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What’s New in the Patient Safety World

March 2021


·       ECRI Partnership Whitepaper on Alert Fatigue

·       The Fiscal Costs of Delirium

·       Medical Crisis Checklists in the ED

·       PPSA Reminder: Weigh Your Patients and Do It In Kilograms




ECRI Partnership Whitepaper on Alert Fatigue



All would agree that alerts generated by clinical decision support systems are valuable patient safety tools. But we’ve all seen how alerts can be obtrusive and interfere with clinician workflow, thus giving rise to “alert fatigue” in which alerts are simply ignored or overridden.


ECRI's Partnership for Health IT Patient Safety is a multi-stakeholder collaborative that sets priorities in health IT safety. You’ll recall we highlighted its previous work on “closing the loop” (see our September 2018 What's New in the Patient Safety World column “ECRI Institute Partnership: Closing the Loop”), which focused on improving communication to prevent things from “slipping through the cracks”.


The Partnership has now concluded efforts of a similar workgroup focused on finding ways to reduce alert fatigue associated with Computerized Physician Order Entry (CPOE) systems. Recommendations are included in their report “Safe Practices to Reduce CPOE Alert Fatigue through Monitoring, Analysis, and Optimization” (ECRI 2021). The workgroup makes four main safe practice recommendations:

The report reiterates the “5 Rights” model of clinical decision support (CDS) adopted from Osheroff et al. (Osheroff 2012):

  1. The right information: evidence-based, suitable to guide action, pertinent to the circumstance
  2. To the right person: considering all members of the care team, including clinicians, patients, and their caregivers
  3. In the right CDS intervention format: such as an alert, order set, or reference information to answer a clinical question
  4. Through the right channel: for example, a clinical information system such as an electronic medical record, personal health record, or a more general channel such as the internet or a mobile device
  5. At the right time in workflow: for example, at time of decision, action, or need

When we did our first CPOE implementation back in 2007, we were flooded with suggestions for potential alerts that could be used for patient safety. But we readily recognized the need to limit such alerts in order to avoid alert fatigue. We set up a multidisciplinary committee to assess all suggested alerts and to monitor at specified intervals both the impact of such alerts and any unintended consequences. Monitoring included documentation of how often alerts triggered and what the acceptance and override rates were. In addition, clinicians were interviewed to assess their impression of both the utility and the degree of obtrusiveness of any alerts.


The Partnership report provides excellent guidance in identifying alert metrics, asking the following key questions:

The report stresses, in initiating optimization efforts, that it is important to ask the following questions:

We’d like to emphasize that last point. In our March 3, 2009 Patient Safety Tip of the Week “Overriding Alerts…Like Surfin’ the Web” we noted that use of standardized order sets may avoid the need to generate some alerts (though standardized order sets can create some problems of the own, particularly when they contain outdated information that is no longer appropriate).


We refer you to the full Partnership report for details on all their recommendations. This is an excellent resource that every organization using any form of clinical decision support tools needs to review and incorporate their recommendations into their own programs.



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





Partnership for Health IT Patient Safety. Safe Practices to Reduce CPOE Alert Fatigue through Monitoring, Analysis, and Optimization. ECRI 2021

(ECRI 2021)




Osheroff JA, Teich JM, Levick D, et al. Improving outcomes with clinical decision support: an implementer’s guide. 2nd ed. Chicago (IL): Healthcare Information and Management Systems Society; 2012






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The Fiscal Costs of Delirium



A lot has been written about the human costs of delirium. But there is also a significant financial impact of delirium. A couple recent articles have attempted to quantify those costs.


Gou and colleagues prospectively analyzed almost 500 elderly patients undergoing major elective surgery in the Successful Aging after Elective Surgery (SAGES) study (Gou 2021). During the index hospitalization, 122 patients (25%) developed postoperative delirium, whereas 375 (75%) did not (note: we were surprised that percentages of patients having post-op delirium were not even higher).


Mean health care costs for patients with delirium compared to those without delirium were: $146,358 vs $94,609. After adjusting for relevant confounders, the cumulative health care costs attributable to delirium were $44,291 per patient per year, with the majority of costs coming from the first 90 days. Breakout of those attributable costs were $20,327 for the index hospitalization, $27,797 for subsequent rehospitalizations, and $2,803 for postacute rehabilitation stays.


The authors also rated the severity of delirium, using the Confusion Assessment Method–Severity long form. Health care costs increased directly and significantly with level of delirium severity (none-mild $83,534, moderate $99,756, severe $140,008). Overall, the adjusted mean cumulative costs attributable to severe delirium were $56,474 per patient per year.


