Prevention of Medical Errors 2017

Course purpose To provide an overview of medical errors in today’s health care system and to identify the incidence and causes of medical errors and the risk factors disposing to medical errors, and to provide strategies to prevent medical errors in the healthcare setting, including by patients.

WHY ARE WE HERE? Concern over incidence of Medical Errors Institute of Medicine Landmark Report ( 1999 ) To Err is Human : Building a Safer Healthcare System Report sparked national effort to : 1) Change the culture and systems of healthcare 2) Put emphasis on compliance with standards and on continuous improvement 3)Move from culture of “blame” to “safety”

2001 FL Legislative response FS 456.013 Mandates 2 hour course for ALL health care providers as part of licensure and renewal process Course shall include: Root Cause Analysis Error Reduction & Prevention Patient Safety

MeDICAL ERROR Failure of a planned action to be completed as intended, or the use of a wrong plan to achieve a goal. Execution Errors can be “errors of commission or errors of omission”. Planning Error is one in which the plan of action is not considered appropriate or correct for the patient.

ADVERSE EVENT Defined as a preventable medical error that causes harm to the patient. Not all medical errors are adverse events and not all medical errors become adverse events. The differences between a side effect and an adverse event are “predictability, severity and consequences.”

SENTINAL EVENT DEFINED BY JOINT COMMISSION…. An unexpected occurrence involving death or serious injury or psychological injury or the risk thereof.

Root cause analysis Goal directed, systematic process Uncovers basic factors that contribute to medical errors Focuses primarily on systems and processes and not individuals Product of root cause analysis is an action plan to reduce risk of similar future events

ROOT CAUSE ANALYSIS Gather facts Assemble team Determine sequence of events Identify causal factors Select root causes Take corrective action and follow up plan

DIAGNOSTIC ERRORS Relatively common Have received much less attention and research Can be a significant cause of morbidity and mortality No universally accepted definition Defined as: The wrong diagnosis was made; and, 1) there was adequate data to suggest the correct diagnosis, or, 2) the clinical finding should have prompted the medical provider to do further evaluation in order to make the proper diagnosis.

CAUSES OF DIAGNOSTIC ERRORS Patient related Patient-practitioner Diagnostic tests Follow-up and tracking Referrals

Patient falls VERY COMMON MEDICAL ERROR ONE OF THE MOST COMMON ADVERSE EVENTS THAT HAPPEN IN HOSPITALS www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html

LABORATORY ERRORS CATEGORIES PRE-TEST TESTING POST-TEST

MEDICATION ERRORS ANY PREVENTABLE EFFECT THAT MAY CAUSE OR LEAD TO INAPPROPRIATE USE OF PATIENT HARM WHILE THE MEDICATION IS IN CONTROL OF THE HEALTHCARE PROFESSIONAL, PATIENT OR CONSUMER. TWO TERMS SHOULD BE REMEMBERED: PREVENTABLE & PATIENT HARM DIVIDED INTO 4 CATEGORIES………..

#1 Prescribing errors Wrong drug because of drug-drug interactions and/or drug allergies Incorrect dose, concentration, route or frequency Drug prescribed for the wrong patient Duplicate drugs prescribed The appropriate drug not prescribed The prescription was written illegibly or improper abbreviation were used

#2 ADMINISTRATION & PREPARATION ERRORS Missed doses or doses given at an incorrect time Medication given by someone unauthorized to do so Improper administration technique Incorrect rate of administration Administration of an expired drug Drug prematurely discontinued or administered for too long Duplicate administration ( double dose ) Incorrect dosage calculations Failure to document administration of a drug or incorrect documentation

Failure to use medication administration safeguards ie: double checking calculations Failure to comply with medication administration policies: leaving meds unattended and not watching a patient take a medications Improper or incomplete administration directions given to a patient

#3 DISPENSING ERRORS A drug can be dispensed to the wrong patient, the drug may not be dispensed in a timely manner or the wrong drug can be dispensed

