In all our columns on opioid-induced respiratory depression
(OIRD) we’ve not come across an article more comprehensive and elegantly
written than one in the May issue of the American Journal of Nursing (Jungquist
2017).
Jungquist and colleages
put together a document focusing on risk assessment and tailoring monitoring to
patient risk, type and route of opioid administration, previous history of
opioid use, concomitant treatments, and the surgery or procedure performed.
They provide an excellent table of risk factors for OIRD and emphasize the time
frames in which OIRD events are most likely to occur.
They discuss the benefits, disadvantages, and barriers
encountered in intermittent pulse oximetry, continuous pulse oximetry,
capnography, or minute ventilation technology. Most of all, they stress the
importance of monitoring a patient’s sedation level, using tools such as the
POSS (Pasero Opioid-Induced Sedation Scale) or RASS
(Richmond Agitation-Sedation Scale), to help determine when a patient might be
prone to OIRD. Also stressed is the importance of assessing level of sedation
and response to pain at a time the peak effect of the opioid is expected. And
they note that the frequency of monitoring must be tailored to multiple factors
rather than being strictly standardized. Importantly, they note the importance
of letting the patient and family know the patient will likely be wakened at
night for assessment and that this is a critical patient safety need. And they
stress the importance of recognizing trends rather than relying solely on
single threshold levels.
They stress another point we have often made: there must be
guidelines and policies for nurses to prepare and administer naloxone in
appropriate circumstances. They describe how naloxone should be administered
and what to watch for. (The only thing we did not find in the article was a
discussion of the phenomenon of “renarcotization”.)
Jungquist and colleagues are to be
commended for this outstanding article.
Our other Patient
Safety Tips of the Week pertaining to opioid-induced respiratory depression and
PCA safety:
References:
Jungquist CR, Smith K, Nicely KLW,
Polomano RC. Monitoring hospitalized adult patients
for opioid-induced sedation and respiratory depression Am J Nurs
2017; 117(3 Supp): S27-S35
Print “June
2017 Masterpiece: Monitoring for Opioid-Induced Respiratory Depression”
We’ve had a flurry of updates on guidelines for prevention
of SSI’s (surgical site infections). Last year the American College of Surgeons
(Ban
2016), the American College of Obstetricians and Gynecologists (Pellegrini
2016), and WHO (Allegranzi
2016a, Allegranzi 2016b) published their updated guidelines. And the Society for
Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society
of America (IDSA) published their update in 2014 (Anderson 2014). Now the Centers for Disease Control and
Prevention has published it’s
new guidelines (Berríos-Torres
2017).
The new CDC guideline focuses heavily on antimicrobial
prophylaxis but includes several other salient recommendations:
Antimicrobial
Prophylaxis
It recommends that preoperative antimicrobial agents be
administered only when indicated based on published clinical practice
guidelines and timed such that a bactericidal concentration of the agents is
established in the serum and tissues when the incision is made (that includes
administration of appropriate parenteral prophylactic antimicrobial agents
before skin incision in all cesarean section procedures). It recommended no
further refinement of timing for preoperative antimicrobial agents based on
clinical outcomes and notes this is an unresolved issue. (Note our comments
below on a new study that showed no advantage of earlier vs. later
administration).
Interestingly, the CDC guideline makes no recommendation
regarding antibiotic dosing either with respect to patient weight or redosing during long procedures. Note that we have often
stressed that these two issues should be discussed during the preoperative
“huddle” (or “briefing”). The CDC guideline acknowledges that several of the
other guidelines do have recommendations about these two issues and provides
that information in supplemental form.
Also the guideline recommends against additional prophylactic antimicrobial doses in clean and
clean-contaminated procedures after the surgical incision is closed in the
operating room, even in the presence of a drain (strong recommendation with
high-quality evidence).
