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In September, IHI (Institute
for Healthcare Improvement) released Safer Together: A National Action Plan to
Advance Patient Safety. This report was the culmination of collaboration among
27 national organizations committed to advancing patient safety, with input
from all relevant stakeholder groups, including patient and family advocates.
The National Action
Plan has 17 recommendations to advance patient safety in 4 categories:
Culture, Leadership,
and Governance
1. Ensure safety is a demonstrated core value.
2. Assess capabilities and commit resources to
advance safety.
3. Widely share information about safety to
promote transparency.
4. Implement competency-based governance and
leadership.
Patient and Family Engagement
5. Establish competencies for all health care professionals
for the engagement of patients, families, and care partners.
6. Engage patients, families, and care partners
in the co-production of care.
7. Include patients, families, and care partners
in leadership, governance, and safety and improvement efforts.
8. Ensure equitable engagement for all patients,
families, and care partners.
9. Promote a culture of trust and respect for
patients, families, and care partners.
Workforce Safety
10. Implement a systems approach to workforce
safety.
11. Assume accountability for physical and
psychological safety and a healthy work environment that fosters the joy of the
health care workforce.
12. Develop, resource, and execute on priority
programs that equitably foster workforce safety.
Learning System
13. Facilitate both intra- and
inter-organizational learning.
14. Accelerate the development of the best
possible safety learning networks.
15. Initiate and develop systems to facilitate
interprofessional education and training on safety.
16. Develop shared goals for safety across the
continuum of care.
17. Expedite industry-wide coordination,
collaboration, and cooperation on safety.
From the IHI site you can download the plan plus an implementation resource guide and a
self-assessment tool.
The focus on
workforce safety is timely, in view of the COVID-19 pandemic, and addresses not
only the physical well-being of our healthcare workers but also the
psychological and emotional health issues, including burnout.
And, of course, it
also emphasizes a need we have long advocated: the need to share lessons
learned on a much wider scale.
References:
IHI (Institute for
Healthcare Improvement). National Action Plan to Advance Patient Safety.
IHI 2020
Print October 2020 IHIs National Action Plan to
Advance Patient Safety
We often do talks on
the adverse effects of low-value care and how such can lead to the diagnostic
cascade and injuries to patients. One of our favorite examples is pre-op
testing prior to cataract surgery. Most patients undergoing cataract surgery do
not need any pre-op testing because it neither decreases the incidence of
perioperative adverse events nor improves cataract surgery outcomes. Yet pre-op
testing continues to be surprisingly frequent.
We often cite an
article by Ganguli et al. (Ganguli
2019) that care cascades after preoperative EKG for cataract surgery can be
costly. Of those who had a pre-op EKG, 15.9% had at least 1 potential cascade
event. Those included more tests, cardiology visits, and treatment. Spending
for the additional services was up to $565 per Medicare beneficiary, or an
estimated $35,025,923 annually across all Medicare beneficiaries in addition to
the $3,275,712 paid for the preoperative EKGs. That study focused on cost and
did not assess whether those who had a care cascade suffered any adverse
events.
But a new study (Chen
2020) shows yet another unexpected adverse effect of pre-op testing in
older patients prior to cataract surgery falls!
Chen and colleagues looked at data on almost 250,000
Medicare patients. They measured the mean and median number of days between
ocular biometry and cataract surgery, calculated the proportion of patients
waiting >30 days or >90 days for surgery, and determined the odds of
having a fall within 90 days of biometry among patients of high-testing
physicians (testing performed in ≥75% of their patients) compared to
patients of low-testing physicians.
Falls before cataract surgery in patients of
high-testing physicians increased by 43% within the 90 days following
ocular biometry (1.0% vs 0.7%). The adjusted odds ratio of falling within 90
days of biometry in patients of high-testing physicians versus low-testing
physicians was 1.10 (1.07 after adjusting for surgical wait time). Fall-related
hip fractures, other fractures and joint dislocations were also significantly
more frequent during the period between biometry and surgery for those patients
treated by high-testing physicians.
The delay associated with having a high-testing physician
was approximately 8 days (estimate 7.97 days).
Confounding factors cannot be excluded as contributing to
the disparity. Patients treated by higher-testing physicians were, on average,
slightly older and in poorer health status but Charlson
comorbidity index was comparable for the 2 groups. However, the authors found a
lack of association between physician testing behavior and falls in the 360
days preceding biometry and felt that supports their hypothesis that falls that
occur after a patient begins preparing for surgery are associated with the
routine use of preoperative testing, rather than from other underlying
differences in patients of high-testing physicians compared to patients of
low-testing physicians.
Though the absolute numbers of
patient having falls or fall-related injuries during the delay before surgery
were low, any such events are unwarranted since the testing is unnecessary.
