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What’s New in the Patient Safety World

May 2021


·       More on Time Spent on the EMR

·       CLABSI’s Up in the COVID-19 Era

·       Another Hands-Free Unintended Consequence

·       Axe the Fax



More on Time Spent on the EMR



Clinicians spend an awful lot of time on the electronic medical record (EMR) and this has been an important factor contributing to burnout. See our What's New in the Patient Safety World columns for April 2017 “How Much Time Do We Actually Spend on the EMR?” and May 2019 “Too Much Time on the EMR”.


Many of the studies have looked at time spent on the EMR in the hospital setting. But a few have looked at EMR use in the ambulatory setting. A time-motion study of physicians in ambulatory practices (Sinsky 2016) found that, during the office day, physicians spent 27.0% of their total time on direct clinical face time with patients and 49.2% of their time on EHR and desk work. While in the examination room with patients, physicians spent 52.9% of the time on direct clinical face time and 37.0% on EHR and desk work. In addition, outside of office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work. Thus, for every hour physicians provide direct clinical face time to patients, they spent nearly 2 additional hours on EHR and desk work within the clinic day. Of the time spent on EHR and desk work, 38.5% was spent on documentation and review tasks, 6.3% on test results, 2.4% on medication orders, and 2.0% on other orders. They spent 1.1% of their time on administrative tasks (0.6% involved insurance-related tasks and 0.5% involved scheduling).


But it turns out that time spent on the EMR is far from uniform across ambulatory specialties. A new study looked at time spent on the EMR both during the day and after hours (Rotenstein 2021). Those researchers found that mean total active daily EMR time was 45.6 vs 85.7 vs. 115.0 minutes for surgical vs. medical vs. primary care specialties, respectively. Mean after hours active use time on the EMR was 16.0 vs 26.2 vs. 29.8 minutes, respectively.


The most time was spent on notes (22.0 minutes vs. 40.8 minutes vs. 51.5 minutes for surgical specialties, medical specialties, and primary care specialties, respectively). Clinical review and orders represented the next biggest areas of time expenditure. Time dealing with messages showed major differences. Compared with surgical colleagues, primary care clinicians received more than twice as many team-derived messages, 5 times as many patient messages, and 15 times as many prescription messages each day.


The authors call for further investigation to identify interventions to reduce the administrative and EMR burden to help avoid clinician burnout.


A second recent study (Eschenroeder 2021) confirmed the impact of after-hours EMR activity on burnout. The researchers found that physicians reporting ≤ 5 hours weekly of after-hours charting were twice as likely to report lower burnout scores compared to those charting ≥6 hours (aOR 2.43).


Of course, the EMR burden impact on burnout is not limited to physicians. Nurses are also impacted. A new study (Kutney-Lee 2021) found that nurses who worked in hospitals with poorer EHR (electronic health record) usability had significantly higher odds of burnout (odds ratio 1.41),  job dissatisfaction (OR 1.61) and intention to leave (OR 1.31) compared with nurses working in hospitals with better usability.


Not only did poor EHR usability impact nurse burnout, it also impacted patient safety and outcomes. Surgical patients treated in hospitals with poorer EHR usability had significantly higher odds of inpatient mortality (OR 1.21) and 30-day readmission (OR 1.06) compared with patients in hospitals with better usability.



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



Some of our prior columns on “burnout”:








Sinsky C, Colligan L, Li L, et al. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann Intern Med 2016; 165: 753-760



Rotenstein LS, Holmgren AJ, Downing NL, Bates DW. Differences in Total and After-hours Electronic Health Record Time Across Ambulatory Specialties. JAMA Intern Med 2021; Published online March 22, 2021



Kutney-Lee A, Brooks Carthon M, Sloane DM, Bowles KH, McHugh MD, Aiken LH. Electronic Health Record Usability: Associations With Nurse and Patient Outcomes in Hospitals. Med Care 2021; Apr 1, 2021



Eschenroeder E, Manzione LC, Adler-Milstein J, et al. Associations of physician burnout with organizational electronic health record support and after-hours charting, Journal of the American Medical Informatics Association 2021; 28(5): 960-966






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CLABSI’s Up in the COVID-19 Era



Several studies have found an increase in CLABSI’s (Central Line-Associated Bloodstream Infections) during the COVID-19 pandemic. Patel et al. (Patel 2021) used data reported to the Centers for Disease Control and Prevention’s National Healthcare Safety Network (NHSN) in almost 3000 acute care hospitals.  They compared standard infection ratios of CLABSI’s from April, May and June of 2019 to the same period of 2020. They found the rate of CLABSI’s increased from 0.68 in 2019 to 0.87 in 2020, an increase of 28%. Critical care units experienced the highest increase at 39% (from 0.75 to 1.04), followed by ward locations at 13%.


