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In our November 1, 2016 Patient Safety Tip of the Week “CMS
Emergency Preparedness Rule” we discussed hospital emergency plans or
disaster plans. But most such plans have dealt with acute emergencies that are
of limited duration. How many of you have updated your emergency preparedness
plan or disaster plan for dealing with pandemics?
Disaster plans may take into account potential sudden influx of patients and
need to rapidly mobilize excess staff for disasters such as a mass casualty
accident or a mass hazardous material exposure. But those are limited to short
timeframes. The COVID-19 pandemic led to massive influx of patients for long
periods of time and resulted in significant workload burdens and staff
shortages over the long haul.
Wei and colleagues
recently published “Nine Lessons Learned From the COVID-19 Pandemic for Improving
Hospital Care and Health Care Delivery” (Wei 2021). It includes a valuable table containing elements to include in
a hospital disaster plan for dealing with increased volume of patients or workforce
shortages. Elements in that table are:
The table and text
outline considerations for each of those elements.
Given that the
COVID-19 pandemic may not be over yet and there may well be a surge this fall
(or a new pandemic in the future), you really need to address all these
elements in your emergency preparedness or disaster plans.
Go to the Wei paper
for its excellent recommendations, not only on the disaster plan elements, but
also on each of their 9 lessons learned from the COVID-19 pandemic:
And, if you are a
teaching hospital, you also need to consider how a long pandemic will impact
your training programs. A timely “Checklist Framework for Surgical Education
Disaster Plans” (Matthews 2021) provides good recommendations for surgical
residency programs but many of the recommendations could apply equally to other
residency programs as well.
References:
Wei EK, Long T, Katz
MH. Nine Lessons Learned From the COVID-19 Pandemic for Improving Hospital Care
and Health Care Delivery. JAMA Intern Med 2021; Published online July 23, 2021
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2782429
Matthews JB, Blair
PG, Ellison EC, et al. Checklist Framework for Surgical Education Disaster
Plans. Journal of the American College of Surgeons 2021; Published online: July
12, 2021
https://www.journalacs.org/article/S1072-7515(21)00493-2/fulltext
Print “September
2021 Have You Added Pandemic Preparation to Your Hospital Disaster Plan?”
Wu and colleagues
recently did a systemic review of systemic reviews on deprescribing in the
elderly (Wu 2021) and it serves as an excellent introduction or primer on the
topic. They conclude that the evidence suggests deprescribing is safe and
feasible as a management strategy in patients at risk of medication-related
problems. The literature shows that deprescribing can reduce the number of
potentially inappropriate medications and rarely causes adverse drug withdrawal
events. However, the authors note there is actually limited
evidence of its effects on global and geriatric outcomes, such as falls,
hospitalization, cognitive and physical function decline. Though common sense
dictates that patient outcomes will be improved by deprescribing potentially
inappropriate drugs in the elderly, studies on deprescribing have been limited
by small sample sizes, confounding factors, and the lack of long-term follow up.
The review has a
nice table listing the challenges and solutions of implementing deprescribing
at the patient, healthcare professional, and health system levels. We just
discussed many of those challenges in our June 29, 2021 Patient Safety Tip of the Week “Barriers
to Deprescribing”.
Patient challenges
include poor health literacy, reluctance to discontinue medications based on
false beliefs, and fact that patients are often not involved in decision making
about the use of medications. At the healthcare professional level, time
constraints, lack of formal training on deprescribing, and the complexity and
multiple comorbidities of the geriatric patient are challenges. At the health
system level, fragmentation of care and poor communication between providers is
the primary challenge.
The Wu review is a
good place to start for those just getting started with deprescribing and has a
good bibliography to help you identify relevant studies. It also points out the
dearth of research linking results of deprescribing to actual patient outcomes.
We hope you’ll go back to our June 29, 2021 Patient Safety Tip of the Week “Barriers to Deprescribing” and the multiple other columns we’ve done
on deprescribing and potentially inappropriate medications in the elderly..
Some of our past
columns on deprescribing:
Some of our past
columns on Beers’ List and
Inappropriate Prescribing in the Elderly:
References:
Wu H, Kouladjian O'Donnell L, Fujita K, et al. Deprescribing in
the Older Patient: A Narrative Review of Challenges and Solutions. International
Journal of General Medicine 2021; 14: 3793-3807
Print “September
2021 A Primer on Deprescribing”
Our May 4, 2021 Patient
Safety Tip of the Week “More
10x Dose Errors in Pediatrics”
discussed multiple examples of errors leading to 10-fold (or higher) overdoses
of medications and discussed many factors contributing to such errors.
