Sound the Alarm – Or Perhaps Not

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If you live or work in a city, you’re likely used to the everyday sounds of car horns honking, jackhammers drilling, sirens ringing and trains rumbling. If you’re like me, you may have developed the ability to tune out these noises without even knowing it. So how do we know which sounds we really need to pay attention to?

That’s the question being asked in hospitals. With so many audible alarms on patient units, clinicians can become desensitized and fail to respond when an emergency arises. And the constant noise of alarms certainly doesn’t make for a restful patient experience either.

In 2015, we found that up to 490 unique alarms sounded per patient bed per day in certain units at the Brigham. That’s roughly 20 alarms per hour. About 75 percent of them were non-critical.

To address this, we conducted a six-month pilot to reduce the number of audible alarms and ensure that alarms indicating an urgent medical need would be heard.

Here are a few examples of the changes we made:

  • Widened the parameters for the high and low heart rate alarm settings to decrease the number of alarms that do not require action from a care provider.
  • Tailored alarms to the needs of each patient care unit. For example, the needs of patients in the Medical Intensive Care Unit are very different from the needs of postpartum patients, and the alarms have been programmed accordingly.
  • Implemented nursing practice changes to reduce alarms caused by poor contact of the monitor with the patient’s skin, such as the monitors that measure oxygen levels or record the electrical activity of the heart.

These efforts resulted in a 70 percent reduction of alarms across the hospital, which made the hospital safer by improving the care team’s ability to hear critical alarms and increased patient satisfaction as well.

Since then, we have heard from providers who said the units were significantly less noisy, allowing them to hear the alarms sounding for a critically-important condition. Patients reported improved satisfaction due to fewer noises, less stress about what the alarms meant and fewer interruptions.

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What Every Expectant Parent Should Know about Hospital C-section Rates

For this post, we spoke with Julian N. Robinson, MD, chief of obstetrics in the Department of Obstetrics and Gynecology, about C-section rates.

Planning for the birth of a child can be a wonderful time. It can also be filled with questions and concerns.

You’re probably thinking about the quality and safety of the care you and your baby will receive during and after delivery. You may have heard about a recent Consumer Reports study suggesting that a women’s risk of a cesarean section, or C-section, depends on the hospital she chooses.

In certain situations, a C-section is the safest option for both mother and baby. For example, when the baby is positioned side-to-side in the belly or the placenta is covering the cervix, or if the baby’s heart rate drops during labor. But C-sections, like any surgery, come with risks, such as infections.

To lower or eliminate these risks, hospitals should strive to perform C-sections only when medically necessary. However, how often a hospital performs this procedure depends on several factors, including risk to mother and baby, patient choice and clinician recommendations. In addition, hospitals with strong high-risk obstetrics programs and those caring for women who haven’t received optimal prenatal care are more likely to have higher C-section rates.

In recent years, patient choice and clinical recommendations have played a bigger role in influencing C-section rates at some hospitals. For example, some patients may think a planned C-section will alleviate stress about when the baby will arrive or whether her health care provider will be available for the delivery. Although a C-section is often recommended for women with high-risk pregnancies, our goal at BWH is for women to have a vaginal delivery when possible.

Because of these factors, you won’t be able to discern from a hospital’s C-section rate how many were medically necessary and how many were not. The national benchmark for low-risk pregnancies is 23.9 percent of births by C-section. At BWH, we fall just below the national target, with 23.2 percent of births by C-section. BWH delivers more babies than any other hospital in Massachusetts and specializes in high-risk pregnancies. If the hospital you are considering has a high C-section rate that doesn’t make it a bad place to give birth, for all the reasons detailed above, but you should ask for more information and talk with your obstetrician about the safest birth plan for you and your baby.

OpenNotes: Building a More Transparent Health Care System

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Seinfeld fans might remember the episode where Elaine can’t find anyone to treat her rash because of something a doctor wrote in her chart. She spends the whole episode trying to figure out what was in the note.

