Release 2 puffs’ — but then say more

Sometimes health care providers assume that patients understand their instructions when that couldn’t be further from the truth. They assume that what is obvious to them is obvious to the patient, so they omit discussing routine details of proper medication use. Unfortunately, patients often misunderstand the instructions. The following anecdote related by the Institute for Safe Medication Practices (ISMP) may convince you to remind nurses under your aegis to be extra careful when giving patients medication instructions.1

The Institute recently heard about an asthmatic patient who was not responding to therapy. The patient said he’d been instructed to use his inhaler by his doctor, who picked up an inhaler, held it in the air, and released two puffs to demonstrate its use. The doctor had given no additional instructions.

During follow-up, the patient described how he was using his inhaler. He would get into his car, roll up the windows, release two puffs of medication into the air, and breathe deeply for 15 minutes! At first, he had been puffing into the air and breathing deeply in his house, but he thought it might be more effective to use the inhaler in the confined space of the car.

The message from ISMP is that instructions need to be clear and complete because patients may take them literally, or may erroneously fill in the gaps when information is omitted. Assume nothing regarding a patient’s knowledge base, and leave no room for erroneous assumptions. Be thorough, and always include the obvious.


1. Safety Briefs. ISMP Medication Safety Alert! 1998; 16:2.

Routine predelivery blood typing not cost-effective

Routine blood type and screen evaluations upon admission should be eliminated for women admitted for a normal vaginal delivery who do not have previously identified risk factors, according to a recent report. Such a move could save $120 million each year. Investigators conducted a retrospective review of women who required blood transfusion during admission for an anticipated vaginal delivery at Hutzel Hospital in Detroit. Over three years, more than 16,000 patients were admitted for vaginal delivery. Of those, 76 required a blood transfusion.

The investigators examined the medical records of the 76 for admission risk factors, as well as indications for and urgency of the blood transfusion. Most of the blood transfusions were related to previously identified risk factors, the investigators write. Only four patients were urgently transfused without at least one of the following identified risk factors: admission anemia, previous cesarean delivery, abruptio placentae, and previous blood transfusion.

The group calculated that urgent blood transfusion was required for 2.5 per 10,000 vaginal deliveries where there were no admission risk factors. They suggest that routine testing on admission does not seem to enhance patient care and should be eliminated for patients without substantial risk factors. "In the rare event that a patient without a previously identified risk factor required an urgent blood transfusion, O negative blood could be given . . . pending formal type and cross match." According the investigators, the cost of a routine type and screen determination is $57. For the more than 3.1 million vaginal deliveries performed in 1996, this equates to a $177,100,000 annual cost for universal testing.

"If admission evaluation of type and screen were only completed on patients with an identified risk factor, . . . the annual cost savings would be approximately $120,000,000," states the report.

Do patients know what they’re signing?

A group of investigators recently analyzed informed consent forms being used by hospitals around the country and concluded that they are unnecessarily complex and make little sense to most patients. In addition, they leave out important information about risks.

Over 600 forms were examined by computer and rated for intelligibility. On average, the documents required at least a high school education to understand. Because 72 million Americans are marginally or functionally illiterate, only between 3% and 20% of adults can understand what the forms say. Reviewing the forms by hand, the investigators gauged the information contained in the forms. While most included blanks for the name and description of procedure, only 5% to 6% included a space for information about benefits, risks, or alternatives.


1. Hopper KD, TenHave TR, Tully DA, et al. The readability of currently used surgical/procedure consent forms in the United States. Surgery 1998; 123:496-503.

Antibiotics reduce infection in chemo patients

Infections are a serious problem for patients undergoing chemotherapy for cancer. A recent study suggests that treatment with quinolone antibiotics dramatically reduces the occurrence of some types of infections common to chemo therapy patients.

Patients receiving oral quinolone antibiotics had roughly 50% fewer infections overall than chemotherapy patients not receiving antibiotics. However, many patients on quinolone antibiotic treatment still developed fevers and had to receive intravenous antibiotics. Furthermore, oral antibiotics had no effect on mortality.

Researchers performed meta-analysis of 18 clinical trials involving 1,408 cancer patients who were undergoing chemotherapy.1 Compared to patients who received no oral antibiotics, patients who received quinolones experienced 79% fewer gram-negative infections and 77% fewer gram-positive infections. The reduction in gram-negative infections translated to 46% fewer total infections in patients taking antibiotics than in patients not taking quinolone antibiotics. Researchers found similar results in clinical trials that used trimethoprim/sulfamethoxazole as the control regimen.

Oncologists have been concerned that quino lones could predispose cancer patients to infections with other bacteria because they eliminate some of the normal bacterial flora. However, researchers found that the incidence of quinolone-resistant infections was no higher in the quinolone group than in the control group.


1. Engels EA, Lau J, Barza M. Efficacy of quinolone prophylaxis in neutropenic cancer patients: A meta-analysis. J Clin Oncol 1998; 16:1,179-1,187.

Check this Web site for your report card score

Your hospital’s cardiac surgery scores may very well appear on the Internet now thanks to a new service that rates cardiac surgery and cardiology programs in hospitals around the United States. Statistics on coronary bypasses, valve replacement surgery, and interventional procedures including angioplasty, stent placement, and atherectomy as well as diagnostic procedures are all out there. The site, www., will update ratings twice a year and will soon also include ratings in other fields, such as:

• orthopedic procedures and diagnoses — total hip replacement, first and repeat surgery; total knee replacement, first and repeat surgery;

• respiratory illness;

• oncology;

• neurosurgery.

It is expected that new areas will be added approximately once a month. The mortality data used to produce the ratings are purchased from the Health Care Financing Administration — Medicare Provider Analysis and Review (MEDPAR). Mortality in the hospital, 30 days after discharge, and six months after discharge are registered for Medicare patients treated between 1995 and 1997. The ratings are "apples to apples" — they are adjusted for the fact that some hospitals attract sicker patients and thus have a higher mortality rate. About 15% of hospitals are ranked four stars (very good) or five (best), and 70% get a three-star rating, meaning they were average or had an expected mortality rate. The site does not include information on physician performance.