A recent case from New Zealand (Connor
2021) highlights yet another factor contributing
to such events. A 4-year-old boy with cerebral palsy was admitted to a New
Zealand hospital for a surgical procedure intended to reduce his lower
extremity spasticity. At one point during his recovery from the surgery he
became confused and looked angry. Staff gave him morphine, thinking his
symptoms may have been secondary to pain. However, he became lethargic, then
obtunded, with his tongue “hanging out” and snoring. Despite his mother’s pleas
that something was terribly wrong, “it took three-and-a-half hours for them to
agree that there was something really wrong - and that's when he coded”.
Staff originally
suspected the morphine as the reason for his deterioration. But his mother
insisted the changes had begun to take place prior to administration of
morphine. That finally led to a review of all his medications.
At the time of admission, hospital policy required his mother
to hand over any of the medicines she gives her son while he is at home. One of
those was baclofen, which he took for his spasticity. The staff used the baclofen
from his home supply. But, at some point, they got the pharmacist in the
hospital to make up his medicine and switched to the hospital supply. The
concentration of the patient's personal supply of baclofen was 1 mg/ml and that
of the hospital pharmacy supply was 10 mg/ml. Up until then they'd been giving
7 ml out of the home supply bottle and
it was supposed to swap to 0.7 ml out of the hospital supply bottle. "The
poor nurse had gone away and checked, and he was told that 7 ml was right, came
back and gave it” according to the mother. Thus, he had received a 10-fold
overdose of the baclofen. He required transfer to the Pediatric ICU but
ultimately recovered fully.
Hospitals in the US
generally do not allow administration of medications brought in from home while
a patient is an inpatient. However, occasionally a patient might be taking a
medication that is not on the hospital formulary. In such cases, hospital staff
may temporarily use the patient’s home supply, as was done at the New Zealand
hospital. The time of subsequent transition to a hospital’s supply of a
medication is obviously a period of vulnerability.
It’s not really surprising that a nurse, used to administering 7 ml
from a vial, would expect to continue administering that amount. We assume
there was a new order when the switch to the hospital supply occurred. But even
that may have been confusing. Would one use the same size syringe (or whatever
instrument was used for administration) for the new dose was supposed to be
less than 1 ml? The nurse apparently did some sort of check about the amount to
be given, but concluded that 7 ml was still appropriate, not recognizing the
disparity in concentration of the preparation.
A second lesson
learned here is not to ignore the observations and concerns of a patient’s
family member. There are many incidents, including the Josie King case that was
a seminal event in the patient safety movement, in which concerns of a parent
went unheeded as clinical deterioration was occurring.
We suggest you go back to our May 4, 2021 Patient Safety
Tip of the Week “More 10x Dose Errors in
Pediatrics” for many more details on factors
contributing to 10-fold overdoses.
Some of our other columns on 10-fold medication dose errors:
March
12, 2007 “10x
Overdoses”
September 9, 2008 “Less is More and Do You Really Need that
Decimal?”
January 18, 2011 “More
on Medication Errors in Long-Term Care”
April 17, 2012 “10x Dose Errors in Pediatrics”
May 4, 2021 “More
10x Dose Errors in Pediatrics”
Some of our other columns on pediatric medication errors:
November 2007 “1000-fold Overdoses by Transposing mg for
micrograms”
December 2007 “1000-fold Heparin Overdoses Back in the News
Again”
September 9, 2008 “Less is More and Do You Really Need that Decimal?”
July 2009 “NPSA Review of Patient Safety for Children
and Young People”
June 28, 2011 “Long-Acting and Extended-Release Opioid
Dangers”
September 13, 2011 “Do You Use Fentanyl Transdermal Patches
Safely?”
September 2011 “Dose Rounding in Pediatrics”
April 17, 2012 “10x Dose Errors in Pediatrics”
May 2012 “Another Fentanyl Patch Warning from FDA”
June 2012 “Parents’ Math Ability Matters”
September 2012 “FDA Warning on Codeine Use in Children
Following Tonsillectomy”
May 7, 2013 “Drug Errors in the Home”
May 2014 “Pediatric Codeine Prescriptions in the ER”
November 2014 “Out-of-Hospital
Pediatric Medication Errors”
January 13, 2015 “More on Numeracy”
April 2015 “Pediatric
Dosing Unit Recommendations”
September 2015 “Alert:
Use Only Medication Dosing Cups with mL Measurements”
November 2015
“FDA Safety Communication on Tramadol in
Children”
October 2016 “Another Codeine Warning for Children”
January 31, 2017 “More Issues in Pediatric Safety”
May 2017 “FDA Finally Restricts Codeine in Kids;
Tramadol, Too”
August 2017 “Medication Errors Outside of Healthcare
Facilities”
August 2017 “More on Pediatric Dosing Errors”
September 2017 “Weight-Based Dosing in Children”
February 19, 2019 “Focus on Pediatric Patient Safety”
June 2020 “EMR and Medication Safety: Better But Not Yet
There”
December 2020 “Guidelines for Opioid Prescribing in Children
and Adolescents After Surgery”
May 4, 2021 “More
10x Dose Errors in Pediatrics”
References:
Connor F. Young boy
'almost killed' after 'accidentally' given 10 times normal dose of medication
at Starship Hospital. Newshub 2021; July 26, 2021
Print “September
2021 Another Unusual Cause for a 10-Fold Overdose”
Our January 5, 2016 Patient Safety Tip of the
Week “Lessons from AirAsia Flight QZ8501 Crash”
discussed the crash of AirAsia Flight QZ8501 into the Java Sea on December 28,
2014, killing all 162 people aboard. Though there were multiple contributory
factors, there were several ambiguous communications that were significant
factors in failure to avert the crash.
