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What’s New in the
Patient Safety World
June 2022
· Where
Are You Barcoding?
· Abbreviations,
But Not The Ones You Were Thinking Of
· Guideline
Update: Preventing Hospital-Acquired Pneumonia
· Gabapentin
and Overdoses
Where Are You
Barcoding?
One of the many
factors contributing to the tragic NMBA (neuromuscular blocking agent) incident
we discussed in multiple columns was lack of barcoding capabilities in the PET
scanning suite (see our Patient Safety Tips of the Week for December 11, 2018 “Another
NMBA Accident”, February 12, 2019 “From
Tragedy to Travesty of Justice”, September
7, 2021 “The Vanderbilt Tragedy Gets
Uglier” and April 12,
2022 “A Healthcare Worker’s Worst
Fear”). Barcoding is
arguably our strongest medication safety intervention. But, like the hospital
in that incident, many hospitals have not expanded barcoding into those patient
care areas where patients may only temporarily visit, such as radiology suites.
ISMP recently reported results of a
survey it had done on implementation for its three new best practices released
in the 2022-2023 ISMP Targeted Medication Safety Best Practices for Hospitals (ISMP 2022). One of those best practices is expansion of barcoding
technology beyond inpatient care areas.
ISMP found that two-thirds to three-quarters of hospitals
reported full implementation of barcode technology in infusion clinics (76%),
post-anesthesia care units (73%), labor and delivery (72%), dialysis centers
(67%), emergency departments (65%), and perioperative holding areas (63%). But, lower levels of full implementation were reported in
radiology (31%), cardiac catheterization labs (23%), procedure rooms (16%), and
operating rooms (7%).
Our numerous columns on patient safety in the radiology
suite (or MRI or PET suite) point out that most of the issues are not directly
related to the imaging study being done. Rather, sick patients with multiple
vulnerabilities are spending time in those areas and problems related to their
ongoing medical interventions can occur while they are in those areas. They
often need to receive medications while in those areas and the lack of
barcoding capabilities there can lead to untoward events.
How is your facility doing on expanding use of barcoding
technology to those areas?
References:
ISMP (Institute for Safe Medication Practices). Survey Shows
Room for Improvement with Three New Best Practices for Hospitals. ISMP
Medication Safety Alert! Acute Care Edition 2022; 27(9): May 5, 2022
https://www.ismp.org/resources/survey-shows-room-improvement-three-new-best-practices-hospitals
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Abbreviations, But
Not The Ones You Were Thinking Of
We’ve done many columns on the dangers of abbreviations in
healthcare. These have predominantly been involved in medication errors, but
we’ve also seen them contribute to wrong-site surgeries. But now there is a new
circumstance where abbreviations can be problematic – when patients are
accessing their electronic medical records or when we communicate with them by
email.
Grossman Liu et al. (Grossman
Liu 2022) looked at patient comprehension of some abbreviations commonly
found the EHR. They compared the rates of patient comprehension of the terms
when the abbreviation was used compared to notes where the term was written out
fully. Whereas only 20% understood the term “HF”, 100% understood “heart
failure”. Only 23% understood “HTN”, but 97% understood “hypertension".
Only 43% understood “hx”, whereas all understood
“history”. But some terms, such as “MI” and “myocardial infarction” were both
poorly understood.
In an interview with Medscape Medical News (McCormack 2022),
Grossman Liu pointed out that some abbreviations can stand for more than one
thing. For example, the abbreviation “PA” has as many as 128 possible meanings!
We use medical abbreviations and acronyms extensively in our
documentation. We need to be concerned that we don’t use terms that will lead
to confusion on the part of our patients. A little extra work when we input
data and records can probably go a long way to avoid problems that can arise
from terms confusing to our patients.
The authors conclude their findings suggest that post hoc or
automated expansion of medical abbreviations and acronyms can improve patient
understanding of their health information. Note that their study only included
only English-speaking adult patients with diagnosed heart failure. It is not
clear if the same results would apply to other patient populations or those
with other medical conditions.
Bottom line: we all need to be cognizant of the fact that
our medical jargon may not be well understood by our patients, whether verbally
or in electronic formats.
Some of our previous columns on the impact of
abbreviations in healthcare:
March 12, 2007 “10x Overdoses”
June 12, 2007 “Medication-Related Issues in Ambulatory
Surgery”
September 2007 “The Impact of Abbreviations on Patient Safety”
July 14, 2009 “Is
Your “Do Not Use” Abbreviations List Adequate?”
April 2015 “Pediatric Dosing Unit Recommendations”
December 22, 2015 “The
Alberta Abbreviation Safety Toolkit”
May 14, 2019 “Wrong-Site Surgery and
Difficult-to-Mark Sites”
References:
Grossman Liu L, Russell D, Reading Turchioe
M, Myers AC, Vawdrey DK, Masterson Creber RM. Effect of Expansion of Abbreviations and
Acronyms on Patient Comprehension of Their Health Records: A Randomized
Clinical Trial. JAMA Netw Open 2022; 5(5): e2212320
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2792294
McCormack J. Spell It Out: Writing Out Common Medical Terms
Boosts Patient Understanding, Says Study. Medscape Medical News 2022;
May 16, 2022
https://www.medscape.com/viewarticle/974030
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You Were Thinking Of”
Guideline Update:
Preventing Hospital-Acquired Pneumonia
The 2022 update of “Strategies to prevent
ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care
hospitals” has just been published (Klompas
2022). This is the first update since 2014 and is the collaborative
work of the Society for Healthcare Epidemiology (SHEA), the Infectious Diseases
Society of America (IDSA), the American Hospital Association, the Association for
Professionals in Infection Control and Epidemiology, and The Joint Commission.
