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Shafi S, Collinsworth AW, Copeland LA, et al. JAMA Surg. 2018;153(8):757-763.
Opioids are known to be high-risk medications. This secondary data analysis of more than 100,000 patients undergoing in-hospital surgical procedures at 21 hospitals found that about 10% experienced an opioid-related adverse drug event during their admission. Patients receiving higher dose and longer duration of opioids were more likely to experience adverse events. Patients who experienced an opioid-related adverse drug event had longer hospital stays, greater inpatient mortality risk, and a higher rate of readmissions compared to those who did not experience problems with opioid medications. The authors call for reducing opioid use in acute care, postoperative settings in order to improve patient safety. A previous WebM&M commentary emphasized the importance of stratifying risk for patients initiated or maintained on chronic opioid therapy to prevent misuse.
Parshuram CS, Dryden-Palmer K, Farrell C, et al. JAMA. 2018;319(10):1002-1012.
Identifying incipient clinical deterioration is a prerequisite for rapid response and prevention of harm for hospitalized patients. This study tested a bedside pediatric early warning system, which included an illness severity score, standardized documentation, and monitoring protocols. In a cluster-randomized trial in several high-income countries, implementation of the bundle did not result in decreased in-hospital mortality compared to usual care. The overall mortality rate in the study was less than 0.2%. The authors suggest that this unexpectedly low mortality rate may have made it difficult to detect differences in intervention versus control hospitals. A related editorial suggests that artificial intelligence should be used to identify clinical deterioration and that outcomes beyond mortality should be considered in their evaluation.
Abbott TEF, Ahmad T, Phull MK, et al. Br J Anaesth. 2018;120:146-155.
Surgical checklists have been shown to improve safety outcomes in randomized trials, but implementation studies have not uniformly demonstrated benefit. This study included a large, multicountry observational cohort of surgical outcomes before and after implementation of a checklist. Mortality declined after checklist implementation, but the rate of postoperative complications remained unchanged. Investigators also conducted a meta-analysis of surgical checklist studies (excluding those that paired the checklist with other interventions) on postoperative mortality and complications. This synthesis of published studies suggests that checklists improved mortality and complications overall. Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists in past PSNet interviews.
Axeen S, Seabury SA, Menchine M. Ann Emerg Med. 2018;71(6):659-667.e3.
As deaths and overdoses related to opioid use have increased, physician prescribing behavior is under greater scrutiny. Prior research has shown significant variation in opioid prescribing among emergency medicine physicians, but the degree to which emergency department prescribing contributes to overall opioid prescribing remains unknown. This retrospective study used data from the Medical Expenditure Panel Survey from 1996 to 2012 and found that the quantity of opioids prescribed increased by 471% during the study period. While the percentage of opioids prescribed in the ambulatory setting increased from 71% in 1996 to 83% in 2012, the percentage of opioids prescribed in the emergency department decreased from 7.4% in 1996 to 4.4% in 2012. Based on these findings, the authors suggest that interventions designed to reduce opioid prescribing should target the outpatient setting rather than the emergency department. A past PSNet perspective discussed opioid medications and associated patient safety risks.
Parent B, LaGrone LN, Albirair MT, et al. JAMA Surg. 2018;153:464-470.
Handoffs represent a significant risk to patient safety. Standardizing communication during the handoff process has the potential to reduce harm. In this trial, researchers assessed the impact of a standardized handoff curriculum on perceived interprovider communication in eight intensive care units (ICUs) across two hospital systems. Although the curriculum was perceived to improve shift preparedness among providers, they found no association with better patient outcomes in the ICUs, including length of stay, duration of mechanical ventilation, or reintubations. An accompanying editorial suggests that further research on standardized handoffs in the ICU is necessary to better understand the potential for improving patient outcomes. A previous PSNet interview discussed handoffs and the implementation and findings of the landmark I-PASS study.
Jones PM, Cherry RA, Allen BN, et al. JAMA. 2018;319(2):143-153.
