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January 2, 2018
Preventing Perioperative Nerve Injuries
We just recently did a column on perioperative nerve injuries (see our November 7, 2017 Patient Safety Tip of the Week “Perioperative Neuropathies”). But since that column two informative papers on the topic have been published.
The American Society of Anesthesiologists just published its “Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies 2018: An Updated Report by the American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies.” (ASA 2018). This is an update to the 2011 Advisory we have discussed before. The Advisory reviews the literature on perioperative nerve injuries and grades the evidence, solicits opinions from consultants with expertise on the topic, and also provides results of surveys of anesthesiologists. Key elements from the update are listed below.
The preoperative history and physical should focus on risk factors for nerve damage including: body habitus, preexisting neurologic symptoms, diabetes mellitus, peripheral
vascular disease, alcohol dependency, arthritis, and sex (e.g., male sex and its association with ulnar neuropathy). It should also ascertain whether patients can comfortably tolerate the anticipated operative position. (Note that in our previous columns we have also noted that patients with recent weight loss and those with hypertrophic neuropathies, whether congenital or acquired, are at particular risk for compressive neuropathies.)
It then focuses on limb positioning issues, first describing vulnerable positions identified from the literature and then making recommendations for positioning to avoid injury to various peripheral nerves. The Advisory has recommendations on positioning to reduce the likelihood of injuries to specific nerves (we refer you to the actual document for details):
The Advisory does recommend that periodic perioperative assessments may be performed to ensure maintenance of the desired position.
It makes recommendations about the use of protective padding:
And recommendations about other equipment:
And a recommendation we wholeheartedly endorse: examine the patient after the procedure! We love telling the story about a time when neurology and neurosurgery residents performed their own angiograms. One neurosurgeon had a much higher complication rate than others, which was surprising since he was one of the best neurosurgeons. Finally, it was recognized why his complication rates were higher than those of his peers: he examined the patients after the procedure! (something his peers were remiss of).
The Advisory also has a section on documentation of perioperative positioning actions.
The second paper was on the “Prevention and Recognition of Ulnar Nerve and Brachial Plexus Injuries” (Duffy & Tubog 2017). It is a well-illustrated article that does an excellent job focusing on the anatomy, physiology, and mechanisms of injury (such as stretch, compression, or ischemia). Though it is written from the perspective of perianesthesia nurses, it stresses that prevention of nerve injuries is the job of all members of the surgical team. It notes that preoperative nurses’ knowledge of risks factors and use of preoperative assessment tools is critical to detecting high-risk patients. The surgeon’s role determines the length of surgical time, type of surgical procedures, and position of the patient. The circulating registered nurse and the anesthesia provider can collaborate in the use of positioning devices, protective pads, and positioning strategies, while frequently monitoring patient’s hemodynamic status during surgery. And the postanesthesia care unit nurses must have knowledge on early identification of signs of nerve injury. This paper is an excellent complement to the updated ASA Advisory.
We’d like to add two things from our November 7, 2017 Patient Safety Tip of the Week “Perioperative Neuropathies”). One is periodic “calling out” the time duration of the procedure. While we know of no evidence-based recommendations regarding specific timeframes, it would make sense in some long cases to briefly reposition patients to relieve pressure on vulnerable parts. Second would be to consider use of electrophysiological tools, such as intraoperative monitoring of somatosensory evoked potentials (SSEP’s) as used by Kamel and colleagues (Kamel 2006, Kamel 2016), in patients deemed to be at high risk for nerve injury. If SSEP’s were being monitored, you would briefly reposition the patient when the amplitude of the SSEP changed. The ASA Advisory unfortunately did not include reference to either Kamel study. The latter Kamel study (Kamel 2016) also noted that at least for one type of surgery and positioning (i.e. spine surgery with the patient in the “superman” or “prone surrender” position) changes in intraoperative MAP (mean arterial pressure) were independent predictors associated with upper extremity position–related neurapraxia. Specifically, they found that intraoperative MAP <55 mm Hg for a total duration of ≥5 minutes was an independent risk factor associated with a greater incidence of upper extremity position–related neurapraxia compared with a duration of <5 minutes with MAP <55 mm Hg. Compared with patients in their control group, patients in the case group had significantly longer duration of surgery. The mean onset time of position-related neurapraxia from the beginning of surgery was 283 minutes (range, 79–700 minutes). Those findings are also in keeping with the argument by Duffy and Tubog that impaired capillary perfusion to nerves is the ultimate mechanism of injury whether the other mechanisms are compression or stretch.
We agree with Duffy and Tubog that everyone on the surgical team has an important role in preventing perioperative nerve injuries. Having a good understanding of the risk factors, vulnerable anatomical positions, preventive measures, and monitoring is critical to minimize the risk of such injuries. We hope all involved in surgery will read the two new papers and heed the recommendations therein and also consider the use of electrophysiologic monitoring at least in patients deemed to be at high risk for perioperative nerve injury. The latter, of course, needs further refinement in studies that might clarify issues such as in which patients and for which procedures would SSEP monitoring prove to be cost-effective.
Some of our prior columns on perioperative nerve injuries:
References:
ASA (Americsn Society of Anesthesiologists). Committee on Standards and Practice Parameters, Jeffrey L. Apfelbaum, M.D. Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies 2018: An Updated Report by the American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies. Anesthesiology 2018; 128(1): 11-26
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2662986
Duffy BJ, Tubog TD. The Prevention and Recognition of Ulnar Nerve and Brachial Plexus Injuries. Journal of PeriAnesthesia Nursing 2017; 32(6): 636-649
Published online: April 14, 2017
http://www.jopan.org/article/S1089-9472(16)30258-1/fulltext
Kamel I, Zhao H, Koch SA et al. The Use of Somatosensory Evoked Potentials to Determine the Relationship Between Intraoperative Arterial Blood Pressure and Intraoperative Upper Extremity Position–Related Neurapraxia in the Prone Surrender Position During Spine Surgery: A Retrospective Analysis. Anesthesia & Analgesia 2016; 122(5): 1423-1433
Kamel IR, Drum ET, Koch SA, Whitten JA et al. The Use of Somatosensory Evoked Potentials to Determine the Relationship Between Patient Positioning and Impending Upper Extremity Nerve Injury During Spine Surgery: A Retrospective Analysis. Anesthesia & Analgesia 2006; 102(5): 1538-1542
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January 9, 2018
More on Fire Risk from Surgical Preps
Among our several columns on surgical fires we have discussed the role of surgical preps as fuels for such fires. Though fuels are but one leg of the “fire triad” (fuel, oxidants, heat source), there are many important interventions we can use to minimize the risks that certain fuels, like alcohol-based surgical preps, present.
A recent study used an ex vivo model to assess the risks of fires from various skin preps (Jones 2017). An electrosurgical “Bovie” pencil was activated for 2 seconds on 30 Watts coagulation mode in 21% oxygen (room air), both immediately and 3 minutes after skin preparation application. No fires occurred with nonalcohol-based preparations. Alcohol-based preparations caused flash flames at 0 minutes in 22% and at 3 minutes in 10% of tests. When examining pooling of alcohol-based preparations, fires occurred in 38% at 0 minutes and 27% at 3 minutes. The authors conclude that following manufacturer guidelines and allowing 3 minutes for drying, surgical fires were still created in 1 in 10 cases without pooling and more than one-quarter of cases with pooling. They recommend that surgeons can decrease the risk of an operating room fire by using nonalcohol-based skin preparations or avoiding pooling of the preparation solution.
Note that the fires in the above model occurred in a room air environment. It would be expected that fires might occur even more readily in the oxygen-rich environments encountered in many surgical cases.
The Canadian Medical Protective Association recently reviewed 54 closed cases of surgical fires and burns in the OR (CMPA 2017). 31% of these involved surgical fires. Incidents involving fuel sources were usually related to incorrectly applying antiseptic agents (usually alcohol-based) during skin preparation by:
CMPA emphasizes that, when preparing the skin, avoid the pooling of antiseptic solutions and allow for sufficient drying before beginning the procedure.
While we usually think about surgical fires occurring most often in procedures around the head and neck or upper thorax, where proximity to an oxygen-rich environment is more likely, surgical fires may occur in more remote areas and in the absence of an oxygen-rich environment. In our January 2011 What's New in the Patient Safety World column “Surgical Fires Not Just in High-Risk Cases” we discussed a case that occurred in Israel during a C-section. The patient had been prepped prior to the planned surgery and allowed to dry off. However, in the OR the surgeon requested the field again be prepped with an alcohol-based prep. This was done and then he began an incision using a diathermy needle and a spark caused the resultant fire. The fire was extinguished and a healthy baby was delivered but the patient suffered severe burns and later required skin grafting to her buttocks and thighs. The Israeli health ministry noted the risk of fire is particularly dangerous in cases where the legs are elevated, promoting pooling of the alcohol-based prep under the buttocks (Even 2010). They also noted the sheets were flammable, which further complicated the case.
Another case (Somers-DeHaney 2008) illustrated that burns may occur at great distance from the airway and in the absence of supplemental oxygen as the oxidizer. A patient underwent a femoral distal bypass graft under general endotracheal anesthesia. The skin was prepared and later re-prepared with an alcohol-based solution that may have saturated skin folds over time producing vapors under the drapes. A sterno-like fire burned the patients' leg after the vapors were exposed to the electrocautery. The authors note that a combination of 3 factors involving alcohol or alcohol prep solutions can lead to fire or burns:
Note that the Israeli case noted above also involved reprepartation of the site.
Somers-DeHaney and Christie went on to describe ECRI Institute recommendations for the use of alcohol-based prep solutions in the operating room:
That last point is a pearl. In the case described by Somers-DeHaney and Christie the surgeon at some point during the procedure reported a heat sensation briefly but ascribed it to something else. It was only while later that the surgical drapes ignited into visible flames.
In emergency situations time pressures may lead to failure to wait an adequate time for skin preps to dry. In our October 1, 2013 Patient Safety Tip of the Week “Fuels and Oxygen in OR Fires” we even noted that, after a patient suffered burns to the neck and shoulders from a fire during an emergency surgical procedure, one hospital (Natt 2013) implemented a policy prohibiting alcohol-based skin preps in any emergency surgery that does not allow sufficient drying time (usually 3 minutes or longer). Instead they went back to non-alcohol-based preps like Betadine for such emergency cases.
In our December 16, 2014 Patient Safety Tip of the Week “More on Each Element of the Surgical Fire Triad” we discussed the Anesthesia Patient Safety Foundation (APSF) article about flammable surgical preps (Cowles 2014). That APSF article has some nice tables listing the alcohol content of commonly used skin preps and alcohol-based hand rubs. It has good advice about the importance of communication in the OR as it pertains to ensuring adequate drying time for surgical preps and assessment for alcohol pooling near the surgical field. It emphasizes that adequate drying time is still important in emergency cases.
Allowing adequate time for skin preps to dry and avoiding pooling of these preps are critical in preventing surgical fires. We know of many hospitals that use timers to ensure that the recommended drying time has elapsed. But that may not be enough. The other “pearl” in the Cowles APSF article about alcohol-based surgical preps is that, whereas the drying time for most such preps is typically at least 3 minutes, drying time of up to 1 hour may be needed when applied to hairy areas, body folds, or body creases. The Jones study in today’s column emphasizes the manufacturer’s suggested drying times of 3 minutes may not be enough in many cases.
And lastly, don’t forget the issue of the “too big” applicator. In our January 10, 2017 Patient Safety Tip of the Week “The 26-ml Applicator Strikes Again!” we described two cases in which surgical fires occurred after use of the 26 ml Chloraprep applicator instead of the 10.5 ml Chloraprep applicator. The smaller applicator did not have the warning to avoid use in head and neck surgery, whereas the 26 ml applicator did have the warning. It is actually quite predictable that staff would assume the new supplies were the same as the old (because the active ingredients and percent of alcohol are the same) and not “read the fine print”. In that column we suggested the most logical way to avoid this mistake is to deliver a real-time message to prevent use of the bigger applicator. How would we do this? We’d add it to the checklists used for the pre-op huddle or the surgical timeout or both. We have long advocated that the surgical fire risk be discussed as part of the pre-op huddle (or pre-op briefing) and, if the case is considered high-risk, respective roles of all OR participants are called out during the surgical timeout. In our January 2011 What's New in the Patient Safety World column “Surgical Fires Not Just in High-Risk Cases” we noted the San Francisco VA checklist “The Surgical Fire Assessment Protocol” (Murphy 2010), This checklist/protocol is actually printed on the reverse side of their larger preoperative checklist. This is really a very good tool! The fire risk is assessed by a simple numerical scale. If the score is 3 (high risk) the rest of the form is filled out, which basically delineates the respective roles of all those participants. That’s a really good way to remind all about their responsibilities in preventing a fire and what to do if a fire occurred. One of the checkbox items for the circulating nurse on that checklist is “Assess that enough time has been allowed for fumes of alcohol-based skin preps to dissipate (minimum of 3 minutes)”. It is there that we would propose adding the warning in bold, colored print that the 26-ml applicator of Chloraprep should not be used in head/neck surgery.
Also, don’t forget that skin disinfectants are not the only substances that are flammable. In our April 2013 What's New in the Patient Safety World column “Reminder: Hand Sanitizers Are Flammable” we reported on a case in which an alcohol-based hand sanitizer contributed to a fire in a young girl. Recently, in the UK, the London Fire Brigade urged doctors to be aware of the risks of prescribing flammable emollient creams for skin conditions such as eczema and psoriasis (Bird 2017). Many moisturizing creams used for common skin conditions such as eczema are based on flammable components, such as paraffin and petroleum. The risks are especially great for smokers, the elderly, those who are less mobile, and patients on oxygen therapy. They note that these creams are especially dangerous if they leach into bedding and clothing, allowing flames to spread rapidly. And because many sufferers use these creams on large areas of their body, there is a high risk of severe burns. This often happens when patients are smoking and drop a cigarette. In fact, at least 37 deaths had been noted in the UK related to such creams since 2010. They offer the following advice regarding such substances:
We hope you’ll look at the many useful recommendations in our previous columns (listed below). And, of course, we again refer you to the valuable resources on surgical fires provided by ECRI Institute, AORN, the FDA, Christiana Care Health System and the APSF.
Our prior columns on surgical fires:
References:
Jones EL, Overbey DM, Chapman BC, et al. Operating Room Fires and Surgical Skin Preparation. J Amer Coll Surg 2017; Published online: February 08, 2017
http://www.journalacs.org/article/S1072-7515(17)30155-2/pdf
CMPA (Canadian Medical Protective Association). Hazards in the operating room: Surgical fires and burns. CMPA 2017; Originally published December 2017 17-23-E
Even D. Operating theater accident sets pregnant woman alight. Hospital staff delivered a healthy baby, but the woman later needed plastic surgery for burns sustained in fire started by diathermic needle. Haaretz.com December 1, 2010
Somers-DeHaney A, Christie J. OR Fire Occurs in Absence of Oxygen Enriched Environment: A Case Report. Anesthesia Patient Safety Foundation Newsletter 2008; 23(1): 8-9
https://www.apsf.org/newsletters/html/2008/spring/06_or_fire.htm
Natt TM. Operating-Room Fire at Hospital Burns Patient, Prompts Changes. thepilot.com August 9, 2013
Cowles CE, Chang JL. Flammable Surgical Preps Require Vigilance. APSF Newsletter 2014; 29(2): 25-28 October 2014
http://www.apsf.org/newsletters/pdf/October2014.pdf
Murphy J. A New Effort to Promote Fire Safety in the OR.
Topics In Patient Safety (TIPS) 2010; 10(6): 3
http://www.patientsafety.va.gov/docs/TIPS/TIPS_NovDec10.pdf#page=3
SF VAMC Surgical Fire Risk Assessment Protocol
http://www.patientsafety.va.gov/docs/TIPS/TIPS_NovDec10.pdf#page=3
Bird E. GPs warned about risks of flammable skin creams. Pulse 2017; 12 June 2017
Christiana Care Health System. Surgical Fire Risk Assessment.
http://www.christianacare.org/FireRiskAssessment
ECRI Institute. Surgical Fire Prevention.
https://www.ecri.org/surgical_fires
AORN (Association of periOperative Registered Nurses). Fire Safety Tool Kit.
https://www.aorn.org/guidelines/clinical-resources/tool-kits/fire-safety-tool-kit
FDA. Preventing Surgical Fires.
http://www.fda.gov/Drugs/DrugSafety/SafeUseInitiative/PreventingSurgicalFires/default.htm
APSF (Anesthesia Patient Safety Foundation). Resources. Fire Safety Video. Prevention And Management Of Operating Room Fires.
http://www.apsf.org/resources/fire-safety/
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January 16, 2018
Just the Fax, Ma'am
We’ll bet the majority of our readers are not old enough to remember Sgt. Joe Friday’s catchphrase “Just the facts, ma’am” on the TV show “Dragnet”. And those same readers probably recognize fax machines as an anachronism. That is, unless they work in a doctor’s office or a hospital! We were shocked to see and hear the recent disclosures about how rampant use of fax machines continues to be in doctors’ offices (Kliff 2017, Hill 2017).
Sarah Kliff and colleagues did a podcast on faxing in doctors’ offices on Vox’s “The Impact” series (Kliff 2017). In Adriene Hill’s interview with Vox’s Sarah Kliff (Hill 2017) it was noted that “Kliff found that it was a combination of culture and well-intended policy that's lead to the fax machine being a staple in doctors' offices.” Kliff had spent a lot of time in backrooms of physician offices and found fax machines “buzzing all the time”. In fact, it appeared that most communication between hospitals and physician offices was via fax rather than, for example, email. Kliff noted that use of faxing has persisted despite 90+% of physician offices now using electronic medical records. Of course, the crux of the problem is lack of interoperability. Simply put, many electronic medical record systems are not interconnected to each other. Kliff describes the situation now as “doctors are printing out their own electronic records, faxing it to another doctor office, and then that doctor uploads the printout of the record into their own electronic record.”
The actual podcast (Kliff 2017) runs about 24 minutes and is quite entertaining and points out the most salient root cause of the problem: business competition. The podcast starts out in a backoffice setting where the fax machine is busy sending or receiving faxes. Sometimes the machine is busy when attempting to send out a fax. A staff member notes that sometimes the faxes are blurry and she has to start the whole process over again. And sometimes the faxes “just don’t show up at all”. It “means calling them and asking them to send records”. Practices often keep thick folders of records they are still waiting to receive. One staff member “estimates that 80% of the faxes she sends need some sort of human intervention”.
Kliff interviewed staff and physicians in several practices. They noted how patients lose time off work because records never came. Often weeks of phone calls and badgering are required to get records and they often have to reschedule appointments because records had not been received. Highlighted were instances where the only way to communicate records from one floor or department of a hospital to another was via fax (because the electronic medical record systems were not capable of interoperability). Staff felt they could do so much more if they didn’t waste time with faxes.
Kliff then goes on to discuss why faxing, variously described as “the cockroach of American medicine” or “clunky” refuses to die. Some office staff say “oh, it’s a HIPAA thing”. Kliff appropriately points out that faxing is not very secure and that HIPAA-secure email is an alternative that is available. She then discusses how the HITECH Act of 2009 “set out to kill the fax”. That act, of course, provided the financial stimulus for widespread adoption of electronic medical records. But there was a fatal flaw: competing businesses guard their info. And that proclivity to hoard information applied both to EMR vendors and to hospitals/practices that were competing for “customers”. EMR vendors did not want to share their secrets with their competitors by allowing sharing of data. And hospitals “down the street” from each other are competing for the same patients and don’t want to share information about those patients.
She interviewed David Blumenthal (former National Coordinator for Health Information Technology), who noted talk is often about “private sector, competition, and choice“ as key principles by which our healthcare system should operate but that raises problems for patient care. Kliff quotes another former ONC director, Farzad Mostishari, “the only way to kill fax is to outlaw it”. But the podcast goes on to discuss that the current administration thinks otherwise, that we need fewer mandates and wants to turn more over to the private sector and “get government out of the way”.
It’s a fascinating podcast and shows that the fax has not died. Rather it seems to still be a major, if not the major, mode of transmitting patient information today. It estimates that billions of patient care-related documents are still transmitted by fax today.
Actually, we are not so surprised. Sometimes when we come to a hospital we’ll wager a friendly bet that we will find certain things (we only bet on things we know are sure winners!). One of those is that we will find alarms that have either been disabled or had their volume altered to make them poorly audible or their parameters have been set so wide that they are unlikely to alarm for important occurrences. Another is that we will find several risk factors for patient suicide. And a third is that we will find examples of problems related to sending or receiving faxed orders or other patient-related material.
So, obviously, it’s worth repeating some of the caveats we raised in our June 19, 2012 Patient Safety Tip of the Week “More Problems with Faxed Orders” and other columns. The problem we have mentioned most often is the missed decimal point (where lines or smudge during fax transmission and printing obscures a decimal point) and the patient receives a 10x overdose of the medication. (In our September 9, 2008 Patient Safety Tip of the Week “Less is More….and Do You Really Need that Decimal?” we cautioned against even using a decimal point when the fraction following the decimal point is clinically irrelevant because that decimal point may be overlooked, especially in faxed orders.) The opposite, of course, may also occur where a smudge on the fax looks like a decimal point (the phantom decimal point) so the patient receives one-tenth the intended amount.
