Nursing Unlimited - HIV Course Page 2

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.

Risk Reduction Strategies for Improving Outcomes

A Continuous Patient Safety Improvement Committee can identify processes to improve patient outcomes. Risk reduction strategies for identified sentinel events can be found in Sentinel Event ALERT issues published for Joint Commission accredited organizations and interested healthcare professionals.

Increasingly, information technology is being used to reduce errors. Computerized systems for order entry and prescribing can decrease the morbidity and mortality rates from drug errors by eliminating poor handwriting. Although computerized physician order entry (CPOE) can reduce errors by 55 to 86 percent, the high costs associated with CPOE have been a deterrent to its widespread implementation.

According to the Medication Errors Reporting Program, approximately 15% of medication errors were related to similar names. Using both brand and generic names for drugs, and writing the purpose of the drug on the prescription will help clarify the drug order. Written information to the patient should also include both the brand and generic names. Bar coding of medication is being used in some facilities. The medication and the patient's wristband are bar coded to confirm that the patient is receiving the right drug. Both are scanned to record drug administration.

CPOE, combined with sophisticated alerts, can detect potential negative drug interaction, dosage irregularities, conflicts with other medical problems, etc., and can greatly reduce errors . It is estimated that computerization and bar coding can reduce medication errors by 90%. In his 2004 State of the Union address, President Bush noted that "by computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care." In April of that year he pledged to make interoperable electronic health records available for most Americans within ten years.

Although gaps in communication are inevitable, they can be minimized by system changes. Some changes noted in the literature include:

• Nurses no longer accepting verbal orders from physicians when the physician is present

• Pharmacies having "active medication lists" that transfer with the patient from one area to another within the facility

• Abbreviation use is limited, and facility policy and procedure dictates acceptable use

JCAHO OFFICIAL "DO NOT USE" ABBREVIATION LIST
Do not use	Potential problem	Use instead
U (unit)	Mistaken for "0" (zero), the number "4," (four) or "cc"	Write "unit"
IU (International Unit)	Mistaken for IV (intravenous), or the number 10 (ten)	Write "International Unit"
Q.D., QD, q.d., qd (daily)	Mistaken for each other	Write "daily"
Q.O.D., QOD, q.o.d, qod (every other day)	Period after the Q mistaken for "I" and the "O" mistaken for "I"	Write "every other day"
Trailing zero (X.0 mg)*	Decimal point is missed	Write X mg
Lack of leading zero (.X mg)	Decimal point is missed	Write 0.X mg
MS	Can mean morphine sulfate or magnesium sulfate	Write "morphine sulfate"
MSO 4 and MgSO 4	Confused for one another	Write "magnesium sulfate"

Safety training during staff orientation must include policies and procedures, as well as safe equipment use. Education must be ongoing, and not just focus on performance. Even the most educated staff member can make a medical error, so other safeguards must be in place.

In July 2001 the Agency for Healthcare Research and Quality released a report outlining evidenced-based clinical recommendations for improving client safety. Titled Making Healthcare Safer: A Critical Analysis of Client Safety Practices , the report reviews 79 practices to prevent adverse events and improve client safety, based on current research. The eleven most highly rated practices are listed below. The authors of this report emphasized that this list should not be considered complete, and that it was weighted toward care of the very ill, rather than the mildly or chronically ill.

• Appropriate use of prophylaxis to prevent venous thromboembolism in clients at risk

• Use of perioperative beta-blockers in appropriate clients to prevent perioperative morbidity and mortality

• Use of maximum sterile barriers while placing central intravenous catheters to prevent infections

• Appropriate use of antibiotic prophylaxis in surgical clients to prevent perioperative infections

• Asking that clients recall and restate what they have been told during the informed consent process

• Continuous aspiration of subglottic secretions (CASS) to prevent ventilator-associated pneumonia

• Use of real-time ultrasound guidance during central-line insertion to prevent complications

• Client self-management for warfarin (Coumadin) to achieve appropriate outpatient anticoagulation and prevent complications

• Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical clients

• Use of antibiotic-impregnated central-venous catheters to prevent catheter-related infections

The AHRQ has also developed three sets of web-based Quality Indicators (QIs), which hospitals and other healthcare providers can download free of charge: Preventive Quality Indicators (PQIs), Inpatient Quality Indicators (IQIs) and Patient Safety Indicators (PSIs). All three use readily available hospital inpatient administrative data.

• The PQIs focus on hospitalizations that could have been avoided with timely access to outpatient care or conditions that could be less severe with early interventions.

• The IQIs measure the quality of care in hospitals and include inpatient mortality for certain procedures and medical conditions; utilization of procedures for which there are questions of overuse, under use and misuse; and volume of procedures for which there is some evidence that a higher volume of procedures is associated with lower mortality.

• The PSIs detect potential adverse events, such as surgical complications and iatrogenic conditions associated with hospitalization.