If their findings were extrapolated nationally, the health care costs attributable to postoperative delirium were estimated at $32.9 billion per year. The authors note that these costs rival those associated with cardiovascular disease and diabetes and identify postoperative delirium as a large-scale public health issue.


Another study (Boone 2020) included delirium in the larger category of postoperative neurocognitive disorders (PND’s). A PND was defined as a diagnosis of delirium, mild cognitive impairment, or dementia within 1 year of discharge from the index surgical admission. The primary outcome was total inflation-adjusted Medicare postacute care payments within 1 year after the index surgical procedure. Eligible for the study were all Medicare patients aged 65 years or older who underwent an inpatient hospital admission associated with a surgical procedure, who did not experience a PND before index admission. Patients on dialysis and those concurrently enrolled in Medicaid were excluded.  Of 2,380 473 patients who underwent surgical procedures, 1.9% were diagnosed with a PND.


Patients with a PND, compared with those without a PND, experienced a significantly longer hospital length of stay (mean 5.91 days vs 4.29 days), were less likely to be discharged home (22.1% vs 39.2%), and had a higher incidence of mortality at 1 year after treatment (10.2% vs 4.4%). After adjusting for patient and hospital characteristics, the presence of a PND within 1 year of the index procedure was associated with an increase of $17,275 in cost in the 1-year postadmission period.


This association was driven largely by differences in skilled nursing care costs during the 1 year following the index surgical procedure. Payments made during the index hospital admission for patients with PND were also higher than for those without PND. Episode and acute care payments for the inpatient stay tied to their index surgical admission were associated with an increase (median $50,63 for those with a PND compared $26,587 for those without a PND).


In our August 17, 2010 Patient Safety Tip of the Week “Preoperative Consultation – Time to Change” we recommended that assessment for delirium risk should be one of the 3 most important considerations in pre-operative assessments (the other 2 being assessment for obstructive sleep apnea and frailty).


Delirium, of course, does not just occur in patients undergoing surgery. The incidence of delirium is significant in patients hospitalized for medical conditions, particularly those requiring stays in the ICU. We would expect that the attributable cost of delirium in those medical patients would likely be comparable to those having postoperative delirium.


We agree with the authors of both studies that delirium is a significant public health issue that adds considerably to our nation’s health care cost burden. The editorial accompanying the Gou study (Katlic 2021) points out that the surgical community has begun to recognize the significant human and financial impact of delirium and calls attention to the American College of Surgeons Geriatric Surgery Verification Program, which we discussed in our September 17, 2019 Patient Safety Tip of the Week “American College of Surgeons Geriatric Surgery Verification Program”.



Some of our prior columns on delirium assessment and management:


·       February 12, 2019 “2 ER Drug Studies: Reassurances and Reservations”

·       September 17, 2019 “American College of Surgeons Geriatric Surgery Verification Program”






Gou RY, Hshieh TT, Marcantonio ER, et al. One-Year Medicare Costs Associated With Delirium in Older Patients Undergoing Major Elective Surgery. JAMA Surg 2021; Published online February 24, 2021



Boone MD, Sites B, von Recklinghausen FM, Mueller A, Taenzer AH, Shaefi S. Economic Burden of Postoperative Neurocognitive Disorders Among US Medicare Patients. JAMA Netw Open 2020; 3(7): e208931



Katlic MR, Robinson TN. The Costs of Postoperative Delirium. JAMA Surg 2021; Published online February 24, 2021



ACS (American College of Surgeons). Geriatric Surgery Verification Program





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Medical Crisis Checklists in the ED



Our regular readers know we are big fans of checklists for multiple problems and in multiple venues (see list of our prior columns on checklists below). A special type of checklist is one intended for use in crisis situations. Checklists for crises were, of course, pioneered in aviation, where pilots and crew members need to take immediate action to avert disasters. Doing the wrong thing or missing critical steps in such crises can be catastrophic, so having a checklist to guide one’s responses is important.


“Crisis” checklists have been shown to be helpful in dealing with crises in the OR (February 2013 What's New in the Patient Safety World column “Checklists for Surgical Crises”). So why not use them in other venues in healthcare where crises occur and require prompt interventions? How about the emergency department?


Dryver and colleagues used simulated environments to test crisis checklists for events often seen in emergency departments (Dryver 2021). They looked at eight crises often seen in the ED (anaphylactic shock, life-threatening asthma exacerbation, hemorrhagic shock from upper gastrointestinal bleeding, septic shock, calcium channel blocker poisoning, tricyclic antidepressant poisoning, status epilepticus, increased intracranial pressure). They then did simulations, once with access to a crisis checklist and once without access. They were only simulated cases. But the lessons learned are helpful.


