Perceived Value of the Daily Safety Briefing.

EXECUTIVE SUMMARY: A hospital-level daily safety briefing (DSB) is a time for leaders to come together and address recent and upcoming safety challenges in the hospital. As tools to facilitate communication and teamwork, DSBs are important, but their value has not been extensively studied. We studied the value of the DSB by means of a prospective written survey of participants of the DSB at an urban academic medical center. Participants were unit managers, directors, vice presidents, and various other hospital leaders.Ninety-seven of 114 participants completed the survey (85%). Of all the activities rated, preprocedural time-outs had the highest rating in terms of impact on patient safety (4.87 ± 0.50 on 5-point Likert scale). The DSB had a rating (4.44 ± 0.77) that was on par with The Joint Commission accreditation activities (4.47 ± 0.68) and higher than use of the Morse Fall Scale (4.10 ± 0.83). Overall, 95% of the participants felt that a DSB was an effective use of participants' time. The top two benefits of the DSB were keeping patient safety a focal point in the organization (4.54 ± 0.74) and increasing awareness about patient safety issues (4.52 ± 0.93).We conclude that the DSB improves communication among team members and is a valuable use of healthcare leaders' time.

Surgical site infection: comparing surgeon versus patient self-report.

BACKGROUND: To compare the rate of surgical site infection (SSI) using surgeon versus patient report. MATERIALS AND METHODS: A prospective observational study of surgical patients in four hospitals within one private health-care system was performed. Surgeon report consisted of contacting the surgeon or staff 30 d after procedure to identify infections. Patient report consisted of telephone contact with the patient and confirmation of infections by a trained surgical clinical reviewer. RESULTS: Between February 2011 and June 2012, there were 2853 surgical procedures that met inclusion criteria. Surgeon-reported SSI rate was significantly lower (2.4%, P value < 0.01) compared with patient self-report (4.3%). The rate was lower across most infection subtypes (1.3% versus 3.0% superficial, 0.3% versus 0.5% organ/space) except deep incisional, most procedure types (2.3% versus 4.4% general surgery) except plastics, most patient characteristics (except body mass index < 18.5), and all hospitals. There were disagreements in 3.4% of cases; 74 cases reported by patients but not surgeons and 21 cases vice versa. Disagreements were more likely in superficial infections (59.8% versus 1.0%), C-sections (22.7% versus 17.7%), hospital A (22.7% versus 17.7%), age < 65 y (74.2% versus 68.3%), and body mass index ≥ 30 (54.2% versus 39.9%). CONCLUSIONS: Patient report is a more sensitive method of detection of SSI compared with surgeon report, resulting in nearly twice the SSI rate. Fair and consistent ways of identifying SSIs are essential for comparing hospitals and surgeons, locally and nationally.

A Tool for the Concise Analysis of Patient Safety Incidents.

BACKGROUND: Patient safety incidents, sometimes referred to as adverse events, incidents, or patient safety events, are too common an occurrence in health care. Most methods for incident analysis are time and labor intensive. Given the significant resource requirements of a root cause analysis, for example, there is a need for a more targeted and efficient method of analyzing a larger number of incidents. Although several concise incident analysis tools are in existence, there are no published studies regarding their usability or effectiveness. METHODS: Building on previous efforts, a Concise Incident Analysis (CIA) methodology and tool were developed to facilitate analysis of no- or low-harm incidents. Staff from 11 hospitals in five countries-Australia, Canada, Hong Kong, India, and the United States-pilot tested the tool in two phases. The tool was evaluated and refined after each phase on the basis of user perceptions of usability and effectiveness. RESULTS: From September 2013 through January 2014, 52 patient safety incidents were analyzed. A broad variety of incident types were investigated, the most frequent being patient falls (25%). Incidents came from a variety of hospital work areas, the most frequent being from the medical ward (37%). Most incidents investigated resulted in temporary harm or no harm (94%). All or most sites found the tool "understandable" (100%), "easy to use" (89%), and "effective" (89%). Some 95% of participants planned to continue to use all or some parts of the tool after the pilot. Qualitative feedback suggested that the tool allowed analysis of incidents that were not currently being analyzed because of insufficient resources. The tool was described as simple to use, easy to document, and aligned with the flow of the incident analysis. CONCLUSION: A concise tool for the investigation of patient safety incidents with low or no harm was well accepted across a select group of hospitals from five countries.

