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This course fulfills the Florida requirement for 2 hours of continuing education in prevention of medical errors, both for initial licensure and biennial renewal.
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COURSE OBJECTIVE: The purpose of this course is to prepare Florida nurses and other healthcare professionals to prevent medical errors in the practice setting using current, evidence-based information.
Upon completion of this course, you will be able to:
Medical errors are a serious public health problem that threatens patient safety. In the 1950s medical errors were considered to be the price paid for modern diagnosis and therapy. But over the ensuing decades, medical errors have increased to epidemic proportions and currently are the third leading cause of death in the United States. Those in leadership roles claim that error reduction is extremely difficult due to the complex nature of healthcare facilities and the fact that patients are very sick. Our expanding awareness of this issue demands improvement in our understanding of the problem and in finding effective solutions and prevention strategies to make our healthcare system safer.
Acknowledging that errors happen, learning from them, and working to prevent future errors represents a major change in the culture of healthcare—a shift from blame and punishment to analysis of the root causes of errors and the creation of strategies to improve. In other words, healthcare organizations need to create a culture of safety that views medical errors as opportunities to improve the system. Every person on the healthcare team has a role in making healthcare safer for patients and workers.
The Institute of Medicine (1999) defines an error as “the failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve an aim (i.e., error of planning).” To ensure consideration of all relevant issues related to medical errors, the Quality Interagency Coordination Task Force (a federal entity overseen by the Agency for Healthcare Research and Quality), has expanded the definition as follows:
An error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems.
An adverse event is an injury caused by medical management rather than the underlying condition of the patient. An adverse event attributable to an error is a preventable adverse event.
The Joint Commission defines a sentinel event as “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. The phrase ‘or the risk thereof’ includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.” Sentinel events are so named because they signal the need for immediate investigation and response (JC, 2013a).
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. Near misses provide opportunities for developing preventive strategies and actions and should receive the same level of scrutiny as adverse events.
Never events are errors that should never happen. The National Quality Forum identifies these as Serious Reportable Events (SREs) and groups them into the categories of:
Research on why humans make errors (Reason, 1990) has identified two types of errors: active and latent. Active errors (human errors) are those that involve individuals who are actually doing a task, and their effects are felt almost immediately. Latent errors are errors in system or process design, faulty installation or maintenance of equipment, or ineffective organizational structure.
Latent errors are present but hidden and may go unnoticed for a long time with no ill effect. However, when a latent error combines with an active human error, an event occurs. The active human error triggers the hidden latent error causing an adverse event.
A root cause is an action, deficiency, or decision that if corrected, eliminated, or avoided will eliminate the undesirable consequence. The most common root cause of medical errors is communication problems, which can include unclear lines of authority, inadequate error sharing, or disconnected reporting systems. Other root causes involve:
A decade and a half has passed since the IOM published To Err Is Human: Building a Safer Health System. This landmark report revealed an epidemic of medical errors in the United States, with an estimate of up to 98,000 people dying each year due to mistakes made in hospitals (IOM, 1999). In 2010, the Office of Inspector General for the Department of Health and Human Services reported that more than 180,000 patients enrolled in Medicare alone die in a given year because of poor hospital care (U.S. DHHS, 2010).
In 2013, the Journal of Patient Safety reported that between 210,000 and 440,000 patients each year who enter a hospital experience some type of preventable harm that contributes eventually to their death, making medical errors the third-leading cause of death in America behind heart disease (the first) and cancer (the second). The study also reported that tens of thousands also die from preventable mistakes made outside hospitals in outpatient settings and the community, including deaths from missed diagnoses or injuries from medication (James, 2013).
A recent study of medical malpractice claims showed that slightly more than half (52.5%) of the paid claims related to outpatient care. Most malpractice claims for hospital care are related to surgical errors, whereas most claims for outpatient care are related to missed or late diagnosis. Medication errors are also common in outpatient malpractice claims, particularly those related to transition from hospital to community-based care (Bishop et al., 2011).
Medical errors add substantially to the direct costs of healthcare and to the loss of income. “More than 400,000 Medicare ‘never events’ occurred in the United States in 2008, with an estimated total cost of $3.7 billion. The cost of these events constitutes 22% of the total cost for medical errors” (van den Bos et al., 2011).
It is not uncommon for healthcare facilities to take cost-containment measures that reduce staffing, particularly RN staffing. When this occurs there is an increase in medical errors and poor outcomes. An analysis of data from nearly 200,000 hospital admissions and 176,000 nursing shifts of eight hours each showed that staffing of RNs below target levels was associated with increased mortality (Needleman et al., 2011).