They found that the median percentage of interventions performed was 38.8% without checklist access and 85.7% with checklist access. The benefit of checklist access was similar in the four EDs and independent of senior physician and senior nurse experience, type of crisis and use of usual cognitive aids. Moreover, there was no evidence that use of the checklists led to any delays in the initial performance of emergency measures.


Most participants reported that they would use the checklists if they had a similar case in reality. Most participants gave a score of 5 or 6 (on a Likert scale of 1–6) to the statement ‘I would use the checklist if I got a similar case in reality’.


Our August 16, 2011 Patient Safety Tip of the Week “Crisis Checklists for the OR” highlighted the work done by Atul Gawande and colleagues (Ziewacz 2011) on use of checklists for various crises that might be encountered in the OR. They had developed a series of “crisis checklists” for 12 of the most frequently occurring operating room crises and tested their use in a high-fidelity surgical simulator. They had OR teams in the surgical simulator address 4 crisis situations with checklists and 4 without. In simulated crises without checklists, the teams’ failure rate to perform critical steps was 24%. When using checklist, the failure rate was only 4%. Surveys of the participating OR teams found that the crisis checklists were very well-received, usable, and likely to prepare the teams well for real crises.


Gawande and colleagues (Arriaga 2013) later expanded on that experience and tested the crises checklists in multiple settings with multiple teams in simulated scenarios (see our February 2013 What's New in the Patient Safety World column “Checklists for Surgical Crises”). They had 17 teams in one academic and two community hospital settings participate in the scenarios, randomized to either using the checklists or dealing with the crises simply by memory. There were a total of 106 simulated crisis scenarios in all. They found that 6% of necessary steps were missed when the checklists were used, compared to 23% of steps missed when memory alone was used. That translates to a 75% improvement! Those numbers are similar to those found in their initial 2011 study. Virtually every team performed better when using the checklists. And 97% of respondents to a survey stated that they would want checklists used if they were a patient undergoing surgery.


The appendices to the 2011 article (Ziewacz 2011) contain the actual checklists they developed and, for each “crisis” a list of the key processes and steps identified as being important. The conditions for which this group developed crisis checklists include malignant hyperthermia, surgical fires, air embolism, anaphylaxis, unstable bradycardia, unstable tachycardia, cardiac arrest (asystolic and VF/VT), failed airway, unexpected hemorrhage, hypotension and hypoxia. And Ariadne Labs, an outgrowth of the Harvard and Stanford initiatives on crisis checklists, has many valuable resources and a toolkit to help you with implementation.


Hepner et al. also published an excellent review of operating room crisis checklists and emergency manuals (Hepner 2017).


Just et al. assessed the effectiveness of checklists for emergency procedures on medical staff performance in intensive care crises (Just 2015). Participants completed 4 crisis scenarios in a simulation setting, in which they were randomized to use checklists or to perform without any aid. In 2 of the scenarios, checklists could be used immediately (type 1 scenarios); and for the remaining, some further steps, for example, confirming diagnosis, were required first (type 2 scenarios). When using checklists, participants initiated items faster and more completely according to appropriate treatment guidelines (9 vs 7 items with and without checklists). Benefit of checklists was better in type 2 scenarios than in type 1 scenarios. In type 2 scenarios, time to complete 50% and 75% of items was faster with the use of checklists.


Subbe et al. (Subbe 2017) led a collaborative developing crisis checklists for rapid response teams to use for in-hospital emergencies. They began with a literature search that failed to identify any studies on crisis checklist outside the OR or ICU.  So, they developed their own crisis checklists and pilot tested them in a simulated setting. Iterations with feedback and retesting in the simulated environment resulted in a number of crisis checklists. Topics for checklists developed included gastrointestinal bleed, myocardial infarction, sepsis, acute kidney injury, fast atrial fibrillation, respiratory distress, “un-specifically unwell”, altered mental status, and objective signs of instability on National Early Warning Score (NEWS) level 3, NEWS level 5, NEWS level 7. They also developed several crisis checklists for the OR, including anaphylaxis. Airway, and advanced life support. When clinical teams were asked to assess their performance during patient management of common simulated emergencies they felt that the use of checklists improved their team work, communication, and overall performance.


You’re probably asking yourself “why are all these studies using simulation to evaluate use of checklists?”. Well, that’s because many of the conditions or situations for which they are intended are relatively infrequent, so it is unlikely that any single site will have enough cases to assess how the checklists facilitated care in actual cases.


We think it is well worth your while having your OR teams or ER teams or ICU teams become familiar with these tools and run “drills” on each of these. Especially if you combine these with other team training programs, such as TeamSTEPPS™, your teams will likely be better prepared to handle these relatively rare but critical scenarios.



