What’s New in the Patient Safety World

June 2012



·        Leapfrog CPOE Simulation: Improvement But Still Shortfalls

·        I-PASS Results and Resources Now Available

·        Parents’ Math Ability Matters

·        John A. Hartford Foundation Poll on Care for Seniors

·        Tailored Timeouts for Ophthalmologists

·        Oregon Adverse Event Disclosure Guide

·        Surgeon Fatigue




Leapfrog CPOE Simulation: Improvement But Still Shortfalls



A couple years ago The Leapfrog Group developed a tool to simulate problematic medication orders (see our July 27, 2010 Patient Safety Tip of the Week “EMR’s Still Have a Long Way to Go”). The tool was to be used by hospitals to assess the vulnerabilities of their CPOE systems to medication errors. Voluntary testing at over 200 hospitals (Leapfrog 2010) then revealed that about half of errors on “routine” medication orders were missed and almost a third of potentially fatal medication errors were also missed. Those hospitals adjusted their CPOE systems and protocols and nearly all showed improvement when retested.


A similar test was conducted in 2011 by over 250 hospitals (Leapfrog 2012). The rate of missed potentially fatal errors dropped to just over 1% but the rate of missed “routine” medication errors was still on aveage about one third.


The CPOE evaluation tool is an excellent tool to identify potential vulnerabilities. When applied in a constructive fashion it has been shown to lead to significant improvement of hospital CPOE systems.






The Leapfrog Group. Leapfrog Group Report on CPOE Evaluation Tool Results

June 2008 to January 2010. June 2010




The Leapfrog Group. Lack of Testing and Monitoring of Health IT by Hospitals and Vendors Potentially Jeopardizes Patients -- Hospital Performance Is Improving, but More Must Be Done. PR Newswire April 27, 2012






Print “June 2012 Leapfrog CPOE Simulation: Improvement But Still Shortfalls







I-PASS Results and Resources Now Available



In our February 14, 2012 Patient Safety Tip of the WeekHandoffs – More Than Battle of the Mnemonics” we highlighted a new standardized handoff project “I-PASS” being piloted in a collaborative project led by Boston Children’s Hospital and several pediatric organizations (Starmer 2012). The leaders of the pediatric collaborative recognized that the SBAR format does not work very well for resident-to-resident handoffs, etc. because the situations are much more complex. So, even though adoption of SBAR has been shown to reduce adverse events in hospitals, they looked at other formats. Feedback from residents involved in a pilot of one tool said that a tool/format needed to be short, easy to remember, and not have elements that overlapped each other. They also recognized that it would have to integrate with the increasing use of computerized tools for handoffs and other communication. So they came up with the I-PASS format (and note that even though it sounds like the I PASS the BATON format it is a totally different format):

I: Illness Severity

P: Patient Summary

A: Action List

S: Situation Awareness and Contingency Planning

S: Synthesis by Receiver


The final “S” emphasizes a key feature of all successful communication: it ensures that the message is fully understood by the person receiving the handoff, including asking questions then summarizing the key steps and restating the key actions/to-do steps. The Starmer article includes a nice example of use of the I-PASS format in a clinical handoff. The Starmer article also summarizes some of the key elements that make a mnemonic successful. It needs to be “catchy”, symbolic, parsimonious, utilitarian, and somehow link a visual image to a process or subject. The I-PASS mnemonic certainly accomplishes that.


But make no mistake. This project is much more than just a new format. It also involves extensive team training (based on TeamSTEPPS™), simulation and role playing, direct observation of handoffs with feedback, and generation of a printed handoff document that can be integrated with the electronic medical record.


The I-PASS Study collaborative is now ongoing at 10 pediatric institutions and they have now demonstrated a significant reduction in medical errors after implementation of the program (Boston Children’s Hospital 2012). They found a 40% reduction in medical errors in a before and after study. Amazingly, they also found significant increases in patient contact and reduced computer time after implementation. They also documented numerous improvements in elements of the handoff process.


They have now made available many of the tools used in the program on the I-PASS website. These include materials for training both residents and faculty/attendings, sample simulations and role playing exercises, tools for feedback for direct observation of handoffs, and many other great tools.


