What’s New in the Patient Safety World

March 2012



·        Helicopter Transport and Stroke

·        Value of an Expanded Early Warning System Score

·        Smile…You’re on Candid Camera!

·        Add a Cognitive Walkthrough to Your FMEA

·        How Dangerous is a Day in the Hospital?

·        Postoperative Complications with Obstructive Sleep Apnea

·        Human Factors and Operating Room Safety

·        More on Perioperative Handoffs





Helicopter Transport and Stroke



We’ve done multiple columns pointing out inappropriate use of helicopters (or other air transport) for many medical patients and the dangerous track records of helicopter safety for patients and medical personnel. In our July 8, 2008 Patient Safety Tip of the Week “Medical Helicopter Crashes” and our October 2008 What’s New in the Patient Safety World “More Medical Helicopter Crashes” we discussed the “epidemic” of crashes of helicopters and other medical rescue aircraft in the recent past. We have been very critical that the regulatory agencies involved in oversight of the air medical industry have focused too much on proximate causes and ignored root causes (see our Patient Safety Tips of the Week for February 3, 2009 “NTSB Medical Helicopter Crash Reports: Missing the Big Picture” and September 1, 2009 “The Real Root Causes of Medical Helicopter Crashes” and our November 2010 What’s New in the Patient Safety World column “FAA Safety Guidelines for Medical Helicopters Short-Sighted). Proposed solutions to these crashes have always focused on proximate causes and recommendations have come out in favor of mandating night vision goggles, terrain warning systems, better weather information, changes in pilot training, etc.


All these solutions ignore some of the most important root causes and failed to ask an important question “Was an air medical evacuation really necessary here or could ground ambulance have been adequate?”. Even the few root cause analyses (RCA’s) we have seen following actual medical helicopter crashes have failed to ask that fundamental question “Was the helicopter transport indicated in the first place?”.


We previously noted a 2006 study done by Dr. Bryan Bledsoe and his colleagues that was a meta-analysis of helicopter transport of trauma patients (Bledsoe 2006). Using several widely-used injury severity or trauma scores, they showed that almost 2/3 of trauma patients brought by helicopter to a trauma center had minor or non-life-threatening injuries and that 25% were discharged from the hospital within 24 hours. Some helicopter services apparently have rates as high as 20% of transported patients being discharged from emergency rooms shortly after arrival (Greene 2009). Even in Maryland, where the trauma system is a model and the medical helicopter system a public one, the post-crash hearings revealed that almost half of patients transported by helicopter to trauma centers were released within 24 hours (Dechter 2008).


In our November 2010 What’s New in the Patient Safety World column “FAA Safety Guidelines for Medical Helicopters Short-Sighted” we highlighted some questions you should ask before sending your patients (and staff) off on medical helicopter transports.


Now some new studies further question the necessity of air transport for transferring some patients to tertiary medical centers. While most research on transfer of patients by air transport has dealt with trauma patients, transplant patients or transplant organs, or acute MI patients, we also see substantial numbers of patients with acute ischemic stroke transferred via helicopter or other forms of air transport. For thrombolytic therapy to be effective in reducing the morbidity and mortality from ischemic stroke, it has to be delivered within a tight time window (generally 4.5 hours from onset of symptoms). Therefore many patients were transferred via air so that they could get to a stroke center within that timeframe. However, now most communities have a “hub and spoke” stroke system in which staff at the “hub” (stroke center) can communicate via telemedicine links to the “spoke” (peripheral hospital) and thrombolysis can be initiated at the remote site and then continued in transit to the stroke center. Many (in fact probably most) patients are still transferred via air transport. Previous studies favoring transfer via helicopter (Reiner-Deitemyer 2011, Silliman 2003) have been done largely in systems where thrombolysis was only initiated on arrival at the stroke center.


