Prevention of Medical Errors Course Description: The Prevention of Medical Errors course was designed to educate the healthcare professional with respect to medical errors in the healthcare setting. This course will provide participants with a critical analysis of the prevention of medical errors; including, definition of medical error; root cause analysis; error reductions and prevention; patient safety; teamwork and communication; pharmacological components of physical and occupational therapy; and therapy management of indications and contraindications. Course Author: Mary Smith, RPT Methods of Instruction: Online course available via internet Target Audience: Physical Therapists, Physical Therapist Assistants, Occupational Therapists, Occupational Therapist Assistants and Athletic Trainers Educational Level: Intermediate Prerequisites: None Course Goals and Objectives: At the completion of this course, participants should be able to: 1. Recognize what encompasses a medical error 2. Define sentinel event 3. Identify factors that could affect clinical practice 4. Recognize reasons for a wrong-site surgery 5. Recognize the Joint Commission's incidence report on sentinel events 6. Recognize the key criterion in identifying a patient's fall risk 7. Identify environmental hazards that can lead to fall risks 8. Recognize ways of reducing patient suicide through education 9. Identify common medication dispersing errors and recognize prevention goals 10. Recognize the components of successful teamwork in the healthcare setting Criteria for Obtaining Continuing Education Credits: A score of 70% or greater on the post-test 1 of 33
DIRECTIONS FOR COMPLETING THE COURSE: 1. Review the goals and objectives for the course. 2. Review the course material. 3. We strongly suggest printing out a hard copy of the test. Mark your answers as you go along and then transfer them to the actual test. A printable test can be found when clicking on View/Take Test in your My Account. 4. After reading the course material, when you are ready to take the test, go back to your My Account and click on View/Take Test. 5. A grade of 70% or higher on the test is considered passing. If you have not scored 70% or higher, this indicates that the material was not fully comprehended. To obtain your completion certificate, please re-read the material and take the test again. 6. After passing the test, you will be required to fill out a short survey. After the survey, your certificate of completion will immediately appear. We suggest that you save a copy of your certificate to your computer and print a hard copy for your records. 7. You have up to one year to complete this course from the date of purchase. 8. If we can help in any way, please don t hesitate to contact us utilizing our live chat, via email at info@advantageceus.com or by phone at 405-974-0164. 2 of 33
Prevention of Medical Errors Introduction The 1999 publication of the Institute of Medicine (IOM) entitled To Err is Human: Building a Safer Health System was a wakeup call toward the realization of the healthcare industry s medical errors. The report revealed the prevalence of medical errors in the United States, and outlined measures necessary for the prevention of such errors. The report revealed that in the United States, more than 44,000 people die yearly due to medical errors. Several organizations and commissions have thus established mechanisms and protocols for reducing medical errors; and consequently, associated possible complications from the errors. The Joint Commission has been in the forefront in their efforts to address the issue of medical errors. Addressing these same efforts has been the National Coordinating Council for Medication Error Reporting and Prevention. This course will provide participants with a critical analysis of the prevention of medical errors; including, definition of medical error; root cause analysis; error reductions and prevention; patient safety; teamwork and communication; and pharmacological components of physical and occupational therapy. 3 of 33
Definition of Medical Error An error is the failure to complete the planned action as intended; or, utilizing the wrong plan to achieve a certain outcome. Medical errors result from medical negligence or medical malpractice rather than intentional wrongdoing. Medical errors depend on two categories of failures; namely, execution error and planning error. The error of execution occurs when the correct action proceeds in a manner in which it was not intended. Planning error occurs when the intended medical action is incorrect. A medical error can occur during any phase of patient care. The patient care processes in which a medical error may occur include: diagnosis, treatment and during preventative care. Some medical errors may not cause harm to the patient. Medical errors that cause harm or injury to the patient are referred to as adverse events (sentinel events). These medical errors require an immediate investigation and timely response. Adverse events are defined as injuries resulting from medical management rather than from the underlying disease. Although the proximal medical error that precedes the adverse event is attributed to human error, its underlying cause results from system flaws. These system flaws are factors designed into the healthcare industry and are mostly beyond an individual s control. This implies that errors have occurred at the system, individual or team level. The adverse events are classified into two categories; namely, preventable adverse events and non- 4 of 33
