Preventing Medical Errors

Presents Preventing Medical Errors Contact Hours: 2 First Published: March 31, 2017 This Course Expires on: March 31, 2019 Course Objectives Upon completion of this course, the nurse will be able to: 1. Define the term medical error 2. Identify factors that impact the occurrence of medical errors 3. Identify the most common medical errors that impact the clinical setting 4. List processes to improve patient outcomes 5. Recognize the Four Elements of the Long Range Plan for Patient Safety 6. Explain the 2016 National Patient Safety Goals 7. Understand responsibilities for reporting Medical Errors

EDUCATION EDGE! Everything written in green throughout this course is information you will need to know! A recent publication by The British Medical Journal (Published May 2016) published a study performed by researchers at John s Hopkins University that reports that medical errors may represent the 3rd leading cause of death in the U.S. The authors call for changes in death certificates to better tabulate fatal lapses in care. In an open letter, they urge the Centers for Disease Control and Prevention to immediately add medical errors to its annual list reporting the top causes of death. Based on an analysis of prior research, the Johns Hopkins study estimates that more than 250,000 Americans die each year from medical errors. A medical error can mean everything from stomach operation complications that go unnoticed, to giving a patient her roommate s medicine instead of her own, to removing the wrong foot during an operation. As the Institute of Medicine would have it, an error in the medical setting is the failure of a planned action to be completed as intended (error of execution) or the use of a wrong plan to achieve an aim (error of planning).

In its November 1999 report To Err is Human: Building a Safer Health System, the Institute of Medicine (IOM) estimated that between 44,000 and 98,000 Americans die each year as a result of medical errors. The IOM report quickly elevated awareness of patient safety. In January 2000, the Senate Committee on Appropriations began hearings on medical errors and patient safety issues. As a result of those hearings, the Committee directed the Agency for Healthcare Research and Quality (AHRQ) to lead the national effort to combat medical errors and improve patient safety. The Committee specifically directed the AHRQ to establish a competitive demonstration program for health care facilities and organizations in geographically diverse locations, including rural and urban areas, to determine the causes of medical errors. These projects were to use a variety of techniques and approaches to: Reduce medical errors Develop models that minimize the frequency and severity of errors Develop mechanisms that encourage reporting, prompt review, and corrective action Develop methods to minimize paperwork Provide a list of the most common root causes of medical errors According to the Agency for Healthcare Research and Quality: One in seven patients in the hospital experiences a medical error. However, medical errors can occur anywhere in the health care system including: Hospitals, clinics, surgery centers, doctors' offices, nursing homes, pharmacies, and patients' homes. ERRORS CAN INVOLVE MEDICINES, SURGERY, DIAGNOSIS, EQUIPMENT, OR LAB REPORTS. They can happen during even the most routine tasks, such as when a hospital patient on a salt-free diet is given a high-salt meal.

Most Common Causes of Medical Errors: COMMUNICATION PROBLEMS REPRESENT THE MOST COMMON CAUSE OF MEDICAL ERRORS Communication problems can cause many different types of medical errors and can involve all members of a health care team. Communication failures (verbal or written) can take many forms, including: Miscommunication within an office practice. Miscommunication between different components of the health care system or health care providers working different shifts. These problems can occur between health care providers such as primary care physicians and emergency room personnel, attending physicians and ancillary services, and nursing homes and patient services in hospitals. Communication problems can result in poorly documented or lost information on laboratory results, diagnostic testing, or medication information, and can occur at any point along the communication chain. Communication problems can also occur within a health care team in one location, between providers at different locations, between health care teams and other non-clinician providers (such as labs or imaging centers), and between health care providers and patients.

