Medication Safety Event Reporting: Factors That Contribute to Safety Events During Times of Organizational Stress.

BACKGROUND: Incident reports submitted during times of organizational stress may reveal unique insights. PURPOSE: To understand the insights conveyed in hospital incident reports about how work system factors affected medication safety during a coronavirus disease-2019 (COVID-19) surge. METHODS: We randomly selected 100 medication safety incident reports from an academic medical center (December 2020 to January 2021), identified near misses and errors, and classified contributing work system factors using the Human Factors Analysis and Classification System-Healthcare. RESULTS: Among 35 near misses/errors, incident reports described contributing factors (mean 1.3/report) involving skill-based errors (n = 20), communication (n = 8), and tools/technology (n = 4). Reporters linked 7 events to COVID-19. CONCLUSIONS: Skill-based errors were the most common contributing factors for medication safety events during a COVID-19 surge. Reporters rarely deemed events to be related to COVID-19, despite the tremendous strain of the surge on nurses. Future efforts to improve the utility of incident reports should emphasize the importance of describing work system factors.

Comparing the Safety Action Feedback and Engagement (SAFE) Loop with an established incident reporting system: Study protocol for a pragmatic cluster randomized controlled trial.

Background: Incident reporting is widely used in hospitals to improve patient safety, but current reporting systems do not function optimally. The utility of incident reports is limited because hospital staff may not know what to report, may fear retaliation, and may doubt whether administrators will review reports and respond effectively. Methods: This is a clustered randomized controlled trial of the Safety Action Feedback and Engagement (SAFE) Loop, an intervention designed to transform hospital incident reporting systems into effective tools for improving patient safety. The SAFE Loop has six key attributes: obtaining nurses' input about which safety problems to prioritize on their unit; focusing on learning about selected high-priority events; training nurses to write more informative event reports; prompting nurses to report high-priority events; integrating information about events from multiple sources; and providing feedback to nurses on findings and mitigation plans. The study will focus on medication errors and randomize 20 nursing units at a large academic/community hospital in Los Angeles. Outcomes include: (1) incident reporting practices (rates of high-priority reports, contributing factors described in reports), (2) nurses' attitudes toward incident reporting, and (3) rates of high-priority events. Quantitative analyses will compare changes in outcomes pre- and post-implementation between the intervention and control nursing units, and qualitative analyses will explore nurses' experiences with implementation. Conclusion: If effective, SAFE Loop will have several benefits: increasing nurses' engagement with reporting, producing more informative reports, enabling safety leaders to understand problems, designing system-based solutions more effectively, and lowering rates of high-priority patient safety events.

Understanding ultrarare adverse events - Lessons learned from a twelve-year review of intraoperative deaths at an academic medical center.

BACKGROUND: Intraoperative death (ID) is rare, the incidence remains challenging to quantify and learning opportunities are limited. We aimed to better define the demographics of ID by reviewing the longest single-site series. METHODS: Retrospective chart reviews, including a review of contemporaneous incident reports, were performed on all ID between March 2010 to August 2022 at an academic medical center. RESULTS: Over 12 years, 154 IDs occurred (∼13/year, average age: 54.3 years, male: 60%). Most occurred during emergency procedures (n = 115, 74.7%), 39 (25.3%) during elective procedures. Incident reports were submitted in 129 cases (84%). 21 (16.3%) reports cited 28 contributing factors including challenges with coordination (n = 8, 28.6%), skill-based errors (n = 7, 25.0%), and environmental factors (n = 3, 10.7%). CONCLUSIONS: Most deaths occurred in patients admitted from the ER with general surgical problems. Despite expectations for incident reporting, few provided actionable information on ergonomic factors which might help identify improvement opportunities.

Advance Care Planning in Patients With Metastatic Cancer: A Quality Improvement Initiative.