A new study from the Mayo Clinic (Olson 2011) analyzed the data on patients within their stroke network. Of the 122 patients analyzed, 94 were transferred via air transport (generally helicopter) and 28 by ground transport. They found that, though the actual transport time was about 30 minutes faster by air, the overall time from activation of the system to arrival at the stroke center was only about 15 minutes faster on average. Moreover, outcomes in the two groups were similar and both modes of transportation appeared to be safe (in terms of complications, etc.). The authors conclude that ground transport should be considered for patients with acute ischemic stroke receiving intravenous rtPA unless endovascular rescue therapy is likely to be pursued. Limitations of this study include the relatively small number of patients transported via ground and the fact that the “spoke” hospitals are all within about 60 miles of the stroke center.


We’ve seen similar recommendations regarding transfer of acute MI patients as well. Percutaneous coronary intervention (PCI) had become the preferred strategy for acute STEMI because of a mortality benefit when PCI could be performed promptly. However, when data are analyzed on transferring acute STEMI patients to centers capable of performing PCI, it turns out that very few patients can get PCI within the prescribed time window even when transported via helicopter. Recent data have caused reconsideration of transfer strategies for STEMI patients (Redberg 2012). For low and intermediate-risk patients with STEMI there appears to be no mortality advantage of PCI over thrombolytic therapy. Even for high-risk patients the mortality risk of PCI over thrombolytics may be lost when there are routine delays of 1-3 hours for transport. Therefore, rather than activating the air transport system routinely, the strategy for most STEMI patients should be to administer thrombolytic therapy. Only in those high-risk patients where it is likely that transfer can take place promptly (and the receiving center by ready to do PCI) should air transport (or even ground transport) be considered.


So you really do need to take a hard look at the types of patient you are sending out to tertiary centers, make sure that they get the best evidence-based treatments available within a realistic timeframe, and make good decisions about mode of transport for those that do need transfer.







Bledsoe BE. Wesley AK. Eckstein M. Dunn TM. O'Keefe MF. Helicopter scene transport of trauma patients with nonlife-threatening injuries: a meta-analysis. Journal of Trauma-Injury Infection & Critical Care 2006; 60(6): 1257-65 http://www.jtrauma.com/pt/re/jtrauma/abstract.00005373-200606000-00015.htm;jsessionid=LzvDYgJNbkdJpBhDDCFtr3VBPJJ6WwQ1bvdXstQHvMNQ7Lk0Mygl!447927974!181195628!8091!-1?index=1&database=ppvovft&results=1&count=10&searchid=1&nav=search



Greene J. Rising Helicopter Crash Deaths Spur Debate Over Proper Use of Air Transport.

Annals of Emergency Medicine 2009; 53: A15-A17 (March 2009)




Dechter G, Jones B. Md. medevac crash raises question about trauma procedures.

The Baltimore Sun. October 1, 2008




Olson MD, Rabinstein AA. Does Helicopter Emergency Medical Service Transfer Offer Benefit to Patients With Stroke? Stroke 2011; published online before print December 8 2011




Reiner-Deitemyer V, Teuschl Y, Matz K, et al. for the Austrian Stroke Unit Registry Collaborators. Helicopter Transport of Stroke Patients and Its Influence on Thrombolysis Rates: Data From the Austrian Stroke Unit Registry. Stroke 2011; 42: 1295-1300




Scott L. Silliman SL, Quinn B, Huggett V, Merino JG. Use of a Field-to-Stroke Center Helicopter Transport Program to Extend Thrombolytic Therapy to Rural Residents. Stroke 2003; 34: 729-733




Redberg RF. Reconsidering Transfer for Percutaneous Coronary Intervention Strategy: Time Is of the Essence. Arch Intern Med 2012; 172: 98 – 99







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Value of an Expanded Early Warning System Score




Use of early warning scores (EWS) has never really caught on in the US. Yet we all agree that earlier recognition of clinical deterioration is critical and needs improvement (see our Patient Safety Tips of the Week for December 29, 2009 “Recognizing Deteriorating Patients”, March 15, 2011 Early Warnings for Sepsis” and Februrary 22, 2011 Patient Safety Tip of the Week “Rethinking Alarms”).


