PREVENTION OF MEDICAL ERRORS FOR RNS AND LPNS |
|||||
• Read the entire course material
or fax to: (305) 651-1427 |
|||||
This course meets the Florida requirement for prevention of medical errors (Florida Statute 456.013), both for initial licensure and biennial renewal. Nursing Unlimited, Inc. is approved as a provider of nursing continuing education by the Florida Department of Health, Division of Quality Assurance, Board of Nursing, Florida Board of Nursing Accreditation #NCE2958-31 October 2009. For many years, the extent of medical errors was unknown. Uncovering the degree of the problem was fueled by the medical error-related death of Boston Globe health columnist Betsy Lehman in 1994. Lehman, who was being treated for breast cancer at Boston's Dana Farber Cancer Institute, died from heart failure after she mistakenly received the cumulative dose of the cancer drug Cisplatin, instead of the daily dose for four days. Her death triggered a landslide of government hearings, meetings, and reports. Post-event findings and analysis culminated in the release in 2000 of " To Err Is Human: Building A Safer Health System ," by the Institutes of Medicine (IOM ), a nonprofit research group that is part of the National Academy of Sciences. This report shocked the nation with its conclusion that preventable medical errors result in 44,000 to 98,000 deaths per year in the United States, making medical errors more deadly than breast cancer, motor vehicle accidents or AIDS. Medical errors are responsible for injury in as many as one out of every 25 hospital patients, and they may cost the economy as much as $29 billion each year. The IOM's report concluded that such errors result from system failures, not people failures ; so achieving acceptable levels of patient safety will require major systems changes ; and a concerted national effort to improve patient safety. The IOM report provided a blueprint for reducing medical errors, naming four key factors that contribute to the epidemic of errors: • Fragmentation and decentralization of the healthcare system may create unsafe conditions for patients and impede patient safety efforts. • Licensing and accreditation processes give insufficient attention to preventing errors. • The medical liability system discourages physicians from admitting mistakes and impedes systematic efforts to uncover and learn from errors. • Third-party purchasers of healthcare offer little incentive for healthcare organizations and providers to improve safety and quality.
To help prevent or decrease the incidence of medical errors, we need to recognize error-prone situations and to be pro-active. It is better for everyone involved if the medical error is prevented before it happens. It has long been an easy or convenient practice to assign blame to the healthcare worker who makes a medical mistake. This practice creates an atmosphere of blame and shame; fear of punitive action leads to hiding and gross underreporting. What it fails to do is find the system or process error that led to the final medical mistake. There are several human factors that can contribute to medical errors. To change the culture of blame to a culture of safety, our focus must be on identifying and correcting process or system failures. Equipment malfunctions and misuse are other factors that must also be addressed. What Is A Medical Error? The IOM Committee on Quality of Healthcare in America defines medical error as "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim". Rarely do errors happen in isolation. Usually, one flaw or problem leads to another and then another. This chain of events, involving many healthcare providers, may result in a medical error and a sentinel event. An adverse event is an injury caused by medical management, rather than from the patient's underlying condition. An adverse event attributable to error is a preventable adverse event, also called a sentinel event , because it signals the need to ask why the error occurred and to make changes in the system. A "sentinel event" is defined by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as "an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof". "Near miss" is a potential error that is found or caught before an actual error or injury occurs. Sentinel events include: • Operative and post-operative complications • Patient suicide • Medication errors • Wrong site surgery • Patient falls Research on why humans make errors has identified two types of errors: active and latent. Active errors tend to occur at the level of the individual, and their effects are felt almost immediately. Latent errors are more likely to be beyond the control of the individual; that is, they are errors in system design, faulty installation or maintenance of equipment, or ineffective organizational structure. The effects of latent errors may not appear for months or even years, but they can lead to a cascade of active errors, ending in catastrophe. For example, an undetected design flaw in an airplane (a latent error) may, years after the aircraft was built, cause the pilot to lose control of the plane (an active error) and result in a crash. Close calls or near misses are potential adverse events , errors that could have caused harm but did not, either by chance or because something or someone in the system intervened. For example, a nurse who recognizes a potential drug overdose in a physician's prescription and does not administer the drug but instead calls the error to the physician's attention has prevented an adverse drug event (ADE) . Close calls provide opportunities for developing preventive strategies and actions, and should receive the same level of scrutiny as adverse events. Taking Action to Prevent Medical Errors An IOM goal is to "break the cycle of inaction". The American Nurses Association (ANA) supports many of the IOM's recommendations. Florida is one of the leading