What’s New in the Patient Safety World

June 2016


·         ISMP Article on Workarounds

·         Disclosure and Apology: The CANDOR Toolkit

·         Weekend Effect Challenged

·         An EMR-Based Early Warning Score




ISMP Article on Workarounds



Regular readers of our columns recognize that when we identify occurrence of a “workaround”, which is often detrimental to patient safety, we always need to investigate and identify the reason(s) why that healthcare worker had to do a workaround.


Last month, ISMP had a great column (ISMP 2016) on the need to turn “first-order thinking” (i.e. the workaround) into second-order thinking where the organization learns and institutes long-term solutions rather than just tolerating short-term fixes that will not prevent recurrences.


The ISMP column notes that we value ingenuity and creativity in healthcare. We have all seen cases where a physician or nurse has encountered an obstacle and found an immediate solution to save a patient’s life or otherwise prevent harm. The problem, of course, is that individuals who use the creativity to develop a workaround or quick fix to a problem do not often enough bring the issues to the greater attention of the organization. As a result, there is no systemic learning and the same set of circumstances that led to the workaround are likely to recur. The next time they recur there may not be as creative a healthcare worker to intervene.


We’ve demonstrated how workarounds may adversely impact patient safety in our Patient Safety Tips of the Week for June 17, 2008 “Technology Workarounds Defeat Safety Intent”, September 15, 2009 “ETTO’s: Efficiency-Thoroughness Trade-Offs”, and April 5, 2016 “Workarounds Overriding Safety” and several other columns listed below.


One question we always ask healthcare workers when we are doing Patient Safety Walkrounds is “Can you tell us one workaround that you have used recently?” (see our October 7, 2014 Patient Safety Tip of the Week “Our Take on Patient Safety Walk Rounds”). We have emphasized that when you identify issues on Patient Safety Walkrounds you need to follow them to closure in a timely fashion and communicate back to the front line staff that you have developed and implemented solutions. That is a point also emphasized in the ISMP column.


Another good venue in which to identify workarounds are your post-op debriefings (see our multiple previous columns on debriefings listed below).


Some workarounds are effective, others are maladaptive. Either way, they serve to identify a system vulnerability that needs to be fixed. So when you identify a workaround is occurring you need to assess the root cause(s) of the problem and come up with solutions. The solution might, in fact, be the one the creative healthcare worker has used. So you need to consider that solution and others. The most important point in the ISMP column is that we need to create cultures that encourage healthcare workers to come forward whenever they have had to create a workaround. If the problems leading to use of that workaround are not brought to the attention of others, those problems will ultimately impact care of other patients.



Some of our prior columns related to workarounds:


September 4, 2007 “Workarounds as a Safety Issue

May 2008 “UK NPSA Alert on Heparin Flushes

June 17, 2008 “Technology Workarounds Defeat Safety Intent

September 15, 2009 “ETTO’s: Efficiency-Thoroughness Trade-Offs

August 24, 2010 “The BP Oil Spill - Analogies in Healthcare

March 6, 2012 “Lab Error

July 2, 2013 “Issues in Alarm Management

April 8, 2014 “FMEA to Avoid Breastmilk Mixups

October 7, 2014 “Our Take on Patient Safety Walk Rounds

April 5, 2016 “Workarounds Overriding Safety” among other columns.



See our prior columns on huddles, briefings, and debriefings:







ISMP (Institute for Safe Medication Practices). Reporting and second-order problem solving can turn short-term fixes into long-term remedies. ISMP Medication Safety Alert! Acute Care Edition. 2016; May 19, 2016







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Disclosure and Apology: The CANDOR Toolkit



Our numerous columns on disclosure and apology after medical error (listed below) have stressed that such are not only the right things to do but in the long run help patients and families reach closure and help prevent other similar errors and adverse outcomes. In addition, that approach is now widely accepted as reducing litigation and malpractice settlements.


But the healthcare professions and organizations have historically done a poor job in preparing individuals in providing disclosure and apology. A new toolkit provided by AHRQ, the CANDOR toolkit, provides excellent resources for organizations in this process (AHRQ 2016). CANDOR stands for Communication and Optimal Resolution. The toolkit comes with 8 modules and an implementation guide. The modules come with PowerPoint slides and videos that illustrate key principles and speaker notes to guide the discussions.


