Patient Safety: Preventing Medical Errors Self-Learning Packet 2008

Transcription

1 : Preventing Medical Errors Self-Learning Packet 2008 This self learning packet is approved for 2 contact hours for the following professionals: 1. Registered Nurses 2. Licensed Practical Nurses 3. Respiratory Therapy 4. Physical Therapists 5. Clinical Laboratory Personnel 6. Certified Nursing Assistants 7. Radiology Technicians (2 hours- personal development) 8. Surgical Technicians

2 Table of Contents Purpose... 3 Objectives... 3 Instructions... 4 Introduction... 5 Regulations... 5 Key Terms... 6 Medical Error... 6 Sentinel Events... 6 Why Mistakes Occur... 7 When an Error Happens... 8 Incident Reports... 8 Risk Management... 8 Root Cause Analysis... 9 Step 1: Setting up the Team... 9 Step 2: What and When?... 9 Step 3: How and Why?... 9 Step 4: Organizing and Planning Step 5: Evaluation Barriers to RCA When Errors Are Not Reported Types of Errors Wrong - Site Surgery Patient Suicide Operative and Post Operative Complications..13 Medication Errors Order/Prescribing Dispensing Administration Monitoring Copyright 2008 Orlando Health, Education & Development Page 1

3 Delays in Treatment Patient Falls Laboratory Errors 17 Special Populations Infants and Children Elderly Psychiatric Patients Anesthetized Patients Critically Ill Patients Public Education Conclusion Appendix...22 Post Test References Copyright 2008 Orlando Health, Education and Development Page 2

4 Purpose Patient Safety The purpose of this self learning packet is to educate nursing staff regarding patent safety issues and to satisfy the continuing education requirements of Orlando Health employees. This packet meets the continuing education requirement for patient safety/ prevention of medical errors for Florida nursing, respiratory, and clinical laboratory personnel licensure. Orlando Health is an Approved Provider of continuing nursing education by Florida Board of Nursing (Provider No. FBN 2459) and the North Carolina Nurses Association, an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation (AP 085). Orlando Health is an Approved Provider of continuing laboratory education by Florida Board of Clinical Laboratory Personnel (Provider No. JP-58, CE Broker Provider # ). Objectives After completing this packet, the learner will be able to: 1. Analyze the incidence and prevalence of medical errors. 2. Discuss key terms related to medical errors. 3. Identify the situations, circumstances and actions that contribute to medical errors. 4. Describe the root-cause analysis process. 5. Identify consequences of failure to report medical errors. 6. Identify methods to decrease medical errors. 7. Discuss sentinel event identified by the Joint Commission. 8. Identify safety needs of special populations. 9. Describe how public education can prevent medical errors. Copyright 2008 Orlando Health, Education & Development Page 3

5 Instructions In order to receive 2.0 contact hours, you must: complete the posttest at the end of this packet achieve an 84% on the posttest Patient Safety For Non-Orlando Health employees: Complete the test using the bubble sheet provided. Be sure to complete all the information at the top of the answer sheet. You will be notified if you do not pass, and you will be asked to retake the posttest. Return to: Orlando Health Education & Development, MP14, 1414 Kuhl Ave, Orlando, FL For ORLANDO HEALTH Team Member: Please complete testing via Online Testing Center. Log on to: SWIFT Departments E-Learning Testing Center. Use your ORLANDO HEALTH Network Login and password. Select SLP under type of test; choose correct SLP Title. Payroll authorization is required to download test. Lab employees will turn their completion certificate in to Laboratory education to receive continuing education credits. Copyright 2008 Orlando Health, Education and Development Page 4

6 Introduction Patient Safety In November 1999, the Institute of Medicine (IOM) released a report titled "To Err is Human: Building a Safer Health System." This report focused on health organizations; specifically, how hospitals promote patient safety. The report revealed that as many as 44,000 to 98,000 people die each year in hospitals as a result of medical errors. Approximately 7,000 deaths were due to medication errors that could have been prevented. Based on the 44,000 figure, medical errors are the 8 th leading cause of death in the United States. This rate is higher than the deaths caused by motor vehicle crashes (43,459), breast cancer (42,297), and AIDS (16,516). Medical errors are not new. In the 1990's, research studies began to review the problem of medical errors and how they occurred. Studies and reports, such as the IOM report, strongly suggest that most medical errors are related to systems and processes and not individual negligence or misconduct. The IOM report recommended that the key to addressing medical errors is to focus on improving the processes used to deliver healthcare and not placing blame on the individuals involved. When investigating incidents, questions to ask are "What happened" and "Why did it happen," instead of "Who did it." As a result of many studies, healthcare providers have become more aware of the issue surrounding the delivery of health care and the medical errors that can occur. Regulations In response to public and professional concerns about medical errors, the Joint Commission revised and added new standards with an emphasis on patient safety. These standards went into effect in July They address fostering an environment in which patient safety is key and medical errors are analyzed and evaluated for ways to prevent them from recurring. In October 2001, the State of Florida enacted legislation (Florida Statue ) requiring all licensed healthcare professionals to obtain 2 hours of continuing education related to patient safety and medical error prevention each licensure period. Since 1985, Florida has required that healthcare facilities must report all serious adverse events and submit a yearly summary that details a number of data. The purpose of these reports is to allow the state to identify patterns within the data and thus help prevent future medical errors and adverse events. Copyright 2008 Orlando Health, Education & Development Page 5