preventable adverse events. Adverse events that are preventable are less common than those that are not preventable. Unfortunately, some adverse events are attributed to negligence. Sentinel events are referred to as unanticipated events that occur in a healthcare setting that lead to serious psychological injury, physical injury, or death to the patient(s). Sentinel events are never related to the patient s natural cause of illness. For example, if a patient undergoes a surgical procedure but dies from pneumonia after the procedure, the patient suffered an adverse event. Without proper analysis, a determination as to whether this adverse event was caused by inaction or medical intervention is difficult to make. This patient case should be thoroughly analyzed to determine the cause of the patient s pneumonia and consequential death. When analyzing this case, two possible causes of the patient s pneumonia can be considered. First, the patient could have contracted pneumonia due to the medical staff s negligence. This cause would be a preventable execution error. Second, the cause could be attributed to the patient s age and co-morbidities. This cause would be a non-preventable adverse event. To provide optimum health care, healthcare professionals should evaluate the cause of adverse events resulting in serious psychological injury, physical injury, or death to the patient. Moreover, by evaluating these sentinel events, healthcare professionals could minimize future errors while better implementing their service delivery in the healthcare setting. Medical errors not resulting in harm or injury to patients must also be 5 of 33
evaluated. Thus, healthcare professionals should have an opportunity to identify and improve systems having the potential of causing adverse events. A regular review of these systems for preventing future adverse events should be implemented. The Joint Commission has emphasized that preventable and non-preventable adverse events, as well as near-misses, should be analyzed by healthcare professionals. The Joint Commission has established guidelines that should be followed by healthcare professionals to recognize such events, perform the root cause analysis of the events, and thus establish the real cause of the events. Root-Cause Analysis The Joint Commission is the national organization whose main mission is the quality of healthcare in the United States. To accomplish this mission, the Commission provides healthcare facilities with accredited status. As an accrediting agency, the Commission plays a major role in supporting and encouraging activities within the healthcare organizations. The Commission holds healthcare facilities accountable in ensuring that their environment is safe for the patients. Therefore, by actively engaging in joint relationships with the Commission, healthcare facilities can reduce the risk of sentinel events in healthcare settings; and thus, facilitate desired healthcare outcomes. According to the Joint Commission, root cause analysis (RCA) is defined as the process that can be used in identifying casual or basic factors 6 of 33
underlying the variation in the performance, which include the occurrence, or the possibility of the occurrence, of the sentinel event. There are two subsets of sentinel events that are reviewed by the Joint Commission. The first subset reviewed is an event leading to the permanent loss of the patient s functions, or unanticipated death, which is unrelated to the patient s underlying condition or illness. The second subset reviewed by the Commission is issues related to outcomes of the sentinel event that lead to permanent disability or death. Included in the Joint Commission s accreditation requirement is that healthcare facilities establish mechanisms of recognizing sentinel events, performing thorough and credible root cause analysis, and documenting strategies to eliminate sentinel events. Root cause analysis is a reflective methodology which is widely used in investigating adverse medicine phenomenon. Root cause analysis offers a well-controlled framework focused on processes and is key in analyzing sentinel events in the medical field. The cardinal principle of root cause analysis is to mitigate the counter-productive and persistent culture of biasness. Root cause analysis results in organizational and system issues being recognized and addressed, and any errors related to the investigation acknowledged. Methodical application of root cause analysis is very instrumental in uncovering the root causes connecting incongruent pools of accidents. In this context, root cause analysis has proven to be very effective in identifying major adverse occurrences commonly found at shift 7 of 33
change. Using this methodology to carefully analyze such events may help in identifying change needed to prevent future incidents. For root cause analysis methodology to be held credible in regard to medical investigations, rigorous solicitation of existing qualitative techniques must be applied. Once the sentry event has been established for the purpose of analysis, the healthcare professional should identify a multidisciplinary team to take charge of the investigation. Members of the team must be fully conversant with root cause analysis techniques and goals to avoid individual biases common in medical investigations. The key to involving a multidisciplinary team in this process is to allow for the corroboration and triangulation of the findings thus increasing the validity of the results. Coupled with latent and active error concepts, root cause analysis is generally divided into two steps. The first step of root cause analysis involves collecting data from the field. The investigators conduct thorough and systematic data collection procedures to determine what occurred or what led to the event. Data collection is done through the process of structured interviews in which the investigators interview respondents, or witnesses, to gain first-hand knowledge regarding the event. The questions are structured in a way that the investigators can optimally reconstruct the events and thus gain factual data. Further, investigators collect data by reviewing existing documents or through field observation. Biasness at this stage is very destructive as it may skew the end results, and thus the validity of the entire process. 8 of 33