Inadequate information flow Can include problems that prevent: The availability of critical information when needed to influence prescribing decisions. Timely and reliable communication of critical test results. Coordination of medication orders at points of interface or transfer of care. Information flow is critical between service areas as well as within service areas in health care. Often, necessary information does not follow the patient when he or she is transferred to another service or is discharged from one component or organization to another. PROBLEMS THAT MAY OCCUR INCLUDE: Human problems: RELATE TO HOW STANDARDS OF CARE, POLICIES, OR PROCEDURES ARE FOLLOWED Failures in following policies, guidelines, protocols, and processes, sub-optimal documentation and poor labeling of specimens. Knowledge-based errors where individuals do not have adequate knowledge to provide the care that is required for any given patient at the time it is needed. PATIENT-RELATED ISSUES CAN INCLUDE: improper patient identification incomplete patient assessment failure to obtain consent inadequate patient education

ORGANIZATIONAL TRANSFER OF KNOWLEDGE CAN INCLUDE: deficiencies in orientation or training lack of, or inconsistent, education and training for those providing care This category of cause deals with the level of knowledge needed by individuals to perform the tasks that they are assigned. Transfer of knowledge is critical in areas where new employees or temporary help is often used. The organizational transfer of knowledge addresses how things are done in a particular organization or health care unit. This information is often not communicated or transferred. STAFFING PATTERNS/WORK FLOW CAN CAUSE ERRORS WHEN PHYSICIANS, NURSES, AND OTHER HEALTH CARE WORKERS ARE TOO BUSY BECAUSE OF INADEQUATE STAFFING OR WHEN SUPERVISION IS INADEQUATE. INADEQUATE STAFFING, BY ITSELF, DOES NOT LEAD DIRECTLY TO MEDICAL ERRORS, BUT CAN PUT HEALTH CARE WORKERS IN SITUATIONS WHERE THEY ARE MUCH MORE LIKELY TO MAKE AN ERROR.

TECHNICAL FAILURES include: device/equipment failure complications or failures of implants or grafts In many instances equipment and devices such as infusion pumps or monitors can fail and lead to significant harm to patients. In many instances inadequate instructions or poorly designed equipment can lead to patient injury. Often technical failure of equipment is not properly identified as the underlying cause of patient injury, and it is assumed that the health care provider made an error. A complete root cause analysis often reveals that technical failures, which on first review are not obvious, are present in an adverse event. Inadequate policies and procedures guiding the delivery of care can be a significant contributing factor in many medical errors. Often, failures in the process of care can be traced to poorly documented, non-existent, or clinically inadequate procedures. PROCESSES TO IMPROVE PATIENT OUTCOMES: Changes in Organizational Culture 1. Changes in organizational culture, particularly creating a positive safety culture, as an essential element in making care safer for patients. 2. These changes primarily focus on human resources management procedures and practices relative to the supervision and discipline of individuals reporting events to institutions and leadership. 3. Organizations found that to encourage reporting of medical errors, it was important to adopt a culture that eliminated the blame and shame associated with medical errors. 4. When such changes were made and employees believed that they would not be punished if they reported medical errors, harm, no harm, or near miss events, the organizations often found that their reporting rates increased.

INVOLVEMENT OF KEY LEADERS When organizational leadership, both administrative and clinical, actively engages in patient safety improvement, it has an exceptionally beneficial impact on all employees and staff of the organization. An example of this involvement is an Executive Safety Round. This is a routine visit to clinical units by an organization's senior leaders to discuss patient safety issues. This technique is increasingly used to involve senior leadership in actively promoting safety and discovering the risks and hazards to patients within the process of care. DEVELOPMENT AND ADOPTION OF SAFE PROTOCOLS AND PROCEDURES Health care facilities and hospitals report that they have been able to develop and adopt safe protocols and procedures to effectively reduce medical errors. These protocols and procedures are often similar to those developed by the Institute of Safe Medication Practices (ISMP). For example, two AHRQ grantees have participated in activities of the Wisconsin Patient Safety Institute, which developed a Medication Safe Practices Manual to help guide safe medication use. Examples include alerts for medications with a high potential for harm if not managed appropriately and guidelines on the use of standard abbreviations.

