What’s New in the Patient Safety World

March 2011



March 6-12, 2011 is Patient Safety Awareness Week



The National Patient Safety Foundation is sponsoring Patient Safety Awareness Week March 6-12, 2011. Visit the NPSF website for tools to use at your organization to promote patient safety awareness.




March 2011



·        Downside of Transfusions in Surgery

·        APSF Fire Safety Video

·        Michigan ICU Collaborative Wins Big

·        Inappropriate Medications Often Start in the ICU






Downside of Transfusions in Surgery


Over the last several years there has been increasing evidence that transfusions during surgery may be more harmful than helpful.


A new study (Glance 2011) looked at the impact of intraoperative transfusions on outcomes in patients undergoing noncardic surgery who had preoperative hemoglobins in the 6-10 g/dl range. Data came from the large, high quality American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) database. Compared to patients not transfused, those transfused had higher mortality rates, as well as increased pulmonary complications, sepsis, thromboembolic complications, and wound complications.


Studies have also shown that anemia increases the morbidity and mortality from surgery. So to try to account for confounding factors, Glance et al decided to look at those patients with hemoglobins in the 6-10 g/dl range, where guidelines suggest decisions about transfusions be based on clinical grounds. They had to apply some fairly sophisticated regression models and adjustments to get good comparisons but those and the overall quality of data in this large database make the results striking. Mortality was 29% higher in those transfused and the increases in complications ranged from 43-87%. The authors discuss several potential theoretical mechanisms that might account for these detrimental effects of transfusions. But the bottom line is that, regardless of what the mechanism is, transfusions appear to result in worse outcomes in this patient population.


Though the authors call for a large randomized controlled trial to put the issue to rest, the accompanying editorial (Spahn 2011) says it is already time for a change in view of the mounting evidence of the detrimental effects of intraoperative transfusions.


Not only may a reduction in blood transfusions reduce complications, it may also save considerable amounts of money. A program at Loyola University Hospital reduced transfusion of blood products by 10% per patient and produced at net savings of over $450,000 (Loyola University Hospital 2010).






Glance LG, Dick AW, Mukamel DB, et al. Association between Intraoperative Blood Transfusion and Mortality and Morbidity in Patients Undergoing Noncardiac Surgery. Anesthesiology 2011; 114(2): 283-292




Spahn DR, Shander A, Hofmann A, Berman MF. More on Transfusion and Adverse Outcome: It's Time to Change. Anesthesiology 2011; 114(2): 234-236




Loyola University Health System. Reducing Blood Transfusions Improves Patient Safety and Cuts Costs. Newswise 10/7/2010





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APSF Fire Safety Video



The Anesthesia Patient Safety Foundation, in conjunction with ECRI Institute, has put together a video on prevention and management of operating room fires. The video lasts about 20 minutes and is an outstanding resource to go along with the many fine resources on surgical fires that ECRI has put together over the years.




Anesthesia Patient Safety Foundation. Fire Safety Video.






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Michigan ICU Collaborative Wins Big



Everyone by now knows about Peter Pronovost’s famous checklist for reducing CLABSI’s (catheter-related bloodstream infections). Pronovost and colleagues worked with the Michigan Health and Hospital Association (MHA) Keystone Project on a multifaceted ICU patient safety/quality improvement collaborative. In 2006 they published their results on the impact on CLABSI’s (Pronovost 2006), demonstrating a dramatic reduction in the occurrence of CLABSI’s in the 18 months following the implementation. Last year they showed that the dramatic improvement was sustained for 36 months (Pronovost 2010).


But the MHA Keystone ICU project was about far more than CLABSI’s. It was a comprehensive program aimed at improving patient safety, engendering a culture of safety, and improving communication between providers. The two evidence-based initiatives included were the CLABSI project and one to reduce ventilator-associated pneumonia (VAP). Now the MHA Keystone ICU project has published more results, again demonstrating striking success. The first paper (Lipitz-Snyderman 2011) demonstrated a roughly 20% improvement in adjusted hospital mortality rates in the study group compared to a control group. The second paper (Berenholtz 2011) reported on the VAP outcomes. There was a 71% reduction in VAP rates that was sustained for at least 30 months post-intervention.


Since the MHA Keystone ICU project involved multiple interventions, the dramatic improvements cannot be attributed to one specific intervention. However, we think one of the secrets to success is the CUSP (Comprehensive Unit-Based Safety Program) approach. In our own experience the patient safety and quality improvement projects that are most successful are those done in relatively small settings where the key participants all know each other and work closely together as affinity groups. Contrast the striking successes of the MHA Keystone ICU project to the relative lack of success of a large scale organizational intervention on patient safety at several UK hospitals (Benning  2011a, Benning 2011b). In the UK project there seemed to be a disconnect between the frontline staff and the group overseeing the project.


