Patient Safety Tip of the Week Archive

What’s New in the Patient Safety World

November 2021

· Panic Buttons to Protect Healthcare Workers – But a Word of Caution

· Yet Another Risk During MRI

· New Risk Factor for Patient Safety Events: Motor Vehicle Accidents

· When a Radiologist Recognizes He Committed an Error

Panic Buttons to Protect Healthcare Workers – But a Word of Caution

The headline reads “COVID-related attacks prompt hospital to issue panic buttons” (Salter 2021). Violence against healthcare workers has been increasing in recent years and really surged during the COVID-19 pandemic, particularly as people rebelled against mask mandates and vaccine mandates. So, a Missouri hospital has added panic buttons to identification badges worn by employees who work in the emergency room and inpatient hospital rooms. Pushing the button immediately alerts hospital security and launches a tracking system that sends help to the endangered worker.

Good idea – but with a caveat: make sure that system is in working order every day. In our February 4, 2014 Patient Safety Tip of the Week “But What If the Battery Runs Low?” we described the following scenario: You implemented a “panic button” system to protect your behavioral health workers from assaults by patients on your locked behavioral health unit. The worker is in a situation where she fears potential harm from a patient and presses the panic button. However, the battery in the panic button is dead. Fortunately, other staff were within audible range of her shouts for help and responded before she was assaulted. The lesson is that any alarm or alert system, regardless of whether it is battery-operated or otherwise, needs frequent testing to ensure it is in working order.

And review of the death of a patient who wandered out of a San Diego hospital several years ago (Luke 2014) illustrates several problems related to reliance on alarms. First, the patient’s bed alarm never sounded. Then, once staff realized the patient was missing, they tried unsuccessfully to page Security and then tried to contact Security by pushing a panic button twice, also with no response. When state inspectors investigated, they found that the panic button had been broken for 8 days. In fact, they found the hospital failed to routinely test the buttons and failed to repair them when broken and that one out of every four panic buttons at the hospital didn’t work.

And a VA audit of MRI safety was initiated after a 2008 incident (Report No. 08-01380-154) in which a patient crawled out of an MRI scanner after his calls for help went unheeded because the panic button was inoperable and no maintenance checks had been done on the intercom system or the panic button.

The system used by the Missouri hospital is tied to their real-time locating system (RTLS). Such systems include both wired and wireless configurations. And the panic buttons have variable battery lives. Those on ID badges are said to have a battery life of 1 to 2 years. Those on bracelets have battery life on the order of 90 days.

Battery life of 1-2 years! Don’t get complacent. We’ve all seen batteries that fail far before their expected expiration dates. And if you are waiting for a year to test batteries, you’ll likely be lulled into thinking you have no problems.

But even if the battery on the panic button is working, there could be problems at the receiving end that prevent or delay a response. Our June 16, 2020 Patient Safety Tip of the Week “Tracking Technologies” discussed the various sorts of technology used in tracking systems. These include radiofrequency, infrared, Bluetooth, and GPS technologies. Some may use your Wi-Fi network. An important thing to remember is that, with any of these technologies, there may be “dead zones” where transmission does not occur. So, you need to be very wary of where such dead zones are when you implement a panic button system.

You’ll also need to educate your staff on use of the panic buttons and how and when to test them. And keep in mind that some assailants may grab the badge containing the panic button.

We’ve long been fans of tracking technologies and think they are still vastly underutilized in hospitals and other healthcare venues. Our June 16, 2020 Patient Safety Tip of the Week “Tracking Technologies” discussed the myriad of potential uses for such devices and systems. If you have already installed such a tracking system or are considering one, you probably should consider including the panic button capability. Just beware that you must regularly check the operating status of all components of the system.

The psychiatrist’s office is another site vulnerable to violent interactions with patients or families. A recent article (Frieden 2021) summarized recommendations presented by Vince Kennedy, DO, at the American Academy of Psychiatry and the Law annual meeting options for psychiatrists to consider to protect themselves from potentially violent patients. It does recommend use of panic buttons but discusses multiple other considerations.

