What’s New in the Patient Safety World


March 8-14, 2009 is Patient Safety Awareness Week

The National Patient Safety Foundation has announced that Patient Safety Awareness Week will be celebrated March 8-14, 2009.






March 2009


·     Joint Commission Puts a Hold on Medication Reconciliation Scoring

·     Followup on the Minnesota Bassinet Fire

·     Surgical Team Training

·     Risk of Burns during MRI Scans from Transdermal Drug Patches




Joint Commission Puts a Hold on Medication Reconciliation Scoring



Our December 30, 2008 Patient Safety Tip of the Week “Unintended Consequences: Is Medication Reconciliation Next?” discussed the difficulties healthcare organizations are encountering in implementation of medication reconciliation programs. Well, Joint Commission must have been listening because shortly thereafter they announced that, effective January 1, 2009, they will temporarily halt inclusion of NPSG #8 (medication reconciliation) in the accreditation decision. They will still survey your organization’s activities on medication reconciliation but there will be no requirements for improvement (RFI’s) issued.


Joint Commission remains committed to the concept of medication reconciliation and will gather evidence on best practices and conduct meetings with stakeholders over the next year with the intent of reinstituting NPSG#8 in 2010. As before, we’ve been very concerned about unintended consequences occurring as a result of hasty implementation of unproven medication reconciliation techniques. We commend Joint Commission for being both practical and considerate in this decision.




Joint Commission. Medication reconciliation National Patient Safety Goal to be reviewed, refined. February 5, 2009




Followup on the Minnesota Bassinet Fire



ECRI Institute, which participated in the root cause analysis of the Minnesota bassinet fire, has issued an important equipment alert. This alert lists the manufacturers and model numbers of infant radiant warmers that have heater elements which ECRI feels have an increased risk of precipitating fires. Your facility needs to determine whether any such units are in use and remove them.



You’ll recall the unfortunate incident at Mercy Hospital in Coon Rapids, Minnesota of in which a neonate suffered burns in a flash fire while in an open-topped bassinette under a warmer while using an oxygen hood (see our January 29, 2008 Patient Safety Tip of the Week “Thoughts on the Recent Neonatal Nursery Fire” and our April 2008 What’s New in the Patient Safety World column “More Neonatal Incubator Fires”). Though nurses promptly extinguished the flames, the infant suffered burns over about 18% of his head and body.


Since that time there have been even more neonatal injuries and fatalities related to incubator fires in India.


Not only do you need to make sure you are no longer using one of the bassinet warming devices in the ECRI alert, but we’d suggest your organization consider performing a FMEA (failure mode and effects analysis) on potential neonatal unit fires. We had hoped by now we’d have several root cause analyses available to provide valuable lessons learned on these neonatal unit fires. However, details have not been published on any of the Indian cases. The executive summary of the Coons Rapids fire investigation is available and is a great place for you to start since it nicely outlines multiple theoretical concerns that you should be addressing. Focus, of course, is on all the components of the fire triad: an oxydizer, a heat source, and a fuel. That summary identifies the multiple potential heat sources you need to consider that could trigger a fire in an oxygen-rich environment. And, as we had expected in our previous columns, it does address potential fuels such as the alcohol-based disinfectants that we use so commonly now in our hospitals. The executive summary of the Minnesota incident does not go into much detail about oxygen but we have previously recommended that hospitals take a careful look to ensure that the clinical indications for use of oxygen are carefully adhered to. Just as in our discussions about the unnecessary use of urinary catheters, undoubtedly there are circumstances where neonates or other patients are “reflexly” begun on oxygen. (Worse yet, we know that reimbursement policies sometimes have the unintended consequence of unnecessarily prolonging oxygen therapy in neonates). Hospitals should have evidence-based criteria not only for starting oxygen therapy but also for its continuation and discontinuation.



Just as we need to ensure that everyone who enters an operating room has had appropriate training in surgical fire risk and procedures, we now need to consider similar training of everyone for any area in which oxygen is being used. This obviously would include not only staff, but everyone who might enter that area. That would include housestaff, agency personnel, and even parents and other visitors.





ECRI Institute High Priority Medical Device Alert

Infant Radiant Warmer Fire Prompts ECRI Institute Recommendations for Replacement.