Errors can be placed into five general categories: surgical, diagnostic, medication, devices and equipment, and systems failures (including healthcare-associated infections, falls, and healthcare technology).
Surgical errors (or surgical adverse events) account for a high percentage of all adverse events. According to a study by the Johns Hopkins University School of Medicine reported in 2012, at least 4,000 surgical errors occur in the United States each year. National data was analyzed and it was estimated that 80,000 “never events” occurred in U.S. hospitals between 1990 and 2010 and that the figure may be on the low side (Johns Hopkins Medicine, 2012).
The Joint Commission found that robotic surgery, a relatively new technological procedure, resulted in an increase in surgery-related sentinel events from 2006 to 2013. Complications were usually due to hemorrhage caused by lacerations and injury to surrounding tissues (JC, 2014a).
The Joint Commission estimates the death toll from diagnostic errors at 40,000 to 80,000 per year, with 40,500 preventable deaths arising in the ICU alone. One patient in every six has personally been affected or has had a family member or friend affected. Almost half of pediatricians come upon one or more diagnostic errors every month, and 1 in every 1,000 primary care encounters will cause preventable harm from diagnostic error (JC, 2014b).
Although delayed or inaccurate diagnoses are often attributed to physician error, members of the healthcare team can and do contribute to delayed or inaccurate diagnoses due to information gaps and communication problems.
Most diagnostic errors occur in primary care settings and most frequently in the testing phase (failure to order, faulty interpretation of results, missed follow-up and tracking) (Joszt, 2013).
Other errors were attributed to failure to make referrals and patient-related issues such as inaccurate medical histories (Wood, 2014).
Misdiagnosis occurs in diagnostic radiology when the radiologist or interpreting physician fails to see an abnormality that is present on the image due to what has been called an unexplainable “psycho-visual phenomenon.” Many other radiologic errors are cognitive: the abnormality is plainly visible but is not appreciated because of lack of understanding or poor judgment (Berlin, 2011).
The most common cognitive error that clinicians make is the premature closure of the diagnostic process, where common benign diagnoses are made for patients with uncommon serious disease, signaling a need to broaden differential diagnosis. It is to be noted that a lot of symptoms patients present with are vague, such as fatigue, resulting in a vague differential diagnosis.
Sentinel event statistics compiled by the Joint Commission from 2004 to 2013 show that one of the most frequently reported events is delay in treatment. In 2013 delay in treatment was the third most documented reviewable sentinel event. This includes delays in medication, lab testing, physical therapy, or any other kind of treatment (Wyatt, 2014).
Diagnostic errors increase costs due to the need for hospital readmission that could have been avoided if the correct diagnosis had been made. Another source of unnecessary costs is unwarranted treatments given due to a wrong diagnosis (Wood, 2014).
The National Coordinating Council for Medication Error Reporting and Prevention (2014) defines a medication error as:
Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Such events may be related to professional practice, healthcare products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.
In a study conducted by the Economic Cycle Research Institute (ECRI) patient safety organization, it was found that the phase of the medication process in which the highest number of medication errors occurred was during the administration phase, and more than a third involved intravenous errors (Oh, 2012a).
According to the Joint Commission (2014c), tubing and catheter misconnections are “a persistent and potentially deadly occurrence.” Although misconnections are often caught and corrected before the patient is injured, these AEs can have life-threatening consequences. This is a complex issue involving medication errors and equipment design problems. Medications are being delivered via the wrong route, and equipment design leads to making such misconnections.
Luer connectors were implicated in many of the misconnections. These universal connectors have a “female” and a “male” component designed to lock together. Unfortunately, this universal design allows tubes or catheters with dissimilar function to be connected, with potentially disastrous results. Other factors contributing to misconnections include the routine use of tubes or catheters for unintended purposes, such as using IV extension tubing for epidurals, irrigation, drains, and central lines.
In addition, movement of a patient from one setting to another and staff fatigue related to working consecutive shifts contribute to these adverse events (JC, 2014c).
Patient’s feeding tube was inadvertently connected to the instillation port on the ventilator in-line suction catheter, delivering tube feeding into the patient’s lungs, causing death. (Source: FDA, 2013.)
Design flaws, misuse, and malfunction of medical devices and equipment are all common causes of medical errors. Subtle differences in a familiar pattern using a device can affect the speed and accuracy of data entry, and the lack of standardization invites user mistakes. Poor medical device design and lack of usability testing have also been repeatedly discussed as being key factors in many device-related incidents.
