What’s New in the Patient Safety World

May  2011



·        Adverse Drug Events and the ER

·        Just How Frequent Are Hospital Medical Errors?

·        The Best Laid Plans…Electronic Water Faucet Paradox

·        ASA Updates Advisory for Prevention of Perioperative Peripheral Neuropathies

·        More on Nursing Workload and Patient Outcomes

·        Update on Pediatric Procedural Sedation






Adverse Drug Events and the ER



There are two types of adverse drug events seen in the ER: (1) those occurring outside the hospital and leading to the ER visit and (2) those occurring as a result of events within the ER. Recently there were studies about each type of adverse event.


A study from Vancouver (Hohl 2011) found that 12.2% of patient presenting to the emergency room were there because of adverse drug reactions. 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.


The most recent AHRQ statistical brief on medication related outcomes (Lucado 2011) was also just released. There has been a dramatic 52% increase in drug-related adverse outcomes in inpatients between 2004 and 2008 and, of those, over half the patients were age 65 or older. Corticosteroid-related adverse events accounted for 13.2% of those on the inpatient side. On the ER side 0.8% of all visits were related to drug-related adverse events. Analgesics, antibiotics, psychotropic agents, and anticoagulants were the most commonly involved drugs in patients seen and released from the ER. Note that opiates were involved in 4.4% and 5.6% of adverse events on the ER and inpatient sides, respectively. We continue to see escalating numbers of hospital visits due to prescription opioids.


The above data reflect adverse drug reactions in patients coming to the hospital. On the other hand, adverse drug events due to care given in the emergency room is also a major problem. The March 2011 issue of the Pennsylvania Patient Safety Advisory had an excellent review on medication errors in the emergency department. It reviewed recent literature on the frequency and types of medication errors in the ER and also provided data from the Pennsylvania Patient Safety Authority reporting database. 6% of the medication-related incidents in that database came from the ER. Wrong dose/overdosage was the most frequent category of adverse drug event in the ER, often with high-alert drugs. Dilaudid was specifically mentioned several times (see our September 21, 2010 Patient Safety Tip of the Week “Dilaudid Dangers”).


They go on to describe some of the reasons for these errors in the ER. Errors in the prescribing and administration phases of the medication process are most frequent. The fact that most of the medications in the ER are stored in automated dispensing cabinets and the medication orders are often not reviewed by a pharmacist are key reasons. To that we’d add that many ER’s have not yet implemented the CPOE (computerized physician order entry) systems with clinical decision support that may already have been implemented on the inpatient side. Also, though medication reconciliation begins in the ER, it is seldom complete while the patient is still in the ER (patients themselves may not be able to disclose all their medications and their families, physicians and pharmacies may not be reachable when the patient is in the ER). In addition, many of the errors were related to use of incorrect patient weights or patient age (particularly problematic with pediatric patients). And, of course, the rising numbers of ER visits nationwide have led to more crowding and time pressures in the ER.


Their major recommendation is to increase both the presence of pharmacists in the ER when possible and to involve pharmacists regularly in other activities related to medication use in the ER. They cite several studies documenting the positive impact of such pharmacist involvement. But they also stress the need for multidisciplinary teamwork, constraints such as ensuring only those necessary drugs are in the ER and in the appropriate dosage forms, redundancies such as independent double checks of high-alert drugs, and readback for any drug ordered verbally or via phone. They particularly stress the importance of recording actual patient weights (having appropriate devices for weighing patients and changing the culture so that weighing the patients is an expectation).







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




Lucado J, Paez K, Elixhauser A. Medication-Related Adverse Outcomes in U.S. Hospitals and Emergency Departments, 2008. AHRQ Statistical Brief #109 April 2011




Pennsylvania Patient Safety Authority. Medication Errors in the Emergency Department: Need for Pharmacy Involvement?  Pa Patient Saf Advis 2011; 8(1): 1-7





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Just How Frequent Are Hospital Medical Errors?



As you know, we have often stated that statistics don’t sell patient safety – stories do. We learned that after watching numerous and varied audiences zone out when we quoted the infamous statistics from the original IOM report “To Err is Human”.