Handoffs between providers are inevitable and are known to introduce risks. This retrospective population-based cohort study in Canada examined the effects of intraoperative handoffs between anesthesiologists on major complications, readmissions, and 30-day mortality among patients undergoing surgery. After adjustment for patient and site characteristics, patients who experienced an anesthesiologist handoff had higher rates of major complications and mortality compared to patients who had the same anesthesiologist throughout their procedure. The number of surgeries in which a handoff occurred increased over time during the 6-year study period. These results suggest that limiting intraoperative anesthesiologist handoffs may improve safety. However, a related editorial posits that reducing handoffs is a simplistic solution that may have unintended consequences and instead recommends that quality improvement approaches, such as developing standardized handoff procedures, may result in more meaningful enhancements for intraoperative anesthesia safety.
Harbaugh CM, Lee JS, Hu HM, et al. Pediatrics. 2018;141(1):e20172439.
Opioid misuse is an urgent patient safety issue. Research has found that a significant proportion of adults prescribed opioids in the short term remain on opioid medications chronically, but less is known about postsurgical opioid use among pediatric patients. This study analyzed a large, commercial health care claims database to determine whether children and adolescents prescribed opioids following surgery were more likely to be prescribed opioids 3 to 6 months later, compared to children who did not undergo surgery. Researchers found that postoperative opioid use was associated with persistent opioid use. A related editorial raises questions about the breadth of procedures included and calls for development and implementation of evidence-based pediatric pain management strategies that address the risk for persistent opioid use and misuse.
Ravi B, Pincus D, Wasserstein D, et al. JAMA Intern Med. 2018;178:75-83.
Overlapping surgery is the practice of surgeons scheduling distinct procedures on different patients concurrently. This practice has raised safety concerns. This large population-based retrospective study examined outcomes for nonoverlapping versus overlapping hip surgeries across Ontario, Canada. After adjustment for factors known to predict surgical outcomes, such as hospital and surgeon case volume and the patient's overall health, researchers found an association between increasing duration of surgical overlap and higher risk of complications. These results contrast with a recent single-center study that found no safety differences between overlapping and nonoverlapping neurosurgeries. An accompanying editorial acknowledges the mixed results of safety studies for overlapping surgeries and calls for large, multicenter, prospective studies across a range of surgical procedures with long-term follow-up.
George BC, Bohnen JD, Williams RG, et al. Ann Surg. 2017;266(4):582-594.
Insufficient trainee supervision may lead to adverse events, but lack of autonomy may leave trainee physicians unprepared for independent practice. In this direct observation surgical education study, attending physicians rated readiness for independent practice and level of supervision for surgical trainees performing specific core procedures throughout the course of their training. At the end of training, 90% of trainees performed competently on average complexity patients, but this proportion dropped to less than 80% for the most complex cases. For about two-thirds of core procedures, surgical residents still had significant supervision in their last 6 months of training. The authors raise concerns about whether graduating residents have sufficient experience practicing independently to enter clinical practice. A previous PSNet perspective advocated for continued appropriate supervision to augment patient safety.
Ball JE, Bruyneel L, Aiken LH, et al. Int J Nurs Stud. 2018;78:10-15.
Missed nursing care may result from inadequate nurse staffing and explain the relationship between nurse-to-patient ratios and patient outcomes. Research has shown that higher nurse staffing levels are associated with lower inpatient mortality and that reduced staffing increases the risk for postoperative complications. In this study, investigators examined data from more than 400,000 surgical patients from 300 hospitals in 9 countries as well as survey responses from 26,516 nurses. They found a significant association between nurse staffing and missed nursing care with 30-day risk-adjusted postoperative mortality. The authors conclude that measuring missed nursing care may help identify patients at greater risk for adverse outcomes earlier in their course. A past WebM&M commentary highlighted important issues associated with nurse staffing ratios.
Chaudhary MA, Schoenfeld AJ, Harlow AF, et al. JAMA Surg. 2017;152:930-936.