To speed the most urgent improvements in client safety, the Institute for Healthcare Improvement (IHI), a nonprofit organization headquartered in Cambridge, Massachusetts, launched the 100,000 Lives campaign in December 2004. The American Medical Association, the American Nurses Association, and JCAHO signed on as collaborators, together with four government agencies: the Centers for Disease Control and Prevention, the Centers for Medicare and Medicaid Services, the Veterans Health Administration, and AHRQ.

This campaign focuses on six basic measures that could save as many as 100,000 lives each year if even 2,000 hospitals adopted them. The good news is that nearly 3,000 hospitals enrolled in this campaign in its first year. The six measures are based on the best practices from AHRQ's Making Healthcare Safer report and include:

To encourage reporting, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has revised its policy on reporting medical errors. Before, when a serious event was reported, JCAHO immediately investigated. They might place the facility on accreditation watch, and alert the public of the status change. Now, the facility will have time to investigate and institute corrective measures.

The medical practitioner who must tell a patient or family of a medical error needs to shift from using "I" to using "we". (Example: " We missed the signs of the heart attack." Do not say, " I am devastated at being responsible for this.") This represents a paradigm shift in the way we think of medical errors. The focus is now on "system failures". The practitioner involved should only "take the blame" after the corporate investigation is completed and the practitioner is found to be at fault. Current research suggests that when hospitals honestly admit blame to parties harmed by medical errors, the result is a more realistic settlement reached out of court and without prolonged litigation. This is seen as a benefit to both parties.

Reporting Responsibilities

The reporting of medical errors is everyone's responsibility. Exact reporting requirements for adverse medical incidents can be found in Chapter 395.0197(4) of the Florida Statutes. Reporting sentinel events to JCAHO is voluntary. However, Florida law makes such reporting mandatory. Florida's Comprehensive Medical Malpractice Reform Act of 1985 (F.S. 395.0197) mandates that each licensed hospital and ambulatory surgery center implement a risk-management program with state oversight and an internal incident-reporting system. State oversight is provided by the Florida Agency for Healthcare Administration (AHCA). Each licensed facility is required to hire a risk manager, licensed under F.S. 395-10974, who is responsible for implementation and oversight of the risk management program.

Statute 395.0197 mandates internal reporting of any adverse incident (event) "over which healthcare personnel could exercise control, and which is associated in whole or in part with medical intervention, rather than the condition for which such intervention occurred, and which:

• A resulting limitation of neurologic, physical, or sensory function which continues after discharge from the facility

• Any condition that required specialized medical attention or surgical intervention resulting from non-emergency medical intervention, other than an emergency medical condition, to which the client has not given his or her informed consent, or

• Any condition that required the transfer of the client, within or outside the facility, to a unit providing a more acute level of care due to the adverse incident, rather than the client's condition prior to the adverse incident

Was the performance of a surgical procedure on the wrong client, a wrong surgical procedure, a wrong-side surgical procedure, or a surgical procedure otherwise unrelated to the client's diagnosis or medical condition
Required the surgical repair of damage resulting to a client from a planned surgical procedure, where the damage was not a recognized specific risk, as disclosed to the client and documented through the informed-consent process, or
Was a procedure to remove unplanned foreign objects remaining from a surgical procedure. (F.S.395.0197)

All incident reports must be filed with the risk manager of the healthcare organization or his or her designee within three days after the event occurred. Following receipt of the report, the risk manager in turn must report the event to the Florida Agency for Healthcare Administration.

In addition to their internal reporting system, Florida hospitals and ambulatory surgical centers also must submit two types of reports to the Florida AHCA:

Code 15 reports, which report in detail on each serious client injury, the facility's investigation of the injury, and whether the factors causing or resulting in the adverse incident represent a potential risk to other clients. The findings of that investigation must be reported to AHCA within 15 days of an adverse incident. Failure to comply with this mandate may result in fines of as much as $25,000.
The annual report, which includes all adverse incidents that occur in the facility and malpractice actions (new, pending, and closed) in the course of a calendar year. Facilities are also required to report any injuries of which they are aware that occur through any healthcare service, including nursing homes, home health organizations, doctors' offices, dentists' offices, or any other purveyor of healthcare service. Florida Statute 641.55 requires similar reporting of client injury incidents by HMOs. These reports are due after the first of each year for the previous year.

Florida law (F.S. 395.051) also requires that hospitals and other healthcare facilities notify each client-or an individual identified pursuant to 765.401(1) F.S.-in person about adverse incidents that result in serious harm to the client. "Notification of outcomes of care that result in harm to the client under this section shall not constitute an acknowledgment or admission of liability, nor can it be introduced as evidence."

According to Carmela Coyle of the American Hospital Association, "reporting should be designed to stimulate organizations and practitioners to analyze what went wrong". We must implement a forum for identifying mistakes, discussing them, learning from them, and preventing them from happening again. Incident reports (official, legal, written reports that document the facts of an actual or potential medical error) are one way of documenting the facts of an incident. Follow your facility's policies and procedures for documentation of an incident/event. Generally, all persons involved in finding an error or participating in a medical error should factually document:

• What measures/actions/orders were implemented to correct the error, or to improve the patient's condition

JCAHO requires that a thorough, credible root cause analysis (RCA) and corrective action plan be performed for each reported sentinel event within 45 days of the event's occurrence or of the organization's becoming aware of the event. According to JCAHO research, the leading root causes of sentinel events between 1996 and 2004 were communication, orientation/training, client assessment, and staffing. The goals of a root cause analysis is to find out what happened, why it happened and what to do to prevent it from happening again.