7 Key Terms Medical Error There are several definitions for medical error. The IOM defines medical errors as "failure to complete a planned action as intended or the use of a wrong plan to achieve an aim." The Joint Commission defines an error as "an unintended act, either of omission or commission, or an act that does not achieve its intended outcome." Medical errors can occur anywhere within healthcare organizations including acute care, ambulatory care, outpatient clinics, pharmacies, and patient homes. Many people assume that medical errors involve only wrong medications administered or the wrong surgery performed. However, there are many other types of errors such as: Diagnostic errors that can result in a misdiagnosis or failure to treat a symptom due to misinterpretation of the results. Equipment failure, which can cause injury to the patient as a result from dead batteries or equipment not maintained. Infections such as nosocomial infections or post-surgical infections. Blood transfusions with the wrong blood or blood given to the wrong patient. Transcription errors which can cause a patient to receive an incorrect or unordered treatment such as an erroneous procedure, medication, activity, or diet. Despite all of the best efforts, medical errors still can happen. It is necessary to recognize the medical error occurrence, the needed care to provide to the patient, report the error and then take a proactive approach to prevent the error from happening again. Sentinel Events The most serious form of medical error is called a sentinel event. Sentinel events are unexpected occurrences involving death or serious physical or psychological injury, or the "risk thereof." "Risk thereof" means that although death or serious injury may not have occurred it could have occurred. Sentinel Events include: Occurrences that have resulted in an unanticipated death or a major permanent loss of function, not related to the natural course of the patient s illness or underlying condition. Each of the following, even if the result was not death or permanent loss of function: Suicide or attempted suicide in a setting where there is around-the-clock care. Infant abduction or discharge of an infant to the wrong family. Rape. Hemolytic transfusion reaction involving administration of blood or blood products that have major blood group incompatibilities. Surgery on the wrong patient or the wrong body part. Copyright 2008 Orlando Health, Education and Development Page 6

8 Why Mistakes Occur "There are some patients we cannot help; there are none we cannot harm." Author Bloomfield, MD Preventable medical errors can occur in any healthcare facility for a wide range of reasons. Research has shown that human error accounts for only a small portion of the incidents. The most frequent cause for human error is related to fatigue and Distractions exhaustion. As people tire, more 41% mistakes are made. Furthermore, in hospital settings, the risk for an error increases when an employee's workload increases (higher nurse to patient ratios), when there is a low number of staff on duty, and when there is a distraction to the employee due to multiple events taking place. The individual may become distracted and lose focus on the task at hand. Factors attruibuted to Medical Errors Workload 26% Staffing 33% Other possibilities that threaten patient safety are based on the individual patient themselves or treatments they may receive. Examples of these situations are patients who have impaired strength and flexibility or impaired cognition; blood product transfusion; and medication ordering and delivery processes, especially for high-risk drugs like potassium chloride, insulin, heparin, lidocaine, and chemotherapeutic agents. Processes that may increase the risk of medical errors must be evaluated and changed accordingly. A variety of factors usually play a role in creating potentially unsafe conditions. Errors often are not spontaneous; instead, they arise from different interactions and situations. For example, the occurrence of wrong-site surgery has been attributed to emergency cases, unusual physical characteristics, unusual time pressures to start or complete the procedure, unusual equipment set up, multiple surgeons involved in the case, and multiple procedures being performed during a single operation. There are a myriad of other causes of medical errors. Many occur due to a breakdown in communication between healthcare providers, poor documentation, poor handwriting, mislabeling of medication, or not following an established facility s policies and procedures. Any deviation from established policies or procedures is considered an error, whether or not the deviation resulted in harm. An adverse event is one that results in injury or harm associated with the treatment rather than the underlying condition. Health care providers must try to promote medical error reduction and prevent medical errors. Preventing Errors The Engineering field has looked at errors differently. They have analyzed ways to prevent systems and products from failing. The assumption is that everything will fail, humans err frequently, and the cause of an error is often beyond the individual s control. They developed a Copyright 2008 Orlando Health, Education and Development Page 7

