What’s New in the Patient Safety World

May 2018



·       ECRI Top 10 Patient Safety Concerns for 2018

·       Antipsychotic Use in Nursing Homes: Progress or Not?

·       Pediatric Early Warning System Fails

·       Cost of Interrupting a Radiologist




ECRI Top 10 Patient Safety Concerns for 2018



Every year ECRI Institute publishes its list of the “Top 10 Patient Safety Concerns for Healthcare Organizations”.


The list for 2018 (ECRI 2018):

  1. Diagnostic errors
  2. Opioid safety across the continuum of care
  3. Internal care coordination
  4. Workarounds
  5. Incorporating health IT into patient safety programs
  6. Management of behavioral health needs in acute care settings
  7. All-hazards emergency preparedness
  8. Device cleaning, disinfection and sterilization
  9. Patient engagement and health literacy
  10. Leadership engagement in patient safety


All 10 topics are ones we’ve covered in numerous columns. As usual, we’ll only comment on a few of this year’s topics and let you go to the ECRI document for details of these and all the others.


It should be no surprise that diagnostic errors head the list, though they were not on last year’s Top 10 list. ECRI emphasizes that diagnostic errors are the result of cognitive, systemic, or a combination of cognitive and systemic factors. ECRI acknowledges that diagnostic errors often go undetected by clinicians and healthcare organizations but data on diagnostic errors and near misses might be captured from multiple sources, such as event-reporting systems, malpractice and payment claims, patient complaints, patient surveys, autopsies, and record reviews.


Miscommunication is a common factor contributing to both diagnostic errors and internal care coordination (#3 on the list). ECRI discusses use of standardized handoff tools, checklists, and safety huddles to improve internal care coordination.


We’re glad to see workarounds on the list (#4 on the list). We’ve done numerous columns on the impact or workarounds. We encourage discussion of workarounds on Patient Safety Walk Rounds (see our February 27, 2017 Patient Safety Tip of the Week “Update on Patient Safety Walk Rounds”). Whenever you see a workaround, there is virtually always an underlying system problem that led to the use of a workaround. That system problem needs to be addressed.


The report also has links to ECRI’s many fine resources for each topic.


We’ll let you go to the full ECRI list for details. Click here to go to the ECRI Institute site where you can download the list.


Another “Top 10” list worth mention is Becker’s Hospital Review’s “10 Top Patient Safety Issues for 2018” (Vaidya 2018). Becker’s list:

  1. Disparate HER’s
  2. Hand hygiene
  3. Nurse-patient ratios
  4. Drug and medical supply shortages
  5. Quality reporting
  6. Resurgent diseases
  7. Mergers and acquisitions
  8. Physician burnout
  9. Antibiotic resistance
  10. Opioid epidemic

See the Becker’s link for details.


The lack of more overlap of these lists is striking but it’s hard to argue with either list. These are all patient safety concerns that pose significant threats to all healthcare organizations.






ECRI (ECRI Institute). ECRI Top 10 Patient Safety Concerns for Healthcare Organizations 2018; ECRI Institute 2018; March 2018




Vaidya A, Zimmerman B, Bean M. 10 top patient safety issues for 2018. Becker’s Hospital Review 2018; January 09, 2018






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Antipsychotic Use in Nursing Homes: Progress or Not?



Antipsychotic medications are often used for treating agitation and aggressive behavior in patients with dementia. Use of antipsychotics in patients with dementia has long under fire because of limited efficacy and occurrence of serious adverse effects, such as an increase in stroke and mortality. They may also cause sedation, extrapyramidal signs, and some may produce orthostatic hypotension. The latter may all contribute to falls and fractures. Some also predispose to development of metabolic syndrome or glucose intolerance. And some may be associated with severe reactions, such as the neuroleptic malignant syndrome.


Our February 3, 2015 Patient Safety Tip of the Week CMS Hopes to Reduce Antipsychotics in Dementia” discussed the National Partnership to Improve Dementia Care, a public-private coalition of CMS and several other partners, which established a new national goal of reducing the use of antipsychotic medications in long-stay nursing home residents by a further 25 percent by the end of 2015, and 30 percent by the end of 2016 (CMS 2014). The Partnership’s larger mission is “to enhance the use of non-pharmacologic approaches and person-centered dementia care practices”.


Recently, CMS announced a new national goal, involving a 15 percent reduction of antipsychotic medication use by the end of 2019 for long-stay residents in those homes with currently limited reduction rates (CMS 2018).


So has the CMS initiative been successful? It may depend on who you ask.