The presentations start with identification of a CANDOR event and how to activate your CANDOR Response Team. Ideally, activation of the CANDOR Response Team should begin within 30 minutes after a CANDOR event has been identified. In addition to initiating the fact-finding investigation of the event, a CANDOR Communication Lead should be identified and immediate emotional support to the patient, family, and caregiver should be provided, the latter by activating the Care for Caregiver program. The CANDOR Response Team and/or CANDOR Communication Lead are responsible for the initial communication with the patient and/or family.  The CANDOR Communication Lead coordinates all communications, and ensures that all caregivers are consistent in their communication, i.e., that they stay "on message." Following the initial disclosure conversation, the CANDOR Response Team ensures that a trained communicator establishes ongoing regular communication with the patient and/or family.


As we’ve so often pointed out in the past, we also need to remember that all these unfortunate events also have “second victims”, that is the caregivers involved in the incidents. One of the other key functions of the CANDOR Response Team is assessing the needs of caregivers involved in the harm event and providing initial emotional support and activating the programs your organization hopefully have implemented for providing ongoing support for the caregivers. Details and resources for dealing with the caregivers are provided in Module 6.


Modules 2 and 3 deal with developing the culture your organization needs and preparing your organization for implementation of the CANDOR program.


The first module also describes the Event Investigation and Analysis and timeframes for its optimal initiation and completion, which is further described in detail in Module 4. This is basically the root cause analysis (RCA) plus other considerations and has a checklist to help guide the team(s). Throughout the process the importance of maintaining a “Just Culture” with shared accountability is stressed.


That fourth module also notes it is important to inform the patient, family, and the involved caregivers of the investigation and analysis results. It provides resources to help your organization engage patients and families. It also discusses how to communicate with and involve your organization’s liability carrier. One of the resources is a link to discussions of the University of Michigan's early disclosure and offer program (see our September 2010 What's New in the Patient Safety World column “Followup to Our Disclosure and Apology Tip of the Week”).


Module 5 discusses the response and disclosure and provides some excellent resources and recommendations, such as how to deal with challenging communications. It provides checklists, case scenarios, and videos of both appropriate and inappropriate disclosures to patients.


Module 7 deals with resolution. Resolution in the CANDOR process involves actions associated with addressing the patient, family, and staff expectations. The main objective of resolution in the CANDOR process is to meet the needs and expectations of the patient. It stresses that failure to do this can lead to a loss of trust from the patient. This component of the overall process might lead to a financial settlement, but notes that such settlements might not always lead to resolution of all issues related to the adverse event. Financial recompense is not always the most important need of the patient and/or family. They often want to know that their unfortunate event may lead to implementation of processes that will prevent others from suffering the same consequences. It stresses the importance of the organization taking responsibility and showing legitimate remorse. It also has excellent resources regarding the skills required in properly communicating with multiple parties throughout this phase.


The final module deals with organizational learning and how to ensure sustainability of the CANDOR program and, more importantly, the culture needed to ensure its sustainability.


Overall, the CANDOR toolkit is an outstanding resource that every healthcare organization must take advantage of. Many organizations have had to stumble through handling adverse events and had to learn the hard way. The CANDOR toolkit can help organizations take a very proactive approach to establishing programs that are the right way to do things.



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

June 2012                    Oregon Adverse Event Disclosure Guide

December 17, 2013     The Second Victim


Other very valuable resources on disclosure and apology:







AHRQ (Agency for Healthcare Research and Quality). Communication and Optimal Resolution (CANDOR) Toolkit. AHRQ 2016; Rockville, MD http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/candor/introduction.html





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Weekend Effect Challenged



The “weekend effect” (sometimes also known as the “after hours effect” since many of the same results apply to patients admitted at night as well as on weekends) in which increases in mortality, complications or adverse events are seen for patients admitted on weekends has been demonstrated for a wide range of both surgical and medical conditions. Our numerous columns on the “weekend effect” have stressed that there are likely both patient-related and system-related factors underlying the phenomenon (see, for example, our November 2013 What's New in the Patient Safety World column “The Weekend Effect: Not One Simple Answer”).


Several recent articles have challenged the concept of the “weekend effect” and pointed out deficiencies in case identification methodologies that may give rise to inaccurate conclusions.


