• Intravenous tube which delivers high calorie intravenous nutrition
• A naso gastric tube that is inserted into the nose and threaded down to the stomach
• A percutaneous endoscopic gastrostomy tube
• A pecutaneous endoscopic jejunostomy tube

• High calorie intravenous nutrition (total parenteral nutrition) is the only option if the gastrointestinal tract is not functioning, which may happen after trauma or surgery. It consists of a potent mix of nutrients used for patients who need long term nutritional therapy.
• A nasogastric tube is used for short term (four to six weeks) nutritional therapy. It delivers fluid, medications, and nutrition into the stomach, and can also be attached to suction to drain fluid out of the stomach.
• A percutaneous endoscopic gastrostomy tube, or a PEG tube, is inserted through the stomach wall into the stomach. It is used for long term nutrition and medication administration.
• A percutaneous endoscopy jejunostomy tube, or PEJ, is inserted through the stomach wall into the jejunum, which is a portion of the gastrointestinal tract below the stomach. It also can be used for long term nutrition and medication administration.

Feeding given into the gastrointestinal tract offers advantages over total parenteral nutrition. There are lower rates of infection, fewer complications, reduced cost and shorter hospital stays. It is more natural and the body tolerates it better.

Patients who are not expected to be able to eat or have not eaten for at least seven days should receive artificial nutrition either in the form of high calorie intravenous feeding or feeding through a nasogastric tube. Feeding may be started sooner than 7 days and is given due to difficulty swallowing, poor appetite, the intense need for nutrients caused by wounds, burns, or trauma, acute pancreatitis or a fistula (a tunnel from the gastrointestinal tract to the outside of the body or another organ).

Patients who cannot receive nutrition into the gastrointestinal tract are those with acute inflammation of the abdomen, paralyzed or poorly functioning intestines, blockages in the intestines, unrelieved vomiting or diarrhea, or severe gastrointestinal bleeding.

What are the risks?
Total parenteral nutrition has a high sugar content. It is a perfect breeding ground for bacteria. Contamination of the solution, dressing, or tubing can result in a serious blood stream infection. The standard of care requires the staff to be diligent about sterility and handwashing. We know from observations that staff do not always wash their hands when they should.

A healthcare provider may accidentally insert a feeding tube into the lungs instead of the stomach. This risk is reduced by checking the placement with an x-ray. The standard of care requires verification of placement before using the tube, listening for gastric gurgles, injecting air into the end of the tube to hear it rumble in the stomach, and testing the secretions coming out of the tube. They should be acidic consistent with stomach acid.

Tube feeding solution can back up in the stomach, causing the patient to vomit and inhale the food into the lungs. This can be fatal. The rate of the tube feeding solution may be reduced or held until testing shows no residual left in the stomach between feedings.

Healthcare personnel who fail to check the placement of the feeding tube can assume it is in the stomach when it has slipped into the lung. Tube feeding solution that goes into the lung can be fatal.

A PEG tube can be surgically inserted into the wrong part of the body, a risk that is minimized when the gastroenterologist performing the procedure is skilled.

A PEG tube can be accidentally pulled out. If it is reinserted by a person who fails to confirm it is in the stomach, tube feeding solution can go into the abdomen. This can be fatal. We’ve seen several cases at Med League of nurses who reinserted a feeding tube into the wrong spot and delivered solution into the abdomen.

Med League supplies nursing expert witnesses for tube feeding-related errors. Please contact us for help.

TPN is delivered either into a large vein in the arm or into a large vein in the chest. The basilic or cephalic vein is used in the arm. The subclavian or jugular veins are used with a temporary central venous access device. Longer term use of TPN can be accomplished by creating a tunnel under the skin of the chest, or implanting a port in the chest.

Risks of insertion
The lungs may be pierced by the needle used to pierce the subclavian vein, causing the lung to collapse. An artery may be accidentally hit by the needle. The standard of care requires obtaining a chest x-ray to verify correct placement of the central venous access device to ensure the line was correctly placed.

The risk of a deep venous thrombosis related to the catheter is minimized by making sure the tip of the IV line is located lost to the right atrium.

Complications
Total parenteral nutrition has a high sugar content. It is a perfect breeding ground for bacteria. Contamination of the solution, dressing, or tubing can result in a serious blood stream infection. This may be heralded by shaking chills, increased white blood cell count, fever, or unexplained rise in blood sugar. Ideally the tube is removed and placed in a new spot while antibiotics treat the infection.