Antiseptic
prophylaxis
Advise patients to shower or bathe (full body) with soap
(antimicrobial or nonantimicrobial) or an antiseptic
agent on at least the night before the operative day (strong recommendation;
accepted practice) and perform intraoperative skin preparation with an
alcohol-based antiseptic agent unless contraindicated (strong recommendation; high-quality
evidence). Our comment: don’t forget the risks for surgical fires with
alcohol-based antiseptics so proper precautions must be maintained at all times
(see our multiple columns on surgical fires).
Glucose control
The CDC guideline recommends blood glucose in the
perioperative period with target levels less than 200 mg/dL
in patients with and without diabetes.
Normothermia
The CDC guideline recommends maintenance of perioperative normothermia, without endorsing a specific method to be
used.
Supplemental Oxygen
Use of supplemental oxygen has long been a controversial
issue and one has to weigh any potential benefits against potential risks. But
the new CDC guideline does recommend that for patients with normal pulmonary
function undergoing general anesthesia with endotracheal intubation, administer
increased FIO2 during surgery and after extubation in
the immediate postoperative period. To optimize tissue oxygen delivery,
maintain perioperative normothermia and adequate
volume replacement (strong recommendation; moderate-quality evidence). Note
that a meta-analysis by Yang et al. (Yang
2016) found moderate evidence to suggest that administration of high FiO2
to patients undergoing surgery, especially colorectal surgery, reduces the risk
of SSI. (Our comment: again keep in mind the risk for surgical fires that a
high oxygen environment brings and take appropriate precautions to minimize
that risk.)
Perhaps the most striking aspect of the CDC guideline
document, as pointed out in the invited commentary (Lipsett
2017), is the sheer number of practices for which there was insufficient
evidence to make a recommendation. We also refer you to those other recent
guidelines listed in the first paragraph of today’s column.
There have been a few other recent studies relevant to
SSI’s. As noted above, a recent randomized controlled trial looked at timing of
antibiotic prophylaxis (Weber
2017). Current practice calls for administration of surgical antimicrobial
prophylaxis for the prevention of SSI’s within 60 minutes before incision. In
this RCT the median administration time was 42 min before incision in the early
group and 16 min before incision in the late group (cefuroxime was the
antibiotic used in this study). Early administration of SAP did not
significantly reduce the risk of SSI compared with late administration. The
findings do not support any narrowing of the 60-min window for the
administration of a cephalosporin with a short half-life.
The accompanying editorialist (Humphreys
2017) stresses that, though we don’t yet know the optimal timing for
prophylactic antibiotics, it is “incumbent on the surgical team, anesthetic
team, pharmacist and antimicrobial stewardship program to ensure the that
patient receives the first dose of antibiotics during this important 1-hour
window”.
Also published recently was a “Consensus Bundle on
Prevention of Surgical Site Infections after Major Gynecologic Surgery” (Pellegrini
2016). This bundle was developed by a multidisciplinary team convened by
the Council on Patient Safety in Women's Health Care and is organized into four
domains: Readiness, Recognition and Prevention, Response, and Reporting and
Systems Learning.
Under “Readiness”
it stresses establishment of standards for preoperative care instructions and education
for women undergoing major gynecologic surgery (such as hysterectomy),
including postoperative wound care instructions, delineation of responsibility
for every member of the surgical team, standards for temperature regulation
(including not only patient normothermia but also ambient
operating room temperature), standardization of selection and timing of
administration and discontinuation of prophylactic antibiotics, ideally using
order sets or checklists, and standards for appropriate skin preparation both
preoperatively and postoperatively.
Under “Recognition
and Prevention” it stresses assessment of patient risk preoperatively for
surgical site infection using criteria that include blood glucose level, BMI,
immune status, MRSA, nutritional status, and smoking status.
Under “Response”
it stresses intraoperative “Timeouts” to address antibiotic dosage, timing,
prophylaxis issues, and patient-specific issues and reassessment of patient
risk for SSI based on length of surgery, potential bowel incision, vaginal contamination,
and amount of blood loss. And, of course, it stresses postoperative care
instructions and education for patients and family/support persons.
