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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%).


The ISMP survey responses did identify multiple barriers to implementation of barcoding in these other areas. These included resource constraints, such as lack of scanners or lack of space, information technology issues, insufficient staffing (particularly pharmacists), and workflow issues such as one-step prescribing and administration and lack of electronic order entry. They also noted that some of the barriers were related to specific outpatient locations, such as concerns about sterility and inaccessible patients’ identification bands in the operating room, and concerns about metal objects and the absence of barcodes on radiopharmaceuticals in radiology.


ISMP is collaborating with a health system to describe how they achieved full implementation of this technology in their operating and procedure rooms and expects to publish an article on these within the next few months.


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?






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





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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






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



McCormack J. Spell It Out: Writing Out Common Medical Terms Boosts Patient Understanding, Says Study. Medscape Medical News 2022; May 16, 2022





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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:



Importantly, several practices are “Not Recommended”:


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






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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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. A new CDC report (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.


CDC says these findings highlight the dangers of polysubstance use, particularly co-use of gabapentin and illicit opioids. They recommend that persons who use illicit opioids with gabapentin should be educated about the increased risk for respiratory depression and death.



Some of our prior columns on safety issues with gabapentinoids:







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




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