Predicting Which Patients will Likely Benefit from Subglottic Secretion Drainage Endotracheal Tubes: A Retrospective Study.

BACKGROUND: Subglottic secretion drainage endotracheal tubes (SSD ETTs) have been shown to decrease ventilator-associated pneumonia and are recommended for patients intubated > 48 h or 72 h. However, it is difficult to determine which patients will be intubated > 48 h or 72 h at the time of intubation. OBJECTIVE: We attempted to determine which patient characteristics were associated with intubations ≥ 48 h or 72 h in order to guide proper placement of SSD ETTs. METHODS: The medical records of 2,159 ventilated patients at a single institution were retrospectively reviewed for intubation duration, age, sex, race, body mass index, weight, intubation reason, whether the intubation was emergent, operative status, intensive care unit (ICU) diagnosis, intubation location, ICU location, comorbidities (e.g., congestive heart failure, chronic obstructive pulmonary disorder, coronary artery disease, dementia, and liver disease), acute kidney injury (AKI), and chronic renal injury. A multivariate regression analysis was then performed with all reliable data. RESULTS: The following were associated with intubation ≥ 48 h: neuroscience critical care unit (NCCU) admission (risk ratio [RR] = 1.85; 95% confidence interval [CI] 1.34-2.56), emergent intubation (RR = 1.97; 95% 1.28-3.03), comorbid dementia (RR = 2.31; 95% 1.28-4.18), nonoperative intubation (RR = 1.77; 95% 1.28-4.18), and AKI (RR = 3.32; 95% 2.56-4.3). The following were independently associated with intubation ≥ 72 h: NCCU admission (RR = 2.2; 95 CI 1.57-3.08), nonoperative intubation (RR = 3.38; 95% CI 2.63-4.35), comorbid dementia (RR = 3.03; 95% CI 1.67-5.48), and AKI (RR = 3.11; 95% CI 2.38-4.07). CONCLUSION: Nonoperative intubation, emergent intubation, history of dementia, admission to NCCU and AKI all appear to be independently associated with increased RRs for either ≥ 48 h or 72 h of ventilation.

Pediatric Emergency Department Return: A Literature Review of Risk Factors and Interventions.

BACKGROUND AND OBJECTIVE: Children discharged from emergency departments (EDs) are often at risk for ED return. The objective was to identify risk factors and interventions to mitigate or prevent ED return among this patient population. METHODS: Structured literature review of PubMed and clinicaltrials.gov was conducted to identify relevant studies. Inclusion criteria were studies evaluating ED returns by identifying risk factors and interventions in the pediatric population. Emergency department return was defined as returning to the ED within 1 year after initial visit. Abstract and full text articles were reviewed, and data were abstracted by 2 independent authors. RESULTS: A total of 963 articles were screened and yielded 42 potential relevant articles involving pediatric population. After full text review, a total of 12 articles were included in the final analysis (6 on risk factors and 6 on interventions). Risk factors for pediatric ED return included behavioral/psychiatric problems, younger age, acuity of illness, medical history of asthma, and social factors. Interventions included computer-generated instructions, postdischarge telephone coaching, ED-made appointments, case management, and home environment intervention. Emergency department-made appointments and postdischarge telephone coaching plus monetary incentive improved outpatient follow-up rate but not ED return. Home environment assessment coupled with case management reduced ED returns specifically among asthma patients. CONCLUSIONS: Several patient and visit characteristics can help predict children at risk for ED return. Although some interventions are successful at improving postdischarge follow-up, most did not reduce ED returns.

The prevalence of long QT interval in post-operative intensive care unit patients.

