What’s New in the Patient Safety World

September 2015



·         Alert: Use Only Medication Dosing Cups with mL Measurements

·         Stroke: Doing Less Well Than You Think?

·         Surgery Previous Night Does Not Impact Attending Surgeon Next Day

·         APIC’s New Guide to Hand Hygiene Programs





Alert: Use Only Medication Dosing Cups with mL Measurements



In our April 2015 What’s New in the Patient Safety World column “Pediatric Dosing Unit Recommendations” we discussed the American Academy of Pediatrics new Policy Statement on “Metric Units and the Preferred Dosing of Orally Administered Liquid Medications” (AAP 2015). That new policy statement recommends switching to sole use of metric dosing, i.e. strictly using milliliters for dosing of orally administered liquid medications in children and infants. Use of measures such as “teaspoon” and “tablespoon” should no longer be used. Moreover, it emphasizes that the correct abbreviation for milliliters is “mL” (rather than “ml”, “ML”, or “cc”). Dispensing devices are also critical. The statement recommends that pharmacies, hospitals, and healthcare centers distribute appropriate-volume milliliter-based dosing devices such as syringes. Another important point is that the syringe (or other dosing device) should not be significantly larger than the dose prescribed. It also recommends that manufacturers avoid labeling, instructions or dosing devices that contain units other than metric units.


Several other organizations have concurred with these recommendation and it should not just apply to pediatric patients.


Now a new national alert has been issued that recommends hospitals replace medication dosage cups that use units other than mL (NAN 2015). This follows reporting of a fatal event to the ISMP National Medication Errors Reporting Program in which a nurse confused two dosing scales that appear on a plastic oral liquid dosing cup. In that event drams were confused with mL, resulting in a fatal overdose of morphine.


Unfortunately, such cups are still available and it’s possible they will be found in your healthcare facility. The alert recommends that in their place you use available oral syringes that measure only in mL whenever possible. If a dosing cup must be used, ideally it should allow measurement in mL only.







AAP (American Academy of Pediatrics). Committee on Drugs. Policy Statement. Metric Units and the Preferred Dosing of Orally Administered Liquid Medications. Pediatrics 2015; 135(4): 784-787; originally published online March 30, 2015




NAN (National Alert Network). Move toward full use of metric dosing: Eliminate dosage cups that measure liquids in fluid drams. Use cups that measure mL. NAN 2015; June 30, 2015







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Stroke: Doing Less Well Than You Think?



It’s human nature to think we are doing better at something than we really are when we don’t know the data. A number of years ago we asked caregivers at a community hospital how well they provided care for patients with acute MI. They weren’t really sure because they sent most of their acute MI patients to a tertiary hospital. But they thought most of their patients would have received percutaneous coronary angioplasty within the prescribed timeframes. When they finally got around to requesting the data from the tertiary hospital it turned out that almost none of the patients got the angioplasty within the recommended timeframe, mainly because of transport delays and delays on arrival. Their patient population would have been much better off receiving thrombolytic therapy at the community hospital before being transported to a tertiary hospital. Once the hospital recognized this problem they began initiating thrombolytic therapy on-site and did a good job achieving this therapy within the prescribed timeframes for most acute MI patients. The problem was clearly one of lack of data availability and lack of timely feedback on performance.


The same applies to acute stroke care. A recent study from hospitals participating in the American Heart Association’s “Get With The Guidelines” (GWTG) program found that hospitals often overestimate their ability to deliver timely tPA to patients treated with tPA (Lin 2015). Less than one third of all hospitals responding to a survey accurately identified their door-to-needle (DTN) time performance. Respondents from hospitals in middle- and low-performing hospitals in particular overestimated their DTN performance.


The key message is that to improve care you need to provide comparative provider performance data routinely to caregivers.


There are many factors that go into running successful stroke programs. We’ve discussed those in the several prior columns listed at the end of today’s column. But there are a few new considerations.


One important factor is coming to a correct diagnosis of stroke. Prior to administering tPA we need to exclude certain stroke “look-alikes” or “mimics” (eg. migraine, post-ictal Todd’s paralysis, etc.). However, we may also fail to diagnosis acute strokes in some patients. A recent study (Richoz 2015) looked at acute stroke “chameleons” presenting to a university hospital emergency department. They found that 2.1% of strokes were missed initially. These were either misdiagnosed as other neurologic diseases (42%) or non-neurologic diseases (17%) or as unexplained decreased level of consciousness (21%) or as concomitantly present disease (19%). These strokes tended to be either very mild or very severe. At 12 months patients with these “chameleons” tended to have less favorable outcomes and higher mortality.