Fakih et al. (Fakih 2021) also used NHSN data to do a retrospective evaluation of CLABSI and CAUTI outcomes in 78 hospitals from a single healthcare system over 2 periods: before the COVID-19 pandemic (March 2019–February 2020; 12 months) and during the COVID-19 pandemic (March–August 2020; 6 months). CLABSI rates increased by 51.0% during the pandemic period from 0.56 to 0.85 per 1,000 line days and by 62.9% from 1.00 to 1.64 per 10,000 patient days. Hospitals with monthly COVID-19 patients representing >10% of admissions had a National Health Safety Network (NHSN) device standardized infection ratio for CLABSI that was 2.38 times higher than hospitals with <5% prevalence during the pandemic period. In contrast, no significant changes were identified for CAUTI’s (0.86 vs 0.77 per 1,000 catheter days).


A number of factors have been hypothesized as contributors to this increase in CLABSI rates. The frequency of contact with patients may have changed during the pandemic in attempt to reduce healthcare worker exposure to patients and to preserve personal protective equipment. Patients admitted during the pandemic were more likely to require critical care support and to need it for a longer period of time, potentially putting them at greater risk for CLABSI. The proportion of COVID-19 patients with CLABSI events was 5 times greater than for non–COVID-19 patients during the pandemic period. The average time from COVID-19 diagnosis to developing CLABSI was 18 days, indicating that the CLABSI events occurred in COVID-19 patients with prolonged hospitalization.


Qualitative feedback from their infection prevention teams reported changes to routine CLABSI prevention practices in ICUs, such as less universal decolonization (eg, mupirocin administration and chlorhexidine bathing), alterations in line care due to intravenous pumps placed in hallways (eg, extension tubing used and less bedside checks on lines), line and dressing integrity gaps related to prone positioning of patients, opportunities in scrub-the-hub compliance, and increases in line draws for blood cultures.


In addition, staffing changes responding to increased patient volume on the units, such as the help of traveling clinicians not as familiar with standard unit prevention practices, may have contributed.


They also noted that “line rounds”, which had been a routine practice prior to the COVID-19 pandemic, often stopped during the COVID-19 pandemic period due to competing priorities. Those rounds had helped ensure proper device selection, utilization, and bedside practices were being followed.


Line rounds are something we advocate be performed on a daily basis to reduce CLABSI’s (we also advocate “Foley rounds” daily to reduce CAUTI’s). During those rounds we consider the continued “appropriateness” of such devices.


The above studies do not separate CLABSI’s due to traditional central lines vs. peripherally inserted central lines (PICC’s). An important milestone in reducing CLABSI’s was publication of the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) (Chopra 2015), which provides evidence-based criteria for multiple types of vascular access devices but especially focused on peripherally inserted central catheter (PICC) use. Chopra and colleagues recently looked at whether implementing MAGIC reduces complications (Chopra 2021). They used data from 52 Michigan hospitals. During the preintervention period, the mean frequency of appropriate PICC use was 31.9% and the mean frequency of complications was 14.7%. Following the intervention, PICC appropriateness increased to 49.0% while complications decreased to 10.7%. Compared with patients with inappropriate PICC placement, appropriate PICC use was associated with a significantly lower odds of complications (OR 0.29), including a decrease in CLABSI’s (OR 0.61). There were also decreases in occlusion (OR 0.25) and VTE (OR 0.40).




