What’s New in the Patient Safety World

October 2014



·         Ebola Exposes Fundamental Flaw

·         Alarm Fatigue: Reducing Unnecessary Telemetry Monitoring

·         Another Rap on the 12-Hour Nursing Shift

·         What Time of Day Do You Want Your Surgery?





Ebola Exposes Fundamental Flaw



There has been considerable attention to the fact that the recent Ebola patient in Dallas had been seen in the ER and sent home a few days prior to the admission in which Ebola was diagnosed. Undoubtedly, a root cause analysis of this case would likely reveal multiple contributing factors. But, in fact, a fundamental flaw in our “advanced” healthcare system played a huge role, predictably so.


The hospital released a statement about this issue (Texas Health Resources 2014). It indicated that the intake nurse in fact had recorded in the hospital’s electronic medical record that the patient had recently traveled to Africa. But it also noted that their electronic medical record had two workflows: one for nurses and one for physicians and that the travel history recorded by the nurse would not automatically appear in the physician’s workflow. Presumably the physician was unaware of the travel history (the implication was that he/she did not see the nurse’s note and presumably did not take a travel history him/herself) and discharged the patient from the ER on antibiotics.


(Note that the hospital, a day after its initial statement, provided a “clarification”: “As a standard part of the nursing process, the patient's travel history was documented and available to the full care team in the electronic health record (EHR), including within the physician’s workflow. There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event.” This clarification did not mention whether the physician actually accessed that screen in the EHR that contained the travel information.)


Our March 22, 2011 Patient Safety Tip of the Week “An EMR Feature Detrimental to Teamwork and Patient Safety” addressed this very issue. Researchers (Hripcsak 2011) used the detailed audit logs of EMR’s to determine the frequency of notes by various members of the healthcare team, the time spent entering such notes, the frequency with which those notes were accessed, and the distribution of types of healthcare workers accessing those notes. They found that while attending notes and resident notes were viewed 97% and 99% of the time, such was not the case for notes authored by other members of the healthcare team. In particular, fewer than 20% of nursing notes were read by attendings and residents and only 38% of nursing notes were read by other nurses. Note that nurses have several other means of communicating with each other (standardized handoffs, etc.). And 16% of all notes were never read by anyone!


This seems like a journey into the past! For the longest time, hospitals were divided in how they partitioned the paper medical chart. Some hospitals kept notes by physicians, consultants, nurses, therapists, dietitians, etc. segregated from each other whereas other hospitals intermingled all the notes in the “progress note” section. We can recall medical staff meetings where some disgruntled physicians indignantly ranted “I’m not interested in seeing the *#!& social work note”. Generally, as the value of teamwork became increasingly appreciated and a culture of safety adopted, most organizations migrated toward the “intermingled” model.


But with the advent of the EMR we have seen a regression back to the “partitioned” model. The statistics above mean that most physicians seldom read notes by anyone other than physicians. This applies not only to nurses’ notes but also to a host of other useful tools (eg. vital sign flow charts, I&O charts, face sheets, etc.) no longer readily or easily accessible in the EMR (see our Patient Safety Tips of the Week for August 26, 2008 “Pattern Recognition and CPOE”, December 29, 2009 “Recognizing Deteriorating Patients”, September 11, 2012 “In Search of the Ideal Early Warning Score”, May 28, 2013 “The Neglected Medications: IV Fluidsand March 11, 2014 Patient Safety Tip of the Week “We Miss the Graphic Flowchart!”). No wonder we have so many adverse events where communication breakdowns are identified as root causes or contributory factors.


Some of the problem may be related to the relative “newness” of the EMR. Most EMR’s do allow some degree of customization of what is displayed and how and where it is displayed. So a user might choose to keep all clinical notes together or to sort them by provider type. In some cases, the “default” setting is the partitioned one and the physician may not even realize he/she can choose the intermingled model.