Stroke is one of the many conditions previously identified as prone to the weekend effect. One new analysis from the UK (Li 2016), however, looks at how use of administrative coding to identify stroke cases may erroneously lead to this conclusion. The authors looked at stroke cases from the Oxford Vascular Study and found that many patients admitted with a stroke diagnosis may not, in fact, have had a new stroke. Rather many had a previous stroke and were admitted for other reason yet administrative coding made them appear to have had new strokes. Such patients obviously have a lower likelihood of mortality during that admission and they are disproportionately admitted on weekdays (often for procedures). Thus, it is not surprising that patients admitted on weekends (who have new strokes) would appear to have higher mortality rates. When the authors looked just at those patients with acute (new) strokes they found no imbalance in baseline stroke severity for weekends vs. weekdays and no difference in the 30-day mortality rates.


A second UK study on stroke (Bray 2016) focused on the impact of not only day of the week but also time of day of admission. They analyzed data from the Sentinel Stroke National Audit Programme with over 74,000 stroke patients. They found variation from day to day and time of day for several measures of stroke care measures. Overall, they found no difference in 30 day survival between weekends and weekdays but patients admitted overnight on weekdays had lower odds of survival.


Another very interesting study looked at patients presenting to emergency rooms (Meacock 2016). They postulated that restricted service availability at weekends on the outpatient side may lead to selection of patients with greater average severity of illness for admission. They found that similar numbers of patients attended emergency rooms on weekends and weekdays and there were similar numbers of deaths amongst patients attending emergency rooms on weekend days compared with weekdays. Attending emergency rooms at the weekend overall was not associated with a significantly higher probability of death. Higher mortality rates at weekends are found only amongst the subset of patients who are admitted. They conclude that reduced availability of primary care services and the higher admission threshold at weekends mean fewer and sicker patients are admitted at weekends than during the week.


And a fourth study, again from the UK, challenged previous studies that had suggested lack of availability of specialists on weekends was responsible for higher mortality rates for patients admitted on weekends. Aldridge and colleagues (Aldridge 2016) found that substantially fewer specialists were present providing care to emergency admissions on Sunday than on Wednesday (11% vs. 42%) but specialists present on Sunday spent 40% more time caring for emergency patients than did those present on Wednesday. Moreover, the median specialist intensity on Sunday was only 48% of that on Wednesday. Thus, their analysis did not detect a correlation between weekend staffing of hospital specialists and mortality risk for emergency admissions.


Our own opinion is that the “weekend effect” and “after-hours effect” are real phenomena but that the causes are multifactorial, including both patient-based and system-based contributing factors. We suspect that, yes, patients admitted at these times are likely sicker and have a higher severity of illness and therefore are likely to have a higher mortality rate. However, as we’ve pointed out over and over, hospitals do not provide the same levels of service 24 hours a day, seven days a week. Staffing patterns, in terms of volume and even more so in terms of experience, are the most obvious difference but there are many others as well. Many diagnostic tests are not as readily available during these times. On-site physician availability may be different and cross-coverage by physicians who lack detailed knowledge about individual patients is common. You also see more verbal orders, which of course are error-prone, at night and on weekends. But the most significant difference is nurse workload on weekends. We’ve described the tremendous increase in nurse responsibilities on weekends due to lack of other staff (no clerical staff, delayed imaging, physicians not on site) that add additional responsibilities to their jobs. Our December 15, 2009 Patient Safety Tip of the Week “The Weekend Effect” discussed how adding non-clinical administrative tasks to already overburdened nursing staff on weekends may be detrimental to patient care. Just do rounds on one of your med/surg floors or ICU’s on a weekend. You’ll see nurses answering phones all day long, causing interruptions in some attention-critical nursing activities. Calls from radiology and the lab that might go directly to physicians now often go first to the nurse on the floor, who then has to try to track down the physician. They end up filing lab and radiology reports or faxing medication orders down to pharmacy, activities often done by clerical staff during daytime hours. Even in those facilities that have CPOE, nurses off-hours often end up entering those orders into the computer because the physicians are off-site and are phoning in verbal orders and this may soon get worse as The Joint Commission is now allowing orders to be texted in (see our May 24, 2016 Patient Safety Tip of the Week Texting Orders – Is It Really Safe?”). You’ll also see nurses giving directions to the increased numbers of visitors typically seen on weekends. They may even end up doing some housekeeping chores and delivering food trays. All of these interruptions and distractions obviously interfere with nurses’ ability to attend to their clinically important tasks (see our Patient Safety Tips of the Week for August 25, 2009 “Interruptions, Distractions, Inattention…Oops!” and May 4, 2010 “More on the Impact of Interruptions”). That is why we think that simply addressing nurse:patient staffing ratios without addressing nurse workload issues may be short-sighted.