9 method of identifying and preventing product and process problems called Failure Mode and Effect Analysis (FMEA). The goals of FMEA are to assess systems for points of potential failure (called modes) and introduce alternative processes or other safeguards to reduce or eliminate the failure mode. FMEA is proactive in trying to prevent failures or errors before they occur. It works well in assessing high risk, problem prone, and complex processes. Historically, FMEA was first used by the military in It was further developed and applied to the aerospace, chemical, and automotive industries during the next four decades. The Joint Commission has placed a high priority on patient safety. The Joint Commission had adopted the FMEA approach to patient safety within the leadership standards. When an Error Happens In the past when an error occurred, the tendency was to look for the cause of the error by examining the person associated with the mistake. Research has shown that many errors are a result of several small failures within a system that were not caught. When an error occurs now, there is a systemic review of all the events that could have lead up to the error. Incident Reports In addition to alerting the supervisor and physician about the medical error, a key means of reporting and tracking medical errors is through incident reports. In the past, incidents reports were perceived as a way to blame, punish, and/or penalize those who made mistakes. Currently, the philosophy of incident reports is to track and trend incidents and to identify system problems. Healthcare professionals should be encouraged to complete incident reports. Incident reports are not part of the medical record, and therefore it should not be documented in the record that an incident report has been completed. Incident reports document occurrences for an organization and begin the process of discovering what happened and how to avoid similar occurrences in the future. Incident reports should be initiated not only when an error occurs but also when an error almost occurs. A "near miss" could be a sign of a process or system issue that uncorrected may result in future errors. Risk Management Risk management departments assist healthcare facilities in designing programs that prevent and/or control medical errors. The programs that they design are intended to prevent and decrease adverse effects on human loss by identifying potential errors within a facility. The risk manager's main concern is to prevent patient injury, as well as to decrease potential financial losses. Florida law requires that hospitals have an internal risk management program and that part of the risk manager's role is to review any and all adverse incidents. In order for this to occur, the error or near miss error needs to be reported to a supervisor immediately. The supervisor must then forward the incident report to risk management Copyright 2008 Orlando Health, Education and Development Page 8

10 for evaluation. The law states that the risk manager must receive these reports within three days of the incident and, depending on the error, the risk manager may have to report the error to Florida s Agency for Health Care Administration (AHCA). Root Cause Analysis Root Cause Analysis (RCA) takes place when a serious incident or a pattern of incidents occur. RCA is conducted on all sentinel events, including those that are considered "risk thereof." A root cause analysis is exactly what it sounds like. It is the process of working through the error to uncover the root causes leading up to the mistake. The review goes well beyond the obvious of who erred; it includes many steps to investigate the processes and systems that may have contributed to the occurrence. The following description is one example of how an RCA can be conducted. Questions on how individual institutions conduct an RCA should be referred to risk management departments. Step 1: Setting up the Team The first step in conducting an RCA is to determine which individuals know the most about the event and the processes involved. Examples of people who may be involved in an RCA include: staff nurses, leadership staff, pharmacists, physicians, process improvement staff, and risk management. The group may include persons directly related to the occurrence. The individuals will vary depending on the type of error and the processes involved. Within this step, it is important to create a "blame free" atmosphere where staff members are not afraid to discuss safety issues and where leadership will support and implement any necessary changes. As previously mentioned, most errors are the result of the processes and systems, not individual negligence. Step 2: What and When? Once key individuals are identified, the group discusses the details of the event. This is the "What and When" part. To begin, the group reconstructs what happened. This may be achieved using a flowchart or just a description. Also details are listed relating to when the incident occurred, such as the date, day of the week, and time. Additionally, all the areas or services impacted by this error are identified. This allows one last check to see if all the needed individuals are included in the RCA meetings. Some RCA groups will flowchart what processes should have been followed. This allows comparison of the differences that may help pinpoint either system or process issues. Step 3: How and Why? Next, the group focuses on the "How and Why." A cause and effect diagram is constructed identifying the root and contributing cause(s) of the occurrence. Then, corresponding processes and systems are identified that related to the roots and causes. Throughout this entire step, the group is brainstorming how this happened and why it happened. The focus is still on the processes and systems, not the individual. Copyright 2008 Orlando Health, Education and Development Page 9