But we’ve also mentioned the case where 2 sheets put into a fax machine stick together and thus only one sheet gets transmitted (see our January 18, 2011 Patient Safety Tip of the Week “More on Medication Errors in Long-Term Care” where we cited such an example from ISMP 2010). Unless you have a cover fax sheet that says “3 pages (cover sheet plus 2 others)” the receiving party may not realize that they are missing a page.
We’ve also seen cases where faxes on multiple patients are sent out at the same time and the receiving party does not recognize that the second sheet is actually for a different patient (see our January 18, 2011 Patient Safety Tip of the Week “More on Medication Errors in Long-Term Care”).
Just as with handwritten orders, on a faxed order with a drug ending in the letter “L” if there is insufficient space between the “L” and the next number, the receiver may think the “L” is actually a “1” (one) and give a dose 10 times too high. And dangerous abbreviations may show up even more frequently on faxed orders than orders written on-site because the provider is more likely to have access to the “do not use” abbreviation list when on-site.
Another mistake is when a person faxes documents that have information on both sides and does not realize that only one side of each page is being faxed.
And remember when you are sending a fax that some elements (eg. text in a different color) may fail to be seen when transmitted. Or that highlighted items (eg. items you tied to stress with a yellow highlighter) may appear blacked out on the received fax! (Reminds me of the time in college when I asked a friend to send me his notes from a class I had missed so I could study for a test the next day. He faxed them and all the important stuff, which he had highlighted with a highlighting marker, was blacked out on the fax!!!).
And one of the most egregious errors of all – faxing to the wrong phone number (the misdirected fax). Ever get a call from the local supermarket that you faxed them a sheet with PHI on it? Your HIPAA compliance officer and risk manager will turn gray when that call comes in! See the discussion at the end of this column.
ISMP Canada (ISMP Canada 2012) came up with a new fax error – the truncation error. They provide a great example of a faxed order for “dalteparin” where the “da” gets cut off in the fax and the “lt” looks like an “H” on the fax, resulting in what clearly looks like an order for “Heparin”. Click on the link above and you’ll see both the faxed prescription and the original.
Note that prescription has lots of other bad errors on it. It uses the do-not-use abbreviation “U” (for units) as well as 2 other abbreviations that should be avoided (“SQ” for subcutaneous and “QD” for once daily). It has a different dose written above and crossed out. And it does not have listed the indication for the drug. It also has an illegible word following the “QD” (is it nitely? or is it a provider’s signature?). And there is nothing on the prescription to indicate the duration of therapy, amount to be dispensed, whether it should be refilled, etc. Who would have thought one prescription could be used as a primer for medication errors!
ISMP Canada notes the importance of reviewing copies of the fax you send or the one you receive. For instance, in the case given one might have noticed that the name of the hospital was also truncated, which might have been a clue that the medication name was truncated. They also note in the example given that the dosing frequency would have been unusual for heparin (it is usually given twice daily or three times daily rather than once daily), perhaps being another clue to the receiver that there was an error. They also note that including both the generic and brand names on the prescription would have provided another clue to the error. They note the importance of engaging the patient to be on the lookout for errors as well.
ISMP Canada lists multiple good recommendations for dealing with faxed orders in their alert. We’ve added some of our own recommendations:
You should have an educational program for all your staff involved in sending and receiving faxed orders (nurses, physicians, clerical staff, etc.). Remember, telling stories about real-life cases where such errors led to bad outcomes is much more effective than just telling them facts and statistics. Tell them one of the stories about a patient getting a 10-fold overdose or the one where a patient got 26 medications (13 of her own and 13 from the sheet faxed in the same batch on a different patient as in our January 18, 2011 Patient Safety Tip of the Week “More on Medication Errors in Long-Term Care”).
And don’t forget that faxing errors don’t just apply to medication orders. Most of the same concerns apply to any patient related material that may be faxed.
There are numerous examples of misdirected fax transmissions containing personal health information. These are often one-time errors but amazingly there are numerous examples in the media of continued recurrences over long periods of time. In one instance (ANewsVanIsland 2011) a person has received at least one such fax per week for over 10 years!!! That person’s phone number was one digit different than the fax number for a medical clinic. Think of all the times you have dialed the wrong phone number and how easy that would be to do when sending a fax.
One of the typical recommendations for avoiding staff keying in the wrong fax number is to use pre-programmed fax numbers. However, that practice has its own set of unintended consequences in that those fax numbers need to be up to date. We’ve seen faxes sent to old fax numbers after a physician has moved to a new office and even faxes sent to physicians who have been deceased for four years! And hospital computer systems often have the wrong physician listed as primary care physician, often leading to faxes being sent to the wrong PCP.
Both AHIMA (Davis 2006) and HIMSS (Demster 2007) had good guidelines on sending and receiving personal health information via fax. It appears that neither of these documents is currently available but you may wish to search the AHIMA and HIMSS websites for updates. Some of the highlights from those original guidelines are still quite valid:
Another point to remember: just because your fax machine indicated your sent fax was received at the number you sent it to does not mean that (1) it was printed out completely and legibly without smudges, etc. and (2) it reached the person for whom it was intended.
And often not mentioned is the fact that copies of what you copied or faxed may remain in the memory or hard drive of your fax machine. We remember a situation where the local police department donated some old fax machines to charity and confidential police records were found in the memory of those machines! The same could obviously happen with a patient’s personal health information on it.
Lastly, the best solution is not to fax at all! As electronic medical record systems are evolving, check to see what your capabilities are for exporting or importing information from other EMR’s. We’ve seen many examples where such capabilities exist, yet practices persist in using the fax machine out of habit. Enabling faxing from within EMR/EHR systems can also improve productivity, security and HIPAA compliance. Similarly, in those areas where regional health information exchanges (HIE’s) have been established, use your connectivity with those HIE’s to share data.
References:
Hill A, McHenry S. Why your doctor still relies on fax machines. Marketplace 2017; December 27, 2017
https://www.marketplace.org/2017/12/27/health-care/why-your-doctor-still-relies-fax-machines
Kliff S, Pinkerton B, Weinberger J, Drozdowska A. It’s 2017. Why does medicine still run on fax machines? Vox “The Impact” (podcast) 2017; October 30, 2017
https://www.vox.com/2017/10/30/16387306/american-medicine-healthcare-fax-machine
ISMP (Institute for Safe Medication Practices). Order scanning systems (and fax machines) may pull multiple pages through the scanner at the same time, leading to drug omissions. ISMP Medication Safety Alert (Nurse Advise-ERR) 2010; 8(11): 1-2
http://www.ismp.org/newsletters/nursing/default.asp
ISMP Canada. ALERT: Medication Mix-up with a Faxed Prescription. ISMP Canada Safety Bulletin 2012; 12(6): 1-3 June 5, 2012
ANewsVanIsland. Medical Records Shared with Roofer. Mar 1, 2011
http://www.youtube.com/watch?v=6z0eIs8LaxM
Davis, Nancy, et al.. "Facsimile Transmission of Health Information." (AHIMA Practice Brief, updated August 2006).
http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_031811.hcsp?dDocName=bok1_031811
Demster B. HIMSS Privacy and Security Toolkit. Managing Information Privacy & Security in Healthcare. Communication Tools. January 2007
http://www.himss.org/content/files/CPRIToolkit/version6/v7/D80_Communication_Tools.pdf
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January 23, 2018
Unintentional Hypothermia Back in Focus
Our Patient Safety Tip of the Week for December 4, 2012 “Unintentional Perioperative Hypothermia: A New Twist” discussed unintentional hypothermia occurring during surgical procedures, primarily cesarean deliveries, performed under spinal anesthesia using morphine. The “twist” was that some of these patients had paradoxical sweating (or vasodilation or feeling “hot”) despite profound hypothermia.
Three articles in the January 2018 issue of Anesthesia & Analgesia discuss the issue of unintentional hypothermia in obstetrics. Using an intestinal telemetric sensor, a rapid decrease in core temperature was documented during cesarean delivery under spinal anesthesia (du Toit 2018). Fifty percent of participants in this study became hypothermic. Although the surgical procedure is typically of short duration, women undergoing spinal anesthesia for cesarean delivery experience significant hypothermic exposure and compromised thermoregulation for several hours.
Participants reached their intestinal temperature nadir after a median of 1 hour. The majority of participants experienced a continued decrease in intestinal temperature after leaving the operating room. Interestingly, despite the significant decrease in core temperature, the median thermal comfort score remained zero (neutral) at all but the late afternoon measurement time.
In another study, Munday and colleagues found that a short period of preoperative warming is not effective in preventing intraoperative temperature decline for women receiving intrathecal morphine (Munday 2018). This was a prospective, single-blinded, randomized controlled trial compared 20 minutes of forced air warming (plus intravenous fluid warming) versus no active preoperative warming (plus intravenous fluid warming) in 50 healthy American Society of Anesthesiologists graded II women receiving intrathecal morphine as part of spinal anesthesia for elective cesarean delivery.
Allen and Habib (Allen 2018), in their editorial accompanying the two new articles on unintentional hypothermia, lament the relative lack of proven interventions to prevent or treat hypothermia in obstetrical patients. They note that current core temperature monitoring practices and temporary management guidelines will need to be updated. They also emphasize the need to extend the duration of temperature monitoring well beyond the early recovery period.
Interestingly, none of the 3 new articles even mentions the phenomenon we highlighted in our Patient Safety Tip of the Week for December 4, 2012 “Unintentional Perioperative Hypothermia: A New Twist”. Specifically, there appears to be a syndrome related to cases (most often obstetrical) in which spinal anesthesia with morphine is used and patients develop hypothermia with paradoxical sweating (Ryan 2012, Hess 2005). Though most cases in the literature have followed cesarean sections, the case described by Ryan et al. was in a patient who underwent a knee arthroplasty. Spinal anesthesia was used with 11 mg of isobaric 0.5% bupivacaine, 15 micrograms of fentanyl, and 150 micrograms of morphine. The patient’s temperature reached a low point of 33.6 degrees C four hours after surgery, though at times her temperature could not be recorded by any route. Despite the hypothermia she felt hot and was diaphoretic without shivering. Warming efforts using forced air warming blankets, infusion of warmed intravenous fluids, and hourly bladder irrigation with warm saline were not successful in elevating her temperature. But a quick literature search by the authors showed the syndrome often responds to benzodiazepines and their patient rapidly became normothermic after receiving a small sublingual dose (0.5 mg) of lorazepam. The authors go on to discuss the cases in the literature and the current theory of the pathogenesis of this syndrome. The theory is that enough of the morphine ascends in the subarachnoid space to reach the hypothalamus where it interacts with receptors important in thermoregulation. Essentially this leads to alteration of the hypothalamic thermoregulatory set point causing the body to feel hot and sweat in attempt to adapt to heat. Benzodiazepine receptors are also found in the hypothalamus and are probably also involved in thermoregulation.
Hess et al had reported on 14 patients who developed hypothermia following cesarean sections in which they had received spinal anesthesia with bupivacaine, morphine and fentanyl (Hess 2005). All had diaphoresis and felt hot. Four of the 14 were given lorazepam and had prompt resolution of symptoms and rapid increase in temperature. The remainder, who received conventional management of hypothermia, were hypothermic and symptomatic for 6 hours on average. The authors subsequently observed 100 consecutive patients and found 6% developed symptomatic hypothermia lasting for several hours.
Another article (Giladi 2015) discussed the differential diagnosis of prolonged hypothermia following cesarean delivery and concluded the patient likely had the syndrome of hypothermia with paradoxical sweating induced by spinal anesthesia with morphine.
There is some evidence suggesting that this phenomenon might be dose-related. In a randomized controlled trial Hui and colleagues randomized patients undergoing elective cesarean section to receive either 150 micrograms of morphine or normal saline along with the bupivacaine in their spinal anesthesia (Hui 2006). They found that both groups developed hypothermia but that the maximum decrease in temperature was greater in the morphine group and of longer duration. This suggests that even a low dose of morphine may intensify the hypothermic effect of spinal anesthesia. However, they point out that many of the cases in the literature had much higher doses of morphine. In fact, they note that larger doses are avoided because they are often associated with nausea, vomiting, pruritis and shivering.
In at least 3 cases hypothermia after intrathecal morphine has improved promptly after administration of naloxone. In one case (Sayyid 2003) the patient’s temperature had dropped to 33.6 degrees C after a cesarean section and the patient was sweating excessively despite the hypothermia. She also had nausea, vomiting, pruritis and some sedation. Following naloxone administration all the above symptoms disappeared and she developed shivering and cessation of sweating concomitant with rising body temperature. In the other case (Mangus 2011) a patient developed hypothermia unresponsive to usual warming measures several hours after a cesarean section in which she received intrathecal morphine. Severe pruritis and lethargy were also present. Naloxone was administered intravenously in incremental doses and her temperature began to rise within 5 minutes. The pruritis and lethargy also improved and her pain control was never compromised. In another case profound hypothermia followed intrathecal injection of an unintended high dose of morphine for a cesarean delivery (Kanazawa 2015). Within 2 hours after completion of surgery, the patient’s axillary temperature decreased to 35.0°C despite an ambient temperature of 25°C. Despite active warming with a forced-air warming device, her temperature continued to drop to 34.0°C over the next 3 hours. The patient was not aware of hypothermia. In fact, she felt hot and was perspiring profusely. After review of the anesthesia record revealed that 1 mg of morphine had been injected intrathecally, 0.2 mg of naloxone was administered intravenously over a 10-minute period. Soon after starting the naloxone injection, the patient felt cold and demonstrated extensive shivering, while her axillary temperature rapidly rose to 35.5°C over the next hour. Nausea and respiratory depression also subsided thereafter.
Another article demonstrated that atropine could stop the excessive sweating associated with intrathecal morphine or fentanyl administration (Mazy 2016). Excessive sweating was observed in three cases among 217 consecutive patients wo underwent lower limb orthopedic surgery under spinal anesthesia using intrathecal morphine or fentanyl administration. The sweating began about 3 hours after spinal injection. Atropine promptly stopped the sweating in 3 cases, followed by slow rise in body temperature. The Mazy article has an excellent discussion about the potential mechanisms. The delayed onset was explained as the time elapsed until cephalad spread of morphine to the hypothalamic opioid receptors involved in temperature regulation.
Admittedly, many of the patients in the 3 new articles were said to have shivering, and sweating was not mentioned. Therefore, those patients may have had different mechanisms responsible for the hypothermia than the mechanism postulated in the Ryan and Hess articles. Nevertheless, it is very important to recognize the hypothermia with paradoxical sweating phenomenon since, as in the case described by Ryan, there may be prompt resolution after a small sublingual dose of lorazepam.
Perioperative hypothermia can have serious adverse consequences, including increased risk of surgical site infections, myocardial ischemia, prolongation of drug effects, bleeding diatheses, shivering, pressure ulcers, poor patient satisfaction, and increased economic effects due to things like increased length of stay (Hart 2011). This excellent review of unintended perioperative hypothermia by Hart and colleagues at the Ochsner Clinic does not mention the “hypothermia with paradoxical sweating” phenomenon. Nor did it consider spinal anesthesia with opioids as a risk factor for hypothermia.
Likewise, this phenomenon also receives little or no attention in most of the major guidelines and other resources on perioperative hypothermia (ASPAN 2010, PPSA 2008, NICE 2008, NICE 2017, AORN 2007, AORN 2013, AORN 2017).
But another study by Munday and colleagues (Munday 2017) refutes the association between perioperative hypothermia and use of intrathecal morphine. That study was a retrospective case controlled study of patients undergoing spinal anesthesia for cesarean delivery, comparing 179 who received intrathecal morphine and 179 without intrathecal morphine (control group). Administration of intrathecal morphine (combined with intrathecal fentanyl and hyperbaric bupivacaine) is standard care in their institution; therefore, the no morphine group was selected first by identifying patients who, because of clinical reasons such as allergy, did not receive intrathecal morphine. This group was then matched with patients who did receive intrathecal morphine. There was no significant difference in mean postoperative temperature for the morphine group (mean postanesthesia care unit arrival temperature, 35.91°C) and the no morphine group (mean postanesthesia care unit arrival temperature, 35.88°C). However, paradoxical sweating was noted in only 3 patients in the morphine group and 1 in the no morphine group. This study did show that there was a decline in core temperature in both groups preoperatively to postoperatively that was statistically and clinically significant. However, overall the fall in temperature was considerably less than that described in the published cases of “unintentional hypothermia with paradoxical sweating”.
Quite frankly, given the difficulties maintaining normothermia in this patient population and given that the timeframe and duration of hypothermia would be compatible with the theoretical “resetting of the hypothalamic thermostat”, we are surprised that no one seems to have tried either lorazepam or naloxone in those cases even though they lacked paradoxical sweating.
Undoubtedly, there would be concern about exposing a neonate to the effects of lorazepam or naloxone or any other drug. However, since the hypothermia extends long after the cesarean delivery, use of lorazepam to reverse hypothermia would be an option after the delivery.
As we noted in our original column, the importance of recognizing the “hypothermia with paradoxical sweating” is twofold. First, you may want to limit the dose of intrathecal morphine used. Second, you need to amend your hypothermia management protocols to take this phenomenon into account. Specifically, there should be a prompt to consider the phenomenon if the expected improvement in hypothermia is not occurring within a reasonable amount of time after conventional warming procedures have been instituted. Perhaps even a prompt at the beginning of your protocol to look for signs you would not expect with hypothermia (i.e. sweating, hot feeling, vasodilation) might suggest this unusual etiology for the hypothermia. The presence of nausea and pruritis might be an additional clue. In either case the prompt should remind you to consider a trial of either low dose benzodiazepine or naloxone.
You probably should have a formal protocol you follow for prevention and management of perioperative hypothermia. Use one of the above mentioned guidelines to start with. But make sure that whatever protocol you choose you add that prompt we noted above to at least consider the possibility of the morphine-induced syndrome because its management requires additional considerations.