The severity of patient illnesses and medication complexity in post-operative critically ill patients increase the risk for a prolonged QT interval. We determined the prevalence of prolonged QTc in surgical intensive care unit (SICU) patients. We performed a prospective cross-sectional study over a 15-month period at a major academic center. SICU pre-admission and admission EKGs, patient demographics, and laboratory values were analyzed. QTc was evaluated as both a continuous and dichotomous outcome (prolonged QTc > 440 ms). 281 patients were included in the study: 92 % (n = 257) post-operative and 8 % (n = 24) non-operative. On pre-admission EKGs, 32 % of the post-operative group and 42 % of the non-operative group had prolonged QTc (p = 0.25); on post-admission EKGs, 67 % of the post-operative group but only 33 % of the non-operative group had prolonged QTc (p < 0.01). The average change in QTc in the post-operative group was +30.7 ms, as compared to +2 ms in the non-operative group (p < 0.01). On multivariable adjustment for long QTc as a dichotomous outcome, pre-admission prolonged QTc (OR 3.93, CI 1.93-8.00) and having had an operative procedure (OR 4.04, CI 1.67-9.83) were associated with developing prolonged QTc. For QTc as a continuous outcome, intra-operative beta-blocker use was associated with a statistically-significant decrease in QTc duration. None of the patients developed a lethal arrhythmia in the ICU. Prolonged QTc is common among post-operative SICU patients (67 %), however lethal arrhythmias are uncommon. The operative experience increases the risk for long QTc.

Effect of altering alarm settings: a randomized controlled study.

UNLABELLED: Medical alarm signals are important for alerting clinicians to life-threatening conditions, but the high rate of false alarms can be problematic. Reduction in alarm signals may lead to increased staff responsiveness to alarms and create a quieter environment for patients. The effect of these changes on patient outcomes is uncertain. METHODS: We conducted a pilot, prospective, randomized, controlled trial in the cardiac care unit (CCU) to test a study protocol and data collection instruments and to examine the differences in alarms between usual care and altered settings. Subjects were randomized daily to either standard or altered CCU alarm settings. Secondary outcomes included the number of clinically significant events (CSEs) detected, event-triggered interventions (ETIs), frequency of alarms per monitored bed, and patient complications. RESULTS: Over the two-week study time frame, 22 unique patients were enrolled. There were 1,710 alarms over 163 hours of monitoring in the standard group and 1,165 alarms over 169 hours in the study group (P < 0.001). There were more CSEs detected (14 vs. 3) and ETIs (12 vs. 2) in the study group, but sample size was too small to determine efficacy. No cardiac arrests or adverse patient outcomes were observed in either group. All patients were discharged from the hospital. Study protocol and outcomes were feasible and lessons were learned. CONCLUSION: This study demonstrated feasibility of a study protocol for conducting a randomized controlled trial to evaluate CSEs, ETIs, frequency of alarms, and adverse patient outcomes when altering default alarm settings. A longer study can be performed using a similar study design.

Reducing medical errors and adverse events.

Medical errors account for ∼98,000 deaths per year in the United States. They increase disability and costs and decrease confidence in the health care system. We review several important types of medical errors and adverse events. We discuss medication errors, healthcare-acquired infections, falls, handoff errors, diagnostic errors, and surgical errors. We describe the impact of these errors, review causes and contributing factors, and provide an overview of strategies to reduce these events. We also discuss teamwork/safety culture, an important aspect in reducing medical errors.

Rapid-response systems as a patient safety strategy: a systematic review.

Rapid-response systems (RRSs) are a popular intervention in U.S. hospitals and are supported by accreditors and quality improvement organizations. The purpose of this review is to evaluate the effectiveness and implementation of these systems in acute care settings. A literature search was performed between 1 January 2000 through 30 October 2012 using PubMed, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials. Studies published in any language evaluating outcome changes that occurred after implementing an RRS and differences between groups using and not using an RRS (effectiveness) or describing methods used by RRSs (implementation) were reviewed. A single reviewer (checked by a second reviewer) abstracted data and rated study quality and strength of evidence. Moderate-strength evidence from a high-quality meta-analysis of 18 studies and 26 lower-quality before-and-after studies published after that meta-analysis showed that RRSs are associated with reduced rates of cardiorespiratory arrest outside of the intensive care unit and reduced mortality. Eighteen studies examining facilitators of and barriers to implementation suggested that the rate of use of RRSs could be improved.

Maintaining and sustaining the On the CUSP: stop BSI model in Hawaii.

