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ISMP has released its “Guidelines for Safe Medication Use in Perioperative and Procedural Settings” (ISMP 2022). As you’d expect from ISMP, it is both comprehensive and practical and covers pre-, intra-, and post-procedure phases.
A section on Patient Information includes comments on medication reconciliation but has several other very important points. It emphasizes that patients need to be characterized as opioid-naïve or opioid-tolerant. It also cautions that patient weights should be obtained on the day of the surgery or procedure and measured only in metric units (e.g., grams or kilograms). It specifically recommends avoiding the use of a stated, estimated, or historical weight.
In keeping with our many columns on opioid-induced respiratory depression, the ISMP guideline recommends use continuous electronic monitoring of both oxygenation (e.g., pulse oximetry) and adequacy of ventilation (e.g., end-tidal carbon dioxide, capnography) for patients in perioperative and procedural settings receiving one or more of the following:
Regarding medication information they focus:
Regarding communication of medication orders and information they stress that verbal orders should only be accepted if done face-to-face with providers who are onsite when ungloving would be impractical. Hearback should be utilized in all such cases.
It has multiple recommendations regarding drug labeling, packaging, nomenclature, standardization, storage, and distribution. There is a section on proven infection prevention practices when storing, preparing, and administering medications, such as avoiding use of syringes or vials intended for single use on multiple patients.
It has multiple recommendations regarding smart pump technology.
It has sections on environmental factors, workflow, staffing patterns, staff competency and education, as well as patient education.
Importantly, it stresses use of redundancies such as independent double checks and use of integrated machine-readable coding (e.g., barcode scanning, RFID) for verification of medications.
A section on quality processes and risk management emphasizes importance of a safety culture of learning and shared accountability (e.g., JUST CULTURE).
ISMP (Institute for Safe Medication Practices). Guidelines for Safe Medication Use in Perioperative and Procedural Settings. ISMP 2022
We’ve done many columns on the relationship between nursing staffing levels and patient outcomes. But what about other staffing levels? A new study (Burns 2022) has looked at the relationship between anesthesia staffing levels and patient outcomes.
Burns and colleagues looked at major noncardiac inpatient surgical procedures performed in 23 US academic and private hospitals from 2010 to 2017. They used propensity score–matching methods to create balanced sample groups with respect to patient-, operative-, and hospital-level confounders. They then examined 30-day mortality and 6 major surgical morbidities (cardiac, respiratory, gastrointestinal, urinary, bleeding, and infectious complications) across groups by the number of overlapping cases an anesthesiologist was supervising. (Note: cases with involvement of residents were excluded.)
Increasing anesthesiologist coverage responsibilities was associated with an increase in risk-adjusted surgical patient morbidity and mortality. Compared with patients in the group supervising 1-2 cases, those in the group supervising 2-3 cases had a 4%relative increase in risk-adjusted mortality and morbidity (5.06% vs 5.25%) and those in the group supervising 3-4 cases had a 14% increase in risk-adjusted mortality and morbidity (5.06%vs 5.75%).
Despite some limitations noted by the authors, the message to hospitals should be clear – stretching anesthesiologists too thinly can have adverse impacts on patient outcomes.
Burns ML, Saager L, Cassidy RB, Mentz G, Mashour GA, Kheterpal S. Association of Anesthesiologist Staffing Ratio With Surgical Patient Morbidity and Mortality. JAMA Surg 2022; Published online July 20, 2022
A recent Canadian study (Plint 2022) sought to understand how often pediatric patients suffered adverse events (AE’s) related to emergency department visits.
The researchers found that 3.0% of over 6000 children studied had at least one adverse event. Moreover, 76.5% of these adverse events were deemed preventable. Management issues (52.4%) and diagnostic issues (19.3%) were the most common types of adverse events. 42.2% of events resulted in a return emergency department visit, 12.8% resulted in hospital admission, and 1.6% resulted in transfer to a critical care unit.