11 In the case of sentinel events, the Joint Commission requires that certain areas be evaluated depending on the type of event. For example, if an infant was abducted, the root case analysis must address staffing levels, orientation and training of staff, competency assessment of staff, communication among staff members, communication with patient/family, the physical environment, and security systems and processes. Step 4: Organizing and Planning Once all of the possible how and why questions are answered, then the possible root causes, processes, and systems are organized into categories. Each category is evaluated to determine if it contributed to the error, did not contribute to the error, or if there was not enough data to show if it contributed. For example, if a blood collection specimen was mislabeled, categories relating to mislabeled specimens would be developed. The categories may include Labels are difficult to read or Improper patient identification. The specimen had a label that was clear to read but placed on the wrong patient. Thus, the appropriate category to further investigate how it contributed to the error would be Improper patient identification. The category of Labels are difficult to read would be classified as non-contributory because the label was easy to read. Once the categories are labeled, those issues that contributed to the error are analyzed to determine how they can be improved. This may involve benchmarking other organizations and reviewing the current literature. After this is complete, a plan for improvement is implemented. Step 5: Evaluation Results must be evaluated in order to verify that any changes put in place as a result of an error have produced the desired effects. Methods to evaluate these changes may consist of reviewing incident reports, chart audits, or other tracking procedures that would alert the healthcare facility to areas that still need improvement. Databases are often developed to track and trend errors, root causes, results, and other pertinent information. The results of the RCA are reported to the appropriate persons and committees. Barriers to RCA Although an RCA sounds like a fairly straightforward process, it is actually rather difficult. Barriers encountered in conducting a thorough RCA are insufficient time, fear of retribution, and discontinuing the review too early. Time must be taken to review all possible root causes and current literature related to the incident. Devoting adequate time to conduct an RCA becomes a cost-effective investment since it can help to avoid future medical errors. Creating a blame free environment helps to build a sense of trust and honesty so that errors and causes can be identified and resolved. Ensuring that the process does not end too soon helps to make sure the group is able to identify all the possible causes, develop and implement appropriate improvements, and reduce recurrences. Copyright 2008 Orlando Health, Education and Development Page 10

12 When Errors Are Not Reported Patient Safety If medical errors are not reported, more patients stand the chance of suffering from an adverse event that could have been prevented. It is important that all adverse events undergo an RCA to help prevent them from reoccurring. Most high profile errors are reported in nursing journals or the nightly news, but many errors still occur on a daily basis and are not reported. Since hospitals have moved toward a blame free system, there is no reason not to report a medical error. Medical errors and near misses should be reported no matter how insignificant they may seem as it can save a person s life. Often patients who suffer from a medical error need immediate interventions such as frequent monitoring, further labs, and/or more intensive nursing care in a critical care area. Failure to report an error is a violation of the Nurse Practice Act and thus increases the nurse's legal liability. Those nurses who do not report the error blame themselves and often suffer long-term guilt. Types of Errors On June 30, 2007, the Joint Commission published a statistical analysis of 4473 sentinel events reported from their accredited healthcare facilities since The Joint Commission felt it was important to track the events in order to identify any recurrent problems, perform their own root cause analysis of the events, and be able to make suggestions to healthcare facilities on how to take preventative and corrective steps. The Joint Commission reported that most common categories of sentinel events were wrong-site surgery (13.2%), patient suicide (12.4%), operative and post operative complications (11.9%), medication errors (9.3%), delay in treatment (7.5%), and patient falls (5.7%). Patient Falls Delay in Treatment Medication Errors Op/Post-op Comp Suicide Wrong-site Surgery Wrong - Site Surgery The errors that are the highest reported and that receive a great amount of publicity are those that involve a wrong body part operated on, or worse, the wrong body part amputated. Studies that examined medical mistakes in hospitalized patients found that almost half of all medical errors in the hospital occur in the operating room. It is very disturbing to a patient knowing that while they are unconscious there is a high probability a mistake may occur and they have no control over it. With the media reporting surgical mistakes now more than ever, the public is demanding to know what is being done to prevent such grievous errors. Hospitals and surgical teams should be prepared to Copyright 2008 Orlando Health, Education and Development Page 11

13 answer questions from the ever- increasing informed patient. Patient Safety Through root cause analysis, it was found that orthopedic operations were the most common type of surgery that resulted in medical errors. The analysis also showed that when mistakes were made they were linked to multiple surgeons, limited operating time, and/or multiple procedures being performed. Many of the hospitals involved with the analysis identified more then one factor leading to the mistake occurring, but most showed that there was a connection between breakdowns in communication between the surgical team and patient when a mistake did occur. As a result of this, hospitals have developed patient safety programs. These programs place a great emphasis on making sure the right patient, the right body part, and the right procedure are all identified before the patient is ever given medication or taken into the operating room. The surgeon should visit with the patient in the pre-op area to discuss the procedure as well as identify the correct site for surgery. The American Academy of Orthopedic Surgeons recommends that the surgeon sign his or her initials on the site where the surgery is to occur and that the initials must be visible before an incision is made. Another suggestion involves the amputation of a body part. Some hospitals mark the operative site with a YES if there is laterality involved. One patient marking that is discouraged is the use of an X. When an X is written, the operating room staff can not be sure if X is marking the site for the operation or if X is marking the site not to be operated on. The patient safety program also suggests a time out immediately before the procedure. Once the patient is in the operating room, the operating staff including the surgeon, anesthesiologist, and nurse should all take a moment and stop to verify the surgical site. This should be documented in the surgical record before the patient is prepped and draped for the operation. Whatever type of patient safety program a hospital uses to reduce the risk of medical errors, it is important that all operating room staff be educated and included in the verification processes. It is not just the surgeons' or the nurses' responsibility, the whole team is responsible in ensuring a correct operation occurs. Patient Suicide Patient suicides are the second highest reported adverse events. When an inpatient suicide occurs, it must be reported, which may explain why it is the second highest incident of all reported sentinel events. Other errors may be more prevalent but are often underreported. Most patient suicides are committed in psychiatric hospitals. There are also a high number of suicides committed on medical/surgical floors of acute care hospitals. In 245 suicides reported, 75% of the patients commit suicide by hanging themselves in a bathroom or closet. The other 25% committed suicide by jumping from the healthcare facility s roof. All suicides reported underwent root cause analysis, which helped to identify six root causes. The patient s environment was linked to many suicides, especially when facilities lacked nonbreakable rods, safety rails, and adequate security. There were several components of the patient assessment lacking that may have identified patients at risk for suicide. These components included inadequate assessment methods, incomplete suicide risk assessments, lack of reassessment, and incomplete examination of the patient, which could have lead to the finding of contraband. Other root causes associated with suicides were issues of staffing, which included insufficient training and/or orientation of staff members, lack of competency reassessments, and insufficient staffing levels. There was also a level of care root cause which found that patients were not being monitored often enough, as well as an acuity root cause that Copyright 2008 Orlando Health, Education and Development Page 12