Kudos to everyone involved in this project! They have done a great job addressing one of the most problematic interactions we see in medicine. Whether or not you adopt the I-PASS format itself at your institution, you will learn an incredible amount about handoffs and communication from this project.




Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:


May 15, 2007              Communication, Hearback and Other Lessons from Aviation

May 22, 2007              More on TeamSTEPPS™

August 28, 2007           Lessons Learned from Transportation Accidents

December 11, 2007     Communication…Communication…Communication

February 26, 2008       Nightmares….The Hospital at Night

September 30, 2008      Hot Topic: Handoffs

November 18, 2008      Ticket to Ride: Checklist, Form, or Decision Scorecard?

December 2008            Another Good Paper on Handoffs”.

June 30, 2009               iSoBAR: Australian Clinical Handoffs/Handovers

April 25, 2009              Interruptions, Distractions, Inattention…Oops!

April 13, 2010              Update on Handoffs

July 12, 2011               Psst! Pass it on…How a kid’s game can mold good handoffs

July 19, 2011               Communication Across Professions

November 2011            Restricted Housestaff Work Hours and Patient Handoffs

December 2011            AORN Perioperative Handoff Toolkit

February 14, 2012       Handoffs – More Than Battle of the Mnemonics






Starmer AJ, Spector ND, Srivastava R, et al. and  the I-PASS Study Group. I-PASS, a Mnemonic to Standardize Verbal Handoffs.

Pediatrics 2012; 129(2): 201 -204




Boston Children’s Hospital. I-PASS: Standardizing patient "handoffs" to reduce medical errors. News Release April 29, 2012




I-PASS Study website.






Print “June 2012 I-PASS Results and Resources Now Available





Parents’ Math Ability Matters



For years when we have talked about health literacy we have focused on reading levels and reading comprehension. Now a new study (AAP 2012) shows that parents’ mathematics skills, independent of reading skills, may play a big role in some pediatric medication errors. The study was done by Marrese et al. and presented as an abstract at the Pediatric Academic Societies (PAS) annual meeting April 28, 2012 (Marrese 2012).


The study showed parents with math skills at the third grade level or below were five times more likely to measure the wrong dose of medication for their child than those with skills at the sixth grade level or higher.


While about a third of the parents had low reading skills, 83% had poor “numeracy” skills, with 27% having skills at or below the third grade level. Parents with low numeracy may especially prone to make errors in tasks requiring dose measurement or measurement conversions.


The study highlights the need to address numeracy skills of parents when communicating medication instructions (we suspect the same is likely to apply to adult medication errors as well). They provide as an example having providers review and give parents pictures of dosing instruments filled to the correct amount for that prescription.







American Academy of Pediatrics (AAP). Parents’ Poor Math Skills May Lead to Medication Errors. AAP press release April 28, 2012





Marrese C, Dreyer B, Mendelsohn A, Moreira H, Yin HS. Parent Medication Dosing Errors: Role of Health Literacy and Numeracy (abstract). Pediatric Academic Societies (PAS) annual meeting April 28, 2012






Print “June 2012 Parents' Math Ability Matters






John A. Hartford Foundation Poll on Care for Seniors



We’ve often talked about the disconnect between perception of quality of care and measures of actual quality of care. The John A. Hartford Foundation recently released results of a poll of over 1000 adults aged 65 and older (John A. Hartford Foundation 2012). While 97% of respondents were satisfied with the care they got from their primary care physician, responses to specific questions identified serious gaps in care. Many of those gaps impact on health status, patient safety and quality of life.


The poll asked about items of care considered important in geriatric care. For example, at least an annual review of all medications taken is very important, yet 32% of seniors responding stated they had not had such a medciation review in the past 12 months. 60-70% did not recall being asked about falls or fear of falling, depression symptoms, or activities of daily living. Less than 20% were counseled on how to avoid falling.


Of seven geriatrician-recommended services, only 7% received all seven and 76% received fewer than half the services.


