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What’s New in the Patient Safety World

June 2021


·       ISMP on Patch-Related Issues

·       Does Nurse-to-Patient Ratio Legislation Help?

·       No More Lead Aprons for Patients?

·       Sleep Hygiene Program Improves Sleep Quality for Hospitalized Patients




ISMP on Patch-Related Issues



Transdermal medication patches are an effective way to administer certain medications under appropriate circumstances. But there are also dangers associated with their use. We’ve noted that discarded patches may still contain active drug and children and pets may be exposed to them. We’ve also noted how a second patch may be applied to a patient’s skin, not recognizing the presence of another patch, resulting in an overdose for the patient. And we’ve also noted that patches containing metal or ferromagnetic components may overheat during MRI scanning, resulting in burns. Most of our columns have dealt with opioid patches, particularly Fentanyl, but problems may occur with virtually any transdermal patch.


ISMP (Institute for Safe Medication Practices) recently reported on more than 50 reports associated with 12 different transdermal medication patches submitted to the ISMP MERP within the past 4 years (ISMP 2021). Patches most frequently involved in reported errors included fentaNYL (n = 16), cloNIDine (n = 10), scopolamine (n = 7), and estradiol (n = 6). ISMP categorized the problems in the following areas:



ISMP reiterated the problem of failing to identify patches on the patient’s skin, not removing an old patch when applying a new patch, and/or finding multiple patches on patients that had been left on longer than prescribed. Hospital admission may be a time of vulnerability to the first failure, since a patch applied prior to admission might be easily overlooked. Failure to recognize prior patches or presence of multiple patches on the skin of some patients may be more likely with those patches that are clear or beige.


Inappropriate patch prescribing applied most often to fentaNYL patches. Our multiple columns on long-acting opioids have stressed that these are intended for opioid-tolerant patients and should not be prescribed for acute pain or in opioid-naïve patients.


We encourage you to read ISMP’s full article. It provides examples in each of the above categories and provides very important recommendations for all patches and for specific patch types.



Our prior articles pertaining to long-acting and/or extended release preparations of opioids:



Our prior columns on iatrogenic burns:






ISMP (Institute for Safe Medication Practices). Analysis of Transdermal Medication Patch Errors Uncovers a “Patchwork” of Safety Challenges. ISMP Medication Safety Alert! Acute Care Edition 2021; 26(5): March 11, 2021






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Does Nurse-to-Patient Ratio Legislation Help?



We’ve done multiple columns discussing how better nursing staffing leads to better patient outcomes and improved patient safety. We’ve stressed the importance of nurse workload rather than staffing levels per se. But most attempts to improve nurse staffing have focused on nurse-to-patient ratios. What is the evidence that just mandating a minimum nurse-to-patient ratio improves outcomes? One of the problems is that all prior studies have been before-and-after evaluations and none were prospective.


A recent study from Queensland, Australia appears to answer that. McHugh et al. (McHugh 2021) were able to prospectively compare patient outcomes at 27 hospitals subject to minimum nurse-to-patient ratios (the “intervention” hospitals) with 28 hospitals that were not (the “comparison” hospitals).


After implementation, mortality rates were not significantly higher than at baseline in comparison hospitals (adjusted odds ratio 1.07) but were significantly lower than at baseline in intervention hospitals (aOR 0.89). From baseline to post-implementation, readmissions increased in comparison hospitals (1.06), but not in intervention hospitals (1.00). Length of stay (LOS) decreased in both groups post-implementation, but the reduction was more pronounced in intervention hospitals than in comparison hospitals. Staffing improvements by one patient per nurse produced reductions in mortality (OR 0.93), readmissions (0.93), and LOS (adjusted incident rate ratio 0.97).


And here’s the key point for administrators and policy makers: in addition to producing better outcomes, the costs avoided due to fewer readmissions and shorter LOS were more than twice the cost of the additional nurse staffing. We always add a point of caution when using formulas to impute cost savings from fewer admissions and shortened length of stay – those savings would come from actually reducing personnel costs. Those hospitals that can benefit the most from such reductions are those that can close a whole nursing unit. Lesser reductions are more difficult to achieve. We also reiterate our position that some flexibility is needed. Rather than just focusing on the nurse-to-patient ratio, we need to match nurse workload to patient load. But improving the nurse-to-patient ratio is a good first step.


We hope that the naysayers to mandated minimum nurse-to-patient ratios who say such mandates would be too costly will look at the results from Queensland and reassess their opposition to such mandates.


As pointed out in the editorial accompanying the McHugh study (Ullman 2021), the current and likely near-future shortage of nurses makes improving nurse-to-patient ratios challenging. Ullman calls for robust efforts to boost the nursing workforce.



Some of our other columns on nursing workload and missed nursing care/care left undone:


November 26, 2013    Missed Care: New Opportunities?

May 9, 2017                Missed Nursing Care and Mortality Risk

March 6, 2018             Nurse Workload and Mortality

May 29, 2018              More on Nursing Workload and Patient Safety

October 2018               Nurse Staffing Legislative Efforts

February 2019             Nurse Staffing, Workload, Missed Care, Mortality

July 2019                    HAI’s and Nurse Staffing

September 1, 2020      NY State and Nurse Staffing Issues

February 9, 2021         Nursing Burnout






McHugh MD, Aiken LH, Sloane DM, et al. Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals. The Lancet 2021; Published: May 11, 2021



Ullman AJ, Davidson PM. Patient safety: the value of the nurse. The Lancet 2021; Published: May 11, 2021





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No More Lead Aprons for Patients?



