Patient Safety Tip of the Week Archive

What’s New in the Patient Safety World

March 2015

· Another Source of Iatrogenic Burns

· CPOE Fails to Catch Prescribing Errors

· Another Paradox: Falls Due to Walking Aids

· Meds Cause ER Visits in Kids Too

Another Source of Iatrogenic Burns

We’re always amazed at the varied circumstances in which hospitalized patients may suffer iatrogenic burns. While we’ve mentioned heat from light sources such as fiberoptic light as a potential heat source for OR fires (see our December 4, 2007 Patient Safety Tip of the Week “Surgical Fires”), we have not discussed light sources in other iatrogenic burns.

Now halogen lights have been identified as the cause for burns of multiple patients in operating rooms at an Oregon hospital (Wozniacka 2015). The report says that about 10 patients, possibly more, suffered burns over a period of several months. The hospital director of quality and risk services was quoted as saying the hospital initially “looked at more common culprits: solutions used to prep skin before surgery, bandages or dressings used after surgery, and cautery devices used to stop bleeding during surgery”. It was only later that a surgery team member recalled maintenance had been done on the OR lights. Apparently halogen lamps require filters for UV light and those were not changed at the time of maintenance. Subsequently, the hospital has switched to light-emitting diodes (LED’s) and it has changed procedures for medical equipment maintenance, requiring the engineering department or the equipment's vendor to do any kind of maintenance.

Sometimes causes for unusual events are not readily apparent. But it sure helps to disseminate such lessons so another facility won’t need months to solve the problem.

Our prior columns on iatrogenic burns:

June 1, 2010 “Iatrogenic Burns”
October 5, 2010 “More Iatrogenic Burns”
December 23, 2014 “Iatrogenic Burns in the News Again”

References:

Wozniacka G. The Associated Press. Oregon hospital patients burned by lights in operating rooms. CTV News. Published Thursday, January 22, 2015

http://www.ctvnews.ca/health/oregon-hospital-patients-burned-by-lights-in-operating-rooms-1.2200261

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CPOE Fails to Catch Prescribing Errors

Our readers might get the erroneous impression that we are not advocates of CPOE from reading our many columns outlining some of the untoward consequences and other problems with CPOE and healthcare IT in general. Nothing could be further from the truth. We remain huge supporters of CPOE and clinical decision support and IT applications in healthcare. However, once again, we find ourselves commenting on yet another example of problematic CPOE.

In the new study, researchers culled the MEDMARX database for medication errors which included some indication that CPOE may have played a role (Schiff 2015). They then developed a taxonomy and coding for the types of errors, why they occurred, and what preventive strategies might be employed. From their list they then developed multiple scenarios and tested on a representative sample of CPOE systems at multiple facilities whether these error-prone scenarios might pass through.

From over 1 million reports available in MEDMARX they found 6.1% reported as CPOE-related. The reviewers actually found only about half of these were truly CPOE-related. The taxonomy was then developed on a sample of these reports and 21 scenarios were developed for vulnerability testing on representative systems.

Overall, 79.5% of the erroneous order scenarios were able to be placed (28% “easily” placed with no additional steps or warnings and 28.3% placed with only “minor workarounds”). Specific computer-generated warnings occurred for 26.6% of the erroneous orders but the vast majority of these (69%) were passive alerts and another 29% required workarounds that could be done. Interestingly, they encountered one system in which no alerts were triggered at all. It was found that alerts in that system had been turned off several months earlier during an upgrade and were never turned back on!

This process, of course, is quite similar in concept to that developed and used by The Leapfrog Group to simulate problematic medication orders (see our previous columns for July 27, 2010 “EMR’s Still Have a Long Way to Go” and June 2012 “Leapfrog CPOE Simulation: Improvement But Still Shortfalls”). That tool was to be used by hospitals to assess the vulnerabilities of their CPOE systems to medication errors. Voluntary testing at over 200 hospitals (Leapfrog 2010) then revealed that about half of errors on “routine” medication orders were missed and almost a third of potentially fatal medication errors were also missed. Those hospitals adjusted their CPOE systems and protocols and nearly all showed improvement when retested. A similar test was conducted in 2011 by over 250 hospitals (Leapfrog 2012). The rate of missed potentially fatal errors dropped to just over 1% but the rate of missed “routine” medication errors was still on average about one third.

Tools like these to identify potential vulnerabilities are really needed to help prevent such errors from occurring elsewhere. Just like the problems we identify in our RCA’s and other case reviews, issues that occur at one facility or organization are likely to also occur at others. It is only through sharing experiences and lessons learned that we are likely to make progress in reducing errors and their consequences.