The second step of root cause analysis involves analyzing data collected. The investigation team analyzes data collected from the field looking for any common sequence of occurrence, with the major objective of identifying mutual underlying factors. In this step, the team seeks to establish how a particular event occurred through identification of dynamic botches in the event. This is done by identifying generalized latent failures in the sequence. In order to determine that all possible root causes are considered, the investigators must critically review all factors affecting clinical practice. Such factors include, but are not limited to, work environment, regulatory and institutional factors, patient characteristics, management or organizational factors, and task related factors. For root cause analysis to be deemed credible, these factors must all be considered before making any form of summarization or conclusions. Only after taking these steps, will the team be able to summarize how various factors contribute to the event; and thus be able to identify probable problems that may call for changes to avoid future incidences. Error Reductions and Prevention By March 31, 2010, the Joint Commission had reviewed a total of 6782 cases of sentinel events that had occurred on 6920 patients. These sentinel events led to the death of 4642 patients. The sentinel events included: wrong-site surgery, patient fall, patient suicide, medication error, operative 9 of 33
and postoperative complications, and delay in treatment whose prevalence rates were 13.4%, 6.4%, 11.9%, 8.1%, 10.8%, and 8.6% respectively among patients. More than 70% of these events led to the loss of function or death of the patients, and approximately 75% of the events occurred in psychiatric hospitals. Thus, it can be determined that the most prevalent sentinel events result from wrong-site surgery. These events should be preventable. Wrong-Site Surgery One of the indicators of a problem in the operation room of a healthcare facility is when an operation is performed on the wrong site/body part of the patient. Wrong-site surgeries most commonly occur in orthopedic procedures. Wrong-site surgery is also common during urological and neurosurgical procedures. Several risk factors can be attributed to these sentinel events. These factors include the involvement of two or more surgeons due to multiple procedures. Wrong-site surgery may also occur when the patent is transferred from one surgeon to another. Wrong-site surgery may also occur as a result of performing multiple surgical procedures on a patient during a single operation. Pressure arising during the operation from time constraints may also lead to wrong-site surgery. These sentinel events may occur because of circumstances peculiar to a patient that could alter the preferred positioning of a surgical operation. The American Academy of Orthopedic Surgeons has taken special steps to eliminate wrong-site surgery. The Academy recommends that 10 of 33
surgeons write with an indelible pen at the correct site where the operation is to be performed. The surgeon should then perform the incision only if the initials at the site of operation are visible. The goal of eliminating wrong-site surgery could also be achieved by writing the word NO on the site that is not intended to be operated on, using big black letters. The recommendation of the Academy regarding spinal surgery is that the radiopaque marker, as well as the intra-operative radiograph, be utilized in determining the precise vertebral level of the spinal surgery. The efforts of reducing and preventing wrong-site surgery should involve all personnel in the operating room. These personnel include the anesthesiologists, nurses, physicians and technicians, among others. The personnel should monitor all procedures to ensure that the verification procedures are strictly adhered to, particularly for procedures considered high-risk. Because wrong-site, wrong-person, and wrong-procedure surgeries have high prevalence rates, the Joint Commission, in conjunction with 50 other healthcare organizations, held two summits to address the issue. The first summit was held in 2003, followed by a second summit in 2007. The 2003 summit led to the establishment of a Universal Protocol, with various recommendations. These recommendations include: pre-procedure verification using indelible markers in marking the procedure or operative site, and all periprocedure or perioperative personnel to take a time out immediately prior to the operation or procedure. Because wrong-site surgery incidences continued to rise, another summit was held in 2007. This summit 11 of 33
emphasized the importance of the Universal Protocol. Most importantly, the summit adopted the policy known as zero tolerance and extended the Universal Protocol to other procedures, such as radiological interventions and regional anesthetic administrations. Delays in Treatment The Joint Commission report revealed that more than 50% of all sentinel events that occurred as a result of delays in treatment, occurred in the emergency department. These sentinel events were attributed to incomplete treatments, misdiagnosis, delays in getting test results, delays in following the patient s care orders and physician emergency room availability. Difficulty in finding the emergency room s entrance was also a factor leading to these sentinel events (delays in treatment). Communication breakdown between, or with physicians, was also identified to be a root cause of delays in treatment. This communication breakdown was due to the inadequacy or insufficiency of trained staff, unavailability of specialists in the time frame required, and overcrowding of the emergency room. In an effort to reduce the sentinel events resulting in delay in treatment, the Joint Commission recommends several remedies. These recommendations include, implementing procedures as well as processes that improved completeness, accuracy of communication and timelines. The Joint Commission also recommends taking steps necessary to reduce reliance on verbal orders, while requiring a verification or read back procedure whenever verbal orders are used. Finally, face-to-face debriefings 12 of 33
