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 Fluids” and
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 Disrespect” and 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:
- June 19, 2007 “Unintended
Consequences of Technological Solutions”
- May 20, 2008 “CPOE
Unintended Consequences – Are Wrong Patient Errors More Common?”
- June 17, 2008 “Technology
Workarounds Defeat Safety Intent”
- August 26, 2008 “Pattern
Recognition and CPOE”
- September 9, 2008 “Less
is More….and Do You Really Need that Decimal?”
- December 16, 2008 “Joint
Commission Sentinel Event Alert on Hazards of Healthcare IT”
- February 2009 “Healthcare
IT The Good and The Bad”
- October 2009 “A
Cautious View on CPOE”
- November 24, 2009 “Another
Rough Month for Healthcare IT
- April 20, 2010 “HIT’s
Limited Impact on Quality To Date”
- March
22, 2011 “An
EMR Feature Detrimental to Teamwork and Patient Safety”
- June
26, 2012 “Using
Patient Photos to Reduce CPOE Errors”
- June 2012 “Leapfrog
CPOE Simulation: Improvement But Still Shortfalls”
- July 17, 2012 “More
on Wrong-Patient CPOE”
- January 2013 “More
IT Unintended Consequences”
- October 8, 2013 “EMR
Problems in the ED”
- March 11, 2014 “We
Miss the Graphic Flowchart!”
References:
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
http://www.texashealth.org/blank.cfm?print=yes&id=1629&action=detail&ref=1871
Clarification from Texas Health Resources, Oct. 3, 9 p.m.
CDT
10/03/2014
http://www.texashealth.org/body.cfm?id=1629&action=detail&ref=1872
Hripcsak G, Vawdrey
DK, Fred MR, Bostwick SB.
Use of electronic clinical documentation: time spent and team interactions.
JAMIA 2011;18:112-117
http://jamia.bmj.com/content/18/2/112.abstract
Benson L. Minnesota hospitals lock down details as they
prepare for Ebola threat. MPR News October 3, 2014
http://www.mprnews.org/story/2014/10/03/mn-ebola-preparations
Allen A. Did computer raise Ebola spread risk? Politico.com
October 5, 2014
http://www.politico.com/story/2014/10/ebola-texas-electronic-records-111598.html?hp=r3
Print “October
2014 Ebola Exposes Fundamental Flaw”
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.
References:
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
http://archinte.jamanetwork.com/article.aspx?articleid=1906998
Najafi N. A Call for
Evidence-Based Telemetry Monitoring: The Beep Goes On. JAMA Intern Med 2014;
published online first September 22, 2014
http://archinte.jamanetwork.com/article.aspx?articleid=1906997&resultClick=3
Najafi N, Auerbach
A. Use and Outcomes of Telemetry Monitoring on a Medicine Service. Arch Intern
Med 2012; 172(17): 1349-1350
http://archinte.jamanetwork.com/article.aspx?articleid=1309575&resultClick=3
Print “October
2014 Alarm Fatigue: Reducing Unnecessary Telemetry Monitoring”
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”
References:
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
http://onlinelibrary.wiley.com/doi/10.1002/nur.21503/abstract
Townsend T, Anderson
P. Are extended work hours worth the risk? Am Nurs Today 2013; 8(5): 8-11 May 2013
http://www.americannursetoday.com/article.aspx?id=10272&fid=10226
Print “October
2014 Another Rap on the 12-Hour Nursing Shift”
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”
References:
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
http://www.ejbjs.org/cgi/content/abstract/91/9/2067
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
http://www.americanjournalofsurgery.com/article/S0002-9610%2814%2900438-3/abstract
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
http://www.ncbi.nlm.nih.gov/pubmed/18376202?dopt=Abstract
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.
http://www.journalacs.org/article/S1072-7515%2809%2900507-9/abstract
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2014 What Time of Day Do You Want Your Surgery?”
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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?”
Print “October
2014 What's New in the Patient Safety World (full
column in PDF version)”
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