Some of our previous columns on maternal and ob/gyn issues:
February 5, 2008 “Reducing Errors in Obstetrical Care”
February 2010 “Joint Commission Sentinel Event Alert on Maternal Deaths”
April 2010 “RCA: Epidural Solution Infused Intravenously”
July 20, 2010 “More on the Weekend Effect/After-Hours Effect”
August 2010 “Surgical Case Listing Accuracy”
September 7, 2010 “Patient Safety in Ob/Gyn Settings”
January 2011 “Surgical Fires Not Just in High Risk Cases”
February 8, 2011 “Inducing Too Early”
April 2011 “Ob/Gyn Patient Safety Programs”
April 24, 2012 “Fire Hazard of Skin Preps Oxygen”
July 2012 “WHO Safe Childbirth Checklist”
December 4, 2012 “Unintentional Perioperative Hypothermia: A New Twist”
September 2013 “Full-Time Laborists Reduce C-Section Rates”
October 2013 “Challenging the 39-Week Campaign”
November 2013 “The Weekend Effect: Not One Simple Answer”
January 2014 “It MEOWS But Doesn’t Purr”
May 13, 2014 “Perioperative Sleep Apnea: Human and Financial Impact”
August 19, 2014 “Some More Lessons Learned on Retained Surgical Items”
November 3, 2015 “Medication Errors in the OR - Part 2”
February 7, 2017 “Maternal Safety Bundles”
References:
du Toit L, van Dyk D, Hofmeyr R, et al. Core Temperature Monitoring in Obstetric Spinal Anesthesia Using an Ingestible Telemetric Sensor. Anesthesia & Analgesia 12018; 126(1): 190-195, January 2018
Munday J, Osborne S, Yates P, et al. Preoperative Warming Versus no Preoperative Warming for Maintenance of Normothermia in Women Receiving Intrathecal Morphine for Cesarean Delivery: A Single-Blinded, Randomized Controlled Trial. Anesthesia & Analgesia 2018; 126(1): 183-189, January 2018
Allen TK, Habib AS. Inadvertent Perioperative Hypothermia Induced by Spinal Anesthesia for Cesarean Delivery Might Be More Significant Than We Think: Are We Doing Enough to Warm Our Parturients? Anesthesia & Analgesia 2018; 126(1): 7-9
Ryan KF, Price JW, Warriner CB, Choi PT. Persistent hypothermia after intrathecal morphine: case report and literature review. Can J Anesth 2012; 59: 384-388
http://www.springerlink.com/content/w05129787067346h/
Hess PE, Snowman CE, Wang J. Hypothermia after cesarean delivery and its reversal with lorazepam. Int J Obstet Anesth 2005; 14(4): 279-283
http://www.obstetanesthesia.com/article/S0959-289X%2805%2900033-6/abstract
Giladi Y, Ioscovich A. Hypothermia Following Intra-Thecal Morphine Injection during Cesarean. Section a Case Report and Literature Review. J Anesth Clin Res 2015, 6: 4
Hui C-K, Huang C-H, Lin C-J, et al. A randomised double-blind controlled study evaluating the hypothermic effect of 150 μg morphine during spinal anaesthesia for Caesarean section. Anesthesia 2006; 61(1): 29-31
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2005.04466.x/full
Sayyid SS, Jabbour DG, Baraka AS. Hypothermia and Excessive Sweating Following Intrathecal Morphine in a Parturient Undergoing Cesarean Delivery. Reg Anesth Pain Med 2003; 28(2): 140-143
Mangus DB, Neumann M, Patchin R. Naloxone reversal of hypothermia following intrathecal morphine for cesarean delivery, a case report. Society for Obstetric Anesthesia and Perinatology 2011; SOAP 2011 Abstract #201
http://soap.org/display_2011_abstract.php?id=201
Kanazawa S, Okutani R. Hypothermia after accidental intrathecal
administration of high-dose morphine. Circulation Control 2015; 36: 25-27
https://www.jstage.jst.go.jp/article/ccm/36/1/36_25/_pdf
Mazy A. Excessive sweating following intrathecal μ agonists: Effective atropine management. Egyptian Journal of Anaesthesia 2016; 32(3): 397-402
https://www.sciencedirect.com/science/article/pii/S1110184916300253
Hart SR, Bordes B, Hart J, et al, Unintended Perioperative Hypothermia, The Ochsner Journal 2011; 11: 259-270
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3179201/
ASPAN (American Society of PeriAnesthesia Nurses). Normothermia Clinical Guideline. ASPAN’s Evidence-Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia.
http://www.aspan.org/Clinical-Practice/Clinical-Guidelines/Normothermia
Hooper VD, Chard R, Clifford, T, et al. ASPAN’s Evidence-Based Clinical Practice Guideline for the Promotion of Perioperative Normothermia: Second Edition. Journal of PeriAnesthesia Nursing 2010; 25(6): 346-365
PPSA (Pennsylvania Patient Safety Authority). Prevention of Inadvertent Perioperative Hypothermia. Pa Patient Saf Advis 2008; 5(2): 44-52
http://patientsafety.pa.gov/ADVISORIES/Pages/200806_44.aspx
NICE (National Institute for Health and Care Excellence). Hypothermia: prevention and management in adults having surgery. Clinical guideline [CG65]. National Institute for Health and Clinical Excellence 2008; last updated December 2016
http://guidance.nice.org.uk/CG65/NICEGuidance/pdf/English
NICE (National Institute for Health and Care Excellence). Inadvertent perioperative hypothermia overview. NICE Pathway 2017; Update 29 March 2017
AORN (Association of periOperative Registered Nurses). AORN Recommended Practices Committee. Recommended practices for the prevention of unplanned perioperative hypothermia. AORN J 2007; 85(5): 972-988
http://onlinelibrary.wiley.com/doi/10.1016/j.aorn.2007.04.015/full
AORN (Association of periOperative Registered Nurses). Prevention of Hypothermia. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2013
https://www.aorn.org/guidelines
AORN (Association of periOperative Registered Nurses). Guideline for prevention of unplanned patient hypothermia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc 2017: 567-590
https://www.aorn.org/guidelines
Munday J, Osborne S, Yates P. Intrathecal Morphine–Related Perioperative Hypothermia in Women Undergoing Cesarean delivery: A Retrospective Case-Control Study
Journal of PeriAnesthesia Nursing 2017; article in press
http://www.jopan.org/article/S1089-9472(16)30251-9/abstract
Print “Unintentional Hypothermia Back in Focus”
January 30, 2018
Texting Errors Revealed
When Joint Commission considered allowing texting of orders we took an immediate stance against the practice (see our May 24, 2016 Patient Safety Tip of the Week “Texting Orders – Is It Really Safe?”), citing numerous opportunities for error and misinterpretation with texted orders.
Joint Commission reconsidered (see our January 2017 What’s New in the Patient Safety World column “Joint Commission Thinks Twice About Texting Orders”) and, thankfully, reimposed its ban on texted orders.
Then in our June 27, 2017 Patient Safety Tip of the Week “Texting – We Told You So!” we began to show examples of the pitfalls of texted orders.
Now ISMP (ISMP 2017a) has accumulated many more examples of patient safety issues created by texting. ISMP did an extensive survey of its readership and identified some interesting findings. First, while 33% of the total healthcare professionals surveyed felt that texted orders should not be allowed under any circumstance, 55% of medication/patient safety officers and risk/quality managers felt they should not be allowed under any circumstance. Not surprisingly, physicians were the group least concerned about the safety of texted orders.
Particularly bothersome was the finding that, despite most hospitals having policies banning texted orders, the practice continues. And many, if not most, texted orders are being sent without encryption.
Another interesting wrinkle is that pharmacists and nurses often communicate with prescribers via text messages for clarification of orders. And the person entering the order into the electronic medical record or ordering system often does not indicate the source of the order was a text message.
Some of the problems associated with texting are ones we noted in our original May 24, 2016 Patient Safety Tip of the Week “Texting Orders – Is It Really Safe?”. For example, we speculated that the autocorrect feature on most smartphones might change the intended word(s) to something else. Most respondents to the ISMP survey felt that the autocorrect feature should be disabled on any smartphone used for texting orders.
Common texting abbreviations are a threat. We’ve spoken before about the example of a texted “2day” (meaning “today”) getting misinterpreted as “two daily” (ISMP 2009). ISMP provided some other examples of errors related to texted abbreviations last summer (ISMP 2017b) and the latest ISMP survey (ISMP 2017a) uncovered a new one: the text abbreviation “BTW” (meaning “by the way”) was misinterpreted as meaning “twice daily”.
The potential for patient misidentification is serious, not only because the sender may not be seeing the patient medical record, but because the sender may not have access to the second identifier (eg. date of birth) that would be used in verification of patient identity. One example given was a texted order to “discharge patient in Room xxx” when the intended patient had previously been transferred to a different room.
Misspellings and incomplete orders were also cited in the survey as special concerns. Misspellings are a particular concern for patient names and drug names (particularly for those drugs that sound alike). ISMP notes that, unlike selecting drugs and doses from a drop-down menu in CPOE, most texted orders must be entered as free-text or via a voice-recognition feature that may be misheard and, thus, misspell words, including drug names. Similarly, orders entered via free text are more likely to omit all the required elements of a complete order.
Texting orders or any health information to the wrong person is a serious issue. Remember when we told a story about patient orders being faxed to the local supermarket? Well the ISMP survey revealed a case of an order being texted to someone outside the hospital. We all laugh about “butt dialing” the wrong person and we’ve all probably done that a few times on our cell phones. What if we mistakenly enter orders (or any PHI) in a message that we send to the wrong phone number?
We all like the convenience of texting and the fact that such a form of asynchronous communication helps us avoid playing telephone tag and save time. But that very asynchronous nature of texting can give rise to problems when urgency is an issue. In our February 9, 2016 Patient Safety Tip of the Week “It was just a matter of time…” we discussed a case where an alarm alert message went to the wrong person (a person who was not the responsible party to respond to that alarm alert). When you text a message that requires an urgent response you need some way of verifying that the responsible party has received and acknowledged the message and is responding appropriately.
“Range of urgency” was one of the themes identified in the study by Luxenberg and colleagues (Luxenberg 2017) that we discussed in our June 27, 2017 Patient Safety Tip of the Week “Texting – We Told You So!”. You’ll recall they looked at a sample of text messages on an internal medicine service at UCSF. The vast majority (93%) of text messages were non-urgent. But most did not indicate the degree of urgency or the expected response. For example, some text messages had a tag “FYI” (for your information) but actually asked a question in the body of the text message for which a response was expected.
And here’s another problem. You’ve heard us say that, when we ask nurses how they identify a person calling in verbal orders, the usual response is “we recognize their voice”. Well, the problem is even worse with texted orders. How do you really know who is on the sending end of a texted order? So any texted communication (not just orders) must be done over a secure system where you can verify the identity of the text sender. Regrettably, that does not protect against the owner of the device sending the text from giving his/her password to someone else. But, of course, the same problem (sharing passwords) exists with CPOE or any EMR system.
And, while we all assume that texting reduces telephone tag and saves us time, we know of no studies in healthcare that confirm that. It is possible that the terse nature of text messages might actually lead to telephone tag since clarification of some questions and responses may require such phone communication.
ISMP disagreed with comments from some survey respondents who thought that texting might be safer than verbal or telephone orders. ISMP noted that at least with verbal or telephone orders the person receiving the communication must read back the order for clarification, accuracy and understanding. (See also our January 10, 2012 Patient Safety Tip of the Week “Verbal Orders”.)
See our May 24, 2016 Patient Safety Tip of the Week “Texting Orders – Is It Really Safe?” and our January 2017 What's New in the Patient Safety World column “Joint Commission Thinks Twice About Texting Orders” for all the areas of concern we had regarding texted orders:
We applaud the strong stance against texting orders that ISMP (ISMP 2017a) has clearly taken: “The texting of medication-specific orders should not be allowed until the safety issues have been identified and resolved through advanced technology along with the development of vetted, industry-wide clinical guidelines that can be employed in organizations to ensure standardized, safe, and secure texting processes. Leadership must establish and communicate policies on the texting of orders and take a strong stance on avoiding texted medication-specific orders at this time until they can be safely introduced into healthcare through careful pilot testing and implementation plans.”
And CMS (Centers for Medicare & Medicaid Services) also recently issued a clarification about its stance on texting (CMS 2017). “CMS does not permit the texting of orders by physicians or other health care providers. The practice of texting orders from a provider to a member of the care team is not in compliance with the Conditions of Participation (CoPs) or Conditions for Coverage (CfCs).“
CMS recognizes CPOE (Computerized Provider Order Entry) as the preferred method of order entry and reaffirms that a physician or Licensed Independent Practitioner (LIP) should enter orders into the medical record via a hand written order or via CPOE.
CMS does recognize that the use of texting as a means of communication with other members of the healthcare team has become a reality. So for communications other than orders it allows texting but specifies that “all providers must utilize and maintain systems/platforms that are secure, encrypted, and minimize the risks to patient privacy and confidentiality as per HIPAA regulations”. CMS also expects that providers/organizations “will implement procedures/processes that routinely assess the security and integrity of the texting systems/platforms that are being utilized, in order to avoid negative outcomes that could compromise the care of patients.”
We all like the convenience of texting and the fact that such a form of asynchronous communication may help us save time in certain circumstances. But in healthcare we need to take every precaution to avoid allowing texting to contribute to medical errors and adverse patient outcomes. Every healthcare organization needs to comply with The Joint Commission and CMS bans on texting orders. Moreover, doing in your organizations the sort of in-depth review of texting practices that UCSF did (Luxenberg 2017) or addressing the issues raised in the ISMP studies and our prior columns may prove eye-opening.
See our other Patient Safety Tip of the Week columns dealing with texting:
See some of our other Patient Safety Tip of the Week columns dealing with unintended consequences of technology and other healthcare IT issues:
References:
ISMP (Institute for Safe Medication Practices). ISMP survey shows provider text messaging often runs afoul of patient safety. ISMP Medication Safety Alert! Acute Care Edition. November 16, 2017
http://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=1182
ISMP (Institute for Safe Medication Practices). Safety Brief: “2day” gets “86ed.” ISMP Medication Safety Alert! Acute Care Edition 2009; February 26, 2009
https://www.ismp.org/newsletters/acutecare/archives/Feb09.asp
ISMP (Institute for Safe Medication Practices). The texting debate: Beneficial means of communication or safety and security risk? ISMP Medication Safety Alert! Acute Care Edition. June 29, 2017
http://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=1170
Luxenberg A, Chan B, Khanna R, et al. Efficiency and Interpretability of Text Paging Communication for Medical Inpatients. A Mixed-Methods Analysis. JAMA Intern Med 2017; Published online June 19, 2017
http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2631559
CMS (Centers for Medicare & Medicaid Services). Memorandum: Texting of Patient Information among Healthcare Providers. December 28, 2017
Print “Texting Errors Revealed”
February 6, 2018
Adverse Events in Inpatient Psychiatry
Much of the good patient safety literature related to behavioral health comes from the VA health system. Two new studies from the VA shed light on some of the adverse events encountered on inpatient behavioral health units.
Mills and colleagues searched the VA’s national database for any reported adverse event that occurred on an inpatient mental health unit over a two year period and found 87 Root Cause Analysis (RCA) reports and 9780 safety reports (Mills 2018). The RCA’s included 31suicide attempts, 16 elopements, 10 assaults, 8 events involving hazardous items on the unit, 7 falls, 6 unexpected deaths, 3 overdoses and 6 cases coded as “other”. In safety reports falls were the most common event, followed by medication events, verbal assaults, physical assaults, medical problems and hazardous items on the unit. Mills and colleagues recommend that mental health unit staff should undertake a structured assessment of all risk on their units and that such a broad approach may be more successful than focusing on a particular event type.
Another study from the VA health system interviewed staff in 7 hospital-based mental health settings for insights on causes of patient safety events and the factors that constrain or facilitate patient safety efforts (True 2017). Those researchers found that protective factors included: promoting a culture of safety, advocating for patient-centeredness, and engaging administrators and organizational leadership to champion these changes.
We’ve discussed suicide attempts, violent behaviors, and elopements in multiple columns (listed below) and will not further discuss them now. However, one point from the current Mills study worth noting is that, since the VA focus on reducing all types of anchor points, available methods for suicide attempts are less lethal, such as use of plastic bags used for asphyxiation and use loose screws and poorly-maintained windows. This likely attests to the success of the from the VA’s Mental Health Environment of Care Checklist, which we’ve discussed in so many columns.
But we will reiterate the many medical issues we first discussed in our May 10, 2016 Patient Safety Tip of the Week “Medical Problems in Behavioral Health”. Behavioral health units, whether they are standalone facilities or part of general hospitals, are prone to many adverse events due to medical rather than psychiatric conditions. There are a variety of factors predisposing to such events and barriers to preventing them (see below).
Medical “Clearance”
What should be done during “medical clearance” in the emergency room prior to admission to behavioral health units has long been debated. Most now agree that the medical history and physical should direct the need for laboratory or imaging studies and that there really is no standard battery of tests that should be done. Most testing is unnecessary and wasteful and delays admission to behavioral health. Traditionally, the main goal of the “medical clearance” is to be sure that the patient’s behavioral health presentation is not the result of an underlying medical condition. But equally important should be identification of medical problems that are likely to complicate management during a behavioral health admission.
As above, “routine” lab testing is seldom of value as part of the medical clearance. Even drug toxicology screening is of limited benefit. Such drug screening is more likely to identify recent use of drugs rather than identify drugs contributing to the current behavioral health condition. However, we’d like to highlight one problem that may be becoming more troubling. The ever-increasing use of long-acting and/or delayed release formulations of opioids raises specific concerns. We’ve seen patients who have taken such drugs and been alert in the ER with low levels of drug in their urine screen yet become obtunded due to opioid intoxication the following day due to the delayed absorption of these drugs.
Falls
Falls are probably one of the more frequent adverse events on behavioral health units. In our Patient Safety Tips of the Week for January 15, 2013 “Falls on Inpatient Psychiatry” we noted that falls are disproportionately more frequent on behavioral health units compared to med-surg units. In that column and in our December 3, 2013 Patient Safety Tip of the Week “Reducing Harm from Falls on Inpatient Psychiatry” we noted also that injuries from falls are also more likely with falls on psychiatric/behavioral health units.
One reason for more falls is likely that patients are more active on behavioral health units. But the other big reason is related to the medications used in behavioral health. Most importantly, they are on a variety of medications that may increase the fall risk (antipsychotics, antidepressants, sedative/hypnotics, and others). Some may be confused or agitated. Others may have impaired gait or balance, sometimes as a result of extrapyramidal side effects of their medications. Many of the medications cause orthostatic hypotension. The elderly patient on the behavioral health unit is especially at risk for falls with injury. Another factor is that sometimes behavioral health units restrict use of canes or other devices that could assist ambulation because such might also be used as weapons.
Our March 14, 2017 Patient Safety Tip of the Week “More on Falls on Inpatient Psychiatry” was a comprehensive discussion on falls in the inpatient behavioral health setting and we refer you to that column and the ones listed above for details and recommendations. That column discussed risk factors for falls, such as prior history of falls, activity levels, primary psychiatric diagnosis, medications, sleep disturbances, and coexisting medical conditions. It also emphasized that, just as on general medical units, falls are often related to toileting activities. It also discussed environmental risk factors for falls, and system issues such as time of day, miscommunication, equipment issues, and issues with the culture of safety. We also noted that staff may not see psychiatric patients as medically ill and thus may overlook their need for assistance in avoiding falls.
That column also discussed fall risk assessment tools and how they apply to patients on behavioral health units. But we can’t overemphasize the fact that, just like on med-surg units, fall risk is a dynamic risk and may change during the course of a behavioral health stay. For example, extrapyramidal side effects may gradually evolve after certain drugs have been started so patients should be examined daily to identify the occurrence of extrapyramidal side effects and the fall prevention strategies modified appropriately as they occur.
We refer you to the 3 columns listed above for details and recommendations on prevention of falls and injuries from falls on behavioral health units.
Seizures
Seizures are not uncommon on behavioral health units. Many of the drugs used may lower the seizure threshold, particularly in patients with a previous history of seizures. Withdrawal syndromes are a major concern, too (keeping in mind that substance abuse a common comorbidity in behavioral health patients) and seizures may be part of those syndromes. While seizures from alcohol withdrawal typically occur early after abstinence, withdrawal from cessation of drugs like benzodiazepines typically occur much later. And in patients with pre-existing seizure disorders who have been on anticonvulsant therapy it is important to recognize they may have been poorly adherent to their regimen. You should check their serum anticonvulsant levels (if they are on anticonvulsants that have therapeutic ranges) and make dosage adjustments as appropriate.
Most importantly, staff need to be trained in what to do when a seizure does occur. That includes ensuring the patient does not injure him/herself during the seizure and knowing how to get help in determining the cause of the seizure and any subsequent management steps. They also need to consider how other patients on the unit might react to seeing a seizure (and especially prevent those patients from inadvertently injuring a patient in attempt to help).
Cardiovascular Events
Cardiovascular events may also occur on behavioral health units. We noted orthostatic hypotension as a cause for falls. Orthostatic hypotension may also cause syncopal episodes. A whole host of drugs used in behavioral health, particularly certain antidepressants and antipsychotic drugs, may cause orthostatic hypotension. We won’t repeat our usual harangue about how to properly assess for orthostatic hypotension but if you really want to know go back to our Patient Safety Tip of the Week for January 15, 2013 “Falls on Inpatient Psychiatry”.
Weight gain, metabolic syndrome, glucose intolerance and frank diabetes mellitus may be seen as side effects of several medications used in behavioral health, most notably the atypical antipsychotics. Such may predispose to cardiovascular events.
Torsade de Pointes is a form of ventricular tachycardia, often fatal, in which the QRS complexes become “twisted” (changing in amplitude and morphology) and is best known for its occurrence in patients with long QT intervals. In our June 29, 2010 Patient Safety Tip of the Week “Torsade de Pointes: Are Your Patients At Risk?” we discussed the risks of this potentially fatal syndrome in hospitalized patients. Though cases of the long QT interval syndrome (LQTS) may be congenital, many are acquired and due to a variety of drugs that we prescribe. And many of those drugs may be used in behavioral health settings. Perhaps the best known are haloperidol and methadone but a variety of antipsychotic drugs and antidepressants may prolong the QT interval (see our February 5, 2013 Patient Safety Tip of the Week “Antidepressants and QT Interval Prolongation”). For a full list of drugs that commonly cause prolongation of the QT interval and may lead to Torsade de Pointes, go to the CredibleMeds™ website. So if one of these drugs will be prescribed for a behavioral health patient they should have a baseline electrocardiogram and then a followup one to see if the QT interval has been prolonged to dangerous levels.
DVT
Deep venous thrombosis (DVT) is relatively rare on behavioral health units. Yet every year state incident reporting systems receive reports of DVT or even fatal pulmonary embolism in patients on behavioral health units. This most often occurs in patients with severe behavioral health problems that leave them bedridden. We’ve seen DVT in one patient who had laid in bed at home several weeks prior to admission. Therefore, it is essential that every patient admitted to behavioral health units received an assessment for DVT risk factors just as if they had been admitted to a med/surg unit.
Extrapyramidal Syndromes
A major category of medications typically used on inpatient psychiatric units are antipsychotic drugs that may have extrapyramidal side effects. These may affect gait, balance, and reaction times to increase the risk of falls. When these drugs are started the patient should be examined daily to identify the occurrence of extrapyramidal side effects and the fall prevention strategies modified appropriately as they occur.
Anticholinergic Side Effects
Many of the drugs used in behavioral health have anticholinergic side effects. Dry mouth is the most common symptom but dry eyes, mydriasis, constipation, and others may occur. Probably the most significant anticholinergic effect would be urinary retention.
