Neurohospitalists and patient safety

The Neurohospitalist
Neurohospitalists and Patient Safety: Lessons Learned in 2013
Sumant R. Ranji and Christopher Moriates
The Neurohospitalist 2014 4: 55
DOI: 10.1177/1941874414525171
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2013 in Retrospect: A Review of Important Clinical Research in Inpatient Neurology
Neurohospitalists and Patient Safety:
Lessons Learned in 2013
The Neurohospitalist
2014, Vol. 4(2) 55-57
ª The Author(s) 2014
Reprints and permission:
DOI: 10.1177/1941874414525171
Sumant R. Ranji, MD1, and Christopher Moriates, MD1
quality improvement, patient safety, outcomes research
Hospitalization remains unacceptably risky, as recent studies
indicate the incidence of adverse events has improved only
marginally over the past several years.1 This disappointing
reality has prompted safety experts to call for shifting focus
from interventions to prevent individual adverse events to
redesigning systems of care to improve safety across multiple
dimensions. Neurohospitalists care for patients who are particularly vulnerable to errors and therefore play a key role in
improving patient safety. In this article, we review 2013’s
most important patient safety developments relevant for
neurohospitalists (and frontline clinicians in general).
Specific Practices Neurohospitalists Should
The seminal Making Health Care Safer report, issued in 2001
by the Agency for Healthcare Research and Quality (AHRQ),
galvanized the safety field by issuing evidence-based recommendations to prioritize safety efforts.2 Published this
past year, the follow-up Making Health Care Safer II again
used a rigorous process to review the evidence supporting
41 commonly used safety practices.3 The authors identified
10 ‘‘strongly recommended’’ practices suitable for wide implementation; Table 1 summarizes those most relevant for neurohospitalists. Implementation of these practices has been
shown to result in decreased rates of health care-associated
infections, pressure ulcers, and hospital-acquired deep venous
Improving Patient Safety at the System
The most important contribution of Making Health Care Safer
II may be its emphasis on the need to redesign systems of care
to improve safety for all patients. Although this work will
require multidisciplinary efforts and engagement of expertise
from other industries, there are 2 ways in which neurohospitalists can contribute to improving flawed systems of care.
Eliminating Waste in Health Care
The issue of overuse of unnecessary health care services was
widely discussed in 2013, with the Institute of Medicine estimating that US$750 billion is spent annually on care that does
not result in improved health outcomes.4 Policy initiatives
within the Affordable Care Act seek to realign hospitals’
financial incentives to focus on the provision of value (defined
as quality divided by cost) rather than merely reward production.5 In addition, professional organizations have developed
the ‘‘Choosing Wisely’’ campaign to provide frontline
clinicians with guidance on targeting overuse of low-value,
nonevidence-based practices. In 2013, both the American
Academy of Neurology (AAN) and the Society of Hospital
Medicine (SHM) joined more than 50 specialty societies that
have released a list of ‘‘Five things that physicians and
patients should question.’’6-8 The low-value practices targeted
by the AAN and SHM include many relevant for neurohospitalists, such as avoiding carotid artery imaging in patients
admitted with syncope and unnecessary use of urinary
catheters (Table 2).
Developing a Culture of Patient Safety
High-risk industries (such as aviation and nuclear power) have
long recognized the importance of developing a ‘‘culture of
safety,’’ characterized by continual efforts to improve safety
through encouraging a blame-free approach to reporting and
analyzing safety problems and engaging both leadership and
frontline clinicians in addressing safety issues. A robust safety
culture is essential to ensure that specific interventions can be
implemented to improve safety. Two analyses published in
Department of Medicine, University of California, San Francisco, CA, USA
Corresponding Author:
Sumant R. Ranji, Department of Medicine, University of California, 533
Parnassus Avenue, Box 0131, room U137, San Francisco, CA 94143, USA.
Email: [email protected]
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The Neurohospitalist 4(2)
Table 1. ‘‘Strongly Encouraged’’ Patient Safety Practices From the AHRQ Making Health Care Safer II Report Most Relevant for
Patient Safety Practice
Practices to prevent health care-associated infections
Bundles that include checklists to prevent central line-associated blood stream infections
Interventions to reduce urinary catheter use which include catheter reminders, stop orders, or nurse-initiated removal protocols
Bundles that include elevation of head-of-bed, sedation vacations, oral care with chlorhexidine, and subglottic suctioning endotracheal tubes
to prevent ventilator-associated pneumonia (VAP)
Hand hygiene
Practices to prevent specific adverse events
Multicomponent interventions to reduce pressure ulcers
Interventions to improve prophylaxis for venous thromboembolism
Documentation of patient’s advanced care planning desires
Practices to reduce radiation exposure from fluoroscopy and CT scans
Abbreviations: AHRQ, Agency for Healthcare Research and Quality; CT, computed tomography.