The modified early warning score (MEWS) is probably the best known of these tools designed to alert staff to early clinical deterioration.


An expanded version of the MEWS was introduced in the Netherlands in 2009. A recent study (Smith 2012) now reports the impact of that score in predicting clinical deterioration in patients admitted to general or trauma surgery wards. The tool included the basic parameters included in earlier versions of the MEWS (heart rate, systolic BP, respiratory rate, oxygen saturation, temperature, and level of consciousness) but added some new parameters. One was urinary output. The other was a more subjective parameter: the nurse’s level of concern about the patient’s condition.


The authors looked at 592 consecutive patients admitted to the general and trauma surgery wards of a level I trauma center in the Netherlands. Overall, 8% of patients met their composite outcome of death, reanimation (resuscitation), unexpected ICU admission, emergency operation, or severe complication. Patients reaching a score of 3 or higher on the expanded tool were 11 times more likely to meet the composite endpoint, even after adjustment for the ASA grade. The negative predictive value of the score was 97%, indicating its use as a screening tool is quite valuable. The sensitivity was 74% and the positive predictive value 26%.


So how was the tool used?  Three times a day, on clinical rounds, the score was recorded. In addition, a score was recorded any time clinical deterioration was noted. If the score was 3 or higher, nursing would advise evaluation by the attending physician and ask for a treatment plan. If that plan was unsuccessful, the ICU physician would be asked to evaluate the patient. The researchers are in the process of determining the impact of the expanded tool on adverse outcomes.


The commentary accompanying the study notes that the average age of the patients was 50 and that it would be useful to know if the scoring tool was as effective in older and younger patients. Also pointed out was that these were all surgical patients, so it is not known whether similar utility would apply to nonsurgical patients.


The concept that no single sign or parameter is likely to readily identify all patients who are deteriorating and that we need a more global assessment of multiple paramters is a good one. The MEWS and its offshoots show us the potential of such scoring systems to identify earlier those patients who are at risk of deterioration. In our December 29, 2009 Patient Safety Tip of the Week “Recognizing Deteriorating Patients” we noted that MEWS was a good start to the concept that monitoring multiple parameters simultaneously and integrating them to provide a “bigger picture” that might be potentially valuable. MEWS began as a paper-based system but with the introduction of more sophisticated physiologic monitoring systems and more widespread us of electronic medical records, the concept of rules-based algorithms running in the background and generating alerts to clinicians has become a reality. With more advanced physiologic monitoring capabilities it is likely that eventually we will have algorithms that incorporate multiple parameters to identify patterns indicative of deterioration that needs more immediate intervention. We’ve previously discussed difficulties in early detection of patient deterioration (see our Februrary 22, 2011 Patient Safety Tip of the Week “Rethinking Alarms”). In that column we highlighted a very insightful study by Lynn et al (Lynn 2011) that described many of the flaws in current patient monitoring systems, particularly those monitoring for respiratory complications. And we stressed the need for “smart” alarm systems that can monitor multiple parameters in an integrated fashion to detect deterioration earlier.


There remains a paucity of randomized controlled trials evaluating use of tools for the identification of deteriorating patients. A recent review by the Canadian Agency for Drugs and Technology in Health could find none but had a good bibliography of 10 non-randomized controlled studies (CADTH 2011).


Nevertheless, despite all the potential merits of technological solutions, we like the idea that the expanded MEWS in the Netherlands study also used what we consider a most valuable measure: the nurse’s bedside gestalt of the patient’s condition!







Smith T, Den Hartog D, Moerman T, et al. Accuracy of an expanded early warning score for patients in general and trauma surgery wards. British Journal of Surgery 2012; 99: 192-197




Lynn LA, Curry JP. Patterns of unexpected in-hospital deaths: a root cause analysis. Patient Safety in Surgery 2011, 5:3 (11 February 2011)




CADTH (Canadian Agency for Drugs and Technology in Health). Tools for the Early Identification of Adult Inpatients at Risk for Deterioration: Clinical Evidence and Guidelines. 22 November 2011







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Smile…You’re on Candid Camera!