Blood sugar can be difficult to control while the patient receives TPN. Untreated or difficult to control hyperglycemia causes increased illness and death. The standard of care requires close monitoring and swift intervention to decrease the risk of infection and improve patient outcomes. The care providers will supply insulin in various combinations and types to maintain blood sugar under 150 mg/dl for critically ill patients and under 180 mg/dl for less ill patients.

Refeeding syndrome is a risk for patients on TPN. It is a series of dangerous electrolyte abnormalities and fluid shifts when TPN is begun. This can result in decreased electrolyte levels in the blood. The patient may be fatigued, lethargic, weak, have cardiac abnormalities and may ultimately die if left untreated. The standard of care requires careful monitoring of electrolytes and slowly starting TPN.

Accidents and injuries happen in health care in a moment. A patient decides to get out of bed without calling for a nurse, trips on her IV tubing and falls, fracturing a hip. Nurses’ aides use a mechanical lift to get a patient out of bed. The sling under the patient is frayed and in a second, rips and drops the patient to the floor, where he lands on his head. A distracted physician writes an order on the wrong chart. A transporter misjudges the speed of the stretcher he is pushing and takes a corner too fast. The momentum throws the patient off the stretcher. These are all real stories. I could go on for pages about the events that occur in moments. Maybe you could too.

When my mother went into the hospital for surgery, she was taken to the surgical holding area. A nurse walked in with a basket of intravenous supplies, and began to lay out her equipment. She said, “Mary, it is good to see you today.” My mother replied, “My name is not Mary. It is Gladys.” The shocked nurse said, “Your name is not Mary Wilson?” and quietly picked up her equipment and disappeared. The nurse did not take the moment to verify the identity of the patient.

Last year a physician examined an abscess under my arm. He then quickly left the room, and did not take the moment to wash his hands, despite a large red sign over the sink that said, “Wash hands”. Who knows where he carried my germs?

It only takes a moment for a patient to speak up, to ask questions, to request attention. One of my employees had a carpal tunnel surgery done. On her first postoperative office visit, the surgeon began to walk out of the room, not allowing her to ask her questions. She said, “Yo! I have questions. Come back.” He did. He closed the door, sat down, and answered her questions.

An incident that forever alters a patient’s life can take place in an instant. Hopefully safeguards are in place that serve as part of the safety net. The fact that they don’t work is one of the foundations of the medical malpractice legal system.

What case have you worked on that resulted from an error that took place in a moment? Share your comments.

This is the real conversation between my wife and her obstetrician “planning” the cesarean section for our third child. A secondary benefit to this “safety” discussion was that the baby would be born on April 2nd, rather than April 1st! The year was 1978, more than 30 years ago.

The question of good surgical practice in regard to sleep deprivation and surgeon exhaustion has been around for a long time, and is certainly not a new phenomenon. Although objective data are nice to have, and may be confirmatory, they are not needed to resolve these issues – experience, common sense, and consideration for social responsibility are all that is needed.

A recent New England Journal of Medicine article (cited below) highlighted the issue of sleep deprived surgeons. It made the point that the working hours of medical residents in their first postgraduate year are restricted to a maximum of 16 hours of continuous work followed by a minimum of 8 hours off duty. There are no such regulations for fully trained physicians. The risks of operating on patients when sleep deprived can be compared to the risks of driving while intoxicated (DUI). In surgery, there is an 83% increase in the risk of complications (e.g., massive hemorrhage, organ injury, or wound failure) in patients who undergo elective daytime surgical procedures performed by attending surgeons who had less than a 6-hour opportunity for sleep during a previous on-call night.

The article recognizes that many patients would prefer to change surgeons or postpone elective surgery if they knew their surgeon was sleep deprived. Surgeons and hospitals may lose money when procedures are cancelled. However, the authors stressed the ethical obligation of surgeons to inform their patients of the risks, and the responsibilities of the hospital to enforce policies about not operating when sleep-impaired.

The recent NEJM article on this subject makes useful recommendations, but it could have gone further. The management of practice patterns is not only the domain of the individual surgeon, nor just for the profession to provide advice and guidance. Speaking as a surgeon, I believe we increasingly need senior hospital management and Boards of Directors of institutions to more fully face their social responsibility to act in the public interest. In an era when much professional behavior is shrouded in unnecessary and self-serving secrecy, it is essential for Boards of Directors to more fully accept that an important part of their role to society is on behalf of the community which they are required to serve.