among healthcare employees at shift change should be implemented in an effort to reduce sentinel events. Patient Falls In healthcare facilities, patient falls are regarded as constant challenges. The patients at highest risk for falls are the elderly, patients with altered mental conditions as a result of acute intoxication or chronic mental condition, and patients with prior falls history. A key criterion in identifying a patient's fall risk is to obtain a complete patient history. According to the Joint Commission, the main cause of patient falls in healthcare facilities leading to sentinel events included issues associated with the organizational culture, care givers, care processes and the environment of care. More than 50% of the healthcare facilities reported that issues related to communication are the root causes of patient falls. These issues included failure in obtaining sufficient information regarding the patient s fall history, failure in communicating the information to other staff members during shift change or reporting time and failure in recording condition changes in the patient s medical record. Other root causes of patient falls included absence of protocols or incomplete care plans, and environmental issues. The environmental issues include, but are not limited to, malfunction or the misuse of healthcare equipment, and poor designing of nurse stations and doors. There are other environmental issues contributing to patient falls, such as inadequate staffing, improper orientation of new staff and inadequate utilization of 13 of 33
constraints. Strategies for reducing the root causes of patient falls are quite straightforward. Most importantly, staff orientation, as well as training, should be improved to incorporate appropriate education relating to the assessment of fall risk processes. In addition, the entire staff should be orientated regarding existing prevention protocols. Patient falls could result in immobility, morbidity and mortality. Therefore, it is necessary for healthcare facilities to initiate sufficient prevention programs for reducing patient falls and injuries associated with such falls. The Florida Hospital Association recommends the establishment of interdisciplinary, comprehensive programs by healthcare facilities to help in eliminating patient falls. These programs should posses several components. First, programs should posses prevention protocols to those patients who have been screened and found to be potentially at the greatest risk of falling. Second, the programs should include the mechanisms of measuring, as well as reporting, fall rates. Third, the programs should be allowed to modify prevention protocols based on information learned regarding patient falls. With the aging population in particular, more Americans live beyond the age of 65 years. This statistic reveals the need for activities created to enhance mobility and reduce falls while these older patients are hospitalized. Patient Suicide Patient suicides are the sentinel events that occur most often in psychiatric hospitals. Though less in numbers, patient suicides also occur in residential facilities as well as in general hospitals. Patient suicide in general 14 of 33
hospitals occur most often on the hospital s psychiatric unit, followed by patient suicide on the surgical/medical floors. Several root causes of patient suicides have been identified by healthcare facilities: First, patient suicides occur due to issues related to the care environment. These issues include the existence of non-breakaway safety rails, rods or bars, not testing the breakaway hardware, and inadequate security. Second, there were inadequate methods for assessing these patients, such as absent or incomplete assessments for suicidal risk at the intake of these patients. Third, a root cause of patient suicide was the incomplete examination and reassessment of the patient, which allowed for the presence of contraband. Fourth, staff-related factors contributed to patient suicides. These factors include incomplete reassessments of the competency of the staff, deficient training or orientation, and inadequate staffing. Fifth, infrequent or incomplete observation of the patients have been identified to be a root cause for patient suicides. Other root causes of patient suicide may include inappropriate patient assignment and information-related factors. Such information-related factors include imperfect communication among the caregivers in the healthcare setting. Several strategies to reduce the risks of patient suicides have been reported by healthcare facilities. These riskreduction strategies include engaging the patient s families and friends in detecting contraband, monitoring the process of implementing consistent observation, and revising the procedures regarding information transfer. Another way of reducing patient suicide is through the implementation of 15 of 33