We continue to generally do a poor job of improving compliance with recommended hand hygiene standards (see our Patient Safety Tips of the Week for January 5, 2010 “How’s Your Hand Hygiene?” and May 24, 2011 “Hand Hygiene Resources”).


Now a new study (Armellino 2012) has shown the video monitoring with feedback can dramatically improve compliance with hand hygiene practices in a sustainable way. The study was conducted in an ICU setting. Cameras were placed to view all sinks and hand sanitizer dispensers and were activated by sensors that detected people entering or exiting rooms. Performance feedback was continuously displayed on electronic boards mounted within the hallways, and summary reports were delivered to supervisors by electronic mail.


In the period prior to providing feedback the compliance rate with hand hygiene was less than 10%. After feedback began compliance rates improved to over 81% at 16 weeks. By 75 weeks compliance was at an astonishing 87.9%!


What we don’t yet have are details of any impact this intervention has had on infection rates and a cost-effectiveness analysis. Some prior studies that demonstrated improvements in hand hygiene compliance did not always show improvement in infections rates. In a previous study (Rupp 2008) the introduction of alcohol-based gel resulted in a significant and sustained improvement in adherence to hand hygiene but did not result in reduction of the incidence of healthcare-associated infection. So keep in mind that the hand hygiene rates are a surrogate measure. The actual outcome measure of importance is the hospital-acquired infection rate.



We can think of a number of other areas in which video surveillance with feedback has the potential to significantly improve compliance with recommended practices. We’ve previously mentioned that the timeout in the OR is one especially in need of improvement and could benefit from video recording with feedback done in a constructive fashion.







Armellino D, Hussain E, Schilling ME, et al. Using High-Technology to Enforce Low-Technology Safety Measures: The Use of Third-party Remote Video Auditing and Real-time Feedback in Healthcare. Clin Infect Dis. (2012) 54 (1): 1-7 First published online: November 21, 2011




Rupp ME, Fitzgerald T, Puumala S, et al. Prospective, Controlled, Cross-Over Trial of Alcohol-Based Hand Gel in Critical Care Units. Infect Control Hosp Epidemiol 2008; 29: 8–15






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Add a Cognitive Walkthrough to Your FMEA



ISMP Canada (ISMP Canada 2012) has a good article about a technique that we were unfamiliar with and which has the potential to improve your FMEA’s (Failure Mode and Effects Analyses). The technique is called a “cognitive walkthrough”.


Rather than just brainstorming and throwing out ideas during a FMEA, the technique involves having a representative user (eg. a front-line practitioner) simulate all parts of the task(s) and “think out loud” while doing so. We often talk about how we need to put ourselves in the mind of the participants when we are doing a root cause analysis of an untoward event. Well, it makes sense to do the same during a FMEA. The technique allows observers to see the task from the perspective of the participant. The technique is especially useful because it not only identifies what the participant was thinking but also helps identify points where the participant had frustrations, confusion, or doubts in doing (or not doing) specific tasks.


The article goes on to describe who can facilitate a cognitive walkthrough, how to choose a participant or participants (making sure no biases are present), and how to conduct the cognitive walkthrough. It even provides helpful hints for the facilitator to coax the participant into revealing what is going on in his/her mind at the time.


This is a very interesting technique that makes a lot of sense. We’ll definitely try it the next time we are doing a FMEA.






ISMP Canada. Include Cognitive Walkthrough in Proactive Risk Assessments. ISMP Canada Safety Bulletin 2012; 12(1): 1-3 January 23, 2012







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How Dangerous is a Day in the Hospital?



How dangerous is a day in the hospital? For many years, we have used the numbers from a study done by Lori Andrews et al. (Andrews 1997) that found you have a 6% chance per inpatient day of having an adverse event. And, of course, a 2010 report (Levinson 2010) showed that one in every seven Medicare patients who is hospitalized experienced adverse events during their hospital stays, up to 44% being potentially preventable.


