in the News Again”

August 23, 2016         “ISMP Canada: Automation Bias and Automation Complacency”

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”

June 11, 2019              “ISMP’s Grissinger on Overreliance on Technology”

September 7, 2021      “The Vanderbilt Tragedy Gets Uglier”

April 12, 2022             “A Healthcare Worker’s Worst Fear”






ISMP (Institute for Safe Medication Practices). Guidelines for Safe Electronic Communication of Medication Information. ISMP 2019; January 16, 2019



ISMP (Institute for Safe Medication Practices). Challenges with Requiring Five Characters During ADC Drug Searches Via Override. ISMP Medication Safety Alert! Acute Care Edition 2021; October 21, 2021





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Outcomes OK When Surgeon Operated the Night Before



The role of fatigue in causing errors in healthcare or any industry is well established. But there is one glaring example that seems to defy this concept. In our September 2015 What's New in the Patient Safety World column “Surgery Previous Night Does Not Impact Attending Surgeon Next Day” we discussed a Canadian study (Govindarajan 2015) that showed outcomes for the “next day” case do not seem to be adversely impacted by the surgeon’s previous night procedures.


Now a new study (Sun 2022) from more than 50 hospitals across 18 states and 2 countries (US and the Netherlands) confirms the results seen in the Canadian study. Sun et al. looked at outcomes of almost 500,000 surgeries, of which 2.6% involved an attending surgeon who operated the night before.


After adjusting for operation type, surgeon fixed effects (indicator variables for each surgeon), and patient characteristics such as age and comorbidities, the incidence of in-hospital death or major complications was 5.89% among daytime operations when the attending surgeon operated the night before compared with 5.87% among daytime operations when the same surgeon did not. There was also no difference in several secondary outcomes studied except for a slight decrease in the length of daytime operations.


Several sensitivity analyses also suggested no difference between overnight work and the primary outcome. There was no statistically significant difference in the incidence of death or major complication for daytime procedures based on procedure length. Each additional hour worked the previous night was associated with a statistically nonsignificant decrease in the probability of death or a major complication for daytime procedures.


The authors conclude that, combined with previous studies, their results provide reassurance concerning the practice of having attending surgeons take overnight call and still perform procedures the following morning. They state their results do not establish that this practice is always safe or that fatigue does not affect outcomes, but that the potential risk was managed well enough to avoid patient harm in this sample of

surgeons. They do note that these cases were done mostly at academic institutions and that the results may not be generalizable to other settings.


Again, this is a very different question from one we have addressed on numerous occasions. Several of our columns have questioned whether surgery should be done “after hours”, particularly for procedures that may not be true emergency ones (see our What’s New in the Patient Safety World columns for September 2009 “After-Hours Surgery – Is There a Downside?”, October 2014 “What Time of Day Do You Want Your Surgery?”, December 2014 “Another Procedure to Avoid Late in the Day or on Weekends” and January 2015 “Emergency Surgery Also Very Costly”).


In those columns we have pointed out that such surgeries and procedures involve considerations far beyond just the surgeon. Why should “after hours” surgery be more prone to adverse outcomes than regularly scheduled elective surgery? There are many reasons aside from the fact that patients needing emergency and after hours surgery are generally sicker. You are operating with a team that is likely different from your daytime team. All members of that team (physicians, nurses, anesthesiologists, techs, etc.) may not have the same level of expertise as your regular daytime team and the team dynamics between members is likely to be different. The post-surgery recovery unit is likely to be staffed much differently after-hours as well. The staff may be more likely to be unfamiliar with things like location of equipment. And some of the other hospital support services (eg. radiology, laboratory) may have lesser staffing after-hours. Just as importantly, many or all of the “on-call” staff that make up the after-hours surgical team have likely worked a full daytime shift that day so fatigue enters as a potential contributory factor. And there are always time pressures after hours as well. In addition, one of the most compelling reasons surgery is done at night rather than deferred to the next morning is the schedule of the surgeon or other physician for that next morning (either in surgery or the cath lab or his/her office). Because the surgeon does not want to disrupt that next day schedule, he/she often prefers to go ahead with the current case at night. Similarly, many hospitals run very tight OR schedules and adding a case from the previous night can disrupt the schedule of many other cases.