Another problem in thrombolytic therapy for acute stroke was recently noted by Bordoehl and colleagues (Brodoehl 2015). Because of the short half-life of tPA, it should be administered as a bolus followed by an immediate infusion. However, they note that in clinical practice there are sometimes delays between the application of the bolus and the start of the infusion. In addition, interruptions of the infusion may occur. They found that even 1-minute delays before the infusion is begun or interruptions of the infusion for more than 1-minute may affect serum tPA concentrations. Their results strongly suggest avoiding bolus-infusion delays by giving the bolus only when the infusion is ready. They went on to estimate the dosing of a potential second bolus depending on the duration of the delay/interruption to allow for the achievement of appropriate serum tPA concentrations. However, they stress that clinical safety data are needed to recommend the application of a second bolus.


Sustaining improvement is often difficult and another recent study illustrates the difficulties encountered in sustaining some components of good stroke care. Perhaps just as important as getting thrombolytic therapy to those eligible acute stroke patients is prevention of complications of stroke, such as UTI’s, pneumonia, and DVT. Williams and colleagues (Williams 2015) conducted a cluster-randomized quality improvement trial, randomizing hospitals to quality improvement training plus indicator feedback versus indicator feedback alone to improve deep vein thrombosis (DVT) prophylaxis and dysphagia screening. DVT prophylaxis improved more during the intervention period in the active intervention group but this improvement was not sustained afterward. For improving dysphagia screening quality improvement training was no better than feedback alone.


So, while we encourage you to make the major changes noted in our columns below, we also use the above examples to remind you that some of the other issues in stroke care also impact the outcomes for your patients.



Some of our previous columns on improving stroke care:

November 6, 2012     Using LEAN to Improve Stroke Care

March 18, 2014          Systems Approach Improving Stroke Care

September 23, 2014   Stroke Thrombolysis: Need to Focus on Imaging-to-Needle Time

January 27, 2015         The Golden Hour for Stroke Thrombolysis

May 12, 2015              More on Delays for In-Hospital Stroke

June 2015                    Too Much of a Good Thing? Very Early Mobilization in Stroke







Lin CB, Cox M, Olson DM, et al. Perception versus actual performance in timely tissue plasminogen activation administration in the management of acute ischemic stroke. Journal of the American Heart Association 2015; DOI: 10.1161/JAHA.114.001298




Richoz B, Hugli O, Dami F, et al. Acute stroke chameleons in a university hospital: Risk factors, circumstances, and outcomes. Neurology 2015; 85: 505-511; published ahead of print July 15, 2015




Brodoehl S, Günther A, Witte OW, Klingner CM. How to Manage Thrombolysis Interruptions in Acute Stroke? Clinical Neuropharmacology 2015; 38(3): 85-88




Williams L, Daggett V, Slaven JE, et al. A cluster-randomised quality improvement study to improve two inpatient stroke quality indicators. BMJ Qual Saf 2015; published online 24 August 2015 doi:10.1136/bmjqs-2015-004188






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Surgery Previous Night Does Not Impact Attending Surgeon Next Day



We’ve done numerous columns discussing the role of fatigue in healthcare. We’ve also done numerous columns discussing the conflicting studies on the impact of resident work hour restrictions on patient outcomes, noting that overall there does not seem to be an impact of such restrictions in either direction. We’ve always suspected that any improvement due to reduction of resident fatigue is offset by the increased number of handoffs and reduction of continuity of care.


But most of the literature has focused on residents and training programs rather than attending physicians. Therefore, a new study from Ontario, Canada sheds important light on the impact on patient outcomes when their attending surgeon has performed late night surgery the previous night. The Canadian researchers (Govindarajan 2015) were able to use administrative (billing) data to identify cases in which a surgeon likely performed one or more procedures after midnight and then performed another surgery the next day. They then created a control group matched for the same surgeon and type of procedure and adjusted for other clinical variables. They essentially found no significant difference in outcomes between the two groups for the primary outcome (a composite of death, complications, and readmission within 30 days) or a number of secondary measures.


The study is limited in that the researchers did not know whether surgeons may have cancelled some cases voluntarily if they felt fatigued after a late night surgery or had lightened their elective schedule in anticipation of night call. They also had no measure of the actual hours of sleep a surgeon may have had the prior day/night. It also is limited by the use of administrative billing data to identify time of surgery. Nevertheless, the study included almost 39,000 patients operated on by 1448 attending surgeons and included data from 12 of the most commonly performed surgical procedures. We think their conclusion that the risks of adverse outcomes for elective daytime procedures were similar whether the surgeon had provided medical services the previous night is likely valid.