Other Medication Adverse Events
The current Mills study did not go into detail about the medication-related adverse events they found. But they did mention that one category of event was overdose. One of the root causes identified was a problem with hazardous items checks. The other primary root cause was poor systems for managing opioid medication on the unit. It is important to make sure that patients are taking their opioid medication and not saving it to give to others or building up their own supply. In addition, having naloxone immediately available to reverse the effects of an opioid overdose is recommended. Along those lines we’d like to reiterate a point made earlier about the ever-increasing use of long-acting and/or delayed release formulations of opioids. We’ve seen patients who have taken such drugs in suicide attempts. They had been alert in the ER with low levels of drug in their urine screen so they are “cleared” for admission to a behavioral health unit. The next day they become obtunded due to opioid intoxication resulting from the delayed absorption of these drugs.
Eye Care and Oral Health/Dental Hygiene
See our May 10, 2016 Patient Safety Tip of the Week “Medical Problems in Behavioral Health” for issues related to eye care that are often overlooked on behavioral health inpatients. Similarly, that column also discusses oral health and dental hygiene that are often problematic in patients with behavioral health issues.
Other Medical Conditions
Two medical conditions particularly prone to problems on inpatient behavioral health units are diabetes and pregnancy. Behavioral health patients often cannot readily identify the insulin regimens they were on at home and access to family or caregivers at home may be limited. One study of psychiatric inpatients in the UK (Kan 2016) found that patients with severe mental illness and diabetes are not receiving standard care in glucose monitoring or appropriate access to specialist diabetes services when admitted to a psychiatric unit. Hyperglycemia events are poorly managed, suggesting an urgent need to raise awareness of diabetes management among clinical teams. They also found that capacity to consent for diabetes treatment needs to be addressed. Care is also complicated in that the patients may be poorly compliant with their medications and diet. We recommend that any diabetic patient who is taking insulin be followed by a medical consultant while they are inpatients on a behavioral health unit.
Pregnancy and behavioral health hospitalization raises both challenges and opportunities. An older study (Miller 1990) found in a group of pregnant psychiatric patients admitted to a psychiatric service a high rate of involuntary admission, homelessness, and substance abuse, and identified many risk factors associated with noncompliance with ongoing prenatal care. They concluded that brief psychiatric hospitalization can be an important aspect in improving obstetric outcome by providing an opportunity to collect obstetric information and promote ongoing prenatal care.
Medical Emergencies
Medical emergencies like the neuroleptic malignant syndrome and serotonin syndrome are rare but potentially life-threatening and need prompt recognition and treatment. Neuroleptic malignant syndrome (NMS) is characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction. NMS usually occurs shortly after the initiation of neuroleptic treatment (4-14 days) or after dose increases. Serum CPK is often elevated and rhabdomyolysis and myoglobinuria may be present. It may progress to renal failure, respiratory failure and death. In addition to cessation of the offending neuroleptic agent, treatment is mostly supportive. Several drugs have been tried as treatments but evidence for their effectiveness is limited (Tse 2015).
The serotonin syndrome is another potentially life-threatening condition with some similarities to the neuroleptic malignant syndrome. It also may have signs of autonomic instability (tachycardia, hypertension, dilated pupils, diaphoresis, piloerection), fever, and muscle rigidity. Other muscular phenomena are twitching, myoclonus, clonus, hyperreflexia, shivering, and loss of coordination. Seizures, unconsciousness and arrhythmia occur in severe cases. It is associated with serotoninergic medications, such as selective serotonin reuptake inhibitors (SSRIs), and usually evolves more rapidly than NMS. Diagnosis is clinical and lab tests are not diagnostic. Treatment consists of cessation of the offending agent(s) and supportive care. Benzodiazepines are often used for sedation. Symptoms and signs usually disappear within a day of cessation of the offending agent(s) though they may last longer if the half-life of the offending agent is longer. Those cases associated with monoamine oxidase inhibitors tend to be more severe. Drugs that have serotonin antagonism (eg. cyproheptadine) have been used in some cases but evidence of efficacy is limited.
In the current Mills study, unexpected death (unrelated to suicide) on a VA mental health unit was relatively rare, with only 5 such deaths in their system over the 2-year period of study. They found that the primary root cause for sudden death on a mental health unit was a delay in recognizing and treating a serious medical condition that ultimately proved to be fatal.
Barriers/Challenges/Models of Care
As opposed to training for staff in prevention of suicide, assaults, and elopements, training for staff in recognizing and preventing medical adverse events is typically less vigorous or totally lacking on behavioral health units.
Moreover, as mentioned above, we noted that staff may not see psychiatric patients as medically ill and therefore are less attuned to prevention of and recognition of factors predisposing to “medical” adverse events.
Barriers to care of comorbid medical conditions are common on behavioral health units (Frost 2006). Psychiatrists often do not do medically-oriented history and physicals on their patients because it might interfere with the therapeutic relationship. In some facilities, a different psychiatrist might do that portion of the H&P. But let’s be frank – most psychiatrists have a limited ability to deal with comorbid medical problems in their patients. Therefore, behavioral health units typically have a medical person (often a nurse practitioner) attend to the comorbid medical conditions on their patients. But all the healthcare workers on behavioral health units may be uncomfortable with the medical conditions. Nurses may have not worked on med/surg units for many years. Many behavioral health units lack rooms or equipment that are needed for medical evaluation. Such equipment and supplies (eg. supplies a surgeon or other physician might need to perform simple wound care) may have to be kept locked securely on behavioral health units. And we often see consultants who are uncomfortable or even fearful when dealing with behavioral health patients.
Getting an adequate medical history may also be more difficult because of limited patient cooperation and difficulty reaching family or others who might be secondary sources of medical information. Behavioral health patients are also more likely to be non-adherent to medication regimens and non-compliant with other medical interventions. In addition, they often have not had the preventive health services that would have been recommended.
Frost (Frost 2006) also points out that some free-standing behavioral health units may have limited lab, radiology, and pharmacy resources available for handling the medical problems in behavioral health patients.
Our May 10, 2016 Patient Safety Tip of the Week “Medical Problems in Behavioral Health” discussed several potential models of care for handling medical problems on behavioral health units:
We refer you to that article for details of each model.
We also need to be cognizant that the hospital may be only source of attention to medical care that many of these patients will be exposed to. We know how difficult it often is just arranging for post-discharge behavioral health care in these patients. It is equally difficult ensuring they get adequate followup for their medical problems.
Some of our past columns on issues related to behavioral health:
References:
Mills PD, Watts BV, Shiner B, Hemphill RR. Adverse events occurring on mental health units. Gen Hosp Psychiatry 2018; 50: 63-68
http://www.sciencedirect.com/science/article/pii/S0163834317303286
True G, Frasso R, Cullen SW, et al. Adverse events in veterans affairs inpatient psychiatric units: Staff perspectives on contributing and protective factors. Gen Hosp Psychiatry 2017; 48: 65-71
http://www.sciencedirect.com/science/article/pii/S0163834317302220
Mental Health Environment of Care Checklist (VA)
http://www.patientsafety.va.gov/docs/MHEOCCed092016508.xlsx
http://www.patientsafety.va.gov/professionals/onthejob/mentalhealth.asp
CredibleMeds™ website.
Kan C, Kaar SJ, M. Eisa M, et al. Diabetes management in psychiatric inpatients: time to change? Diabetes Medicine 2016; 33(3): 407-408; Article first published online: 11 FEB 2016
http://onlinelibrary.wiley.com/doi/10.1111/dme.12838/abstract
Miller WH, Resnick MP, Williams MH, Bloom JD. The pregnant psychiatric inpatient: a missed opportunity. Gen Hosp Psychiatry 1990 ; 12(6): 373-378
http://www.sciencedirect.com/science/article/pii/016383439090004V
Tse L, Barr AM, Scarapicchia V, Vila-Rodriguez F. Neuroleptic Malignant Syndrome: A Review from a Clinically Oriented Perspective. Curr Neuropharmacol 2015; 13 (3): 395-406
http://benthamscience.com/journals/current-neuropharmacology/volume/13/issue/3/page/395/
Frost M. The Medical Care of Psychiatric Inpatients: Suggestions for Improvement. The Internet Journal of Healthcare Administration 2006; 4(2)
http://ispub.com/IJHCA/4/2/9240
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February 13, 2018
Interruptions in the ED
Our March 8, 2011 Patient Safety Tip of the Week “Yes, Physicians Get Interrupted Too!” included reference to several studies addressing the impact of interruptions and distractions on emergency physicians. Those showed that ED physicians are interrupted more often than primary care physicians (Chisholm 2001) and that interruptions occur more often during certain activities than others (Jeanmonod 2010).
Chisholm and colleagues (Chisholm 2011) found that emergency physicians in academic sites experienced a median of 12 interruptions per 2-hour observation period and those at community sites a median of 6 interruptions per period. Of the interruptions, almost half resulted in breaks in task. These are interruptions that result in changing tasks. The authors note that both the times spent in direct and indirect patient care and the frequency of interruptions have changed little since they did similar surveys a decade ago (Chisholm 2000). That previous work had also shown that both the number of interruptions and breaks in task increased with the average number of patients being managed simultaneously.
Another study of emergency physicians (Friedman 2005) showed emergency physicians at Toronto General Hospital were interrupted every 13.8 minutes on average (4.4 interruptions per hour) and that the rate of interruptions increased with increasing shift intensity. Half the interruptions were from nurses and a third from other physicians. While most interruptions did not require the physician to move to a new location, about 10% did require a move.
In an Australian study (Westbrook 2010) emergency department physicians were interrupted 6.6 times/h. 11% of all tasks were interrupted, 3.3% more than once. Doctors multitasked for 12.8% of time. The mean TOT (time on task) was 1:26 min. Interruptions were associated with a significant increase in TOT. However, when length-biased sampling was accounted for, interrupted tasks were unexpectedly completed in a shorter time than uninterrupted tasks. Doctors failed to return to 18.5% of interrupted tasks.
Another study (Jeanmonod 2010) showed that emergency physicians are interrupted more often in certain activities than others. For example, they were interrupted during charting or reviewing data about 50% of the time. Bedside interruptions were less common (26%) but had a negative impact on patient satisfaction. The majority of interruptions were initiated by another physician or nurse. Unlike the above studies, these authors found physicians rarely changed tasks after an interruption.
Breaks in task are especially important because one may never return appropriately to the previous task. Even when using checklists (whether in healthcare or aviation or other industry) breaks in task may result in steps of a sequence being skipped or overlooked. That is one of the reasons that during critical activities pilots use the “sterile cockpit” concept and nurses or pharmacists use a similar concept wherein they flag themselves in some manner to prevent interruptions.
In the Westbrook study, 11% of tasks were interrupted (and 3.5% were interrupted more than once). The total time for tasks increased with interruptions. But, interestingly, when the authors corrected for a length of time of observation bias, they found that interrupted tasks were actually completed in shorter times! They speculated that physicians may be “catching up for lost time”. We would anticipate that such shortened duration tasks, rather than being examples of improved efficiency, might actually be especially prone to errors and omissions.
Another new study from Johanna Westbrook and colleagues in Australia looked at the impact of several factors on performance of emergency department physicians (Westbrook 2018). The researchers shadowed 36 emergency physicians over 120 hours. All tasks, interruptions and instances of multitasking were recorded. The task assessed for errors was physician prescribing (assessed by a pharmacist, unaware of physician status, reviewing all medication orders entered by physicians during the study period).
Medication orders were assessed for legal/procedural errors (eg, unapproved abbreviations, missing drug units) and clinical errors (eg, wrong drug due to a drug–disease interaction). Physicians’ working memory capacity (WMC) was measured via the OSPAN test. “Polychronicity” (ie, preference for multitasking and a belief that this is efficient) was assessed using the adapted version of the Inventory of Polychronic Values (IPVs).
They found that physicians experienced 7.9 interruptions/hour on average but while prescribing clinicians experienced 9.4 interruptions/hour. Those rates are comparable to those demonstrated in previous studies of ED physicians.
It’s no surprise: error rates increased almost three-fold when physicians were interrupted while prescribing (RR 2.82). But multitasking was also clearly related to more frequent errors (RR 1.86).
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As you’d expect, lack of sleep was associated with more frequent prescribing errors. But the magnitude of the increase was eye-opening. Having below-average sleep in the previous 24 hours was associated with a >15-fold increase in clinical error rate (RR 16.44). Our focus today is on the impact of interruptions rather than fatigue but we’ve listed our numerous columns on fatigue in healthcare at the end of today’s column.
Error rates also increased with each year of patient age (RR 1.05) and physician age (RR 1.07). The implication is that increasing age is associated with decreasing working memory capacity (WMC), as other studies have shown WMC to decrease with increasing age. Other studies have also shown that individuals with lower WMC scores may exhibit increased task times and more errors when interrupted. Physicians’ working memory capacity (WMC) in this study was protective against errors; for every 10-point increase on the 75-point OSPAN, a 19% decrease in prescribing errors was observed.
But clinical error rates were inversely related to doctor seniority with residents having the highest error rate relative to consultants. There was no effect of polychronicity, workload, physician gender or above-average sleep on error rates.
Multitasking merits specific comment. We often pride ourselves in our ability to multitask. But you’ve often heard us say that such pride is probably misplaced. Indeed, in the Westbrook study multitasking was related to an almost 2-fold increase in errors (RR 1.86). Interestingly, though, multitasking was significantly associated with legal/procedural errors (eg, unapproved abbreviations, missing drug units), but not clinical errors (eg, wrong drug due to a drug–disease interaction).
The Westbrook study demonstrated that the medication prescribing process is particularly prone to errors when interruptions occur and drew the analogy to nursing, where the medication administration process is also prone to errors when interruptions occur.
Keep in mind that not all interruptions are detrimental and many are necessary. Particularly in an ED settting, where physicians are caring for multiple patients at a time, an interruption may be critical to alert a physician to an urgent need for one of those patients. We’ve also stated before that, in such healthcare settings, focusing on just one outcome parameter (such as prescribing errors) may not accurately reflect the “big picture”. For example, if physicians were to focus on prescribing to the detriment of maintaining situational awareness for all their patients, the prescribing error rate might decline while the overall adverse event rate goes up.
So what are we to do? We doubt anyone is likely to increase their working memory capacity (regardless of all those TV commercials you see to take product X to improve your brain function!). You might be able to impact the fatigue factor through judicious scheduling practices (and even some of the practices such as “power naps” that we’ve described in our many columns on the 12-hour shift for nurses). So we’re left largely with focusing on interruptions. Westbrook and colleagues admit that “blanket interventions aimed at reducing all interruptions are likely to be ineffective, inefficient and at times unsafe.” But they do recommend the following “targeted” interventions:
They also note that the application of cognitive systems engineering to ED information systems shows promise.
And, lest we forget, we physicians are also probably the most frequent cause for interruptions to other healthcare professionals, particularly nurses.
Prior Patient Safety Tips of the Week dealing with interruptions and distractions:
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 2012 “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”
September 2015 “Surgery Previous Night Does Not Impact Attending Surgeon Next Day”
September 6, 2016 “Napping Debate Rekindled”
April 18, 2017 “Alarm Response and Nurse Shift Duration”
July 11, 2017 “The 12-Hour Shift Takes More Hits”
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”
September 2015 “Surgery Previous Night Does Not Impact Attending Surgeon Next Day”
March 2016 “Does the Surgical Resident Hours Study Answer Anything?”
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”
October 2014 “Another Rap on the 12-Hour Nursing Shift”
December 2, 2014 “ANA Position Statement on Nurse Fatigue”
September 29, 2015 “More on the 12-Hour Nursing Shift”
July 11, 2017 “The 12-Hour Shift Takes More Hits”
References:
Chisholm CD, Dornfeld A, Nelson DR, Cordell WH. Work interrupted: A comparison of workplace interruptions in emergency departments and primary care offices. Ann Emerg Med 2001; 38(2): 146-151
http://www.annemergmed.com/article/S0196-0644%2801%2967082-3/abstract
Jeanmonod R, Boyd M, Loewenthal M, Triner W. The nature of emergency department interruptions and their impact on patient satisfaction. Emerg Med J 2010; 27: 376-379
http://emj.bmj.com/content/27/5/376.abstract
Chisholm CD, Weaver CS, Whenmouth L, Giles B. A Task Analysis of Emergency Physician Activities in Academic and Community Settings. Ann Emerg Med 2011; published ahead of print January 31, 2011
http://www.annemergmed.com/article/S0196-0644%2810%2901823-8/abstract
Chisholm CD, Collison EK, Nelson DR, Cordell WH. Emergency Department Workplace Interruptions Are Emergency Physicians “Interrupt-driven” and “Multitasking”? Academic Emergency Medicine 2000; 7(11): 1239–1243
http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2000.tb00469.x/pdf
Friedman SM, Elinson R, Arenovich T. Emergency Physician Work, Communication and Interruptions: A Human Factors Approach. Israeli Journal of Emergency Medicine 2005; 5(3): 35-42
http://www.isrjem.org/IJEM_Aug_TimeandMotion_Proof.pdf
Westbrook JI, Coiera E, Dunsmuir WTM, et al. The impact of interruptions on clinical task completion. BMJ Quality & Safety 2010; 19: 284-289
http://qualitysafety.bmj.com/content/19/4/284
Westbrook JI, Raban M, Walter SR, Douglas H. Task errors by emergency physicians are associated with interruptions, multitasking, fatigue and working memory capacity: a prospective, direct observation study. BMJ Qual Saf 2018; 9 January 2018
http://qualitysafety.bmj.com/content/early/2018/01/09/bmjqs-2017-007333.full
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February 20, 2018
Delirium and Falls
Delirium is a risk factor for falls and falls in patients with delirium are particularly likely to result in injuries. A recent CDPH (California Department of Public Health) statement of deficiencies provides an example (CDPH 2017). A patient was admitted to an acute rehabilitation service following a stroke. Fall Risk Indicators assessed on admission indicated the patient was at high risk for falling. A sitter was ordered and an order was issued to “…assess assistance level required for safe/effective self care. Encourage functional activity performance with appropriate level of assistance based upon level of ability." (Keep in mind that on rehab services there is often a fine line between promoting fall safety and “pushing” patients to ambulate as part of their rehab program. We discussed many issues related to falls on rehab in our October 7, 2008 Patient Safety Tip of the Week “Lessons from Falls....from Rehab Medicine”.) The patient was receiving gait training and safe bed mobility and transfers with a four-wheel walker.
During the second week she was described as being uncooperative and combative. A sitter was in the doorway with a clear view of the patient. However, the sitter may have temporarily gone outside the room to get a nurse to assist in transferring the patient from a wheelchair to bed. The patient apparently arose from the wheelchair on her own and fell forward, striking her face on the floor. There was no loss of consciousness. Exam showed facial ecchymoses and blood coming from her mouth. No other head or neck injuries were noted. CT scan of the head showed a small amount of subarachnoid blood, felt to be most likely from trauma. The patient was transferred to the Trauma ICU for observation. Plavix and subcutaneous heparin, which she had been on prior to the fall, were held. A Consult-Liaison psychiatrist diagnosed delirium. She had a progressive decline in function and cognition and an impaired alertness level. Family decided she should be placed on comfort care. She died several months later. During the latter period she was described as moving from a hyperactive delirium to a profound hypoactive delirium.
Review by the CDPH found that, rather than having a 1:1 sitter as ordered, one sitter had been assigned to observe patients in two adjacent rooms. There were also issues regarding the training the sitter had for observing such patients (lack of proper training of sitters is a problem we’ve noted in several other columns). The sitter (a CNA) stated that she had gone outside the patient’s room to call for help in moving the patient but then saw the patient rise from the wheelchair and fall before she could get back to the patient. The Director of Risk Management stated the sitter should not have left the room and should have remained within arm’s distance of the patient so she could reach the patient if she stood up. Also, the patient had not already been diagnosed as having delirium and the patient’s combative and aggressive behavior should have led to a call to the physician for evaluation.
Unfortunately, the case example above is repeated at multiple hospitals every year. Timely recognition of delirium is important and patients with delirium can be very difficult to manage. Therefore, prevention and early recognition are important.
One healthcare organization recently published results of its years-long program on delirium and saw a substantial reduction in falls related to delirium (Ferguson 2017). A multidisciplinary team at Virginia Mason Medical Center developed a program for both prevention of and recognition and treatment of delirium. They used an EMR-based version of the CAM (Confusion Assessment Method) and the CAM-ICU tools to screen for delirium. This used “nonpharmacological interventions that included efforts to minimize, treat, or prevent sensory deprivation or overload; impaired sleep-wake cycle; immobility; poor nutrition or dehydration; urinary retention; constipation; suboptimal pain management; deliriogenic medications; unnecessary lines or tethers; hypoxia; and alcohol withdrawal.” Regular readers of our own columns (see full list below) will recognize those interventions as part of the HELP (Hospital Elder Life Program) or similar multicomponent programs used to prevent and manage delirium. An EMR-based form included questions about risk factors for delirium and CAM assessment was to be completed at least twice per day for every hospitalized patient. Rates of the latter increased from 9.5% at baseline to 86% over a 5-year period. Audits also revealed CAM accuracy ranged between 85% and 98% (average 91%).