This is probably the first study to document actual detrimental patient
outcomes that occur as
a result of unnecessary
testing in this population. So not only does such unnecessary testing lead to
unnecessary cost to the healthcare system, it probably does also result in some
degree of patient harm. We also suspect that procedures related to diagnostic
cascades following such testing may well also be associated with some degree of
patient harm.
This is likely yet another example of less is more.
Weve done several columns (listed below) on the
relationship, at times complex and sometimes counterintuitive, between vision
problems and falls.
Some of our previous
columns on falls after correction of vision:
June 2010 Seeing Clearly a Common Sense Intervention
June 2014 New Glasses and Fall Risk
August 2014 Cataract Surgery and Falls
October 2019 Visual
and Hearing Loss and Medical Costs
Some of our prior
columns related to falls:
References:
Ganguli I, Lupo C, Mainor AJ, et
al. Prevalence and Cost of Care Cascades After Low-Value Preoperative
Electrocardiogram for Cataract Surgery in Fee-for-Service Medicare Beneficiaries.
JAMA Intern Med 2019; 179(9): 1211-1219
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2735387
Chen CL, McLeod SD, Lietman TM, et
al. Preoperative medical testing and falls in Medicare beneficiaries awaiting
cataract surgery. Ophthalmology 2020; Published online September 10, 2020
https://www.aaojournal.org/article/S0161-6420(20)30886-1/fulltext
Print October 2020 Pre-op Testing Before Cataract
Surgery Leads to What?
We learn a great deal from performing root cause analyses
(RCAs) after various incidents. But one thing many organizations fail to do is
to learn to identify themes that are common to multiple incidents. One process
to identify such themes is called common cause analysis.
Basically, a common cause analysis involves aggregation of
RCAs and identification of themes common to events found in RCAs done after
the individual events. It often better brings into focus system vulnerabilities
that might be downplayed in individual RCAs. For example, you might identify
one or more factors in multiple RCAs on seemingly unrelated events.
A recent paper showed how one
pediatric hospital used common cause analysis of hospital safety events that
involve radiology to identify opportunities to improve quality of care and
patient safety (Khalatbari 2020). The authors reviewed all RCAs of
incidents involving diagnostic or interventional radiology over a 5+ year
period.
From 19 safety events, they identified 64 sequential
interactions that were attributed to the radiology department. Of these 19
events, 9 were classified as a serious safety event, 9 as a precursor safety
event, and 1 as a known complication. The 9 serious safety events included a
delay in diagnosis or treatment (6) or other procedural errors (3). The 9
precursor safety events included a wrong or unnecessary procedure (3),
procedural errors (3), delay in diagnosis or treatment (2) and loss of patient data
(1). Overall, five diagnostic errors occurred. The two most common system
failure modes identified for all 64 sequential interactions were culture
(32.8%) and process (21.9%).
Common cause analysis uses Pareto charts to prioritize those
factors that occur most often in untoward incidents. It also uses
identification of key processes (specific sequences of distinct tasks that are
essential to the delivery of care and service in the hospital) and key
activities (distinct tasks that are part of a key process and which may be
components of multiple key processes). Some of you may recognize those concepts
as being similar to some of the important elements of
LEAN.
The authors conclude that common cause analyses of safety
events allow for a more robust understanding of system failures and have the
potential to generate more specific process improvement strategies to prevent
the reoccurrence of similar errors.
We cite this study not so much to highlight their specific
findings, especially since the paper is somewhat difficult to read and uses a
lot of technical jargon and taxonomies not often used by most of us. Rather, we
wish to draw your attention to the potential utility of common cause analysis.
In another paper that may be a bit more clinically relevant
to most, Clapper and Crea (Clapper 2010) used
common cause analysis to investigate medication errors throughout the system in
a large health organization, identify solutions, and reduce adverse events in
high-risk medications by 50%.
And, in our September 10, 2013 Patient Safety Tip of the
Week Informed
Consent and Wrong Site Surgery we discussed a paper that performed a
common cause analysis after a series of wrong-site surgical events in a US
hospital (Mallett 2012).
One of the themes they identified was related to documents used in
verification. They found that the consents were not always placed in the
correct location in the medical record, were not available to be reconciled,
did not specify laterality, and were not obtained by the practitioner
performing or involved in the procedure. One of their solutions was revision of
the consent form to include a legend (right, left, and bilateral) next to where
the practitioner writes the name of the procedure to be performed. That
provides a visual cue to the practitioner to ensure laterality during the
informed consent procedure. Secondly, they implemented a policy that informed
consent must be only obtained by the physician/practitioner performing the
procedure or by the resident/fellow who will be performing or assisting with
the procedure.
Common Cause Analysis (CCA) is another tool to add to your
armamentarium for identifying system factors contributing to adverse events. Its particularly good for identifying factors whose
importance you might otherwise underattribute as
significant vulnerabilities in your organization.