But the basic problem usually lies in the design of the EMR. Quite frankly, most EMR design has lacked adequate input from clinicians and other healthcare workers with a full understanding of both workflow issues and safety issues. Most current EMR’s typically require the user to click into one progress note, then click out, search for another note and click into that note. That obviously reduces the likelihood that one user will look at the notes from other members of the healthcare team.


But let’s not just place the blame on IT here. The problem is as much a cultural issue as an IT issue. As noted above and several prior columns (see our What’s New in the Patient Safety World columns for January 2011 “No Improvement in Patient Safety: Why Not?” and July 2012 “A Culture of Disrespectand our March 29, 2011 Patient Safety Tip of the Week “The Silent Treatment: A Dose of Reality”), too many healthcare workers don’t respect the work done by other healthcare workers. We suspect that even in those old paper-based charts that had intermingled notes many physicians probably ignored many of the notes by other healthcare workers (though less so than when the paper charts had “partitioned” sections).


One other unintended consequence of healthcare IT is that it has reduced face-to-face communication between healthcare workers. Today a doctor and nurse taking care of the same patient sometimes don’t even have a single face-to-face conversation about that patient. So much is done on the computer and we often, incorrectly, assume that the other party has read our notes and knows what we are thinking.


Aside from the impact on teamwork and quality and patient safety, think of the potential liability issues from failure to read nursing notes on your patients. “Doctor, why didn’t you know the patient was complaining about ___? The nurse’s notes clearly state he complained about ___ daily.” Try explaining that to a jury in a malpractice hearing! The plaintiff’s lawyers will have a heyday when you try to explain it was the EMR’s fault. They love getting the hospital and physician to point fingers at one another.


For those of you out there saying “not my EMR!” we encourage you to use the audit tools built into your EMR and see how often physicians (or others) access the nurses’ notes or other important notes and documents. We suspect you’ll be unpleasantly surprised that your results are similar to those in the Hripcsak study.


We also encourage you to take a look at the way clinical documentation is displayed in your EMR and whether you can change that display. Also assess the number of clicks necessary to get from one area of the EMR to another and you’ll find these are a significant barrier to sharing of information.


The full potential benefit of the EMR on patient safety has yet to be realized in most organizations and has often introduced unintended consequences. The recent Ebola case is but one example of such unintended consequences.


The EHR could and should be used to facilitate identification and appropriate management of such patients. At least two medical centers, Hennepin County Medical Center (Benson 2014) and Mt. Sinai Hospital in NYC (Allen 2014) have created flags that will trigger for such patients so there's an alert on that patient when their chart is opened or will alert the staff to begin isolation on that patient. Hopefully, the lessons learned from the Ebola case in Texas will be used by other healthcare systems to avoid similar problems in the future.



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







Texas Health Resources. News Release. Ebola Update. Texas Health Presbyterian Hospital Dallas. Report on Events Related to Ebola Diagnosis. Texas Health Resources. News Release. Ebola Update, Oct. 2, 8:35 p.m. CDT 10/02/2014




Clarification from Texas Health Resources, Oct. 3, 9 p.m. CDT




Hripcsak G, Vawdrey DK, Fred MR, Bostwick SB. Use of electronic clinical documentation: time spent and team interactions. JAMIA 2011;18:112-117




Benson L. Minnesota hospitals lock down details as they prepare for Ebola threat. MPR News October 3, 2014




Allen A. Did computer raise Ebola spread risk? Politico.com October 5, 2014






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Alarm Fatigue: Reducing Unnecessary Telemetry Monitoring



In our July 2, 2013 Patient Safety Tip of the Week “Issues in Alarm Management” we noted that telemetry is one technology we often see overutilized in many hospitals, which may contribute to alarm fatigue. When we discuss alarm management strategies with hospitals one of the first areas of focus we recommend is telemetry, particularly that occurring outside ICU’s. The American Heart Association and American College of Cardiology (AHA/ACC) have published guidelines on telemetry monitoring and suggested criteria. Yet many hospitals have never developed local guidelines to help identify which patients should be monitored (and which should not). Moreover, criteria for continued monitoring are extremely important because all too often a physician orders telemetry and it gets continued indefinitely. Getting your physician staff involved early in developing your telemetry criteria is the key.