The rate of delirium-related falls decreased from 0.91 per thousand patient days before the intervention to 0.75 per thousand patient days during the implementation, before stabilizing at a postintervention rate of 0.50 per thousand patient days. The rate of delirium falls with injury was too low for analysis. Overall hospital falls also decreased during the period from 2.58 to 2.03 per thousand patient days (P = .0007).
The authors also found that education related to delirium screening, prevention, and treatment and bedside tools such as “The Language of Delirium” (Puelle 2015) were vital foundational elements necessary to nurse and program success.
Falls related to delirium may be devastating. Programs like the one at Virginia Mason demonstrate that organization-wide nonpharmacologic multicomponent programs can substantially reduce rates of delirium-related falls. They also likely help mitigate the numerous other consequences of delirium that we’ve discussed in our prior columns. The Ferguson study did not report a cost effectiveness analysis of their program but we’d be willing to bet that the savings accrued (not just from fall prevention but also from prevention of other consequences of delirium) likely exceeded the costs of implementing and maintaining the program.
Some of our prior columns on delirium assessment and management:
Some of our prior columns related to falls:
References:
CDPH (California Department of Public Health). 2017. Intake Number CA00500940
Ferguson A, Uldall K, Dunn J, et al. Effectiveness of a Multifaceted Delirium Screening, Prevention, and Treatment Initiative on the Rate of Delirium Falls in the Acute Care Setting. Journal of Nursing Care Quality 2017; Published Ahead of Print: October 13, 2017
Puelle MR, Kosar CM, XU G, et al. The language of delirium: keywords for identifying delirium from medical records. J Gerontol Nur. 2015: 41(8): 34-42
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February 27, 2018
Update on Patient Safety Walk Rounds
Our October 7, 2014 Patient Safety Tip of the Week “Our Take on Patient Safety Walk Rounds” discussed positive features of Patient Safety Walk Rounds but also warned that such rounds done poorly can actually be detrimental, especially if the rounds are perceived as being perfunctory and feedback is not provided. We ended by stating that measurement of the impact of these rounds can be difficult.
A new study attempts to provide such measurement (Sexton 2017). Sexton and colleagues did a cross-sectional survey of healthcare workers in multiple settings in the Michigan Keystone collaborative to determine the impact of Walk Rounds (WR) on domains such as safety culture, employee engagement, burnout and work-life balance. Focus was on the importance of feedback.
Over 16,000 surveys were returned, for a response rate of 70.4%. Of those responding, 32.7% reported that they had participated in WR, and 24.3% reported that they participated in WR with feedback. Work settings reporting more WR with feedback had substantially higher safety culture domain scores and significantly higher engagement scores for four of its six domains.
The authors suggest that “when WRs are conducted, acted on, and the results are fed back to those involved, the work setting is a better place to deliver and receive care as assessed across a broad range of metrics, including teamwork, safety, leadership, growth opportunities, participation in decision-making and the emotional exhaustion component of burnout.”
The researchers found that both personal burnout and burnout climate were lowest in work settings that had the highest rates of WR with feedback. Workforce engagement was also clearly higher in work settings with highest rates of WR with feedback and the highest scores in participation in decision-making and growth opportunities. The authors tie this to the concept of “small wins”, in which “a pattern of small wins is a series of concrete outcomes of moderate importance, which attracts allies and deters opponents”.
The study, of course, does not prove causality. It remains conceivable that a strong culture of safety might lead to the positive results found rather than the Walk Rounds being the cause of the better culture of safety.
Sara Singer, whose work we highlighted in our October 7, 2014 Patient Safety Tip of the Week “Our Take on Patient Safety Walk Rounds”, commented in the accompanying editorial (Singer 2018). She again cautioned on the importance of doing Walk Rounds correctly and the risk of their backfiring if done improperly. She offered 3 important keys to successful Walk Rounds:
She makes careful reference to the role of middle managers, noting that ignoring the role of middle managers when engaging front-line workers can risk “igniting” middle managers’ fears and negative repercussions. Rather, she recommends engaging middle managers as hosts, guides, and navigators during WR. She also notes the importance of recognizing informal social networks as potential vehicles to promote positive messages.
It’s worth reiterating some of the observations and recommendations we made in our October 7, 2014 Patient Safety Tip of the Week “Our Take on Patient Safety Walk Rounds”:
How often should you do Walk Rounds? Unfortunately, there are no hard and fast guidelines. We usually recommend that each unit be visited at least every two months, perhaps supplemented by monthly rounds done by other staff.
One bad habit organizations have is only doing Patient Safety Walk Rounds on the day shift. It is extremely important that you do them on all shifts. That takes planning and commitment. Why is it important? Because two-thirds of the staff you want to include in your safety culture work on those other shifts! Not only do you need to convey to them your commitment to improving patient safety but you will also better see and hear about some of the barriers to patient safety on the evening and night shifts.
Who should be there on Patient Safety Walk Rounds? Your core team should include your CEO, COO, CMO, CNO, and head of Quality and Patient Safety. But there are others that should also participate. You’ll want a pharmacist for rounds on almost all units. Bringing your CFO on such rounds is a good way of giving him/her a better understanding of how patient safety issues can impact the bottom line. Your CIO may also gain valuable insights into how staff interact with technology and many of the safety issues resulting from complex IT issues or ones that could use an IT solution. Including representatives from other departments (eg. engineering, housekeeping, SPD, etc.) can also bring unique perspectives. We also recommend that you include your Board members in Patient Safety Walk Rounds. Not every rounds, but mandate that each Board member attend at least one walk rounds session annually. Not only will that help educate them about patient safety but you’ll be pleasantly surprised by the insights they bring to your rounds, either by their perspective as a “consumer” or patient or the perspective of whatever industry they happen to come from. For example, a banker might cringe looking at patients in line in your antiquated patient registration system and have good ideas for improving efficiency and patient flow. Note also that the previous Singer & Tucker review (Singer & Tucker 2014) mentioned the importance of including physicians in such rounds. We wholeheartedly agree. Almost every study done on culture of safety shows disparities between the impressions of frontline staff and physicians (and administrators). However, equally important is not having the physician presence stifle open discussion of issues with staff. We’ve all too often seen situations in which behavior of a physician is the critical safety issue and staff are unwilling to speak about it in front of another physician, even the CMO. Lastly, some include a patient or patient family member. A Board member might fulfill that role but Board members may have an “insider” bias. Having an “outsider” pair of eyes and ears may be important.
Should all those individuals be on every Walk Rounds? Definitely not. Having too many upper management people on rounds can be very intimidating to staff. So split them up. Have 2-3 team members do walk rounds on one unit and others do them on another unit or another shift. You really want to be able to interact with your frontline staff and make them feel comfortable in speaking up.
What units should get Walk Rounds? Answer: all of them. But some may need particular attention, particularly those that are “melting pots” like the Radiology suite. In our October 22, 2013 Patient Safety Tip of the Week “How Safe Is Your Radiology Suite” we discussed the multitude of safety issues seen in Radiology suites that have little to do with radiology per se. And don’t forget to include non-clinical units. You’d be surprised how often your Walk Rounds with your housekeeping department provides insights into patient safety issues.
Remember, you are not just doing walk rounds for show. The most important thing you can do is identify issues and follow up. One member of each team should keep a formal issues log that includes action items and dates for expected actions. Timely feedback to frontline staff on actions taken for each item is extremely important. And beware of simply telling staff “that’s been referred to Committee X” because that often conveys the message “nothing is going to be done”. You will encounter some items that cannot be fixed simply or expediently. In such cases you need to be honest with your staff and tell them, for example, that a current budgetary or technical restraint won’t allow a quick fix (eg. “that is in the software version update to be installed in 3 months”). But at least they will know that it is still on your list. Singer & Tucker also stress that frontline staff become frustrated when senior management spends too much time prioritizing issues rather than taking actions. We recommend that you use the same process for follow up that you use to ensure actions taken when you do a Root Cause Analysis. That means you keep a list of actions not yet completed or other “open” items and discuss these at each of your regular Quality Improvement/Patient Safety Committee meetings until you have closed the loop.
Body language on Walk Rounds is extremely important. Not theirs, yours!!! The old adage that 90% of communication is nonverbal holds true. If your body language conveys disinterest or “let’s just get this over” it won’t matter what you are saying with your staff. They will recognize that such rounds are perfunctory. But don’t ignore the body language of your workers either. You may notice one worker “squirm” a bit when something is being said. In such cases, it is worthwhile to have someone later meet that worker in a very non-threatening setting and say “I noticed you seemed uncomfortable when so-and-so was saying…”. You may be surprised at what you hear.
We agree with Singer & Tucker that “surveillance” on walk rounds can be counterproductive but that applies mainly to surveillance of people. That doesn’t mean you shouldn’t look for some unsafe conditions when doing your safety rounds. For example, if your facility handles behavioral health patients (even if it is only in your ER) you should be looking for things like “loopable” items in the bathrooms in your radiology suite that might be used for suicide. Or you might check floor stock to make sure you don’t have vials of concentrated heparin that might mistakenly be given to patients during a heparin “flush”. Or some of the battery charging/recharging issues we raised in our February 4, 2014 Patient Safety Tip of the Week “But What If the Battery Runs Low?”. And we always recommend vigilance to alarm safety issues during Walk Rounds (see our July 2, 2013 Patient Safety Tip of the Week “Issues in Alarm Management”) or issues with filled and unfilled oxygen cylinders being intermingled. Looking for all those things can be done in a less conspicuous and non-threatening manner.
The most important thing on Walk Rounds is encouraging staff to speak up about potential safety issues. To do this you need a comfortable, nonpunitive culture in which staff understand that they will be praised, not vilified, for their openness. For example, we all know that workarounds are usually potentially dangerous, yet they are ubiquitous. Workarounds are almost always a sign of an underlying root cause that needs to be fixed, so identifying workarounds is important. When you ask staff about workarounds you need to let them know you are looking to fix whatever problem makes them do a workaround and that you are not going to punish them for doing a workaround.
Walk Rounds are also a good way to get a feel for safety culture on each unit. We feel you get a much better understanding of “local (unit)” culture on such rounds than you get on the many formal safety culture assessment tools used by many organizations.
Be considerate of your workers’ time constraints. The last thing you want is for them to be thinking “Oh no! Here we go again! I’ll never get my work done today!”. There are no hard and fast rules for the time duration of individual walk rounds. But planning with the middle managers ahead of time can help ensure that workers are freed up to engage and participate without fear that their workload is accumulating in the background.
Lastly, how do you measure the impact of your Walk Rounds? That, of course, is difficult because it’s hard to separate out the results from Walk Rounds from all the other patient safety activities your organization is doing. And surveys such as that in the Sexton study can be expensive to administer and analyze. We think the most important measure is looking at the issues log you accumulated through WR and being able to report the percentage of safety issues identified and resolved. You can also elicit informal feedback from staff on how they perceive such rounds.
We think Patient Safety Walk Rounds are a very important component of your patient safety efforts. But be sure you do them constructively!
References:
Sexton JB, Adair KC, Leonard MW, et al Providing feedback following Leadership WalkRounds is associated with better patient safety culture, higher employee engagement and lower burnout. BMJ Qual Saf 2017; Published Online First: 09 October 2017
http://qualitysafety.bmj.com/content/early/2017/10/09/bmjqs-2016-006399
Singer SJ. Successfully implementing Safety WalkRounds: secret sauce more than a magic bullet. BMJ Qual Saf 2018; Published Online First: 09 February 2018
http://qualitysafety.bmj.com/content/early/2018/02/09/bmjqs-2017-007378
Singer SJ, Tucker AL. The evolving literature on safety WalkRounds: emerging themes and practical messages. BMJ Qual Saf 2014; 23: 789-800
http://qualitysafety.bmj.com/content/23/10/789.full.pdf+html
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March 6, 2018
Nurse Workload and Mortality
There have been numerous studies linking poor nurse:patient ratios with adverse patient outcomes. A study by Aiken and colleagues found that each additional patient per nurse was associated with a 7% increase in the likelihood of dying within 30 days of admission and a 7% increase in the odds of failure-to-rescue (Aiken 2002).
California was the first state to mandate nurse:patient ratios and multiple other states have also already mandated or are considering mandating nurse:patient ratios. But the issue is more complex than simple nurse:patient ratios. Those ratios do not take into account actual nurse workload nor do they take into account the fatigue factor that may accompany long work shifts or forced overtime. One factor that comes into play in those conditions is the concept of “missed nursing care” or “care left undone” (see our Patient Safety Tips of the Week for November 26, 2013 “Missed Care: New Opportunities?” and May 9, 2017 “Missed Nursing Care and Mortality Risk”).
In our July 11, 2017 Patient Safety Tip of the Week “The 12-Hour Shift Takes More Hits” we discussed a study by Ball and colleagues (Ball 2017a), using survey data from the RN4CAST study to correlate measures of nurse-reported quality with shift duration. They found the rate of “care left undone” was 1.13 times higher for nurses working ≥12 hours. A previous study by Ball (Ball 2017b) showed that a 10% increase in the amount of care left undone by nurses was associated with a 16% increase in mortality.
The two studies by Ball and colleagues focus on nurse staffing levels and fatigue as big issues leading to care left undone and its potential effects on patient care. But another issue that we have discussed, primarily in our columns on “the weekend effect”, has to do with nurse workload. We often see circumstances where a nurse:patient ratio is reasonable, yet the workload placed on nurses leads to care left undone.
Patient acuity and case mix, of course, are primary factors contributing to nurse workload. There are a number of tools used to factor patient acuity into nurse workload estimates. These have been used primarily in intensive care unit settings. But factors other than patient acuity also contribute to nurse workload.
A recent retrospective analysis of adult patients admitted to two multi-disciplinary Intensive Care Units in Hong Kong showed that exposing critically ill patients to high workload/staffing ratios is associated with a substantial reduction in the odds of survival (Lee 2017). Data required to calculate TISS-76 (Therapeutic Intervention Scoring System), Acute Physiology and Chronic Health Evaluation III (APACHE III) and the average number of bedside nurses working on each day were collected on almost 900 patients over a 5-month period. TISS-76 uses 76 possible interventions to quantify nursing workload
They found that survival to hospital discharge was more likely to occur when the maximum workload-to-nurse ratio was low and that death was more likely to occur when the ratio was high. Moreover, exposure to as little as one day of high workload/staffing ratios was associated with a substantially increased risk of death in critically ill patients.
Results of the Lee study suggest that staffing should be based on workload, not just patient numbers, and that “making do” with fewer nurses even for a short time or temporary increases in ICU capacity without a corresponding increase in staffing may adversely affect patient outcome.
Of course, extrapolation of the ICU experience described by Lee et al. to other settings is not possible. The measures of nurse workload in the TISS-76 may not be applicable to the med/surg or pediatric wards, ob/gyn or rehab settings, etc. And it’s not known whether the type of additional activities we’ve described in “the weekend effect” that increase nurse workload would have the same impact as those in an ICU.
But the overall implication is clearcut: nurse staffing considerations must take into account not only the nurse:patient ratio but also a measure of nurse workload.
In our many previous columns on the weekend effect or after-hours effect we have pointed out how hospitals differ during these more vulnerable times. Staffing patterns (both in terms of volume and experience) are the most obvious difference but there are many others as well. We’ve often said the use of the simple nurse:patient staffing ratio on weekends may be misleading. That is because there is often a significant difference in nurse workload on weekends. We’ve described the tremendous increase in nurse responsibilities on weekends due to lack of other staff (no clerical staff, delayed imaging, physicians not on site) that add additional responsibilities to their jobs. Our December 15, 2009 Patient Safety Tip of the Week “The Weekend Effect” discussed how adding non-clinical administrative tasks to already overburdened nursing staff on weekends may be detrimental to patient care. Just do rounds on one of your med/surg floors or ICU’s on a weekend. You’ll see nurses answering phones all day long, causing interruptions in some attention-critical nursing activities. Calls from radiology and the lab that might go directly to physicians now often go first to the nurse on the floor, who then has to try to track down the physician. They end up filing lab and radiology reports or faxing medication orders down to pharmacy, activities often done by clerical staff during daytime hours. Even in those facilities that have CPOE, nurses off-hours often end up entering those orders into the computer because the physicians are off-site and are phoning in verbal orders. You’ll also see nurses giving directions to the increased numbers of visitors typically seen on weekends. They may even end up doing some housekeeping chores and delivering food trays. All of these interruptions and distractions obviously interfere with nurses’ ability to attend to their clinically important tasks (see our Patient Safety Tips of the Week for August 25, 2009 “Interruptions, Distractions, Inattention…Oops!” and May 4, 2010 “More on the Impact of Interruptions”). We thus think that simply addressing nurse:patient staffing ratios without addressing nurse workload issues may be short-sighted.
Few attempts to predict nurse workload have taken into account factors beyond patient acuity. One study in Singapore (Hoi 2010) did take into account other factors and developed a nursing workload intensity measurement system (WIMS). In addition to patient diagnoses, WIMS incorporated nursing diagnoses and nursing time spent on direct patient care and time spend on indirect patient care. They found that patient dependency measurements were not correlated with nursing time. The authors concluded that workload predictions should de-link patient dependency with acuity status as both do not correlate, as evidenced by this study.
A protocol for more accurately measuring nurse workload has been proposed in the Netherlands (van den Oetelaar 2016). The researchers expanded upon a framework for nurse workload management that had been developed in the Netherlands, called the NZi methodology, which consisted of the following items:
These data are combined to estimate and validate the workload of nurses.
But several disadvantages of that methodology led to modification by the new researchers. The proposal uses a new list of patient characteristics expected to influence care time. It also more specifically determines the required nurse resources, differentiating for levels of education and experience. Finally, it also uses a validated questionnaire to determine nurses' perceived workload. They choose to measure five dimensions of perceived workload: work pace (time pressure), amount of work, emotional load, physical load and mental load, as experienced by nurses.
Identifying relevant patient characteristics
Rather than classifying patients in categories of intensity of care, the researchers sought to directly predict care time of patient characteristics. Focus will be on finding patient characteristics that are expected to cause additional care time, on top of “baseline” care time that all patients get.
Time study nursing staff
A random sample of the activities of nurses is a useful and cost-effective methodology to explore work-related activities and provide broad insight into the way nurses spend their working hours, and to what extent their work is directly patient-related. The time study would utilize trained observers but might incorporate some self-reporting when certain activities (such as cognitive activities) cannot be directly observed. From the time study, time spent on non-patient-related activities can also be estimated.
Estimating required care time
Results of the patient characteristic checklist will be combined with work sampling results. Data will be analyzed from the perspective of the nurse (How do they spend their time?) and the perspective of the patient (How much time is spent on caring for patients?). This is designed to answer questions such as: Does care time increase when certain characteristics apply? Also, what is the baseline care time for a patient when none of the characteristics apply?
Estimating allocated care time
Allocated care time can be calculated by simply counting the number of nurses in a shift and multiplying this amount by the shift hours. However, that ignores staff skill and experience mix. Therefore, it is necessary to introduce nurse education levels and level of expertise into the workload equation.
Estimating nurses' workload
An estimate of nurses' workload can be made by dividing the estimate of allocated care time by the estimate of required care time. Patient type profiles for all admitted patients in a shift can be added up to get to the total required care time for patient-related activities for that shift and added to an estimate for time spent on non-patient-related activities per shift to determine the total estimated required nursing time. Allocated nursing time is then determined by counting the number of nurses on duty and multiplying this by the shift time. This will be performed for each type of nurse on duty (registered, student, etc).
Measuring perceived nurses' workload
Job demands and resources will be assessed with shortened scales of the validated Questionnaire on the Experience and Evaluation of Work (QEEW).
Validation
The workload management method will be validated by comparing the estimated nurses' workload to the workload as it was perceived by the nurses on duty.
There are a host of factors that contribute to nursing care left undone and ultimately to adverse patient outcomes. Nurse:patient ratio is a major factor, but nurse fatigue contributes and nurse workload is likely a major factor. Workload is not simply a function of patient acuity and we need to take into account all the other factors that impact a nurse’s time. We are pleased to see that ongoing studies are beginning to look at those factors so we can appropriately address ways to ensure our nurses are able to safely address the needs of our patients.
Some of our other columns on missed nursing care/care left undone:
November 26, 2013 “Missed Care: New Opportunities?”
May 9, 2017 “Missed Nursing Care and Mortality Risk”).
