What’s New in the Patient Safety World

June 2018



·       Deprescribing Benzodiazepine Receptor Agonists

·       Too Much Oxygen

·       ISMP on Fire Risk from Skin Preps

·       Incorrect Weights in the EMR




Deprescribing Benzodiazepine Receptor Agonists



We’ve done many columns on potentially inappropriate medications in the elderly. One class of drugs that always appears on all such lists is benzodiazepines and benzodiazepine receptor agonists. That includes those that are used for promoting sleep, including benzodiazepines, zopiclone, and zolpidem. Such are intended for short-term use but, unfortunately, many patients end up taking them chronically. We’ve described the safety issues associated with these in multiple columns (listed below).


An excellent evidence-based guideline to help clinicians make decisions about when and how to safely taper and stop benzodiazepine receptor agonists was recently published in the journal Canadian Family Physician (Pottie 2018). They note the harms associated benzodiazepine receptor agonists include physical dependence, drowsiness, balance issues, falls, fractures, cognitive impairment, memory disorders (including anterograde amnesia), functional impairment, and motor vehicle accidents. They conducted a systematic review of benzodiazepine receptor agonist (BZRA) deprescribing trials for insomnia, as well as performing a review of the harms of continued BZRA use. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach was used for guideline development.


The guideline recommends that deprescribing (tapering slowly) of BZRA’s be offered to elderly adults (≥ 65 years) who take BZRA’s, regardless of duration of use, and suggest that deprescribing (tapering slowly) be offered to adults aged 18 to 64 who have used BZRA’s for more than 4 weeks. Note that the recommendations apply to patients who use BZRA’s to treat insomnia on its own (primary insomnia) or comorbid insomnia where potential underlying comorbidities are effectively managed. It does not apply to those with other sleep disorders or untreated anxiety, depression, or other physical or mental health conditions that might be causing or aggravating insomnia.


The Canadian guideline article also notes the potential financial savings from deprescribing BZRA’s. That includes not just the cost of the drugs themselves but the savings from fewer resultant falls and other adverse patient events.


The guideline comes with an algorithm for deprescribing that includes recommendations about the tapering and need to monitor the patient every 1-2 weeks for the duration of the tapering process. The notes attached to the guideline have a list of the commonly used offending drugs and excellent tips on how to promote sleep non-pharmacologically, both in primary care and institutional settings. It also includes notes about the role of cognitive behavioral therapy (CBT).


The Pottie article also acknowledges the importance of the discussion that needs to take place with patients about deprescribing. Any decision needs to be based on a balance of knowledge about a drug’s indication and effectiveness, as well as risks of use (actual or potential side effects), drug interactions, pill burden, and cost. Decisions also need to take into account patient or family values and preferences as part of shared decision making.  The authors note they have developed a patient pamphlet to help with these discussions.


This is a well-referenced and resourced article with excellent recommendations about helping our patients discontinue drugs that may likely have outlasted their temporary benefits but are still putting our patients at risk of many potential adverse consequences.


For more on deprescribing, see our past columns listed below. Also, ISMP Canada (ISMP Canada 2018) recently published a Safety Bulletin that had links to many excellent deprescribing resources that you will find very valuable. One of the linked resources is a toolkit for deprescribing benzodiazepines in older adults put out by Choosing Wisely Canada. Choosing Wisely Canada has also developed several other toolkits for deprescribing other drugs.



Some of our past columns on deprescribing:




Some of our previous columns on safety issues associated with sleep meds:


August 2009               “Bold Experiment: Hospitals Saying No to Sleep Meds”

March 23, 2010           “ISMP Guidelines for Standard Order Sets”

May 2012                    “Safety of Hypnotic Drugs”

November 2012          “More on Safety of Sleep Meds”

March 2013                 “Sedative/Hypnotics and Falls”

June 2013                    “Zolpidem and Emergency Room Visits”

August 6, 2013           “Let Me Sleep!”

June 3, 2014                 “More on the Risk of Sedative/Hypnotics”

May 15, 2018              “Helping Inpatients Sleep”



Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:







Pottie K, Thompson W, Davies S, et al. Deprescribing benzodiazepine receptor agonists. Evidence-based clinical practice guideline. Canadian Family Physician 2018; 64(5): 339-351




ISMP Canada. Deprescribing: Managing Medications to Reduce Polypharmacy. ISMP Canada Safety Bulletin 2018; 18(3): 1-4 March 28, 2018




Choosing Wisely Canada. DROWSY WITHOUT FEELING LOUSY. A toolkit for reducing inappropriate use of benzodiazepines and sedative-hypnotics among older adults in primary care. July 2017





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Too Much Oxygen



We’ve done multiple columns questioning the likely overuse of oxygen and its potential untoward side effects, particularly in patients with stroke or myocardial infarction who are not hypoxemic (see list of those prior columns below).