Since the start of the CMS National Partnership, there has been a decrease of 27 percent in the prevalence of antipsychotic medication use in long-stay nursing home residents, to a national prevalence of 17.4 percent in 2015 Quarter 3 (CMS 2016). Success has varied by state and CMS region, with some states and regions having seen a reduction of greater than 25 percent. A statement emailed to CNN (Ravitz 2018) actually notes that the use of antipsychotic drugs has been reduced by 35% since inception of the program in 2011.


On the other hand, Human Rights Watch (Flamm 2018) recently published a paper with scathing criticism of long-term care facilities for continued inappropriate use of antipsychotics, including the lack of free and informed consent in many such cases. The paper does acknowledge that there has been improvement in recent years but that abuses persist.


Researchers visited 109 facilities in six states between October 2016 and March 2017, though they were allowed to conduct their research in only 92 of these. They interviewed 323 people, including residents, family members, nurses, social workers, pharmacists, patient advocates, long-term care experts, administrators, state and federal officials, and others.


Human Rights Watch noted that there are significant challenges in doing quantitative analyses of inappropriate use of antipsychotics in nursing facilities. It is often not possible to determine from a single publicly available data set the proportion of all individuals with dementia in nursing facilities that take antipsychotic medication without a psychiatric or neurological diagnosis for which an antipsychotic drug is clinically indicated. Also, a significant amount of the data on nursing homes is self-reported by those facilities. And it is difficult to determine what forms of non-pharmacologic interventions were tried prior to use of antipsychotics.


Though the study was not a scientific one, it provides numerous anecdotal examples of patients with side effects of antipsychotic treatment and some examples of dramatic improvements once these drugs were discontinued.


Note that we like to tell our own anecdotal story that is relevant. A nursing home one month experienced a dramatic reduction in reported falls. It turned out there had been a contractual issue with a consulting psychiatrist and, as a result, many psychotropic medications had temporarily not been renewed! This included not only antipsychotics but a variety of psychotropic medications. In our February 3, 2015 Patient Safety Tip of the Week CMS Hopes to Reduce Antipsychotics in Dementiawe noted that antipsychotics, of course, are not the only medication commonly misused in dementia patients in nursing homes. Sedatives and hypnotics and antianxiety agents are also commonly misused and will be monitored in the CMS/Partnership initiative as well. And in advanced dementia several other medications of questionable benefit are often continued. This includes drugs that may have been started for treating mild or moderate Alzheimer’s disease but are no longer indicated for advanced disease.


The Human Rights Watch paper goes on to describe a “culture” of antipsychotic drug use and antipsychotic medication use for the convenience of staff as potential explanations for their widespread use.


The Human Rights Watch paper discusses in detail the issues regarding lack of free and informed consent, noting that many such patients with dementia lack capacity to provide consent and other mechanisms for consent may be inadequate. It goes on to discuss deficiencies in governmental regulation and enforcement. It concludes with multiple recommendations for CMS, Congress, the Department of Justice, state legislatures and other regulatory bodies, and others.


Bottom line: the goals of the CMS National Partnership to Improve Dementia Care in Nursing Homes are laudable but the Human Rights Watch study shows we have a long way to go to optimize care for many long-term care patients with dementia.






CMS. National Partnership to Improve Dementia Care exceeds goal to reduce use of antipsychotic medications in nursing homes: CMS announces new goal. CMS Press Release September 19, 2014




CMS (Centers for Medicare and Medicaid). National Partnership to Improve Dementia Care in Nursing Homes. CMS 2018




CMS (Centers for Medicare and Medicaid). Update Report on the National Partnership to Improve Dementia Care in Nursing Homes. CMS 2016; June 3, 2016




Ravitz J. Nursing homes sedate residents with dementia by misusing antipsychotic drugs, report finds. CNN 2018; February 5, 2018




Flamm  H, McLemore M, Brown B, et al. Human Rights Watch. “They Want Docile”. How Nursing Homes in the United States Overmedicate People with Dementia. Human Rights Watch 2018; February 5, 2018







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Pediatric Early Warning System Fails



We’ve long attempted to develop early warning systems that identify patients at risk for deterioration at a time when intervention may avert disaster (see the list of our prior columns below). These systems have met with varying degrees of success.


Most studies on early warning systems have taken place in adult populations. We did discuss pediatric early warning systems in our September 17, 2013 Patient Safety Tip of the Week “First MEWS, Now PEWS”. In that column we noted a study by Parshuram et al (Parshuram 2011a) that demonstrated implementation of a validated modified PEWS system (Parshuram 2011b) in a community hospital was associated with fewer late transfers to tertiary pediatric centers, fewer serious clinical deterioration events, and fewer stat calls to pediatricians. In addition, there was no change to pediatrician workload and staff noted decreased apprehension when calling the physician.


