What’s New in the Patient Safety World


November 2007    



More Patient Deaths from Luer Misconnections

1000-fold overdoses by Transposing “mg” for micrograms

FMEA on Neuromuscular Blocking Agents

Cost of ICU Adverse Events

ACR Guidance on MRI Safety

Tracking Test Results

Guilty, Afraid, and Alone - Struggling with Medical Error





November 2007


More Patient Deaths from Luer Misconnections


Our July 10, 2007 Tip of the Week focused on catheter misconnections. The October 2007 issue of FDA Patient Safety News highlights continued deaths from Luer misconnections and cites an excellent summary article by Gallauresi, Eakle, and Morrison in Safe Practices in Patient Care. It includes the history of the Luer connector, multiple real examples of misconnections, and the state of the industry in its attempts to develop standards to avoid this serious problem. It reiterates the recommendations of the 2006 Joint Commission Sentinel Event Alert on this issue.




1000-fold Overdoses by Transposing “mg” for micrograms




The September 6, 2007 ISMP Safety Alert describes the case of an infant who received a lethal dose of zinc stemming from an error that occurred during the order entry and compounding of a TPN solution. Because the automated compounder used for TPN required entry of zinc in a micrograms/kg dose, the pharmacist converted the micrograms/mL dose to a micrograms/kg dose. The pharmacist performed this calculation correctly, but accidentally entered the zinc dose in the pharmacy computer in mg, not micrograms. This resulted in a final concentration that was a 1,000-fold overdose. The ISMP provides a very good root cause analysis of the event, noting multiple system errors, and provides multiple recommendations for safe practices.




FMEA Related to Neuromuscular Blocking Agents





In our July 31, 2007 Tip of the Week dedicated to errors in use of neuromuscular blocking agents (MNBA’s), we recommended this is a good issue to address in FMEA (Failure Mode and Effects Analysis) in your organization. Susan Paparella, from ISMP, did exactly that in a recent issue of Journal of Emergency Nursing. The ED staff had recognized NMBA’s as high-alert drugs and were contemplating their removal from ED stores, to be replaced in kits prepared for rapid-sequence intubation. FMEA is especially useful in such situations where change is to take place, because it helps identify potential unintended consequences. The article nicely describes how you do a FMEA exercise and provides examples for scoring probability and severity and use of a hazard scoring matrix. She also lists 10 other problems commonly encountered in emergency rooms that could be candidates for FMEA.


Paparella, Susan RN, MSN Failure Mode and Effects Analysis: A Useful Tool for Risk Identification and Injury Prevention. Journal of Emergency Nursing. 33(4):367-371, August 2007



Cost of adverse events in intensive care units




Our August 21, 2007 Tip of the Week quantified the cost of several complications that are potentially preventable. Add to that the costs of adverse events in ICU’s. Kaushal et al have just published a study of the cost for adverse events in ICU’s. The average cost per adverse event for patients in the MICU was $3961 and the attributable increase in LOS was 0.77 days. Corresponding numbers for patients in the CCU were $3857 and 1.08 days. The extrapolated annual cost for adverse events in these two 10-bed ICU’s was nearly $1.5 million. Clearly, there is significant opportunity for costs savings in prevention of adverse events in this setting. Organizations looking for a good ROI (return on investment) in their patient safety programs may want to focus on ICU’s.



Kaushal R, Bates DW, Franz C, Soukup JR, Rothschild JM. Cost of adverse events in intensive care units. Critical Care Med 2007; 35: 2479–2483



ACR Guidance Document for Safe MR Practices: 2007



The American College of Radiology issued its guidance document for safe MR practices in the June issue of the American Journal of Radiology.


Kanal E et al. ACR Guidance Document for Safe MR Practices: 2007. AJR 2007; 188: 1-27




Tracking Test Results




This one’s not really new but we just came across it. In our May 1, 2007 Tip of the Week we talked about the need for all physicians to have a system for tracking patient test results to help avoid such disasters as the missed cancer. The Kentucky Medical Association published a nice tool for Tracking Test Results Within a Physican Practice. It provides solid advice on setting up a system in your office, whether electronic or paper-based.


However, even computerized alert and reminder systems aren’t 100% successful. Singh et al  reported followup on 1017 imaging report alerts transmitted electronically. They found that over a third of the alerts went unacknowledged, including 4% of abnormal results. Overall, 0.2% of outpatient imaging was lost to followup. Clearly, we still have a long way to go in fixing the barriers and system issues in ensuring test results get appropriately acknowledged and acted upon.



Singh H, Arora HS, Vij MS, MDc, Rao R, Khan MM, Petersen LA. Communication Outcomes of Critical Imaging Results in a Computerized Notification System .J Am Med Inform Assoc. 2007; 14:459-466



Guilty, Afraid, and Alone – Struggling with Medical Error




This “Perspective” by Tom Delbanco and Sigall Bell in the October 25, 2007 issue of the New England Journal of Medicine provides insights gleaned from interviews with patients and families that had been affected by medical error. It provides excellent insight into how those same emotions in clinicians may further compound the emotions the patient or family is going through. It’s another compelling example of why honest disclosure and sincere apology are the right thing to do after medical error.



Delbanco T, Bell SK.  Guilty, Afraid, and Alone — Struggling with Medical Error. NEJM 2007; 357:1682-1683





In addition to this month’s column below, there are 2 important new patient safety resources we’d like to point out:


(1)   an excellent paper by ECRI Institute on how to get ready for the CMS final rule on Hospital-Acquired conditions. There is also a video and podcast available. You'll see that you should already have the coding end up and running now even though payment won't be withheld until October. It gives good recommendations on putting together a multidisciplinary team to get ready for this.

(2)   AHRQ has made available 17 patient safety toolkits produced under it's Partnerships in Implementing Patient Safety (PIPS) grant program. We’ll be reviewing some of these in future Tip of the Week columns.












Patient Safety Tip of the Week Archive


What’s New in the Patient Safety World Archive