An increasing number of medical devices are also implanted in patients. These include cardiac pacemakers, defibrillators, and deep brain stimulation neurotransmitters to control tremors in people with Parkinson’s disease. Any malfunction of such devices can be serious and even life threatening.
HAIs are considered a systems failure. According to the CDC, 1 of every 20 hospitalized patients will experience a healthcare-acquired infection. These infections lengthen hospital stays, cost U.S. hospitals an estimated $33 billion annually, increase patients’ pain and suffering, and can prove fatal.
Failure of physicians, nurses, and other caregivers to practice basic hand hygiene helps spread bacteria, some of which are antibiotic-resistant and can prove life-threatening. Studies have shown that hospital workers wash their hands as little as 30% of the time that they interact with patients and that physicians tend to be the most resistant to hand hygiene (Hartocollis, 2013).
Falls are also considered a systems failure. Falls are a commonly reported sentinel event in 24-hour care facilities and can be fatal. Each year, one third of people over 65 suffer a fall, and one third of these falls cause both fatal and nonfatal injuries. In 2013 the Joint Commission reviewed 82 fall-related events resulting in death or permanent loss of function (JC, 2013b).
Older patients are not the only population at risk. Any patient who has had excessive blood loss may experience postural hypotension, increasing the risk of falling. Maternity patients or other patients who have epidural anesthesia are at risk for falls due to decreased lower-body sensation.
Risk factors associated with falling are clinically identified as either intrinsic or extrinsic. Intrinsic factors include the characteristics or conditions of a person, which can include vision, gait, and health history. Intrinsic factors may or may not be modifiable. Extrinsic factors involve conditions outside the person, such as environmental hazards and medications. Extrinsic factors are modifiable.
The Institute of Medicine (IOM) has evaluated safety concerns and identified actions that can be taken to lessen safety risks linked with health IT. The literature about health IT and patient safety is inconclusive, yet it shows substantial potential hazards for patient safety (IOM, 2012).
While adoption of EHR systems offers to provide substantial benefits, there are serious unintended consequences that have emerged from their implementation. Currently, there is no regulatory framework to monitor EHR system safety and no agreed-upon design standards.
Many providers find that EHRs decrease efficiency and add hours to their workday due to non-user-friendly interfaces and difficult navigation. They report many EHR systems are awkward and time consuming. In addition, they report the computer comes between the patient and provider and fosters distractions.
CPOE can help hospitals reduce ADEs, but only about one third of hospitals have a CPOE system and less than half use barcode medicine administration (BCMA) (Halvorson, 2011). Research shows that BCMA can reduce the rate of potential ADEs as much as 50%, but errors can still occur (Poon et al., 2010).
Only 8% of U.S. hospitals have fully implemented CPOE systems. One obstacle is the upfront cost, which is approximately $1.9 million, with $500,000 per year for maintenance. Another obstacle is resistance by physicians to utilize such tools, instead preferring to rely on practice experience (Leapfrog, 2014).
People age 65 years and older consume more prescription and over-the-counter (OTC) medications than any other age group. Although medications may improve the quality of life and health, they also hold the potential for misuse, overuse, and life-threatening complications.
The older adult population (ages 65 and older) receives more than 50% of all prescription medication, and most who engage in the healthcare system take 6 to 8 medications (polypharmacy). The prevalence of older adults taking five or more medications is close to 7%. In addition to prescription medications, older adults purchase 40% of over-the-counter medications, use OTCs three times more, and use herbals twice as much as the younger population.
The risk for an adverse drug event is 15% with two medications, 58% with five, and 82% with seven or more medications. Nearly 17% of hospital admissions are due to an adverse drug event, and the rate increases to 33% in patients 75 years of age and older. Additionally, while in hospital, 17% of older adults experience an adverse drug event (Bland, 2013).
Visual, hearing, or cognitive problems may lead to misunderstanding of instructions or failure to question an incorrect or unfamiliar drug.
Older adult patients are also at high risk of falling, and medications increase that risk. Researchers in Sweden found that two thirds of patients with hip fracture were prescribed fall risk–increasing drugs before fracture, and the number increased after fracture (Kragh et al., 2011).
Prescribing physicians need to consider the slowed metabolism and excretion of drugs in older adult patients—not only the choice of drugs but also the dosage and timing of administration. Because older adults experience a decrease in total body water and a relative increase in body fat, water-soluble drugs become more concentrated and fat-soluble drugs have a longer half-life.