References:

Salter J. COVID-related attacks prompt hospital to issue panic buttons. AP News 2021; September 28, 2021

https://apnews.com/article/coronavirus-pandemic-business-covid-19-pandemic-missouri-springfield-397f9fca72155f35035df85c9f2e0941

Luke S. Broken Bed Alarm Blamed for Walkaway Patient's Death. Thomas Vera died after he became disoriented and walked away from his hospital room at UCSD Medical Center in May 2013. NBC San Diego 2014 Published September 15, 2014, Updated on September 16, 2014

https://www.nbcsandiego.com/news/local/broken-bed-alarm-allowed-patient-to-walk-from-hospital-die-report/93024/

Report No. 08-01380-154. Department of Veterans Affairs Office of Inspector General. Healthcare Inspection Alleged Patient Neglect During a Magnetic Resonance Imaging Exam Michael E. DeBakey VA Medical Center Houston, TX. Report No. 08-01380-154. June 27, 2008

http://www.va.gov/oig/54/reports/VAOIG-08-01380-154.pdf

Frieden J. Psychiatrists Have Lots of Options When it Comes to Office Security

— Consider both physical and non-physical measures. MedPage Today 2021; October 23, 2021

https://www.medpagetoday.com/meetingcoverage/aapl/95227

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Yet Another Risk During MRI

We’ve done many columns on adverse events occurring in the MRI suite, some of them directly related to the MRI scanner and others indirectly related.

Recently, ISMP (Institute for Safe Medication Practices) reported on a new type of event during MRI scanning (ISMP 2021). They reported on two patients inadvertently given opioid overdoses via PCA infusion systems during MRI. The two cases were similar. In each, because the PCA pump was not MRI-compatible, extension tubing was used so that the PCA pump could be located outside the MRI scanner room. Staff added several feet of extension sets to the PCA tubing and “primed” the tubing using the pump, which contained morphine in one case and HYDROmorphone in the other. Each patient became somnolent and had oxygen desaturation before any PCA doses were given.

In one case, the nurse noted this before leaving the MRI room and suspected morphine overdose. The patient was given supplemental oxygen and multiple doses of naloxone. It was calculated that the patient had received a bolus of approximately 56 mg of morphine in the “priming” fluid.

In the second case, the MRI scanning was performed and the patient was reported to be sleeping throughout the scan. When the patient was brought back to the nursing unit, his respirations were minimal and shallow, and the patient was barely conscious. The patient required multiple doses of IV naloxone before returning to his baseline status. Again, it was concluded that the patient had received an inadvertent bolus of opioid due to the extension tubing setup and priming.

ISMP made several recommendations for safer practices. They noted that the hospital adopted a policy of removing patients from PCA pumps prior to undergoing MRI. However, they noted this requires alternative pain management and monitoring during the time it takes to perform the MRI (which could take anywhere from 15 to 90 minutes to complete) plus any transport time. Alternatively, ISMP notes there are MRI-compatible infusion pumps and shielded PCA pump systems that could be used.

ISMP also notes the hospital could elect to send the PCA pump with the patient and utilize extension sets for a basal rate, supplemented by a nurse injecting the patient with a prescribed bolus dose of pain medication, as necessary.

ISMP also points out that, while the risks with PCA pumps in this scenario are most risky, similar risks apply to when patients are receiving infusions of other medications (eg. insulin, anticoagulants, vasopressors). So, it is incumbent upon hospitals to ensure all staff are aware of these issues and that appropriate policies and procedures are in place to manage such patients when going for MRI.

Some of our prior columns on patient safety issues related to MRI:

February 19, 2008 “MRI Safety”

March 17, 2009 “More on MRI Safety”
October 2008 “Preventing Infection in MRI”
March 2009 “Risk of Burns during MRI Scans from Transdermal Drug Patches”
January 25, 2011 “Procedural Sedation in Children”
February 1, 2011 “MRI Safety Audit”
October 25, 2011 “Renewed Focus on MRI Safety”
August 2012 “Newest MRI Hazard: Ingested Magnets”
October 22, 2013 “How Safe Is Your Radiology Suite?”
October 21, 2014 “The Fire Department and Your Hospital”
August 25, 2015 “Checklist for Intrahospital Transport”
August 2016 “Guideline Update for Pediatric Sedation”
October 2016 “MRI Safety: There’s an App for That!”
January 17, 2017 “Pediatric MRI Safety”
August 8, 2017 “Sedation for Pediatric MRI Rising”
March 2018 “MRI Death a Reminder of Dangers”
March 2018 “Cardiac Devices Safe During MRI But Spinners!?”
November 2018 “OMG! Not My iPhone!”
April 2, 2019 “Unexpected Events During MRI”
September 2019 “New MRI Hazard: Magnetic Eyelashes”
October 15, 2019 “Lots More on MRI Safety”
November 5, 2019 “A Near-Fatal MRI Incident”
November 2019 “ECRI Institute’s Top 10 Health Technology Hazards for 2020”
January 7, 2020 “Even More Concerns About MRI Safety”
March 2020 “Airway Emergencies in the MRI Suite”
October 2020 “New Warnings on Implants and MRI”
January 2021 “New MRI Risk: Face Masks”
June 1, 2021 “Stronger Magnets, More MRI Safety Concerns”

