Frontline nursing staff's perceptions of intravenous medication administration: the first step toward safer infusion processes-a qualitative study.

OBJECTIVES: Intravenous medication errors continue to significantly impact patient safety and outcomes. This study sought to clarify the complexity and risks of the intravenous administration process. DESIGN: A qualitative focus group interview study. SETTING: Focused interviews were conducted using process mapping with frontline nurses responsible for medication administration in September 2020. PARTICIPANTS: Front line experiened nurses from a Japanese tertiary teaching hospital. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was to identify the mental models frontline nurses used during intravenous medication administration, which influence their interactions with patients, and secondarily, to examine the medication process gaps between the mental models nurses perceive and the actual defined medication administration process. RESULTS: We found gaps between the perceived clinical administration process and the real process challenges with an emphasis on the importance of verifying to see if the drug was ordered for the patient immediately before its administration. CONCLUSIONS: This novel and applied improvement approach can help nurses and managers better understand the process vulnerability of the infusion process and develop a deeper understanding of the administration steps useful for reliably improving the safety of intravenous medications.

Serious hazards of transfusion: evaluating the dangers of a wrong patient autologous salvaged blood in cardiac surgery.

BACKGROUND: The past half century has seen the near eradication of transfusion-associated hazards. Intraoperative cell salvage while widely used still poses significant risks and hazards due to human error. We report on a case in which blood collected from a patient with lung cancer was mistakenly administered to a patient undergoing cardiac surgery who should have received his own collected blood. The initial investigation found that the cause of the patient harm was violations of procedures by hospital personnel. A detailed investigation revealed that not only violations were the cause, but also that the underlying causes included haphazard organizational policies, poor communication, workload and staffing deficiencies, human factors and cultural challenges. CASE PRESENTATION: On August 14, 2019, a 72-year-old male was admitted to our hospital for angina pectoris and multivessel coronary artery disease. Cardiac surgery was performed using an autologous salvage blood collection system, and there were no major problems other than the prolonged operation time. During the night after the surgery, when the patient's blood pressure dropped, a nurse retrieved a blood bag from the ICU refrigerator that had been collected during the surgery and administered it at the physician's direction, but at this time neither the physician nor the nurse performed the required checking procedures. The blood administered was another patient's blood taken from another surgery the day before; an ABO mismatch transfusion occurred and the patient was diagnosed with DIC. The patient was discharged 65 days later after numerous interventions to support the patient. An accident investigation committee was convened to analyze the root causes and develop countermeasures to prevent a recurrence. CONCLUSION: This adverse event occurred because the protocol for intraoperative blood salvage management was not clearly defined, and the procedure was different from the standard transfusion practices. We developed a new workflow based on a human factors grounded, systems-wide improvement strategy in which intraoperative blood collection would be administered before the patient leaves the operating room to completely prevent recurrence, instead of simply requiring front-line staff to do a double-check. Implementing strong systems processes can reduce the risk of errors, improve the reliability of the work processes and reduce the likelihood of patient harm occurring in the future.

Do failures in non-technical skills contribute to fatal medical accidents in Japan? A review of the 2010-2013 national accident reports.

OBJECTIVES: We sought to clarify how large a proportion of fatal medical accidents can be considered to be caused by poor non-technical skills, and to support development of a policy to reduce number of such accidents by making recommendations about possible training requirements. DESIGN: Summaries of reports of fatal medical accidents, published by the Japan Medical Safety Research Organization, were reviewed individually. Three experienced clinicians and one patient safety expert conducted the reviews to determine the cause of death. Views of the patient safety expert were given additional weight in the overall determination. SETTING: A total of 73 summary reports of fatal medical accidents were reviewed. These reports had been submitted by healthcare organisations across Japan to the Japan Medical Safety Research Organization between April 2010 and March 2013. PRIMARY AND SECONDARY OUTCOME MEASURES: The cause of death in fatal medical accidents, categorised into technical skills, non-technical skills and inevitable progress of disease were evaluated. Non-technical skills were further subdivided into situation awareness, decision making, communication, team working, leadership, managing stress and coping with fatigue. RESULTS: Overall, the cause of death was identified as non-technical skills in 34 cases (46.6%), disease progression in 33 cases (45.2%) and technical skills in two cases (5.5%). In two cases, no consensual determination could be achieved. Further categorisation of cases of non-technical skills were identified as 14 cases (41.2%) of problems with situation awareness, eight (23.5%) with team working and three (8.8%) with decision making. These three subcategories, or combinations of them, were identified as the cause of death in 33 cases (97.1%). CONCLUSIONS: Poor non-technical skills were considered to be a significant cause of adverse events in nearly half of the fatal medical accidents examined. Improving non-technical skills may be effective for reducing accidents, and training in particular subcategories of non-technical skills may be especially relevant.