The potential for ADEs is higher in the pediatric population than that found in hospitalized adult patients. The factors that place them at higher risk include:
Medication dosing errors occur in up to 17.8% of hospitalized children (Wesley & Washick, 2013).
Intensive care units (ICUs) host the sickest patients whose conditions require extraordinarily complex care. Errors associated with drugs can be particularly common in the ICU. Critically ill patients receive nearly twice as many medications as patients in general care units, and most medications involve calculations for bolus administration or continuous infusion. The most common medication error types in ICU are administering the wrong dose, omission of a dose, wrong administration rate, and wrong administration time (Blumenthal, 2014).
The complexity of care in the ICU can lead to life-threatening, sometimes fatal, tubing misconnections, infections, and other complications. These patients often have feeding tubes, chest drainage tubes, and central venous catheters, and the most common types of adverse events in the ICU involve these lines, tubes, and drains.
The National Institutes of Health (2014) reports that less than 60% of the U.S. population has English as a first language, and 10 million Americans speak no English at all. Health literacy is defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Low health literacy is linked to a higher risk of death and more emergency room visits and hospitalizations.
Oversight of healthcare quality in the United States is accomplished through both professionally based accrediting bodies in the private sector and through federal and state regulatory agencies.
The Joint Commission is an independent not-for-profit agency whose mission is to continuously improve the safety and quality of care provided to the public.
The Joint Commission encourages, but does not require, reporting of any sentinel event. However, in the interest of continuous improvement in safety and quality of care, the Joint Commission requires that healthcare organizations:
The sentinel event policy (JC, 2013c) has four goals:
Although accredited facilities are expected to identify and respond appropriately to all sentinel events, but not to report them, if the Joint Commission becomes aware of an event, facilities are required to submit the findings of their root cause analyses and corrective action plans. This information can be included in the Joint Commission’s review of sentinel events, helping track national trends and develop strategies for improving patient safety.
The Joint Commission has issued mandatory goals and recommendations to improve patient safety. Hospitals and other organizations will be evaluated by accreditation representatives to see whether these recommendations or acceptable alternative measures are being implemented. Failure to implement the recommendations could result in loss of accreditation and federal funding.
Misreading medical abbreviations can also be a cause of serious medication errors, and the Joint Commission has created a “do not use” list of abbreviations that endanger patients’ safety and that it requires its members to follow.
The Joint Commission requires that a thorough, credible root cause analysis 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 (JC, 2013d). (See also “Root Causes of Medical Errors” earlier in this course.)
Root cause analysis is a tool for identifying prevention strategies. It is a process that is part of the effort to build a culture of safety and move beyond the culture of blame. In RCA, basic and/or contributing causes are discovered in a focused review process similar to diagnosis of disease—with the goal always in mind of preventing recurrence. The goal of a root cause analysis
Root cause analysis is:
To be credible, a RCA must:
The Accreditation Association for Ambulatory Health Care was founded in 1999 by the AAAHC Institute for Quality Improvement, which offers ambulatory healthcare organizations opportunities to learn about and become involved in performance measurement, benchmarking, and quality improvement. The studies conducted by the institute are designed specifically for ambulatory care environments (AAAHC, 2014).
Ambulatory care organizations are offered accreditation by AAAHC to demonstrate that the organization takes part in ongoing self-evaluation, peer review, and education to continuously improve its care and services. The organization performs on-site surveys by healthcare professionals at least every three years.
In 2006, Congress passed the Deficit Reduction Act of 2005, authorizing Medicare and Medicaid to tie healthcare facilities’ Medicare eligibility to the occurrence of preventable “never events,” and in 2007 the Center for Medicare and Medicaid Services issued a new rule denying reimbursement for treatment to hospitals for treatment of preventable errors, injuries, and infections.
The following preventable complications are no longer reimbursed by Medicare and Medicaid if acquired during an inpatient stay:
Source: CMS, 2014.
Reporting sentinel events to the Joint Commission 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 Health Care 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.
The 2014 Florida Statute 395.0197 mandated internal reporting of any adverse incident (event) over which healthcare personnel could exercise control, that is associated in whole or in part with medical intervention rather than the condition for which such intervention occurred, and that:
Every licensed facility must establish an internal risk management program that must:
Licensed facilities in Florida are required to submit two types of reports to AHCA: Code 15 reports and annual reports.
