10/9/2011. At the end of this program, the learner will be able to:

Transcription

1 Medical Errors Prevention Gail Fox-Seaman, MSN, ARNP VA Medical Center West Palm Beach, Fl. At the end of this program, the learner will be able to: Define root cause analysis (RCA), List the five most misdiagnosed conditions, Recognize error prone situations, Identify special populations, Recognize factors that impact the occurrence of medical errors, Define reporting responsibilities, Discuss public education as it relates to medical errors. 1

2 Introduction Medical Errors can: Happen to anyone, anytime, anywhere During routine tasks During communication breakdown When staff and patients do not make informed decisions Introduction Drug errors harm 1.5 million people each year (American Nurse Today, 2006). At least 25% of harmful adverse drug events are preventable (Institute of Medicine, 2006). Nurses intercept 86% of errors made by physicians, pharmacists, and others (American Nurse Today, 2006). Why do a few errors matter? At 99% accuracy 12 newborns would be given to the wrong parents daily! 2 million documents would be lost by the IRS yearly! 20,000 incorrect drug prescriptions would be written this year! 114,500 mismatched shoes would be shipped this year! 2

3 Florida Law Serious events must be reported to Florida Agency for Healthcare Administration (FS ) Internal risk management program Reporting tools and mechanisms Time frame to report incidents Risk manager reports adverse incidents Patient Education Responsibility of patient and family Clear, concise communication Review of ALL medications Other providers, facilities Herbs, vitamins, OTCs Risk Factors Work conditions Communication problems Poor or improper labeling Failure or poor maintenance of equipment Additional responsibilities with poorly educated staff Increased acuity of pts Fatigue, illness, substance abuse, emotional status of staff 3

4 Hospital Patient Safety Indicators Complications of anesthesia Decubitus ulcer Iatrogenic pneumothorax Postoperative pulmonary embolism, DVT Transfusion reaction Obstetric trauma Outpatient Indicators Low birth weight due to inadequate prenatal care. Hospital admissions for asthma due to failure to prescribe adequate treatments. Diabetic complications due to lack of self- management. Patient with appendicitis without ready access to surgical evaluation causing perforated appendix. Hospital admissions for COPD exacerbations caused by poor patient compliance or lack of preventative treatment. Medical Errors 4

5 Medical Errors Active vs. latent Patient falls Pacemaker failure 3 months later Near misses AKA close calls JC reports that their Sentinel Event Database has 9 reports of misconnections that involve 7 adults and 2 infants. There were 8 deaths and 1 permanent loss of function from these mishaps The reported misconnections involved central venous catheters, peripheral IVs, nasogastric tubes, percutaneous enteral feeding tubes, peritoneal dialysis catheters, tracheostomy tubes and blood pressure monitoring equipment 9 cases may not seem like many but it is suspected that misconnections are underreported and are often caught and corrected before any injury to the patient occurs Following are actual cases of misconnections that occurred and preventive measures health care institutions and nurses should take to prevent misconnections 5

6 What s wrong with this picture? Patient in ER scheduled for CT scan with saline lock inserted for CTAC scan (no IV running) Patient had NIBP attached to his arm Disconnected from NIBP monitoring pump but cuff left on when he went to bathroom Reconnected to NIBP monitor upon return from bathroom Patient s wife found him blue from the neck up Resuscitation efforts failed Found with NIBP monitor tubing connected to saline lock Autopsy: patient died from 15 ml air embolism delivered by the NIBP monitor pump What s wrong with this picture? 6

7 Patient wearing SCDs was disconnected from SCD pump and assisted to bathroom He returned to bed independently and hooked his SCD hose to his IV tubing Fortunately SCD pump had been turned off and misconnection was discovered before any harm came to patient After aortic aneurysm repair a ventilatordependent patient was receiving enteral nutrition Patient disconnected from tube feeding to facilitate a diagnostic study After test the enteral feeding tube was misconnected to his central venous catheter Patient received 45 ml of enteral feeding intravenously Patient s clinical status after event not reported Patient with tracheostomy tube was being repositioned when IV tubing became disconnected IV tubing was inadvertently reconnected to the inflation port of the tracheostomy cuff An hour later patient suffered respiratory arrest and died Approximately 20 ml of IV fluid had infused into trach cuff and caused an airway obstruction 7

8 Other Examples of Misconnects: IV fluids to an epidural line Bladder irrigations to a peripheral or central IV line Enteric feedings to an IV line Blood transfusions given through primary intravenous infusion tubing What s wrong with this picture What s wrong with this picture 8