BACKGROUND: Hawaii joined the On the CUSP: Stop BSI national effort in the United States in 2009 (CUSP stands for Comprehensive Unit-based Safety Program). In the initial 18-month study evaluation, adult ICUs decreased central line-associated bloodstream infection (CLABSI) rates by 61%. The impact of a series of novel strategies/tools in reducing infections and sustaining the collaborative in ICUs and non-ICUs in Hawaii was assessed. METHODS: This cohort collaborative consisted of 20 adult ICUs and 18 nonadult ICUs in 16 hospitals. Hawaii developed and implemented six tools between July 2010 and August 2011: a tool to investigate CLABSIs, a video to address cultural barriers, a standardized dressing change kit, a map of the cohort's journey, a 12-strategies leadership dashboard, and a geometric plot of consecutive infection-free days. The primary outcome measure was overall CLABSI rates (mean infections per 1,000 catheter-days). RESULTS: A comparison of baseline data from 28 ICUs with 12-quarter (36-month) postimplementation data indicated that the CLABSI rate decreased across the entire state: overall, 1.57 to 0.29 infections/1,000 catheter-days; adult ICUs, 1.49 to 0.25 infections/1,000 catheter-days; nonadult ICUs, 2.54 to 0.33 infections/1,000 catheter-days, non-ICUs (N= 14), 4.52 to 0.25 infections/1,000 catheter-days, and PICU/NICU (N = 4), 2.05 to 0.53 infections/1,000 catheter-days. Days between CLABSIs in the adult ICUs statewide increased from a median of 5 days in 2009 to 70 days in 2011. DISCUSSION: Hawaii successfully spread the program beyond adult ICUs and implemented a series of tools for maintenance and sustainment. Use of the tools shaped a culture around the continued belief that CLABSIs can be eradicated, and infections further reduced.

Association of allogeneic red-blood cell transfusion with surgeon case-volume.

BACKGROUND: Surgeon case-volume predicts a variety of patient outcomes. We hypothesize that surgeon case-volume predicts RBC transfusion across different surgical procedures. METHODS: We performed a cohort study of 372,670 in-patient surgical cases in the 52 non-federal hospitals in Maryland between 2004 and 2005. The main outcome measure was relative risk of receiving a transfusion. RESULTS: Overall, 13.9% of patients received a transfusion. Patients seen by the highest case-volume surgeons (>161 cases/y) were more likely to receive a transfusion (16% versus 11%, P < 0.01) compared with middle case-volume surgeons (89-161 cases/y). After adjusting for confounders, the highest case-volume patients were still at increased risk of transfusion [relative risk (RR) 1.10, 1.07-1.14]. This result was true across many surgery types. CONCLUSIONS: Surgeon case-volume is independently associated with the likelihood of RBC transfusion across a broad range of surgical procedures. Future efforts should be directed towards studying and standardization of transfusion practices.

Using the Opportunity Estimator tool to improve engagement in a quality and safety intervention.

Teams throughout the United States participating in a program to reduce central line-associated bloodstream infections (CLABSIs) are using the Opportunity Estimator. This web-based tool translates CLABSI-related data into "opportunity estimates" of the patient lives and money that could be saved by reducing these infections.

Cardiac surgery errors: results from the UK National Reporting and Learning System.

OBJECTIVE: To describe cardiac surgery-related incidents and compare the types and severity of incidents occurring in the operating room (OR) versus non-OR locations. We hypothesized that the type and severity of incidents in cardiac surgery would differ in the OR compared with non-OR locations. DESIGN: A retrospective cross-sectional study of all incidents categorized as cardiac surgery in the UK National Reporting and Learning System database between January 2003 and February 2007. Differences in proportions were evaluated by χ(2) or Fischer's exact test. The odds ratio of an event occurring in the OR compared with all non-OR settings was calculated using logistic regression. The harm susceptibility ratio ranked locations by the degree of harm. SETTING: All trusts performing cardiac surgery. PARTICIPANTS: None. INTERVENTION: None. MAIN OUTCOME MEASURES: Cardiac surgery incidents occurring in the OR versus non-OR. RESULTS: A total of 4828 (<1%) incidents from 55 trusts were designated as involving cardiac surgery patients during the study period; 21% occurred in the OR. Overall, 32% of incidents resulted in harm: 23% of OR and 34% of non-OR incidents. The distribution of incident type and harmful incidents differed in the OR compared with the non-OR setting (P < 0.05). CONCLUSIONS: Our findings offer unique insights into the types of incidents occurring during cardiac surgical care in the UK. In the OR, interventions should focus on reducing errors associated with medical devices/equipment, whereas outside the OR, they may focus on medication errors and patient accidents.