Lethal ventricular tachycardia triggered after femoral fracture repair in an obese man with insulin-resistant diabetes.

An obese man (height, 178 cm; weight, 160 kg; body mass index, 50.5 kg/m2) with a history of recurrent ventricular tachycardia (VT), cardiomyopathy, coronary sclerosis, and insulin-resistant diabetes suffered a right femur fracture in a vehicular accident. His fracture was repaired the following day, but shortly after surgery, his serum potassium (K+) level increased, presumably due to K+ leakage from the injured muscles, leading to persistent VT and death. An autopsy revealed severe cardiac hypertrophy, moderate coronary sclerosis, and histological findings of myocardial hypercontraction, but not myoglobin-related renal failure, pulmonary thrombosis, lipid emboli, or inflammation. The hyperkalemia was not corrected by glucose-insulin infusion and led to the death of the patient due to the preexisting cardiomyopathy, coronary sclerosis, and a predisposition to VT. In addition to the autopsy, the analysis of the clinical course was indispensable for determining the cause of death as hyperkalemia-related VT.

Introduction of the non-technical skills for surgeons (NOTSS) system in a Japanese cancer center.

PURPOSE: Non-technical skills rating systems, which are designed to support surgical performance, have been introduced worldwide, but not officially in Japan. We performed a pilot study to evaluate the "non-technical skills for surgeons" (NOTSS) rating system in a major Japanese cancer center. METHODS: Upper gastrointestinal surgeons were selected as trainers or trainees. The trainers attended a master-class on NOTSS, which included simulated demo-videos, to promote consistency across the assessments. The trainers thereafter commenced observing the trainees and whole teams, utilizing the NOTSS and "observational teamwork assessment for surgery" (OTAS) rating systems, before and after their education. RESULTS: Four trainers and six trainees were involved in this study. Test scores for understanding human factors and the NOTSS system were 5.89 ± 1.69 and 8.00 ± 1.32 before and after the e-learning, respectively (mean ± SD, p = 0.010). The OTAS scores for the whole team improved significantly after the trainees' education in five out of nine stages (p < 0.05). There were no differences in the NOTSS scores before and after education, with a small improvement in the total scores for the "teamwork and communication" and "leadership" categories. CONCLUSION: These findings demonstrate that implementing the NOTSS system is feasible in Japan. Education of both surgical trainers and trainees would contribute to better team performance.

Twenty years of countermeasures against postoperative methicillin-resistant Staphylococcus aureus infections.

PURPOSE: A total of 7345 cases of digestive organ surgery were investigated over the course of 20 years. METHODS: Owing to the increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) infections, we classified our countermeasures into periods A (September 1987 to February 1990), B (March 1990 to February 1997), C (March 1997 to February 1999), D (March 1999 to October 2004), and E (November 2004 to August 2007), and compared the number of infections during these periods. In period B, cefazolin and cefotiam were administered as prophylaxis. The treatment continued for 4 days, including the day of surgery. The patients undergoing endotracheal intubation or tracheotomy were managed with nonscreening pre-emptive isolation and cohorting (NSPEI&C), regardless of whether MRSA was present. However, NSPEI&C was halted in period C, but it was thereafter implemented again, and prophylactic antibiotics were administered only on the day of surgery during period D. In period E, prophylactic antibiotics were administered for 3 days. RESULTS: In period A, MRSA was contracted in 4.1% (34/833) of patients. In period B, the MRSA isolation rate decreased to 0.3% (8/2722). In period C, the MRSA isolation rate increased to 3.4% (23/681). In period D, the MRSA isolation rate fell to 2.2% (40/1807). In period E, MRSA isolation cases significantly decreased to 0.4% (5/1302; P < 0.002 vs period D). CONCLUSION: The comprehensive management, selection of prophylactic antibiotics, and NSPEI&C were all considered to be effective.