9 Nursing measures to prevent misconnections: 1. Always trace tubing from the patient to the point of origin before connecting anything to the tubing. This is the number one safe guard 2. Recheck connections and trace all tubing to the source upon the patient s arrival to a new setting or service Nursing measures cont. 3. Route tubes that have different purposes in different, standardized directions (i.e.: IV tubing toward the head of the bed, Foley catheter tubing towards the foot of the bed) 4. Instruct non-clinical staff, family and patients to seek help from clinical staff whenever there is a need to connect or disconnect medical devices. Even highly trained professional staff have made misconnections so do not allow others to connect or disconnect patient tubing Nursing measures cont. 5. Avoid the use of adapters unless absolutely necessary 6. If it is difficult to connect STOP and think are these two devices meant to be connected? 7. Know the equipment you work with. 8. Attend all in-services being given on equipment you may be asked to work with. 9

10 Nursing Errors Medication Errors Unauthorized medication Administration of wrong medication Failure to administer the medication Errors in route, dose, quantity 5 rights U (unit) DO NOT USE Abbreviations Mistaken as zero, four or cc Write unit IU (international unit) Mistaken as IV (intravenous) or 10 (ten). Q.D.;.; Q.O.D. (Latin abbreviations for once daily and every other day) Trailing zero (X.0 mg) Lack of leading zero (.X mg) MS; MSO4; MgSO4 Qn or qn Mistaken for each other. The period after the Q can be mistaken for an I and the O can be mistaken for I. Decimal point is Missed Write international unit Write daily and every other day Never write a zero by itself after a decimal point (X mg). Always use a zero before a decimal point.(0.x mg) Confused for one another. Can mean Write morphine sulfate morphine sulfate or magnesium sulfate or magnesium sulfate Mistaken for every hour Write every night S.C. or S.Q. (subcutaneous) Mistaken as SL for sublingual, or 5 every. T.I.W. (three times a week) Write Sub-Q, subq subq, or subcutaneously Mistaken for three times a day or twice Write 33 times weekly or weekly resulting in an overdose three times weekly. 10

11 Diagnostic Errors Labs read incorrectly Labs drawn on wrong patient, incorrectly labeled. Xray reports incorrect, delayed Delay in treatment Death 5 Most Misdiagnosed Conditions Cancer * + Cardiac * + Timely diagnosis of surgical complications * + Acute abdomen * Stroke and related cranial conditions * Wrong site/pt surgery + Failure to diagnose pt condition prior to prescribing contraindicated meds + * Board of Medicine + Board of Osteopathic Medicine Surgical Errors 11

12 Surgical Errors Wrong site surgery Wrong patient surgery Consent failures Unexpected events Code on table Nick to an artery Wrong medication ordered Instruments/sponges left inside pt Documentation Errors Chart accurately, timely, factually Errors of commission Treatment or med charted as 7am Not done til 3pm Errors of omission Lack of documentation Pre-op IV gentamycin not charted Pt may receive 2nd dose Procedure delayed 12

13 At Risk Populations Special Population & Vulnerability Elderly Vision, hearing, cognition Herbs, vitamins, OTCs Decreased metabolism Polypharmacy Infants Young children Ethnopharmacology Falls Large numbers of falls causing sentinel events Many deaths annually Risk factors : medical, cognitive, environment, drug related 13

14 JCAHO Have process in place to document sentinel events Conduct complete RCA of process and systems Utilize preventive risk reduction JCAHO patient safety goals Root Cause Analysis Looks at the what and why Interdisciplinary, involves those close to the process Focuses on systems, not individuals Finalized, signed (by Quadrad), completed within 45 days RCA term used will keep it confidential (Title 38 United States Code 5705) Sentinel Event Joint Commission Sentinel Event Database- JC defines a sentinel event as an unexpected occurrence involving death or serious physical or psychological injury or risk thereof Such events are called sentinel because they signal the need for immediate investigation and response Sentinel events are reported to the JC sentinel event database 14

15 Falls Rape Death Suicide Sentinel Events Events that worsen patient condition Tubing misconnections Sentinel Event Alerts: Serious events must be reported to Florida Agency for Healthcare Administration (FS ) Internal risk management program Reporting tools and mechanisms Time frame to report incidents Risk manager reports adverse incidents References Agency for Healthcare Research and Quality. (2000). 20 tips to help prevent medical errors: Patient fact sheet. February Publication No. 00-PO38. Retrieved September 12, 2007 from: Institute for Safe Medication Practices. (2005). Medication safety alert: New dangers in the drug reimportation process: Will we know what our patients are taking? Retrieved December 5, 2005 from: Joint Commission on Accreditation of Hospital Organizations. (2005). Facts about the 2007 National patient safety goals. Retrieved September 12, 2007 from: Karch, A. M. (2005). Not all brands are created equal [Practice errors]. American Journal of Nursing 105 (8), Kennedy, P. (2006). Medical Errors Prevention. Department of Veterans Affairs, West Palm Beach VAMC. Munoz, C., & Hilgenberg, C. (2005). Ethnopharmacology Understanding how ethnicity can affect drug response is essential to providing culturally competent care. American Journal of Nursing, 105 (8), Wooten, J., & Galavis, J. (2005). Polypharmacy: Keeping the elderly safe. RN, 68 (8),