Kanwar S. Concern focuses on patient safety. The Times of India. February 1, 2009



Allina Hospitals & Clinics. January 15, 2009





Surgical Team Training


Many of our columns have discussed teamwork, crew/cockpit resource management (CRM), communication, and handoffs. We are big advocates of the TeamSTEPPS™ program for teamwork training (see our our May 22, 2007 Patient Safety Tip of the Week “More on TeamSTEPPS™”). One of the problems we encounter in planning and implementing such team training programs, however, is measuring success of such programs. Many of the benefits of such teamwork training help the team function much better in emergency circumstances or in preventing unwanted events that are very rare to start with (eg. wrong site surgeries). So such events are likely to be absent in both pre- and post-intervention studies. Metrics of operating room efficiency can be used. But most assessments need to rely on process measures that are fairly labor-intensive to collect.


We previously noted a study by Lingard et al (Lingard 2008) that used a checklist to structure short team briefings and documented reduction in the number of communication failures.


A new study by Havlerson et al. from Northwestern Memorial Hospital (Halverson et al 2009) attempts to demonstrate the benefits of an intensive crew resource management training for all surgeons, anesthesiologists, OR nursing and ancillary personnel. The curriculum included a 4-hour training class plus some in-OR coaching. The intervention resulted in performance of a preoperative briefing in 86% of cases 2 weeks after the intervention but this fell to 66% at 6 months post-intervention. There was a modest improvement in formal announcement of intraoperative changes in staffing. There was no significant difference in timing of prophylactic antibiotic administration or case turnover times. A modest improvement in on-time first case starts may have been influenced by a concomitant intervention. A survey showed that 75% of participants had the perception that the briefings provided a better sense of teamwork. However, they noted a marked disparity in those perceptions by discipline, with nurses and anesthesiologists perceiving more benefit from the briefings than surgeons did.


This paper is definitely worth your reading. It details a whole host of lessons learned in implementing a program of this magnitude. They discuss not only the issue of metrics, but also the time and financial resources necessary, resistance to some of the concepts by some individuals, the need to get clinical leaders committed by actions rather than just words, and the issue of sustainability.




Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D, Espin S, Bohnen J, Whyte S. Evaluation of a Preoperative Checklist and Team Briefing Among Surgeons, Nurses, and Anesthesiologists to Reduce Failures in Communication. Arch Surg, Jan 2008; 143: 12-17




Halverson AL, Andersson JL, Anderson K, et al. Surgical Team Training. The Northwestern Memorial Hospital Experience. Arch Surg 2009; 144(2):107-112






Risk of Burns during MRI Scans from Transdermal Drug Patches



In our Patient Safety Tips of the Week for February 19, 2008 “MRI Safety and May 13, 2008 “Medication Reconciliation: Topical and Compounded Medications” we noted that drug patches may become patient safety issues in patients undergoing MRI. That is primarily because some of the patches contain metal or ferromagnetic elements that may overheat during MRI and cause burns. An article in Medscape had discussed which patches need to be removed prior to MRI and which are safe. That article stressed that communication should take place with the prescribing physician to see whether interruption in that drug therapy would be harmful to the patient. And a pharmacist may help determine whether a removed patch needs to be discarded or can be reused by the patient.


Now the FDA has issued a Public Health Advisory “Risk of Burns during MRI Scans from Transdermal Drug Patches with Metallic Backings”. The FDA notes that not all transdermal patches that contain metal have this warning for patients in the labeling.

FDA is in the process of reviewing the labeling and composition of all medicated patches to ensure that those made with materials containing metal provide a warning about the risk of burns to patients who wear the patches during an MRI scan.  But until this review is complete, FDA recommends that healthcare professionals referring patients to have an MRI scan identify those patients who are wearing a patch before the patients have the MRI scan. The healthcare professional should advise these patients about the procedures for removing and disposing of the patch before the MRI scan, and replacing the patch after the MRI scan.






Hulisz DT. Are Topical Patches Safe During MRI or CT Scans? Medscape. May 2, 2008. http://www.medscape.com/viewarticle/572561


FDA. FDA Public Health Advisory. Risk of Burns during MRI Scans from Transdermal Drug Patches with Metallic Backings. March 5, 2009












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