Under “Reporting
and Systems Learning” we are pleased to see they stress establishment of a “culture
of huddles” for high-risk patients. They also note the importance of creating a
system to analyze and report surgical site infection data, monitor outcomes and
process metrics, collect and share physician-specific surgical site infection
data with all surgeons as part of their ongoing professional practice
evaluation, and standardize a process to actively monitor and collect surgical
site infection data with postdischarge follow-up.
Not included in the CDC guideline is information from a just
published study demonstrating the incidence
of SSI’s is highly seasonal (Anthony
2017). Basically, warmer weather increases the SSI rate and lower
temperatures decrease the rate. SSI incidence is highest in August and lowest
in January (rates 26.5% higher in August than January). Utilizing a large
national database and average monthly temperatures based on hospital location,
the found the odds of a primary SSI admission increased by roughly 2.1% per
2.8°C (5°F) increase in the average monthly temperature. The highest
temperature group, >32.2°C (>90°F), was associated with an increase in
the odds of an SSI admission of 28.9% compared to temperatures <4.4°C
(<40°F). Note that the study did not report whether there is an association
between humidity and SSI’s. Our own experience is that OR’s sometimes have
difficulty maintaining their OR ambient temperature and humidity within
prescribed limits during hot, humid summer months. Since we can’t control the
outside temperature, these new data suggest we need to pay more careful
attention to maintain OR temperature and humidity within prescribed range
limits and to defer surgery in those OR rooms that are not within the range.
And, speaking about assessment for risk of SSI, there was
recently published a new simple risk stratification score for SSI’s (Amri
2017). Retrospectively
looking at almost 1500 patients treated surgically for colon cancer at
Massachusetts General Hospital over a ten year period, they identified the
following risk factors as being significant for SSI’s: smoking, alcohol abuse,
type 2 diabetes, obesity, surgical durations greater than 140 minutes, and nonlaparoscopic approaches. SSI rates were:
The authors suggest
that this simple risk score can be used to stratify patients by SSI risk and
identify patients at risk during their postoperative admission, potentially
focusing frequent monitoring and more aggressive preventive efforts on
high-risk patients.
And on the Ob/Gyn side there was
an abstract (Reddy
2017) at the recent ACOG annual meeting which suggested that changing gloves during cesarean section prior
to abdominal wall closure may reduce the risk of wound complications in
non-emergent cesarean sections. The authors report preliminary findings in
their randomized controlled trial and found a significant reduction in a composite
of wound complications (seroma, hematoma, wound infection, skin separation of
at least 1cm, or other incisional separation or abnormality requiring a bedside
procedure) in the glove-changing group compared to the control group (5.9% vs.
12.9%). The intervention is based on the theory that vaginal flora might be
transferred to the abdominal area during the procedure. The intervention
consisted of the entire surgical team changing gloves prior to abdominal wall
closure. This was a relatively small, single-site study but the intervention is
quite low-cost. So it will be interesting to see if the results can be
replicated in larger multi-site studies.
References:
Ban KA, Minei JP, Laronga C, et al, American College of Surgeons and Surgical
Infection Society: Surgical Site Infection Guidelines, 2016 Update. Journal of
the American College of Surgeons 2016; Published online: November 30, 2016
http://www.journalacs.org/article/S1072-7515(16)31563-0/fulltext
Pellegrini JE, Toledo
P, Soper DE, et al. Consensus Bundle on Prevention of
Surgical Site Infections after Major Gynecologic Surgery. Obstetrics
& Gynecology 2016; Published ahead of print (Post Author Corrections):
December 02, 2016
Allegranzi B, Bischoff P, de Jonge S, et al; WHO Guidelines Development Group. New WHO
recommendations on preoperative measures for surgical site infection
prevention: an evidence-based global perspective. Lancet Infect Dis 2016; 16(12): e276-e287
http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(16)30398-X/fulltext
Allegranzi B, Zayed
B, Bischoff P, et al; WHO Guidelines Development Group. New WHO recommendations
on intraoperative and postoperative measures for surgical site infection
prevention: an evidence-based global perspective. Lancet Infect Dis 2016; 16(12): e288-e303
http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(16)30402-9/fulltext
Anderson D, Podgornny K,
Berrios-Torres S, et al. Strategies to Prevent Surgical Site Infections in
Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology
2014; 35(6): 605-627 (June 2014) electronically published May 5, 2014
http://www.jstor.org/stable/10.1086/676022
Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. for
the Healthcare Infection Control Practices Advisory Committee
. Centers for Disease Control and Prevention Guideline for the
Prevention of Surgical Site Infection, 2017. JAMA Surg
2017; Published online May 3, 2017
http://jamanetwork.com/journals/jamasurgery/fullarticle/2623725
Yang W, Liu Y, Xhang Y, et al.