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 2012 “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”
September 2015 “Surgery Previous Night Does Not Impact Attending Surgeon Next Day”
September 29, 2015 “More on the 12-Hour Nursing Shift”
September 6, 2016 “Napping Debate Rekindled”
April 18, 2017 “Alarm Response and Nurse Shift Duration”
July 11, 2017 “The 12-Hour Shift Takes More Hits”
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”
October 2014 “Another Rap on the 12-Hour Nursing Shift”
December 2, 2014 “ANA Position Statement on Nurse Fatigue”
September 29, 2015 “More on the 12-Hour Nursing Shift”
July 11, 2017 “The 12-Hour Shift Takes More Hits”
References:
Aiken LH, Clarke SP, Sloane DM, et al. Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. JAMA 2002; 288(16): 1987-1993
https://jamanetwork.com/journals/jama/fullarticle/195438
Ball J, Day T, Murrells T, et al. Cross-sectional examination of the association between shift length and hospital nurses job satisfaction and nurse reported quality measures. BMC Nursing 2017; 16: 26
https://bmcnurs.biomedcentral.com/articles/10.1186/s12912-017-0221-7#CR25
Ball JE. Nurse Staffing Levels, Care Left Undone, & Patient Mortality in Acute Hospitals. Karolinska Institutet; Stockholm 2017
Lee A, Cheung YSL, Joynt GM, et al. Are high nurse workload/staffing ratios associated with decreased survival in critically ill patients? A cohort study. Ann Intensive Care 2017; 7: 46
https://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-017-0269-2
Hoi SY, Ismail N, Ong LC, Kang J. Determining nurse staffing needs: the workload intensity measurement system. J Nurs Manag 2010; 18(1): 44-53
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2834.2009.01045.x/full
van den Oetelaar WFJM, van Stel HF, van Rhenen W, et al. Balancing nurses' workload in hospital wards: study protocol of developing a method to manage workload. BMJ Open 2016; 6: e012148
http://bmjopen.bmj.com/content/6/11/e012148
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March 13, 2018
Intercepting Errors
Errors are inevitable. Therefore, a good patient safety system recognizes that errors occur and seeks to identify those errors before they reach the patient. We, of course, already have some interventions that intercept errors and protect patients. Some examples are (1) bedside medication verification systems using barcoding, (2) independent double checks, (3) having a pharmacist and a nurse check the order prescribed by a physician before a drug gets dispensed and administered, (4) clinical decision support systems that create alerts during CPOE (eg. when a dose is higher than the expected range for “usual” doses).
But sometimes even those tools that are designed to intercept errors may fail and a medication may be administered to a patient in error. There is still time, however, in some circumstances to mitigate the effects of that error and spare the patient harm. That is especially likely when the medication is given slowly over a period of time, such as by IV infusion.
So researchers at Cincinnati Children’s Hospital Medical Center developed a system for real-time identification of medication administration errors and were able to demonstrate the efficacy of that system in preventing patient harm (Ni 2018). They focused on reconciling 10 high-risk continuous intravenous infusions and medications prescribed to NICU inpatients: total parenteral nutrition (TPN), lipids, intravenous fluids (IVF), insulin, morphine, fentanyl, milrinone, vasopressin, dopamine, and epinephrine.
Previous studies have shown that continuous intravenous infusion has a higher risk and severity of error than other medication administrations. The pediatric population, and especially a NICU population, is ideal for such a system since so many drugs are given based upon patient weight and dosage calculations and therefore are prone to error. In addition, intravenous infusions usually span multiple nursing shifts and involve complex dosage adjustments that are not captured by in-place interventions such as BCMA.
The researchers developed a “data extractor” module that extracted data about medications from 4 separate sources (entered medication orders, structured order modifications that adjusted the original doses/rates via CPOE, medication administration records that documented actual doses/rates administered to patients, and free-text orders communicated from physicians to nurses that delivered complex dose/rate adjustments). Then they developed a “detector” module that identified discrepancies in doses/rates between MAR’s and other data sources. If a discrepancy was identified, the module would trigger a medication administration error (MAE) event with a summary and suggestion. (A 30-minute grace period was allotted for verbal orders to allow for delays in processing these orders.) A “notifier” module then sent a message about the suspected MAE event to the clinician via a secure messaging platform and the clinician would decide whether the event was truly an MAE event.
Among the targeted medications/infusions, epinephrine had the highest MAE rate, followed by TPN, IVF, morphine, and lipid. Five medications had no associated MAEs. The frequency of dose adjustments varied between medications/infusions during patient care. In particular, most adjustments for TPN, lipid, and IVF were delivered via free-text communication from physician to nurse. There was also a moderate positive correlation between error rate and number of dose adjustments.
The automated MAE detection system achieved an overall sensitivity of 85.3% and positive predictive value (PPV) of 78.0%. Sensitivity was >75% across all medications/infusions except lipid and morphine, where one lipid and one morphine MAE each was missed. With adjustments, the system achieved 100% PPV for the majority of the medications/infusions and >75% for those with frequent dose adjustments (epinephrine, TPN, and IVF). However, there was a very high negative correlation between PPV and number of free-text dose adjustments.
The automated system detected 84% of MAE events that represented overdose or underdose, and 100% of MAE events that represented significant overdose.
Chart review of MAE events detected by the automated MAE detection system then helped identify system problems underlying the errors. The 78.0% PPV achieved by the system suggests that for every 10 error notifications, 2 were false positive alarms. This relatively low false positive rate is encouraging in averting alert fatigue.
Overall, the automated system detected 86.7% of clinical errors that reached patients and, importantly, captured all rare but substantial dosing errors. Though the most substantial reductions were realized for long-time intravenous medications/infusions such as TPN and lipid, the system has the potential to reduce harm exposure significantly for all medications via real-time messaging technology.
This is an exciting development that has the potential to help us intercept errors that have occurred before significant harm comes to the patient, thus adding yet an additional layer of defense against patient harm.
Note also that, unlike the dangers we’ve discussed regarding texting orders, this is an example of the positive potential of text messaging in health care. It is similar to the alerts sent to responsible parties that we’ve discussed in our numerous columns on alarm management systems.
We look forward to refinements of this system and extrapolation to other patient populations and healthcare settings. Nice work!
References:
Ni Y, Lingren T, Hall ES, et al. Designing and evaluating an automated system for real-time medication administration error detection in a neonatal intensive care unit. Journal of the American Medical Informatics Association 2018; Published: 10 January 2018
https://academic.oup.com/jamia/advance-article/doi/10.1093/jamia/ocx156/4797402
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March 20, 2018
Minnesota Highlights Lost Tissue Samples
Minnesota’s Department of Health recently released it annual report Adverse Health Events in Minnesota. 14th Annual Public Report. The category with a frequency of events that caught our eye was “Irretrievable Loss of an Irreplaceable Biological Specimen”. That category has been included in its adverse event reporting system since 2014. It’s, of course, of great concern since these represent incidents in which a biopsy or surgical specimen is lost, leaving a patient to not know whether he/she had cancer (or other serious condition) or a benign condition. Twenty-six of these events were reported during this fourth year of reporting, down slightly from the 31 events in 2016. Of those, 12 patients required additional monitoring or treatment as a result of the loss/damage to the specimen.
Specimens were lost during collection or obtaining the specimen in 54%, internal transport in 15%, and during lab processing during 31%. 77 percent of these specimens were lost, the rest being destroyed or damaged to the point that they could not be tested.
The majority of lost specimens were polyps obtained during a colonoscopy, but other types included placentas, masses/tumors, cervical tissue/cysts, and skin lesions.
Note that this category in adverse event reporting system does not include all lost specimens. To be reported, a specimen must both be lost and another procedure cannot be done to obtain a new specimen.
Inclusion of this category in the adverse event reporting system has led to changes (Olson 2017). Mayo switched to a standard container for specimens being sent to labs. Essentia Health added a computerized lab system, which uses bar-coding and other measures to track samples, to its northern Minnesota hospitals. Minneapolis-based Allina Health enacted policies governing the labeling, handling and transporting of hospital tissue samples. In addition, the Minnesota Hospital Association collaborated with multiple organizations to develop some excellent tools that we describe later.
There aren’t any great statistics on how often surgical specimens are lost. One study (Makary 2007) looking at surgery in an outpatient clinic or a hospital operating room found 4.3 surgical specimen identification errors in every 1000 cases (and about 60% of those errors were in biopsies)but did not note cases of lost specimens. The Pennsylvania Patient Safety Authority did a Patient Safety Advisory “Lost Surgical Specimens, Lost Opportunities” in 2005. They had received at least 30 reports of lost surgical specimens through their patient safety reporting system but did not provide any denominator data so the actual rates of lost specimens is unknown. Fortunately, these are probably rare events. However, they can be devastating to patients and staff when they occur.
We first highlighted the issue of lost lab specimens in our November 16, 2010 Patient Safety Tip of the Week “Lost Lab Specimens”. In that column we described participating in a FMEA (Failure Mode and Effects Analysis) after a near-miss where surgical biopsy specimens were temporarily misplaced (but fortunately found in a few days). Given the gravity of losing a specimen, we recommend organizations do their own FMEA of specimen management to identify vulnerabilities in their processes and procedures.
The process for specimen management begins well before the patient arrives in the OR. During booking onto the OR schedule one of the questions that should be asked is “Do you anticipate there will likely be surgical specimens to be sent to the lab?”. That is important since it can help facilitate having the correct specimen containers available before the case begins. Then, during the “pre-op huddle” or “pre-op briefing” that question should be asked again and all participants should verify that the correct specimen containers are present. Specimen containers come in different sizes and may or may not contain a preservative (eg. formalin), depending upon the size and nature of the expected specimen. Some organizations now utilize ways to further identify the nature (or destination) of the specimen by special means (eg. different colored lids).
We also advocate for including on your checklist during the surgical timeout an item to let all parties know that a specimen is expected (because more parties are in the OR than may have been at the pre-op huddle).
There should be no pre-labeling of specimen containers. Labeling specimens should take place immediately when the specimen is removed in the OR. Specimens are usually given to a nurse in the OR, who then puts the specimens in a container, or put directly into the container by the surgeon. Caution must be used if any instruments are used in order to avoid crushing the specimen or causing thermal injury. The nurse labels the container with the patient’s identification (at least 2 methods of patient identification), date/time taken, surgeon’s name, and description of the tissue (what it is and where it was taken from), any preservative used, and a requisition slip with similar information. Labels may also require a biohazard notification. Note that the labels should be generated in close proximity (in both space and time) to specimen procurement and are generated just prior to when they are placed on the specimen container. For those few facilities that do not have label printers in their OR/procedure rooms, make sure you inscribe using indelible ink that will not smudge and clearly and legibly print all information. Also, when using labels, take care to make sure the label is not positioned in a manner that it might be torn when the container lid is removed.
See also below for a great description the Minnesota Hospital Association suggests for the verbal communication that should take place at the time of specimen removal and transfer to containers (using “hearback” or “readback”) and the use of verification by two trained clinical professionals (eg. scrub and circulating nurse).
The OR surgery/procedure documentation sheet should contain a section detailing what specimens were obtained and sent to the laboratory. In fact, we recommend you also have a check box for when no specimen is sent and have the surgeon sign or initial that box when no specimens are sent.
Using forms or checklists may help remind people what to do with the specimen. If you use the World Health Organization’s Surgical Safety Checklist the Sign Out phase is completed before the patient leaves the operating room. The Checklist coordinator verbally confirms the name of the procedure, the instrument and sponge counts, correct labeling of any specimens, any equipment problems, and key concerns for postoperative care and recovery. It is important this be conducted prior to any cleaning of the room. We’ve seen cases where a “missing” specimen is found on a table (or elsewhere!). Note that should never happen if you did appropriate communication and verification as the specimen was removed.
The post-op debriefing is also important. Yes, you should discuss specimen handling during the debriefing. But you also should discuss any problems you had with the instruments used for procuring or handling the specimens or the containers, so that future OR/ procedure cases do not experience similar problems. We recall a case where a spring-loaded instrument used for procuring a specimen malfunctioned, tossing the specimen off. Staff said “Oh. Dr. X had the same problem with that last time.”!
One fortunate thing has come out of Minnesota’s event reporting: the Minnesota Hospital Association has collaborated with multiple organizations to develop guidelines and tools to help prevent loss of specimens. In 2015 they put together a document “Specimen Management in the Operating Room. Gap Analysis” that includes a checklist for organizations to use to assess their compliance with best practices for specimen management. That has also been incorporated into the MHA’s Surgery Road Map.
It amplifies some of our above recommendations. For example, the huddle should review anticipated specimens, specimen containers, and any special considerations (e.g., research specimen, forensics, patient and family wishes). The process for generating a specimen label should produce only as many labels as needed and labels are generated just prior to when they are placed on the specimen container. It also suggests that pathology specimen containers have visual cues to make them more recognizable in the environment (e.g., all surgical specimens have a colored lid and/or colored specimen label). And during the post-op debriefing all specimens and orders are accounted for prior to clearing and cleaning the designated specimen area. And a reconciliation process should be in place for any specimen discrepancies noted before, during or after the procedure.
But the MHA Surgery Road Map has really good recommendations on communication during specimen management. It notes that as specimens are procured, the surgeon/proceduralist verbally communicates to the team:
The circulator verbally confirms (read back) the specimen and handling instructions.
Specimen containers are labeled as the specimen is placed in the container rather than before specimen is placed in container.
In addition, it recommends that procure specimens are visualized by two trained clinical professionals (e.g., scrub and circulator) at the time of procurement, labeled, and placed in the container. They ensure:
Moreover, it emphasizes some of the specimen tracking methods that we suggested were coming in our November 16, 2010 Patient Safety Tip of the Week “Lost Lab Specimens”. It specifies that an automation and health information technology (HIT) is present within the specimen management process:
AORN best practices for specimen management (Van Wicklin 2015) include even more valuable pearls. Once the need for a specimen is identified, the perioperative nurse conducts an assessment including the following:
Van Wicklin notes that specimens must be labeled to communicate preservative and biohazard information. She also stresses the importance of prompt use of correct preservatives and avoiding air exposure that can desiccate the tissue. For example, dry surfaces (eg if the specimen is put on a towel) may adhere to the tissue, and this can result in loss of portions of the resection margins when the specimen is removed from the dry surface. The Van Wicklin article also has a nice cartoon illustrating multiple things not to do regarding specimens in the OR.
The MHA Surgery Road Map really just describes specimen handling up to the point of specimens leaving the OR/procedure room. In our November 16, 2010 Patient Safety Tip of the Week “Lost Lab Specimens” our FMEA went on to follow specimens on their way to and through the pathology lab. When we did that column there was limited data available on the impact of new technologies (barcoding, RFID’s, etc.) on tracking lab specimens. These obviously have the potential to significantly reduce the loss of specimens.
So what happens to specimens once the surgery/procedure has been completed? Each hospital needs to look at all the steps in that subsequent process and especially take into account how the steps might differ after-hours and on weekends. And you need to take into account how the process in clinic or outpatient settings differs from that in the OR or procedure rooms.
In general, the process goes something like this at most hospitals:
The containers with the specimens are generally placed in a receptacle in the “pick-up” area of the OR nurses’ station and entered into a log book. The specimens are then taken by someone (that “someone” could be a nurse, a courier, or anybody who happened to be going to the lab). That person would sign the log book in the OR and take the specimens to the lab. At the lab they would sign a log book, as would the person receiving the specimens in the lab. After logged in at the lab the specimens are taken by the technician to the “grossing” section and the technician prepares cassettes to be matched to each specimen. The pathologist then does a gross examination (dictating his/her report) and places specimen parts into the labeled cassettes. From there the specimens are put into the “processing” machine overnight. A technician maintains the lab log and indicates on there how many cassettes the pathologist listed in his dictated report. However, sometimes the technician does not hear the dictation until the following morning. In the morning the technician removes the cassettes from the processing machine and takes them to the “embedding” machine (paraffin bath). From there they go to a microtome where slides are prepared and labeled. They then go to a warming oven to dry, then are cooled off, and stained. Once stained and dried the slides are placed in a slide holder and placed, along with the corresponding gross descriptions, on the pathologist’s desk. The pathologist adds the microscopic examination to his report and the slides are put in a filing cabinet for storage. This is the process that takes place at most labs.
As you can readily see, that’s a lot of handoffs and handoffs are times of vulnerability to errors. “Ownership” becomes a key element. In one article (Slavin 2001), the pathology department decided that it would take ownership of the transport process from the OR to the lab. That effectively reduced the number of handoffs. Handoffs are always opportunities for errors to occur so anything that reduces the number of handoffs generally improves safety. In our own RCA/FMEA the OR staff decided to take ownership for the process when done after hours (taking the specimen to the lab, entering it into the log there, and putting it in formalin). This step basically says “we will not assume that someone else will do it”. Another example was our lab staff deciding to take over removal of the waste receptacles (rather than housekeeping) so they would have control in the event of a missing specimen.
Chain of custody is a term usually associated with precise tracking of forensic specimens or evidence in legal cases. Most labs at times do have to adhere to strict chain of custody procedures when they do handle items involved in litigation. Yet shouldn’t every specimen be handled with the same level of scrutiny and security? We would certainly hope any specimen of ours were handled that way! Chain of custody is nicely described in the PPSA Patient Safety Advisory “Lost Surgical Specimens, Lost Opportunities”. It usually involves logs containing the names/departments releasing the specimen, names/departments accepting the specimen, dates and times of such transfers, patient identification, specimen number, specimen description, and others.
One very simple intervention that should be done at all handoffs is a specimen count. If you knew you had 14 specimens or cassettes at Step B and you now have only 13 at Step D, you have at least isolated the locations where the specimen was most likely lost or misplaced. It’s just like doing a sponge count when you are doing surgery. (Speaking of sponges…one cause of “lost” specimens is when tiny tissue specimens get attached to small sponges that may be put in specimen containers).
During the discussion with key stakeholders, anecdotal items tend to come out. In our original FMEA, it was brought out that sometimes the receiving person in the lab after hours did not always put the larger specimens in formalin. The pathologists also often grumbled that the surgeons weren’t providing enough detail about the specimens.
What happens after hours probably differs from facility to facility. In our FMEA the OR nurse would deliver the specimen to the lab and turn it over to whoever was working in the lab that night (that might be someone other than the normal tissue lab technician). One must be certain that the person receiving specimens after hours is as fully trained in proper handling and processing of those specimens as your day staff are.
Specimens coming from outside the hospital via courier (eg. from offices) can be especially problematic. You may have little control over the labeling and handling that occur in those offices. And there are lots of anecdotes of such specimens never reaching the lab. It may make sense to have some communication from the offices to the lab ahead of time, notifying them that a specimen or specimens are on their way to the lab. In any event, the logbook and chain of custody procedures should take place every time a handoff takes place (eg. office-to-courier, courier-to-lab, etc.) and specimen counts should match.
One other caveat that comes from the literature on mislabeling of specimens: if you can avoid it, don’t batch! Deal with specimens one at a time. Any time you are dealing with labeling multiple specimens at the same time you run the risk of transposing labels.
Having a checklist “where to look for lost specimens” may also help when the specimen is lost after leaving the OR. This should include places in the lab where previously misplaced specimens were ultimately found and should point staff to review the chain of custody logs to identify where the specimen was last recorded.
Prompt communication upon identifying a lost specimen is critical. That communication starts the search for the missing specimen, whether in the OR or the lab. Such cannot be delayed. For instance, if the specimen is in a trash can it may be gone and irretrievable by morning. Similarly, if your specimen count on arrival at the lab does not match what was in the logbook at the OR end, an immediate call to the OR is needed to avoid having a specimen discarded along with the other surgical paraphernalia.
A recent AHRQ WebM&M (Heher 2017) had a nice table showing factors affecting the likelihood that a specimen might be lost or misprocessed. It categorized these factors as below:
Ordering and transport factors
Laboratory factors
Test and patient factors
Another study in an outpatient setting (Sandbank 2010) identified a critical point of specimen loss to be noninsertion of the specimen into the container by medical staff. The authors in that article and subsequent one (Shalom 2013) recommend strict guidelines, such as immediate insertion of the specimen into the container and signing on the container confirming that the specimen is in the correct labeled container at the end of the procedure.
Obviously, this is a great topic for your organization to consider for a FMEA (Failure Mode and Effects Analysis). Flowcharting the entire process from pre-procedure through the entire pathology process will help you identify not only potentials for losing specimens but also those potentials for mislabeling specimens and mixing them up.
You begin by flowcharting the entire process. After you do your initial pass at flowcharting, you need to go back and ask questions like “How is that handled after hours (at night or on weekends)?”.
Key to doing a good RCA or FMEA is involving the key players who are closest to the process. They are the ones most likely to tell you where the problematic points are (and tell you the solutions!). You also need to visually observe the entire process as it plays out in real time. You will be surprised at how often you see things that others have come to accept as “normal”. And you’ll see the various “workarounds” that have crept into the process.
Having “outsiders” (i.e. people who do not ordinarily work in the pathology lab) observe the process also provides an opportunity to observe the work environment. That is where the little things, that escape the attention of the lab personnel, may be identified. For example, you might notice that the trash receptacles sit in locations where it might be possible to accidentally knock a specimen or cassette into them (don’t be afraid to ask them “Have you ever knocked a cassette into that trash can?”). Or you might notice that all the specimen containers and their matching cassettes are lined up like dominoes and vulnerable to being knocked over by an errant elbow!
Review of the work environment should include attention not only items like lighting and clutter but also workload issues. Mistakes tend to occur most often under stressful conditions, such as time pressures or deadlines, understaffing, fatigue, conflicting goals and incentives, etc.
Education, training and competency assessment are, of course, essential to quality in any laboratory setting. But don’t forget you also need to make sure everyone who might be in that laboratory, including your housekeeping staff, understand security of specimens.