Parshuram and colleagues (Parshuram 2018) recently reported on use of the Bedside Pediatric Early Warning System (BedsidePEWS) in a multicenter cluster randomized trial of 21 hospitals located in 7 countries (Belgium, Canada, England, Ireland, Italy, New Zealand, and the Netherlands) that provided inpatient pediatric care for infants (gestational age ≥37 weeks) to teenagers (aged ≤18 years). The BedsidePEWS intervention was used at 10 hospitals and outcomes were compared with usual care (no severity of illness score) at 11 hospitals.


All-cause hospital mortality, the primary outcome, was 1.93 per 1000 patient discharges at hospitals with BedsidePEWS and 1.56 per 1000 patient discharges at hospitals with usual care (non-significant). Significant clinical deterioration events, a secondary outcome, occurred during 0.50 per 1000 patient-days at hospitals with BedsidePEWS vs 0.84 per 1000 patient-days at hospitals with usual care (P = .03). There was no significant difference in rates of cardiac arrest, potentially preventable cardiac arrest, unplanned ICU readmission, or hospital readmission. And for those with urgent ICU admission there were no differences in severity of illness at ICU admission, ventilator-free days, organ dysfunction, and resource use.


There was also no significant difference in calls for immediate physician review, immediate calls for the resuscitation team, or urgent ICU consultation.


The composite outcome measure of late ICU admission (significant clinical deterioration events) was the sole positive outcome in favor of the BedsidePEWS group but was not accompanied by significant differences in related outcomes.


The authors conclude that implementation of the Bedside Paediatric Early Warning System compared with usual care did not significantly decrease all-cause mortality among hospitalized pediatric patients and that use of this system to reduce mortality is not supported.


In the accompanying editorial (Halpern 2018), Halpern notes that the mortality rates were lower than expected in both groups and that perhaps mortality is not the most appropriate outcome parameter. He notes that the decrease in significant clinical deterioration events suggests fewer delays in ICU admissions. He suggests that “future studies should be designed to advance BedsidePEWS to the next level with informatics development as well as dynamic and time-based integration with other data elements in the electronic medical record”.


We concur that we should not give up on the concept of the early warning system and should continue to look for ways to optimize recognition of patients at risk for deterioration before such deterioration occurs.



Some of our other columns on MEWS or recognition of clinical deterioration:




Our other columns on rapid response teams:







Parshuram CS, Bayliss A, Reimer J, et al. Implementing the Bedside Paediatric Early Warning System in a community hospital: A prospective observational study. Paediatr Child Health. 2011; 16(3):  e18–e22.




Parshuram CS, Duncan HP, Joffe AR, et al. Multicentre validation of the bedside paediatric early warning system score: a severity of illness score to detect evolving critical illness in hospitalised children. Crit Care 2011; 15(4): R184




Parshuram CS, Dryden-Palmer K, Farrell C, et al. Effect of a Pediatric Early Warning System on All-Cause Mortality in Hospitalized Pediatric Patients. The EPOCH Randomized Clinical Trial. JAMA 2018; Published online February 27, 2018




Halpern NA. Early Warning Systems for Hospitalized Pediatric Patients. JAMA 2018; Published online February 27, 2018








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Cost of Interrupting a Radiologist



In several columns we’ve described the impact of interruptions on radiologist performance (see our July 1, 2014 Patient Safety Tip of the Week “Interruptions and Radiologists” and our November 2014 What's New in the Patient Safety World column “More Radiologist Interruptions”) and the impact of fatigue on radiologist performance (see our April 2018 What's New in the Patient Safety World column “Radiologists Get Fatigued, Too”).


In our July 1, 2014 Patient Safety Tip of the Week “Interruptions and Radiologists” we discussed a study that looked at how often a radiologist on-call gets interrupted (Yu 2014). During a typical 8PM to 8AM overnight shift there was an average of 72 telephone calls, with a median call duration 57 seconds, and the average time spent on the phone was 108 minutes. The median interval from the start of one telephone call to the start of the next ranged from 3 to 10 minutes, depending on the time of day.


Then in our November 2014 What's New in the Patient Safety World column “More Radiologist Interruptions”) we noted another study that looked at the impact of telephone calls on radiology residents on-call to determine whether there was a relationship between these and discrepancies on reports (Balint 2014). While there was a only a slight difference in total phone calls per shift between those shifts with and without report discrepancies, there was a statistically significant increase in the average number of phone calls in the 1 hour preceding the generation of a discrepant preliminary report (4.23 vs. 3.24 calls). The authors suggest that one additional phone call during the hour preceding the generation of a discrepant preliminary report resulted in a 12% increased likelihood of a resident error.


Now a new study (Trafton 2018) has utilized the eye tracking methodology we described in our April 2018 What's New in the Patient Safety World column “Radiologists Get Fatigued, Tooto assess the impact of interruptions on radiologists in simulated exercises.