But statistics do keep popping up. A new study (Classen 2011), using IHI’s Global Trigger Tool to identify hospital adverse events, found that the numbers may be 10-fold higher than what was noted in the IOM report. Potentially avoidable adverse events occurred in a third of hospital admissions. In addition to the human cost of iatrogenic adverse events, the financial costs are huge. A second study in the same issue of Health Affairs (Van Den Bos 2011) pegs that cost at $17.1 billion annually. And a third paper (Goodman 2011) estimates the annual social cost of medical errors ranges from $393 billion to $958 billion.


The IHI Global Trigger Tool clearly identifies more adverse events than are found either via voluntary reporting or using administrative data tools like AHRQ’s PSI indicators. In our January 2011 What’s New in the Patient Safety World column “No Improvement in Patient Safety: Why Not?” we noted a study (Landrigan 2010) that showed there has been little improvement in hospital adverse events overall over a long time frame. That study, done on data from 10 North Carolina hospitals, used IHI’s Global Trigger Tool to estimate rates of patient harm and preventable harm over a 6-year period. They found essentially no reduction in harm over that period. They had chosen North Carolina because many hospitals there had participated in patient safety collaboratives and North Carolina had a much higher percentage of hospitals participating in IHI’s patient safety programs.


While the IHI Global Trigger Tool measures events somewhat differently than in the studies that formed the basis of the IOM report, the global trigger tool methodology is “doable” with limited resources and provides a more reliable comparison over time. See our October 30, 2007 Patient Safety Tip of the Week “Using IHI's Global Trigger Tool” and our April 15, 2008 Patient Safety Tip of the Week Computerizing Trigger Tools” for more details on how to use it.


A related article by the group that did the North Carolina study (Sharek 2011) provides an excellent discussion on use of IHI’s Global Trigger Tool to measure hospital adverse events and allow for trending over time. It also provides a good description of how the tool is used, its performance characteristics, and its potential for use not only by hospitals but also by state or national groups to measure patient safety events. You’ll recall that the trigger tool just points to potential iatrogenic adverse events and then chart review is still necessary. One of the most interesting and unexpected findings in the Sharek study was that teams of internal reviewers actually performed better than the more experienced external reviewers.






Classen D, Resar R, Griffin F, et al. ‘Global Trigger Tool’ Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured. Health Affairs 2011; 30(4): 581-589




Van Den Bos J, et al "The $17.1 Billion Problem: The annual cost of measurable medical errors" Health Affairs 2011; 30(4): 596-630.




Goodman J, et al "The social cost of adverse medical events, and what we can do about it" Health Affairs 2011; 30(4): 590-595.




Christopher P. Landrigan CP, Parry GJ, Bones CB, et al. Temporal Trends in Rates of Patient Harm Resulting from Medical Care. N Engl J Med 2010; 363: 2124-2134




Sharek PJ, Parry G, Goldmann D, et al.Performance Characteristics of a Methodology to Quantify Adverse Events over Time in Hospitalized Patients. Health Services Research 2011; 46(2): 654-678






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The Best Laid Plans…Electronic Water Faucet Paradox



What a great idea for infection control – water faucets that let you wash your hands without touching any handles or other surfaces! Or is it? Turns out what sounds like a great idea may be backfiring. A new study from the infection control service at Johns Hopkins (Johns Hopkins Medicine 2011) has shown that electronic faucets may be harboring bacteria, including pathogens potentially very dangerous in hospitals. The researchers at Hopkins demonstrated 50% of electronic water faucets grew Legionella species, compared to 15% of manual faucets. The study, presented by Sydnor ERM, et al. as an abstract at the SHEA 2011 Scientific Meeting, was actually conducted to see if flushing the faucets with chlorine helped reduce bacterial counts. Of special concern was that such flushing with chlorine did not appear to be as successful in reducing bacteria in the electronic faucets as in manual faucets. They felt that the complex valve structure of the electronic faucets predisposed to growth of Legionella.


Not everyone is jumping on the bandwagon, though. A joint statement (ASHE/APIC 2011) issued by the American Society for Healthcare Engineering (ASHE) and the Association for Professionals in Infection Control and Epidemiology (APIC) cautioned that the data have only been presented in abstract form and may conflict with other evidence in the literature. The joint statement highlights some of the previous studies and provides comments as to why the findings may not be of serious significance but also notes potential reasons why the new faucets might be more prone to bacterial growth (such as the complexity and materials making them more prone to biofilms). Both the joint statement and comments from the Hopkins group note that the electronic faucets have been very successful at reducing total amounts of water used, the other main reason for their installation. ASHE and APIC undoubtedly will be looking at the issue as they start work on a planned update of their “Guidelines for Design and Construction of Health Care Facilities”.


