Email Updates
July 16, 2008 Weekly Issue
PSNet highlights the latest patient safety literature, news, and expert commentary, including Weekly Updates, WebM&M, and Perspectives on Safety. The current issue highlights what's new this week in patient safety literature, news, conferences, reports, and more. Past issues of the PSNet Weekly Update are available to browse. WebM&M presents current and past monthly issues of Cases & Commentaries and Perspectives on Safety.
Sitzman BT. Pain Medicine. 2008;9(suppl 1).
This study describes implementation of a standardized protocol for responding to adverse events associated with interventional pain procedures.
Sittig DF, Ash JS, Guappone KP, et al. Int J Med Inform. 2008;77(7):440-7.
This study surveyed clinicians to gauge their concerns about computerized provider order entry (CPOE) prior to implementation. The authors discovered that the most common unintended consequences anticipated were more or new work for clinicians, workflow issues, and never-ending system demands.
Bonis PA, Pickens GT, Rind DM, et al. Int J Med Inform. 2008;77(11):745-53.
This study discovered that hospitals providing access to a popular clinical knowledge support system (called "UpToDate") were associated with improved health outcomes and shorter length of stay. However, use of the application itself may only be a marker rather than a direct cause of a hospital's favorable outcomes.
Fairbanks RJ, Crittenden CN, O’Gara KG, et al. Acad Emerg Med. 2008;15(7):633-640.
This study used focus groups, in-depth interviews, and event reporting methods to conclude that Emergency Medical Services (EMS) providers are concerned about existing system issues that require improvement strategies, and about the safety culture in which they work.
Maniaci MJ, Heckman MG, Dawson NL. Mayo Clin Proc. 2008;83(5):554-8.
This study surveyed patients following discharge from an inpatient medical service and discovered that the majority were aware of new medications prescribed, but fewer could identify the name, dose, schedule, or purpose. The authors report that there was no association between survey responses and the educational level of patients.
Cima RR, Kollengode A, Garnatz J, et al. J Am Coll Surg. 2008;207(1):80-7.
Retained foreign objects (RFOs) are a rare but serious complication of surgical procedures. While radiofrequency detection systems, intraoperative radiographic screening, and bar coding have been described as strategies to prevent these occurrences, simple counting may not be as effective. This study examined more than 190,000 operations performed and found an actual RFO rate of 1 per 5,500 operations. Investigators discovered that the majority of RFOs occurred in patients with reportedly correct counts and even in patients who underwent intraoperative imaging. The authors advocate for new technologies that improve upon current imperfect systems to prevent RFOs. A case of an error of a retained sponge and a preventable death was discussed in an AHRQ WebM&M commentary.
Thomas AN, Panchagnula U. Anaesthesia. 2008;63(7):726-33.
This study categorized more than 12,000 medication-related incidents in an intensive care unit and found that the greatest number resulted during administration. Morphine was the most common medication involved.
Launiainen T, Vuori E, Ojanperä I. Int J Legal Med. 2009;123(2):109-15.
This study examined more than 37,000 post-mortem cases and discovered that 0.71% were associated with potentially severe drug–drug interactions. The most common medications implicated were those causing serotonin syndrome and combinations of atrioventricular nodal agents (e.g., beta blockers and calcium-channel blockers).
Wachter R, Flanders S, Fee C, et al. Ann Intern Med. 2008;149(1):29-32.
Efforts to improve the quality and safety of care are being driven in part by a growing focus on public reporting. This commentary shares the potential for the unintended consequences of reporting on flawed performance measures, using time to first antibiotic dose (TFAD) in patients with pneumonia as an example. The authors discuss the background data for this particular quality measure, how it was translated into a performance standard, and the response it generated from emergency departments as well as payers, regulators, and professional societies. The authors conclude with a number of lessons learned from this case example, including the tension that results from having providers balance their desire to do the right thing with the public's view of their quality of care when they are in conflict with each other. A past AHRQ WebM&M commentary discussed the unintended consequences of achieving a good report card on such measures.
Sevdalis N, Davis R, Koutantji M, et al. Am J Surg. 2008;196(2):184-90.
This study describes the use of an assessment tool called NOTECHS to evaluate surgical nontechnical skills. The authors report on the reliability of the tool in assessing cooperation, leadership and managerial skills, situational awareness, and decision making.