states in medical error prevention. In 2002, the Florida Board of Nursing decided that "all licensees must complete a two hour course on prevention of medical errors, which meets the criteria of Section 456.013, F.S., as part of the total hours of continuing education required for initial licensure and biennial renewal." ( Chapter 64B9-5.011, Florida Administrative Code). In 2003, Florida passed the nation's most comprehensive patient safety legislation, the Medical Incident Bill. Its objectives are to create a near-miss reporting system, establish quality indicators for consumers' use in selecting hospitals, and create the Florida Patient Safety Authority - an organization established to analyze patient safety data, identify best practices, provide continuing education to practicing healthcare providers and institute statewide electronic infrastructure. Florida has taken other important steps to prevent medical errors and improve patient safety. Handwritten prescriptions are now illegal in Florida. The Clients' Right-To-Know About Adverse Medical Incidents Act allows clients who have been harmed to gain access to all records of their care, including documents of provider deliberation. The Three Strikes and You Are Out Act asks the Florida Board of Medicine to revoke medical licenses of providers who have had three adjudicated malpractice incidents. The Florida Patient Safety Corporation (FPSC) was created by the 2004 Florida Legislature under Section 381.0271, Florida Statutes. The purpose of this nonprofit corporation is to continuously improve patient safety in Florida by serving as a learning organization, assisting health care providers in improving the quality and safety of health care and reducing harm to patients, and working with a consortium of patient safety centers and other patient safety programs. The Florida Patient Safety Corporation created a Near Miss Reporting System (NMRS) website in 2006 to help healthcare providers improve the quality and safety of care and reduce harm to patients. Under the NMRS:
In July 2005, President Bush initiated a national medical error prevention policy by signing into law S.544, the Client Safety and Quality Improvement Act, which established a voluntary confidential reporting system to create a national database of medical errors for analysis and development of evidence-based client safety measures. Private Sector Response Most notable in the private sector for improving performance standards has been the Leapfrog Group, a consortium of several Fortune 500 companies and other private and public health care purchasers, sponsored by the Business Roundtable. The Leapfrog Group seeks to create meaningful marketplace incentives for the healthcare sector to adopt systemic quality improvement processes, and encourages large employers to reward health plans and hospitals that make breakthrough improvements in patient safety and quality. The Leapfrog Group has identified three initial patient safety standards as the focus for consumer education and information and hospital recognition and reward: . Reduce medication-prescribing errors using CPOE; . Refer patients undergoing certain high-risk procedures to high volume hospitals); and . Staff ICUs with intensivists (i.e., physicians certified in critical care medicine). Error-Prone SituationsBecause the healthcare system is very complex, the likelihood of medical errors is high. Recognizing error-prone situations and "near misses" can facilitate improvements in the system, lead to a reduction in overall errors and improve patient outcomes. Three major error-prone areas include: • Medication practices • Surgical practices • Patient falls The Florida Hospital Association (FHA), in its efforts to improve patient safety, has suggested several guidelines for improvement in these three areas. Medication Errors The 2000 IOM report placed medication errors among the most common preventable mistakes in hospitals, contributing to more than 7,000 deaths annually. One recent study found that medication errors occur in nearly one of every five doses in hospitals and skilled nursing facilities. Medication errors are one of the most common areas identified in incident reports and sentinel events. Medications with similar names, but different action classes, effects, and dose ranges further complicate the medication management process. According to the Florida Hospital Association, their Patient Safety Steering Committee has developed safe medication practices that focus on the ordering, prescribing, dispensing, and monitoring of drug therapies.
It directs the ordering healthcare practitioner to gather essential patient data prior to writing any medication orders. This information should include: diagnoses, allergies and sensitivities, lab values, current medications and other pertinent data. It encourages the practitioner to be involved in reviewing hospital formularies with the Pharmacy and Therapeutics Committee, to have essential medication references on hand when prescribing and to help in developing special protocols for the use of "high risk" medications. According to the U.S. Pharmacopeia (USP), insulin, heparin, warfarin and albuterol are the medications most often associated with errors. Safe medication practices require the practitioner to use the metric system only, to avoid abbreviations and to avoid confusing orders such as "resume same meds" and "resume pre-op medications". Verbal and telephone orders are being discouraged unless absolutely unavoidable. Florida took a simple but important step towards improving client safety on July 1, 2003, when 456.42, F.S. went into effect. This law requires physicians in Florida to either print legibly or type prescriptions and to include the name and strength of the drug prescribed, the quantity of the drug prescribed in both textual and numerical formats, and the directions for taking the drug.