Although it made for very entertaining television, I’m happy to say that if Elaine were a patient at the Brigham today, she would have instant access to the note with just a few clicks of the mouse. In the spirit of transparency and patient safety, patients can now read doctors’ notes in their electronic health record through a feature called OpenNotes.

This is an important step toward improving communication and empowering patients to be more involved in their care, which improves outcomes. The Brigham introduced OpenNotes in January, giving patients access to summaries written by their physicians.

OpenNotes gives patients the opportunity to validate the information their provider wrote and correct inaccuracies. If a note says the patient has a peanut allergy and they don’t, the patient can simply mark it as incorrect.

During the course of an appointment, a patient may be taking in a lot of information and can forget something the doctor said. OpenNotes includes the doctor’s recommendations so patients can review them after the appointment.

Patients may also choose to give access to their health care proxy or family members.

We are working on making OpenNotes available to inpatients too. Soon everyone will be on the same page!

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PS: If you haven’t seen the Seinfeld episode, here’s a quick video produced by OpenNotes featuring snippets of Elaine’s unsuccessful quest.

“The Scariest Moment of My Life”

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During an office visit, a patient with diabetes was switched to a highly concentrated dose of insulin. The Food and Drug Administration requires that a special U-500 syringe be used with this concentration. The physician placed an order in our electronic health record for the high-concentrated insulin and the U-500 syringes. He noted the need for the U-500 syringes on both orders. The physician then electronically sent the orders to the patient’s pharmacy and informed the patient that he would receive a special syringe.

When the patient filled his prescription, the pharmacy provided him with the correct concentration of insulin but – unbeknownst to the patient – gave him the wrong syringe. The syringe the patient received is meant to be used with a much lower concentration of insulin and measures dosing in a different way. Imagine filling a 12 oz. mug with espresso instead of coffee – it’s the same amount of liquid in the cup, but the espresso is much more potent. As a result of the error, the patient unintentionally injected himself with five times more insulin than intended.

The overdose could have been fatal, but the patient, who had been managing his diabetes for quite some time, was able to recover after eating foods high in sugar to normalize his blood sugar. He remembers, “It was the scariest moment of my life.”

Upon learning what happened, the prescribing physician called the pharmacy to discuss what went wrong. He also found an alternative option: a high dose of insulin prescribed with a pen. The correct concentration of insulin is already inside the pen, so the opportunity for error is minimized.

At the Brigham, we are recommending changing our electronic ordering system to direct providers to the pen when they are placing an order for high-dose insulin.

In addition, I’ve shared this key learning with safety leaders at the pharmacy where this occurred, other pharmacies, and the Institute for Safety Medication Practices, a medication error group, which sends national alerts and identifies patient safety trends, with the aim of reducing the potential for harm to patients across the country.

As part of our commitment to transparency, we will continue to share stories about errors at Brigham Health and what we’ve done to prevent similar errors from happening again.

Have you experienced a medical error?  We’d like to hear from you.

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The Most Difficult Conversations in Health Care

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Health care providers choose medicine because we want to help people get better, but sometimes, we make them worse. Complications and injuries happen as a result of the disease or a natural consequence of treatment, and occasionally, as a result of a medical error. As providers, realizing that we’ve made a mistake that has caused harm to our patient and their loved ones is devastating.

We know that to preserve trust, we must have open, honest, timely conversations with patients and their families about what happened, but those conversations can be incredibly hard, because care providers, after all, are only human.

At Brigham Health, we have a long-standing commitment to transparency and have supported staff in having these difficult conversations. We still face challenges, but remain dedicated to taking steps to proactively bridge the gap of trust that may occur after a medical error, which is why we have joined the Massachusetts Alliance for Communication and Resolution following Medical Injury (MACRMI). The alliance consists of patient advocacy groups, teaching hospitals, medical liability insurers and statewide provider organizations committed to providing transparent communication, sincere apologies and fair resolution in cases of medical harm resulting from care that is not up to standards.

Communicating openly with patients about mistakes, apologizing and coming to a resolution is the right thing to do, and we are committed to doing it, even when it is difficult.

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