Trowbridge RL.
This article describes techniques for educating trainees on how to prevent diagnostic error.
No results.
No results.
Newspaper/Magazine Article
Preidt R. ABC News. July 4, 2008.
This article discusses the findings of a recent study that reported deficiencies in barcode systems requiring numerous overrides and "workarounds" by nurses.
Sentinel Event Alerts
Sentinel event alert. 2008;(40):1-3.
The Joint Commission issues sentinel event alerts one to two times yearly to highlight areas of high risk and to promote the rapid adoption of risk reduction strategies. Adherence to these strategies is then assessed on Joint Commission site visits at health care organizations nationwide. This newly released sentinel event alert focuses on intimidating and disruptive behaviors and the role they play in the costs, quality, safety, and satisfaction of care delivered. The alert outlines existing Joint Commission requirements and provides a series of suggested actions that include educational programs, "zero tolerance" policies, and clear processes for detecting, reporting, and documenting all instances of such unacceptable behavior.
Newspaper/Magazine Article
ISMP Medication Safety Alert! Acute Care Edition. July 3, 2008;13:1-3.
This article reports on the potentially fatal error of administering epidural medications intravenously and provides guidelines to safeguard against such epidural–IV route mix-ups.
Government Resource
Darzi A. National Health Service. London, England: Crown Publishing; June 2008. ISBN: 9780101743228.
This report outlines several strategies to improve the National Health Service's quality of care, including drafting an NHS constitution, further collaboration with local agencies, and greater transparency on safety and clinical outcomes.
Newspaper/Magazine Article
Smith S.
This article reports on a wrong-side surgery that was immediately disclosed to the patient along with an apology. Hospital administrators also disclosed the error to staff.
Nance JJ. Boseman, MT: Second River Healthcare Press; 2008. ISBN: 9780974386058.
This book describes six guidelines for hospital safety improvement and provides a fictionalized account of one hospital integrating these principles as a prototype for an idealized safety culture.
This Month’s WebM&Ms
WebM&M Cases
Spotlight Case
Adam J. Gordon, MD, MPH |
A man with a history of heroin use came to the hospital with abdominal pain, nausea, and vomiting. Admitted for dehydration and opiate withdrawal, he was given intravenous fluids, methadone, and morphine for abdominal pain. The patient complained of worsening pain overnight and was given more methadone. In the morning, the patient had more severe pain and tachycardia, and was found to have a perforated colon.
WebM&M Cases
Jill R. Scott-Cawiezell, RN, PhD |
An elderly man receiving feedings through a percutaneous enterostomy tube was prescribed intravenous total parenteral nutrition (TPN). A licensed practical nurse (LPN) mistakenly connected the TPN to the patient's enterostomy tube. His daughter (a retired nurse) asked her about it, and the RN on duty confirmed the error. The LPN disconnected the mistakenly placed (and now contaminated) line, but then prepared to attach it to the intravenous catheter. Luckily, both the patient's daughter and the RN were present and stopped her.
WebM&M Cases
Roslyn Yomtovian, MD |
Following spinal surgeries, two different patients developed tachycardia, hypotension, and hypoxia due to sepsis. Given the similarity in clinical course, the hospital investigated and found that both patients had received platelets contaminated with Staphylococcus aureus.
This Month’s Perspectives
Interview
Albert Wu, MD, MPH, is Professor of Health Policy and Management at the Johns Hopkins School of Public Health and is presently working with the World Health Organization's World Alliance for Patient Safety, based in Geneva. He is a leading expert on several aspects of patient safety, including disclosure and evaluation. He recently wrote a commentary on the use of root cause analysis in patient safety in the Journal of the American Medical Association (JAMA).
Perspective
Patrice Spath, BA, RHIT, and William Minogue, MD |
Throughout most of his life, 19th century French chemist Louis Pasteur insisted that germs were the cause of disease, not the body. It wasn't until Pasteur was nearing the end of his life that he came to believe just the opposite. After reaching this conclusion, he declined treatment for potentially curable pneumonia, reportedly saying, "It is the soil, not the seed."(1) In other words, a germ (the seed) causes disease when our bodies (the soil) provide a hospitable environment.
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