For good descriptions of the CUSP model, see Pronovost 2006b and Timmel 2010. The CUSP model is also nicely described in Peter Pronovost’s book “Safe Patients, Smart Hospitals” (see our July 6, 2010 Patient Safety Tip of the Week “Book Reviews: Pronovost and Gawande”).







Pronovost P, Needham D, Berenholtz S, et al. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. N Engl J Med 2006; 355: 2725-2732




Pronovost PJ, Goeschel CA, Colantuoni E, et al. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study. BMJ 340:doi:10.1136/bmj.c309 (Published 4 February 2010)




Lipitz-Snyderman A, Steinwachs D, Needham DM, et al. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. BMJ 2011; 342:doi:10.1136/bmj.d219 (Published 31 January 2011)




Berenholtz SM, Pham JC, Thompson DA, et al. Collaborative Cohort Study of an Intervention to Reduce Ventilator-Associated Pneumonia in the Intensive Care Unit. Infect Control Hosp Epidemiol 2011; 32(4): 0000 published online February 17, 2011




Benning A, Ghaleb M, Suokas A, et al. Large scale organisational intervention to improve patient safety in four UK hospitals: mixed method evaluation. BMJ 2011; 342: doi:10.1136/bmj.d195 (Published 3 February 2011)




Benning A, Dixon-Woods M, Nwulu U, et al. Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase. BMJ 2011; 342: doi:10.1136/bmj.d199 (Published 3 February 2011)




Timmel J, Kent PS, Holzmueller CG, et al. Impact of the Comprehensive Unit-Based Safety Program (CUSP) on Safety Culture in a Surgical Inpatient Unit.

Joint Commission Journal on Quality and Patient Safety 2010; 36(6): 252-260




Pronovost PJ, King J, Holzmueller CG, et al. A Web-based Tool for the Comprehensive Unit-based Safety Program (CUSP). Joint Commission Journal on Quality and Patient Safety 2006; 32(3): 119-129




Pronovost P, Vohr E. Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out. Hudson Street Press 2010






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Inappropriate Medications Often Start in the ICU



We’ve written several columns on Beers’ List of potentially inappropriate medications (see our Patient Safety Tips of the Week for January 15, 2008 “Managing Dangerous Medications in the Elderly  and October 19, 2010 “Optimizing Medications in the Elderly” and September 22, 2009 “Psychotropic Drugs and Falls in the SNF” and our What’s New in the Patient Safety World columns for June 2008  Potentially Inappropriate Medication Use in Elderly Hospitalized Patients” and September 2010 “Beers List and CPOE”).


A new study from Vanderbilt University Medical Center (Morandi 2011) showed that the proportion of patients on potentially inappropriate or actually inappropriate medications increased by 20% after a critical illness and that about half of these were started in the intensive care unit. The most common inappropriate drugs were anticholinergics but the authors also note that antipsychotic agents, often used to treat delirium in the ICU, are also often continued after discharge.


This study highlights the importance of medication reconciliation at all transitions of care. Today most hospital activities on medication reconciliation have focused on admission and discharge. But is it just as important that medication reconciliation take place when patients are transferred from the ICU to the floor (or vice versa) or from one service to another. Physicians are always reluctant to discontinue drugs started by someone else. So it is incumbent upon the transferring physicians to review all drugs and determine which truly need to be continued and, if so, for how long.


The other classic drugs that get started in the ICU and are often continued inappropriately are proton pump inhibitors and H2-blockers. While such acid-suppressing drugs have been demonstrated to reduce the risk of GI bleeding in critically ill ICU patients, they have not been shown to be of similar benefit in other settings and patients not critically ill. A new study (Herzig 2011) confirms that nosocomial bleeding outside the ICU setting is rare and that there is little benefit to use of PPI’s or H2-blockers in the non-ICU population. The number needed to treat (NNT) to prevent one episode of nosocomial GI bleeding was 770 and the NNT to prevent one episode of clinically significant bleeding was 834. There has been increasing evidence that acid-suppressing medications, PPI’s in particular, may increase the likelihood of Clostridiium difficile (C.diff) infections and hospital-acquired pneumonia. So it is critical on both internal transfers and at discharge that PPI’s and H2-blockers be specifically scrutinized. We also recommend that third party payors should use their large drug databases to screen for new starts of such drugs after a hospitalization and then have programs in place to examine the necessity of such drugs.






Morandi A, et al. Society of Critical Care Medicine (SCCM) 40th Critical Care Congress: Abstract 569. Presented January 17, 2011 as reported in Lowry F. Inappropriate Medications Commonly Prescribed to the Elderly in the ICU. Medscape  January 2011




Herzig SJ, Vaughn BP, Howell MD, et al.  Acid-Suppressive Medication Use and the Risk for Nosocomial Gastrointestinal Tract Bleeding. Arch Intern Med. 2011; published online February 14, 2011





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