Some of our other columns on IV access, central venous catheters and PICC lines:


January 21, 2014         The PICC Myth

December 2014           Surprise Central Lines

July 2015                    Reducing Central Venous Catheter Use

October 2015              Michigan Appropriateness Guide for Intravenous Catheters

March 27, 2018           PICC Use Persists

February 26, 2019       Vascular Access Device Dislodgements

July 16, 2019              Avoiding PICC’s in CKD

March 2, 2021             Barriers to Timely Catheter Removal






Patel P, Weiner-Lastinger L, Dudeck M, et a;. Impact of COVID-19 Pandemic on Central Line-Associated Bloodstream Infections During the Early Months of 2020, National Healthcare Safety Network. Infection Control & Hospital Epidemiology 2021; 1-8 Published online by Cambridge University Press:  15 March 2021



Fakih MG, Bufalino A, Sturm L, et al. Coronavirus disease 2019 (COVID-19) pandemic, central-line-associated bloodstream infection (CLABSI), and catheter-associated urinary tract infection (CAUTI): The urgent need to refocus on hardwiring prevention efforts. Infect Control Hosp Epidemiol 2021; Published online 2021 Feb 19



Chopra V, Flanders SA, Saint S, et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results from a Multispecialty Panel Using the RAND/UCLA Appropriateness Method. Ann Intern Med 2015; 163(6_Supplement): S1-S40



Chopra V, O'Malley M, Horowitz J, et al. Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals. BMJ Quality & Safety 2021; Published Online First: 29 March 2021






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Another Hands-Free Unintended Consequence



Some solutions sound intuitive. But common sense doesn’t always pan out. When it comes to hand hygiene, it is logical that transmission of infectious agents should be reduced if you don’t have to touch various surfaces. But, is that borne out in practice?


Electronic faucets are one such example. The idea is great. You don’t have to touch the faucet to turn it on. It simply turns on when it senses the presence of your hands beneath the faucet. In our May 2011 What's New in the Patient Safety World column “The Best Laid Plans,,,Electronic Water Faucet Paradox” we noted that researchers at Johns Hopkins demonstrated 50% of electronic water faucets grew Legionella species, compared to 15% of manual faucets. They felt that the complex valve structure of the electronic faucets predisposed to growth of Legionella. While some wanted more studies to confirm this finding, Hopkins was so concerned that they removed 20 electronic faucets in patient care areas and cancelled planned installation of about 1000 such faucets in a new clinical building.


Now a new study questions use of high speed air dryers (Moura 2021). These are devices that blow warm or hot air over your hands to dry them off after you wash them. Theoretically, if you don’t have to touch the device, you would be less likely to get contamination compared to touching a paper towel dispenser. Moura et al. used a bacteriophage as a surrogate for bacterial pathogens and compared bacteriophage counts on volunteers’ hands dried via high speed air dryers vs. those dried by paper towels. The volunteers first cleansed their hands or gloved hands in 70% alcohol gel, then immersed their hands in the study solution containing the bacteriophage. The researchers then measured bacteriophage levels not only on the volunteers’ hands, but also on their clothing and on surfaces they might touch (eg. stethoscope, arms of a chair, and several other surfaces).


Both the jet air dryer and the paper towel methods significantly reduced bacteriophage contamination of the hands. But, apron (simulated trunk or clothing) contamination by bacteriophage during hand drying was significantly higher after jet air dryer use. The bacteriophage levels detected on the volunteers’ hands at the end of the experiments suggested gross persistence of bacteriophage contamination throughout the sampling period.


Moreover, all 8 surfaces investigated following jet air dryer use had bacteriophage contamination above the limit of detection, whereas this occurred for only 5 surfaces after paper towel use. For all samples, there was a significantly higher level of surface contamination following hand drying with the jet air dryer than with paper towels. Samples obtained from smaller surface areas, namely elevator and ward access buttons, showed lower bacteriophage contamination. Interestingly, simulated use of a hospital phone for 10 seconds resulted in detectable contamination only following jet air dryer use. The average surface contamination following hand contact was >10-fold higher after jet air dryer use than after paper towel use (4.1 log10 copies/µL versus 2.9 log10 copies/µL, respectively).


This, of course, is not the first study to warn of potential contamination from high speed air dryers. Best et al. (Best 2018) compared bacterial contamination levels in washrooms with hand-drying by either paper towels (PT) or jet air dryer (JAD). Bacterial contamination was lower in PT versus JAD washrooms. Total bacterial recovery was significantly greater from JAD versus PT dispenser surfaces and significantly more bacteria were recovered from JAD washroom floors. Multiple examples of significant differences in surface bacterial contamination, including by fecal and antibiotic-resistant bacteria, were observed, with higher levels in JAD versus PT washrooms. The authors concluded that hand-drying method affects the risk of (airborne) dissemination of bacteria in real-world settings.


The findings of these studies certainly question the use of hand drying with jet air dryers in a hospital setting.