The epidemic of deaths associated with opioid medications has spurred research examining clinicians' prescribing patterns. Recent studies have shown that opioids are frequently prescribed in situations where there is little evidence of their benefit—such as after dental procedures—and that there is considerable variation in prescribing rates between providers. However, the true incidence of inappropriate opioid prescribing has not yet been defined. This retrospective study of patients who had sustained traumatic injuries examined the relationship between injury severity and opioid prescribing. Investigators found that patients with more severe injuries were more likely to be prescribed opioids, indicating that opioid prescribing in this context was likely appropriate in most cases. The study and accompanying editorial emphasize the importance of targeted efforts to reduce inappropriate opioid prescribing, focusing primarily on reducing opioid use for chronic noncancer pain (where there is no evidence opioids are beneficial) while not denying opioids to those in acute pain from trauma or other reasons.
Walker S, Mason A, Quan P, et al. Lancet. 2017;390:62-72.
The weekend effect (higher mortality for patients in acute care settings on weekends compared to weekdays) has led to widespread concerns about hospital staffing. This retrospective study examined whether mortality for emergency admissions at four hospitals in the United Kingdom differed on weekends compared to weekdays. Unlike prior studies of the weekend effect, this study included multiple specific markers of patients' illness severity as well as hospital workload. Investigators found higher mortality associated with being admitted to the hospital during weekends compared to weekdays, but a significant proportion of the observed weekend effect was explained by severity of patient illness. They used three measures to approximate hospital workload: total number of admissions, net admissions (subtracting discharges from admissions), and percentage of beds occupied. None of these workload measures was associated with mortality. The authors conclude that differences in illness severity rather than health care team staffing explain the weekend effect. A recent PSNet interview discussed the weekend effect in health care.
Dykes PC, Rozenblum R, Dalal AK, et al. Crit Care Med. 2017;45.
Establishing a strong safety culture may lead to a reduction in adverse events. Many health care institutions are focused on improving multiple aspects of culture including teamwork, communication, and patient engagement to mitigate harm. In this prospective study, researchers sought to understand the impact of a multicomponent intervention involving structured team communication as well as patient engagement tools and training on patient safety in the intensive care unit. They included 1030 admissions in the baseline period and 1075 in the intervention period. The rate of adverse events decreased by almost 30%, from 59.0 per 1000 patient days in the baseline period to 41.9 per 1000 patient days during the intervention period. Patient and care partner satisfaction improved as well. A past PSNet perspective discussed the relationship between patient engagement and patient safety.
Haynes AB, Edmondson L, Lipsitz SR, et al. Ann Surg. 2017;266:923-929.
Checklists have been shown to reduce surgical morbidity and mortality in randomized trials, but results of implementation in clinical settings have been mixed. This study reports on a voluntary, statewide collaborative program to implement a surgical safety checklist in South Carolina hospitals. Participating sites undertook a multifaceted process to support checklist implementation and culture change. Cross-institutional educational activities were available to all hospitals in the collaborative. Investigators determined that rates of surgical complications declined significantly in hospitals involved in the collaborative compared with those that did not participate, which had no change in postsurgical mortality over the same time frame. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.
Cooper WO, Guillamondegui O, Hines J, et al. JAMA Surg. 2017;152:522-529.
Most patient safety problems can be ascribed to underlying systems failures, but issues with individual clinicians play a role as well. Prior studies have shown that a small proportion of physicians account for a disproportionate share of patient complaints and malpractice lawsuits. This retrospective cohort study used data from the Patient Advocacy Reporting System (which collects unsolicited patient concerns) and the National Surgical Quality Improvement Program to examine the association between patient complaints and surgical adverse events. The investigators found that patients of surgeons who had received unsolicited patient concerns via the reporting system were at increased risk of postoperative complications and hospital readmission after surgery. Although the absolute increase in complication rates was relatively small across all surgeons, surgeons in the highest quartile of unsolicited observations had an approximately 14% higher risk of complications compared to surgeons in the lowest quartile. This study extends upon prior research by demonstrating an association between patient concerns about individual clinicians and clinical adverse events, and it strengthens the argument for using data on patient concerns to identify and address problem clinicians before patients are harmed.
Obermeyer Z, Cohn B, Wilson M, et al. BMJ. 2017;356:j239.
