What’s New in the Patient Safety World

May 2013


·        Joint Commission Sentinel Event Alert: Alarm Safety

·        Ireland First to Adopt National Early Warning Score

·        BBC Horizon 2013 – How to Avoid Mistakes in Surgery

·        Scope and Consequences of Diagnostic Errors

·        Beta Blocker Debate Just Won’t Go Away





Joint Commission Sentinel Event Alert: Alarm Safety



Our February 2013 What’s New in the Patient Safety World column “Joint Commission Proposes New 2014 National Patient Safety Goal” discussed the newly proposed NPSG dealing with alarms. Joint Commission has now published a Sentinel Event Alert dealing with alarms (Joint Commission 2013a).


We’ve mentioned before that we often make amicable bets with CEO’s when we enter their facilities that we will find within a specified timeframe some alarms that have been disabled or otherwise manipulated. It’s a problem that is obviously widespread and dangerous. But its roots are many and deep. We have far too many alarms and this leads to the phenomenon of alarm fatigue. The new Joint Commission sentinel event alert cites the statistic that between 85% and 99% of alarm signals do not require clinical intervention. Their sentinel event database has 98 alarm-related events over a little more than 3 years, 80 of which resulted inpatient death. Major contributing factors included absent or inadequate alarm systems, improper alarm settings, inaudible alarms, alarm settings inappropriately turned off, and others. They also cite events and contributing factors and recommendations from studies by ECRI Institute and the FDA and the Association for the Advancement of Medical Instrumentation.


They provide 11 recommendations that are in keeping with the newly proposed NPSG. These include involving leadership and management in developing programs of alarm management and oversight, doing an inventory of all alarms (and eliminating those not necessary), establishing guidelines for alarm settings and individualizing them for each patient or patient type, and regularly inspecting, checking and maintaining all alarms. They stress ongoing education and updates on alarmed medical devices. They recommend a multidisciplinary team lead the oversight and provide lessons learned from other organizations. They recommend using single use sensors (such as ECG leads) to reduce nuisance alarm signals. They also recommend checking the acoustics of the environment to assure alarms will be audible.


Regarding the latter recommendation we also suggest the environmental design be checked to ensure that it does not promote turning alarm volumes down. One of our earliest columns on alarm issues (April 2, 2007 Patient Safety Tip of the Week “More Alarm Issues”) focused on a faulty design where proximity of the ECG monitoring system to the nursing charting area often led to nurses and others turning down the volumes, eventually leading to a disastrous consequence.


Checking alarms should be a regular component of your Patient Safety Walk Rounds. More importantly, it should be something your staff does daily on every unit that utilizes alarms of any type. Some units even do it on every shift. And when you find alarms that have been disabled or otherwise manipulated make sure you find out why. Such actions always have an underlying root cause that must be addressed.


You should include alarm status as part of your structured handoff tool used at changes of shift. And alarm status must be included in your “Ticket to Ride” tool for in-hospital transports (eg. to radiology).


We also strongly recommend that any time you set up a new piece of equipment on a patient you use a checklist specific to that piece of equipment that forces you to verify that all alarms are appropriately set and functional and that parameters chosen are appropriate. We also recommend you review some of the useful tips we’ve included in our February 23, 2010 Patient Safety Tip of the Week “Alarm Issues in the News Again” and the several other columns noted below.



Prior Patient Safety Tips of the Week pertaining to alarm-related issues:








The Joint Commission. Medical device alarm safety in hospitals. The Joint Commission Sentinel Event Alert 2013; 50: 1-3 April 8, 2013



The Joint Commission. Proposed 2014 National Patient Safety Goal on Alarm Management. January 15, 2013






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Ireland First to Adopt National Early Warning Score



In our September 11, 2012 Patient Safety Tip of the Week “In Search of the Ideal Early Warning Score” we discussed a recommendation in the UK for hospitals to adopt a national early warning score system. In February 2013 Ireland became the first country to adopt such a nationwide system (Press Release 2013).


The guideline applies to all adult patients in acute care hospital settings, including outpatients and day treatment patients receiving invasive procedures or moderate sedation. It does not apply to pediatric or obstetrical patients, for whom different physiological parameters apply. There are 60 recommendations in the guidelines. Both a summary of the guideline and a full text version are available.