Some of our prior
columns on RCAs, FMEAs, response to serious incidents, etc:
July 24, 2007 Serious
Incident Response Checklist
March 30, 2010 Publicly Released RCAs: Everyone Learns from
Them
April 2010 RCA:
Epidural Solution Infused Intravenously
March 27, 2012 Action Plan Strength in RCAs
March 2014 FMEA to Avoid Breastmilk Mixups
July 14, 2015 NPSFs RCA2 Guidelines
July 12, 2016 Forget
Brexit Brits Bash the RCA!
May 23, 2017 Trolling
the RCA
October 2019 Human
Error in Surgical Adverse Events
January 2020 ISMP
Canada: Change Management to Prevent Recurrences
References:
Khalatbari H, Menashe SJ, Otto RK,
et al. Clarifying radiologys role in safety events: a 5-year retrospective
common cause analysis of safety events at a pediatric hospital. Pediatr Radiol 2020; 50, 1409-1420
https://link.springer.com/article/10.1007%2Fs00247-020-04711-3
Clapper C, Crea K. Common Cause
Analysis. Patient Safety & Quality Healthcare 2010; May/June 2010
https://www.psqh.com/analysis/common-cause-analysis/
Mallett R, Conroy M, Saslaw LZ,
Moffatt-Bruce S. Preventing Wrong Site, Procedure, and Patient Events Using a
Common Cause Analysis. American Journal of Medical Quality 2012; 27: 21-29
https://journals.sagepub.com/doi/pdf/10.1177/1062860611412066
Print October 2020 Common Cause Analysis
In our many columns on patient safety issues in the MRI
suite, issues related to implants have often been stressed. Certain implants
can become heated during MRI scans, they may become dislodged, or they might
malfunction.
Analysis of an FDA database revealed
over 600 adverse events related to implantable hearing devices during
MRI scanning over a 10-year period (Ward 2020a). Most were cochlear implants, but a few were middle ear
implants or bone conduction implants and 2 were brainstem implants. The most
common cause of the adverse events was dislocation of the magnet in the
implantable device, often causing pain. This often leads to premature cessation
of the MRI study. In some cases, manufacturer protocols may allow removal of
the magnet prior to the MRI but some events occurred even when following
manufacturer guidelines. Headbands or splints are recommended by manufacturers
in some cases but, even then, adverse events sometimes occurred. Rarely, there
was malfunction of the implanted device. Also, implantable devices may lead to
artifacts that make interpretation of certain areas difficult.
Thermal burns are the most common adverse MRI event in an
FDA database (Forrest
2020a) but most of these are related to superficial devices like coils and
EKG leads. Yet even deep implants that have ferromagnetic properties can heat
and cause internal thermal injuries. But reassuring was a recent study showing
that clinicians can safely perform clinical 3-tesla MRI scans with metal
artifact reduction sequence (MARS) protocols on patients with hip arthroplasty
implants without excessive thermal heating of the devices (Forrest
2020b). On the other hand, the thermal effects due to the switching of
gradient coil (GC) fields on metallic hip implants has been less well studied (Ward
2020b) For the echo-planar imaging (EPI) sequence, which is needed to
perform functional MRI and diffusion-tensor imaging, heating is strongly
dependent on the position of the body within the scanner The researchers found almost no heating when
the implant is at z ≈ 0 from the scanner center, whereas the worst cases
occur with z ≈ 300 mm
All the more important that we
always ascertain the presence of any implant in a patient prior to undergoing
an MRI scan.
Some of our prior
columns on patient safety issues related to MRI:
References:
Ward P. Implantable hearing devices cause MRI safety
concerns. AuntMinnieEurope.com 2020; August 10, 2020
https://www.auntminnieeurope.com/index.aspx?sec=sup&sub=mri&pag=dis&ItemID=619122
Forrest W, Thermal burns top FDA list of MRI adverse event
reports. AuntMinnie.com 2020; August 13, 2020
https://www.auntminnie.com/index.aspx?sec=rca&sub=ismr_2020&pag=dis&ItemID=129887
Forrest W. ARRS: MRI protocols don't
affect hip implant temperature. AuntMinnie.com 2020; May 10, 2019
https://www.auntminnie.com/index.aspx?sec=sup&sub=mri&pag=dis&ItemID=125415
Ward P. Caution needed with MRI of patients with metallic
implants. AuntMinnie.com 2020; August 13, 2020
https://www.auntminnie.com/index.aspx?sec=rca&sub=ismr_2020&pag=dis&ItemID=129881
Print October 2020 New Warnings on Implants and
MRI
Print October
2020 What's New in the Patient Safety World (full column)
Print October 2020 IHIs National Action Plan to
Advance Patient Safety
Print October 2020 Pre-op Testing Before Cataract
Surgery Leads to What?
Print October 2020 Common Cause Analysis
Print October 2020 New Warnings on Implants and
MRI
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