Interstingly, over two-thirds of the seniors were unaware that Medicare covers an annual “wellness” visit that has no out-of-pocket expense to them.


Of course, some critics will note that the survey was based upon the patient’s recall and that perhaps some of the services were actually rendered. But you get the idea – we often fail to deliver services that are important in preventing harm to our patients (and could avoid substantial unnecessary costs to our healthcare system).


When we do the “brown bag” visit (where we have our patient bring in all the medicines he/she is taking at home) we cease to be amazed at how many medications we end up taking away. Similarly, while we see many physicians ordering DEXA scans to look for osteoporosis, only a minority of those same physicians actually perform a fall risk assessment on those same patients. Yet many physicians don’t schedule their Medicare patients for that annual wellness visit where such services should take place (and the Medicare reimbursement for such visits is better than for most office visits).


Now that electronic medical records are being adopted in the majority of medical practices, we need to make better use of alerts, reminders, and registries to identify such gaps in care and be proactive in providing these services.


We’re missing a big opportunity to improve health status, prevent untoward events, and save money at the same time. Hopefully, our move towards more accountable care will help close some of these gaps.






John A. Hartford Foundation. John A. Hartford Foundation Public Poll: “How Does It Feel? The Older Adult Health Care Experience” April 23, 2012






Print “June 2012 John A. Hartford Foundation Poll on Care for Seniors






Tailored Timeouts for Ophthalmologists



Just as we’ve discussed using different structured formats for handoffs depending on the setting and context, the same can be said for the format and structure of surgical timeouts. In fact, when the WHO Surgical Safety Checklist project was launched they encouraged that the checklist be modified for the needs of each setting (see our Patient Safety Tips of the Week for July 1, 2008 “WHO’s New Surgical Safety Checklist” and January 20, 2009 Patient Safety Tip of the Week “The WHO Surgical Safety Checklist Delivers the Outcomes”).


A new study by Tina Rutar and colleagues at UCSF, presented at this year’s annual meeting of the American Association for Pediatric Ophthalmology and Strabismus (AAPOS) and recently summarized in Medscape (Zimmerman 2012), illustrates this concept nicely. They surveyed ophthalmologists about errors made during strabismus surgery and noted that Universal Protocol would likely have prevented only 16% of the errors in this field. Strabismus surgery is prone to errors because of the multiple muscles involved in eye movements, fact that sometimes you are strengthening a muscle and at other times weakening one, and that the surgeon is typically looking at the patient upside down, adding to right/left and up/down confusion. They also noted that terminology used may lead to problems (eg. the terms “recess” and “resect” or the abbreviations “rec” and “res” probably lead to more confusion that the terms “strengthening” and “weakening”).


The article has good suggestions from this team on ways to tailor surgical checklists for strabismus surgery.






Zimmerman R. Strabismus Surgical Checklist Can Help Prevent Errors. One Third of Eye Surgeons Report Having Made Operating Room Errors. Medscape News May 7, 2012






Print “June 2012 Tailored Timeouts for Ophthalmologists






Oregon Adverse Event Disclosure Guide



Disclosure and apology after adverse medical events have become the recommended actions (see the links to multiple columns on disclosure and apology at the end of today’s column). There have been many excellent resources on disclosure and apology, including:

·        IHI’s “Respectful Management of Serious Clinical Adverse Events” (Conway 2010)

·        The Canadian Disclosure Guidelines (Canadian Patient Safety Institute 2008)

·        The Harvard Disclosure Guidelines (Massachusetts Coalition for the Prevention of Medical Errors 2006)

·        The ACPE Toolkit (American College of Physician Executives)


Now the Oregon Patient Safety Commission has developed the Oregon Adverse Event Disclosure Guide. Oregon is one of the states with laws governing disclosure and some degree of legal protection in the disclosure process. The Guide has a good discussion on the goals of disclosure. Disclosure is not just to satisfy the state’s legal requirements. Rather it is to demonstrate empathy and respect for the patient, increase trust between the providers/healthcare system and the patient, family, and community at large, enhance accountability and transparency, give patients and families an opportunity to understand what happened, and demonstrate to employees the organization’s commitment to safety and quality. Additionally, disclosure may have a positive impact on both litigation outcomes and media attention. They recommend disclosure not only in those adverse events defined by statute but even in those cases where no patient harm occurred and sometimes where no errors occurred.