It is reassuring, however, that both the studies by Sun et al. and Govindarajan et al. seem to indicate that surgeons operating the day following a night procedure have managed potential risk well enough to avoid patient harm.



Some of our other columns on the role of fatigue in Patient Safety:


November 9, 2010      “12-Hour Nursing Shifts and Patient Safety”

April 26, 2011             “Sleeping Air Traffic Controllers: What About Healthcare?”

February 2011             “Update on 12-hour Nursing Shifts”

September 2011          “Shiftwork and Patient Safety

November 2011          “Restricted Housestaff Work Hours and Patient Handoffs”

January 2012               “Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety

January 3, 2012           “Unintended Consequences of Restricted Housestaff Hours”

June 2012                    “June 2012 Surgeon Fatigue”

November 2012          “The Mid-Day Nap”

November 13, 2012    “The 12-Hour Nursing Shift: More Downsides”

July 29, 2014              “The 12-Hour Nursing Shift: Debate Continues”

October 2014              “Another Rap on the 12-Hour Nursing Shift”

December 2, 2014       “ANA Position Statement on Nurse Fatigue”

August 2015               “Surgical Resident Duty Reform and Postoperative Outcomes”

September 2015          “Surgery Previous Night Does Not Impact Attending Surgeon Next Day”

September 29, 2015    “More on the 12-Hour Nursing Shift”

September 6, 2016      “Napping Debate Rekindled”

April 18, 2017             “Alarm Response and Nurse Shift Duration”

July 11, 2017              “The 12-Hour Shift Takes More Hits”

February 13, 2018       “Interruptions in the ED”

April 2018                   “Radiologists Get Fatigued, Too”

August 2018               “Burnout and Medical Errors”

September 4, 2018      “The 12-Hour Nursing Shift: Another Nail in the Coffin”

August 2020               “New Twist on Resident Work Hours and Patient Safety”

August 25, 2020         “The Off-Hours Effect in Radiology”

September 2020          “Daylight Savings Time Impacts Patient Safety?”

January 19, 2021         “Technology to Identify Fatigue?”

October 12, 2021        “FDA Approval of Concussion Tool – Why Not a Fatigue Detection Tool?”

February 2022             “Does Time of Day Matter?”


Some of our previous columns on “after-hours” surgery:

·       September 2009        “After-Hours Surgery – Is There a Downside?”

·       October 2014            “What Time of Day Do You Want Your Surgery?”

·       January 2015             “Emergency Surgery Also Very Costly”

·       September 2015        “Surgery Previous Night Does Not Impact Attending Surgeon Next Day”

·       October 4, 2016        “More on After-Hours Surgery”

·       August 15, 2017        “Delayed Emergency Surgery and Mortality Risk”

·       October 24, 2017      “Neurosurgery and Time of Day”

·       December 2019         “Surgeon On-Call Shifts”

·       October 13, 2020      “Night-Time Surgery”







Govindarajan A, Urbach DR, Kumar M, et al. Outcomes of Daytime Procedures Performed by Attending Surgeons after Night Work. N Engl J Med 2015; 373: 845-853

(Govindarajan 2015)



Sun EC, Mello MM, Vaughn MT, et al. Assessment of Perioperative Outcomes Among Surgeons Who Operated the Night Before. JAMA Intern Med 2022; Published online May 23, 2022

(Sun 2022)






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C. diff Success Story



A community hospital within an academic health care system was struggling with high hospital-onset C. diff infection (HO-CDI) rates. An interdisciplinary team put together evidence-based interventions to successfully reduce HO-CDI rates (Walter 2022). Interventions included: diagnostic stewardship, enhanced environmental cleaning, antimicrobial stewardship and education and accountability. After one year, they achieved a 63% reduction in HO-CDI and have sustained a 77% reduction. The infection rate remained below national benchmark for HO-CDI for over 4 years at a rate of 2.80 per 10,000 patient days.