TECHNOLOGY Technology is being used as a tool to reduce errors and improve safety (e.g., through the use of computerized physician order entry and infusion pumps). However, we know that use of technology must be implemented and monitored carefully to prevent the introduction of new errors and to ensure that the intended solutions are indeed achieved. One AHRQ grantee has found that medical device use errors that occur can be attributed to design problems and lack of user training. Another AHRQ grantee has found that the introduction of a computerized order entry system was itself a cause of stress and error.

AHRQ HAS ADOPTED A MULTI-ELEMENT MODEL AS THE PARADIGM FOR THE LONG RANGE PLAN FOR PATIENT SAFETY. ELEMENT 1: IDENTIFYING THREATS TO PATIENT SAFETY. Identify medical errors and causes of patient injury associated with the delivery of health care. ELEMENT 2: IDENTIFYING AND EVALUATING EFFECTIVE PATIENT SAFETY PRACTICES. Identify, design, and evaluate practices that eliminate or mitigate the effects of medical errors and system-related risks and hazards which compromise patient safety. ELEMENT 3: TEACHING, DISSEMINATING, AND IMPLEMENTING EFFECTIVE PATIENT SAFETY PRACTICES. Educate health care providers, purchasers, patients, and policymakers about successful patient safety interventions and best practices. Disseminate information to a variety of users on the causes of and successful interventions to identify, reduce, eliminate, or mitigate the effects of error. Implement patient safety best-practices to reduce medical errors and improve patient safety. Raise awareness that patients are at risk for health care associated injury and harm. ELEMENT 4: MAINTAINING VIGILANCE. Continually monitor and evaluate threats to patient safety to ensure that a positive safety culture is maintained and a safe environment continues.

Joint Commission on Accreditation of Health Care Organizations (JCAHO) published new language recognizing that "effective medical/health care error reduction requires an integrated and coordinated approach." In an effort improve patient safety, to reduce risks, and to minimize medical errors standards have been implemented which include: o Leaders ensuring implementation of an integrated patient safety program throughout the [healthcare] organization. o Designation of one or more qualified individuals or an interdisciplinary group to manage the organization-wide patient safety program. Typically these individuals may include directors of performance improvement, safety officers, risk managers and clinical leaders. o Procedures for immediate response to medical/health errors, including care of the affected patient(s), containment of risk to others, and preservation of factual information for subsequent analysis. o Clear systems for internal and external reporting of information relating to medical/health care errors. o Defined mechanisms for support of staff that have been involved in a sentinel event. o Definition of the scope of the program activities, which is the types of occurrences to be addressed, ranging from no harm frequently occurring slips to sentinel events with serious adverse outcomes. o At least annually, a report to the governing body on the occurrence of medical/health care errors and actions taken to improve patient safety, both in response to actual occurrences and proactively. o Defined mechanisms for responding to the various types of occurrences, e.g., root cause analysis in response to a sentinel event, or for conducting proactive risk reduction activities.

JOINT COMMISSION 2016 NATIONAL PATIENT SAFETY GOALS Identify patients correctly Improve staff communication Use medicines safely Use alarms safely Prevent infection Identify patient safety risks Prevent mistakes in surgery IDENTIFY PATIENTS CORRECTLY Use at least two ways to identify patients. For example, use the patient s name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment. Make sure that the correct patient gets the correct blood when they receive a blood transfusion.

IMPROVE STAFF COMMUNICATION Get important test results to the right staff person on time. Eliminate poor or illegible handwriting. Repeat/read back verbal orders. Clear language when giving report to next shift, reduce interruptions during reports. USE MEDICINES SAFELY Before a procedure, label medicines that are not labeled. Take extra care with patients who take medicines to thin their blood. Record and pass along correct information about a patient s medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor. USE ALARMS SAFELY MAKE IMPROVEMENTS TO ENSURE THAT ALARMS ON MEDICAL EQUIPMENT ARE HEARD AND RESPONDED TO ON TIME. IDENTIFY PATIENT SAFETY RISKS FIND OUT WHICH PATIENTS ARE MOST LIKELY TO TRY TO COMMIT SUICIDE.