But the folks at Hopkins were so concerned that they have removed 20 electronic faucets in patient care areas and cancelled planned installation of about 1000 such faucets in a new clinical building.


You can bet other investigators will be trying to replicate these findings elsewhere, given the potentially serious infection control implications. There will be lots of people watching to see how this issue plays out. We’re not changing our faucets yet – but this could be well another item added to our ever-increasing list of unintended consequences.






Johns Hopkins Medicine. Latest Hands-Free Electronic Water Faucets Found to be Hindrance, Not Help, in Hospital Infection Control. Newswise 3/28/2011




ASHE/APIC. Joint ASHE & APIC Statement on Recently Presented Research on Electronic Faucets. April 7, 2011






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ASA Updates Advisory for Prevention of Perioperative Peripheral Neuropathies



In our September 29, 2009 Patient Safety Tip of the Week “Perioperative Peripheral Nerve Injuries” we noted that peripheral nerve injuries are now among the most common reasons for anesthesia-related malpractice claims.


The American Society of Anesthesiologists has just updated its “Advisory for the Prevention of Perioperative Peripheral Neuropathies”, originally published in 2000. It’s called an “advisory” rather than a guideline because it relies heavily on expert opinion given the relative paucity of an evidence base in the literature for prevention of peripheral nerve injuries during anesthesia or sedation in various settings.


It points out that the preoperative assessment should take into account history of neurological symptoms, diabetes, alcohol use and consider potential risk factors such as body habitus, gender, vascular disease, and arthritis or other deformities. Both extremes of weight are important considerations (remember that many patients who develop peroneal nerve palsies have a history of recent significant weight loss, voluntary or involuntary, with loss of the protective fat pad likely being a contributory factor.) Almost any pre-existing peripheral neuropathy renders nerves more prone to the effects of compression. Some neuropathies, particularly the “hypertrophic” neuropathies where peripheral nerves may be palpably enlarged, render patients even more vulnerable in perioperative settings.


The advisory does do a good job of identifying which peripheral nerves or plexuses are most vulnerable to harm in the perioperative setting. And it provides reasonable recommendations for proper positioning to help reduce the risk of nerve injuries in the upper and lower extremities when the patient must be in various positions (eg. supine vs. prone).


It also has a discussion about the use of padding, arm boards, chest rolls, etc. to minimize the risk to specific nerves. But it does note that padding may also have unintended consequences, particularly if it is applied to tightly. The section on the effects of equipment is also interesting, though almost all the literature is from isolated case reports or small series. However, items such as automated blood pressure cuffs, shoulder braces or rests, Foster frames, self-retaining retractors, leg holders, surgical stockings, pneumatic compression devices, stirrups (particularly when patient is in the lithotomy position), slings, continuous passive motion machines, etc. have all been implicated in peripheral nerve injuries.


We refer you back to our September 29, 2009 Patient Safety Tip of the Week “Perioperative Peripheral Nerve Injuries” for many other examples of peripheral nerve injuries occurring in the perioperative setting.



While there is no good evidence base on the practice, we advocate that the need for positioning or repositioning to be discussed during the pre-surgical huddle (or the surgical timeout) and that the duration of the procedure be announced periodically so that consideration can be given to repositioning the at-risk patient. At any rate, now is a good time to review your perioperative procedures for preventing peripheral nerve injuries.






The American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies presents an updated report of the Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies. Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies: An Updated Report by the American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies. Anesthesiology 2011; 114(4): 741-754







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More on Nursing Workload and Patient Outcomes



Last month, in our April 2011 What’s New in the Patient Safety World column “Nursing Staffing and Mortality”, we highlighted a study (Needleman 2011) using an improved methodology which confirmed that both low nursing staffing levels and higher than normal nursing workloads correlate with increased patient mortality rates. That study, in conjunction with the numerous prior studies, should leave little doubt about the importance of matching nursing staffing levels to the needs of patients (both census and acuity).