education for the patients friends and family regarding the risk factors for suicide. Operative and Postoperative Complications Most of the sentinel events that have been reported to the Joint Commission concerning operative and postoperative complications occur as a result of non-emergency procedures. The categories of procedures most associated with postoperative or operative care complications included: orthopedic surgery, head and neck surgery, catheter or tube insertion, thoracic surgery, open abdominal surgery and interventional endoscopy and/or imaging. Most of reporting facilities indicated that miscommunication was the key cause of operative and postoperative complications. Other root causes that were identified by reporting facilities included improper preoperative assessment, failing to follow existing protocols, failure in questioning inappropriate orders, and inconsistent monitoring during postoperation. Several strategies have been identified by reporting healthcare facilities that could help in reducing operative and postoperative complications. These strategies include improving training and orientation of staff, increasing the physicians educational opportunities, defining the necessary communication channels, and monitoring the procedures to ensure consistent compliance. The monitoring procedures for postoperative patients should be reviewed in order to meet the needs of every patient, irrespective of settings conducting the procedure. This monitoring should be 16 of 33
adopted in all settings where the procedure could be performed, such as the radiology department, operating room, and the endoscopy suite. Healthcare professionals should also be educated and trained in these preventive measures. Most importantly, direct communication among the caregivers in the healthcare setting is the key to eliminating operative and postoperative complications. Medication Errors A medication error is defined as a preventable sentinel event that may cause the inappropriate use of medication resulting in harm to the patient, while such medication is under the control of the consumer, patient or healthcare professional. Such events may be attributed to healthcare products, systems, professional practice, and procedures. These errors relating to the prescription may include: product labeling; compounding; order communication; dispensing, monitoring; packaging and nomenclature; monitoring; education; and use. According to Nair, Kappil & Woods, medication errors are the cause of the highest mortality rates in the United States. Of all the medical errors, dispensing errors amount to approximately 21% of all the sentinel events. Apart from causing serious mortality and morbidity, dispensing errors increase society s economic burden by increasing healthcare costs. A dispensing error is traumatic to the pharmacist, but it can be both traumatic and potentially life threatening to the patient. Medication errors often occur at three crucial points: when the 17 of 33
medication is ordered by the physician, administered by the nurse, or dispensed by the pharmacist. Medical errors can be attributed to the health professional who prescribes the medications due to the use of abbreviations and dose expressions. Table 1 lists some of the dangerous abbreviations. In an effort to reduce medical errors, the Council has issued several recommendations to those who prescribe medicine. First, all prescription documents should be legible. The Council recommends that verbal orders should be minimized if at all possible. Second, all prescription orders should contain a brief notation regarding the purpose of the prescribed medication. These notations of purpose can facilitate dispensation of proper medication while also creating an additional safety check for the prescription and the dispensation of the medication prescribed. 18 of 33
Table 1: Dangerous abbreviations Source: National Coordinating Council for Medication Error Reporting and Prevention. The third recommendation by the Council is that all prescription orders should be clearly written in the metric system. An exception to this recommendation is for those therapies that employ standard units such as vitamins and insulin. All the units should be correctly spelled out instead of 19 of 33
writing U (National Coordinating Council for Medication Error Reporting and Prevention, 2013). Misinterpretations of units and symbols could be avoided by changing the archaic avoirdupois and apothecary system into the metric system. This will further help in avoiding miscalculations in the process of converting such units to metric units, which are normally used in package inserts and product labeling. According to the Council, the prescribers should include the age, and if necessary, the patient s weight on the medication or prescription order. The Council also recommended that all medication orders should include the name of the drug, exact concentration or weight in metric units and dosage form. The strengths of the drug should be listed in metric amounts with its concentration specified. Each medication order should be complete and the pharmacist should check, along with the subscriber, that all information is correct and that none is questionable or missing. Also, the use of trailing or terminal zeros after the decimal point should be avoided in order to avoid confusion. The use of trailing zeros, absence of the leading zeros could lead to the occurrence of ten-fold errors in terms of drug strength. Table 2 lists some common dispensing errors. 20 of 33
Table 2: Common dispensing errors Source: Nair, Kappil & Woods (2010). Studies have revealed that transcription errors, such as inaccuracies and omissions, account for approximately 15% of all dispensing errors. These errors could be eliminated through constant use of reliable techniques in verifying the identity of the patient while entering the patient s prescription in the computer. According to the recommendation by the Joint Commission, more than one patient identifier should be used in administering medications. This recommendation could help in eliminating medication errors as a result of look-alike and sound-alike names. It is necessary to obtain patient information, such as age, allergies, therapeutic duplications, contaminant medications, and contraindications. Another way to reduce dispensing errors is to organize the workplace in the healthcare setting. Organizing workflow, work environment, and the work space can reduce dispensing errors significantly. Sufficient counter space, proper lighting, and comfortable humidity and temperature could 21 of 33