Code 15 reports must be submitted to the agency within 15 calendar days after its occurrence for any of the following adverse incidents, whether occurring in the licensed facility or arising from healthcare prior to admission to the licensed facility:
The annual report summarizes the incident reports that have been filed in the facility for that year, and includes:
Changes in organizational culture, involvement of leadership, education of providers, development of patient safety committees, adoption of safe protocols and procedures, and use of technology are all essential strategies healthcare facilities must consider in their efforts to reduce medical errors.
The mistaken attitude in healthcare that errors are solely the fault of individual practitioners has proven a major barrier to reporting. When the reporting of medical errors focuses on the identification and punishment of individual health professionals, there is a huge disincentive for reporting errors, and this punitive attitude severely limits the reporting of errors. In fact, research shows that when the fear of punishment is removed, reporting of errors actually increases.
One of the main goals of organizations working to improve patient safety should be to encourage the creation of a “culture of safety” in which medical errors are discussed openly and addressed thoroughly. A culture of safety includes:
A challenge exists in distinguishing between a system that might cause errors, human error that might result in a bad outcome, and reckless behavior that intentionally puts lives or organizations at risk. One popular approach is the Just Culture model developed by David Marx and colleagues (2005), which helps differentiate human error from blameworthy errors. The Just Culture model involves:
A just culture acknowledges that competent professionals make mistakes and recognizes that competent professionals may develop unhealthy norms such as shortcuts and routine rule violations, but has zero tolerance for reckless behavior.
The National Quality Forum (2010) lists “Leadership Structures and Systems” as the first of 34 safe practices for better healthcare, stating: “Leadership structures and systems must be established to ensure that there is organization-wide awareness of patient safety performance gaps, direct accountability of leaders for those gaps, and adequate investment in performance improvement abilities, and that actions are taken to ensure safe care of every patient served.” The overarching goal should be to create and sustain a culture of safety rather than a culture of blame.
HIT has great potential for improvement in the quality and safety of healthcare. Electronic health records (EHRs) should help reduce medication errors, avoid the need to repeat laboratory tests, and improve continuity of care across the healthcare system. Facilities should carefully select the best system available, adopt best practices for EHR implementation and management, monitor how the health IT system is used, and report any adverse events.
Surgical errors are not the sole responsibility of the operating surgeon. All operating room personnel have a role in ensuring patient safety by verifying the surgical site and pointing out a possible error. To reduce the risk of wrong-site, wrong-procedure, or wrong-person surgeries, the Joint Commission developed a Universal Protocol (UP) in 2004 requiring compliance by all accredited hospitals, ambulatory care, and office-based surgery facilities (JC, 2014e). The three principal components of the UP include a pre-procedure verification, site marking, and a time out.
A surgical checklist is an algorithmic listing of actions to be taken in any given clinical situation intended to make everyone aware that others expect these things to be done. Checklists have been responsible for some of the greatest successes of the patient safety era, particularly in improving safety for surgical patients.
“SIGN IN” checklist must be completed before induction of anesthesia (with at least a circulating nurse and anesthetist)
“TIME OUT” checklist must be completed before skin incision (with circulating nurse, anesthetist, and surgeon)
“SIGN OUT” checklist must be completed before the patient leaves the operating room (with circulating nurse, anesthetist, and surgeon)
Source: WHO, 2014.
AHRQ (2012b) has identified four pathways between a healthcare provider’s prescribing decision and the patient who will receive the medication:
For each of the pathways, there are strategies recommended to prevent adverse drug reactions.
There are many facilities that have instituted the practice of medication reconciliation at all transitions in care to prevent adverse drug events. Medication reconciliation is the process of creating the most accurate list possible of all the medications a patient is taking—including the drug name, dosage, frequency, and route—and comparing that list against the physician’s admission, transfer, and/or discharge order. The goal is to ensure the correct medication is provided to a patient at all points of transition within the facility (IHI, 2014a).
Published studies of ADEs have consistently identified certain classes of medications as particularly serious threats to patient safety. The Joint Commission and the Institute for Safe Medication Practices (ISMP) have published lists of high-alert medications. These “high-risk” medications include:
In 2012 the Institute for Healthcare Improvement (IHI) created a how-to guide for the prevention of harm from high-alert medications, recommending three principles of safe system design: 1) design processes to prevent errors and harm, 2) design methods to identify errors and harm when they do occur, and 3) design methods to lessen the harm that may result from the error.
Processes to prevent errors and harm:
Methods to identify errors and harm when they do occur:
Methods to lessen the harm that may result from the error:
High-alert (high-risk/high-hazard) drugs such as neuromuscular blocking agents, chemotherapy agents (some of which are carcinogens), and opioid analgesics require special precautions to prevent catastrophic errors. Although many of these drugs carry a black box warning (BBW), the FDA’s strongest labeling requirement, one study indicated that some physicians and pharmacists might ignore BBWs in prescribing and dispensing drugs.