But a new study points out one of the flaws in most early warning systems: incomplete recording of key elements in the early warning score (Hands 2013). Vital signs are key elements in all such scores but very often they are recorded inconsistently. The authors found only partial adherence to the vital signs monitoring protocol. Sicker patients were more likely to have vital signs measured overnight, but even their observations were often not followed by timely repeat assessments. The authors felt that the observed pattern of monitoring may reflect the impact of competing clinical priorities.


The whole point of early warning scores is to pick up on more subtle signs of clinical deterioration so that early interventions can take place. It is important that the data elements chosen for such scores will, in fact, be regularly assessed and used in the early warning score.







Press Release. Minister for Health, Dr. James Reilly TD endorses and launches first National Clinical Guideline: National Early Warning Score. 18th February 2013




Patient Safety Initiative in Ireland. National Clinical Effectiveness Committee. National Early Warning Score. National Clinical Guideline No. 1. An Roinn Slainte Department of Health. February 2013



full text of the guideline




Hands C, Reid E, Meredith P, et al. Patterns in the recording of vital signs and early warning scores: compliance with a clinical escalation protocol. BMJ Qual Saf 2013; published online first 19 April 2013 doi:10.1136/bmjqs-2013-001954








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BBC Horizon 2013 – How to Avoid Mistakes in Surgery



The BBC has a great video “How to Avoid Mistakes in Surgery” that is now on YouTube. It’s an hour-long presentation that incorporates human factors principles into a variety of surgical scenarios. It begins with a case where a patient dies because the team focused on trying to intubate an obstructed airway and overlooked performng an emergency tracheostomy. It emphasizes how we focus our attention and may develop tunnel vision and lose situational awareness. It also shows how both lack of a person in charge and the authority gradient come into play (a nurse brought an emergency tracheostomy kit into the OR but did not speak up to suggest it be used). It gives great examples from other industries about human factors involved in emergent situations. It shows firefighters going through a simulated exercise emphasizing the importance of situational awareness. It includes Atul Gawande discussing the WHO Surgical Safety Checklist. It has good segments on the value of simulation and handoffs, again using analogies with Formula-1 race cars. Then it talks about dealing with emergencies for which you have never been trained, using Sully Sullenberger and the plane he landed safely on the Hudson River. It even includes neurophysiological substrates of how we think about errors and how a positive attitude about errors can foster the sort of quick solutions used by people like Sullenberger.


It’s a very well done presentation that really shows how human factors should be incorporated into our every day healthcare world. It’s an hour but one that will be well spent.






BBC Horizon 2013 – How to Avoid Mistakes in Surgery






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Scope and Consequences of Diagnostic Errors



Diagnostic error has always lurked in the background of the patient safety movement. But in the past several years there has been a renewed focus on diagnostic error. Now researchers from Johns Hopkins have analyzed diagnosis-related claims from the National Practitioner Data Bank (NPDB) and the results are eye-opening (Tehrani 2013). They found that among malpractice claims, diagnostic errors appear to be the most common, most costly and most dangerous of medical mistakes. Diagnostic errors include failure to diagnose, wrong diagnosis, delayed diagnosis, failure to follow up on tests, etc.


Analyzing over 350,000 paid claims over a 25-year period they found diagnostic errors accounted for 28.6% of the claims, more than any other category. Moreover, they accounted for 35.2% of the total payments.


Diagnostic errors more often resulted in death than other categories of malpractice claims. Significantly, they also found that disability as a result of diagnostic error was substantial. The authors note that this means previous estimates of the impact of diagnostic errors were probably significant underestimates because they were based largely on autopsy studies. Outpatient diagnostic errors leading to claims were over twice as common as inpatient diagnostic errors, though the latter were more likely to lead to fatal outcomes.


What’s ironic is that we often don’t even know about our diagnostic errors unless there is a malpractice claim. Substantial periods of time typically elapse before it becomes apparent that a diagnostic error occurred. And it usually becomes apparent when the patient is elsewhere (another physician’s office, an emergency room, another hospital, etc.). An angry patient may call you and let you know about it but more often the patient simply loses confidence in you and just never returns to you for care. And if we don’t get feedback about our diagnostic errors or diagnostic accuracy we often get overconfident in our own abilities. And, of course, many of our diagnostic errors do not result in patient harm at all. However, they may result in delays and inconveniences.