PREVENT MISTAKES IN SURGERY, as reported in the Universal Protocol on the Joint Commissions website to prevent the wrong site, wrong procedure, or wrong person surgery: Conduct a pre-procedure verification process Mark the procedure site Perform a Time-Out PREVENT INFECTION Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Use proven guidelines to prevent infections that are difficult to treat. Use proven guidelines to prevent infection of the blood from central lines. Use proven guidelines to prevent infection after surgery. Use proven guidelines to prevent infections of the urinary tract that are caused by catheters.

CONDUCT A PRE-PROCEDURE VERIFICATION PROCESS Promptly address missing information or discrepancies before starting the procedure Verify the correct procedure, for the correct patient, at the correct site When possible, involve the patient in the verification process Identify the items that must be available for the procedure Use a standardized list to verify the availability of items for the procedure. At a minimum, these items should include: Relevant documentation (history and physical, signed consent form, pre-anesthesia assessment) Labeled diagnostic and radiology test results that are properly displayed (radiology images and scans, pathology reports, biopsy reports) Any required blood products, implants, devices, special equipment

MARK THE PROCEDURE SITE THE SITE IS MARKED BY A LICENSED INDEPENDENT PRACTITIONER WHO IS ULTIMATELY ACCOUNTABLE FOR THE PROCEDURE AND WILL BE PRESENT WHEN THE PROCEDURE IS PERFORMED. PERFORM A TIME OUT: The procedure is not started until all questions or concerns are resolved. Conduct a time-out immediately before starting the invasive procedure or making the incision. A designated member of the team starts the timeout. The time-out is standardized. The time-out involves the immediate members of the procedure team: the individual performing the procedure, anesthesia providers, circulating nurse, operating room technician, and other active participants who will be participating in the procedure from the beginning. All relevant members of the procedure team actively communicate during the time-out.

DURING THE TIME-OUT, THE TEAM MEMBERS AGREE, AT A MINIMUM, ON THE FOLLOWING: correct patient identity correct site procedure to be done Reporting Medical Errors Mandatory reporting of medical errors is part of a system that holds providers accountable for serious patient injuries and deaths. Most mandatory reporting systems are operated by state regulatory programs that have the authority to investigate facts surrounding specific cases and issue penalties or fines for provider or facility wrong-doing. Each state has the responsibility for delineating the specific types of adverse outcomes that must be reported and in what fashion. In Florida, medical errors must be reported within 15 days.

WHAT TO TEACH YOUR PATIENT TO HELP PREVENT MEDICAL ERRORS: MEDICATIONS: 1. Make sure that all of your doctors know about every medicine you are taking. This includes prescription and over-the-counter medicines and dietary supplements, such as vitamins and herbs. 2. Bring all of your medicines and supplements to your doctor visits. "Brown bagging" your medicines can help you and your doctor talk about them and find. 3. Ask for information about your medicines in terms you can understand both when your medicines are prescribed and when you get them: 4. What is the medicine for? 5. How am I supposed to take it and for how long? 6. What side effects are likely? What do I do if they occur? 7. Is this medicine safe to take with other medicines or dietary supplements I am taking? 8. What food, drink, or activities should I avoid while taking this medicine? 9. When you pick up your medicine from the pharmacy, ask: Is this the medicine that my doctor prescribed? 10. If you have any questions about the directions on your medicine labels, ask. Medicine labels can be hard to understand. For example, ask if "four times daily" means taking a dose every 6 hours around the clock or just during regular waking hours. 11. Ask your pharmacist for the best device to measure your liquid medicine. For example, many people use household teaspoons, which often do not hold a true teaspoon of liquid. Special devices, like marked syringes, help people measure the right dose. 12. Ask for written information about the side effects your medicine could cause. If you know what might happen, you will be better prepared if it does or if something unexpected happens.