The emergency department is considered a high-risk setting for diagnostic errors. This analysis of Medicare claims data found that a significant number of adults age 65–89 died within a week of visiting and being discharged from an emergency department, even when no life-limiting illness was noted. Hospitals that admit a lower proportion of emergency department patients to the inpatient setting had a higher mortality rate among discharged patients, even after adjusting for patient characteristics. Consistent with prior studies relating patient outcomes to volume, higher-volume emergency departments had lower 7-day mortality among discharged patients. These results suggest that emergency department discharges may represent missed diagnoses. A WebM&M commentary discussed an incident involving a patient who died after being discharged from the emergency department.
Hyder JA, Hanson KT, Storlie CB, et al. Ann Surg. 2017;265:639-644.
Overlapping surgery refers to when two procedures are performed concurrently, but important portions occur at different times. Experts have raised concerns about the safety of scheduling coincident procedures. This study compared overlapping surgeries with nonoverlapping surgeries of the same type at a single referral center. After adjusting for surgeon and patient characteristics, investigators found no differences in inpatient mortality or length of stay. They performed an analogous analysis in the National Surgical Quality Improvement Program registry medical record data, which resulted in similar findings. Although these results should allay concerns about concurrent surgeries, the authors caution that further studies at multiple centers are needed to ensure that overlapping procedure practices do not carry excess risk to patients.
Anselmi L, Meacock R, Kristensen SR, et al. BMJ Qual Saf. 2017;26:613-621.
Previous research has shown that patients admitted to the hospital on the weekend are at increased risk for worse outcomes, including mortality. This retrospective study examined more than 3 million emergency admissions to 140 hospital trusts in England between April 2013 and February 2014. Patient arrival times were recorded by day of the week and nighttime versus daytime. Using administrative data and standard risk adjustment, mortality rates were higher for patients arriving during the week on Wednesday and Thursday nights. Risk-adjusted mortality rates were also found to increase for patients arriving over the weekend from daytime on Saturday through nighttime on Sunday. However, when researchers adjusted for arrival by ambulance, higher mortality was statistically significant only for those patients arriving at the hospital during the day on Sunday. Investigators suggest that prior research supporting the weekend effect is overly reliant on administrative data, which may not accurately characterize illness severity. It is often debated whether the weekend effect could be due to factors related to the system of care (i.e., reduced staffing on weekends) or patient factors (i.e., increased severity of illness of patients admitted on the weekend). An Australian study sought to answer this question and found that certain diagnoses appeared to be associated with higher mortality for weekend admissions, largely due to health system factors.
Shehab N, Lovegrove MC, Geller AI, et al. JAMA. 2016;316(20):2115-2125.
Adverse drug events (ADEs) in outpatient settings can cause significant morbidity and mortality. Updating a prior study, this surveillance study identified more than 40,000 ADEs among 58 emergency departments in the United States. Investigators estimated that 4 emergency department visits for ADEs occurred per 1000 patients annually during the study period, with more than one-quarter of these visits resulting in hospitalization. Antibiotic reactions were the most common ADE for children. Among patients age 65 or older, anticoagulants, diabetes medications, and opioids were most commonly implicated in ADEs, as seen in a previous study. Medications considered inappropriate for older adults according to Beers criteria were involved in less than 2% of ADEs. The authors conclude that preventing ADEs requires attention to older adults and to antibiotic, anticoagulant, diabetes, and opioid medications, consistent with recommendations from the 2014 National Action Plan for Adverse Drug Event Prevention.
Vadnais MA, Hacker MR, Shah NT, et al. The Joint Commission Journal on Quality and Patient Safety. 2016;43.
Cesarean delivery is associated with increased morbidity, mortality, longer hospital stays, and increased costs. From 2008 through 2015, a single tertiary care academic medical center implemented a quality improvement initiative designed to address factors influencing the rate of nulliparous term singleton vertex (NTSV) cesarean delivery rate. The initiative consisted of provider education, provider feedback, and implementation of new policies. The rate of NTSV cesarean delivery decreased from 34.8% to 21.2% and total cesarean delivery rate decreased from 40.0% to 29.1%. Researchers also noted a decline in the incidence of episiotomy and third-degree lacerations.