A new study (Hauck 2011) tries to quantifty the risk even further. Using a large database from public hospitals in Australia, the authors calculated that the average hospital stay carries a:

·        5.5% risk of adverse drug reaction

·        17.6% risk of infection

·        3.1% risk of pressure ulcers


Moreover, each additional night in the hospital increases the risk by 0.5% for adverse drug reactions, 1.6% for infections, and 0.5% for pressure ulcers.


They used a complex set of equations to do these calculations and did adjust for such variables as age, sex, whether the patient died, whether the patient was admitted emergently, and complexity (as measured via the Charlson index). They also adjusted for outliers with respect to LOS.


Interesting. Our grandparents always regarded hospitals as dangerous places. They had no idea what the statistics were!







Andrews LB, Stocking C, Krizek T, et al. An alternative strategy for studying adverse events in medical care. Lancet 1997; 349: 309–313




Levinson DR. Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2010. Report No. OEI-06-09-00090




Hauck K, Zhao X. How Dangerous is a Day in Hospital?: A Model of Adverse Events and Length of Stay for Medical Inpatients. Medical Care 2011; 49(12): 1068-1075, December 2011







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Postoperative Complications with Obstructive Sleep Apnea



We’ve done multiple columns on the risks in the perioperative period of patients with known or suspected obstructive sleep apnea (OSA). A new study (Kaw 2012) identified patients who had undergone polysomnography and then had noncardiac surgery. From the group they identified 282 patients with apnea-hypopnea indices (AHI) of 5 or above as having OSA. They then developed a propensity score-matched control group from those who had a polysomnogram but had AHI indices less than 5. The group with OSA was almost 7 times more likely to have overall complications, 8 times more likely to have postoperative hypoxemia, and over 4 times more likely to require transfer to an ICU. They also had longer lengths of stay.


Respiratory failure accounted for 35% of the complications. A previous study (Memtsoudis 2011) had also shown about a 5-fold increase in respiratory failure in patients with OSA undergoing noncardiac surgery. The latter study showed patients with OSA developed pulmonary complications more frequently than their matched controls after both orthopedic and general surgical procedures.


Kaw et al. discuss that the negative effects of sedative, analgesic and anesthetic agents can worsen OSA both by decreasing pharyngeal tone and by decreasing the arousal responses to hypoxia, hypercarbia, and obstruction. They also note that some of the “later” events may be due to the rebound increase in REM sleep that is higher, for example, on the third night rather than first night.


A brief article (Nitsun 2012) on using the STOP-BANG questionnaire to screen for OSA pre-operatively also gave some common sense guidelines for managing patients with suspected OSA postoperatively. Those recommendations include considering opioid-sparing pain management, full reversal of any neuromuscular blockade used, monitoring the patient with capnography, and ensuring patients are not kept supine when extubated. It also has a discussion about whether procedures in patients with known or suspected OSA should be done in an ambulatory vs. hospital setting.



See some of our prior columns on obstructive sleep apnea in the perioperative period:


Patient Safety Tips of the Week:

June 10, 2008              Monitoring the Postoperative COPD Patient

August 18, 2009           Obstructive Sleep Apnea in the Perioperative Period

August 17, 2010           Preoperative Consultation – Time to Change

July 13, 2010               Postoperative Opioid-Induced Respiratory Depression

February 22, 2011       Rethinking Alarms

November 22, 2011     Perioperative Management of Sleep Apnea Disappointing



What’s New in the Patient Safety World columns:

July 2010                     Obstructive Sleep Apnea in the General Inpatient Population

November 2010           More on Preoperative Screening for Obstructive Sleep Apnea








Roop Kaw R, Pasupuleti V, Walker E et al. Postoperative Complications in Patients With Obstructive Sleep Apnea. Chest 2012; 141(2): 436-441




Memtsoudis S,  Liu SS, Ma Y, et al. Perioperative Pulmonary Outcomes in Patients with Sleep Apnea After Noncardiac Surgery. Anesth Analg 2011; 112: 113-121




Nitsun M. A Simple Way to Screen For Obstructive Sleep Apnea. Outpatient Surgery Magazine. February 2012






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Human Factors and Operating Room Safety



The February 2012 issue of Surgical Clinics of North America is dedicated to patient safety. It has multiple good articles on issues related to patient safety in the OR and other venues involved in surgical care.