PURPOSE: An initiative aimed to increase the rate of advance care planning (ACP) activities for outpatients with metastatic cancer, an essential step to achieving goal concordant care. METHODS: Patients with metastatic cancer were identified by International Classification of Diseases-10 coding and later by oncologists' electronic health record documentation of metastatic tumor status. ACP activities were defined as either an ACP note, Advance Directive, Physician Orders for Life-Sustaining Therapy (POLST), or a Palliative Medicine (PM) consultation within the prior year. From 2017 to 2020, the initiative screened more than 5,000 total unique cancer patients per year. PM consultants were embedded in tumor boards, oncology care team meetings, and shared oncology clinic space. Quarterly reports were sent to 60 oncologists at three cancer care sites with data of their percentage of ACP activities for patients with metastatic cancer compared with their peers. Oncologists' identities were initially blinded, but later unblinded. Oncologists also received a monthly list of patients with metastatic cancer without ACP activities. RESULTS: The rate of ACP activities for patients with metastatic cancer increased from a baseline of 37% in July 2017 to 57% by the end of 2020. PM consultations increased from 12% to 39% and ACP notes increased from 16% to 29% during the same interval. There was no change in Advance Directive (17%-20%) or POLST completion (7%-6%). CONCLUSION: ACP activities are an essential step to achieve goal concordant care, and this initiative successfully increased ACP activities for patients with metastatic cancer. However, given that the main source of increased ACP activities during this initiative was PM referrals, further progress will depend upon strengthening the oncology care teams' ACP skills and motivation for completion.

Choosing Wisely For Critical Care: The Next Five.

OBJECTIVES: To formulate new "Choosing Wisely" for Critical Care recommendations that identify best practices to avoid waste and promote value while providing critical care. DATA SOURCES: Semistructured narrative literature review and quantitative survey assessments. STUDY SELECTION: English language publications that examined critical care practices in relation to reducing cost or waste. DATA EXTRACTION: Practices assessed to add no value to critical care were grouped by category. Taskforce assessment, modified Delphi consensus building, and quantitative survey analysis identified eight novel recommendations to avoid wasteful critical care practices. These were submitted to the Society of Critical Care Medicine membership for evaluation and ranking. DATA SYNTHESIS: Results from the quantitative Society of Critical Care Medicine membership survey identified the top scoring five of eight recommendations. These five highest ranked recommendations established Society of Critical Care Medicine's Next Five "Choosing" Wisely for Critical Care practices. CONCLUSIONS: Five new recommendations to reduce waste and enhance value in the practice of critical care address invasive devices, proactive liberation from mechanical ventilation, antibiotic stewardship, early mobilization, and providing goal-concordant care. These recommendations supplement the initial critical care recommendations from the "Choosing Wisely" campaign.

Enhancing POLST Completion in a Hospital Setting: An Interdisciplinary Approach.

EXECUTIVE SUMMARY: With increased therapeutic capabilities in healthcare today, many patients with multiple progressive comorbidities are living longer. They experience recurrent hospitalizations and often undergo procedures that are not aligned with their personal goals. That is why it is essential to discuss and document healthcare preferences prior to an acute event when significant interventions could occur, especially for patients with serious and progressive illness. Completion of an advance directive and a physician order for life-sustaining treatment (POLST) supports provision of goal-concordant care. Further, for patients who have do not attempt resuscitation (DNAR) orders or are diagnosed with advanced dementia, having a POLST is essential. This may be best accomplished with hospitalization discharge plans. Our 896-bed academic medical center, Cedars-Sinai Medical Center, launched a quality initiative in 2015 to complete POLSTs for patients being discharged with DNAR status or with dementia returning to a skilled nursing facility. As part of interdisciplinary progression of care rounds, emphasis was placed on those patients for whom POLST completion was indicated. Proactive, facilitated discussions with patients, family members, and attending physicians were initiated to support POLST completion. The completed forms were then uploaded to the electronic health record. Individual units and physicians received regular feedback on POLST completion rates, and the data were later shared at medical staff quality improvement meetings.During the initiative, POLST completion rates for DNAR patients discharged alive rose from 41% in fiscal year (FY) 2014 to 75% in FY 2019. Similar improvement was seen for patients with dementia discharged to skilled nursing facilities, regardless of code status (rising from 14% in FY 2014 to 54% in FY 2019). Subsequently, we have expanded our efforts to include early discussion and completion of these advanced care planning documents for patients recently diagnosed with high mortality cancers (ovarian, pancreatic, lung, glioblastoma), focusing on the completion of advanced care planning documentation and palliative care referrals.