Antibiotic time-lag combination therapy with fosfomycin for postoperative intra-abdominal abscesses.

The first-line treatment for intra-abdominal abscess is source control. Sometimes, however, source control is too invasive for relatively small abscesses and is not feasible due to the risk of injury to some organs. Based on reports that fosfomycin (FOM) can break up biofilms to enhance the permeability of other antibiotics, we investigated the FOM time-lag combination therapy (FOM-TLCT). We enrolled 114 patients who had intra-abdominal abscess after gastrointestinal surgery and examined the efficacy of FOM-TLCT using the same therapeutic antibiotic (TA) as that which had been used previously, but had proven ineffective, at the same dose schedule. The efficacy endpoint determination was carried out as follows: among the systemic inflammatory response syndrome (SIRS)-positive cases, even after administration of TA, excellent outcome was defined as SIRS negative within 7 days of FOM-TLCT with TA without the need for other treatment, including other antibiotics or drainage. Of the 114 patients enrolled, 104 cases (SIRS positive 73; SIRS negative 31) were assessed. Ten patients were excluded; four had received TA at higher doses, three had received different TAs, and three were considered to have bacteria resistant to TAs. Among these patients, 86.3% (63/73) of the SIRS-positive cases were classified as excellent, and 90.3% (28/31) of the SIRS-negative cases were classified as effective. In total, the efficacy rate was 87.5% (91/104). The total no-response rates were 12.5% (13/104). FOM-TLCT seems to be effective for treating refractory intra-abdominal abscess.

Involvement of endotoxin in the mortality of mice with gut-derived sepsis due to methicillin-resistant Staphylococcus aureus.

MRSA causes a wide diversity of diseases, ranging from benign skin infections to life-threatening diseases, such as sepsis. However, there have been few reports of the pathophysiology and mechanisms of sepsis resulting from the gut-derived origin of MRSA. Therefore, we established a murine model of gut-derived sepsis with MRSA and factors of MRSA sepsis that cause deterioration. We separated mice into four groups according to antibiotic treatment as follows: (i) ABPC 40 mg/kg; (ii) CAZ 80 mg/kg; (iii) CAZ 80 mg/kg + endotoxin 10 microg/mouse; and (iv) saline-treated control groups. Gut-derived sepsis was induced by i.p. injection of cyclophosphamide after colonization of MRSA strain 334 in the intestine. After the induction of sepsis, significantly more CAZ-treated mice survived compared with ABPC-treated and control groups. MRSA were detected in the blood and liver among all groups. Endotoxin levels were significantly lower in the CAZ-treated group compared to other groups. Inflammatory cytokine levels in the serum were lower in the CAZ-treated group compared to other groups. Fecal culture showed a lower level of colonization of E. coli in the CAZ-treated group compared to other groups. In conclusion, we found that CAZ-treatment ameliorates infection and suppresses endotoxin level by the elimination of E. coli from the intestinal tract of mice. However, giving endotoxin in the CAZ-treated group increased mortality to almost the same level as in the ABPC-treated group. These results suggest endotoxin released from resident E. coli in the intestine is involved in clinical deterioration resulting from gut-derived MRSA sepsis.

Interleukin-1 deficiency in combination with macrophage depletion increases susceptibility to Pseudomonas aeruginosa bacteremia.