While many studies have shown lack of benefit of oxygen in patients who are not hypoxemic, only some have suggested that the oxygen supplementation may actually be harmful. Now, a new systematic review and meta-analysis (Chu 2018) concludes that, n acutely ill adults, high-quality evidence shows that liberal oxygen therapy increases mortality without improving other patient-important outcomes. The new review included not only studies of patients with stroke or myocardial infarction but also patients with sepsis, critical illness, trauma, or cardiac arrest, and patients who had emergency surgery. In all, the review included 25 randomized controlled trials with 16,037 total patients.


Compared with a conservative oxygen strategy, a liberal oxygen strategy (median baseline saturation of peripheral oxygen [SpO2] across trials, 96%) increased mortality in-hospital (relative risk 1.21), and at 30 days (RR 1.14), and at longest follow-up (RR 1.10). Morbidity outcomes (disability at longest follow-up, risk of hospital-acquired pneumonia, any hospital-acquired infection, and length of hospital stay) were similar between groups.


They conclude that supplemental oxygen might become unfavorable above an SpO2 range of 94–96% and that these results support the conservative administration of oxygen therapy.



Some of our prior columns on potential harmful effects of oxygen:


April 8, 2008 “Oxygen as a Medication”

January 27, 2009 “Oxygen Therapy: Everything You Wanted to Know and More!”

April 2009 “Nursing Companion to the BTS Oxygen Therapy Guidelines”

October 6, 2009 “Oxygen Safety: More Lessons from the UK”

July 2010 “Cochrane Review: Oxygen in MI”

December 6, 2011 “Why You Need to Beware of Oxygen Therapy”

February 2012 “More Evidence of Harm from Oxygen”

March 2014 “Another Strike Against Hyperoxia”

June 17, 2014 “SO2S Confirms Routine O2 of No Benefit in Stroke”

December 2014 “Oxygen Should Be AVOIDed”

August 11, 2015 “New Oxygen Guidelines: Thoracic Society of Australia and NZ”

November 2016 “Oxygen Tank Monitoring”

November 2016 “More on Safer Use of Oxygen”

October 2017 “End of the Oxygen in MI and Stroke Debate?”

February 2018 “Oxygen Cylinders Back in the News”






Chu DK, Kim L H-Y, Young PJ, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet 2018; 391(10131): 1693-1705, Published 28 April 2018







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ISMP on Fire Risk from Skin Preps



Among our numerous columns on surgical fires, several have focused on the role of skin preps or ointments as fuels for such fires:


Surgical fires caused by skin preps and ointments also recently was highlighted in an ISMP Medication Safety Alert  (ISMP 2018). Over the years, ISMP’s MERP (Medical Error Reporting Program) has noted fires related to a number of substances, mostly flammable substances such as surgical skin preps containing alcohol or alcohol-containing iodophors; eye lubricants and ointments containing petrolatum; wound dressings containing tincture of benzoin or collodion; and skin numbing agents containing ethyl chloride. The latest alert, however, notes some new potentially flammable substances.


Gebauer’s Ethyl Chloride spray, which had been applied as a numbing agent to a patient’s big toe prior to a minor surgical procedure, was ignited when electrocautery was used during the procedure. There are warnings on the bottle, both in the form of a small icon of a flame on the front of the bottle and warning text on the side buried within dense text that it should never be used in the presence of an open flame or electrical cautery equipment. It’s certainly not surprising that such warnings were not heeded.


That is very reminiscent of the easily missed warning we have described in numerous columns about the 26-ml Chloraprep applicator as long ago as 2012 (see, for example, our January 10, 2017 Patient Safety Tip of the Week “The 26-ml Applicator Strikes Again!”). Indeed, the new ISMP report also includes yet another instance related to the 26-ml applicator.


The ISMP article goes on to mention past cases related to Gebauer’s Ethyl Chloride spray, LACRI-LUBE S.O.P. ocular lubricant (white petrolatum and mineral oil ophthalmic ointment), and tincture of benzoin.


