ABSTRACT
OBJECTIVE: To determine the root causes of patient safety events in a high-volume intravitreal injection clinic and to assess the effect of interventions to reduce the rate of events. DESIGN: Quality improvement study. SUBJECTS: All cases of intravitreal injection in a designated injection clinic between January 1, 2016, and December 31, 2019. METHODS: The injection clinic model involved an injecting physician, who usually differed from a prescribing physician. The procedural injection area was also physically separate from the retina outpatient clinic. A root cause analysis was used to determine the factors that contributed to possible patient safety events in an institutional quality improvement project. Specific interventions were implemented to address each specific root cause. The rates of patient safety events (never events and near misses), whether associated with patient harm or not, were compared before and after the intervention. MAIN OUTCOME MEASURES: Frequency (%) of patient-safety-related intravitreal injection events before (January 1, 2016, to December 31, 2018) and after (January 1, 2019, to December 31, 2019) intervention. RESULTS: The root cause analysis included complex treatment plans that could be difficult to interpret, insufficient time to adequately review the designated treatment plans, and the risk of human error given the pace and volume of scheduled injections. Quality improvement strategies included revising the standardized treatment plan documentation template, scheduling block time for injecting physicians to review treatment plans within 24 hours of the injection clinic, and requiring agreement between dual, independent, site, and medication verifications of the treatment plan by the injecting physician and an allied health coordinator before site marking. The rate of events was 0.1% (28 in 27 400, or 9.3 events per year) before intervention and decreased to 0.01% (1 in 9375, or 1 event per year) after intervention (P = 0.01). Most events were classified as near misses, and there were no instances of patient harm. CONCLUSIONS: A high level of patient safety can be achieved in a complex, high-volume intravitreal injection practice by recognizing potential safety issues and root causes and implementing relevant quality improvements. Although most events were near misses and no patients were harmed, reducing near misses can reduce the likelihood of harm associated with never events.
Subject(s)
Medical Errors , Patient Safety , Ambulatory Care Facilities , Humans , Intravitreal InjectionsABSTRACT
BACKGROUND: With a dramatic rise in prescription opioid use, it is imperative to review postsurgical prescribing patterns given their contributions to the opioid epidemic. OBJECTIVE: To evaluate the impact of departmental postoperative prescribing guidelines on opioid prescriptions following elective spine surgery. METHODS: Patients undergoing elective cervical or lumbar spine surgery between 2017 and 2018 were identified. Procedure-specific opioid prescribing guidelines to limit postoperative prescribing following neurosurgical procedures were developed in 2017 and implemented in January 2018. Preguideline data were available from July to December 2017, and postguideline data from July to December 2018. Discharge prescriptions in morphine milliequivalents (MMEs), the proportion of patients (i) discharged with an opioid prescription, (ii) needing refills within 30 d, (iii) with guideline compliant prescriptions were compared in the 2 groups. Multivariable (MV) analyses were performed to assess the impact of guideline implementation on refill prescriptions within 30 d. RESULTS: A total of 1193 patients were identified (cervical: 308; lumbar: 885) with 569 (47.7%) patients from the preguideline period. Following guideline implementation, fewer patients were discharged with a postoperative opioid prescription (92.5% vs 81.7%, P < .001) and median postoperative opioid prescription decreased significantly (300 MMEs vs 225 MMEs, P < .001). The 30-d refill prescription rate was not significantly different between preguideline and postguideline cohorts (pre: 24.4% vs post: 20.2%, P = .079). MV analyses did not demonstrate any impact of guideline implementation on need for 30-d refill prescriptions for both cervical (odds ratio [OR] = 0.68, confidence interval [CI] = 0.37-1.26, P = .22) and lumbar cohorts (OR = 0.95, CI = 0.66-1.36, P = .78). CONCLUSION: Provider-aimed interventions such as implementation of procedure-specific prescribing guidelines can significantly reduce postoperative opioid prescriptions following spine surgery without increasing the need for refill prescriptions for pain control.