Researchers at Christiana Care Health System successfully implemented a system that significantly reduced unnecessary non-ICU telemetry and achieved substantial financial savings while not adversely impacting patient safety (Dressler 2014). A multidisciplinary team designed the program and ensured appropriate training of impacted departments. The key component was hardwiring the AHA guidelines into their electronic ordering system. Providers were now required to choose an indication from a list, each of which included a duration based upon the AHA guidelines. In addition, they removed telemetry orders from order sets for conditions where monitoring was not supported by the AHA guidelines. Also, guidelines were established for automatic discontinuation of telemetry monitoring.


After implementation there was a 70% reduction in the mean daily number of patients being monitored by telemetry. The mean weekly number of telemetry orders dropped 43% and the mean duration of telemetry dropped by 47%. They assessed for potential impact on patient safety and found no worsening of mortality, code blues, or rapid response team activations. Their mean daily cost for non-ICU telemetry decreased from $18,971 to $5,772, with a projected annual savings of $4.8 million. Undoubtedly, this also had a beneficial effect on the phenomenon of alarm fatigue, though they had no specific measure of the latter.


Commentary on the study points out that the AHA guidelines were primarily aimed at patients with cardiac diagnoses so their appropriateness for non-ICU patients with non-cardiac diagnoses is not fully understood (Najafi 2014). Najafi had previously done a study (Najafi 2012) of telemetry use in patients admitted to a medical service with non-cardiac diagnoses and found very few patients had meaningful telemetry events or events that led to a change in management.


This excellent work by Christiana Care Health System demonstrates that such a focus on unnecessary telemetry monitoring can lead to significant financial savings without sacrificing patient safety and likely reducing alarm fatigue.






Dressler R, Dryer MM, Coletti C, et al. Altering Overuse of Cardiac Telemetry in Non–Intensive Care Unit Settings by Hardwiring the Use of American Heart Association Guidelines. (Research Letter). JAMA Intern Med 2014; published online first September 22, 2014




Najafi N. A Call for Evidence-Based Telemetry Monitoring: The Beep Goes On. JAMA Intern Med 2014; published online first September 22, 2014




Najafi N, Auerbach A. Use and Outcomes of Telemetry Monitoring on a Medicine Service. Arch Intern Med 2012; 172(17): 1349-1350








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Another Rap on the 12-Hour Nursing Shift



Since our original November 9, 2010 Patient Safety Tip of the Week “12-Hour Nursing Shifts and Patient Safety” we’ve discussed the pros and cons of the 12-hour work shift as they relate to both healthcare and other industries. We concluded that the literature to date really did not answer the question as to whether those shifts had a detrimental impact on patient safety or patient outcomes. In several subsequent columns (see list at the end of today’s column) we discussed some evidence suggesting a detrimental impact of such hours on patient care and satisfaction as well as a longer term negative impact on nurses’ satisfaction.


The fundamental question should be “Is there evidence that the 12-hour nursing shift results in more patient harm or worse patient outcomes than the more traditional 8-hour shift?” And, because no studies have been done allowing direct comparison of care rendered via the two scheduling patterns and eliminating potential confounding factors, we still cannot confidently answer that question.


There are some features of the 12-hour shift that we like because they could at least theoretically improve patient safety. These include fewer handoffs and a reduction in the consecutive day phenomenon” (see our July 29, 2014 Patient Safety Tip of the Week “The 12-Hour Nursing Shift: Debate Continues”). But these must be balanced against the negative influence of worker fatigue that may worsen patient safety.