The issue begins with an overview of high-reliability organizations (HRO’s) by Sanchez and Barach (Sanchez 2012). It describes the principles of high-reliability organizations that have managed to operate safely in other complex industries with capability of responding rapidly to changing conditions. In addition to the HRO literature, it also discusses James Reason’s Swiss cheese model of accident causation and Charles Perrow’s normal accident theory. It is particularly useful in its description of microsystems in an HRO and how clinical microsystems are of great importance in healthcare.


An article by ElBardissi and Sundt (ElBardissi 2012) on human factors and OR safety discusses both environmental and interpersonal aspects of OR design and function. They discuss factors in the OR layout that may impede good communication between all parties. These include positioning of equipment, the collection of wires/tubes/lines (the “spaghetti syndrome”), noise, and other factors that need to be considered in designing good surgical flow and information exchange. They have a very good discussion on the flexibility vs. standardization debate.


On reducing distractions related to noise, they discuss policies restricting the number of observers in the OR, radios, pagers, music, non-essential personnel movement, and non-case-related conversations. However, they note downsides to each of those recommendations as well and sometimes offer compromise positions. For example, noting that non-case-related conversations may have a role in promoting teamwork and job satisfaction, they suggest we adopt the sterile cockpit rule from aviation, in which such extraneous conversations are barred during critical phases of the case.


They also discuss issues related to team familiarity and note that the literature shows stable teams have shorter OR times, fewer surgical flow disruptions, higher satisfaction, and more trust. They note that team stability helps in recognition of non-verbal communication and anticipation of others’ activities. Team stability applies not only to scheduling cases with stable personnel but also ensuring, within feasible limits, that the same personnel are present through the whole case.


They have an excellent discussion on preoperative briefings. They cite their own experience and that from the literature, which demonstrate such preoperative briefings reduce the number of surgical flow disruptions and miscommunications per case, trips out of the OR, staff turnover and wrong-site surgeries and increase staff satisfaction and perception of safety culture.


Their discussion of tools and technology focuses on the need to involve all the OR personnel in the design and planning for implementation of new technologies so that usability and workflow factors are considered and unintended consequences might be anticipated. They note how something seemingly benign may eliminate desirable functions. One example they give is how electronic whiteboards might eliminate the social and teambuilding functions that the old whiteboards provided. They encourage basic usability assessment for any new technologic introduction and recommend simulation testing where possible.


They have a good section on standardized procedures and checklists. On the latter they note the importance of good checklist design and identifying where checklists are truly needed, so we’re not just adding on layers of complexity or additional burdens. They note that “checklist fatigue” can lead to teams performing the checklist in a perfunctory manner, defeating the purpose for which good checklists are designed.


Lastly, they discuss the importance of developing a culture of safety. This includes leadership engagement (for example, doing regular executive walkrounds and engaging involved staff in discussions on safety), the role of the surgeon, the recognition that errors occur and we need to identify them and mitigate their effects, and the importance of teamwork.


An article by Cooper and Makary (Cooper 2012) on the comprehensive unit-based safety programs (CUSP’s) made famous at Johns Hopkins describes the regular meetings by both members of frontline staff and representatives from administration to discuss issues related to patient safety. Assessment of the culture of safety, including tools such as the Safety Attitudes Questionnaire (SAQ), physician champions, and teamwork training are important components. They also have a good section on both preoperative briefings and postoperative debriefings. At the preoperative briefings, staff can become familiar with others (if not already familiar) and patient/procedure can be confirmed, and discussion can include things like use/timing of antibiotics, critical steps of the case, and potential problems. In addition to the benefits mentioned above, they note that preoperative briefings have also been demonstrated to identify equipment problems earlier, reduce OR delays, and reduce OR costs. The postoperative debriefings can include discussions about what went well, what went wrong, and what could have been done better. They can also include verification of needle and instrument counts and confirmation of correct labeling of OR specimens.


