What’s New in the Patient Safety World

October 2012


·        More on Medical Errors in Children

·        Monitoring During Procedural Sedation in Children

·        Hyponatremia Predicts Surgical Complications

·        ISMP Canada: Another Look-Alike/Sound-Alike Issue

·        Another PCA Pump Safety Checklist




More on Medical Errors in Children



In our September 2012 What’s New in the Patient Safety World column “Canadian Paediatric Adverse Events Study” we discussed a study using a trigger tool to assess rates of adverse events in hospitalized pediatric patients in Canada (Matlow 2012). The overall rate of adverse events was 9.2%. The overall rate of adverse events was almost 3 times higher in the academic centers but this was largely driven by a higher rate of non-preventable adverse events.


A new study (Ahuja 2012) shows that the medical error rate in pediatric inpatients in the US is proportionate to the number of chronic conditions that the child has. Those researchers used the large KID (2006 Kids’ Inpatient Database) database and ICD-9-CM codes for iatrogenic medical errors. While the overall rate of medical errors was 3.0 per 100 discharges, there was a big disparity between rates for children with and without chronic conditions. For those without chronic conditions the rate was 1.3 per 100 discharges whereas for those with one or more chronic conditions it was 5.3 per 100 discharges. Moreover, the rates increased in proportion to the number of chronic conditions, though in the adjusted models this tended to level off somewhat once 3 chronic conditions were reached.


They also noted that the error rates were higher in urban hospitals, teaching hospitals, children’s hospitals, and general hospitals with children’s units. These hospitals also had higher numbers of patients with chronic conditions.


So how does this study mesh with the Canadian Paediatric Adverse Events Study? The adverse event rates were higher in the Canadian study. However, that largely reflects different methodologies and not measuring exactly the same things. The Canadian study utilized a trigger tool methodology, which has been shown to uncover many more events than seen in studies using administrative databases only. The use of ICD-9_CM coding for errors in the Ahuja study would be expected to pick up considerably fewer adverse events. So that latter study certainly does not imply that medical error rates are any lower in the US than in Canada.


But both studies add considerably to our knowledge base. The Canadian study also showed higher overall adverse event rates in teaching hospitals (though the higher rates were primarily in the nonpreventable category) and this may well be due to the higher percentage of patients with chronic illnesses at those hospitals as well. It certainly makes sense that patients who are sicker and on more complex medication regimens and interact with the healthcare system more often are probably going to be the most vulnerable to medical errors. We certainly see that in the adult population as well.








Matlow AG, Baker GR, Flintoft V, et al. Adverse events among children in Canadian hospitals: the Canadian Paediatric Adverse Events Study. CMAJ 2012; July 30, 2012 First published July 30, 2012, doi: 10.1503/cmaj.112153

July 30, 2012




Ahuja N, Zhao W, Xiang H. Medical Errors in US Pediatric Inpatients With Chronic Conditions. Pediatrics 2012; 130: e786-e793 Published online September 10, 2012






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Monitoring During Procedural Sedation in Children



In our January 25, 2011 Patient Safety Tip of the Week “Procedural Sedation in Children” we mentioned the Pediatric Sedation Research Consortium (PSRC). That’s a large collaborative group of institutions doing sedation for procedures in pediatrics who have come together to share data and foster research. They now have accumulated data on over 100,000 children undergoing sedation for procedures outside the operating room (including procedures such as MRI scans, lumbar punctures, bone marrow biopsies, endoscopies, etc.).


While the overall rates of serious adverse events have been relatively low, a new study from the PSRC (Langhan 2012) shows wide variation in compliance with monitoring guidelines during procedural sedation. Guidelines published by the American Academy of Pediatrics, American College of Emergency Physicians, and American Society of Anesthesiologists were adhered to in only 52% of procedures.


They noted tremendous variability between specialties in the monitoring used. Of particular concern, radiologists used pulse oximetry in only a third of cases and did not use any monitoring in about 40% of cases.