Effect of intra-operative high inspired oxygen fraction on surgical site
infection: a meta-analysis of randomized controlled trials. J Hosp Infection 2016; 93(4): 329-338
http://www.journalofhospitalinfection.com/article/S0195-6701(16)30002-0/fulltext
Lipsett PA. Surgical Site Infection Prevention—What We Know
and What We Do Not Know (Invited Commentary). JAMA Surg
2017; Published online May 3, 2017
http://jamanetwork.com/journals/jamasurgery/article-abstract/2623721
Weber WP, Mujagic E, Zwahlen M, et al.Timing
of surgical antimicrobial prophylaxis: a phase 3 randomised
controlled trial. The Lancet Infectious Diseases 2017; published 03 May 2017
http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(17)30176-7/fulltext
Humphreys H. Precise timing might not be crucial: when to
administer surgical antimicrobial prophylaxis. The Lancet Infectious Diseases
2017; published 03 May 2017
http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(17)30178-0/fulltext
Amri R, Dinaux
AM, Kunitake H. Risk Stratification for Surgical Site
Infections in Colon Cancer. JAMA Surg 2017; Published
online April 12, 2017
http://jamanetwork.com/journals/jamasurgery/article-abstract/2618384
Reddy B, Scrafford J. Effect of
Intra-operative Glove-changing During Cesarean on Post-op Complications: A
Randomized Controlled Trial. Abstract 12OP. ACOG 2017
https://plan.core-apps.com/tristar_acog17/abstract/709ad73436b413473149963de4e633b3
Anthony CA, Peterson RA, Polgreen
LA, et al. The Seasonal Variability in
Surgical Site Infections and the Association With
Warmer Weather: A Population-Based Investigation. Infection Control & Hospital
Epidemiology 2017; 1 DOI: 10.1017/ice.2017.84
Print “June
2017 New CDC Guideline for SSI Prevention”
Checklists are great
tools for helping ensure that important steps in a variety of patient safety
activities are not missed. But checklists are only as good as the degree to
which they are complied with, as exemplified in our May 2, 2017 Patient Safety
Tip of the Week “Anatomy
of a Wrong Procedure”.
We’ve often noted
that most facilities have no idea whether their Universal Protocol or Surgical
Safety Checklist is being used well. That is because they don’t audit
compliance with its use. Even those that think they have good compliance
usually rely on self-reporting rather than more objective measurements. We
recommend direct observation or use of video recording as ways to assess
compliance. The former is obviously subject to the Hawthorne effect. The latter
is more effective but many physicians and OR personnel have objected to video
recording and few OR’s use it today.
A third way is to
use simple audio recording. While audio recording may miss some of the “body
language” aspects that may provide important details about communication in the
OR, it may still provide insight into how well OR teams are complying with the
checklists. A recent study reported use of such an audio audit of use of a
Surgical Safety Checklist at a US hospital (Salgado
2016). Whereas a compliance rate was previously reported as 97.6%, the audio-recorded
audits revealed a precisely executed checklist only 73.6% of the time.
The Salgado article is useful not only for details about the
method of recording but also for the checklist scoring system they developed.
