What You Need to Know

​​​Facebook is screening users for suicide risk, 70 percent of electronic medical records contain wrong information, and a jazz musician undergoes surgery while awake​

​Patient-controlled analgesia (PCA) can help patients better manage their pain by allowing them to self-administer more frequent but smaller doses of injectable analgesia. When used as intended, a PCA pump actually reduces the risk of oversedation due to a “built-in” safety feature that is often overlooked: the device is intended for use by patients.

A sedated patient will not press the button to deliver more opioids, thus avoiding toxicity; however, family members and health professionals have administered doses for the pa- tient by proxy, hoping to keep them comfortable. This well-intentioned effort has resulted in cases of oversedation, respiratory depression, and even death.

Both the Authority and The Joint Commission have published articles addressing the safety risk this practice presents, yet the Authority continues to receive reports of patient harm from PCA by proxy.

A recent event specifically stated that the patient’s wife reported that she had been pressing the button on the PCA pump to deliver pain medication to the patient while he was sleeping. The patient required naloxone treatment to reverse the effects of the opioid overdose.

To reduce the risk of overdoses with PCA therapy, educate patients and families about proper PCA use before initiation. Starting this education during the preoperative testing visit may improve the patient’s understanding and recall, and warning family members and visitors about the danger of PCA by proxy may also help to prevent this type of error.

In 2016, more than 6,000 youth younger than 25 died by suicide in the Unit- ed States, and suicide rates continue to rise. As studies indicate that many of the youth who committed suicide had a healthcare interaction within a month of their death, medical settings may present an opportunity to intervene—if those at risk for suicide first can be identified. The Joint Commission requires that all patients are screened for suicidal ideation who are being evaluated or treated for behavioral health conditions as their primary reason for care using a validated screening tool when they present to the hospital. As it turns out, universal screening is easier said than done, since healthcare facilities have limited resources; however, a report published in Psychosomatics in Sep- tember 2018 may offer a practical and efficient solution.

In the report, “Suicide Risk Screening in Pediatric Hospitals: Clinical Pathways to Address a Global Health Crisis,” researchers from the National Institute of Mental Health (NIMH) laid out a three-tiered clinical pathway model with three key, cascading steps for assessing suicide risk through surveys and clinical judgment:

The NIMH report also provides an ASQ Toolkit to assist healthcare providers in implementing the model.

We may never agree whether social media is good, bad, or ugly, but we can agree that it is here to stay in some way, shape, or form. So, how do we har- ness the good? This article from The New York Times describes how Facebook is trying to help decrease one of the biggest health threats in our country and around the world, suicide.

Reading the article resonated with me because I personally have seen the di- rect impact that social media can have on someone contemplating suicide. I was scrolling through my Facebook feed one morning and came across a post from a “friend of a friend” in which he described the lack of will to live and a suicide plan. Unfortunately, many of the comments in response to his post were not positive. Not knowing this person or whether they were serious left me with an ethical dilemma. Should I do something? Even if I wanted to help, what could I do? Did I have an ethical obligation to intervene? I’m a nurse, so did that matter?

I don’t have all the answers to these questions, but I did do something. I was ​able to determine a general location of where this individual lived, and I called the local police department with the information I had. The officers took the situation seriously. They called me later that day to let me know that they had located the individual. I don’t believe he harmed himself. The world is chang- ing—harness the good.

— Regina Hoffman, MBA, BSN, RN, CPPS Executive Director, Patient Safety Authority

We all know to drink eight glasses of water a day, but for some people this advice could cause serious harm, if they have a condition called hyponatre- mia, in which sodium concentrations in their blood is abnormally low. Sodium is important in regulating water in the body’s cells, so when sodium levels are diluted—either because of a medical condition, or simply from drinking too much water (known as “water intoxication,” which typically occurs in ath- letes)—the amount of water in the cells rises and they swell. If untreated, that can lead to big trouble, and even death.

Water intoxication, clinically identified as syndrome of inappropriate ADS se- cretion (SIADH) also happens in patients with lung disease, heart failure, and cancer; however, a recent, groundbreaking study from researchers at NYU Winthrop Hospital reveals that many such cases are actually misdiagnosed, and these patients have a different form of hyponatremia called “cerebral salt wasting,” in which they are depleted of salt and water. The two diagnoses require completely opposite treatments: in SIADH, you withhold water, but in salt wasting, you must administer water and salt.