If these premises are accepted, then Boards of Directors, through their senior management, should establish clear and unambiguous Standard Operating Procedures (SOPs) about the rules concerning “on-call” hours and associated clinical conduct. These must cover the common eventuality of physician sleep deprivation and exhaustion in regard to continuing clinical practice in general, and the needs of the operating room in particular. These conditions should form part of the contractual, and therefore legally binding, relationship between the surgeon, the institution and the patient.

Fixing the Problem
1. A surgeon who is on call for a hospital must not have on-call duty or patient clinical activity in another hospital for the total period involved.
2. A surgeon should not arrange elective surgery following a 24 hour on- call period.
3. A surgeon should not undertake elective surgery when, during the previous night, he/she has not had an appropriate period of rest (probably 6 hours – to be defined), or if, for any reason, the surgeon feels exhausted.
4. If there are circumstances in which sleep deprivation or exhaustion have occurred, and the surgeon feels the need to operate on an elective patient, the patient should be so informed. Both parties should be required to sign an informed consent document before surgery commences (as recommended in the NEJM article.)
5. A parallel set of SOPs could be developed to consider the need for urgent/emergent surgical interventions when the surgeon is sleep deprived or exhausted.

Part of our professional responsibilities as surgeons is to make sure that we are all involved in “clinical outcome improvement.” Arranging for this surgeon performance issue to be addressed at individual, at professional, and at institutional levels would be a step in the right direction.

For those surgeons who are already conducting their clinical practice with these concerns in mind, there would be little to change. For the rest, patients and society need mandates for our protection.

For more information on sleep impairment see

http://www.nejm.org/doi/full/10.1056/NEJMp1007901

Surgeon L. Peter Fielding, MD FACS FRCS received his medical degree from the University of London (with Honors) and Advanced Surgical Training in Gastrointestinal Surgery. He is a Fellow of the American College of Surgeons. He holds or has held senior academic appointments in the role of Clinical Professor of Surgery at Yale, Rochester, U Penn and Penn State Universities. He is experienced in medical staff credentialing, and the provision of medicalegal opinions. For over two decades, he has provided expert witness services for both plaintiff and defense attorneys.

A version of this article with specific guidance for patients appears in Avoid Medical Errors Magazine, Issue 3. Get your free digital subscription at www.avoidmedicalerrors.com.

As a result of the focus on sentinel events, many states have put mandatory reporting of these events into place. The government defined “hospital acquired conditions” for which Medicare and Medicaid will not pay. Here is what the government says:

Hospital Acquired Conditions (HAC) are serious conditions that patients get during an inpatient hospital stay. If hospitals follow proper procedures, patients are less likely to get these conditions. Medicare doesn’t pay for any of these conditions, and patients can’t be billed for them, if they got them while in the hospital. Medicare will only pay for these conditions if patients already had them when they were admitted to the hospital. Read more about never events here and about non-payment for these events., as well as here.

These are the current HACs. The first 3 are quite common, according to newly released data:

• Catheter associated urinary tract infection
• Falls and trauma
• Vascular catheter associated infection

  Of these 3, Med League receives the most calls about cases involving falls and trauma.

  Other HACs include

• Manifestations of poor glycemic control (evidence of unstable blood sugar)
• Blood incompatibility (giving the wrong blood transfusion to a patient)
• Stage III and IV pressure ulcers (stage IIIs sores are deep pressures sores to just above the muscle level. Stage IV sores expose muscle or bone.)
• Air embolism (bubble of air in the blood)
• Retained object after surgery such as a dressing or instrument left behind

You can see how well your hospital is doing on the HACs compared to other hospitals at the link below.
The file in the Downloads section at this link shows how often HACs occurred for Medicare fee-for-service claims from October 2008 through June 2010. The measures are expressed as the number of HACs per 1,000 discharges; they are not adjusted for hospitals’ patient population (case-mix).

Source: http://www.cms.gov/HospitalQualityInits/06_HACPost.asp
Study: Classen, D and others, Global trigger tool shows that adverse events in hospitals may be ten times greater than previously measured, Health Affairs April 2011

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See www.avoidmedicalerrors.com for more information on avoiding medication errors.