Interventions recommended in CDC’s “CDI Prevention Strategies” (CDC 2021) were used. A key to any quality improvement program is having clinical champions. Their interdisciplinary team had both unit nurse champions and physician champions. In addition to a strong nursing team leader, they had an infection preventionist, a clinical microbiologist, an epidemiologist, an antimicrobial stewardship pharmacist, and an environmental services representative on the interdisciplinary team.


One important element was development of a new clinical testing protocol. This allowed nurses to test any unformed stool for C. diff without the need for a provider order. The patient with a loose stool would be placed on contact enteric isolation until a negative test result was received.


Another important element was reinforcement that staff members conduct hand hygiene with soap and water rather than hand sanitizer. Programs to improve hand hygiene have often focused on increased use of alcohol-based hand sanitizers. But those don’t kill C. diff spores. Use of soap and water is the best way to eliminate C. diff spores.


Another key was enhancement of environmental cleaning. Environmental services workers changed to a more effective sporicidal disinfectant and started using that in all patient rooms regardless of isolation status. In addition, in patient rooms that were placed under contact enteric isolation for a C. diff infection, cleaning was intensified, including a terminal cleaning with disinfectant and UV light disinfection, and cleaning equipment with bleach wipes.


Their antimicrobial stewardship program focused on reducing the use of fluoroquinolones. Clinical staff could now only order them fluoroquinolones as part of an order set and clinical decision support was built into the electronic medical record to prevent standalone orders for fluoroquinolones.


The educational component utilized multiple modalities, including emails, flyers, meetings, educational sessions, and huddles. New hires also learned about the new protocols during orientation.


The addition of an accountability processes further improved compliance with standards of practice. Staff on the team and units received emailed notices about compliance issues and held meetings to discuss how to improve compliance.


Kudos to the team at Emory Saint Joseph's Hospital in Atlanta, Georgia for this successful project!



Some of our prior columns on C. diff infections:

·       August 2021               “Updated Guidelines on C. diff”

·       October 2021              “HAI’s Increase During COVID-19 Pandemic”

·       March 2022                 “Predicting C. diff Infection in Just 6 Hours?”






Walter C, Soni T, Gavin MA, et al. An interprofessional approach to reducing hospital-onset Clostridioides difficile infections. American Journal of Infection Control 2022; Published:May 11, 2022



CDC (Centers for Disease Control and Prevention). CDI Prevention Strategies

Strategies to Prevent Clostridioides difficile Infection in Acute Care Facilities. CDC

Page last reviewed: December 17, 2021





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Asymptomatic Bacteriuria Still Problematic



Inappropriate antibiotic prescribing can lead to emergence of antibiotic resistance, adverse drug reactions, development of opportunistic infections like C. diff, and add to unnecessary healthcare costs. Hence, the need for antibiotic stewardship programs.


One area of inappropriate antibiotic prescribing where attention has been focused is asymptomatic bacteriuria. Guidelines from the Infectious Diseases Society of America (Nicolle 2019) and Choosing Wisely recommend we do not treat asymptomatic bacteriuria with antibiotics.


But University of Maryland researchers recently identified a disturbing trend regarding how physicians approach asymptomatic bacteriuria. Baghdadi and colleagues (Baghdadi 2022) reported the results of a survey of 723 primary care clinicians (physicians and advanced practice clinicians) in active practice regarding their approach to a hypothetical patient with asymptomatic bacteriuria. Results were striking. 71% of respondents indicated that they would prescribe antibiotic treatment for asymptomatic bacteriuria in the absence of an indication. The tendency was more pronounced among family medicine physicians and those with a high score on the Medical Maximizer-Minimizer Scale (individuals with a stronger orientation toward medical maximizing prefer treatment even when the value of treatment is ambiguous). The tendency was less common among resident physicians and clinicians in the US Pacific Northwest.