This is good work. Schiff and colleagues are to be commended for this considerable undertaking.

See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:

June 19, 2007 “Unintended Consequences of Technological Solutions”
May 20, 2008 “CPOE Unintended Consequences – Are Wrong Patient Errors More Common?”
June 17, 2008 “Technology Workarounds Defeat Safety Intent”
August 26, 2008 “Pattern Recognition and CPOE”
September 9, 2008 “Less is More….and Do You Really Need that Decimal?”
December 16, 2008 “Joint Commission Sentinel Event Alert on Hazards of Healthcare IT”
February 2009 “Healthcare IT The Good and The Bad”
October 2009 “A Cautious View on CPOE”
November 24, 2009 “Another Rough Month for Healthcare IT
April 20, 2010 “HIT’s Limited Impact on Quality To Date”
March 22, 2011 “An EMR Feature Detrimental to Teamwork and Patient Safety”
June 26, 2012 “Using Patient Photos to Reduce CPOE Errors”
June 2012 “Leapfrog CPOE Simulation: Improvement But Still Shortfalls”
July 17, 2012 “More on Wrong-Patient CPOE”
January 2013 “More IT Unintended Consequences”
October 8, 2013 “EMR Problems in the ED”
March 11, 2014 “We Miss the Graphic Flowchart!”
October 2014 “Ebola Exposes Fundamental Flaw”
January 2015 “Beneficial Effect of EMR on Patient Safety”

References:

Schiff GD, Amato MG, Eguale T, et al. Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems. BMJ Qual Saf 2015; Published Online First 16 January 2015

http://qualitysafety.bmj.com/content/early/2015/01/16/bmjqs-2014-003555.short?g=w_qs_ahead_tab

The Leapfrog Group. Leapfrog Group Report on CPOE Evaluation Tool Results

June 2008 to January 2010. June 2010

http://www.leapfroggroup.org/media/file/CPOEEvaluationToolResultsReport.pdf

The Leapfrog Group. Lack of Testing and Monitoring of Health IT by Hospitals and Vendors Potentially Jeopardizes Patients -- Hospital Performance Is Improving, but More Must Be Done. PR Newswire April 27, 2012

http://www.prnewswire.com/news-releases/lack-of-testing-and-monitoring-of-health-it-by-hospitals-and-vendors-potentially-jeopardizes-patients----hospital-performance-is-improving-but-more-must-be-done-149230435.html

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Another Paradox: Falls Due to Walking Aids

We all know that sometimes our patient safety interventions may have unintended consequences. In fact, sometimes they may paradoxically worsen the condition for which we implemented them. For example, in our What’s New in the Patient Safety World columns for June 2010 “Seeing Clearly a Common Sense Intervention” and June 2014 “New Glasses and Fall Risk” we noted that sometimes new glasses may paradoxically result in increased falls even though impaired vision is a risk factor for falls.

Now another paradox has been reported: devices designed to aid walking may produce an increase in falls! Researchers looked at 43 elderly patients living in residential aged care facilities and compared 22 patients who used walking aids (predominantly walkers) to 21 who did not use walking aids (Roman de Mettelinge 2015). Those who used them were slightly older, more likely to report fear of falling, and more likely to be taking psychotropic medications. They also fell more frequently. 68% of those using walking aids had at least one fall during the one year of followup, compared to 35% for those not using walking aids. Those using a walking aid demonstrated a significantly different gait pattern than those not using them. They walked slower and took shorter steps, greater step times, and fewer steps per minute.

We need to be careful in interpreting the results of this study. It does show an association between use of an assistive device for walking and future falls. However, the study was based upon a small population. More importantly, the association does not necessarily imply a cause-and-effect relationship, a point readily acknowledged by the authors. It is almost impossible to exclude selection bias in such studies (i.e. those patients using walking aids may have been doing so because they were already at greater risk of falls than those not using them). Indeed, the group using walking aids did have more risk factors for falls, such as more use of psychotropic medications.

Nevertheless, there are several factors that may make patients more prone to falls when using a walking aid. They note patients must have sufficient strength, balance, coordination, and attention to master the walking aid. And the environment comes into play as well. Stairs present a challenge to those walking with walkers. Also, the devices may put excessive strain on the patient’s upper limbs. And using such devices may inhibit compensatory grasping that a patient might use to prevent a fall. And incorrect posture while using the devices, particularly walkers, may result in both falls and injuries related to the falls.