HOSPITAL STAYS If you are in a hospital, consider asking all health care workers who will touch you whether they have washed their hands. When you are being discharged from the hospital, ask your doctor to explain the treatment plan you will follow at home. This includes learning about your new medicines, making sure you know when to schedule followup appointments, and finding out when you can get back to your regular activities. It is important to know whether or not you should keep taking the medicines you were taking before your hospital stay. Getting clear instructions may help prevent an unexpected return trip to the hospital. SURGERY If you are having surgery, make sure that you, your doctor, and your surgeon all agree on exactly what will be done. Having surgery at the wrong site (for example, operating on the left knee instead of the right) is rare. But even once is too often. The good news is that wrong-site surgery is 100 percent preventable. Surgeons are expected to sign their initials directly on the site to be operated on before the surgery. If you have a choice, choose a hospital where many patients have had the procedure or surgery you need. Research shows that patients tend to have better results when they are treated in hospitals that have a great deal of experience with their condition.

SPEAK UP IF YOU HAVE QUESTIONS OR CONCERNS. YOU HAVE A RIGHT TO QUESTION ANYONE WHO IS INVOLVED WITH YOUR CARE. Make sure that someone, such as your primary care doctor, coordinates your care. This is especially important if you have many health problems or are in the hospital. Make sure that all your doctors have your important health information. Do not assume that everyone has all the information they need. Ask a family member or friend to go to appointments with you. Even if you do not need help now, you might need it later. Know that "more" is not always better. It is a good idea to find out why a test or treatment is needed and how it can help you. You could be better off without it. If you have a test, do not assume that no news is good news. Ask how and when you will get the results. Learn about your condition and treatments by asking your doctor and nurse and by using other reliable sources. Healthcare providers must work together as a team to ensure that Medical Errors are prevented before they happen. By implementing pre-procedure verifications and timeouts, preventable medical errors will be eliminated and patient safety and improved outcomes will be achieved.

REFERENCES 20 Tips to Help Prevent Medical Errors: Patient Fact Sheet. (2016). Retrieved May 7, 2016 from, http://archive.ahrq.gov/patients-consumers/care-planning/errors/20tips/index.html AHRQ's Patient Safety Initiative: Building Foundations, Reducing Risk. (2016). Retrieved May 7, 2016 from, http://archive.ahrq.gov/research/findings/final-reports/pscongrpt/psinisum.html Help prevent medical errors. (2015). Retrieved May 7, 2016 from, https://www.nlm.nih.gov/ medlineplus/ency/patientinstructions/000618.htm https://obssr.od.nih.gov/medical-errors-soft-skills-ensure-a-hard-bottom-line/ Internal risk management program. (2015). Retrieved May 7, 2016 from, https://www.flrules.org/gateway/chapterhome.asp?chapter=59a-10 JCAHO Revises Standards to Help Reduce Medical Errors. (2011). Retrieved May 7, 2016 from, http://www.apsf.org/newsletters/html/2001/fall/08jcaho.htm Joint Commission, Universal Protocol. Safe surgery checklist. (2015). Retrieved May 7, 2016 from, https://www.jointcommission.org/standards_information/up.aspx Medical error, the third leading cause of death in the US. (2016). Retrieved May 7, 2016 from, http://dx.doi.org/10.1136/bmj.i2139 Preventing errors in healthcare: a call for action. (2013). Retrieved May 7, 2016 from, http://www.ncbi.nlm.nih.gov/pubmed/15141846 Study Urges CDC to Revise Count of Deaths from Medical Error. (2016). Retrieved May 7, 2016 from, https://www.propublica.org/article/study-urges-cdc-to-revise-count-of-deaths-from-medical-error