Safe practices for dispensing medications by the pharmacist should include a process to clarify incomplete or illegible orders and a process for double-checking mathematical calculations. The environment in the pharmacy should minimize distractions and interruptions. Single-dose vials and ampoules should be dispensed from the pharmacy whenever available, to minimize the risk of over-dosing. Many facilities are using medication dispensing systems, such as Sur-Med and PYXIS, which record who removed the individual dose of medication, for which patient, at what time and date. The system can generate reports for drug counts and discrepancies, as well as other vital information. Only healthcare providers who are knowledgeable about a medication's use, precautions, contraindications, potential adverse reactions, interactions and appropriate route of administration should administer medications. The medication administration record (MAR) should have both brand and generic drug names to minimize confusion. All math calculations should be double-checked with another nurse. Changes in the environment to minimize distractions, improve lighting and provide current reference material will be beneficial for the administration of correct medications. All rights of administration should be confirmed (right patient, right drug, right dose, right dose form, right route, right time and right education) before administration. The healthcare practitioner (HCP) should monitor patients who are receiving medications with narrow therapeutic windows. The practitioner should order drug levels for digoxin, theophylline, lithium and phenytoin; lab tests for monitoring effectiveness of heparin and warfarin; and peak and trough levels for antibiotics such as vancomycin and gentamycin. The HCP should then review the lab results and intervene appropriately. Surgical Errors Although many people are under the impression that medical errors only involve drugs, surgical errors account for 2/3 of all adverse events and 1 out of 8 hospital deaths, and include: • Wrong side/site surgeries (right leg amputated instead of the left, or healthy organ removed) • Surgery to remove a foreign object left behind from a previous surgery. A JCAHO review found that wrong-site surgery was most common in orthopedic procedures. Risk factors contributing to the error included: more than one surgeon involved in the case, multiple procedures performed during a single operating room visit and unusual time pressures - particularly pressure to speed up preoperative procedures. JCAHO recommendations for preventing these types of errors include: • Clearly marking the surgical side/site. • Involving family/patient in the marking of the side/site. • Use of a pre-operative verification process. • Calling a "time out" just before the start of the procedure for a verification process including the entire procedural staff. Falls A fall is defined as: "An unintentional event resulting in a person coming to rest on the ground/floor or other lower level ( witnessed ), or reported to have landed on the floor ( unwitnessed ), not due to any intentional movement or extrinsic force such as stroke, fainting or seizure." The National Patient Safety Foundation thinks that early identification of risk is the key to the prevention of patient injuries. Since falls are usually the result of several factors, Fall Prevention Programs should use a multi-faceted approach. The interdisciplinary program should include:
Diagnostic Inaccuracies An accurate diagnosis is the first requirement for correct and effective treatment. Inaccurate diagnosis may delay treatment or result in incorrect, ineffective treatment or unnecessary tests, which can prove costly and invasive. Misdiagnoses lead to incorrect choice of therapy or to no therapy when needed. Diagnostic inaccuracies may also include misinterpretation of test results, failure to relay or to act on abnormal results. System Failures
A system is a collection or assembly of parts (processes) that, when unified, make a whole. In a facility, the system may be defined as "an interdependent group of items, people, or processes with a common purpose." A process is a series of interdependent steps leading to a conclusion, resolution, or action. Process problems may result from variable input. For example, a process may appear very complete on paper. However, things may change when the patient's personality, preferences, medical condition, or tolerance level is taken into consideration. Inconsistencies in the process may lead to misunderstanding and/or omissions. Other problems may occur because of the complexity of a process. The greater the number of steps in a process, the greater the potential for an error to occur. Research on system failures that have led to major industrial disasters (Peterson, 1996) found that the systems that failed had nine characteristics in common:
Healthcare systems with these characteristics create an unsafe environment for both clients and staff. Equipment Failures It isn't always user error when equipment fails. However, proper training on all equipment is essential, and is required during the healthcare worker's orientation process. Additional training occurs per institution policy and as needed. The patient may also need training on the proper use of a piece of equipment. All patient education must be documented, along with an evaluation of the patient's understanding and/or the patient's return demonstration. This helps to ensure safety for both healthcare workers and patients. Occasionally, equipment has a design flaw. Inferior equipment may not meet standards, or function appropriately, making it unsafe. The Occupational Safety and Health Administration (OSHA) requires proper maintenance of equipment as a safety standard. For example, within the last 10 years, 1000 deaths have been linked to infusion
The maintenance or bio-medical department must provide adequate servicing of equipment and maintain adequate documentation and record keeping on all service provided. Any piece of equipment that is not functioning properly must be removed from use, appropriately labeled with the problem, and the maintenance department must be notified, per facility policy. High Risk Patient PopulationsPatient safety is a basic element of good nursing care. Certain patient populations are at greater risk for adverse effects and outcomes related to medical errors. These groups include the elderly, the young, psychiatric patients and intensive care patients. These populations are more at risk of causing their own deaths. Factors that decrease someone's ability to participate in their own care may increase the likelihood of adverse events. Such factors include: • Decreased cognitive function • Decreased sensory function • Learning disabilities • Developmental disabilities
The normal aging process commonly includes some degree of impairment in vision and hearing, and older people may also suffer varying degrees of cognitive impairment. Alone or in combination, these problems contribute to difficulties in communication between clients and care providers. When caring for older clients, communication with a responsible family member or other client advocate is essential. Elderly patients are frequently on several medications, but, because of the aging process, their bodies have a decreased ability to absorb, distribute and eliminate drugs. Older clients are also at high risk of falling, because of medication effects, existing health problems such as arthritis, confusion or other cognitive deficit, or postural hypotension. Many older people need to use the bathroom during the night and require assistance to avoid falls.