As usual, the ISMP alert has excellent recommendations for reducing the risks of surgical fires related to such substances. First is taking inventory of such substances in multiple areas (not just OR’s but any procedural locations, including doctors’ offices, clinics, and ambulatory surgery units). Then the list should be evaluated to see whether safer alternatives are available.


Ensuring awareness of the risks should be a priority. This includes affixing ancillary labeling to the products where the manufacturer’s warnings are “not prominent or distinctive”, as in the case of the 26-ml Chloraprep applicator or the Gebauer’s Ethyl Chloride spray. The also emphasize selection of properly sized prefilled applicators of alcohol-based surgical skin prep solutions.


They also reiterate the other important aspects for prevention of surgical fires, including:


We’ve pointed out in our previous columns that there has been a shift over the years in the “setting” of surgical fires. They now occur more frequently in relatively “minor” surgeries like temporal artery biopsies, or removal of skin lesions or cosmetic procedures on the head/neck region. Two key factors contribute to that trend. One is that in such cases oxygen may be given in a “free” fashion (i.e. it may be delivered via nasal prongs or a face mask rather than via an endotracheal tube or otherwise secured airway). The other factor is a general cavalier attitude when doing “minor” cases and lack of attention to things like the risk of flammable substances as described in today’s column.


Surgical fires are “never events” that are fully preventable. But organizations need to ensure they have raised awareness, done appropriate training, discuss the fire risk during the pre-procedure huddle and/or surgical timeout, and do the things noted above.



Our prior columns on surgical fires:








ISMP (Institute for Safe Medication Practices). Surgical fires caused by skin preps and ointments: Rare but dangerous and preventable. ISMP Medication Safety Alert! Acute Care Edition 2018; March 8, 2018






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Incorrect Weights in the EMR



We’ve done several columns highlighting the dangers of inaccurate patient weights in the electronic medical record (EMR). The biggest danger is that incorrect weights may lead to over- or under-dosing for medications whose dose is calculated based upon patient weights. And since many such calculations are based upon the weight entered into a single field in the EMR, a single error may be propagated many times.


We came across an interesting study that looked at incorrect weights in the EMR (Chen 2018). While the focus of the study was identifying errors that skewed data trends over time, the findings of the study have potential patient safety implications and potential solutions.


The authors wrote a program using Perl (Strawberry Perl, to calculate the percentage of weight change for all the possible time intervals between measures (not just consecutive ones) for each patient.


After applying the algorithms and conducting a manual review, they found 2638 spurious values from 317,115 weight data points. This suggests that, at minimum, 0.8% of all the weight values in this EMR were spurious. By examining each patient record, they found that 1976 of the 10,000 patients (19.8%) had ≥1 spurious value recorded in the observation period.


Types of error:


Single digit error                    148 for 178                 42.4%

Decimal misplacement           15.63 for 156.3           0.8%

Missing digit error                  11 for 191                   5.4%

Transposition                          137 for 173                 4.2%

kg value entered in lbs.           70 for 154                   7.1%

lb value multiplied by 2.2       338.8 for 154              5.6%

No clear reason                       237 for 185                 34.5%


Weights found to be spurious by all 3 of their algorithms and by manual review comprised 1% of all the weight recordings. At least one spurious weight occurred in 1 in 5 patient charts over a 10-y period.


When analyzing such weights in the EMR over time, straightforward algorithms can identify and remove them. Such algorithms, however, might not be useful in acutely hospitalized patients unless a whole host of prior weights were available for analysis. Nevertheless, the types of error identified by Chen et al. are informative because they demonstrate the potential for similar erroneous weights to be recorded in the EMR at a time when they could lead to potentially serious over- or under-dosing of medications.



Some of our other columns on errors related to patient weights:


March 23, 2010           “ISMP Guidelines for Standard Order Sets”

September 2010          “NPSA Alert on LMWH Dosing”

August 2, 2011           “Hazards of ePrescribing”

January 2013               “More IT Unintended Conseequences”

December 8, 2015       “Danger of Inaccurate Weights in Stroke Care”

May 2016                    “ECRI Institute’s Top 10 Patient Safety Concerns for 2016”

September 2017          “Weight-Based Dosing in Children”

January 2018               “Can We Improve Barcoding?”







Chen S, Banks WA, Sheffrin M, et al. Identifying and categorizing spurious weight data in electronic medical records. The American Journal of Clinical Nutrition 2018; 107(3): 420-426






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