A previous survey of nurses in the US (Stimpfel 2013) suggested a detrimental impact of such extended work hours on patient care. Now another nursing survey has linked prolonged nursing shifts to problems in quality and patient safety. Griffiths and colleagues for the RN4CAST Consortium (Griffiths 2014) reported the results of a survey of over 30,000 RN’s in general med/surg units at 488 European hospitals. Nurses working shifts of 12 hours or more were more likely to perceive poor or failing patient safety, poor or fair quality of care, and more care activities being left undone. Working overtime, regardless of shift length, was also associated with nurses’ perception of poor or failing patient safety, poor or fair quality of care, and more care activities being left undone.


Though this was a survey that relied on nurse self-reported responses, previous studies have validated that such nurses’ perceptions correlate with actual patient safety and quality measures (McHugh 2012).


12-hour shifts are not yet as common in most European countries compared to the US. In the US the most common shift length in a survey was 12-13 hours, worked by 65% of nurses responding (Stimpfel 2013) and another paper put that number at 75% (Townsend 2013). In contrast, only 15% of nurses in the current survey of European hospitals worked shifts of 12 or more hours. That did, however, vary by country. Less than 5% of nurses responding in Belgium, Germany, Greece, The Netherlands, Norway and Sweden worked shifts of 12 hours or more whereas in Ireland and Poland such shifts were worked 73% of the time and in England such shifts accounted for about a third of shifts.


But there are questions left unanswered by this and all previous studies. The Griffiths study did not distinguish between nurses who chose to work 12-hour shifts vs. those for whom it was mandated. Given the correlation between overtime and nurses’ perceptions of suboptimal quality and patient safety, one might anticipate that the degree of discomfort nurses have with their shift length may be an important contributory factor.


Because the 12-hour shift has become so popular in the US, both with nurses and hospitals, it will likely take compelling evidence to cause reversion to shorter shifts. The majority of nurses we know like the 12-hour shift because of its flexibility and that it allows them to spend more time with their families and other activities outside the hospital. But it is this very personal preference that would make it very difficult for the ultimate study on this issue – a randomized controlled trial (RCT) – to be performed. Probably the only way to do such a quasi-RCT would be to take a sizeable hospital with multiple wards handling comparable patients and then make half the units 8-hour shift units and the others 12-hour shift units, letting nurses choose which unit they want to work on. Objective quality and patient safety outcomes would have to be measured in addition to nurses’ impressions of care. Such a study would probably still be subject to selection bias. Given the hospital nursing shortages in the US it would be very difficult to adjust results for the occurrence of overtime.


This is a critically important issue in quality and patient safety. But conclusive answers are not yet available. In the interim see some of our prior columns regarding strategies to mitigate nurse fatigue and also our columns on the impact of fatigue in healthcare and other industries and use of strategies such as power naps.



Our previous columns on the 12-hour nursing shift:


November 9, 2010      12-Hour Nursing Shifts and Patient Safety

February 2011             Update on 12-hour Nursing Shifts

November 13, 2012    The 12-Hour Nursing Shift: More Downsides

July 29, 2014               The 12-Hour Nursing Shift: Debate Continues



Some of our other columns on the role of fatigue in Patient Safety:


November 9, 2010      12-Hour Nursing Shifts and Patient Safety

April 26, 2011             Sleeping Air Traffic Controllers: What About Healthcare?

February 2011             Update on 12-hour Nursing Shifts

September 2011          Shiftwork and Patient Safety

November 2011          Restricted Housestaff Work Hours and Patient Handoffs

January 2010               Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety

January 3, 2012           Unintended Consequences of Restricted Housestaff Hours

June 2012                    June 2012 Surgeon Fatigue

November 2012          The Mid-Day Nap

November 13, 2012    The 12-Hour Nursing Shift: More Downsides

July 29, 2014               The 12-Hour Nursing Shift: Debate Continues



Some of our other columns on housestaff workhour restrictions:


December 2008           IOM Report on Resident Work Hours

February 26, 2008       Nightmares: The Hospital at Night

January 2010               Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety

January 2011               No Improvement in Patient Safety: Why Not?