facilitate smooth flow and reduce the chances of medication errors. The healthcare setting should establish routine checking, entering and filling of prescriptions to assist in organizing workflow. In addition, healthcare professionals should affix labels to prescription containers of the patient and process only one drug at a time in order to prevent error. Patient Safety Several organizations have developed guidelines to encourage patients so they can play a role in their safety. For example, the Agency for Healthcare Research and Quality established the Patient Fact Sheet to help improve patient safety. This sheet contains 20 tips for patients to help reduce the incidence of medication errors. Each guideline is aimed at informing and involving the patient in order to achieve better outcomes. This is not to imply that the burden of ensuring the safety of the patient should be shifted to the patient alone, but all others in the healthcare setting, including family and friends, should collaborate to improve patient safety. The IOM report recommends several processes to enhance patient safety. These processes include: patient-centered design; communication teamwork and collaboration; evidence-based practice; establishing the safety culture; and attending to work safety. Patient-Centered Design According to the IOM recommendation, healthcare organizations, public and private purchasers and professional groups should adopt ways of 22 of 33
reducing the patient s burden of injury, disability and injury in order to improve the patient s functioning and health. To accomplish this, healthcare facilities must: be effective; safe; equitable; timely; efficient, and patientcentered. Healthcare facilities should also be redesigned to ensure that the care provided is based on a healing relationship; customized to include the values and needs of the patient. Patient-centered care can help in improving health outcomes and eliminate disparities regarding access to necessary care and quality. Avoiding Relying on Memory Another strategy that can improve patient safety in the healthcare setting is the simplification and standardization of tasks in order to reduce the demand on problem-solving, working memory and planning. This strategy includes two processes: standardizing equipments and processes; and simplifying the key processes. Standardizing equipments and processes in the healthcare setting could minimize reliance on memory. Standardization could also help to educate new staff who may be unfamiliar with certain equipment. Standardization could help staff carry out the processes safely. For example, standardizing operations of the displays of devices (such as readout units) and doses are necessary to minimize the chances of errors. Other processes and devices that should be standardized include administration times, categories of equipment, order forms, and prescribing protocols. Those devices or medications that are impossible to standardize must be distinguishable from others. For example, strengths of 23 of 33
medications should be labeled in a consistent manner. Established protocols should be used wisely and updated regularly so as to enhance patient safety. Simplifying the healthcare setting s key processes could significantly reduce the chances of error and minimize problem-solving. Simplifying the key processes includes decreasing the number of handoffs or steps that are required in a particular procedure. Several processes can be simplified in health care settings. These processes include writing of orders, transcribing and entering information into the computer. Others processes include maintaining an inventory of drugs that are frequently prepared, reducing the frequency of daily administration of the drug, and keeping one record for the administration of medication and purchasing devices that can be used and maintained easily. Avoiding Relying on Vigilance Health professionals should avoid depending on vigilance, as individuals cannot be vigilant all of the time. Current approaches toward reducing the reliance on vigilance include minimizing long shifts, utilizing machines with automated functions, provision of check lists and ensuring that such lists are used regularly. This could also be achieved by employing signals such as auditory and visual alarms. However, relying solely on automation can have its pitfalls as well. For example, when the user adapts to ignoring wrong alarms, such user may become inattentive to a certain process. 24 of 33
Involving Patients in Their Own Care The patients, their family members, friends and other caregivers need to be involved in the healthcare process. The clinicians should obtain the medications and allergies of each patient and ensure that such information is available to the patient. In addition, the patient, as well as the patient s family members, should be informed of the patient s treatments, conditions and the technologies employed in providing their care. During the time of discharge, the patient should be given a list of their medications, dosing schedule, doses, side effects of the medications, precautions against interactions and activities to be avoided during the course of the medication. The patient should also be given written information regarding what to do after discharge, such as follow-up visits and who should be contacted in case of questions or problems. Family caregivers deserve attention regarding their ability to provide safe care, manage medication and devices and responding to the patient s needs. Family caregivers, however, may be overwhelmed by emotional, physical and health challenges; inadequacy of rest; work responsibilities, care of other members of the family, and financial constraints. Lack of family and patient health literacy should also be addressed. Family caregivers may be faced with the challenge of frightening and unfamiliar language, or the complexity of the healthcare information. Thus both the family caregivers and the patient should be given relevant information, including sterilization techniques, and the use of the equipment. The patient should also be 25 of 33