Some of our prior columns on patient safety issues in the radiology suite:

October 16, 2007 “Radiology as a Site at High-Risk for Medication Errors”
February 19, 2008 “MRI Safety”
September 16, 2008 “More on Radiology as a High Risk Area”
October 7, 2008 “Lessons from Falls....from Rehab Medicine”
October 2008 “Preventing Infection in MRI”

March 17, 2009 “More on MRI Safety”
March 2009 “Risk of Burns during MRI Scans from Transdermal Drug Patches”

August 11, 2009 “The Radiology Suite…Again!”
January 2010 “Falls in the Radiology Suite”
August 2010 “Sedation Costs for Pediatric MRI”
January 25, 2011 “Procedural Sedation in Children”

February 1, 2011 “MRI Safety Audit”
October 25, 2011 “Renewed Focus on MRI Safety”
March 13, 2012 “Medical Emergency Team Calls to Radiology”
August 2012 “Newest MRI Hazard: Ingested Magnets”
October 22, 2013 “How Safe Is Your Radiology Suite?”
February 25, 2014 “Joint Commission Revised Diagnostic Imaging Requirements”
July 2014 “New MRI Risks: for Staff!”
July 1, 2014 “Interruptions and Radiologists”
November 2014 “More Radiologist Interruptions”
October 21, 2014 “The Fire Department and Your Hospital”
June 23, 2015 “Again! Mistaking Antiseptic Solution for Radiographic Contrast”
August 25, 2015 “Checklist for Intrahospital Transport”
March 22, 2016 “Radiology Communication Errors May Surprise You”
August 2016 “Guideline Update for Pediatric Sedation”
October 2016 “MRI Safety: There’s an App for That!”
January 17, ,2017 “Pediatric MRI Safety”
August 8, 2017 “Sedation for Pediatric MRI Rising”
November 14, 2017 “Tracking C. diff to a CT Scanner”
March 2018 “MRI Death a Reminder of Dangers”
March 2018 “Cardiac Devices Safe During MRI But Spinners!?”
April 2018 “Radiologists Get Fatigued, Too”
May 2018 “Cost of Interrupting a Radiologist”
November 2018 “OMG! Not My iPhone!”
December 11, 2018 “Another NMBA Accident”
April 2, 2019 “Unexpected Events During MRI”
September 2019 “New MRI Hazard: Magnetic Eyelashes”
October 15, 2019 “Lots More on MRI Safety”
November 5, 2019 “A Near-Fatal MRI Incident”
November 12, 2019 “Patient Photographs Again Help Radiologists”
November 26, 2019 “Pennsylvania Law on Notifying Patients of Test Results”
January 7, 2020 “Even More Concerns About MRI Safety”
July 14, 2020 “A Thesis on Intrahospital Transports”
August 25, 2020 “The Off-Hours Effect in Radiology”

· October 2020 “New Warnings on Implants and MRI”

· January 2021 “New MRI Risk: Face Masks”

· May 25, 2021 “Yes, Radiologists Have Handoffs, Too”

June 1, 2021 “Stronger Magnets, More MRI Safety Concerns”

References:

ISMP (Institute for Safe Medication Practices). How will PCA be administered to patients during an MRI? ISMP NurseAdviseERR 2021; 19(9): 2-3 September 2021

https://www.ismp.org/nursing/medication-safety-alert-september-2021

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New Risk Factor for Patient Safety Events: Motor Vehicle Accidents

Kudos to Elizabeth Kukielka and the Pennsylvania Patient Safety Authority for uncovering a previously underrecognized risk factor for patient safety events – motor vehicle accidents!

Kukielka analyzed reports of patient safety events submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) related to motor vehicle crashes and identified 282 reports for analysis that occurred from 2018–2020 (Kukielka 2021). 13.1% of reports were classified as serious events (i.e., events that resulted in patient harm), a significantly higher percentage compared with that of the full acute care PA-PSRS database (2.9%). Most common were problems with monitoring or treatment (43.3%), problems with evaluation (18.4%), falls (11.7%), problems with documentation (7.4%), medication errors (7.4%), and problems with transfers (6.4%).

Kukielka notes that, when a patient who has experienced trauma in a motor vehicle accident presents to the emergency department, they may be unable to participate in their own care due to numerous factors, such as being unconscious, physically incapacitated, or suffering from confusion. In addition, her analysis showed other potential contributing factors:

communication breakdowns
lack of policies or protocols or unawareness about existing policies or protocols for treating certain patient populations
prioritization of conditions related to a motor vehicle crash over underlying health conditions

The latter category included numerous reports where a patient with a known underlying condition did not receive appropriate care for that condition while care for injuries related to the motor vehicle crash were ongoing. Examples included a patient with obstructive sleep apnea who did not receive treatment with CPAP or a patient with diabetes was not prescribed basal insulin.