Participating radiologists were given a worklist populated with a mixture of volumetric (e.g., chest CT) and 2-D (e.g., chest radiograph) images and told they had 45 minutes to complete their work. Each worklist contained 11 cases, 4 of which were the experimental cases which contained at least one significant finding (the others were largely uncomplicated normal images).


Phone call interruptions took place on two out of four of the experimental cases. The interruption took place 3min into each case. Upon answering the phone, a prerecorded message simulating a clinician asked them to find a patient from a different worklist and provide a quick diagnostic interpretation. Both prerecorded messages asked the radiologist to examine the case of a patient who was not on the initial worklist who was complaining of abdominal pain. This meant that the radiologist had to exit the current worklist, open a second worklist, and find the patient in question. If the radiologist did not hear the name of the patient, the experimenter played the message again. Once the case had been found, the radiologist was asked to verbally indicate the diagnosis as if relaying it to the referring physician. Verbal responses were recorded using the audio input on the eye-tracking glasses. On average, radiologists devoted 2.2 minutes to the telephone interruption before returning to the original case.


The researchers found that the first telephone interruption led to a significant increase in time spent on the case, but there was no effect on diagnostic accuracy. Eye-tracking revealed that interruptions strongly influenced where the radiologists looked: they tended to spend more time looking at dictation screens and less on medical images immediately after interruption. There was also no evidence of a time cost in response to the second interruption. (Note also that in a second simulation, there was no evidence of a time cost where an interpersonal interruption was not relevant to the task and did not involve medical images.)


The authors were surprised there was no effect on diagnostic accuracy after the first interruption. But that was not unexpected for the second interruption since prior research has shown that practice with a task leads to less disruption in response to interruptions.


Their work suggests that the interruption reduced the amount of time spent examining medical images even when an overall time cost was not observed. The authors felt it likely that the dictation screen serves as an external memory aid that helps the radiologist determine where they have and have not previously examined, which is predicted to be an effective strategy in the cognitive psychology literature.


However, the fact that less time is being spent examining medical images after interruption without a concomitant increase in total time spent per case raises concerns. The authors point out that, in aggregate (for instance over the thousands of cases a given clinic examines each year), they expect this would lead to worse performance on interruption cases as a result.


The authors noted that a number of the radiologists noted that both interruptions employed in this study (phone call and interpersonal interruption) were benign relative to the disruptive interruptions they often face, especially if interrupted more than once. They mentioned that interruptions which require leaving the reading room are particularly disruptive, often leading to the radiologist restarting the interrupted case.


While Trafton and colleagues consider their research to be preliminary, they note that further research is needed to determine best ways to minimize the impact of interruptions. But efforts to reduce interruptions are obviously also desirable. One of the strategies recommended in the Balint study to prevent such interruptions is to have other staff handle phone calls. Additional potential strategies include interruption-free zones and having a separate radiologist or radiology resident handle consultations. The previous study by Yu and colleagues noted that posting preliminary reports on the electronic medical record has likely had a beneficial effect on frequency of calls. They, too, have also begun having medical students assist the on-call radiologist by answering the phone and triaging imaging reports. We added that radiology physician assistants can help with things like contrast injections, etc. during high activity periods that might also interrupt radiologists’ reading. Hospitals having the luxury of larger radiology staffs might have a dedicated second radiologist during high volume periods whose sole responsibility is interpreting images. Note that the latter might also be reading images off-site via teleradiology.


We’ve also stressed that much time can be wasted in tracking down the appropriate physician when communicating significant findings. So anything you can do to facilitate identification of the responsible physician would be a positive step.



Prior Patient Safety Tips of the Week dealing with interruptions and distractions:








Yu J-P, Kansagra AP, Morgan J. The Radiologist's Workflow Environment: Evaluation of Disruptors and Potential Implications. JACR 2014; published online April 26, 2014




Balint BJ, Steenburg SD, Lin H, et al. Do Telephone Call Interruptions Have an Impact on Radiology Resident Diagnostic Accuracy? Academic Radiology 2014; published online September 30, 2014




Trafton D, Williams LH, Aldred B, et al. Quantifying the costs of interruption during diagnostic radiology interpretation using mobile eye-tracking glasses, Journal of Medical Imaging 2018; 5(3), 031406 Published online 2 March 2018







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Print “May 2018 What's New in the Patient Safety World (full column)

Print “May 2018 ECRI Top 10 Patient Safety Concerns for 2018

Print “May 2018 Antipsychotic Use in Nursing Homes: Progress or Not?

Print “May 2018 Pediatric Early Warning System Fails

Print “May 2018 Cost of Interrupting a Radiologist




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