Pediatric Patients Young children and infants cannot participate in their care, or question therapies and treatments. Weight dosing is required for all pediatric medication, and overdose can be potentially fatal. The younger the patient, the greater the risk of serious medication errors. Errors often occur when physicians or pharmacists convert dosage from pounds (for adults) to kilograms (for children). The USP advises that parents should know their child's weight in kilograms and reconfirm with the doctor that the dosage is correct for that weight. Most pediatric medication errors are due to mathematical miscalculations, especially in relation to decimal point, rounding of numbers and the use of multi-dose vials. Parents of infants and children need to be fully informed and involved in their child's care during hospitalization, and must be educated to question caregivers about medications and procedures. Children are also at an increased risk for sentinel events such as abduction or discharge to the wrong person/family.
Psychiatric Patients Psychiatric patients may have cognitive impairment and find it difficult to participate in their care. They are often on sedative and psychotropic medications that change perceptions of reality. They can be depressed or delusional. They are at an increased risk for sentinel events from medication errors and death or injury from restraints and falls. Patients in Intensive Care Intensive care units (ICUs) host the sickest clients, which makes them more vulnerable to medical errors and more prone to injury. Other At-Risk Populations Other populations at increased risk of medical errors include persons with limited literacy skills and persons of different cultures who lack mastery of the English language. Many hospitals have translators available for clients who do not speak English. If translation assistance is not available, communicating with a family member or other support person is essential. It is important to keep your words simple and concrete, and to use pictures or diagrams to explain procedures. Pregnant women, patients with liver/renal impairment, those with developmental disabilities and low-income populations are also at increased risk of medical errors. Factors Increasing the Risk of Medical Errors Human beings may have problems with: • Use of knowledge • Performance of skills • Decision-making • Choice of the right course of action once a decision is made. About 10% of the time, a lack of knowledge is the problem. Taking the time to look up the policy and procedure for central line care, for drawing blood, or for giving an in-line respiratory treatment is much easier than treating a patient for a hospital-acquired infection. Remember, if you try a new task without the proper training, you will probably use the "trial and error" method. That may result in a medical error.
Two skills that may be performed poorly are communication and handwriting. If either verbal or written communication is incomplete, incorrect or illegible, these may lead to inappropriate decision-making or improper diagnosis and treatment of the patient. Communication includes the medical record, which records the care and safety measures provided for the patient. Gaps in communication lead to medical errors. Gaps in communication include: • Miscommunication during shift-to-shift report • Incomplete information before transfer of a patient from one healthcare setting to another • Caregivers failing to document changes in the patient's condition in the medical record • Families not communicating information about the patient's current and previous conditions or the patient's history of falls to the healthcare provider Incorrect information leads to incorrect decisions and actions. Illegible handwriting and use of abbreviations by physicians and other healthcare professionals are mentioned in many medication error reports. Research has shown that certain factors can increase the error rate :
|
|||||
Falls are a commonly reported sentinel event, and can be fatal. Older clients are not the only population at risk. Any client who has had excessive blood loss may experience postural hypotension, increasing the risk of falling. Maternity clients or other clients who have had epidural anesthesia are at risk for falls due to decreased lower-body sensation. Factors that increase the risk of falls include: 
The Agency for Healthcare Research and Quality (AHRQ) has shown that medical errors result most frequently from systems errors - the organization of healthcare delivery and the ways resources are provided in the delivery system. Only rarely are medical errors the result of the carelessness or misconduct of a single individual. 
pumps. Causes of problems include: 
Elderly Patients 
Occasionally, a person knows how to perform a task correctly, but decides to take a shortcut. Choosing the wrong course of action doesn't save time. Having to redo or fix mistakes takes more time than doing it the right way the first time! "If you don't have time to do it right the first time, when will you have time to do it over?"