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HM19: Point-of-Care Ultrasound for Patient Safety and the Prevention of “Never Events”

Op-Med is a collection of original articles contributed by Doximity members.

Point-of-care ultrasound (POCUS) is a well-established field of medicine in which clinicians use ultrasound at the bedside for clinical decision-making as well as procedural guidance. In use for decades in fields such as Emergency Medicine and Obstetrics, POCUS has now earned its place in Hospital Medicine. The recent Society of Hospitalist Medicine Annual Meeting's POCUS pre-course was sold out again — fitting for its 10th year!  

Currently, over half of U.S. medical schools include POCUS training in their curriculum and a quarter of Internal Medicine residency programs surveyed do the same. Amongst this groundswell of interest in POCUS nationwide, hospitalists are increasingly gaining access to POCUS through a variety of training opportunities. This comes at a time when the cost of portable (and even handheld) ultrasound machines is falling.  

A “never event” refers to a rare, but serious medical error that is preventable, such as wrong-site surgery.  Retention of guidewires during central venous catheter (CVC) placement is already considered a “never event” by many because it is entirely preventable. Given that POCUS has previously been shown to reduce the complications of central venous catheter (CVC) placement, should we, for instance, also consider arterial cannulation during CVC placement a “never event?”   

The term “never event” might sound overly harsh, but the framework of this patient safety concept could be helpful; if we consider certain outcomes unacceptable the way we do “never events,” then we can put in place systematic approaches to track, study, and prevent these adverse events. If a case of arterial cannulation during CVC placement occurred in the current era, but POCUS was not being used, quality improvement around this event would surely include making POCUS training/equipment available for future CVC placement by this user/team. If POCUS was in use for this misplaced CVC, quality improvement might include additional POCUS training focusing on real-time needle guidance.

Some procedural complications, such as pneumothorax from thoracentesis are reduced by the use of POCUS but are not entirely preventable. For instance, pneumothorax after thoracentesis can still occur when an endobronchial lesion prevents re-expansion of a collapsed lung. Thus, this complication might not rise to the level of a “never event.” However, wrong-side chest tube insertion should be considered a “never event,” because POCUS makes it easy to confirm the correct side for unilateral pathology diagnosed on other imaging modalities.     

POCUS appears to be effective in reducing procedure-related “never events,” but what if we elevated other diagnostic and clinical management errors to the level of “never event?” While clinical management of hospitalized patients is often very challenging with multiple comorbidities and many active issues, undiagnosed pericardial effusion leading to morbidity or mortality from cardiac tamponade is an example of a POCUS-enabled “never event.” For those hospitalists who scan their critically ill patients with POCUS using binary, goal-directed techniques, it is unfathomable that a patient with pericardial effusion could go undiagnosed if presenting with cardiopulmonary symptoms or hypotension. Prioritizing drainage or surgery for a pericardial effusion, of course, requires expert consultation and often formal echocardiography, but missing a large pericardial effusion is entirely preventable in this current era of POCUS-trained hospitalists.  

One clear benefit for POCUS enthusiasts is that they can define the role of POCUS as a patient safety tool in their own institution. Considering POCUS as a tool to reduce “never events” does not require external reporting nor is it inherently punitive. New POCUS programs should emphasize patient safety when seeking to develop and implement their curricula. The ways in which POCUS improves the care of hospitalized patients should continue to be rigorously studied. Broadening the list of “never events” to include not only preventable procedural complications but also adverse clinical outcomes, might benefit new POCUS programs.

Benjamin Galen, MD (@DrGalenMD) is an assistant professor in the Division of Hospital Medicine at Montefiore Medical Center and the associate program director and director of ultrasound and procedure training at the Einstein/Montefiore Internal Medicine Residency program.

Renee Dversdal, MD (@DRsonosRD) is an associate professor in the Division of Hospital Medicine at Oregon Health & Science University (OHSU), director of OHSU Point-of-Care Ultrasound, and general medicine ultrasound fellowship director.  

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