Moura I, Ewin D, Wilcox M. From the hospital toilet to the ward: A pilot study on microbe dispersal to multiple hospital surfaces following hand drying using a jet air dryer versus paper towels. Infection Control & Hospital Epidemiology 2021; 1-4

Published online 17 March 2021



Best E, Parnell P, Couturier J, et al. Environmental contamination by bacteria in hospital washrooms according to hand-drying method: a multicentre study. J Hosp Infect 2018; 100: 469-475





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Axe the Fax



We’ve done multiple columns on problems created by use of fax in healthcare. But, it just won’t go away! A recent opinion column in the Toronto Star (Singh 2021) serves as a reminder that fax machine use in healthcare just won’t die!


The problem really is one of interoperability, or rather, lack of interoperability. Singh notes that millions of medical records are faxed in Ontario every month. He points out that doctors’ offices and hospitals use various electronic medical record systems to document patients’ medical information, but if they want to send a patient to a specialist or a prescription to a pharmacy, they often need to print out the paperwork and fax it.

He compares that to the equivalent of drafting an email, printing it out, and then mailing it to the recipient.


Moreover, Singh notes that about 20% of faxes sent on traditional fax machines fail daily. That leads to many hours of unnecessary work and inefficiency. That leads to errors, lost patient information, and slows down the process of getting patients connected to the health care they need.


Beth Gerritsen, who did a Masters thesis on fax usage in Ontario, notes that the COVID-19 pandemic has exacerbated problems related to use of fax in healthcare (Gerritsen 2021). She notes that, before the pandemic, the healthcare system’s reliance on the fax was embarrassing, but now it’s a critical failure point for the entire system. Her work on fax usage in Ontario showed that:


Gerritsen notes that, during the pandemic, clinicians stepped up with a quick shift to virtual care in order to support patients but quality virtual care needs proper support from digital infrastructure. She notes that a fax failure of a prescription or lab order after a virtual visit critically impacts a patient and nobody should experience a delay in a referral for specialty care because of a misdirected or a failed fax transmission.


She goes on to discuss the steps Ontario needs to take to move away from use of fax in healthcare. 


Though both Singh and Gerritsen are discussing use of fax in Ontario, the situation in the US is not much better. Yes, we are making strides in improving interoperability but every hospital and physician’s office in the US still relies on fax at least to some degree. Our January 16, 2018 Patient Safety Tip of the Week “Just the Fax, Ma’am” discussed a podcast on faxing in US doctors’ offices by Sarah Kliff and colleagues on Vox’s “The Impact” series (Kliff 2017). And, even where hospitals and physician’s offices have joined in regional healthcare information exchanges, other third parties that must receive healthcare information (eg. insurers, home care agencies, etc.) may not be included.


Our Patient Safety Tips of the Week for June 19, 2012 “More Problems with Faxed Orders” and January 16, 2018 “Just the Fax, Ma’am” outline many patient safety issues associated with use of faxes.


It’s worth repeating some of the caveats we raised in our June 19, 2012 Patient Safety Tip of the Week “More Problems with Faxed Orders” and other columns. The problem we have mentioned most often is the missed decimal point (where lines or smudge during fax transmission and printing obscures a decimal point) and the patient receives a 10x overdose of the medication. (In our September 9, 2008 Patient Safety Tip of the Week “Less is More….and Do You Really Need that Decimal?” we cautioned against even using a decimal point when the fraction following the decimal point is clinically irrelevant because that decimal point may be overlooked, especially in faxed orders.) The opposite, of course, may also occur where a smudge on the fax looks like a decimal point (the phantom decimal point) so the patient receives one-tenth the intended amount.


But we’ve also mentioned the case where 2 sheets put into a fax machine stick together and thus only one sheet gets transmitted (see our January 18, 2011 Patient Safety Tip of the Week “More on Medication Errors in Long-Term Care” where we cited such an example from ISMP 2010). Unless you have a cover fax sheet that says “3 pages (cover sheet plus 2 others)” the receiving party may not realize that they are missing a page.


We’ve also seen cases where faxes on multiple patients are sent out at the same time and the receiving party does not recognize that the second sheet is actually for a different patient (see our January 18, 2011 Patient Safety Tip of the Week “More on Medication Errors in Long-Term Care”).


Just as with handwritten orders, on a faxed order with a drug ending in the letter “L” if there is insufficient space between the “L” and the next number, the receiver may think the “L” is actually a “1” (one) and give a dose 10 times too high. And dangerous abbreviations may show up even more frequently on faxed orders than orders written on-site because the provider is more likely to have access to the “do not use” abbreviation list when on-site.