informed when they should take the dosage and given warning information contained in the medication packages. Anticipating the Unexpected The chances of the occurrence of errors increase with changes in organizations that lead to new care processes and patterns. Some technologies, including computerized physician order entry systems (CPOE), are specifically designed to prevent the occurrence of errors. However, such technologies are prone to introducing new errors. The safe design and use of equipment depend on the degree of commitment and involvement with the equipment s manufacturer and the consumer. Healthcare professionals should therefore anticipate any new errors that may be introduced by the use of new technologies. Healthcare professionals should adopt the custom necessary for automating cautiously and test technologies thoroughly before implementing them. Attending to Work Safety Work conditions can affect the safety of the patient. Factors that can contribute to the safety of the worker include the workloads, work hours, shift changes, distraction sources and staffing ratios. All these factors should be addressed by the healthcare facilities so patient safety can be enhanced. An increase in systematic evidence regarding the comparative importance of these factors exists, with special emphasis on staffing in the healthcare setting. 26 of 33
Design for Recovery Design for recovery is another strategy to enhance patient safety. In this strategy, healthcare facilities should assume that medical errors will occur and develop necessary plans in recovering through duplication of critical functions. The facilities should also initiate reverse operations and discourage nonreversible ones. For example, facilities should keep drug antidotes for drugs associated with high risks. Another recovery plan is to employ simulation training, where learners practice on the important processes, tasks, and rescue techniques, using virtual reality or models. Teamwork and Communication Failure in communication is the main root cause of preventable sentinel events. Communication failure causes the occurrence of medical errors in the healthcare setting. For example, the delivery process in healthcare settings could involve multiple patient handoffs and interfaces among several healthcare professionals. These professionals have varying occupational training and educational levels. During hospitalization, the patient could interact with multiple health care employees, including physicians, therapists and nurses. Thus, effective communication among these healthcare professionals is a must. Equally important, is team collaboration in the healthcare setting. Lack of effective collaboration among the healthcare professionals can potentially put the patient s safety at risk. This could lead to misinterpreting 27 of 33
information, lack of adequate critical information and changes in the patient s status may be overlooked. Collaboration in the healthcare setting can be achieved when healthcare professionals work together in cooperation and assume complementary roles. This can also be achieved through collective decision making and problem-solving among healthcare professionals, thus benefiting the patient. The characteristics of effective teamwork include collaboration, respect and trust. The healthcare setting s teamwork model requires the application of an interdisciplinary approach rather than a multidisciplinary approach. An interdisciplinary approach allows for collective efforts on the patient s behalf with a common objective from all involved disciplines in a particular care plan. This leads to the integration or pooling together of specialized services. The care plan would take into consideration several assessments as well as treatment regimens. Thus, it becomes easier for the patient to communicate with a cohesive team, compared to communicating with several professionals who may not know each other s activities with regard to the management of the patient. The components of successful teamwork in the healthcare setting include: open communication; clear direction; non-punitive environment; respective atmosphere; enabling environment and clearly defined roles. Successful teamwork should also include equally-shared responsibilities. Member participation should be balanced for a given task. Moreover, the team should have a system of evaluating the outcomes and adjust them 28 of 33
accordingly. Many healthcare professionals have become used to poor teamwork and communication due to low expectations that exist in healthcare settings. A culture where healthcare professionals expect incomplete and faulty information exchange is attributed to the occurrence of errors, as those conscientious professionals will ignore potential clinical discrepancies and red flags. This is because the conscientious professionals will assume the warning indicators to be typical poor communication in the facility rather than worrisome indicators. Effective communication will thus lead to effective interventions, increased employee morale, improved safety and enhanced information flow. There can be several barriers to effective communication in the healthcare setting. For example, some healthcare professionals like working autonomously while claiming to be part of the team. These collaboration and communication barriers among the clinical staff often jeopardize efforts aimed at improving the quality and safety of the healthcare setting. Common barriers to effective inter-personal collaboration and communication include: personal expectations and values; hierarchy; personal differences; generational differences; gender inequality; disruptive behaviors; and ethnic and cultural differences. Others barriers include differences in jargon and language; differences in professional routines and schedules; varying preparation levels; differences in professional norms, regulations and requirements; fears of diluting the professional identity, and differences in rewards, payments and accountability. 29 of 33