14 showed patients at risk for suicide were assigned to inappropriate units. Some other findings were that incomplete communication among the caregivers and difficulty receiving patient data when needed contribute as root causes of patient suicides. Through the root cause analysis, risk reduction suggestions were recommended such as ensuring staff were monitoring patients, reviewing patient transfer procedures, involving the patient s family as well as educating them on risk factors for suicide. The root causes identified along with the suggestions can assist healthcare facilities in decreasing the risk of suffering a patient suicide. Operative and Post Operative Complications The Joint Commission has reported that over the past seven years sentinel events associated with operative and post-operative complications surprisingly often do not occur in emergency situations. The type of procedures frequently associated with operative or post-operative care complications included imaging and/or endoscopy, tube or catheter insertion, open abdominal surgery, head and neck surgery, orthopedic surgery, and thoracic surgery. The root cause analysis also revealed procedures that resulted in the most recurrent complications. These procedures were nasogastric/feeding tube insertions, open orthopedic procedures, central venous catheter insertions, and imaged directed percutaneous biopsies. Through analysis, eight root causes were identified. The most prominent factor contributing to an error was miscommunication or incomplete communication among the healthcare providers. The other root causes identified were failure to follow established procedures, incomplete preoperative assessment, inconsistent post-operative monitoring, necessary personnel unavailable when needed, inadequate supervision of residents, and a failure to question inappropriate orders. The root cause analysis also identified risk reducing strategies for healthcare facilities which included improving the orientation and training of not only new staff nurses, but also of the residents and house physicians. There was a need for physicians to undergo more educational opportunities, as well as expanding on call coverage, especially in radiology. Channels of communication were to be clearly defined. Physicians involved made suggestions that all healthcare facilities review post-operative monitoring policies to make certain that the adequate level of care was given to the patient regardless of where the operative procedure was performed. For example, the patient should receive the same level of care whether the procedure was performed in the operating room or the radiology department. Those involved in the root cause analysis emphasized that the risk-reducing strategy with the most impact was direct communication between the physician and the other healthcare personnel involved in patient care. Medication Errors The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as any preventable event that may cause or lead to inappropriate medication use or patient harm with the medication in the control of the healthcare professional or patient. Copyright 2008 Orlando Health, Education and Development Page 13

15 Research has illustrated that there are five errors for every 100 orders and 1.4 per hospital admission. This means that an estimated 7,000 patients die each year as a result of a medication error. Medication error deaths have increased more than eight times in outpatient settings and inpatient deaths have increased more than three times in a ten-year period. Indisputably, medication errors are one of the most common causes of preventable harm a patient can experience. Why are there so many medication errors? The Institute for Safe Medication Practices (ISMP) reports that 30% of errors are due to deficient drug knowledge, 20% are caused by limited patient knowledge, and the remaining 50 % are a result of poor labeling or drug nomenclature errors. Most medication errors fit into one of four causes: ordering/prescribing error, dispensing error, administration error, or monitoring error. Order/Prescribing The most common type of medication error is a result of ordering/prescribing errors, which account for 80% of all medication mistakes. A majority of the errors in this category are associated with the use of dangerous abbreviations. The ISMP for years has cautioned against using certain abbreviations that have and continue to be linked with deadly medical errors. One of the most common mistakes is when an order is written with a "u" for units. This has lead to many pharmacist and/or nurses to misread the "u" for a (0) or a (4), causing a 10-fold overdose or greater. There is no acceptable abbreviation for "unit" and therefore needs to be written out. Another warning the P Error Reducers for Verbal Orders Repeat the order to the physician. Record the order and the time into the patient s chart as soon as order is received. Follow-up with a written order, ensuring it is signed and dated according to policy. Only use in emergency situations. Never use verbal orders for chemotherapy or high-alert drugs. Limit who may take verbal orders. Table 1 ISMP has issued is to always use a leading zero (0.4mg) and never use a trailing zero (4.0 mg) when using decimal points. When healthcare providers adhere to these rules, they can cut the risk of medication errors dramatically. Other factors that lead to medication mistakes under this category include illegible handwriting and verbal orders. It is never good practice for a nurse to take verbal orders, but if they must, there are some simple guidelines that should be followed to decrease the risk of an error occurring (see Table 1). Dispensing Research estimates that 5% of all prescriptions are dispensed improperly. Problems in this category result in incorrect doses being administrated, a miscalculated dose, the wrong dose sent from the pharmacy, or a dose borrowed from another patient's supply. Many of the dispensing errors have been attributed to work overload and confusion between similar sounding drugs. Through root cause analysis, several means to reduce dispensing errors were identified. Most of the error-preventing strategies are simple to perform and should be incorporated into daily Copyright 2008 Orlando Health, Education and Development Page 14

