1. Prevention of Medical Errors
2017

2. 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.

3. 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”

4. 2001 FL Legislative responseFS
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

5. 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.

6. 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.”

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

8. 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

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

10. 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.

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

12. Patient falls VERY COMMON MEDICAL ERROR
ONE OF THE MOST COMMON ADVERSE EVENTS THAT HAPPEN IN HOSPITALS

13. LABORATORY ERRORS
CATEGORIES
PRE-TEST
TESTING
POST-TEST

14. 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………..

15. #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

16. #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

17. 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

18. #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

19. #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

20. 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

21. 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

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

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

24. SURGICAL ERRORS

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

26. 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

27. 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.

28. 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

29. 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

30. 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

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

32. 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:

33. 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

34. 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???