Another mistake is when a person faxes documents that have information on both sides and does not realize that only one side of each page is being faxed.


And remember when you are sending a fax that some elements (eg. text in a different color) may fail to be seen when transmitted. Or that highlighted items (eg. items you tied to stress with a yellow highlighter) may appear blacked out on the received fax! (Reminds me of the time in college when I asked a friend to send me his notes from a class I had missed so I could study for a test the next day. He faxed them and all the important stuff, which he had highlighted with a highlighting marker, was blacked out on the fax!!!).


And one of the most egregious errors of all – faxing to the wrong phone number (the misdirected fax). Ever get a call from the local supermarket that you faxed them a sheet with PHI on it? Your HIPAA compliance officer and risk manager will turn gray when that call comes in! We’ve seen faxes sent to old fax numbers after a physician has moved to a new office and even faxes sent to physicians who have been deceased for four years! And hospital computer systems often have the wrong physician listed as primary care physician, often leading to faxes being sent to the wrong PCP.


ISMP Canada (ISMP Canada 2012) came up with a new fax error – the truncation error. They provide a great example of a faxed order for “dalteparin” where the “da” gets cut off in the fax and the “lt” looks like an “H” on the fax, resulting in what clearly looks like an order for “Heparin”. Click on the link above and you’ll see both the faxed prescription and the original.


Note that prescription has lots of other bad errors on it. It uses the do-not-use abbreviation “U” (for units) as well as 2 other abbreviations that should be avoided (“SQ” for subcutaneous and “QD” for once daily). It has a different dose written above and crossed out. And it does not have listed the indication for the drug. It also has an illegible word following the “QD” (is it nitely? or is it a provider’s signature?). And there is nothing on the prescription to indicate the duration of therapy, amount to be dispensed, whether it should be refilled, etc. Who would have thought one prescription could be used as a primer for medication errors!


ISMP Canada notes the importance of reviewing copies of the fax you send or the one you receive. For instance, in the case given one might have noticed that the name of the hospital was also truncated, which might have been a clue that the medication name was truncated. They also note in the example given that the dosing frequency would have been unusual for heparin (it is usually given twice daily or three times daily rather than once daily), perhaps being another clue to the receiver that there was an error. They also note that including both the generic and brand names on the prescription would have provided another clue to the error. They note the importance of engaging the patient to be on the lookout for errors as well.


We refer you back to our Patient Safety Tips of the Week for June 19, 2012 “More Problems with Faxed Orders” and January 16, 2018 “Just the Fax, Ma’am” for our multiple recommendations on faxing issues.


Our January 2019 What's New in the Patient Safety World column Still Faxing?” noted initiatives in the UK and the US to eliminate use of fax in healthcare. But we are still not there. Both Singh and Gerritsen use the catchy phrase “Axe the Fax”. It seems that, in politics, catchy 3-word phrases go a long way. Maybe it’s time we all adopt “Axe the Fax”!



See our prior columns on problems related to use of fax in healthcare:


June 19, 2012              More Problems with Faxed Orders

January 16, 2018         Just the Fax, Ma’am

September 2018          ECRI Institute Partnership: Closing the Loop

January 2019               Still Faxing?






Singh P, Aggarwal S. We need to axe the fax in health care — now. Toronto Star 2021; March 24, 2021



Gerritsen B. Axe the fax: A primer on fax tech in the 21st century, an Ontario’s healthcare system perspective. Canadian Healthcare Network. The Medical Post 2021



Kliff S, Pinkerton B, Weinberger J, Drozdowska A. It’s 2017. Why does medicine still run on fax machines? Vox “The Impact” (podcast) 2017; October 30, 2017



ISMP (Institute for Safe Medication Practices). Order scanning systems (and fax machines) may pull multiple pages through the scanner at the same time, leading to drug omissions. ISMP Medication Safety Alert (Nurse Advise-ERR) 2010; 8(11):  1-2



ISMP Canada.  ALERT: Medication Mix-up with a Faxed Prescription. ISMP Canada Safety Bulletin 2012; 12(6): 1-3 June 5, 2012






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

Print “May 2021 More on Time Spent on the EMR

Print “May 2021 CLABSI’s Up in the COVID-19 Era

Print “May 2021 Another Hands-Free Unintended Consequence

Print “May 2021 Axe the Fax




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