In our April 2013 What’s New in the Patient Safety World column “AHRQ Recommended Patient Safety Practices” we noted the ten strategies identified by the AHRQ project that are "strongly encouraged" for adoption based on the strength and quality of evidence and twelve other strategies "encouraged" for adoption based on a slightly lesser strength and quality of evidence. Strategies targeted at diagnostic errors did not make the final list but the supplement with the evidence reviews (Annals of Internal Medicine 2013) did provide a systematic review of those strategies targeted at diagnostic errors (McDonald 2013). One is really struck by the paucity of good research on interventions to reduce diagnostic errors or at least identify them before they lead to patient harm or inconvenience.


Our March 2013 What’s New in the Patient Safety World column “Diagnostic Error in Primary Care” focused on a study using a trigger tool methodology to help identify diagnostic errors in primary care settings (Singh 2013). Singh and colleagues make several salient points about interventions to prevent diagnostic errors. First, given the wide variety of conditions and presenting symptoms they found in their study it is very unlikely that focusing solely on specific presentations will be successful in reducing overall errors. They note that most of the breakdowns occurred in the clinical encounter, perhaps with time pressures and short encounters contributing to inadequate decision making. Further yet they note that the trend toward team care and the patient-centered medical home may not result in the level of cognitive support needed for complex decision making. And the current levels of technological decision support for diagnosis are not readily available in most of today’s electronic medical records.


In our September 28, 2010 Patient Safety Tip of the Week “Diagnostic Error” we highlighted a review of diagnostic error by the Pennsylvania Patient Safety Authority. The PPSA review also provides a couple nice tools to help clinicians identify and avoid diagnostic errors. One is a chart audit tool to help identify errors adopted from the article by Schiff et al (Schiff 2009). The other is a simple checklist the clinician can use to help focus the things he/she needs to do to in each case avoid diagnostic errors.


We hope you’ll look at some of our prior columns on diagnostic error, listed below, that highlight some of the work by some excellent researchers (like Mark Graber, Pat Croskerry, John Ely, Gordon Schiff, Hardeep Singh, Jerry Groopman, Gary Klein and many others) on the way clinicians think and the cognitive biases that are important in diagnostic errors. Now that these recent studies have identified the scope of the problem it is time to begin focusing on ways to mitigate the problem.




Some of our prior Patient Safety Tips of the Week on diagnostic error:

·        September 28, 2010     Diagnostic Error

·        November 29, 2011     More on Diagnostic Error

·        May 15, 2012              Diagnostic Error Chapter 3

·        May 29, 2008             If You Do RCA’s or Design Healthcare Processes…Read Gary Klein’s Work

·        August 12, 2008           Jerome Groopman’s “How Doctors Think”

·        August 10, 2010           It’s Not Always About The Evidence

·        January 24, 2012          Patient Safety in Ambulatory Care

·        October 9, 2012          Call for Focus on Diagnostic Errors

·        March 2013                  Diagnostic Error in Primary Care

·        And our review of Malcolm Gladwell’s “Blink” in our Patient Safety Library








Tehrani ASS, Lee HW, Mathews SC, et al. 25-Year summary of US malpractice claims for diagnostic errors 1986–2010: an analysis from the National Practitioner Data Bank

BMJ Qual Saf 2013; Published online 22 April 2013 doi:10.1136/bmjqs-2012-001550




Annals of Internal Medicine. Making Health Care Safer: A Critical Review of Evidence Supporting Strategies to Improve Patient Safety. Annals of Internal Medicine 2013; 158(5_Part_2)




McDonald KM, Matesic B, Contopoulos-Ioannidis DG, et al. Patient Safety Strategies Targeted at Diagnostic Errors: A Systematic Review. Ann Intern Med 2013; 158(5_Part_2): 381-389




Singh H, Giardina TD, Meyer AND, et al. Types and Origins of Diagnostic Errors in Primary Care Settings. JAMA Intern Med 2013; published online February 25, 2013




Pennsylvania Patient Safety Authority (PPSA). Diagnostic Error in Acute Care. Pa Patient Saf Advis 2010 Sep;7(3):76-86




Schiff GD, Hasan O, Kim S; et al. Diagnostic Error in Medicine: Analysis of 583 Physician-Reported Errors. Arch Intern Med, Nov 2009; 169: 1881 – 1887




DEER Taxonomy Chart Audit Tool




Pennsylvania Patient Safety Authority. A Physician Checklist for Diagnosis.