The Guide recommends oral disclosure followed by written disclosure. They strongly recommend that the initial disclosure always be done in-person but that the written disclosure be used to enhance, not replace, that in-person interaction.


The best part of the Guide is its terrific set of links to other resources. While they provide links to all the valuable resources we’ve mentioned above, they also provide links to sample disclosure policies, letters, work plans, and tools to improve the ability of providers to do disclosure in the proper, empathetic manner.




Some of our prior columns on Disclosure & Apology:

July 24, 2007               Serious Incident Response Checklist

June 16, 2009              Disclosing Errors That Affect Multiple Patients

June 22, 2010              Disclosure and Apology: How to Do It

September 2010           Followup to Our Disclosure and Apology Tip of the Week

November 2010           IHI: Respectful Management of Serious Clinical Adverse Events

April 2012                    Error Disclosure by Surgeons







Oregon Patient Safety Commission. Oregon Adverse Event Disclosure Guide. A Resource for Physicians and Healthcare Organizations. 2012






Print “June 2012 Oregon Adverse Event Disclosure Guide







Surgeon Fatigue



In our January 3, 2012 Patient Safety Tip of the Week “Unintended Consequences of Restricted Housestaff Hours” we highlighted a study from Children’s Hospital in Boston (Chua 2011) that found a “night float” system ended up leading to a paradoxical decrease in sleep for residents. Now that same group has published a great study on fatigue in orthopedic residents (McCormick 2012).


Using some tools used in other industries to measure the effects of fatigue they demonstrated that the residents were fatigued almost 50% of their waking time and functioning at an “impaired” level a quarter of the time! Residents wore an actigraphy watch and recorded logs and the study utilized the SAFTE (sleep, activity, fatigue, and task effectiveness) model and Fatigue Avoidance Scheduling Tool for assessment. The average amount of daily sleep per resident was 5.3 hours. According to the tools, they functioned at less than 80% mental effectiveness 48% of the time. More strikingly, they functioned at less than 70% mental effectiveness (equivalent to a blood alcohol level of 0.08%) 27% of their wake time! Numbers for night float residents were even worse. Though they did not actually measure patient outcomes, the tools predicted the overall fatigue levels would increase the risk of medical errors by 22%.


The authors note that the increased fatigue in the night float system, combined with the issues related to cross-covering many patients with whom they are less familiar, results in a situation highly likely to produce many errors.


This is a really good demonstration on borrowing tools and concepts from other industries and applying them to critical healthcare situations. Moreover, it’s also a reminder to always look for unintended consequences when implementing solutions we think make logical sense. Nice work from solid, practical researchers.




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 2010                Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety

January 3, 2012            Unintended Consequences of Restricted Housestaff Hours






Chua K-P, Gordon MB, Sectish T, Landrigan CP. Effects of a Night-Team System on Resident Sleep and Work Hours. Pediatrics 2011; 128:6 1142-1147




McCormick F, Kadzielski J, Landrigan CP, et al. Surgeon Fatigue. A Prospective Analysis of the Incidence, Risk, and Intervals of Predicted Fatigue-Related Impairment in Residents. Arch Surg 2012; 147(5): 430-435






Print “June 2012 Surgeon Fatigue




Print “June 2012 What's New in the Patient Safety World (full column)

Print “June 2012 Leapfrog CPOE Simulation: Improvement But Still Shortfalls

Print “June 2012 I-PASS Results and Resources Now Available

Print “June 2012 Parents' Math Ability Matters

Print “June 2012 John A. Hartford Foundation Poll on Care for Seniors

Print “June 2012 Tailored Timeouts for Ophthalmologists

Print “June 2012 Oregon Adverse Event Disclosure Guide

Print “June 2012 Surgeon Fatigue













Tip of the Week Archive


What’s New in the Patient Safety World Archive