We evaluated the role of IL-1 during Pseudomonas aeruginosa bacteremia by intravenously injecting P. aeruginosa strain D4 into IL-1-deficient and WT mice. The two strains showed equivalent mortality rates. However, when the mice were pretreated with cyclophosphamide, bacteremia-induced mortality was significantly greater in the IL-1-deficient mice than in the WT mice (P < 0.01). We then investigated the role of neutrophils and macrophages in protecting IL-1-deficient mice from bacteremia by administering anti-Gr-1 antibody or liposomes containing dichloromethylene diphosphonate, respectively. After P. aeruginosa inoculation survival was significantly lower in the macrophage-depleted IL-1-deficient mice than in the WT mice. In contrast, neutrophil depletion did not have this effect. Compared to the macrophage-depleted WT mice, the macrophage-depleted IL-1-deficient bacteremic mice had higher bacterial counts in various organs 48 and 72 hr post-infection. They also had lower TNF-alpha, IL-6, and INF-gamma concentrations in their livers during the early phase of sepsis. Thus, IL-1 deficiency becomes disadvantageous during P. aeruginosa bacteremia when it is accompanied by immunosuppression, particularly when macrophage functions are seriously impaired.

Interleukin-1-deficient mice exhibit high sensitivity to gut-derived sepsis caused by Pseudomonas aeruginosa.

BACKGROUND: The role of interleukin (IL)-1 in infectious diseases is controversial; some investigators indicated an enhancing effect of IL-1 on host resistance whereas others demonstrated the protective role of IL-1 receptor antagonist in infection. We evaluated the role of endogenous IL-1 in gut-derived sepsis caused by Pseudomonas aeruginosa, by comparing IL-1-deficient mice and wild-type (WT) mice. METHODS: Gut-derived sepsis was induced by intraperitoneal injection of cyclophosphamide after colonization of P. aeruginosa strain D4 in the intestine. RESULTS: The survival rate of IL-1-deficient mice was significantly lower than that of WT mice (P<0.01). Bacterial counts in the liver, mesenteric lymph node and blood were significantly higher in IL-1-deficient mice than in WT mice. Tumor necrosis factor alpha and IL-6 in the liver were significantly higher in IL-1-deficient mice than in WT mice. In vitro, phagocytosis and cytokine production by macrophages were impaired in IL-1-deficient mice compared with WT mice. CONCLUSION: Our results indicate a critical role for IL-1 during gut-derived P. aeruginosa sepsis. The results also suggest that both impairment of cytokine production and phagocytosis by macrophages are caused by IL-1 deficiency and lead to impaired host response.

Long-term prognosis of preoperative "bridge to surgery" expandable metallic stent insertion for obstructive colorectal cancer: comparison with emergency operation.

PURPOSE: Expandable metallic stent endoprosthesis for preoperative "bridge to surgery" treatment of obstructive colorectal cancer has been broadly, clinically used with good short-term results. Stent insertion for malignant tumor, however, is controversial because of the increased risk of metastasis, invasion, and advancement of the cancer. We, first in the world, evaluated the long-term prognosis of expandable metallic stent insertion compared with emergency surgery without expandable metallic stent. METHODS: Forty emergency operations (1986-1996) and 44 expandable metallic stent insertions (1993-2001) were retrospectively compared by history, duration, morbidity, and cumulative survival rate. RESULTS: There was no significant difference in age or lesion between the two groups. Postoperative complications were significantly less frequent in the expandable metallic stent group: wound infection was 14 vs. 2 percent; leakage following to anastomosis was 11 vs. 3 percent. Long-term prognosis did not significantly differ: three-year overall survival rate was 50 vs. 48 percent; five-year survival rate was 44 vs. 40 percent in the emergency operation and expandable metallic stent groups, respectively. CONCLUSION: Because preoperative expandable metallic stent insertion for obstructive colorectal cancer had good postoperative results and no disadvantages in long-term prognosis, this procedure should be used in preoperative treatments of obstructive colorectal cancer.