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Beta Blocker Debate Just Won’t Go Away



The controversy over perioperative use of beta blockers just won’t go away. We’ve addressed the issue in multiple columns (see the list at the end of today’s column). After several years in which we pushed for almost universal use of beta blockers perioperatively, publication of the POISE trial (Devereaux 2008) significantly changed things. You’ll recall that the POISE trial showed that, though preoperative beta blockers prevented 15 MI’s for every 1000 patients treated, there was an increased risk of stroke and an excess of 8 deaths per 1000 patients treated. Largely since that time recommendations have been to continue beta blockers in the perioperative period in patients previously taking them but most no longer begin them perioperatively in patients not previously taking them.


But there have been numerous criticisms of the POISE trial. Specifically, patients received fairly large doses of metoprolol shortly before their surgery and many have argued that starting beta blockers well in advance of surgery and titrating the dose slowly would not have produced the adverse outcomes seen in POISE.


There certainly are studies that demonstrate a continued need to continue beta blockers in patients previously taking them. Our November 2010 What’s New in the Patient Safety World column “More Perioperative Beta Blocker Controversy noted some observational data (Wallace 2010) suggesting that perioperative beta blockade reduces mortality at both 30 days and one year. And that data reinforces that perioperative withdrawal of beta blockers increases mortality. In fact, the Wallace paper showed that beta blocker withdrawal almost quadrupled the 30-day mortality rate and almost doubled the 1-year mortality rate. In our November 2012 What’s New in the Patient Safety World column “Beta Blockers Losing Their Luster?” we noted an observational study supporting the current practice of continuing beta blockers perioperatively in patients who had been taking them prior to their surgery (Kwon 2012). This study, part of a collaborative quality improvement project in Washington state, found that failure to continue beta blockers in patients previously on them almost doubled their rate of adverse events within 90 days after noncardiac surgery.


We previously joked that one pro-beta-blocker article always engenders another anti-beta-blocker article and vice versa! That trend continues.


Now a new observational study again raises the question of utility of perioperative beta blockers in patients undergoing noncardiac surgery (London 2013). The researchers looked at a large population of patients in 104 VA medical centers who underwent major noncardiac surgery and matched them to a control group using propensity scores. They found that among propensity-matched patients undergoing noncardiac, nonvascular surgery, perioperative β-blocker exposure was associated with lower rates of 30-day all-cause mortality in patients with 2 or more Revised Cardiac Risk Index factors.


This study again points out the need for a large randomized controlled trial, similar to the POISE trial that looks at whether the slower, titrated perioperative beta blocker use is of benefit.





Our prior columns on perioperative use of beta blockers:


November 20, 2007     New Evidence Questions Perioperative Beta Blocker Use

November 4, 2008       Beta Blockers Take More Hits

December 2009           Updated Perioperative Beta Blocker Guidelines

November 2010           More Perioperative Beta Blocker Controversy).

November 2012           Beta Blockers Losing Their Luster?






Devereaux PJ, Yang H, Yusuf S, et al for the POISE Study Group. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet 2008; 371(9627): 1839-1847




Wallace AW, Au S, Cason BA. Association of the Pattern of Use of Perioperative ß-Blockade and Postoperative Mortality. Anesthesiology 2010; 113(4): 794-805




Kwon S, Thompson R, Florencem M, et al. β-Blocker Continuation After Noncardiac SurgeryA Report From the Surgical Care and Outcomes Assessment Program

Arch Surg. 2012; 147(5): 467-473




London MJ, Hur K, Schwartz GG, Henderson WG. Association of Perioperative β-Blockade With Mortality and Cardiovascular Morbidity Following Major Noncardiac Surgery. JAMA 2013; 309(16): 1704-1713






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