The time-honored procedure of shielding patients’ gonads from radiation with lead aprons during diagnostic radiology exams has come to an end. In January 2021 both the American College of Radiology (ACR 2021) and the National Council on Radiation Protection and Measurement (NCRP 2021) announced that routine gonadal shielding during abdominal and pelvic radiography is no longer recommended.


Gonadal shielding has been used since the 1950’s with the rationale that it prevented radiation damage to reproductive organs and consequent heritable genetic defects. The NCRP statement notes that the risks of heritable genetic effects are now considered to be much less than previously estimated and that improvements in technology since the 1950’s have resulted in up to a 95 % reduction in the absorbed dose to pelvic organs from radiography.


It also notes that gonadal shielding can interfere with the use of automatic exposure control, thereby causing an increase in dose to other pelvic and abdominal organs that may be more radiosensitive. It also may not completely shield the gonads in the majority of patients due to the limited area of the shield and the normal variations in patient anatomy. Moreover, a substantial portion of gonadal dose to the ovaries is delivered by scattered x rays that are not attenuated by gonadal shielding.


Gonadal shielding also obscures portions of pelvic anatomy and may obscure important findings on radiographs, limiting the practical dimensions and area of the shield.


Thus, NCRP concludes that in most circumstances gonadal shielding use does not contribute significantly to reducing risks from exposure and may have the unintended consequences of increased exposure and loss of valuable diagnostic information. Therefore, use of gonadal shielding is not justified as a routine part of radiological protection.


NCRP notes that gonadal shielding may be used for circumstances where a patient, parent or caregiver requests that gonadal shielding be used. It recommends such requests for use of gonadal shielding should be discussed to facilitate informed and mutual decision making. Information should be provided that will help to answer the patient’s questions and understand the risks and benefits. Gonadal shielding may be permissible when it will not interfere with the purpose of the examination. If consent for the examination cannot be obtained without its use, gonadal shielding use should adhere to institutional or practice guidelines or policies that minimize or eliminate the negative impact on diagnostic potential.


Acknowledging that many will question this move away from such a time-honored practice, NCRP also issued a companion statement “Implementation Guidance for Ending Routine Gonadal Shielding During Abdominal and Pelvic Radiography”.






ACR (American College of Radiology). NCRP Recommends Against Routine Gonadal Shielding. American College of Radiology 2021; January 13, 2021



NCRP (National Council on Radiation Protection and Measurement). NCRP Recommendations for Ending Routine Gonadal Shielding During Abdominal and Pelvic Radiography. NCRP Statement No. 13, January 12, 2021



NCRP (National Council on Radiation Protection and Measurement). Implementation Guidance for Ending Routine Gonadal Shielding During Abdominal and Pelvic Radiography. Companion to NCRP Statement No. 13, January 12, 202






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Sleep Hygiene Program Improves Sleep Quality for Hospitalized Patients



Our August 6, 2013 Patient Safety Tip of the Week “Let Me Sleep!” highlighted the problem of sleep deprivation amongst hospitalized inpatients. Interference with sleep is also a contributing factor to other problems, such as delirium. For years we’ve espoused the “Say no to sleep meds” approach to hospitalized patients. That means identifying the numerous things we do that prevent patients from getting needed sleep and using nonpharmacological approaches to improve their sleep while hospitalized.


Herscher et al. (Herscher 2021) recently reported on successful implementation of a nonpharmacologic sleep hygiene intervention to improve sleep quality in hospitalized patients. The intervention consisted of a bundle with the following components:


Their program also included provider education and use of front-line “champions”.


Patients’ sleep was measured by the Richards-Campbell Sleep Questionnaire (RCSQ). 931 patients received the intervention. A sample of surveyed patients showed an increase in the RCSQ global score from 6.0 to 6.2 from the pre- to post- intervention periods (p = 0.041), plus increases in three of the five individual survey components. In addition, there was an improvement in the HCAHPS “quietness at night” score, from 34.1% pre-intervention to 42.5% post-intervention.


Those results are modest and we don’t know if they are sustainable or generalizable, but it is a step in the right direction.


We recommend you go back to our Patient Safety Tips of the Week for November 6, 2018 “More on Promoting Sleep in Inpatients” and March 16, 2021 “Sleep Program Successfully Reduces Delirium” and our August 2019 What's New in the Patient Safety World column “Tools for Reducing Sleep Meds in Hospitals” for more nonpharmacologic interventions to promote healthier sleep in hospitalized inpatients.



Some of our previous columns on safety issues associated with sleep meds and promoting sleep in inpatients:


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

June 2018                    Deprescribing Benzodiazepine Receptor Agonists

November 6, 2018      More on Promoting Sleep in Inpatients

June 2019                    FDA Boxed Warning on Sleep Meds

August 2019               Tools for Reducing Sleep Meds in Hospitals

March 16, 2021           Sleep Program Successfully Reduces Delirium






Herscher M, Mikhaylov D, Barazani S, et al. A Sleep Hygiene Intervention to Improve Sleep Quality for Hospitalized Patients. The Joint Commission Journal on Quality and Patient Safety 2021; 47(6): 343-346. Published: February 10, 2021




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Print “June 2021 ISMP on Patch-Related Issues

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