John Smith manages NursingUniforms.net a one stop shop for all your medical and nursing scrubs requirements.

For more tips on avoiding medication errors, see www.avoidmedicalerrors.com

What patient safety procedures have we already incorporated?
1. Preoperative checklists: on the nursing unit and in the operating room holding area
Before a patient goes to the operating room, a nurse uses a checklist to verify certain information has been gathered. These preoperative checklists are not standardized from facility to facility unless the hospital is part of a chain. This includes preoperative testing, signed operative consent, history and physical is completed, and so on. If there are missing items, the nurse is expected to follow up on them. In some instances, that may mean surgery is postponed until the issues can be addressed. For example, the nurse will ask the patient when was the last time he ate or drank. If he had breakfast in the morning before surgery, his surgery may be delayed because of the risk of you vomiting while under anesthesia.
Recently, an attorney contacted Med League about a case in which an abnormal finding on a chest x-ray was not followed up on. His question: Did the preoperative nurse have an obligation to bring it to the attention of the surgeon? Our expert’s response: the phsyicians are obligated to read the results of the study. The nurse is obligated to make sure it is on the chart.

2. Operating room staff checklist(s) to verify identity and the correct site of the surgery
The World Health Organization recommends use of a challenge and response checklist. This means that one person asks the question and other person answers. See the video for an explanation of this type of surgical checklist.

Healthcare personnel are increasingly using checklists to prevent a vital detail or procedure from being overlooked. Checklists have to be accurately and attentively filled out. Routine aspects of care can become rote, followed without thinking, and subject to error. See Atul Gawande, MD’s book, The Checklist Manifesto, for more information.

Also see this company for unique wall mounted boards that define each step in a procedure and provide a way to show it has been completed.

Of the 773 hospitals who responded to a request to supply data about their delivery rates, numbers varied widely. More than half reported rates higher than 12%, with some having as high as 60%. Some hospitals declined to respond, leading one to wonder if they did not keep statistics, or their performance was poor on this indicator.

This kind of information is pointing to the standard of care being defined as discouraging early delivery without medical indication. Consider the risks to the fetus and to the mother when labor is induced or a cesarean section performed to meet the convenience factor.

A short term convenience for the mother or the obstetrician may result in long term complications when the fetus is between 37-39 weeks. The baby may not developmentally ready. Cesarean sections carry risk of bleeding, perforation of surrounding organs, anesthesia complications, need for repeat cesarean sections, and more. Increasingly, hospitals should be putting pressure on their obstetricians to not participate in early deliveries without medical necessity. And patients should be educated about the risks.

Read more.

Find out what rate a hospital reported- or didn’t.

I recall when my father was in ICU nearly 33 years ago, he thought the alarms represented fire trucks, and could not understand why there were so many fires in the blocks around the hospital.

Alarm fatigue can be deadly

But technology relies on humans to hear, interpret, and respond to alarms. Sometimes alarms are false alarms and do not signify anything. Sometimes alarms are annoying; the nurses turn them off. Sometimes the alarm is turned off because the patient is being taken off the equipment temporarily and the nurse forgets to turn it back on. Sometimes the nurse mis-programs a complicated piece of medical equipment. And sometimes the volume is turned down, or the nurse is at a point on the nursing unit where she cannot hear the alarm.

The Boston Globe provided a special report on this subject. It offers the perspectives of the healthcare providers and the manufacturers. When an investigation of a patient death associated with an alarm failure occurs, it is often not the equipment at fault, but the staff who did not respond to the alarm. Healthcare professionals and manufacturers are trying to create safety solutions, for example, by creating more technology, like signs in the hallways to warn staff of an alarm. For more information, read the report and watch the video.

Investigating a claim
1. The biomedical department is typically asked to look at a piece of equipment associated with an untoward outcome. The hospital may generate a report that details their findings. This may or may not be discoverable.
2. The manufacturer may be asked to examine the equipment, and they also generate a report.
3. The hospital will have discoverable policies on setting and checking alarms.
4. The medical record may incorporate flow sheets with boxes to check off that alarms were set.
5. Cardiac monitors that detect arrhythmias may spit out paper that is time stamped. These times should be compared with the medical record.
6. Nurse defendants and fact witnesses should be asked about the healthcare environment, the frequency of alarms, the responses, and the nursing practices associated with alarms.