Harry Sax (Sax 2012) provides insight into what it takes to develop high-performing teams, noting how the traditional surgical training programs tend to be at odds with what is needed for good teamwork. The focus of team building is on creation of a shared vision and mission, clear and achievable goals, ensuring desire to work with others to achieve those goals, recognizing the value of all team members (including making sure that all team members recognize their own value), and rewarding desirable team behavior. He provides a good discussion on the challenges of team building in the OR: differing motivations, distractions (production pressures, outside responsibilities, etc.), fact that we tend to reward for individual accomplishments rather than team accomplishments, problems with the hierarchy, and attitude that perfection is assumed. He provides solid common-sense advice on buiding teams, including how to bring new people onto teams, aligning incentives correctly (so we don’t “reward” staff for being efficient by making them do additional work uncompensated), ensuring multidisciplinary input and discussion at morbidity and mortality conferences, embracing informal leaders, soliciting feedback and suggestions from all staff, and rapidly addressing disruptive behavior by staff at all levels. His advice “hire for attitude, train for aptitude” rings true. And he notes that commitment from leadership is critical, not only for providing resources but also for promptly addressing issues as they arise.


An article on surgeon’s non-technical skills (Yule 2012) provides excellent insight into key skills such as situational awareness, decision-making, leadership, communication and teamwork. We’ll be discussing the issue of non-technical skills and their impact on surgery in a future column. There is even an article on how unconscious biases may impact patient safety and outcomes (Santry 2012).


There are two papers on root cause analyses (RCA’s) in healthcare. Karl and Karl (Karl 2012) present a hypothetical poorly done (but unfortunately typical) RCA from healthcare and compare it to one done by the NTSB on an airline accident. They discuss the appropriate way to do RCA’s, focusing on system errors and contributing factors with the goal of fixing those and preventing future occurrences. Cassin and Barach (Cassin 2012) discuss the limitations of RCA’s.


This issue also has many other good articles on various aspects of patient safety in surgery, including a good article on disclosure and apology (Eaves-Leanos 2012).






Surgical Clinics of North America. Patient Safety. February 2012




Sanchez JA, Barach PR. High Reliability Organizations and Surgical Microsystems: Re-engineering Surgical Care. Surgical Clinics of North America 2012; 92(1): 1-14




ElBardissi AW, Sundt TM. Human Factors and Operating Room Safety. Surgical Clinics of North America 2012; 92(1): 21-35




Cooper M, Makary MA. A Comprehensive Unit-Based Safety Program (CUSP) in Surgery: Improving Quality Through Transparency. Surgical Clinics of North America 2012; 92(1): 51-63




Sax H. Building High-Performance Teams in the Operating Room. Surgical Clinics of North America 2012; 92(1): 15-19




Yule S, Paterson-Brown S. Surgeons’ Non-technical Skills. Surgical Clinics of North America 2012; 92(1): 37-50




Karl R, Karl MC. Adverse Events: Root Causes and Latent Factors. Surgical Clinics of North America 2012; 92(1): 89-100




Cassin BR, Barach PR. Making Sense of Root Cause Analysis Investigations of Surgery-Related Adverse Events. Surgical Clinics of North America 2012; 92(1): 101-115




Santry HP, Wren SM. The Role of Unconscious Bias in Surgical Safety and Outcomes. Surgical Clinics of North America 2012; 92(1): 137-151




Eaves-Leanos A, Dunn EJ. Open Disclosure of Adverse Events: Transparency and Safety in Health Care. Surgical Clinics of North America 2012; 92(1): 163-177






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More on Perioperative Handoffs



Our February 14, 2012 Patient Safety Tip of the Week “Handoffs – More Than Battle of the Mnemonics” discussed several handoff tools and corresponding mnemonics which may be very helpful in your handoffs. The key message is that you need to implement tools that address the needs of each particular type of handoff that occurs in your organization. Though using a structured communication format or tool is important, the exact tool or format needed will vary by the nature of the handoff so “one size does not fit all”.