Representatives from multiple other organizations and societies also
contributed.
The major changes are summarized below:
- Added a recommendation for high flow nasal oxygen or noninvasive
positive pressure ventilation as options to avoid intubation, minimize
duration of intubation, and prevent reintubations
- Added a recommendation for spontaneous awakening trials or sedation
protocols as effective strategies to minimize sedation in adults
- Reclassified endotracheal tubes with subglottic secretion drainage
from an Essential Practice to an Additional Approach
- Added a recommendation for daily toothbrushing
- Added a recommendation to use caffeine therapy to facilitate extubation in preterm neonates
- Reclassified endotracheal tubes with subglottic secretion drainage
as an additional approach rather than an essential practice for adults and
older children
- Added a recommendation to consider early tracheostomy
- Added a recommendation to consider postpyloric
rather than gastric feeding in patients at high risk for aspiration
Importantly, several practices are “Not Recommended”:
- Oral care with chlorhexidine
- Probiotics
- Ultrathin polyurethane endotracheal tube cuffs
- Tapered endotracheal tube cuffs
- Automated control of endotracheal cuff pressures
- Frequent endotracheal cuff pressure monitoring
There is also a new section on prevention of nonventilator hospital-acquired pneumonia (NV-HAP). This
section emphasizes oral care, recognizing and managing dysphagia, early
mobilization, and implementing multimodal approaches to prevent viral
infections. It also notes there is insufficient evidence regarding any
recommendations about bed positioning or stress-ulcer prophylaxis and it states
that systemic antibiotic prophylaxis is not generally recommended.
The guideline update is comprehensive and provides the
rationales for each of the recommendations and has almost 400 references.
Some of our prior
columns on HAI’s (hospital-acquired infections):
December 28, 2010 “HAI’s: Looking In
All The Wrong Places”
October 2013 “HAI’s:
Costs, WHO Hand Hygiene, etc.”
February 2015 “17% Fewer HAC’s: Progress or Propaganda?”
April 2016 “HAI’s:
Gaming the System?”
September 2016 “More
on Preventing HAI’s”
November 2018 “Privacy
Curtains Shared Rooms and HAI’s”
December 2018 “HAI
Rates Drop”
January 2019 “Oral
Decontamination Strategy Fails”
February 2019 “Infection
Prevention for Anesthesiologists”
March 2019 “Does
Surgical Gowning Technique Matter?”
May 2019 “Focus
on Prophylactic Antibiotic Duration”
July 2019 “HAI’s
and Nurse Staffing”
February 2020 “NICU:
Decolonize the Parents”
June 16, 2020 “Tracking Technologies”
August 2020 “Surgical
Site Infections and Laparoscopy”
December 2020 “Do
You Have These Infection Control Vulnerabilities?”
May 2021 “CLABSI’s
Up in the COVID-19 Era”
August 2021 “Updated
Guidelines on C. diff”
October 2021 “HAI’s
Increase During COVID-19 Pandemic”
References:
Klompas M, Branson R, Cawcutt K, et al.. Strategies to
prevent ventilator-associated pneumonia, ventilator-associated events, and nonventilator hospital-acquired pneumonia in acute-care
hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 20: 1-27
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Hospital-Acquired Pneumonia”
Gabapentin and
Overdoses
Gabapentinoids have become widely
used in pain management. In fact, they are among the top 20 most prescribed
medications in the US. We used to consider them as relatively safe drugs,
perhaps one of the factors contributing to their widespread use. But, over the
past 5 years, there have been many reports that have raised red flags about gabapentinoids, particularly when they are used in
conjunction with opioids.
Overdose deaths due to gabapentinoids
alone are quite rare. However, gabapentinoids are
being found in more and more fatal overdose cases. (Mattson
2022) has found that gabapentin-involved overdose deaths have increased in
recent years. In almost 60,000 fatal overdoses analyzed, 9.7% had detectable
gabapentin on toxicology testing, and 52.3% of those were labeled as
“gabapentin-involved” deaths. Opioids, whether prescription or street drugs,
were involved in 85-90% of cases. Illicit fentanyl has increased recently as a
cause of these overdose deaths.
Some of our prior columns on safety issues with gabapentinoids:
- November 2017 “Bad Combination:
Gabapentin and Opioids”
- March 2019 “Gabapentin and
Pregabalin on the Radar Screen”
- January 2020 “FDA Warning on Gabapentinoids”
- February 25, 2020 “More on Perioperative Gabapentinoids”
- January 2021 “Gabapentinoids Again”
References:
Mattson CL, Chowdhury F, Gilson TP. Notes from the Field: Trends
in gabapentin detection and involvement in drug overdose deaths — 23 states and
the District of Columbia, 2019–2020. MMWR Morb Mortal
Wkly Rep 2022; 71: 664-666
https://www.cdc.gov/mmwr/volumes/71/wr/mm7119a3.htm?s_cid=mm7119a3_w#suggestedcitation
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2022 What's New in the Patient Safety World (full column)”
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Print “June 2022 Abbreviations, But Not The Ones
You Were Thinking Of”
Print “June 2022 Guideline Update: Preventing
Hospital-Acquired Pneumonia”
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