The reason for this misdiagnosis? Salt wasting is uncommon compared to SIADH and seemed to always involve a brain injury. The NYU Winthrop study debunked this assumption, reporting that of 62 hyponatremic patients, 33 had SIADH and 24 had salt wasting; and of those 24 patients, 21 of them had no neurological findings. In the absence of a cerebral condition, those patients would have been treated for SIADH and been restricted of fluids—exacerbat- ing their water depletion and contributing to higher morbidity and mortality.

The study, first published in The American Journal of the Medical Sciences, recommends renaming “cerebral salt wasting” to “renal salt wasting” and pres- ents a diagnostic algorithm to help differentiate between it and SIADH.

 

Being on the front lines of patient care and safety also may mean putting your own safety at risk—sometimes even from the patients themselves. Sta- tistics show that staff in long-term care (LTC) facilities experience the highest rate of nonfatal occupational violence, 6.8 per 100 full-time workers. Nurses working with Alzheimer’s and dementia patients in particular are at high risk, with 35 percent reporting injuries from resident aggression, including 12 per- cent reporting a human bite.

The top four safety concerns, according to an International Association for Healthcare Security and Safety (IAHSS) survey of security directors and manag- ers at LTC facilities, are:

In response to this study, the IAHSS issued new guidance for LTC facilities con- cerning violence and security issues, which emphasizes collaboration between security, administration, and staff to safeguard against violence and theft. Their recommendations include implementing a disruptive patient and visitor program, customer service training, an electronic access control platform, a visitor management system, video surveillance, panic buttons, a mass commu- nication system, and education.

The IAHSS also suggests deterring patient elopement with sufficient staffing, elopement risk assessments, strategic placement of residents on the floor, and conducting safety rounds and elopement drills to prepare for an emer- gency response.

Your electronic medical record (EMR) is an important part of who you are, medically speaking, that is. Like your credit score, driving record, and every- thing you’ve ever posted online, it follows you around all your life, and it’s an essential tool for healthcare providers when diagnosing and treating you. Yet few people have ever seen their own medical record, and as 20-year-old patient advocate Morgan Gleason recently discovered, they frequently contain mistakes—and it’s an onerous process to correct them.

Gleason has spent plenty of time in hospitals since she was diagnosed with juvenile dermatomyositis, a rare autoimmune disease, nine years ago. She al- ways requests a copy of her medical record, which is how one day after visiting a women’s health clinic, she discovered a note about her two children—chil- dren she had never had. On another occasion, when a doctor interrogated her about her blood sugar, she discovered another record of a diabetes diagnosis. Wrong again.

 

​According to health IT expert Ross Koppel, as much as 70 percent of medi- cal records contain incorrect information. Many of these mistakes are small, harmless details, but some could have a major impact on the kind of care and interventions you receive. A missed allergy to medication or a misdiagnosis could be a matter of life and death.

Gleason also learned that even if a patient finds a mistake in their record, it may not be easy to have it corrected. Many doctors distrust patients, even where their own care is concerned; and now, Gleason also distrusts the system to accurately document her own medical history.

A recent multicenter study provided evidence that overlapping orthopedic surgeries (in which one attending surgeon is the primary surgeon for multiple patients at once in separate ORs) in an inpatient setting is just as safe as non- overlapping surgery—and now there is data suggesting that the same may be true of overlapping outpatient surgeries. Researchers at Washington Universi- ty School of Medicine, St. Louis, published a study in The Journal of Bone and Joint Surgery in December which found that overlapping surgeries are just fine for “same-day” orthopedic procedures as well.

They looked at more than 22,000 outpatient surgeries performed between 2009 and 2015, of which 23 percent were overlapping, and determined there was no meaningful different in complication rates between the overlapping surgery group (0.66 percent) and the nonoverlapping surgery group (0.54 percent). Although the results are truly indicative of only one ambulatory sur- gery center, this is encouraging evidence that supports the use of overlapping orthopedic surgery in outpatient settings.

Jazz musician Musa Manzini recently gave the performance of his life, play- ing his guitar for a small audience of surgeons and OR staff in Durban, South Africa—as they performed a delicate operation to remove a tumor from his brain.

In order to protect his musical talent, surgeons opted for an “awake craniot- omy,” in which Manzini was given a local anesthetic and wakened toward the end of the procedure to give his doctors real-time feedback on what they were doing inside his skull. By stimulating parts of his brain with electricity and ob- serving the effect on his playing, they could determine what areas to preserve during tumor resection. The surgery was successful, and they removed 90 percent of the growth.

Riffing on the old joke, “Doctor, doctor, will I be able to play the guitar after the operation?”, in Manzini’s case, the answer is a resounding yes.​