16 practice. References must be referred to administering unfamiliar medications. The labels must be read, calculations double-checked, and caution used when multiple vials, tablets, or capsules are dispensed. Communication is the key to help prevent mistakes with medication administration. The pharmacist, physician, and nurse should all work together as a collaborative team, taking the time to speak with each other as questions arise. Administration It is the nurse's job to administer medication. Nurses need to be knowledgeable about medications including their interactions, side effects, administration routes, and contraindications. The nurse not only has the responsibility to administer the medication safely, but they also have an opportunity to catch a mistake prior to giving the medication by being the final check. Most nurses can recall the "five rights" associated with medication administration and are taught to review the rights before giving any medication. The nurse should check that the "right" patient is receiving the "right" drug with the "right" dose, at the "right" time, and through the "right" route. When nurses review the five routes before administering any type of medication, they can decrease the chance of error greatly. Most medication errors fall into the category of one of the five rights. It is important to have all correct patient information available before giving a drug. The nurse should check the patient s weight, allergies, and other medications he or she is currently taking. If the nurse is not familiar with the medication, it is his/her responsibility to check drug reference texts or online resources. A jury in one case found a nurse negligent for giving a drug without reviewing the literature, which outlined the precautions for the administration of the drug and required a physician s involvement. If the orders are illegible or incomplete, the nurse must clarify the order prior to administering the medication. Lastly, if the drug is highly caustic and to be infused via a pump, two nurses should take the time to verify the pump settings. All healthcare facilities should take the time to orient new nurses to the policies, procedures, and guidelines of medication administration. Other methods to decrease the risk of errors associated with medication administration are using standardized medication time schedules, requiring a second person to verify dose calculation when a mathematical calculation is necessary, and educating all staff on the operation and use of equipment that delivers medication such as the patient-controlled analgesia (PCA) pumps. Monitoring All facilities that administer medications must have processes in place to track medication errors and near misses. There should be a committee dedicated to looking at all medication errors with the responsibility to form guidelines and policies that help prevent the errors from reoccurring. When healthcare providers take the time to read the labels of medications, look up drugs they are unfamiliar with, and report medication errors and near misses, the amount of medication Copyright 2008 Orlando Health, Education and Development Page 15

17 errors will decrease, and more patients will not suffer from preventable life-threatening mistakes. Delays in Treatment Patient Safety The Emergency Department (ED) is the source for over half of all reported cases of patient death or permanent injuries due to delays in treatment. The data does reveal though that serious problems can occur in any hospital unit and in other health care settings. Of the 55 reported cases, 52 resulted in patient death. The reported reasons for the delays include; misdiagnosis (42%), delayed test results (15%), physician availability (13%), delayed administration of ordered care (13%), incomplete treatment (11%), delayed initial assessment (7%), patient left unattended (4%), paging system malfunction (2%), and patient unable to locate ED entrance (2%). The root cause analysis found that breakdown in communication with or between physicians accounted for most of the problems. Other factors included; patient assessment problems, continuum of care issues, mainly discontinuity of care across settings or shifts, orientation or training of staff, availability of patient information, staffing levels, and the availability of physician specialists. Overcrowding of majority hospital emergency departments is a significant contributing factor. According to an April 2002 American Hospital Association survey of hospitals, the majority of hospital EDs perceive they are at or over operating capacity with more than 90% of large hospitals reporting that they are over capacity. This directly leads to longer wait times, longer stays in the ED, and longer waits for admission to other areas of the hospital. Strategies for improvement include better orientation and training processes, efficient transfer procedures, increased staffing, procedures for contacting on-call specialists, more efficient triage procedures, and an increase in physical space. In addition, other strategies include implementing formal verbal communication methods. Patient Falls The risk of a patient fall has always been an issue in hospitals. In some cases, those who are hospitalized are weak, medicated, and/or have an altered mental status. All are contributing factors to an increased chance of the patient becoming unsteady and susceptible to falling. The group most at risk from falling while they are hospitalized is the elderly. Not only are they the highest risk, but if they do fall they are more likely to die as a result of the fall or die from a complication associated with the fall. Root cause analysis identified many causes for falls. Over fifty percent of the hospitals identified poor communication as leading to a fall. It was found that there was a lack of information regarding the patient and the risk for a fall. For example, a fall assessment may not have been performed. Nurses often failed to report to each other patients who were at risk for falls. The environment played a role in some patient falls, especially in rooms where there were wet floors, clutter, or rugs. It was also discovered that nurses were not familiar with the bed alarms that alert nursing staff. The alarms were either turned off or misused, thus increasing the number of patient falls. Many of the risk reduction strategies identified by the Joint Commission through their root cause analysis are straightforward and easy to implement. Copyright 2008 Orlando Health, Education and Development Page 16