National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors.

BACKGROUND: Medication errors contribute to significant morbidity, mortality, and costs to the health system. Little is known about the characteristics of Emergency Department (ED) medication errors. STUDY OBJECTIVE: To examine the frequency, types, causes, and consequences of voluntarily reported ED medication errors in the United States. METHODS: A cross-sectional study of all ED errors reported to the MEDMARX system between 2000 and 2004. MEDMARX is an anonymous, confidential, de-identified, Internet-accessible medication error-reporting program designed to allow hospitals to report, track, and share error data in a standardized format. RESULTS: There were 13,932 medication errors from 496 EDs analyzed. The error rate was 78 reports per 100,000 visits. Physicians were responsible for 24% of errors, nurses for 54%. Errors most commonly occurred in the administration phase (36%). The most common type of error was improper dose/quantity (18%). Leading causes were not following procedure/protocol (17%), and poor communication (11%), whereas contributing factors were distractions (7.5%), emergency situations (4.1%), and workload increase (3.4%). Computerized provider order entry caused 2.5% of errors. Harm resulted in 3% of errors. Actions taken as a result of the error included informing the staff member who committed the error (26%), enhancing communication (26%), and providing additional training (12%). Patients or family members were notified about medication errors 2.7% of the time. CONCLUSION: ED medication errors may be a result of the acute, crowded, and fast-paced nature of care. Further research is needed to identify interventions to reduce these risks and evaluate the effectiveness of these interventions.

Use of advanced radiology during visits to US emergency departments for injury-related conditions, 1998-2007.

CONTEXT: Excessive use of medical imaging increases health care costs and exposure to ionizing radiation (a potential carcinogen) without yielding significant benefits to all patients. OBJECTIVE: To determine whether there has been a change in the prevalence of emergency department visits for injury-related conditions for which computed tomography (CT) or magnetic resonance imaging (MRI) was obtained and whether there has been a change in the diagnosis of life-threatening conditions and patient disposition. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cross-sectional analysis of emergency department visits using data from the National Hospital Ambulatory Medical Care Survey (1998-2007). Sampled visits were weighted to produce estimates for the United States. MAIN OUTCOMES MEASURES: Proportion of visits for injury-related conditions during which a CT or MRI was obtained, a life-threatening condition was diagnosed (eg, cervical spine fracture, skull fracture, intracranial bleeding, liver and spleen laceration), and which resulted in hospital and intensive care unit admission. RESULTS: The prevalence of CT or MRI use during emergency department visits for injury-related conditions increased from 6% (95% confidence interval [CI], 5%-7%) (257 of 5237 visits) in 1998 to 15% (95% CI, 14%-17%) (981 of 6567 visits) in 2007 (P < .001 for trend). There was a small increase in the prevalence of life-threatening conditions (1.7% [95% CI, 1.2%-2.2%; 89 of 5237 visits] in 1998 and 2.0% [95% CI, 1.6%-2.5%; 142 of 6567 visits] in 2007; P=.04 for trend) [corrected].There was no change in prevalence of visits during which patients were either admitted to the hospital (5.9% [95% CI, 4.9%-6.9%] in 1998 and 5.5% [95% CI, 4.7%-6.5%] in 2007; P = .50 for trend) or to an intensive care unit (0.62% [95% CI, 0.40%-1.00%] in 1998 and 0.80% [95% CI, 0.53%-1.21%] in 2007; P = .14 for trend). Visits during which CT or MRI was obtained lasted 126 minutes (95% CI, 123-131 minutes) longer than those for which CT or MRI was not obtained. CONCLUSION: From 1998 to 2007, the prevalence of CT or MRI use during emergency department visits for injury-related conditions increased significantly, without an equal increase in the prevalence of life-threatening conditions.