The Physician-Patient Alliance for Health & Safety (PPAHS) reported that there is cause for concern in patients using patient-controlled analgesia (PCA), and there is a great lack of consistency in safety procedures followed by hospitals across the country. This is believed to account for a large proportion of adverse events and deaths related to its use. There is evidence that hospitals that continuously monitor their patients with pulse oximetry and/or capnography are better able to avert adverse events.
Checklists for safe use of PCA pumps are available. The PPAHS checklist recommends certain steps be taken when initiating, refilling, or reprogramming PCA pumps, and PCA checks to be taken at shift change and hourly.
PCA pump initiation, refilling, or programming a change require:
Change of shift and every hour require:
Source: Wong et al., 2013.
Many health professionals work or consult in non-healthcare settings such as adult daycare, summer camps, schools, group homes, board-and-care facilities, and jails. These facilities are usually licensed by the state but often use unlicensed staff members to dispense medications to patients. According to the National Coordinating Council for Medication Error Reporting and Prevention, medication errors are a significant problem in these settings.
The council’s recommendations for the handling of medications (including OTC medications) in these settings include proper storage, written policies and procedures, limitations on the type of medications stored by the organization, training programs, safeguards to prevent theft of controlled medications, and reporting and evaluation of medical errors.
An analysis of research and recommendations for preventing misconnections suggests that equipment redesign to make enteral and IV systems incompatible is the most effective way to reduce misconnection errors (Simmons et al., 2011). The International Organization for Standardization (ISO) has adopted new standards intended to address connector cross-compatibility issues between products for a variety of medical applications (e.g., enteral, parenteral, IV, epidural, etc.) and identifies specific designs for each application to eliminate the possibility of misconnections (JC, 2014f).
Connectors manufactured according to the new specifications are entering the workplace, and temporary adaptors are being introduced to connect the old tubing with the new tubing. However old connectors will remain in use and the potential for misconnections will still exist until existing supplies are depleted (JC, 2014f).
Until tubing has been redesigned to meet safer standards, the Joint Commission recommends the steps outlined below:
Source: JC, 2014g.
The FDA regulates devices that support or sustain human life, are of substantial importance in preventing impairment of human health, or present a potential unreasonable risk of illness or injury by using a process of scientific and regulatory review to evaluate safety and effectiveness.
Health professionals should familiarize themselves with their institution’s procedures for reporting adverse events to the FDA (FDA, 2009a & b). Under the Safe Medical Devices Act of 1990, facilities (hospitals, ambulatory surgical centers, nursing homes, or outpatient centers) are required to:
The medical device and equipment user (physician, nurse, therapist, technologist, patient, and other service personnel) is the human factor that must be taken into consideration when a new device is being designed in order for it to be operated correctly and safely. This means the design must consider the perceptual abilities associated with sight, hearing, and touch.
The CDC (2012) provides recommendations for prevention of these infections. A summary of the top recommendations for preventing each type of infection follows.
CLABSIs typically cause a prolonged hospital stay with increased cost and mortality risk. Preventing these dangerous oversights may have a low-cost, high-yield solution, such as a simple checklist of evidence-based practices in infection control, like handwashing and other fundamental procedures. CDC guidelines include a checklist that covers the following:
Many hospitals are reporting significant reductions in ventilator-acquired pneumonia (VAP) in critical care units. Some have reached zero cases by taking an approach that involves a checklist that includes a “bundle” of evidence-based care processes that reduces the incidence of pneumonias in ventilator patients by one fourth and reduces length of stay in ICU by one half. The bundle includes four processes: peptic ulcer disease prophylaxis, deep vein thrombosis prophylaxis, elevation of the head of the bed, and a “sedation vacation.”
Preventing falls begins with assessment of the patient using one of the several tools available, such as the Morse Fall Scale. It is recommended that assessment for fall risk should be done by nursing for every patient on admission. Reassessment should be done upon transfer of a patient from one unit to another, with any status change, following a fall, at regular intervals, and with changes in caregivers. Post-fall assessment should include a history of the fall from the patient and/or witnesses; the circumstances (e.g., time, location, activity); review of underlying illness, medications, and environmental conditions; and functional, sensory, and psychological status.