A series of serious miscommunications
occurred once the stall alarm triggered. The pilot in command shouted
“level…level…level” (repeated 4 times). But it was not clear whether he meant
to level the wings or level the “attitude” or orientation of the plane to the
ground. Then he followed with the command to “pull down…pull down” (repeated 4
times). As above, this order is ambiguous because if you pull the level/stick
down, the plane goes up and accentuates a stall.
It should come as
no surprise that use of ambiguous language in the OR can be dangerous and
contribute to adverse events and poor patient outcomes. Liu et al. (Liu
2021) reviewed video recordings of six surgical
procedures performed by residents under the supervision of specialist
physicians. In all, there were 319
minutes of surgery recorded and reviewed. Overall, they found 3912
examples of potentially ambiguous language, a rate of 12.3 per minute. Of
these, they identified 131 near misses associated with potentially ambiguous
language.
It does have a table
that provides examples of how the various types of ambiguous language led to
near misses and what alternative language might have been used.
Of interest to us
is lack of comment on other forms of communication that should have taken
place. Of course, we are talking about “hearback”.
The Liu article does note that airline pilots must repeat safety messages back
to the controller but does not go into detail about use of hearback
in the OR.
Back in that January 5, 2016 Patient Safety
Tip of the Week “Lessons from AirAsia Flight QZ8501 Crash” we
noted another miscommunication that was one that did not take place but should
have. When the pilot in control began to manipulate his stick/lever, standard
operating procedure would have been to call out “I HAVE CONTROL” and responded
by the other pilot transferring the control by call out “YOU HAVE CONTROL”. Had
that happened, perhaps the cancelling action of operating to sticks/levers
simultaneously would not have occurred. Perhaps the analogy in the OR would be
communication between the surgeon and anesthesiologist regarding when it is
safe to use electrocautery once oxygen flow has been stopped. It might go
something like this: surgeon “READY TO USE ELECTROCAUTERY”, anesthesiologist
“YOU MAY USE ELECTROCAUTERY”.
Hierarchy in the OR may also affect
communication. Liu et al. acknowledge that ambiguous language use between
teaching and training surgeons has the potential to lead to catastrophic surgical
outcomes, “especially when the training surgeon is junior”.
There is much more to language than the
actual words. The way the words are spoken is critical. Tone and inflection
count as well. We always tell the story about the copilot saying softly in a
monotone voice “We are running out of gas” several times before a plane crashed
because it ran out of gas. He obviously should have been shouting it out
loudly. The hierarchical nature of that cockpit probably prevented the copilot
from speaking up. How many times has that happened in the OR? Lots.
And you’ve heard us often remind everyone
that 90% of communication is nonverbal. While body language may be somewhat
obscured in the OR due to masks and gowns, it still occurs. People can convey
an awful lot of information with their eyes.
Though the Liu article has the problems we noted
above, it does have some thoughtful and useful recommendations for improving
communication in the OR and avoiding ambiguity. Some are very practical. For
example, defining a directional frame of reference at the start of a procedure
may be very useful (eg. left-right from the patient’s
perspective or the surgeon’s prospective, use “toward the head” rather than
“up/down”, etc.). It’s worth having not only your surgeons, but your whole OR
team, look at these recommendations.
References:
Liu C, McKenzie A, Sutkin G. Semantically Ambiguous Language in the Teaching
Operating Room. Journal of Surgical Education 2021; Article in press 23 April
2021
https://www.sciencedirect.com/science/article/abs/pii/S1931720421000738?via%3Dihub
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2021 Ambiguous Language in the OR”
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Safety World (full column)”
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2021 Have You Added Pandemic Preparation to Your Hospital Disaster Plan?”
Print “September
2021 A Primer on Deprescribing”
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2021 Another Unusual Cause for a 10-Fold Overdose”
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2021 Ambiguous Language in the OR”
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