We’ve done numerous articles (see the list at the end of this article) on radiology as a high risk area for a variety of reasons, many of which are not directly related to radiology. But procedural sedation is one of the areas directly related to radiology personnel. What’s compliance with monitoring like in your radiology department?


We hope you’ll look at our extensive discussion on procedural sedation in our January 25, 2011 Patient Safety Tip of the Week “Procedural Sedation in Children”.



Some of our prior columns on procedural sedation:

·        May 25, 2010              “Propofol Issues”

·        August 2012                 “Sedation Costs for Pediatric MRI”

·        January 25, 2011          “Procedural Sedation in Children”

·        May 2011                    “Update on Pediatric Procedural Sedation”

·        August 2011                 “NEJM Video on Conscious Sedation for Minor Procedures in Adults”

·        October 2011              “The Procedural Sedation Debate Rages On”

·        April 2012                    “Problems with Ketofol”



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”

·        September 16, 2008     “More on Radiology as a High Risk Area”

·        October 7, 2008          “Lessons from Falls....from Rehab Medicine”

·        January 2010                “Falls in the Radiology Suite”

·        August 2010                 “Sedation Costs for Pediatric MRI”

·        January 25, 2011          “Procedural Sedation in Children”

·        February 19, 2008       “MRI Safety”







Langhan ML, Mallory M, Hertzog J, Lowrie L, Cravero J for the Pediatric Sedation Research Consortium. Physiologic Monitoring Practices During Pediatric Procedural Sedation. A Report From the Pediatric Sedation Research Consortium. Arch Pediatr Adolesc Med 2012;  Published online September 10, 2012





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Hyponatremia Predicts Surgical Complications



Over 20 years ago a group of hospitals in the WNY region collaborated with a local payer to see if we could predict outcomes in hospitalized patients based on readily available parameters such as lab test results (unpublished data). At the top of our list was serum sodium. Hyponatremia was a very good predictor of adverse outcomes in the hospitalized adult population. Subsequent published studies have demonstrated hyponatremia is a good predictor of mortality, length of stay and overall costs.


Now a new study (Leung 2012) shows that preoperative hyponatremia in patients undergoing surgery predicts higher 30-day mortality and more numerous complications, including wound infections, perioperative cardiovascular events, and pneumonia. After adjustment for confounding factors, length of stay in patients with preoperative hyponatremia is also about a day longer.


Perhaps the most interesting finding was that the risks were increased the most in patients undergoing nonemergent surgery and those in the lowest ASA classes, hence patients who would ordinarily be considered less risky.


The debate is around whether the hyponatremia is simply a marker of higher risk or is somehow causally related to the adverse outcomes. Most likely it is simply a marker of higher risk. Hyponatremia is commonly seen in patients with multiple comorbidities (including conditions like heart failure, chronic liver or kidney disease, cancer, etc.) and patients on multiple medications.


Of course, what is not known is whether correction of the hyponatremia preoperatively reduces these excess risks. That would require a randomized controlled trial of considerable magnitude and complexity (since the etiology and management of hyponatremia is quite diverse).


As we’ve pointed out on numerous occasions, screening for risk factors may be important from a prognostic standpoint but really adds little other than cost if you don’t have interventions that are shown to reduce that excess risk.







Leung AA, McAlister FA, Rogers SO, et al. Preoperative Hyponatremia and Perioperative Complications. Arch Intern Med 2012; Published online September 10, 2012






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ISMP Canada: Another Look-Alike/Sound-Alike Issue



ISMP Canada this month has a good article about another look-alike/sound-alike (LASA) drug mixup, this time between bisoprolol and bisacodyl (ISMP Canada 2012). The former drug is a beta blocker and the latter a stimulant laxative so mixups between these two drugs can have potentially significant consequences for patients. They analyzed not only the index case reports but found 32 such mixups involving this drug pair in their database. The article is worth reading not just from the standpoint of this specific LASA pair but provides good information on how LASA errors are enabled at each stage of the medication process.