Table 2. ‘‘Choosing Wisely’’ Recommendations From the American Academy of Neurology and the Society of Hospital Medicine.a
American Academy of Neurology Choosing
Wisely Recommendations
Society of Hospital Medicine Choosing
Wisely Recommendations
1. Don’t perform EEGs for headaches
1. Do not place, or leave in place, urinary catheters for incontinence
or convenience, or monitoring of output for noncritically ill patients
(acceptable indications: critical illness, obstruction, hospice,
perioperatively for <2 days, or urologic procedures; use weights
instead to monitor diuresis)
2. Do not prescribe medications for stress ulcer prophylaxis to
medical inpatients unless at high risk for GI complication
3. Avoid transfusing red blood cells just because hemoglobin levels are
below arbitrary thresholds such as 10, 9, or even 8 mg/dL in the
absence of symptoms
4. Avoid overuse/unnecessary use of telemetry monitoring in the
hospital, particularly for patients at low risk of adverse cardiac
5. Do not perform repetitive CBC and chemistry testing in the face of
clinical and lab stability
2. Don’t perform imaging of the carotid arteries for simple syncope
without other neurologic symptoms
3. Don’t use opioids or butalbital for treatment of migraine, except as
a last resort
4. Don’t prescribe interferon-b or glatiramer acetate to patients with
disability from progressive, nonrelapsing forms of multiple sclerosis
5. Don’t recommend carotid endarterectomy for asymptomatic
carotid stenosis unless the complication rate is low (<3%)
Abbreviations: EEG, electroencephalogram; CBC, complete blood count; GI, gastrointestinal.
The complete lists from all participating societies, along with explanations and references for each recommendation, are available at
2013 identify challenges to establishing safety culture and
evidence-based methods for improving safety culture.
The United Kingdom’s National Health Service (NHS) has
suffered high-profile safety failures in the recent years,
prompting an exhaustive mixed-method analysis of safety culture within the NHS.9 The investigators found wide variation
in safety culture between and within institutions, with highand low-performing units often coexisting within a single hospital—a finding that will not surprise anyone whose practice
spans multiple units or sites of care. The barriers to improving
safety culture included a lack of actionable data, suboptimal
organizational and information systems, and variations in staff
and leadership commitment. This study, as well as a systematic review performed as part of Making Health Care Safer II,
did identify ways that organizations can improve safety culture.10 The priorities should include active engagement of
frontline providers in error reporting and analysis, an explicit
commitment between clinicians and leadership to prioritize
safety, structured approaches to improve communication
between disciplines, and formal teamwork training where possible. Although some of these interventions require additional
resources and commitment, frontline clinicians can emphasize
safety culture through everyday actions such as reporting
safety hazards, openly discussing errors, and treating the
entire health care team with respect (especially after an error
Neurohospitalists are ideally positioned to improve patient
safety at their institutions through their role in caring for complex hospitalized patients and as consultants interfacing with
multiple specialties and disciplines. Neurohospitalists should
partner with safety champions to introduce the practices
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Ranji and Moriates
strongly recommended in the AHRQ Making Health Care
Safer II report and should help shape safer systems of care
by minimizing overuse of unnecessary care and establishing
a culture of safety.
The authors gratefully acknowledge Vida Lynum for assistance with
literature searching.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
The authors disclosed receipt of the following financial support for
the research, authorship and/or publication of this article: Dr Ranji
received funding from AHRQ (Contract No. 290-2007-10062-I) for
his work on Making Health Care Safer II, and both Dr Moriates and
Dr. Ranji receive funding from AHRQ as editors of AHRQ Patient
Safety Net (, Contract No. 290-04-0021).
1. Wang Y, Eldridge N, Metersky ML, et al. National Trends in
Patient Safety for Four Common Conditions, 2005-2011. N Engl
J Med. 2014;370(4):341-351.
2. Shojania KG, Duncan BW, McDonald KM, Wachter RM, eds.
Making Health Care Safer: A Critical Analysis of Patient Safety
Practices. Rockville, MD: Agency for Healthcare Research and
Quality; 2001.
3. Shekelle PG, Wachter RM, Pronovost PJ, eds. Making Health
Care Safer II: An Updated Critical Analysis of the Evidence for
Patient Safety Practices. Rockville, MD: Agency for Healthcare
Research and Quality; 2013.
4. Institute of Medicine. Committee on the Learning Health Care
System in America. Best Care at Lower Cost: The Path to
Continuously Learning Health Care in America. Washington,
DC: National Academies Press; 2012.
5. VanLare J, Conway P. Value-based purchasing—national programs to move from volume to value. N Engl J Med. 2012;
6. Langer-Gould AM, Anderson WE, Armstrong MJ, et al. The
American Academy of Neurology’s top five choosing wisely
recommendations. Neurology. 2013;81(11):1004-1011.
7. Bulger J, Nickel W, Messler J, et al. Choosing wisely in adult
hospital medicine: five opportunities for improved healthcare
value. J Hosp Med. 2013;8(9):486-492.
8. American Board of Internal Medicine Foundation. Choosing
Wisely—An Initiative of the ABIM Foundation. Accessed January 14, 2013.
9. Dixon-Woods M, Baker R, Charles K, et al. Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. BMJ Qual Saf. 2014;
10. Weaver SJ, Lubomksi LH, Wilson RF, Pfoh ER, Martinez
KA, Dy SM. Promoting a culture of safety as a patient safety
strategy: a systematic review. Ann Intern Med. 2013;158(5 pt
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