A multidisciplinary, multifaceted improvement initiative to eliminate mislabelled laboratory specimens at a large tertiary care hospital.

OBJECTIVES: To sustainably reduce the rate of mislabelled laboratory specimens through implementation of a series of interventions as led and coordinated by a multidisciplinary performance improvement team. METHODS: The quality improvement project was performed at Cedars-Sinai Medical Center in Los Angeles, an academic care tertiary care hospital. Phlebotomy services are provided by unit-based nursing and dedicated laboratory-based phlebotomists. Baseline mislabelled specimen rate was obtained for a 6-month period prior to the first improvement intervention. Included in the rate of mislabelled specimens were inpatient blood and body fluid specimens. Anatomic pathology and cytological specimens and outpatient specimens were excluded. Mislabelled specimens were identified preanalytically, analytically or postanalytically. A specimen was considered mislabelled under the following circumstances: (1) specimen/requisition mismatch; (2) incorrect patient identifiers and (3) unlabelled specimen. Specimen mislabels were identified and validated monthly by a multidisciplinary team composed of personnel from nursing, laboratory and performance improvement. Performance improvement initiatives were implemented over a 2-year period with control charts used to assess improvement over time. RESULTS: The rate of mislabelled specimens varied by clinical area and decreased significantly over a 24-month time period during the initiative from 4.39 per 10,000 specimens to 1.97 per 10,000 specimens. All clinical areas achieved a significant decrease in the rate of mislabelled specimens except for the operating room and labour and delivery. CONCLUSIONS: A multidisciplinary unit specific approach using performance improvement methodologies focusing on human factors can reliably and sustainably reduce the rate of mislabelled laboratory specimens in a large tertiary care hospital.

Epidemiology of critical care syndromes, organ failures, and life-support interventions in a suburban US community.

BACKGROUND: ICU services represent a significant and increasing proportion of medical care. Population-based epidemiologic studies are essential to inform physicians and policymakers about current and future ICU demands. We aimed to determine the incidence of critical care syndromes, organ failures, and life-support interventions in a defined US suburban community with unrestricted access to critical care services. METHODS: This population-based observational cohort from January 1 to December 31, 2006, in Olmsted County, Minnesota, included all consecutive critically ill adult residents admitted to the ICU. Main outcomes were incidence of critical care syndromes, life-support interventions, and organ failures as defined by standard criteria. Incidences are reported per 100,000 population (95% CIs) and were age adjusted to the 2006 US population. RESULTS: A total of 1,707 ICU admissions were identified from 1,461 patients. Incidences of critical care syndromes were respiratory failure, 430 (390-470); acute kidney injury, 290 (257-323); severe sepsis, 286 (253-319); all-cause shock, 194 (167-221); acute lung injury, 86 (68-105); all-cause coma, 43 (30-55); and overt disseminated intravascular coagulation, 18 (10-26). Incidence of mechanical ventilation was invasive, 310 (276-344); noninvasive, 180 (154-206); vasopressors and inotropes, 183(155-208). Renal replacement therapy incidence was 96 (77-116). Of the cohort, 1,330 patients (91%) survived to hospital discharge. Short- and long-term survival decreased by the number of failing organs. CONCLUSIONS: In a suburban US community with high access to critical care services, cumulative incidences of critical care syndromes and life-support interventions were higher than previously reported. The results of this study have important implications for future planning of critical care delivery.

Economic implications of nighttime attending intensivist coverage in a medical intensive care unit.