They cover such issues as the need to spell out the drug name rather than just repeating the name when receiving a verbal order, handwriting legibility errors, lack of including indication for use, choosing adjacent drugs from drop-down lists, using drug mnemonic codes that are confusing, failure to recognize unusual dosages, failure to recognize that “prn” use of the beta-blocker would be inappropriate, storage of such medications in proximity (particularly if purchased from the same vendor there may be further similarities in packaging and labeling), and failure to involve the patient or caregiver in the medication administration process.


They have a good discussion on how confirmation bias increases the likelihood of many LASA errors.


Read the article and then make sure your systems incorporate the suggested interventions to prevent such mixups in your facilities, not just for this particular LASA pair but for LASA pair mixups in general.






ISMP Canada. Concerned Reporting: Mix-ups Between Bisoprolol and Bisacodyl. ISMP Canada Safety Bulletin 2012; 12(9): 1-6  August 30, 2012







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Another PCA Pump Safety Checklist



In our February 21, 2012 Patient Safety Tip of the Week “Improving PCA Safety with Capnography” we mentioned that the Physician-Patient Alliance for Health & Safety (PPAHS) had a workgroup addressing PCA safety. On their website are some heart-wrenching stories about patients who died during PCA, likely as a result of inadequate monitoring. We said we look forward to seeing that checklist when it is ready. Well, the PPAHS has now released that checklist for PCA pump safety (PPAHS 2012). Their website not only has the link to the PCA Safety Checklist itself but also links to several columns and blogs regarding PCA safety, PCA hazards, monitoring, capnography, etc. These are excellent resources.


Another excellent resource on PCA safety is the San Diego Patient Safety Council and the San Diego Patient Safety Taskforce, which put together a tool kit for PCA safety. It is a comprehensive document that discusses assessment for PCA appropriateness, distinction between opioid naοve and opioid tolerant patients, PCA patient education, pain assessment, sedation assessment, respiratory assessment, monitoring, adjuvant therapies (eg. for treating side effects of opioid therapy such as constipation, nausea and vomiting, pruritis), multimodal pain management strategies, standardized order sets, and specific issues related to equipment and products.


In our May 17, 2011 Patient Safety Tip of the Week “Opioid-Induced Respiratory Depression – Again!” we encouraged hospitals to perform their own FMEA (Failure Mode and Effects Analysis) on the PCA process and provided links to two tools we use when doing FMEA’s of the PCA pump process: the PCA Pump Audit Tool and the PCA Pump Criteria.  And we hope that you’ll go back and look at the string of recommendations we made in our September 6, 2011 Patient Safety Tip of the Week “More Tips on PCA Safety”. We think you will find them extremely helpful. And don’t forget that most of the issues pertaining to patients on PCA pumps apply also to patients receiving postoperative opioids by other routes.



Other Patient Safety Tips of the Week pertaining to opioid-induced respiratory depression and PCA safety:








PPAHS (Physician-Patient Alliance for Health & Safety)




PPAHS (Physician-Patient Alliance for Health & Safety). Physician-Patient Alliance for Health & Safety Announces New Expert Checklist for Facilitating Safety of Hospital-Based Intravenous Patient-Controlled Analgesia Pumps. July 17, 2012




PPAHS. PCA Safety Checklist.




San Diego Patient Safety Taskforce. Tool Kit: Patient Controlled Analgesia (PCA) Guidelines of Care for the Opioid Naοve Patient. Published: December 2008







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Print “October 2012 What's New in the Patient Safety World (full column)”

Print “October 2012 More on Medical Errors in Children”

Print “October 2012 Monitoring During Procedural Sedation in Children”

Print “October 2012 Hyponatremia Predicts Surgical Complications”

Print “October 2012 ISMP Canada: Another Look-Alike/Sound-Alike Issue”

Print “October 2012 Another PCA Pump Safety Checklist”













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