The MFS is used widely by nurses in both hospital and long-term care inpatient settings. The MFS requires systematic, reliable assessment of a patient’s fall risk factors upon admission, after a fall, upon change in status, and at discharge or transfer to a new setting. MFS subscales include assessment of:
|1. History of falling; immediate or within 3 months||No = 0
Yes = 25
|2. Secondary diagnosis||No = 0
Yes = 15
|3. Ambulatory aid||None, bed rest, wheelchair, nurse = 0
Crutches, cane, walker = 15
Furniture = 30
|4. IV/heparin lock||No = 0
Yes = 20
|5. Gait/transferring||Normal, bed rest, immobile = 0
Weak = 10
Impaired = 20
|6. Mental status||Oriented to own ability = 0
Forgets limitations = 15
|Risk Level||MFS Score||Action|
|Low Risk||25–50||Standard fall prevention interventions|
|High Risk||51+||High-risk fall prevention interventions|
Source: Oh, 2012b.
Fall prevention interventions include both standard and high-risk categories.
Standard fall prevention strategies:
High-risk prevention strategies:
Many errors have been demonstrated to arise from the lack of adequate or accurate communication. Meticulous medical documentation helps to prevent practice errors and provides a shield against errors arising from miscommunication.
Documentation must be credible and timely and must accurately reflect the patient’s condition as well as the care given. Illegible writing, overuse of abbreviations, and poor transfer of information (both within a department and when a patient transfers to another department) can cause medical errors. Healthcare professionals must learn and follow their facility’s policies and procedures about charting.
It is necessary to consider the possibility of malpractice lawsuits and how best to avoid potential legal liability. Documentation must be complete, correct, and timely. To avoid liability, it is important to be able to explain and justify (based on EBP) the care given by each person if one is subpoenaed.
Research indicates that poor communication is a root cause in more than half of all sentinel events. Whether it is nurse-to-nurse, nurse-to-physician, or physician-to-physician communication, having a standard framework and proven tools for reporting and sharing information can enable more effective communication.
One increasingly popular communication tool is the SBAR format: Situation (S), Background (B), Assessment (A), and Recommendation (R). It was originally developed by the U.S. Navy and since the 1990s has been used in healthcare settings. This tool can be used for hand-offs between shifts and between caregivers, as well as for debriefings on internal issues, information on new procedures, and email communication.
Source: IHI, 2014c.
For over a decade, patient safety has become a topic of national concern. Everyone has a stake in the safety of the healthcare system—healthcare workers as well as the general public. In the past, patient safety and quality have not been a traditional part of the education of most healthcare workers, but today this is no longer an acceptable reason for not taking an active role in the prevention of negative outcomes for those we care for. It is essential that we all understand the journey every patient makes through the system, recognizing how the system can fail and what can be done to prevent those failures.
To counter errors and safeguard patients, changes must continue to be made in how the workforce is deployed, how work processes are designed, and to leadership, management, and the culture of healthcare organizations. Physicians, nurses, therapists, and other healthcare personnel are members of a team, and it is crucial that these team members work together and communicate effectively. Collaborative teamwork is essential for optimizing quality and safety in healthcare.
Florida Agency for Health Care Administration, Division of Health Quality Assurance
Health Care at the Crossroads: Strategies for Improving the Medical Liability System and Preventing Client Injury (Joint Commission) (PDF)
List of High-Alert Medications (Institute for Safe Medication Practices) (PDF)
NCCMERP (National Coordinating Council for Medication Error Reporting and Prevention)
Your Medicine: Be Smart, Be Safe (AHRQ) (PDF)
NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course (view/download PDF from the menu at the top of this page).
Accreditation Association for Ambulatory Health Care (AAAHC). What is accreditation? (2014). Retrieved from http://aaahc.org
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Berlin L. (2011). Avoiding errors in radiology: case-based analysis of causes and prevention strategies. JAMA, 306(11), 1267–8.
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Bland CM. (2013). Polypharmacy and the elderly. Retrieved from http://www.acponline.org
Blumenthal D. (2014). Reflecting on health reform: good news! High performance in action. Retrieved from http://www.commonwealthfund.org
Centers for Disease Control and Prevention (CDC). (2012). Top CDC recommendations to prevent healthcare-associated infections. Retrieved from http://www.cdc.gov
Centers for Medicare and Medicaid Services (CMS). (2014). Hospital-acquired conditions and present on admission indicator reporting provision. Retrieved from http://www.cms.gov
Florida Statutes. (2014). Title XXXII, chapter 456, 456.42, written prescriptions for medicinal drugs. Retrieved from http://www.leg.state.fl.us
Food and Drug Administration (FDA). (2013). Examples of tubing and Luer misconnections. Retrieved from http://www.fda.gov
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Halvorson D. (2011). Signs of a turnaround are mounting in 2010. Pharmacy Purchasing and Products, 7(8), 4–21.