Note that their
version of the WHO Surgical Safety Checklist was modified for their own
use, as is strongly recommended for any facility using the checklist. So some
items on their checklist audit tool may differ from those you might audit at
your facility. They audited items from all 3 components of the Surgical Safety
Checklist (pre-procedure, just before skin incision or start of procedure, and
post-procedure before patient leaves the OR).
Audit of the middle
section of the checklist (just before skin incision or start of the procedure)
revealed suboptimal compliance with two key items we have stressed before.
Confirmation of the procedure with the consent form was only completed in 69%
of audited cases. And asking whether essential imaging was required was
completed in only 81% of audited cases. We found it somewhat surprising that
the question about whether antibiotic prophylaxis has been given within the
last 60 minutes was only completed in 80% of audited cases. On the other hand,
we were pleased to see that this facility included a question about letting the
alcohol prep dry before draping and that compliance with this item was 89%. We
were also glad to see the item addressing anticipated surgical specimens and
tests was completed in 94% of cases. The item asking whether venous
thromboembolism prophylaxis is needed is also a question we think is important
(though we usually recommend it as an item to be discussed during the pre-op
huddle) but this item was only completed in 55% of audited cases.
Regarding the
pre-procedure portion of the checklist, compliance was pretty good regarding
the anesthesia check, medication check, and pulse oximetry items. Risk of
hypothermia was formally completed in only 52%. The “site marked” item was
complete in only 56%. That sounds awfully low, but it is not clear whether this
is adjusted for those cases in which site marking is not indicated (eg. bilateral procedures).
Compliance with the
post-procedure portion of the checklist was, in general, poor. Several items
are of particular concern. One is that labeling of specimens was completed as
an item in only 34% (it is not clear from the article whether this might
reflect that specimens were not taken in some cases). And only 43% of cases
completed the item asking if instrument, sponge and needle counts were
complete. And only 22% asked whether any equipment problems needed to be
addressed.
They were also able
to identify some barriers to communication, such as distractions. Those identified
included personal conversations, staff changes, and room setup noise as major
distractors. The researchers also looked at whether “quiet” was requested for
various parts of the checklist and whether “quiet” was actually achieved.
“Quiet” was actually achieved in less than 50% for each section of the
checklist and for only 20% for the post-procedure period.
Note that the Surgical
Safety Checklist used by Salgado et al. asked for confirmation of the procedure
with the informed consent. It did not require confirmation with the H&P. We
feel that requiring the latter is equally important since informed consents are
not without problem (see our September 10, 2013 Patient Safety Tip of the Week
“Informed
Consent and Wrong-Site Surgery”). And, as discussed in our May 2, 2017 Patient
Safety Tip of the Week “Anatomy
of a Wrong Procedure”, it is
critical that all participants have actually looked at these primary source documents
(the consent and the H&P).
You should refer to
the actual article for a description of the audio recording protocol.
The Salgado study is
an excellent contribution to patient safety. Every facility should be auditing
compliance with their checklists and both the audio format and the scoring tool
developed by these researchers could be adapted to almost any facility. We also
suspect that the results found in their audit are probably pretty
representative of what the majority of facilities will find when they do their
own audit.
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”
July 19, 2016 “Infants
and Wrong Site Surgery”
September 13, 2016 “Vanderbilt’s
Electronic Procedural Timeout”
May 2017 “Another
Success for the Safe Surgery Checklist”
May 2, 2017 “Anatomy
of a Wrong Procedure”
Some of our prior columns on checklists:
References:
Salgado D, Barber KR, Danic M.
Objective Assessment of Checklist Fidelity Using Digital Audio Recording and a
Standardized Scoring System Audit. Journal of Patient Safety 2016; Published
Ahead of Print Post Author Corrections: November 2, 2016
Print “June
2017 Another Way to Verify Checklist Compliance”
We described NCCN’s
“Just Bag It!” campaign in our December 2016 What's New in the Patient Safety
World column “Standardize
4 Safety and Just Bag It!”. The campaign
was launched last year by the National
Comprehensive Cancer Network (NCCN
2016). Vincristine is a chemotherapy agent intended for intravenous use.