The authors note that characteristics of both ED’s and children likely contribute to the occurrence of adverse events. They note that high-acuity patient presentations, increasing
patient volumes, and frequent interruptions make ED’s a challenging environment for providing pediatric care. But developmental and physical characteristics of children affect communication, treatment strategies, procedures, and medication regimens.
Examples of AE’s include delay in diagnosis and treatment of osteomyelitis; lack of documented reassessments for patients in respiratory distress who returned requiring escalated care; missed diagnoses of pneumonia or fractures on X-ray that required further treatment; and adverse effects of medications.
Increasing age, triage category, and treatment in the acute care area of the ED were factors associated with being a patient with an AE. Increasing age, having a chronic condition, increasing time to physician assessment, and treatment in the acute care area of the ED were significantly associated with a preventable AE.
The authors cite the need for quality improvement programs targeting the high-risk groups they identified and addressing the system issues that contribute to AE’s.
In an accompanying editorial, Michelson and Griffey (Michelson 2022) discuss some of the methodological challenges in determining pediatric AE rates. They also point out that the study was on true pediatric ED’s, whereas in the US, about 90% of children’s ED visits are to general ED’s, with only 10% taking place in dedicated pediatric ED’s. That makes generalizability difficult.
Plint AC, Newton AS, Stang A, et al. How safe are paediatric emergency departments? A national prospective cohort study. BMJ Quality & Safety 2022; Published Online First: 19 July 2022
Michelson KA, Griffey RT. Why identifying adverse events in paediatric emergency care matters. BMJ Quality & Safety 2022; Published Online First: 21 July 2022
In medicine, we often use probabilities to help us decide about diagnoses or whether a procedure should be done. The chance of errors occurring is a function of the number of steps involved in a process. Probabilities are not simply derived from addition of risks but rather probabilities are the result of multiplying the risks of each step.
We often quote that a 50-step process, such as might occur in the continuum from ordering a medication to the patient actually receiving the medication, with a 1% error rate at each step would result in an overall potential error rate of 39%.
But when it comes to multistep clinical issues, we often fail to take understand how probabilities are calculated and we may underestimate the chance of unwanted outcomes or overestimate the chance of successful outcomes.
A recent study illustrated this phenomenon. Arkes et al. (Arkes 2022) note that the probability of a conjunction of 2 independent events is the product of the probabilities of the 2 components and therefore cannot exceed the probability of either component. Violation of this basic law is called the conjunction fallacy. They note that conjunction fallacy can lead to diagnostic or prognostic errors.
They used 3 scenarios and surveyed 215 experienced physicians and found that 78.1% estimated the probability of a medical outcome resulting from a 2-step sequence to be greater than the probability of at least 1 of the 2 component events, a result that was mathematically incoherent.
One scenario, given to obstetricians, was that of a brow presentation discovered during labor. They were asked the probabilities that the brow presentation would resolve and that the delivery would be vaginal. 50 of 67 obstetricians (74.6%) committed the conjunction fallacy, overestimating the combined probability by 12.8%. This could result in delaying a C-section, which could be detrimental to the child or mother.
The second scenario was an incidentally discovered pulmonary nodule. The probability that a biopsy reveals cancer in the patient is a function of both the probability that the nodule is cancerous and the probability of the biopsy successfully detecting cancer in the presence of a cancerous nodule. 73 of 84 pulmonologists (86.9%) committed the conjunction fallacy, overestimating the combined probability by 19.8%.
The third scenario was a variation of the first one, but they attempted to “debias” the physicians’ estimates. But even in that one, 45 of 64 obstetricians (70.3%) committed the conjunction fallacy, overestimating the combined probability by 18.0%.
The authors caution that “because many diagnostic and prognostic decisions require more than 1 step or the consideration of more than 1 probability, this misestimation may have substantial implications for diagnostic and prognostic decision-making.”
Arkes HR, Aberegg SK, Arpin KA. Analysis of Physicians’ Probability Estimates of a Medical Outcome Based on a Sequence of Events. JAMA Netw Open 2022; 5(6): e2218804
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