#4 MONITORING ERRORS Not ordering the proper laboratory tests Not responding appropriately to laboratory tests Ordering test but the test are4 not performed Failure to monitor for drug effectiveness, adverse effects, and side effects

CAUSES OF MEDICATION ERRORS Inattention was the most common cause of medication errors Work conditions ( poor staffing and heavy workload) Lack of knowledge or medications by health staff

RISKS OF MEDICATION ERRORS INCREASE IF….. PATIENT IS VERY YOUNG PATIENT IS VERY OLD PATIENT HAS COMPLEX MEDICAL PROBLEMS OR IS TAKING MULTIPLE MEDICATIONS RISK FOR MEDICATION ERRORS HAS ALSO BEEN ASSOCIATIED WITH SPECIFI DRUGS

Medications commonly involved in medication errors Insulin Morphine Potassium chloride Albuterol Heparin Vancomycin Cefazolin Acetaminophen Warfarin Furosemide

OTHER MEDICAL ERRORS Surgical Errors Treatment Errors Fragmentation Time Constraints Poor communication Lack of knowledge Health care setting

SURGICAL ERRORS

TREATMENT ERRORS Administering blood and blood products Advanced monitoring ( ICP monitoring ) Intravenous insertions Nasogastric tube insertions Phlebotomy Urinary catheterizations

Fragmentation The use of multiple medical specialists or medical systems to care for one individual is a large contributor to errors. Information does not always follow patients Fragmented health services are largely responsible for healthcare information not being centralized. Can also be a result of the use of different pharmacies and hospitals

TIME CONSTRAINTS Providers see a large volume of patients Pharmacists fill a large number of prescriptions Nurses care for more patients than they should Many are over worked. People work too quickly and this increases the risk of errors.

POOR COMMUNICATION OFTEN IDENTIFIED AS THE MAJOR CAUSE OF MEDICAL ERRORS. COMMUNICATION ERRORS ARE COMMON AND CAN HAPPEN ANYWHERE WITHIN THE HEALTHCARE SYSTEM ARE A LEADING CAUSE OF SENTINEL EVENTS

LACK OF KNOWLEDGE RECOGNIZED BY RESEARCHERS AND HEALTHCARE PROFESSIONALS AS A MAJOR CAUSE OF MEDICAL ERRORS ALSO NOTED THAT THERE IS A LACK OF RESOURCES AND/OR TIME FOR INCREASING KNOWLEDGE

HEALTHCARE SETTING EMERGENCY ROOMS INTENSIVE CARE UNITS OPERATING ROOMS ARE ALL HIGH RISK AREAS FOR MEDICAL ERRORS… ADMISSION AND DISCHARGE ARE COMMON TIMES IN WHICH MEDICAL ERRORS OCCUR

MEDICATION ERROR PREVENTION Right patient Right drug Right dose Right route Right time Right documentation Right reason Right response

Abbreviations related to medication errors U ( or u )  intended to mean unit but easily mistaken for 0 or 4 SC intended to mean subcutaneous but easily mistaken for SL (sublingual) QOD intended to mean every other day but easily mistaken as QD ( every day) if it is written sloppily The Institute for Safe Medication practices has a list of dangerous abbreviations and dose designations on its’ website at: www.ismp.org/newsletters/acutecare/articles/dangerousabbrev.asp

PREVENTING MEDICAL ERRORS: HELPING THE PATIENT Teaching patients about medication safety Spend time teaching patients about their medications Write information down for patients Explain the purpose for taking a medication and common side effects Explain interactions and risks that require ongoing monitoring

REFLECTION….. WHAT ARE YOUR THOUGHTS ON MEDICAL ERRORS??? WHAT AREAS IN HEALTHCARE DO YOU FEEL ARE THE MOST COMMON AREAS FOR ERROR AND WHY? WHAT CAN WE DO ABOUT MAKING OUR PRACTICE SAFER?? HOW CAN WE CONTINUE TO IMPROVE PATIENT SAFETY???