About a quarter of the reports came from the emergency department. Kukielka cites other studies which noted contributing factors such as unavailability or limited access to key patient information, high workload, crowding, nonlinear patient flow, and unclear responsibility for patient sign-out or follow-up.

This study is an important contribution to the patient safety literature. It reveals both patient and system vulnerabilities that have previously flown “under the radar”.

References:

Kukielka E. Safety Events Impacting Hospitalized Patients Following Motor Vehicle Crashes: A Qualitative Study of Reports from Pennsylvania Hospitals. Patient Safety 2021; 3(3): 18-27 September 2021

https://patientsafetyj.com/index.php/patientsaf/article/view/motor-vehicle-crash

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When a Radiologist Recognizes He Committed an Error

We’ve done many columns on the importance of disclosure and apology when a medical error occurs. But most of those columns deal with errors by clinicians providing direct care to patients. What about errors that are made by physicians who may have no direct interaction with patients, for example, radiologist and pathologists?

Recently, it was asked “When you, as a radiologist, come across a significant finding (or findings) that you missed, what would you do or not do next and why?” (Lexa 2021). Answers from all four of the radiologists responding emphasized doing what’s best for the patient. All would immediately contact the ordering clinician and make them aware of the error. Some noted they would speak to the patient themselves if the error had no clinical consequence. Most would also discuss the error with their risk manager and were concerned about the particular wording that would be used in any communication with the patient.

We especially liked the response from Johns Hopkins’ David M. Yousem: “Right it, own it, learn from it, share it.” “Right it” meant calling the clinician and correcting reports with addendums, putting the patient’s well-being first. “Owning it” meant admitting the error and moving forward with humility. He would also make a call to risk management and “state the facts”. “Learn from it” meant trying to understand why the oversight occurred (eg. blind spot? distraction? fatigue? cognitive bias?, etc.) and making changes to avoid mistakes in the future. And “sharing it” meant helping others understand how such an error happened so they don’t make similar mistakes.

The scenario given with the above question was one where the radiologist reads a CT scan and finds significant pathology that needs emergent attention from the referring physician. But on reviewing the current study with one done just a few days earlier, he/she realizes he/she had missed the significant finding on that prior CT scan.

We’ve certainly seen cases where the timeframe between imaging studies is not so acute. Perhaps the most common scenario is when a patient has a CT scan that shows a large mass or an obvious metastatic lesion and review of a chest x ray or CT scan done a year ago actually shows the abnormality, albeit much smaller and more obscure at the time. In those cases, we always recommend that the patient (or family) be informed of the missed finding. Transparency is of the utmost importance. Such disclosure must be done with an apology that is truly sincere. Who makes the disclosure to the patient or family? Most often it is done with the clinician who has an established relationship with the patient. But that is not always possible. Sometimes a hospitalist has just begun caring for the patient and has no such established relationship. So, sometimes it is the medical director that delivers the disclosure. The radiologist who missed the original abnormality should be there at the time of disclosure. Showing contrition and concern for the patient helps the patient and family understand that we are human and make mistakes. We’ve certainly seen cases where patients and families have chosen not to take malpractice actions in that scenario. It is much easier to sue an individual or entity that does not “have a face”.

Unfortunately, most physicians are poorly prepared to such disclosure and apology. We strongly recommend that all healthcare organizations train their physician staffs on how to deal with such instances. There is nothing more powerful that having a physician who has been involved in such incidents share with others the thoughts and feelings he/she experienced in recognizing the error and communicating with the patient and family. Most often, that physician felt a certain amount of relief after the disclosure and it helps others understand that disclosure and apology may be the first step in a physician successfully dealing with his/her own infallibility.

See our many columns listed below for details on disclosure and apology and also on “communication and resolution” programs.

Some of our prior columns on Disclosure & Apology:

July 24, 2007 “Serious Incident Response Checklist”

June 16, 2009 “Disclosing Errors That Affect Multiple Patients”

June 22, 2010 “Disclosure and Apology: How to Do It”

September 2010 “Followup to Our Disclosure and Apology Tip of the Week”

November 2010 “IHI: Respectful Management of Serious Clinical Adverse Events”

April 2012 “Error Disclosure by Surgeons”

June 2012 “Oregon Adverse Event Disclosure Guide”

December 17, 2013 “The Second Victim”h

July 14, 2015 “NPSF’s RCA2 Guidelines”

June 2016 “Disclosure and Apology: The CANDOR Toolkit”