So you haven’t had a lost specimen yet? Not yet. Just one critical lost specimen or mislabeling of specimens might lead to devastation for one of your patients and headlines in your local newspaper, not to mention costly litigation. Doing a FMEA on specimen handling will give you good insight into your vulnerability for lost specimens and mislabeled specimens, and may well help you identify other problems with efficiency in the OR, transport, or lab that are easily fixed.
If you can’t do a full FMEA, at least look at the Minnesota Hospital Association’s “Specimen Management in the Operating Room. Gap Analysis” that includes a checklist for organizations to use to assess their compliance with best practices for specimen management. Detailed guidelines for specimen handling and management are also available from the Association of Surgical Technologists (AST 2008) and the College of American Pathologists (Lott 2015).
Some of our other columns on errors related to laboratory studies:
References:
Minnesota Department of Health. Adverse Health Events in Minnesota. 14th Annual Public Report; February 2018
http://www.health.state.mn.us/patientsafety/ae/2018ahereport.pdf
Minnesota Department of Health. Adverse Health Events in Minnesota. 13th Annual Public Report; February 2017
http://www.health.state.mn.us/patientsafety/ae/2017ahereport.pdf
Minnesota Department of Health. Adverse Health Events in Minnesota. 12th Annual Public Report; February 2016
http://www.health.state.mn.us/patientsafety/ae/2016ahereport.pdf
Olson J. Annual report on Minnesota hospital errors finds problems with lost tissue samples. State's medical errors report finds that the problem is common. Star Tribune 2018; February 17, 2017
http://www.startribune.com/annual-report-on-hospital-errors-includes-lost-polyps-tumors/414030033/
Makary MA, Epstein J, Pronovost PJ et al. Surgical specimen identification errors: A new measure of quality in surgical care. Surgery 2007; 141(4): 450-455
http://www.surgjournal.com/article/S0039-6060%2806%2900624-6/abstract
Pennsylvania Patient Safety Authority. Lost Surgical Specimens, Lost Opportunities.
PA PSRS Patient Saf Advis 2005 Sep; 2(3):1-5
http://patientsafety.pa.gov/ADVISORIES/Pages/200509_01b.aspx
WHO Surgical Safety Checklist
http://www.who.int/patientsafety/safesurgery/tools_resources/SSSL_Checklist_finalJun08.pdf
Minnesota Hospital Association. Specimen Management in the Operating Room. Gap Analysis. 2015
Minnesota Hospital Association. Surgery Road Map. 2017
https://www.mnhospitals.org/Portals/0/Documents/patientsafety/Surgery/Surgery%20Road%20Map.pdf
Van Wicklin SA. Back to Basics: Specimen Management. AORN Journal 2015;
101; 559-563 May 2015
https://www.aorn.org/websitedata/cearticle/pdf_file/CEA15518-0001.pdf
Slavin L. Best MA. Aron DC. Gone but not forgotten: the search for the lost surgical specimens: application of quality improvement techniques in reducing medical error.
Quality Management in Health Care 2001. 10(1): 45-53
Heher YK. Specimen Almost Lost. Cases & Commentaries WebM&M. AHRQ PSNet 2017; Published November 2017
https://psnet.ahrq.gov/webmm/case/427/specimen-almost-lost
Sandbank S, Klein D, Westreich M, Shalom A. The loss of pathological specimens: incidence and causes. Dermatol Surg 2010; 36(7): 1084-1086
Shalom A1, Westreich M, Sandbank S. An intervention study to reduce the loss of pathology specimens. Isr Med Assoc J 2013; 15(7): 356-358.
https://www.ima.org.il/FilesUpload/IMAJ/0/65/32859.pdf
AST (Association of Surgical Technologists). AST Standards of Practice for Handling and Care of Surgical Specimens. 2008. Accessed February 27, 2018
Lott R, Tunnicliffe J, Sheppard E, et al. Practical Guide to Specimen Handling in Surgical Pathology. CAP (College of American Pathologists) 2015
Print “Minnesota Highlights Lost Tissue Samples”
March 27, 2018
PICC Use Persists
One of our most frequently accessed columns is our January 21, 2014 Patient Safety Tip of the Week “The PICC Myth”. In that column and the others listed below we noted that the presumed safety advantage of PICC catheters compared to central lines may be misleading.
Then in our December 2014 What's New in the Patient Safety World column “Surprise Central Lines” we noted that very often responsible physicians are surprised to find their patient has either a central line or PICC line. We followed that up with our What's New in the Patient Safety World columns for July 2015 “Reducing Central Venous Catheter Use” and October 2015 “Michigan Appropriateness Guide for Intravenous Catheters” to discuss guidelines for appropriate use of such lines and ways to reduce their inappropriate use.
But a new study in the Journal of Hospital Medicine shows that inappropriate use of PICC lines persists (Paje 2018). Guidelines for peripherally inserted central catheters (PICC’s) recommend avoiding insertion if the anticipated duration of use is ≤5 days. The researchers collected data from medical records of adults that received PICCs during hospitalization at 52 Michigan Hospital Medicine Safety (HMS) Consortium sites. They found that, of the 15,397 PICCs placed, 25.3% had a dwell time of ≤5 days. Among those with short-term PICCs, 9.6% experienced a complication (2.5% experiencing VTE and 0.4% experiencing CLABSI events). The most common minor complications were catheter occlusion (4%) and tip migration (2.2%).
Some of the factors identified with short-term PICCs included difficult venous access, multilumen devices, and teaching hospitals. They conclude that short-term use of PICCs is common and associated with patient, provider, and device factors and that because PICC placement, even for brief periods, is associated with complications, efforts targeted at factors underlying such use appear necessary.
One contributing factor that we have seen is that it’s too easy to order a PICC insertion. Most hospitals today have PICC line “teams” led by nurses skilled at PICC insertion. So it’s very easy for a physician, who need not be bothered by the effort to insert a line, to simply order a PICC line and have the team insert one.
We’ve discussed unnecessary central venous catheter or PICC line use in our previous columns of January 21, 2014 “The PICC Myth” and December 2014 “Surprise Central Lines”. In the latter we noted that oversight is needed to avoid what we consider an example of a predictable error and put systems in place to help us avoid the problem. One of the items on our checklist for daily rounds on patients in all locations should be “Does this patient have any catheters or lines in place and, if so, are they still necessary?” Use of such lines should be evidence-based where possible. Alert fatigue aside, we also recommend that flags be set in the electronic medical record (EMR) to highlight for the clinician that such catheters are in place and need to be reviewed for continuation on a daily basis.
But the best interventions are those that can be delivered before a central venous catheter or PICC line are placed. There are two ways to do this. One is to require an order in CPOE that requests the indication before the catheter insertion kit is dispensed. The other is a paper-based checklist with indications that is filled out before the catheter insertion kit can be opened. We actually prefer the latter since your checklist can and should also include all the elements for proper catheter insertion, i.e. the classic Pronovost checklist (see our March 2011 What’s New in the Patient Safety World column “Michigan ICU Collaborative Wins Big”), and correct patient and procedure verification.
So we hope your organization is following the Michigan Appropriateness Guide for Intravenous Catheters, also known as MAGIC (Chopra 2015) that we discussed in our October 2015 What's New in the Patient Safety World column “Michigan Appropriateness Guide for Intravenous Catheters” for appropriate use of such lines and ways to reduce their inappropriate use. The UM Health System also has a comprehensive website, ImprovePICC, that offers easy access to the MAGIC recommendations and a host of valuable PICC resources (videos, slides, etc.).
Also, we hope you have a formal mechanism for tracking PICC lines and assessing their appropriateness.
Update: Since we first posted this column a report was published on results of a Michigan collaborative using the MAGIC guideline (Swaminathan 2018). A multimodal intervention (tool, training, electronic changes, education) derived from MAGIC was implemented at one hospital and rates of inappropriate PICC’s and patient outcomes were compared to 9 other hospitals over a 2 year period from 2014 to 2016. Absolute rates of inappropriate PICC use decreased substantially at the study site versus controls after implementation but, after adjusting for underlying trends and patient characteristics, there was only a marginally significant 13.8% decrease in inappropriate PICC use at the study site (P=0.048). Also, while the incidence of all PICC complications decreased to a greater extent at the study site, the absolute difference between controls and intervention was small. The authors caution that, given the size and resources required for this study and the modest improvements seen, future work should consider cost-to-benefit ratio of similar approaches.
Some of our other columns on central venous catheters and PICC lines:
January 21, 2014 “The PICC Myth”
December 2014 “Surprise Central Lines”
July 2015 “Reducing Central Venous Catheter Use”
October 2015 “Michigan Appropriateness Guide for Intravenous Catheters”
References:
Paje D, Conlon A, Kaatz S, et al. Patterns and Predictors of Short-Term Peripherally Inserted Central Catheter Use: A Multicenter Prospective Cohort Study. J. Hosp Med 2018; 13(2): 76-82
Chopra V, Flanders SA, Saint S, et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results from a Multispecialty Panel Using the RAND/UCLA Appropriateness Method. Ann Intern Med 2015; 163(6_Supplement): S1-S40
http://annals.org/article.aspx?articleid=2436759&atab=7
Universitiy of Michigan Health System. Improve PICC website.
Swaminathan L, Flanders S, Rogers M, et al. Improving PICC use and outcomes in hospitalised patients: an interrupted time series study using MAGIC criteria. BMJ Qual Saf 2018; 27: 271-278
http://qualitysafety.bmj.com/content/27/4/271
Print “PICC Use Persists”
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Mixed Message on Number of Open EMR Records
May 14, 2019
Wrong-Site Surgery and Difficult-to-Mark Sites
May 7, 2019
Simulation Training for OR Fires
April 30, 2019
Reducing Unnecessary Urine Cultures
April 23, 2019
In and Out the Door and Other OR Flow Disruptions
April 16, 2019
AACN Practice Alert on Alarm Management
April 9, 2019
Handoffs for Every Occasion
April 2, 2019
Unexpected Events During MRI
March 26, 2019
March 19, 2019
March 12, 2019
Update on Overlapping Surgery
March 5, 2019
Infusion Pump Problems
February 26, 2019
Vascular Access Device Dislodgements
February 19, 2019
Focus on Pediatric Patient Safety
February 12, 2019
From Tragedy to Travesty of Justice
February 12, 2019
2 ER Drug Studies: Reassurances and Reservations
February 5, 2019
Flaws in Our Medication Safety Technologies
January 29, 2018
National Patient Safety Goal for Suicide Prevention
January 22, 2019
Wandering Patients
January 15, 2019
Another Plus for Prehabilitation
January 8, 2019
Maternal Mortality in the Spotlight
January 1, 2019
More on Automated Dispensing Cabinet (ADC) Safety
December 25, 2018
Happy Holidays!
December 18, 2018
Great Recommendations for e-Prescribing
December 11, 2018
December 4, 2018
Don’t Use Syringes for Topical Products
November 27, 2018
November 20, 2018
November 13, 2018
Antipsychotics Fail in ICU Delirium
November 6, 2018
More on Promoting Sleep in Inpatients
October 30, 2018
October 23, 2018
Lessons From Yet Another Aviation Incident
October 16, 2018
October 9, 2018
October 2, 2018
Speaking Up About Disruptive Behavior
September 25, 2018
Foley Follies
September 18, 2018
September 11, 2018
September 4, 2018
The 12-Hour Nursing Shift: Another Nail in the Coffin
August 28, 2018
Thought You Discontinued That Medication? Think Again
August 21, 2018
Delayed CT Scan in the Anticoagulated Patient
August 14, 2018
ISMP Canada’s Updated “Do Not Use” Abbreviation List
August 7, 2018
Tip of the Week on Vacation
July 31, 2018
Surgery and the Opioid-Tolerant Patient
July 24, 2018
More on Speech Recognition Software Errors
July 17, 2018
OSA Screening in Stroke Patients
July 10, 2018
Another Jump from a Hospital Window
July 3, 2018
Tip of the Week on Vacation
June 26, 2018
Infection Related to Colonoscopy
June 19, 2018
June 12, 2018
Adverse Events in Cancer Patients
June 5, 2018
Pennsylvania Patient Safety Authority on Iatrogenic Burns
May 29, 2018
More on Nursing Workload and Patient Safety
May 22, 2018
Hazardous Intrahospital Transport
May 15, 2018
May 8, 2018
May 1, 2018
April 24, 2018
April 17, 2018
More on Tests Pending at Discharge
April 10, 2018
Prepping the Geriatric Patient for Surgery
April 3, 2018
March 27, 2018
March 20, 2018
Minnesota Highlights Lost Tissue Samples
March 13, 2018
March 6, 2018
February 27, 2018
Update on Patient Safety Walk Rounds
February 20, 2018
February 13, 2018
February 6, 2018
Adverse Events in Inpatient Psychiatry
January 30, 2018
January 23, 2018
Unintentional Hypothermia Back in Focus
January 16, 2018
January 9, 2018
More on Fire Risk from Surgical Preps
January 2, 2018
Preventing Perioperative Nerve Injuries
December 26, 2017
Tip of the Week on Vacation
December 19, 2017
December 12, 2017
Joint Commission on Suicide Prevention
December 5, 2017
Massachusetts Initiative on Cataract Surgery
November 28, 2017
More on Dental Sedation/Anesthesia Safety
November 21, 2017
OSA, Oxygen, and Alarm Fatigue
November 14, 2017
Tracking C. diff to a CT Scanner
November 7, 2017
Perioperative Neuropathies
October 31, 2017
Target Drugs for Deprescribing
October 24, 2017
Neurosurgery and Time of Day
October 17, 2017
Progress on Alarm Management
October 10, 2017
More on Torsade de Pointes
October 3, 2017
Respiratory Compromise: One Size Does Not Fit All
September 26, 2017
Tip of the Week on Vacation
September 19, 2017
Tip of the Week on Vacation
September 12, 2017
Can You Hear Me Now?
September 5, 2017
Another Iatrogenic Burn
August 29, 2017
Suicide in the Bathroom
August 22, 2017
August 15, 2017
Delayed Emergency Surgery and Mortality Risk
August 8, 2017
Sedation for Pediatric MRI Rising
August 1, 2017
Progress on Wrong Patient Orders
July 25, 2017
Can We Influence the “Weekend Effect”?
July 18, 2017
Another Hazard from Alcohol-Based Hand Gels
July 11, 2017
The 12-Hour Shift Takes More Hits
July 4, 2017
Tip of the Week on Vacation
June 27, 2017
June 20, 2017
June 13, 2017
June 6, 2017
NYS Mandate for Sepsis Protocol Works
May 30, 2017
Errors in Pre-Populated Medication Lists
May 23, 2017
May 16, 2017
Are Surgeons Finally Ready to Screen for Frailty?
May 9, 2017
Missed Nursing Care and Mortality Risk
May 2, 2017
Anatomy of a Wrong Procedure
April 25, 2017
April 18, 2017
Alarm Response and Nurse Shift Duration
April 11, 2017
Interruptions: The Ones We Forget About
April 4, 2017
Deprescribing in Long-Term Care
March 28, 2017
More Issues with Dental Sedation/Anesthesia
March 21, 2017
Success at Preventing Delirium
March 14, 2017
More on Falls on Inpatient Psychiatry
March 7, 2017
February 28, 2017
February 21, 2017
Yet More Jumps from Hospital Windows
February 14, 2017
February 7, 2017
January 31, 2017
More Issues in Pediatric Safety
January 24, 2017
Dexmedetomidine to Prevent Postoperative Delirium
January 17, 2017
January 10, 2017
The 26-ml Applicator Strikes Again!
January 3, 2017
What’s Happening to “I’m Sorry”?
December 27, 2016
Tip of the Week on Vacation
December 20, 2016
End-of-Rotation Transitions and Mortality
December 13, 2016
More on Double-Booked Surgery
December 6, 2016
Postoperative Pulmonary Complications
November 29, 2016
Doubling Down on Double-Booked Surgery
November 22, 2016
Leapfrog, Picklists, and Healthcare IT Vulnerabilities
November 15, 2016
November 8, 2016
Managing Distractions and Interruptions
November 1, 2016
CMS Emergency Preparedness Rule
October 25, 2016
Desmopressin Back in the Spotlight
October 18, 2016
Yet More Questions on Contact Precautions
October 11, 2016
New Guideline on Preop Screening and Assessment for OSA
October 4, 2016
September 27, 2016
September 20, 2016
Downloadable ABCDEF Bundle Toolkits for Delirium
September 13, 2016
Vanderbilt’s Electronic Procedural Timeout
September 6, 2016
August 30, 2016
Can You Really Limit Interruptions?
August 23, 2016
ISMP Canada: Automation Bias and Automation Complacency
August 16, 2016
How Is Your Alarm Management Initiative Going?
August 9, 2016
August 2, 2016
Drugs in the Elderly: The Goldilocks Story
July 26, 2016
Confirmed: Keep Your OR Doors Closed
July 19, 2016
Infants and Wrong Site Surgery
July 12, 2016
Forget Brexit – Brits Bash the RCA!
July 5, 2016
Tip of the Week on Vacation
June 28, 2016
Culture of Safety and Catheter-Associated Infections
June 21, 2016
Methotrexate Errors in Australia
June 14, 2016
Nursing Monitoring of Patients on Opioids
June 7, 2016
CPAP for Hospitalized Patients at High Risk for OSA
May 31, 2016
More Frailty Measures That Predict Surgical Outcomes
May 24, 2016
Texting Orders – Is It Really Safe?
May 17, 2016
Patient Safety Issues in Cataract Surgery
May 10, 2016
Medical Problems in Behavioral Health
May 3, 2016
Clinical Decision Support Malfunction
April 26, 2016
Lots More on Preventing Readmissions But Where's the Beef?
April 19, 2016
Independent Double Checks and Oral Chemotherapy
April 12, 2016
April 5, 2016
Workarounds Overriding Safety
March 29, 2016
March 22, 2016
Radiology Communication Errors May Surprise You
March 15, 2016
March 8, 2016
Tip of the Week on Vacation
March 1, 2016
February 23, 2016
February 16, 2016
February 9, 2016
February 2, 2016
January 26, 2016
More on Frailty and Surgical Morbidity and Mortality
January 19, 2016
Patient Identification in the Spotlight
January 12, 2016
New Resources on Improving Safety of Healthcare IT
January 5, 2016
Lessons from AirAsia Flight QZ8501 Crash
December 29, 2015
More Medical Helicopter Hazards
December 22, 2015
The Alberta Abbreviation Safety Toolkit
December 15, 2015
Vital Sign Monitoring at Night
December 8, 2015
Danger of Inaccurate Weights in Stroke Care
December 1, 2015
TALLman Lettering: Does It Work?
November 24, 2015
Door Opening and Foot Traffic in the OR
November 17, 2015
Patient Perspectives on Communication of Test Results
November 10, 2015
Weighing in on Double-Booked Surgery
November 3, 2015
Medication Errors in the OR - Part 2
October 27, 2015
Sentinel Event Alert on Falls and View from Across the Pond
October 20, 2015
Updated Beers List
October 13, 2015
Dilaudid Dangers #3
October 6, 2015
Suicide and Other Violent Inpatient Deaths
September 29, 2015
More on the 12-Hour Nursing Shift
September 22, 2015
The Cost of Being Rude
September 15, 2015
Another Possible Good Use of a Checklist
September 8, 2015
TREWScore for Early Recognition of Sepsis
September 1, 2015
August 25, 2015
Checklist for Intrahospital Transport
August 18, 2015
Missing Obstructive Sleep Apnea
August 11, 2015
New Oxygen Guidelines: Thoracic Society of Australia and NZ
August 4, 2015
Tip of the Week on Vacation
July 28, 2015
July 21, 2015
Avoiding Distractions in the OR
July 14, 2015
July 7, 2015
June 30, 2015
What Are Appropriate Indications for Urinary Catheters?
June 23, 2015
Again! Mistaking Antiseptic Solution for Radiographic Contrast
June 16, 2015
June 9, 2015
Add This to Your Fall Risk Assessment
June 2, 2015
May 26, 2015
May 19, 2015
May 12, 2015
More on Delays for In-Hospital Stroke
May 5, 2015
Errors with Oral Oncology Drugs
April 28, 2015
April 21, 2015
April 14, 2015
Using Insulin Safely in the Hospital
April 7, 2015
March 31, 2015
Clinical Decision Support for Pneumonia
March 24, 2015
Specimen Issues in Prostate Cancer
March 17, 2015
March 10, 2015
FDA Warning Label on Insulin Pens: Is It Enough?
March 3, 2015
Factors Related to Postoperative Respiratory Depression
February 24, 2015
More Risks with Long-Acting Opioids
February 17, 2015
Functional Impairment and Hospital Readmission, Surgical Outcomes
February 10, 2015
The Anticholinergic Burden and Dementia
February 3, 2015
CMS Hopes to Reduce Antipsychotics in Dementia
January 27, 2015
The Golden Hour for Stroke Thrombolysis
January 20, 2015
He Didn’t Wash His Hands After What!