18 The best way a hospital can help prevent falls is the make sure every patient is assessed for risk of falling. The nursing staff must be educated on how to provide a safe environment for the patients, including locking the bed, placing objects within the patient s reach, and always having the call bell within reach of the patient. The patient and their families must be taught ways to prevent falls. Have the family bring in non-skid socks for their loved one and teach them about the importance of leaving the siderails up and wheelchairs locked in place. Finally, whatever type of fall prevention program a hospital uses, all hospital staff must be educated on the policies and procedures. Staff orientation must include education about how to assess for falls, as well as teach the staff about fall prevention protocols. The risk of patient falls must be addressed seriously. Often times, those who suffer a fall either die, have a permanent disability, or end up in a nursing home. Failure to follow policies and procedures addressing fall prevention will result in more patients suffering from falls, especially the elderly, raising the rate of preventable medical errors. Hospitals should create a database tracking their patient falls. In order for an institution to determine whether or not its fall prevention program is working, it must be able to examine the number of cases as well as the causes. This information can only lead to changes in prevention programs and decreased numbers of falls. Laboratory Errors Errors in the Laboratory are generally divided between Pre-analytical Operations, Analytical Operations and Post-analytical Operations. Examples of Pre-analytical Operations include patient and sample identification/labeling, order communication, specimen collection and handling, and appropriate ordering of laboratory services. Depending on systems, many healthcare personnel may be involved in Pre-analytical steps before the specimens arrive in the Laboratory. Detailed instructions must be provided to individuals responsible for patient identification, specimen collection, labeling, and handling. Open communication encourages asking questions prior to specimen collection. The desired goal is to collect the right specimen the first time. Assessment of Pre-analytical steps provides opportunities for improvement in patient safety by working collaboratively with other healthcare providers in direct patient contact. Potential sources of Pre-analytical errors include: Patient identification requires inpatients to have an identification armband. All patients must be identified with two identifiers (patient s name, date of birth, medical record number). All laboratory specimens must be labeled in the presence of the patient. Careful skin preparation prior to performing a blood culture procedure to prevent contamination with skin flora. Proper specimen collection and handling to prevent hemolysis or clotting. The Analytical Operations area in the Laboratory is considered as least subject to error. Potential risks to Laboratory Quality and Patient Safety include introducing new tests, ongoing quality management of tests, establishing reference ranges and issues with reference laboratories. Laboratory personnel usually have stricter control over these processes as fewer individuals are involved in the processes. Post-analytical Operations usually involves a larger number of healthcare professionals. Potential areas of error include reporting results, administration of blood products, Copyright 2008 Orlando Health, Education and Development Page 17

19 interpretation of test results and correcting errors. The Joint Commission and College of American Pathologists Patient Safety Goals address some of these areas. Systems improvements include the read-back process, documenting full name and title of licensed individual receiving critical tests, values or results, improving timeliness of communications/reporting, and requiring two forms of patient identifiers for administering blood/products as well as for patient specimen collection. Independent double verification is required for collection of specimens for blood bank testing and when administering blood/products to the patient. Special Populations Certain groups of individuals, when entered into the realm of healthcare, need special attention and care in order to reduce their risk of medical errors. These groups are: infants and children, elderly, psychiatric patients, anesthetized patients, and critically ill patients. Infants and Children Infants and young children have an increased risk to experience a medical error due to their inability to participate in their care. They don t have the ability to ask questions or challenge a procedure. Children also lack the ability to report any changes they are experiencing to the nurse. It is important to educate the pediatric patient's family about the treatment the child is undergoing as well as encourage them to ask questions and report anything that seems out of the ordinary. Children are at higher risk for medication errors because their doses are weight based. In order to reduce this risk, some hospitals require the use of portable calculators by all pediatric house staff. Not only are infants and children at high risk for medication errors, they are at a higher risk for suffering severe complications from medication errors. This is attributed to the immaturity of their body organs and increased sensitivity to the effects of drugs. It is believed that because of the special vulnerability of children the safety of pediatric care will be inspected more closely than adult care. Hospitals must implement specific policies and procedures that deal with decreasing the chance a child will suffer a medical error. Elderly The elderly patient has an increased risk of suffering a medical error due to changes in their senses as well as other health changes that occur with age. The elderly patient may have changes that affect their vision, hearing, and/or movement and are therefore at the greatest risk for suffering a fall. Key to taking care of an elderly patient is to follow the institution's fall policy. The elderly patient is also at an increase risk of suffering from pressure sores or skin breakdown due to decreased sensation. It is important that elderly patients be turned often and checked regularly for any sign of skin breakdown. Furthermore, the elderly patient is at an increased risk for an error related to medication administration. They may have dementia or other altered mental states that interferes with their ability to understand instructions involving Copyright 2008 Orlando Health, Education and Development Page 18

