High Risk Patient Populations
Patient 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 sensitive 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.
Young children and infants cannot participate in their care, or question therapies and treatments. 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. Weight dosing is required for all pediatric medication, and overdose can be potentially fatal. 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.
Children are also at an increased risk for sentinel events such as abduction or discharge to the wrong person/family.
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.
Risk Reduction Strategies for Improving Outcomes
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.
Information technology is being used to 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. Now computerized systems for order entry and prescribing have demonstrated decrease of the morbidity and mortality rates from drug errors by eliminating poor handwriting. 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.
Prevention of medication errors is an important step in improving patient outcomes. 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.
Gaps in communication can be minimized by system changes. Some changes 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