OBJECTIVE: Our objective was to assess the cost implications of changing the intensive care unit staffing model from on-demand presence to mandatory 24-hr in-house critical care specialist presence. DESIGN: A pre-post comparison was undertaken among the prospectively assessed cohorts of patients admitted to our medical intensive care unit 1 yr before and 1 yr after the change. Our data were stratified by Acute Physiology and Chronic Health Evaluation III quartile and whether a patient was admitted during the day or at night. Costs were modeled using a generalized linear model with log-link and γ-distributed errors. SETTING: A large academic center in the Midwest. PATIENTS: All patients admitted to the adult medical intensive care unit on or after January 1, 2005 and discharged on or before December 31, 2006. Patients receiving care under both staffing models were excluded. INTERVENTION: Changing the intensive care unit staffing model from on-demand presence to mandatory 24-hr in-house critical care specialist presence. MEASUREMENTS AND MAIN RESULTS: Total cost estimates of hospitalization were calculated for each patient starting from the day of intensive care unit admission to the day of hospital discharge. Adjusted mean total cost estimates were 61% lower in the post period relative to the pre period for patients admitted during night hours (7 pm to 7 am) who were in the highest Acute Physiology and Chronic Health Evaluation III quartile. No significant differences were seen at other severity levels. The unadjusted intensive care unit length of stay fell in the post period relative to the pre period (3.5 vs. 4.8) with no change in non-intensive care unit length of stay. CONCLUSIONS: We find that 24-hr intensive care unit intensivist staffing reduces lengths of stay and cost estimates for the sickest patients admitted at night. The costs of introducing such a staffing model need to be weighed against the potential total savings generated for such patients in smaller intensive care units, especially ones that predominantly care for lower-acuity patients.

Comparison of community and referral intensive care unit patients in a tertiary medical center: evidence for referral bias in the critically ill.

OBJECTIVE: To determine the existence of referral bias in the critically ill by comparing the clinical and epidemiologic characteristics of community (Olmsted County, MN residents) and referral (non-Olmsted County residents) patients admitted to the intensive care unit. DESIGN: Retrospective, cohort study. SETTING: Academic tertiary care medical center. PATIENTS: Patients admitted to the medical and surgical intensive care units at Mayo Medical Center from 1995 to 2004. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Residency status, demographics, Acute Physiology and Chronic Health Evaluation III score, intensive care unit admission diagnosis and treatment status, intensive care unit and hospital mortality, length of stay, and travel distances to Mayo Clinic. Referral patients with a medical intensive care unit admission were more severely ill, had greater mortality rates and length of stay and were more likely to receive an active intensive care unit intervention compared with community patients (p < 0.0001). Referral and community patients who had a surgical intensive care unit admission had similar severity of illness, length of stay, and intensive care unit mortality rate. Hospital mortality rate was lower in the referral surgical patients compared with community surgical patients (p = 0.0001). When adjusted for severity of illness, intensity of treatment, and admission source, community and referral medical intensive care unit patients had a similar risk of hospital death, whereas referral surgical patients had a lower risk of hospital death compared with community patients. Referral patients who had a medical intensive care unit admission and traveled greater distances to Mayo Clinic had greater mortality rates and length of stay; those who had a surgical intensive care unit admission and traveled greater distances had lower mortalities and length of stay. CONCLUSIONS: Patients who resided outside of our local community and who had medical admissions to the intensive care unit were more severely ill, had greater mortality rates, and had longer length of stay compared with community patients. Our findings support the existence of referral bias in critically ill medical patients at our tertiary medical center.

The association between nighttime transfer from the intensive care unit and patient outcome.