The authors suggest that clinician characteristics should be considered when designing antibiotic stewardship interventions. Specifically, physician culture (rather than urine culture) may be an important determinant of inappropriate prescribing. The concept of “medical maximizers” was especially of interest. “Medical maximizers favor errors of commission over errors of omission, preferring to treat even when treatment has uncertain value and may introduce a chance of harm.” The authors note that their finding of an association between medical maximizing and inappropriate antibiotic prescribing is important because it suggests that certain tendencies among clinicians may pose a barrier to initiatives, such as Choosing Wisely, that are intended to combat the emergence of antimicrobial resistance.


Though not specifically addressing the issue of prescribing antibiotics for asymptomatic bacteriuria, there have been several other recent studies addressing physician characteristics related to inappropriate antibiotic prescribing. In our May 24, 2022 Patient Safety Tip of the Week “Requiring Indication for Antibiotic Prescribing” we noted a study (Neels 2020) citing many factors that contribute to inappropriate antibiotic prescribing in general practice. These include automatic repeat prescriptions, inappropriate durations and quantities and the extended period of time during which a prescription may be filled. In addition, some prescriptions are dispensed more than 60 days after the prescription date, suggesting likely usage for an alternate indication to that intended by the prescriber. Patient expectations may also lead to inappropriate antibiotic prescribing. They implemented an educational intervention in a large general practice clinic in Australia. It included face-to-face education sessions with physicians on antimicrobial stewardship principles, antimicrobial resistance, current prescribing guidelines and microbiological testing. This resulted in a significant reduction in prescriptions without a listed indication for antimicrobial therapy, prescriptions without appropriate accompanying microbiological tests and the provision of unnecessary repeat prescriptions. There were significant improvements in appropriate antimicrobial selection, appropriate duration, and compliance with guidelines. And two recent studies in BMJ Quality & Safety discussed factors related to long-term and repeat antibiotic prescriptions in primary care in the UK (Krockow 2022, Van Staa 2022).



Some of our prior columns on antibiotic stewardship:



Our other columns on urinary catheter-associated UTI’s:







Nicolle LE, Gupta K, Bradley SF, et al.  Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clin Infect Dis 2019; 68(10): e83-e110



Choosing Wisely Campaign. Infectious Diseases Society of America. Don’t treat asymptomatic bacteruria with antibiotics. Released February 23, 2015



Baghdadi JD, Korenstein D, Pineles L, et al. Exploration of Primary Care Clinician Attitudes and Cognitive Characteristics Associated With Prescribing Antibiotics for Asymptomatic Bacteriuria. JAMA Netw Open 2022; 5(5): e2214268



Neels AJ, Bloch AE, Gwini SM, Athen E. The effectiveness of a simple antimicrobial

stewardship intervention in general practice in Australia: a pilot study. BMC Infectious Diseases 2020; 20: 586



Krockow EM, Harvey EJ, Ashiru-Oredope D. Addressing long-term and repeat antibiotic prescriptions in primary care: considerations for a behavioural approach. BMJ Quality & Safety 2022; Published Online First: 15 June 2022



Van Staa T, Li Y, Gold N, et al. Comparing antibiotic prescribing between clinicians in UK primary care: an analysis in a cohort study of eight different measures of antibiotic prescribing. BMJ Quality & Safety 2022; Published Online First: 03 March 2022





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Print “July 2022 What's New in the Patient Safety World (full column)”

Print “July 2022 Five-Character Drug Search Has Problems, Too”

Print “July 2022 Outcomes OK When Surgeon Operated the Night Before”

Print “July 2022 C. diff Success Story”

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