Prior studies have had mixed results regarding use of walking aids and risk of falls. But a systematic review and meta-analysis (Deandrea 2013) found that walking aid use was one of the three strongest associations with falls in nursing home residents (the other two being history of falls and moderate disability). Walking aid use roughly doubled the risk of falls.

Several studies have shown high rates of injury with falls related to walking aids, particularly walkers. Stevens and colleagues (Stevens 2009) found an estimated 47,312 older adult fall injuries associated with walking aids were treated annually in U.S. ED’s (87.3% with walkers, 12.3% with canes, and 0.4% with both). Walkers were associated with seven times as many injuries as canes and women's injury rates exceeded those for men. The most prevalent injuries were fractures and contusions or abrasions. Approximately one-third of subjects were hospitalized for their injuries.

A study done in the Netherlands also showed that falls associated with use of four-wheeled walkers in adults 65 and older were at high risk for serious injury (van Riel 2014). The majority of injuries were fractures (60%) with hip fracture (25%) being the most common injury. Contusions and abrasions accounted for 23% of injuries. The lower extremity, including hip, leg and foot, was the most frequently injured body region. As a second most common injury, men injured their head and neck, whereas women more often injured their arm or hand. Nearly half of all four-wheeled walker related injuries required hospitalization, mostly due to hip fractures.

The importance of training the patients on how to correctly use the walking devices is obvious. Many patients first use their device when recovering from surgery or other hospital event and the training may be very brief and never reinforced following discharge.

References:

Roman de Mettelinge T, Cambier D. Understanding the Relationship Between Walking Aids and Falls in Older Adults: A Prospective Cohort Study. Journal of Geriatric Physical Therapy 2015; Published Ahead-of_Print January 15, 2015

http://journals.lww.com/jgpt/Abstract/publishahead/Understanding_the_Relationship_Between_Walking.99863.aspx

Deandrea S, Bravi F, Turati F, Lucenteforte E, La Vecchia C, Negri E. Risk factors for falls in older people in nursing homes and hospitals. A systematic review and meta-analysis. Arch Gerontol Geriatr 2013; 56 (3): 407-415

http://www.aggjournal.com/article/S0167-4943%2812%2900245-2/abstract

Stevens JA, Thomas K, Teh L, Greenspan AI. Unintentional fall injuries associated with walkers and canes in older adults treated in U.S. emergency departments. J Am Geriatr Soc 2009; 57(8): 1464-1469

http://onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2009.02365.x/abstract

van Riel KMM, Hartholt KA, Panneman MJM, Patka P, van Beeck EF, van der Cammen TJM. Four-wheeled walker related injuries in older adults in the Netherlands. Inj Prev 2014; 20(1): 11-15

http://injuryprevention.bmj.com/content/20/1/11.full

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Meds Cause ER Visits in Kids Too

Emergency Department visits related to medication issues are very common in adults. In our May 2011 What’s New in the Patient Safety World column “Adverse Drug Events and the ER” we cited a study from Vancouver (Hohl 2011) which found that 12.2% of patients presenting to the emergency room were there because of medication-related issues. Most were for unintended consequences of appropriately prescribed drugs. Compared to patients who did not have such reactions these patients had 50% higher rates of hospitalization, 20% higher outpatient encounters, and almost double the healthcare median monthly costs.

Now another Canadian study found an almost as many pediatric ED visits are due to medication-related issues. Zed and colleagues (Zed 2015) found that medication-related issues accounted for one in every 12 pediatric ED visits and that almost two-thirds of these were potentially preventable. Adverse drug reactions accounted for 26.4%, subtherapeutic dosage 19.0%, and nonadherence. Of these patients, 7.2% required hospitalization and medication-related issues contributed to prolonged lengths of stay.

The most commonly implicated drugs were anti-infective, respiratory, and nervous system agents.

Basically, the study highlights the fact that medication-related events lead to increased utilization of emergency department and inpatient resources not only in adults but in children as well.

References:

Hohl CM, Nosyk B, Kuramoto L, et al. Outcomes of Emergency Department Patients Presenting With Adverse Drug Events. Ann Emerg Med 2011; online ahead of print February 28, 2011

http://www.annemergmed.com/article/S0196-0644%2811%2900019-9/abstract

Zed PJ, Black KJL, Fitzpatrick EA. Medication-Related Emergency Department Visits in Pediatrics: a Prospective Observational Study. Pediatrics 2015; Published online February 2, 2015

http://pediatrics.aappublications.org/content/early/2015/01/28/peds.2014-1827.abstract