November 2011          Restricted Housestaff Work Hours and Patient Handoffs

January 3, 2012           Unintended Consequences of Restricted Housestaff Hours

June 2012                    Surgeon Fatigue

November 2012          The Mid-Day Nap

December 10, 2013     Better Handoffs, Better Results

April 22, 2014             Impact of Resident Workhour Restrictions







Stimpfel AW, Aiken LH. Hospital Staff Nurses' Shift Length Associated With Safety and Quality of Care. Journal of Nursing Care Quality 2013; 28(2): 122-129




Griffiths P, Dall’Ora C, Simon M, et al. Nurses' Shift Length and Overtime Working in 12 European Countries: The Association With Perceived Quality of Care and Patient Safety. Medical Care 2014; published online September 15, 2014




McHugh MD, Stimpfel AW. Nurse reported quality of care: A measure of hospital quality. Res Nurs Health. 2012; 35(6): 566–575; Article first published online: 21 AUG 2012




Townsend T, Anderson P. Are extended work hours worth the risk? Am Nurs Today 2013; 8(5): 8-11 May 2013





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What Time of Day Do You Want Your Surgery?



We’ve done a number of columns that seem to indicate the day of the week or the time of day may impact outcomes for some surgeries and other procedures. Most of those columns have been on the “weekend effect”, in which patients admitted on weekends tend to have worse outcomes than those admitted during “normal” daytime hours. We also often use the term “after hours effect” since some of the same issues occur in patients admitted at night.


The reasons for the phenomena are multifactorial and include both patient-related factors, which we can’t do much about, and system-related factors, which offer considerable opportunity for improvement (see our November 2013 What’s New in the Patient Safety World column “The Weekend Effect: Not One Simple Answer” and the list of our other prior columns at the end of today’s column).


In our September 2009 What’s New in the Patient Safety World column After-Hours Surgery – Is There a Downside?” we discussed an article on adverse outcomes associated with doing certain types of orthopedic surgery after hours (Ricci 2009). We think the issues raised are significant to almost every type of surgery, not just orthopedic surgery. Surgery in the “after hours” group was associated with an increased need for reoperations for removal of painful fracture hardware.


Now a new study has looked at laparoscopic cholecystectomies done at night compared to daytime (Wu 2014). The authors note that there has long been debate about the urgency of laparoscopic cholecystectomy for acute cholecystitis. They hypothesized that doing such surgeries urgently at night would result in a decreased length of stay. But they found that the length of stay and complication rates were no different between those done at night and those done during daytime hours. However, nighttime cholecystectomy was associated with a higher conversion rate to open cholecystectomy (11% vs 6%). They discuss potential contributory issues but conclude that laparoscopic cholecystectomy for acute cholecystitis should be delayed until normal working hours.


Previous studies by Kelz and colleagues have shown increased morbidity in non-emergent surgical cases done “after hours”, one in the VA system (Kelz 2008)

and another in a private hospital setting (Kelz 2009).


Why should nighttime surgery be more prone to adverse outcomes than daytime surgery? When you think about it, there are many reasons aside from the fact that patients needing emergency nighttime surgery are generally sicker. You are operating with a team that is likely different from your daytime team. All members of that team (physicians, nurses, anesthesiologists, techs, etc.) may not have the same level of expertise as your regular daytime team and the team dynamics between members is likely to be different. The post-surgery recovery unit is likely to be staffed much differently after-hours as well. The staff may be more likely to be unfamiliar with things like location of equipment. And some of the other hospital support services (eg. radiology, laboratory) may have lesser staffing after-hours. Just as importantly, many or all of the “on-call” staff that make up the after-hours surgical team have likely worked a full daytime shift that day so fatigue enters as a potential contributory factor. And there are always time pressures after hours as well. Our February 26, 2008 Patient Safety Tip of the Week “Nightmares….The Hospital at Night” discussed other adverse events occurring after hours in hospitals as well as in other industries and talked about the many potential contributory factors.