January 13, 2015
January 6, 2015
Yet Another Handoff: The Intraoperative Handoff
December 30, 2014
Data Accumulates on Impact of Long Surgical Duration
December 23, 2014
Iatrogenic Burns in the News Again
December 16, 2014
More on Each Element of the Surgical Fire Triad
December 9, 2014
December 2, 2014
ANA Position Statement on Nurse Fatigue
November 25, 2014
Misdiagnosis Due to Lab Error
November 18, 2014
Handwashing Fades at End of Shift, ?Smartwatch to the Rescue
November 11, 2014
Early Detection of Clinical Deterioration
November 4, 2014
Progress on Fall Prevention
October 28, 2014
RF Systems for Retained Surgical Items
October 21, 2014
The Fire Department and Your Hospital
October 14, 2014
October 7, 2014
Our Take on Patient Safety Walk Rounds
September 30, 2014
More on Deprescribing
September 23, 2014
Stroke Thrombolysis: Need to Focus on Imaging-to-Needle Time
September 16, 2014
Focus on Home Care
September 9, 2014
The Handback
September 2, 2014
Frailty and the Trauma Patient
August 26, 2014
Surgeons’ Perception of Intraoperative Time
August 19, 2014
Some More Lessons Learned on Retained Surgical Items
August 12, 2014
Surgical Fires Back in the News
August 5, 2014
Tip of the Week on Vacation
July 29, 2014
The 12-Hour Nursing Shift: Debate Continues
July 22, 2014
More on Operating Room Briefings and Debriefings
July 15, 2014
Barriers to Success of Early Warning Systems
July 8, 2014
Update: Minor Head Trauma in the Anticoagulated Patient
July 1, 2014
Interruptions and Radiologists
June 24, 2014
Lessons from the General Motors Recall Analysis
June 17, 2014
SO2S Confirms Routine Oxygen of No Benefit in Stroke
June 10, 2014
Another Clinical Decision Support Tool to Avoid Torsade de Pointes
June 3, 2014
More on the Risk of Sedative/Hypnotics
May 27, 2014
A Gap in ePrescribing: Stopping Medications
May 20, 2014
May 13, 2014
Perioperative Sleep Apnea: Human and Financial Impact
May 6, 2014
Monitoring for Opioid-induced Sedation and Respiratory Depression
April 29, 2014
More on the Unintended Consequences of Contact Isolation
April 22, 2014
Impact of Resident Workhour Restrictions
April 15, 2014
Specimen Identification Mixups
April 8, 2014
FMEA to Avoid Breastmilk Mixups
April 1, 2014
Expensive Aspects of Sepsis Protocol Debunked
March 25, 2014
March 18, 2014
Systems Approach Improving Stroke Care
March 11, 2014
We Miss the Graphic Flowchart!
March 4, 2014
Evidence-Based Prescribing and Deprescribing in the Elderly
February 25, 2014
Joint Commission Revised Diagnostic Imaging Requirements
February 18, 2014
February 11, 2014
Another Perioperative Handoff Tool: SWITCH
February 4, 2014
But What If the Battery Runs Low?
January 28, 2014
Is Polypharmacy Always Bad?
January 21, 2014
January 14, 2014
Diagnostic Error: Salient Distracting Features
January 7, 2014
Lessons From the Asiana Flight 214 Crash
December 24-31, 2013
Tip of the Week on Vacation
December 17, 2013
December 10, 2013
Better Handoffs, Better Results
December 3, 2013
Reducing Harm from Falls on Inpatient Psychiatry
November 26, 2013
Missed Care: New Opportunities?
November 19, 2013
Can We Improve Dilaudid/HYDROmorphone Safety?
November 12, 2013
More on Inappropriate Meds in the Elderly
November 5, 2013
Joint Commission Sentinel Event Alert: Unintended Retained Foreign Objects
October 29, 2013
PAD: The Pain, Agitation, and Delirium Care Bundle
October 22, 2013
How Safe Is Your Radiology Suite?
October 15, 2013
October 8, 2013
October 1, 2013
Fuels and Oxygen in OR Fires
September 24, 2013
Perioperative Use of CPAP in OSA
September 17, 2013
September 10, 2013
Informed Consent and Wrong-Site Surgery
September 3, 2013
Predicting Perioperative Complications: Slow and Simple
August 27 2013
Lessons on Wrong-Site Surgery
August 20 2013
Lessons from Canadian Analysis of Medical Air Transport Cases
August 13 2013
August 6, 2013
July 9-30, 2013
Tip of the Week on Vacation
July 2, 2013
June 25, 2013
June 18, 2013
DVT Prevention in Stoke – CLOTS 3
June 11, 2013
June 4, 2013
May 28, 2013
The Neglected Medications: IV Fluids
May 21, 2013
May 14, 2013
Acute Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)
May 7, 2013
April 30, 2013
Photographic Identification to Prevent Errors
April 23, 2013
Plethora of Medication Safety Studies
April 16, 2013
April 9, 2013
Mayo Clinic System Alerts for QT Interval Prolongation
April 2, 2013
Absconding from Behavioral Health Services
March 26, 2013
Failure to Recognize Sleep Apnea Before Surgery
March 19, 2013
Dealing with the Violent Patient in the Emergency Department
March 12, 2013
More on Communicating Test Results
March 5, 2013
Underutilized Safety Tools: The Observational Audit
February 26, 2013
Insulin Pen Re-Use Incidents: How Do You Monitor Alerts?
February 19, 2013
Practical Postoperative Pain Management
February 12, 2013
CDPH: Lessons Learned from PCA Incident
February 5, 2013
Antidepressants and QT Interval Prolongation
January 29, 2013
A Flurry of Activity on Handoffs
January 22, 2013
You Don’t Know What You Don’t Know
January 15, 2013
January 8, 2013
More Lessons Learned on Retained Surgical Items
January 1, 2013
Don’t Throw Away Those View Boxes Yet
December 25, 2012
Tip of the Week on Vacation
December 18, 2012
Unintended Consequences of the CAUTI Measure?
December 11, 2012
December 4, 2012
Unintentional Perioperative Hypothermia: A New Twist
November 27, 2012
November 20, 2012
Update on Perioperative Management of Obstructive Sleep Apnea
November 13, 2012
The 12-Hour Nursing Shift: More Downsides
November 6, 2012
Using LEAN to Improve Stroke Care
October 30, 2012
October 23, 2012
Latent Factors Lurking in the OR
October 16, 2012
What is the Evidence on Double Checks?
October 9, 2012
Call for Focus on Diagnostic Errors
October 2, 2012
Test Results: Everyone’s Worst Nightmare
September 25, 2012
Preoperative Assessment for Geriatric Patients
September 18, 2012
September 11, 2012
In Search of the Ideal Early Warning Score
September 4, 2012
August 28, 2012
New Care Model Copes with Interruptions Better
August 21, 2012
More on Missed Followup of Tests in Hospital
August 14, 2012
August 7, 2012
Cognition, Post-Op Delirium, and Post-Op Outcomes
July 31, 2012
Surgical Case Duration and Miscommunications
July 24, 2012
FDA and Extended-Release/Long-Acting Opioids
July 17, 2012
July 10, 2012
Tip of the Week on Vacation
July 3, 2012
Recycling an Old Column: Dilaudid Dangers
June 26, 2012
Using Patient Photos to Reduce CPOE Errors
June 19, 2012
More Problems with Faxed Orders
June 12, 2012
Lessons Learned from the CDPH: Retained Foreign Bodies
June 5, 2012
Minor Head Trauma in the Anticoagulated Patient
May 29, 2012
Falls, Fractures, and Fatalities
May 22, 2012
Update on Preoperative Screening for Sleep Apnea
May 15, 2012
May 8, 2012
Importance of Nontechnical Skills in Healthcare
May 1, 2012
April 24, 2012
Fire Hazard of Skin Preps Oxygen
April 17, 2012
April 10, 2012
April 3, 2012
New Risk for Postoperative Delirium: Obstructive Sleep Apnea
March 27, 2012
March 20, 2012
Adverse Events Related to Psychotropic Medications
March 13, 2012
Medical Emergency Team Calls to Radiology
March 6, 2012
February 28, 2012
AACN Practice Alert on Delirium in Critical Care
February 21, 2012
Improving PCA Safety with Capnography
February 14, 2012
Handoffs More Than Battle of the Mnemonics
February 7, 2012
Another Neuromuscular Blocking Agent Incident
January 31, 2012
January 24, 2012
Patient Safety in Ambulatory Care
January 17, 2012
Delirium and Contact Isolation
January 10, 2012
January 3, 2012
Unintended Consequences of Restricted Housestaff Hours
December 20, 2011
December 13, 2011
December 6, 2011
Why You Need to Beware of Oxygen Therapy
November 29, 2011
November 22, 2011
Perioperative Management of Sleep Apnea Disappointing
November 15, 2011
November 8, 2011
WHOs Multi-professional Patient Safety Curriculum Guide
November 1, 2011
So Whats the Big Deal About Inserting an NG Tube?
October 25, 2011
October 18, 2011
October 11, 2011
October 4, 2011
Radiology Report Errors and Speech Recognition Software
September 27, 2011
The Canadian Suicide Risk Assessment Guide
September 20, 2011
When Practice Changes the Evidence: The CKD Story
September 13, 2011
Do You Use Fentanyl Transdermal Patches Safely?
September 6, 2011
August 30, 2011
Unintentional Discontinuation of Medications After Hospitalization
August 23, 2011
Catheter Misconnections Back in the News
August 16, 2011
August 9, 2011
Frailty and the Surgical Patient
August 2, 2011
July 26, 2011
July 19, 2011
Communication Across Professions
July 12, 2011
Psst! Pass it onHow a kids game can mold good handoffs
July 5, 2011
Sidney Dekker: Patient Safety. A Human Factors Approach
June 28, 2011
Long-Acting and Extended-Release Opioid Dangers
June 21, 2011
June 14, 2011
June 6, 2011
May 31, 2011
Book Review Human Factors and Team Psychology in a High Stakes Environment
May 24, 2011
May 17, 2011
Opioid-Induced Respiratory Depression Again!
May 10, 2011
Preventing Preventable Readmissions: Not As Easy As It Sounds
May 3, 2011
April 26, 2011
Sleeping Air Traffic Controllers: What About Healthcare?
April 19, 2011
DVT Prophylaxis in Acute Stroke: Controversy Reappears
April 12, 2011
Medication Issues in the Ambulatory Setting
April 5, 2011
March 29, 2011
The Silent Treatment:A Dose of Reality
March 22, 2011
An EMR Feature Detrimental to Teamwork and Patient Safety
March 15, 2011
March 8, 2011
Yes, Physicians Get Interrupted Too!
March 1, 2011
February 22, 2011
February 15, 2011
Controversies in VTE Prophylaxis
February 8, 2011
February 1, 2011
January 25, 2011
Procedural Sedation in Children
January 18, 2011
More on Medication Errors in Long-Term Care
January 11, 2011
NPSA (UK) How to Guide: Five Steps to Safer Surgery
January 4, 2011
December 28, 2010
HAIs: Looking In All The Wrong Places
December 21, 2010
More Bad News About Off-Hours Care
December 14, 2010
NPSA (UK): Preventing Fatalities from Medication Loading Doses
December 6, 2010
More Tips to Prevent Wrong-Site Surgery
November 30, 2010
SURPASS: The Mother of All Checklists
November 23, 2010
Focus on Cumulative Radiation Exposure
November 16, 2010
November 9, 2010
12-Hour Nursing Shifts and Patient Safety
November 2, 2010
Insulin: Truly a High-Risk Medication
October 26, 2010
Confirming Medications During Anesthesia
October 19, 2010
Optimizing Medications in the Elderly
October 12, 2010
October 5, 2010
September 28, 2010
September 21, 2010
September 14, 2010
Wrong-Site Craniotomy: Lessons Learned
September 7, 2010
Patient Safety in Ob/Gyn Settings
August 31, 2010
August 24, 2010
The BP Oil Spill Analogies in Healthcare
August 17, 2010
Preoperative Consultation Time to Change
August 10, 2010
Its Not Always About The Evidence
August 3, 2010
Tip of the Week on Vacation
July 27, 2010
EMRs Still Have A Long Way To Go
July 20, 2010
More on the Weekend Effect/After-Hours Effect
July 13, 2010
Postoperative Opioid-Induced Respiratory Depression
July 6, 2010
Book Reviews: Pronovost and Gawande
June 29, 2010
Torsade de Pointes: Are Your Patients At Risk?
June 22, 2010
Disclosure and Apology: How to Do It
June 15, 2010
Dysphagia in the Stroke Patient: the Scottish Guideline
June 8, 2010
Surgical Safety Checklist for Cataract Surgery
June 1, 2010
May 25, 2010
May 18, 2010
Real-Time Random Safety Audits
May 11, 2010
May 4, 2010
More on the Impact of Interruptions
April 27, 2010
April 20, 2010
HITs Limited Impact on Quality To Date
April 13, 2010
April 6, 2010
March 30, 2010
Publicly Released RCAs: Everyone Learns from Them
March 23, 2010
ISMPs Guidelines for Standard Order Sets
March 16, 2010
A Patient Safety Scavenger Hunt
March 9, 2010
Communication of Urgent or Unexpected Radiology Findings
March 2, 2010
Alarm Sensitivity: Early Detection vs. Alarm Fatigue
February 23, 2010
Alarm Issues in the News Again
February 16, 2010
Spin/HypeKnowing It When You See It
February 9, 2010
More on Preventing Inpatient Suicides
February 2, 2010
January 26, 2010
Preventing Postoperative Delirium
January 19, 2010
January 12, 2010
Patient Photos in Patient Safety
January 5, 2010
December 29, 2009
Recognizing Deteriorating Patients
December 22, 2009
December 15, 2009
December 8, 2009
December 1, 2009
Patient Safety Doesnt End at Discharge
November 24, 2009
Another Rough Month for Healthcare IT
November 17, 2009
November 10, 2009
Conserving ResourcesBut Maintaining Patient Safety
November 3, 2009
Medication Safety: Frontline to the Rescue Again!
October 27, 2009
Co-Managing Patients: The Good, The Bad, and The Ugly
October 20, 2009
Radiology AgainBut This Time Its Really Radiology!
October 13, 2009
October 6, 2009
Oxygen Safety: More Lessons from the UK
September 29, 2009
Perioperative Peripheral Nerve Injuries
September 22, 2009
Psychotropic Drugs and Falls in the SNF
September 15, 2009
ETTOs: Efficiency-Thoroughness Trade-Offs
September 8, 2009
Barriers to Medication Reconciliation
September 1, 2009
The Real Root Causes of Medical Helicopter Crashes
August 25, 2009
Interruptions, Distractions, InattentionOops!
August 18, 2009
Obstructive Sleep Apnea in the Perioperative Period
August 11, 2009
August 4, 2009
July 28, 2009
Wandering, Elopements, and Missing Patients
July 21, 2009
Medication Errors in Long Term-Care
July 14, 2009
Is Your Do Not Use Abbreviations List Adequate?
July 7, 2009
Nudge: Small Changes, Big Impacts
June 30, 2009
iSoBAR: Australian Clinical Handoffs/Handovers
June 23, 2009
June 16, 2009
Disclosing Errors That Affect Multiple Patients
June 9, 2009
CDC Update to the Guideline for Prevention of CAUTI
June 2, 2009
Why Hospitals Should FlyJohn Nance Nails It!
May 26, 2009
Learning from Tragedies. Part II
May 19, 2009
May 12, 2009
May 5, 2009
Adverse Drug Events in the ICU
April 28, 2009
Ticket Home and Other Tools to Facilitate Discharge
April 21, 2009
April 14, 2009
More on Rehospitalization After Discharge
April 7, 2009
March 31, 2009
Screening Patients for Risk of Delirium
March 24, 2009
March 17, 2009
March 10, 2009
Prolonged Surgical Duration and Time Awareness
March 3, 2009
Overriding AlertsLike Surfin the Web
February 24, 2009
Discharge Planning: Finally Something That Works!
February 17, 2009
Reducing Risk of Overdose with Midazolam Injection
February 10, 2009
Sedation in the ICU: The Dexmedetomidine Study
February 3, 2009
NTSB Medical Helicopter Crash Reports: Missing the Big Picture
January 27, 2009
Oxygen Therapy: Everything You Wanted to Know and More!
January 20, 2009
The WHO Surgical Safety Checklist Delivers the Outcomes
January 13, 2009
January 6, 2009
December 30, 2008
Unintended Consequences: Is Medication Reconciliation Next?
December 23, 2008
December 16, 2008
Joint Commission Sentinel Event Alert on Hazards of Healthcare IT
December 9, 2008
December 2, 2008
Playing without the ballthe art of communication in healthcare
November 25, 2008
November 18, 2008
Ticket to Ride: Checklist, Form, or Decision Scorecard?
November 11, 2008
November 4, 2008
October 28, 2008
More on Computerized Trigger Tools
October 21, 2008
October 14, 2008
October 7, 2008
Lessons from Falls....from Rehab Medicine
September 30, 2008
September 23, 2008
Checklists and Wrong Site Surgery
September 16, 2008
More on Radiology as a High Risk Area
September 9, 2008
Less is More.and Do You Really Need that Decimal?
September 2, 2008
August 26, 2008
August 19, 2008
August 12, 2008
Jerome Groopmans How Doctors Think
August 5, 2008
July 29, 2008
Heparin-Induced Thrombocytopenia
July 22, 2008
Lots New in the Anticoagulation Literature
July 15, 2008
July 8, 2008
July 1, 2008
WHOs New Surgical Safety Checklist
June 24, 2008
Urinary Catheter-Related UTIs: Bladder Bundles
June 17, 2008
Technology Workarounds Defeat Safety Intent
June 10, 2008
Monitoring the Postoperative COPD Patient
June 3, 2008
UK Advisory on Chest Tube Insertion
May27, 2008
If You Do RCAs or Design Healthcare ProcessesRead Gary Kleins Work
May20, 2008
CPOE Unintended Consequences Are Wrong Patient Errors More Common?
May13, 2008
Medication Reconciliation: Topical and Compounded Medications
May 6, 2008
Preoperative Screening for Obstructive Sleep Apnea
April 29, 2008
ASA Practice Advisory on Operating Room Fires
April 22, 2008
CMS Expanding List of No-Pay Hospital-Acquired Conditions
April 15, 2008
April 8, 2008
April 1, 2008
Pennsylvania PSAs FMEA on Telemetry Alarm Interventions
March 25, 2008
March 18, 2008
Is Desmopressin on Your List of Hi-Alert Medications?
March 11, 2008
March 4, 2008
Housestaff Awareness of Risks for Hazards of Hospitalization
February 26, 2008
Nightmares.The Hospital at Night
February 19, 2008
February 12, 2008
February 5, 2008
Reducing Errors in Obstetrical Care
January 29, 2008
Thoughts on the Recent Neonatal Nursery Fire
January 22, 2008
More on the Cost of Complications
January 15, 2008
Managing Dangerous Medications in the Elderly
January 8, 2008
Urinary Catheter-Associated Infections
January 1, 2008
December 25, 2007
December 18, 2007
December 11, 2007
CommunicationCommunicationCommunication
December 4, 2007
November 27,2007
November 20, 2007
New Evidence Questions Perioperative Beta Blocker Use
November 13, 2007
AHRQ's Free Patient Safety Tools DVD
November 6, 2007
October 30, 2007
Using IHIs Global Trigger Tool
October 23, 2007
Medication Reconciliation Tools
October 16, 2007
Radiology as a Site at High-Risk for Medication Errors
October 9, 2007
October 2, 2007
Taking Off From the Wrong Runway
September 25, 2007
Lessons from the National Football League
September 18, 2007
Wristbands: The Color-Coded Conundrum
September 11, 2007
Root Cause Analysis of Chemotherapy Overdose
September 4, 2007
August 28, 2007
Lessons Learned from Transportation Accidents
August 21, 2007
Costly Complications About To Become Costlier
August 14, 2007
More Medication-Related Issues in Ambulatory Surgery
August 7, 2007
Role of Maintenance in Incidents
July 31, 2007
Dangers of Neuromuscular Blocking Agents
July 24, 2007
Serious Incident Response Checklist
July 17, 2007
Falls in Patients on Coumadin or Other Anticoagulants
July 10, 2007
Catheter Connection Errors/Wrong Route Errors
July 3, 2007
June 26, 2007
Pneumonia in the Stroke Patient
June 19, 2007
Unintended Consequences of Technological Solutions
June 12, 2007
Medication-Related Issues in Ambulatory Surgery
June 5, 2007
Patient Safety in Ambulatory Surgery
May 29, 2007
Read Anything & Everything Written by Malcolm Gladwell!
May 22, 2007
May 15, 2007
Communication, Hearback and Other Lessons from Aviation
May 8, 2007
Doctor, when do I get this red rubber hose removed?
May 1, 2007
April 23, 2007
April 16, 2007
April 9, 2007
Make Your Surgical Timeouts More Useful
April 2, 2007
March 26, 2007
Alarms Should Point to the Problem
March 19, 2007
Put that machine back the way you found it!
March 12, 2007
March 5, 2007
February 26, 2007
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