OBJECTIVE: To determine the impact of nighttime transfer of patients from the intensive care unit (ICU) on clinical outcome. DESIGN: Retrospective, observational. SETTING: Three intensive care units of a tertiary care medical center. PATIENTS: We used prospectively collected information from the Acute Physiology and Chronic Health Evaluation III database of 11,659 patients transferred from the ICU to the regular ward. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Based on the time of transfer, patients who were transferred from the ICU to the regular ward were categorized into daytime (7:00 am-6:59 pm) and nighttime (7:00 pm-6:59 am) transfers. Patients who were transferred to other ICUs or other facilities, died in the ICU, were discharged home, or did not authorize their medical records to be reviewed for research were excluded. Only the first ICU admission of each patient was considered for outcome analysis. Of the 11,659 study patients, 418 (3.6%) were transferred at night. The first ICU day predicted mortality rate and the last ICU day Acute Physiology Score and Acute Physiology and Chronic Health Evaluation III scores in the nighttime transfer group were higher compared with the daytime transfers. The hospital mortality rate of the nighttime transfers was 5.3% compared with 4.5% of the daytime transfers (p = 0.478). There was no statistically significant difference between the two groups in severity adjusted hospital mortality rate. The ICU readmission rate of the nighttime transfers was higher (12.2% compared with 9.0%, p = 0.027) and the median (interquartile range) hospital length of stay longer (8 [5-15] vs. 7 [4-13] days, p = 0.013) compared with the daytime transfer group. CONCLUSIONS: Our study did not find an association between nighttime ICU discharge and hospital mortality. However, the ICU readmission rate was higher and the hospital length of stay longer in the nighttime transfer group.

Impact of introducing multiple evidence-based clinical practice protocols in a medical intensive care unit: a retrospective cohort study.

BACKGROUND: Recently completed clinical trials have shown that certain interventions improve the outcome of the critically ill. To facilitate the implementation of these interventions, professional organizations have developed guidelines. Although the impacts of the individual evidence-based interventions have been well described, the overall impact on outcome of introducing multiple evidence-based protocols has not been well studied. The objective of this study was to determine the impact of introducing multiple evidence-based protocols on patient outcome. METHODS: A retrospective, cohort study of 8,386 patients admitted to the medical intensive care unit (MICU) of an academic, tertiary medical center, from January 2000 through June 2005 was performed. Four evidence-based protocols (lung protective strategy for acute lung injury, activated protein C for severe sepsis/septic shock, intravenous insulin for hyperglycemia control and a protocol for sedation/analgesia) were introduced in the MICU between February 2002 and April 2004. We considered the time from January 2000 through January 2002 as the pre-protocol period, from February 2002 through March 2004 as the transition period and from April 2004 through June 2005 as the protocol period. We retrieved data including demographics, severity of illness as measured by the Acute Physiology and Chronic Health Evaluation (APACHE) III, MICU length of stay and hospital mortality. Student's t, Kruskal-Wallis, Mann-Whitney U, chi square and multiple logistic regression analyses were used to compare differences between groups. P-values < 0.05 were considered significant. RESULTS: The predicted mean mortality rates were 20.7%, 21.1% and 21.8%, with the observed mortality rates of 19.3%, 18.0% and 16.9% during the pre-protocol, transition and protocol periods, respectively. Using the pre-protocol period as a reference, the severity-adjusted risk (95% confidence interval) of dying was 0.777 (0.655-0.922) during the protocol period (P = 0.0038). The average 28-day MICU free days improved during the protocol period compared to the pre-protocol period. The benefit was limited to sicker patients and those who stayed in the MICU longer. CONCLUSION: The introduction of multiple evidence-based protocols is associated with improved outcome in critically ill medical patients.

Comparison of chronic illness among children receiving mechanical ventilation in a cohort of children's hospitals in 1991 and 2001.

OBJECTIVE: To compare the prevalence of chronic illness and characteristics of children who underwent mechanical ventilation in a cohort of patients at large children's hospitals between 1991 and 2001. STUDY DESIGN: This was a retrospective, cross-sectional study using the National Association of Children's Hospitals and Related Institutions (NACHRI) case mix database to identify children who underwent mechanical ventilation and compare the prevalence of chronic illness and incidence of mechanical ventilation. RESULTS: The proportion of children who underwent mechanical ventilation who had at least 1 chronic condition increased from 72% in 1991 to 75% in 2001. The incidence of mechanical ventilation in hospitalized children almost doubled during this decade, from 77 per 1000 hospitalizations in 1991 to 124 per 1000 in 2001. The rate of mechanical ventilation increased with increasing numbers of chronic conditions. The mortality of children who underwent mechanical ventilation decreased from 14% in 1991 to 11% in 2001. CONCLUSIONS: The increase in mechanical ventilation in hospitalized children is due to both an increased incidence of chronic illness and higher use within diagnostic categories. Unlike utilization of some services, the use of mechanical ventilation in hospitalized children may be a marker of increased severity of illness and need, because it is plausible that mechanical ventilation use is not primarily supply-sensitive.