However, one of the most compelling reasons surgery is done at night rather than deferred to the next morning is the surgeon’s schedule for that next morning (either in surgery or his/her office). Because the surgeon does not want to disrupt that next day schedule, he/she often prefers to go ahead with the current case at night. Similarly, many hospitals run very tight OR schedules and adding a case from the previous night can disrupt the schedule of many other cases.


We highly recommend hospitals take a hard look at surgical cases done “after hours”. In particular, you need to determine which cases truly needed to be done after hours and, perhaps more importantly, which ones could have and should have been done during “regular hours”. If the latter are significant, you need to consider system changes such as reserving some “regular hours” for such cases to be done the following morning. You may have to alter the scheduling of cases for individual surgeons as well. For example, perhaps the surgeon on-call tonight should not have elective cases scheduled tomorrow morning. That way, if a case comes in tonight that should be done tomorrow morning you will have both a “free” OR room and a “free” surgeon. And you would need to develop a list of criteria to help you triage cases into “regular” or “after-hours” time slots.


When we reviewed the Ricci paper we said we hoped that other researchers would take the lead and do similar studies for other types of surgery (and help develop the criteria for which cases could be delayed to daytime hours). Wu and colleagues have done just that. We need to keep in mind that the studies by Ricci, Wu, and Kelz were not randomized controlled trials but rather retrospective reviews. Lacking randomized controlled trials that demonstrate improved outcomes by deferring such cases to the next morning means we can’t apply a solid evidence-based approach at this time. But sometimes common sense needs to be applied while waiting for such studies to be done. At least take a look at the experience at your own hospital. We bet you’ll be surprised by the findings.





Some of our previous columns on the “weekend effect:

·         February 26, 2008     Nightmares….The Hospital at Night

·         December 15, 2009   The Weekend Effect

·         July 20, 2010             More on the Weekend Effect/After-Hours Effect

·         October 2008             Hospital at Night Project

·         September 2009         After-Hours Surgery – Is There a Downside?

·         December 21, 2010   More Bad News About Off-Hours Care

·         June 2011                  Another Study on Dangers of Weekend Admissions

·         September 2011         Add COPD to Perilous Weekends

·         August 2012              More on the Weekend Effect

·         June 2013                  Oh No! Not Fridays Too!

·         November 2013         The Weekend Effect: Not One Simple Answer

·         August 2014              The Weekend Effect in Pediatric Surgery






Ricci WM, Gallagher B, Brandt A, Schwappach J, Tucker M, Leighton R. Is After-Hours Orthopaedic Surgery Associated with Adverse Outcomes? A Prospective Comparative Study. J Bone Joint Surg Am. 2009; 91: 2067-2072




Wu JX, Nguyen AT, de Virgilio C, et al. Can it wait until morning? A comparison of nighttime versus daytime cholecystectomy for acute cholecystitis. Amer J Surg 2014; published online first September 20, 2014




Kelz, R.R., Freeman, K.M., Hosokawa, P.W. et al. Time of day is associated with postoperative morbidity: an analysis of the national surgical quality improvement program data. Annals of Surgery 2008; 247: 544–552




Kelz RR, Tran TT, Hosokawa P, et al. Time-of-day effects on surgical outcomes in the private sector: a retrospective cohort study. J Am Coll Surg 2009; 209(4): 434-445.e2.






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Print “October 2014 What's New in the Patient Safety World (full column)

Print “October 2014 Ebola Exposes Fundamental Flaw

Print “October 2014 Alarm Fatigue: Reducing Unnecessary Telemetry Monitoring

Print “October 2014 Another Rap on the 12-Hour Nursing Shift

Print “October 2014 What Time of Day Do You Want Your Surgery?



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Tip of the Week Archive


What’s New in the Patient Safety World Archive