Yet since the 1960’s there have been numerous incidents where it has been
administered intrathecally or via Omaya
reservoirs. The results are disastrous, with patients developing quadriplegia,
encephalopathy, and usually death. In 2013 ISMP summarized the literature (ISMP
2013) and noted that virtually all cases involved vincristine being
prepared in a syringe and that there were no cases when vincristine was
prepared in an IV bag. There are, of course, other contributing factors in such
incidents. ISMP noted the following contributing factors: mislabeling of
syringes; bringing IV and intrathecal medications into a treatment area
together; failing to administer vinca alkaloids in a
specialty oncology unit or with only experienced, oriented staff familiar with
current operational and clinical standards, procedures, or protocols;
administering chemotherapy outside of normal hours; not conducting an
independent double check or “time out” before intrathecal medication
administration; and incomplete or missing warning labels. But, given that all
reported incidents occurred when vincristine was in a syringe, ISMP recommended
that vincristine instead by diluted in a minibag for
infusion and syringes be avoided.
The Just Bag It! campaign calls for health care
professionals to always dilute vincristine in a 50ml mini-IV drip bag
and never in a syringe. The campaign comes with Christopher’s Story, the sad
story of a patient who died as the result of one of the above vincristine
errors. All NCCN member institutions have already adopted this best practice
for handling vincristine but the campaign calls on all other oncology providers
to do the same.
Researchers from
Johns Hopkins presented a poster (Olsen 2017) at the recent Oncology Nursing Society
42nd Annual Congress as described in an NCCN press release (NCCN 2017).
Olsen and colleagues described barriers
to standardizing vincristine administration in mini-IV drip bags. They noted
that many nurses believed the risk of extravasation would be higher when
administering via min-bag than when pushing the agent. However, they found zero
cases of extravasation among the more than 1,300 mini-bag administrations of
vincristine after the practice change.
Instead of pushing
the medication through a syringe, in the new technique the nurse holds the
mini-bag as it runs through the side port of a free flowing line. Understanding
the rationale for the new practice and becoming familiar with the technique
were critical. Nurses received training that included background on the
reasons for the switch, watched a video of the technique, and had hands-on
training in a skills lab to ensure proper technique before going live with this
practice change.
We hope that all sites administering vincristine, not just
NCCN member institutions, will use the techniques that are part of the Just Bag
It! Campaign. Following the recommendations in the Olsen study should help you
in your implementation.
References:
NCCN (National Comprehensive Cancer Network). Just Bag It: The NCCN Campaign for Safe
Vincristine Handling. NCCN 2016; accessed November 14, 2016
https://www.nccn.org/justbagit/
ISMP (Institute for Safe Medication Practices). Death and
neurological devastation from intrathecal vinca
alkaloids: Prepared in syringes = 120; Prepared in minibags
= 0. ISMP Medication Safety Alert! Acute Care Edition. September 5, 2013
https://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=58
NCCN (National Comprehensive Cancer Network). In Oncology
Nursing, One Small Change Can Potentially Prevent Deadly Medical Error in
Thousands of Patients. Press Release May 1, 2017
https://www.nccn.org/about/news/newsinfo.aspx?NewsID=872
Olsen M, Benani D, Przybylski A, Carrol S, Szabo K. Putting an Old Oncology
Nursing Practice to Bed: A Hospital-Wide Initiative Using Evidence-Based
Practice to Standardize the Administration of Vinca
Alkaloids Using a Minibag, Side-Arm Technique.
Oncology Nursing Society 42nd Annual Congress. Poster 187. May 5, 2017
http://epo.epostersonline.net/ons2017/node/863
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2017 Just Bag It Campaign Success Story”
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2017 What's New in the Patient Safety World (full
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2017 Masterpiece: Monitoring for Opioid-Induced Respiratory Depression”
Print “June
2017 New CDC Guideline for SSI Prevention”
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2017 Another Way to Verify Checklist Compliance”
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2017 Just Bag It Campaign Success Story”
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