20 medication use. They also may forget they took a medication and take it again. It is important to assess the patient, make sure they understand instructions, and never leave medications in the patient s room. Psychiatric Patients Patients admitted to psychiatric units are sometimes depressed and suicidal. They must be carefully assessed for their risk of suicide as well as checked for contraband and monitored regularly. The psychiatric patient is also at an increased risk for elopement. Hospital staff must be aware of patients who are often found near the unit s door, those who repeatedly look at the unit s doors and those who are trying to read the door s keypad. Psychiatric units should have a policy on how to handle patients at risk for elopement and in-service all staff frequently on the policies that decrease the risk of patient elopement. Anesthetized Patients Those who are having surgery are at an increased risk for experiencing a medical error. Once a patient is under anesthesia, they no longer have the cognitive ability to ask questions or alert medical staff to changes in their health. The anesthetized patient relies solely on the surgical team to provide competent care. Hospitals should have policies that specifically address correctly identifying patients, the procedure, the surgical site, and ensure that all surgical staff members are educated on these policies. Institutions must have clear policies on pre-op and post-op monitoring. Many patients who experienced an error under anesthesia had incomplete pre-op assessment as well as inconsistent post-op monitoring. Healthcare providers can help reduce the risk of error for anesthetized patients by becoming informed. Before any procedure is performed, it should be explained to the patient and the family. This allows time for questions to be asked and answered. Another suggestion is that post-op instructions be reviewed with the patient prior to any medication administration and with a family member or friend present. This decreases the likelihood of the patient confusing what medication to take or what needs to be done after the operation. Critically Ill Patients Patients in critical care units or those suffering extreme distress are often vulnerable to medical mistakes due to their inability to participate in their care. Comatose patients have unique vulnerability since they can not be involved in the identification process. Those who take care of patients that are extremely ill or comatose must have certain guidelines to follow that decrease the risk of a medical error occurring. Nurses caring for the critically ill, need to be certified in advanced life support training and closely monitor the patient for signs of shock, hemorrhage, and sepsis. These patients have an increased risk for these complications, and they will not be able to alert the nursing staff to changes in their status. Copyright 2008 Orlando Health, Education and Development Page 19

21 Public Education Patient Safety According to a poll conducted by the National Patient Safety Foundation, many Americans have a true fear that a medical error could happen to them or to a family member when hospitalized. Many of the people polled believed that when an error occurs it is a result of an individual provider, such as a nurse or physician, with 75% of all respondents believing that it would be a good idea to "keep health professionals with bad track records from providing patient care." Healthcare providers know that most errors are results of faulty systems rather than single individuals. We need to assure the public that the health care system is safe. One means to help decrease the public's fear is to include them in their own care. Encourage patients and their family members to ask questions and always be informed about the care they are receiving. Take the time to teach the patient about the illness, medications, procedure, and any other treatments they have. Also, give them Tips To Encourage Patient Safety the time to reflect and ask questions after the information has been presented. All people do not learn the same way; thus, a variety of teaching materials must be available (charts, videos, handouts, lecture, audio-tapes). A handout that the patient or the family can review at a later time is very beneficial. It is important that safety be thought of and taught as everyone's responsibility. When patients are informed, they are more likely to question things. For example, patients will more likely question a medication if they have knowledge of it and are familiar with it. Also, when patients are more knowledgeable about the type of treatment they are to receive, they are more likely to question the healthcare provider when something does not seem right. When patients ask questions about their care, it helps them feel empowered and can help prevent errors. 1. Encourage patients to become active members of their health team. 2. Educate patients about their diseases, medications, and treatments. 3. Encourage patients to ask questions. 4. Discuss with patients the need to have a primary physician who is in charge of their care. 5. Empower patients to know that "more" is not always better. Encourage them to ask why something is needed. 6. Instruct patients to ask for test results; the adage "no news is good news" is no longer true. Copyright 2008 Orlando Health, Education and Development Page 20