Adult intensive care unit use at the end of life: a population-based study.

OBJECTIVES: To determine population-based rates of intensive care unit (ICU) use at the end of life in adults and describe demographic and clinical variation in end-of-life ICU use. PATIENTS AND METHODS: A retrospective, population-based cohort study set in Olmsted County, Minnesota, was performed. We identified adult residents admitted to an ICU in 1998 and determined those who were in the last year of life. Demographic data, ICU admission diagnoses, ICU Interventions, and length of stay were collected. We obtained Charlson comorbidity diagnoses and Indices for residents of Olmsted County to calculate condition-specific rates of end-of-life ICU use. RESULTS: Of the 818 residents who had an ICU admission in 1998, 90 died in either the ICU or the hospital after having received ICU care. One in 8 decedents from Olmsted County in 1998 received ICU care during a terminal hospital admission. Six-month decedents who had received ICU care were older, had longer lengths of stay, and had a higher degree of comorbid illness compared with 6-month survivors. The ICU admission rates in the last 6 months of life increased with age and number of chronic conditions, ranging from 0.26 per 1000 person-years in the 18- to 44-year-old group to 18.5 per 1000 person-years in those 85 years or older and from 0.34 per 1000 person-years in those with no chronic conditions to 302.1 per 1000 person-years in those with 5 or more chronic conditions. CONCLUSION: The rate of ICU use at the end of life Increases significantly with age and with the number of coexisting chronic illnesses.

Demographic and clinical variation of adult intensive care unit utilization from a geographically defined population.

OBJECTIVE: To determine population-based rates of adult intensive care unit (ICU) use and evaluate the effects that demographic variables and chronic illness have on ICU utilization. DESIGN: Retrospective, population-based cohort study. SETTING: Olmsted County, Minnesota. PARTICIPANTS: Adult residents admitted to an ICU in 1998. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Measurements included demographics, Acute Physiology and Chronic Health Evaluation III score, ICU admission diagnosis, ICU interventions, Charlson comorbidity index and conditions, ICU length of stay (LOS), and ICU, hospital, 1-month, and 1-yr mortalities. Risk of ICU admission and rates of ICU utilization increased substantially with increasing age, peaking in the very elderly. The rates of ICU admission and utilization in those > or =85 yrs old were 58.2 admissions/1,000 residents and 195.8 days/1,000 residents compared with 3.8 admissions/1,000 residents and 11.5 days/1,000 residents in those 18 to 44 yrs old. Residents > or =85 yrs old were 3.75 times as likely (p < .001) to be admitted to the ICU compared with those 18-44 yrs old after controlling for the presence of comorbid illness. ICU admission rates increased with an increasing number of comorbid illnesses. Residents with cardiovascular conditions and renal disease had high rates of ICU admission. Repeat users of the ICU were more likely to have a chronic condition and higher degree of comorbid illness compared with nonrepeat users. ICU mortality was similar across all age groups, except in those > or =85 yrs old, for whom mortality was greater. One-year mortality after ICU admission increased with increasing age. CONCLUSIONS: Population-based rates of ICU admission and utilization in Olmsted County, Minnesota, increased with age and are highest in the very elderly. The presence of chronic illness, particularly cardiovascular conditions, significantly increases ICU utilization and risk of ICU admission.

High-frequency oscillatory ventilation in an infant with cystic fibrosis and bronchiolitis.

Infants with cystic fibrosis (CF) may develop severe respiratory compromise related to viral lower respiratory tract infections due to impaired mucous clearance and plugging of small airways. Consequently air trapping may lead to lung hyperinflation, impaired gas exchange, and respiratory failure. We describe the case of an infant with newly diagnosed CF who developed severe hypercarbic respiratory failure in the setting of viral bronchiolitis successfully treated with high-frequency oscillatory ventilation (HFOV).