Note that this is a very different question from one we have addressed on numerous occasions. Several of our columns have questioned whether surgery should be done “after hours”, particularly for procedures that may not be true emergency ones (see our What’s New in the Patient Safety World columns for September 2009 After-Hours Surgery – Is There a Downside?”, October 2014 “What Time of Day Do You Want Your Surgery?”, December 2014 “Another Procedure to Avoid Late in the Day or on Weekends” and January 2015 “Emergency Surgery Also Very Costly”).


In those columns we have pointed out that such surgeries and procedures involve considerations far beyond just the surgeon. Why should “after hours” surgery be more prone to adverse outcomes than regularly scheduled elective surgery? There are many reasons aside from the fact that patients needing emergency and after hours 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. In addition, one of the most compelling reasons surgery is done at night rather than deferred to the next morning is the schedule of the surgeon or other physician for that next morning (either in surgery or the cath lab 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.


The current Canadian study is reassuring in that outcomes for the “next day” case do not seem to be adversely impacted by the surgeon’s previous night procedures. But it does not address outcomes of the cases done the previous night.


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.



Some of our previous columns on the “weekend effect” or “after-hours 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

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

·         December 2014         Another Procedure to Avoid Late in the Day or on Weekends

·         January 2015             Emergency Surgery Also Very Costly

·         May 2015                  HAC’s and the Weekend Effect

·         August 2015              More Stats on the Weekend Effect




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

October 2014              Another Rap on the 12-Hour Nursing Shift

December 2, 2014       ANA Position Statement on Nurse Fatigue

August 2015               Surgical Resident Duty Reform and Postoperative Outcomes



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

January 2015               More Data on Effect of Resident Workhour Restrictions

August 2015               Surgical Resident Duty Reform and Postoperative Outcomes







Govindarajan A, Urbach DR, Kumar M, et al. Outcomes of Daytime Procedures Performed by Attending Surgeons after Night Work. N Engl J Med 2015; 373: 845-853






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APIC’s New Guide to Hand Hygiene Programs



APIC (Association for Professionals in Infection Control and Epidemiology) has published its updated guide to hand hygiene (APIC 2015). The guide begins with an overview summarizing the scientific evidence for hand hygiene in infection control. It also lists hand hygiene elements required by regulatory and accrediting bodies. It has a good section on hand hygiene products, including details about both ingredients and formulations and also delivery systems. The section on monitoring hand hygiene compliance covers direct observation, measuring product usage, and newer electronic or hi-tech methods but also notes the importance of timing of the monitoring to actually impact compliance. But the best sections are those on implementing multimodal hand hygiene programs and changing culture. These include elements regarding access to hand hygiene products, workflow considerations, supply chain issues, role of management, leadership, integration with organizational goals, educational and training issues, and more. A whole section is dedicated to strategies for behavior change. The APIC guide is well referenced and includes links to many valuable resources and tools.


Sharp Healthcare has a new video on hand hygiene that is quite good. Links to some hand hygiene videos we’ve used in the past can be found in our May 24, 2011 Patient Safety Tip of the Week Hand Hygiene Resources”.


But our favorite video on HAI’s and hand washing is still the one done by the Penn State Hershey Medical Center Infection Control Team. This also sends a powerful message that is likely to be remembered. Its semi-animated format also introduces a bit of levity that makes this one an ideal video to be shown to patients and families as well.




Some of our other columns on handwashing:



January 5, 2010           How’s Your Hand Hygiene?

December 28, 2010     HAI’s: Looking In All The Wrong Places

May 24, 2011              Hand Hygiene Resources

October 2011              Another Unintended Consequence of Hand Hygiene Device?

March 2012                 Smile…You’re on Candid Camera

August 2012               Anesthesiology and Surgical Infections

October 2013              HAI’s: Costs, WHO Hand Hygiene, etc.

November 18, 2014    Handwashing Fades at End of Shift, ?Smartwatch to the Rescue

January 20, 2015         He Didn’t Wash His Hands After What!









APIC (Association for Professionals in Infection Control and Epidemiology). Guide to Hand Hygiene Programs for Infection Prevention (2015).




Sharp HealthCare. "It's OK to Ask" (video)




Penn State Hershey Medical Center Infection Control Team/McGuckinMethodsIntl.

Healthcare Worker Hand Hygiene Educational Training Video.





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Print “September 2015 What's New in the Patient Safety World (full column)

Print “September 2015 Alert: Use Only Medication Dosing Cups with mL Measurements

Print “September 2015 Stroke: Doing Less Well Than You Think?

Print “September 2015 Surgery Previous Night Does Not Impact Attending Surgeon Next Day

Print “September 2015 APIC’s New Guide to Hand Hygiene Programs






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