This month another study (Trinkoff 2011) found that pneumonia deaths were significantly more likely in hospitals where nurses reported increased psychological demands and more adverse work schedules. Postoperative pulmonary embolism/deep vein thrombosis was also more likely. They also correlated more post-op hemorrhages in cases where nurses were frequently interrupted, more CHF deaths when nurses worked long shifts, and several other adverse patient outcomes associated with various stresses on nurses.


And another interesting study (Weiss 2011) correlates nursing overtime with both hospital readmissions and increased ER visits. The study was done at 4 acute care hospitals and found that hospitals having higher nursing staffing levels (not relying on overtime) had reduced readmission levels (odds ratio = 0.56), whereas staffing utilizing increased overtime resulted in increased ER visits (odds ratio = 1.70). The implication is that nurses are less effective at certain processes when working overtime. Interestingly, to perform better a hospital would have to pay more for higher staffing and then see fewer visits! So in today’s reimbursement world you won’t find many hospitals wanting to do that. However, in the reimbursement world of the future (ACO’s, global budgets, etc.) doing better staffing and not relying on overtime will make great sense. Hmm…if you are a payor today, why wouldn’t you incentivize hospitals to ensure adequate (or even “luxury” nursing staffing)!


There are lots of other examples of where investing more in certain areas creates savings much greater than your extra investment (see our November 10, 2009 Patient Safety Tip of the Week “Conserving Resources…But Maintaining Patient Safety”). In that Tip we noted  examples where you do not want to cut and where investment in resources may save money in the long run. Housekeeping is one of those areas. We have seen hospitals faced with budget deficits cut housekeeping staff, only to encounter increased nosocomial infection rates. We also noted a study from the UK (Dancer et al 2009) which found that hiring an additional cleaner who focuses near-patient high-touch sites has the potential to save a hospital $50,000 to $116,000 annually even after accounting for the salary for the extra cleaner.


Sometimes spending a little extra in some areas can improve both patient safety and your budget.






Needleman J, Buerhaus P,  Pankratz VS, et al. Nurse Staffing and Inpatient Hospital Mortality. N Engl J Med 2011; 364:1037-104




Trinkoff A, Johantgen M, Storr CL, et al. Linking Nursing Work Environment and Patient Outcomes. J Nursing Regulation 2011; 2(1): 10-16




Weiss ME, Yakusheva O, Bobay KL. Quality and Cost Analysis of Nurse Staffing, Discharge Preparation, and Postdischarge Utilization. Health Services Research 2011; Article first published online: 21 APR 2011




Dancer SJ, White LF, Lamb J, Girvan EK, Robertson C. Measuring the effect of enhanced cleaning in a UK hospital: a prospective cross-over study. BMC Medicine 2009, 7:28  doi:10.1186/1741-7015-7-28







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Update on Pediatric Procedural Sedation



An early release paper in the journal Pediatrics (Couloures 2011) provides patient safety data from the Pediatric Sedation Research Consortium, a group of 38 organizations that provide self-audited data via a web-based data collection tool. They found an overall low rate of adverse events related to pediatric procedural sedation and no significant differences by nature of the specialty involved in the sedation. Rates of major complications ranged from 7.6 to 12.4 per 10,000 sedations and there were no deaths.


Though these rates of major complications are relatively low, see our January 25, 2011 Patient Safety Tip of the Week “Procedural Sedation in Children” for a good discussion of the many potential complications, best practices, and recommendations for safe procedural sedation in children.






Kevin G. Couloures KG, Beach M, Cravero JP, et al. Impact of Provider Specialty on Pediatric Procedural Sedation Complication Rates.
Pediatrics published online April 25, 2011






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Print “May 2011 What's New in the Patient Safety World (full column)

Print “May 2011 Adverse Drug Events and the ER

Print “May 2011 Just How Frequent Are Hospital Medical Errors?

Print “May 2011 The Best Laid Plans... Electronic Water Faucet Paradox

Print “May 2011 ASA Updates Advisory for Prevention of Perioperative Peripheral Neuropathies

Print “May 2011 More on Nursing Workload and Patient Outcomes

Print “May 2011 Update on Pediatric Procedural Sedation












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