Root cause analysis is a process for identifying the causal factors that underlie variation in performance. The focus is on systems and processes, not individual performance. A root cause analysis is:

• Progress from special causes in clinical processes to common causes in organizational process

• Identify changes which could be made in systems and processes to reduce the risk of such events occurring in the future

Action Plan : The product of the root cause analysis that identifies strategies that the organization intends to implement to reduce the risk of similar events in the future. The plan should address:

• Assemble a team of staff members from all levels closest to the issue involved.

• Designate a team leader to schedule the meetings and assist the team in developing an agenda for each meeting.

• Due to the nature of the team's work, it should be completed in a timely fashion with confidentiality.

• Begin by clearly defining the problem, outlining the sequence of events, and identifying those involved.

• Areas to address include human error, contributing systems, and environmental factors.

• Identify the relationships between the causes and effects. Use of a flowchart may be helpful.

• Develop recommendations pertinent to the contributing factors. Consider what will be involved to implement any changes.

• Specify an evaluation plan to determine if patient outcomes through error-reduction are improved.

Patient Involvement in Prevention Strategies

"Educate before you medicate: Knowledge is the best medicine". The National Council on Patient Information and Education used this title for their October 2000 website message. Healthcare providers have the opportunity to help patients understand the importance of compliance with medications. There is mounting evidence that, when physicians involve their patients in clinical decisions, there is better understanding and compliance with treatments and medical regimens. Family members and significant others should be involved in the learning process so that they can help the patient. Healthcare providers need to utilize critical thinking skills and establish a connection between their actions and the possible outcomes, both positive and negative.

The Agency for Healthcare Research and Quality has several patient and family teaching tools available on-line. They can be printed from http://www.ahrq.gov/consumer and used in your facility. Two of the Patient Fact Sheets are summarized below.

• Talk with your doctor and healthcare team about your options if you need hospital care.

1. The single most important way you can help to prevent errors is to be an active member of your healthcare team.

2. Make sure that all of your doctors know about everything you are taking. This includes prescription and over-the-counter medicines and dietary supplements, such as vitamins and herbs.

3. Make sure your doctor knows about any allergies and adverse reactions you have had to medicines.

5. Ask for information about your medicines in terms you can understand - both when your medicines are prescribed and when you receive them.

6. When you pick up your medicine from the pharmacy, ask: "Is this the medicine that my doctor prescribed?"

8. Ask your pharmacist for the best device to measure your liquid medicine. Also, ask questions if you're not sure how to use it.

9. Ask for written information about the side effects your medicine could cause.

10. If you have a choice, choose a hospital at which many patients have had the procedure or surgery you need.

11. If you are in the hospital, consider asking all healthcare workers who have direct contact with 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 use at home.

• If you are having surgery, make sure that you, your doctor and your surgeon all agree and are clear on exactly what will be done.

15. Make sure that someone, such as your personal doctor, is in charge of your care.

16. Make sure that all healthcare professionals involved in your care have important healthcare information about you.

17. Ask a family member or friend to be there with you and to be your advocate (someone who can help get things done and speak up for you if you can't).

20. Learn about your condition and treatments by asking your doctor and nurse and by using other reliable sources.

The Joint Commission for accreditation of Healthcare Organizations set the following National Patient Safety Goals for 2003:

• Accurately and completely reconcile medications across the continuum of care

• Reduce the risk of influenza and pneumococcal disease in institutionalized older adults

• Implementation of applicable National Patient Safety Goals and associated requirements by components and practitioner sites

• Encourage patients' active involvement in their own care as patient safety strategy

As of January 1, 2008, all Joint Commission accredited health care organizations and the Disease-Specific Care certified programs will be surveyed for implementation of applicable 2008 goals and requirements-or acceptable alternatives-as appropriate to the services the organization or program provides.

• Using at least two client identifiers (neither of which is the client's room number) whenever administering medications or blood products.

• Final verification before surgery to confirm the correct patient procedure and body site

• A "read-back" of all oral or telephone orders for medications and procedures (may consider 2 nurses to confirm prn)

• Using a pre-operative process to confirm that appropriate documents, such as records and images, are available for surgery

• Ensuring that alarms are activated, set appropriately, and can be heard by the person monitoring them

• Implementing a process for obtaining and documenting a complete list of the client's current medications upon the client's admission to the organization and with the involvement of the client.

Since the IOM's To Err Is Human presented its dramatic findings of preventable death and injury in US hospitals in 2000, notable advances have been made. They include the development of performance standards, an increase in error reporting, integration of information technology and improved safety systems. However, more is still needed to improve safety and reduce errors, including the development of data standards for patient safety information, the establishment of a national health information infrastructure and a need for comprehensive patient safety programs in healthcare organizations. The reduction of medical errors must remain a top priority for all healthcare professionals.