Particularly in the perioperative setting, the nature of handoffs is often very different from the resident-to-resident or nurse-to-nurse handoffs done on a medical unit.


We highlighted the AORN toolkit in our December 2011 What’s New in the Patient Safety World column “AORN Perioperative Handoff Toolkit” and several abstracts (Greenberg 2012) presented at the 2011 American Society of Anesthesiologists annual meeting dealt with perioperative handoffs/handovers.


But the folks at Johns Hopkins have taken the perioperative handoff to a new level (Petrovic 2012a). Most of the handoffs we have talked about in our prior columns have been handoffs either between like healthcare workers (eg. resident-to-resident, nurse-to-nurse, etc.) or between individual healthcare workers (eg. nurse-to-physician). The handoff process developed at Hopkins is a true multidisciplinary and interdisciplinary handoff. It was designed for transfers of patients from OR to PACU or PACU to ICU, etc. They first developed it and piloted it for patients destined for their cardiac-surgical ICU (CSICU) from the OR. It consists of a protocol and series of checklists. The protocol has 5 steps and takes place with the entire team in the patient room. The first step involves identifying the patient and introducing all members of the team. Step 2 involves “transfer of technology” (monitors, lines, etc.). Subsequent steps are checklist-guided handoffs by the surgeon, anesthesiologist, and OR nurse. Each of the latter 3 handoffs concludes with a statement of “anticipatory guidance” by the presenter, stating what he/she is most concerned about regarding the patient. Plenty of time is provided for members of the receiving team to ask questions and clarify items. The handoff formally concludes with an announcement “the handoff is now complete”. The article includes copies of the checklists and protocol and delineates the steps you need to go through to implement the protocol. The authors also have prepared a multimedia toolkit for those who want to implement the protocol at their institutions.


In a companion paper, they also have published some outcome measures from that protocol and process (Petrovic 2012b). After the protocol's implementation, the presence of all handoff core team members at the bedside increased from 0% at baseline to 68%, the percentage of missed information in the surgery report decreased from 26% to 16% , and handoff satisfaction scores among intensive care unit (ICU) nurses increased from 61% to 81%. On average, the duration of handoff increased by 1 minute.


This is really nice work. Do yourselves a favor and borrow from all the hard work they have done to develop this protocol and adapt it for your own needs.







Greenberg SB, Murphy GS, Vender JS. Scientific Papers Address Patient Safety. Patient Handover Communication. APSF Newsletter 2012; 26(3): 57 Winter 2012




Petrovic MA, Martinez EA, Aboumatar H. Implementing a Perioperative Handoff Tool to Improve Postprocedural Patient Transfers. Joint Commission Journal on Quality and Patient Safety 2012; 38(3): 135-4AP(-130)



Petrovic MA, Aboumatar H , Baumgartner WA. Pilot Implementation of a Perioperative Protocol to Guide Operating Room–to–Intensive Care Unit Patient Handoffs. J Cardiothorac Vasc Anesth 2012; 26(1): 11-16







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Print “March 2012 What's New in the Patient Safety World (full column)

Print “March 2012 Helicopter Transport and Stroke

Print “March 2012 Value of an Expanded Early Warning System Score

Print “March 2012 Smile…You’re on Candid Camera!

Print “March 2012 Add a Cognitive Walkthrough to Your FMEA

Print “March 2012 How Dangerous is a Day in the Hospital?

Print “March 2012 Postoperative Complications with Obstructive Sleep Apnea

Print “March 2012 Human Factors and Operating Room Safety

Print “March 2012 More on Perioperative Handoffs














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