Hartocollis A. (2013). With money at risk, hospitals push staff to wash hands. Retrieved from http://www.nytimes.com
Institute for Healthcare Improvement (IHI). (2014a). Medication reconciliation to prevent adverse drug events. Retrieved from http://www.ihi.org
Institute for Healthcare Improvement (IHI). (2014b). SBAR toolkit. Retrieved from http://www.ihi.org
Institute for Healthcare Improvement (IHI). (2012). How-to guide: prevent harm from high-alert medications. Retrieved from http://www.ihi.org
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Johns Hopkins Medicine. (2012). John Hopkins malpractice study: surgical “never events” occur at least 4,000 times per year. Retrieved from http://www.hopkinsmedicine.org
Joint Commission. (2014a). The Joint Commission reports increase in robotic surgery-related sentinel events. Retrieved from http://bulletin.facs.org
Joint Commission. (2014b). Addressing diagnostic error: the challenge for public health organizations. The Joint Commission Journal on Quality and Patient Safety, 40. Retrieved from http://www.npsf.org
Joint Commission. (2014c). Joint Commission alerts organizations to tubing misconnection risks. Retrieved from http://www.jointcommission.org
Joint Commission. (2014d). Joint Commission National Patient Safety Goals, 2014. Retrieved from http://www.patientsafety.va.gov
Joint Commission. (2014e). Facts about the universal protocol. Retrieved from http://bulletin.facs.org
Joint Commission. (2014f). Sentinel event alert. Retrieved from http://www.jointcommission.org
Joint Commission (2014g). Managing risk during transition to new ISO tubing connector standards. Retrieved from http://www.jointcomission.org
Joint Commission. (2013a). Sentinel event policy and procedures. Retrieved from http://www.jointcommission.org
Joint Commission. (2013b). Sentinel event data: event type by year, 1995–2013. Retrieved from http://www.jointcommission.org
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Joint Commission. (2013d). Root cause analysis and action plan framework template. Retrieved from http://www.jointcommission.org
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Leape LL. (2014). Patient safety in the era of healthcare reform. Retrieved from http://www.ncbi.nlm.nih.gov
Leapfrog Hospital Survey. (2014). Key facts about medication errors. Retrieved from http://www.leapfroggroup.org
Marx D, Comden SC, Sexhus Z. (2005). Our inaugural issue—in recognition of a growing community. The Just Culture Community News and Views, 1(1).
National Coordinating Council for Medication Error Reporting and Prevention. (2014). What is a medication error? Retrieved from http://www.nccmerp.org
National Institutes of Health (NIH). (2014). What is health literacy? Retrieved from http://www.nih.gov
National Quality Forum (NQF). (2010). Safe practice #1: culture of safety leadership structures and systems. Retrieved from http://www.hospitalsafetyscore.org
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Poon EG, Keohane CA, Yoon CS, Ditmore M, Bane A, et al. (2010). Effect of barcode technology on the safety of medication administration. New England Journal of Medicine, 362, 1698–1707.
Reason JT. (1990). Human error. Cambridge: Cambridge University Press.
Simmons D, Symes L, Guenter P, Graves K. (2011). Tubing misconnections: normalization of deviance. Nutrition in Clinical Practice, 26, 286–93.
U.S. Department of Health and Human Services (U.S. DHHS), Office of the Inspector General. (2010). Adverse events in hospitals: National incidence among Medicare beneficiaries. OEI-06-09-00090. Retrieved from http://oig.hhs.gov
Van den Bos J, Rustagi K, Gray T, Halford M, et al. (2011). The $17.1 billion problem: The annual cost of measurable medical errors. Health Affairs, 30(4), 596–603.
Wesley KI, Washick MJ. (2013). Researchers study medication dosing errors & pediatric care. Retrieved from http://www.jems.com
Wong M, Mabuyi A, Gonzalez B. (2013). First national survey of patient-controlled analgesia practices. Retrieved from http://ppahs.files.wordpress.com
Wood D. (2014). Diagnostic errors common and preventable: 1 in 20 missed. Retrieved from http://amnhealthcare.com
World Health Organization (WHO). (2014). WHO surgical safety checklist and implementation manual. Retrieved from http://www.who.int
Wyatt RM. (2014). Don’t make me wait! Retrieved http://www.jointcommission.org