So while the recent articles may dilute the weekend effect for some conditions, all you have to do is spend some time in your hospital on weekends and you’ll readily see that things are different on weekends.



Some of our previous columns on the “weekend effect:

·         February 26, 2008     Nightmares….The Hospital at Night

·         December 15, 2009   The Weekend Effect

·         July 20, 2010             More on the Weekend Effect/After-Hours Effect

·         October 2008             Hospital at Night Project

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

·         December 21, 2010   More Bad News About Off-Hours Care

·         June 2011                  Another Study on Dangers of Weekend Admissions

·         September 2011         Add COPD to Perilous Weekends

·         August 2012              More on the Weekend Effect

·         June 2013                  Oh No! Not Fridays Too!

·         November 2013         The Weekend Effect: Not One Simple Answer

·         August 2014              The Weekend Effect in Pediatric Surgery

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

·         December 2014         Another Procedure to Avoid Late in the Day or on Weekends

·         January 2015             Emergency Surgery Also Very Costly

·         May 2015                  HAC’s and the Weekend Effect

·         August 2015              More Stats on the Weekend Effect

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

·         February 23, 2016     Weekend Effect Solutions?






Li L, Rothwell PM on behalf of the Oxford Vascular Study. Biases in detection of apparent “weekend effect” on outcome with administrative coding data: population based study of stroke. BMJ 2016; 353: i2648




Bray BD, Cloud GC, James MA, et al. Weekly variation in health-care quality by day and time of admission: a nationwide, registry-based, prospective cohort study of acute stroke care. Lancet 2016; published online first May 10, 2016




Meacock R, Anselmi L, Kristensen SR, et al. Higher mortality rates amongst emergency patients admitted to hospital at weekends reflect a lower probability of admission. J Health Serv Res Policy 2016; Published online before print May 6, 2016




Aldridge C, Bion J, Boyal A, et al. Weekend specialist intensity and admission mortality in acute hospital trusts in England: a cross-sectional study. Lancet 2016; published online first May 10, 2016







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An EMR-Based Early Warning Score



One of the reasons that rapid response teams have been less successful than we all once anticipated is due to weakness on the afferent limb of the rapid response system – i.e. that we don’t identify clinically deteriorating patients soon enough to make a difference. Therefore, multiple attempts have been made to develop scoring systems like MEWS (the modified Early Warning Score) that will help in that earlier identification. Many such systems have been automated, using data readily available from electronic medical records and computerized monitoring devices.


One recent study used real-time automated continuous sampling of electronic medical record data to enable early identification of patients at risk for death (Khurana 2016). An alert would trigger when at least 2 of 4 systemic inflammatory response syndrome (SIRS) criteria plus at least one of 14 acute organ dysfunction parameters was detected. 5.2% of patients for whom the alert triggered died compared to only 0.2% of those without the alert. Those for whom alerts triggered also had more hospital days and ventilator days. In the validation phase, the sensitivity, specificity, and positive and negative likelihood ratios for predicting mortality were quite good.


It’s, of course, interesting in that we just recently applauded the proposed removal of the SIRS criteria from the definition of sepsis (see our March 2016 What's New in the Patient Safety World column “Finally…A More Rationale Definition for Sepsis”). However, the current study would certainly suggest that the SIRS criteria may still be valuable when part of a broader score in predicting mortality in hospitalized patients.



Some of our other columns on MEWS or recognition of clinical deterioration:





Our other columns on rapid response teams:





Our other columns on sepsis:








Khurana HS, Groves RH, Simons MP, et al. Real-Time Automated Sampling of Electronic Medical Records Predicts Hospital Mortality. The American Journal of Medicine 2016; published online 17 May 2016







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Print “June 2016 What's New in the Patient Safety World (full column)

Print “June 2016 ISMP Article on Workarounds

Print “June 2016 Disclosure and Apology: The CANDOR Toolkit

Print “June 2016 Weekend Effect Challenged

Print “June 2016 An EMR-Based Early Warning Score







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