Some of our prior columns on checklists:

·       May 2019 “WHO Surgical Safety Checklist Cut Mortality 37% in Scotland”

·       July 16, 2019 “Avoiding PICC’s in CKD”

·       June 2020 “Are Two Checklists Better Than One?”







Dryver E, Lundager Forberg J, Hεrd af Segerstad C, et al. Medical crisis checklists in the emergency department: a simulation-based multi-institutional randomised controlled trial. BMJ Quality & Safety 2021; Published Online First: 17 February 2021



Ziewacz JE, Arriaga AF, Bader AM, Berry WR, et al. Crisis Checklis ts for the Operating Room: Development and Pilot Testing. J Am Coll Surg 2011; 213(2): 212-219



Arriaga AF, Bader AM, Wong JM, et al. Simulation-Based Trial of Surgical-Crisis Checklists. N Engl J Med 2013; 368: 246-253



Ariadne Labs. Surgery: OR Crisis Checklists.



Hepner DL, Arriaga AF, Cooper JB, et al. Operating Room Crisis Checklists and Emergency Manuals. Anesthesiology 2017; 127(2): 384-392



Just KS, Hubrich S, Schmidtke D, et al. The effectiveness of an intensive care quick reference checklist manual--a randomized simulation-based trial. J Crit Care 2015; 30: 255–260



Subbe CP, Kellett J, Barach P, et al. Crisis checklists for in-hospital emergencies: expert consensus, simulation testing and recommendations for a template determined by a multi-institutional and multi-disciplinary learning collaborative. BMC Health Serv Res 2017; 17: 334







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PPSA Reminder: Weigh Your Patients and Do It In Kilograms


Regina Hoffman, in a Pennsylvania Patient Safety Authority blog (Hoffman 2021), issues a simple reminder for all healthcare organizations “weigh your patients and do it in kilograms


She points out that th​e United States is one of only three countries in the world that does not use the metric system. But all our medications are based on the metric system. The big problem arises when we use patient weights in pounds rather than kilograms. In addition to most pediatric medications being weight-based, there are multiple adult medications that are also weight-based. These include some anticoagulants, thrombolytic agents, some antibiotics, and many chemotherapy agents. Calculation of drug doses can lead to overdosing or underdosing when pounds and kilograms get mixed up. Our multiple prior columns, listed below, give many examples of such errors.


In addition to dosages based on the metric system, some doses are also very dependent on patient weight. These include anticoagulants, certain antibiotics, chemotherapy agents, and many pediatric doses. The very young, very old, and people with certain medical conditions are at the highest risk of experiencing harm because their bodies are more sensitive to the effects of an error.​


Pennsylvania Patient Safety Authority had published in 2016 data on medication errors associated with incorrect patient weights (Bailey 2016) and in 2018 published in conjunction with the Pennsylvania Department of Health “Final Recommendation to Ensure Accurate Patient Weights” (Pennsylvania Bulletin 2018).


Several of our own columns (listed below) have highlighted errors created by inaccurate patient weights, particularly with regard to medication errors.



Some of our other columns on errors related to patient weights:


March 23, 2010           “ISMP Guidelines for Standard Order Sets”

September 2010          “NPSA Alert on LMWH Dosing”

August 2, 2011           “Hazards of ePrescribing”

January 2013               “More IT Unintended Conseequences”

December 8, 2015       “Danger of Inaccurate Weights in Stroke Care”

May 2016                    “ECRI Institute’s Top 10 Patient Safety Concerns for 2016”

September 2017          “Weight-Based Dosing in Children”

January 2018               “Can We Improve Barcoding?”

June 2018                    “Incorrect Weights in the EMR”






Hoffman R. Weight-Based Medication Errors: How to Tip the Scale in the Right Direction. Pennsylvania Patient Safety Authority Blog 2021; Published February 4​​, 2021



Bailey, BR, Gaunt, MJ, Grissinger, M. Update on Medication Errors Associated With Incorrect Patient Weights. Pennsylvania Patient Safety Advisory 2016; 13(2): 50-57



Pennsylvania Bulletin.  Final Recommendation to Ensure Accurate Patient Weights. Pennsylvania Bulletin 2018; 48(36): 5679




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Print “March 2021 What's New in the Patient Safety World (full column)”

Print “March 2021 ECRI Partnership Whitepaper on Alert Fatigue”

Print “March 2021 The Fiscal Costs of Delirium”

Print “March 2021 Medical Crisis Checklists in the ED”

Print “March 2021 PPSA Reminder: Weigh Your Patients and Do It In Kilograms”




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