Still other barriers that have been identified include complexity of care, and clinical responsibility concerns. Thus, establishing opportunities, either formal or informal, for all professional groups to interact with each other is an effective strategy toward enhancing communication and collaboration. Encouraging collaborative rounds of open dialogue, and implementing postop and pre-op team briefings can assist in effective communication and collaboration. Healthcare facilities should, then, create task forces and interdisciplinary committees that discuss areas of problems and recommend solutions to curb the occurrence of disruptive events. Pharmacological Components of Physical and Occupational Therapy Therapists can play crucial roles in eliminating the severity and frequency of medical errors. Several recommendations outline how the rehabilitation professional can help referring physicians in the pharmacological management of patients (Khanna, et al, 2012). First, therapists should take an accurate and complete subjective history of all their patients. This history should include the current, as well as previous, medical problems, noting the inconsistencies, if any, or omissions from the medical records reviewed previously. Therapists should take the patient s history of all current medications, including frequency, dosage, and potential side effects. Second, rehabilitation professionals should collect objective data from all patients, including the assessment of common therapies and 30 of 33
the pharmacological side effects associated with the patient s medication. Third, the rehabilitation professionals should establish effective and safe rehabilitation programs to accommodate or address the side effects that are common pharmaceutically. Last, rehabilitation professionals should continuously monitor and document the overall condition of each patient throughout the course of their rehabilitation process. The therapist should communicate continuously with the relevant referring physician, as the therapist sees the patient more frequently than the physician. In addition, the therapist should observe all patient activities, including listening to the patient and reporting these activities to the physician. If the therapist discovers the patient has given the doctor information that is incomplete or inaccurate, the therapist should notify the physician as soon as possible. The therapist should also notify the physician if medications prescribed to the patient are causing adverse side effects or are not helping improve the patient s current health condition. Therapy Management of Indications and Contraindications To be an effective therapist, it is the therapist's job to understand when and when not to provide therapy to his or her patients. Therapists should confer with colleagues and always research current literature regarding safe practices whenever a questionable situation arises. Recognizing potential issues that may contraindicate therapy and knowing when to refer the patient to other healthcare providers if situations present 31 of 33
that require additional medical services is paramount in providing safe and effective patient care. Conclusion Medical errors can, and do, occur in all healthcare settings. These medical errors result in the occurrence of several sentinel events each year. Medical errors will, then, continue to be an issue in our healthcare settings. Efforts have been made by the Joint Commission to address these medical errors, and the sentinel events associated with them. The recommendations of the Joint Commission, if used diligently, can help in significantly eliminating sentinel events. Eliminating medical errors can be achieved, or at least greatly reduced, when healthcare facilities work together with all team members, including patients, families, and caregivers, in a unified effort to eliminate a widespread and potentially life threatening problem. 32 of 33
References Agency for Healthcare Research and Quality. (2011). 20 Tips to Help Prevent Medical Errors. AHRQ. (2009). Advancing Patient Safety: A Decade of Evidence, Design, and Implementation. Agency for Healthcare Research and Quality: Advancing Excellence in Healthcare. CME Resource. (2010). 9133: Medical Error Prevention and Root Cause Analysis. Donaldson, M. S. (n.d). An Overview of to Err is Human: Re-emphasizing the Message of patient Safety. Hughes, R. G. (n.d). Chapter 2Nurses at the Sharp End of Patient Care. Patient Safety and Quality: An evidence-based Handbook for Nurses. Vol. 1. Khanna, et al. (2012). 2012 American College of Rheumatology Guidelines for Management of Gout. Part 1: Systematic Non-pharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia. Arthritis Care & Research. Vol. 64(10). Pp. 1431 1416. Nair, R.P. Kappil, D. & Woods, T.M. (2010). 10 Strategies for Minimizing Dispensing Errors. Pharmacy Times. National Coordinating Council for Medication Error Reporting and Prevention. (2013). About Medication Errors. Rogers, A. I. (n.d). Medical Errors Prevention. The Joint Commission. (2012). Proceedings from the National Summit on Overuse. The Joint Commission. 33 of 33