Prevention of Medical Errors for RNs and LPNs

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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.

LEARNING OBJECTIVES:

Upon completion of this program the learner will be able to:

  • Define medical error.
  • Identify the 8 different types of medical errors.
  • Identify 3 factors that increase the risk of medical errors.
  • Recognize 3 error-prone situations.
  • Identify safety needs of special patient populations.
  • Discuss processes and strategies to improve patient outcomes.
  • Discuss strategies for preventing medical errors in 3 different areas.
  • Recognize responsibilities according to Florida Law for reporting medical errors.
  • Discuss 5 way for patient involvement in medical error’s prevention.
  • Identify the National Patient Safety Goals of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for 2012.

For many years, the extent of medical errors was unknown. Uncovering the degree of the problem was fueled by the medical error-related death of Boston Globe health columnist Betsy Lehman in 1994. Lehman, who was being treated for breast cancer at Boston’s Dana Farber Cancer Institute, died from heart failure after she mistakenly received the four days cumulative dose of the cancer drug Cisplatin, instead of the daily dose. Her death triggered a landslide of government hearings, meetings, and reports.

Post-event findings and analysis culminated in the release in 2000 of “To Err Is Human: Building A Safer Health System,” by the Institute of Medicine (IOM),a nonprofit research group that is a part of the National Academy of Sciences. This report shocked the nation with its conclusion that preventable medical errors in the United States result in 44,000 to 98,000 deaths per year, making medical errors more deadly than breast cancer, motor vehicle accidents or AIDS. Medical errors were responsible for injury in as many as one out of every 25 hospital patients, and their cost was as much as 28 billion each year. The IOM’s report have concluded that such errors are result from system failures, not people failures; so achieving acceptable levels of patient safety will require major systems changes; and a concerted national effort to improve patient safety.

For year 2007 the World Health Organization reported that medical care errors affect up to 10 % of patients worldwide (WHO, 2010). More than 10 years after the report of the IOM, the rate of medical errors in different areas in the USA is not improved according to the recently published articles.

The IOM report have provided a blueprint for reducing medical errors, naming four key factors that have contributed to the epidemic of errors:

1) Fragmentation and decentralization of the healthcare system, which may create unsafe conditions for patients.
2) Licensing and accreditation processes, which gives insufficient attention to preventing errors.
3) The medical liability system, which discourages physicians from admitting mistakes and impedes systematic efforts to uncover and learn from errors.
4) The third-party purchasers of healthcare, which offer little incentive for healthcare organizations and providers to improve safety and quality.

Taking Action to Prevent Medical Errors

To help decrease the incidence of medical errors, we need to recognize medical errors, error-prone factors, and to develop a system for their prevention. An IOM goal was to “break the cycle of inaction”. The American Nurses Association (ANA) supports many initiatives of the IOM’s and other national organizations. JCAHO (Joint Commission on Accreditation of Healthcare Organizations) and the Florida Hospital Association (FHA), have suggested also several guidelines for improvement in this area.

Florida is one of the leading states in medical error prevention. In 2002, the Florida Board of Nursing decided that “all licensees must complete a two hour course on prevention of medical errors, which meets the criteria of Section 456.013, F.S., as part of the total hours of continuing education required for initial licensure and biennial renewal.” (Chapter 64B9-5.011, Florida Administrative Code)

In 2003, Florida passed the nation’s most comprehensive patient safety legislation, the Medical Incident Bill. Its objectives are to create a near-miss reporting system, establish quality indicators for consumers’ use in selecting hospitals, and create the Florida Patient Safety Authority – an organization established to analyze patient safety data, identify best practices, provide continuing education to practicing healthcare providers and institute statewide electronic infrastructure.

Florida has taken also other important steps to prevent medical errors and improve patient safety. Handwritten prescriptions are now illegal in Florida. The Clients’ Right-To-Know About Adverse Medical Incidents Act allows clients who have been harmed to gain access to all records of their care, including documents of provider deliberation. The Three Strikes and You Are Out Act asks the Florida Board of Medicine to revoke medical licenses of providers who have had three adjudicated malpractice incidents.

The Florida Patient Safety Corporation (FPSC) was created by the 2004 Florida Legislature under Section 381.0271, Florida Statutes. The purpose of this nonprofit corporation is to continuously improve patient safety in Florida by serving as a learning organization, assisting health care providers in improving the quality and safety of health care and reducing harm to patients, and working with a consortium of patient safety centers and other patient safety programs.

The Florida Patient Safety Corporation created a Near Miss Reporting System (NMRS) website in 2006. Under the NMRS:

  • Reporting is voluntary, anonymous and independent of mandatory reporting systems used for regulatory purposes. Reports of near-miss data must be published regularly. Special alerts must be published regarding newly identified, significant risks.
  • Aggregated data should be made publicly available.
  • Performance and results of the near-miss project must appear in its annual report.

In July 2005, President Bush initiated a national medical error prevention policy by signing into law S.544, the Client Safety and Quality Improvement Act, which established a voluntary confidential reporting system to create a national database of medical errors for analysis and development of evidence-based client safety measures.

Private Sector Response

Most notable in the private sector for improving performance standards has been the Leapfrog Group, a consortium of several Fortune 500 companies and other private and public health care purchasers, sponsored by the Business Roundtable. The Leapfrog Group seeks to create meaningful marketplace incentives for the healthcare sector to adopt systemic quality improvement processes, and encourages large employers to reward health plans and hospitals that make breakthrough improvements in patient safety and quality.

The Leapfrog Group has identified three initial patient safety standards as the focus for consumer education and information and hospital recognition and reward:

• Reduce medication-prescribing errors using CPOE;
• Refer patients undergoing certain high-risk procedures to high volume hospitals); and
• Staff ICUs with intensivists (i.e., physicians certified in critical care medicine).

What Is A Medical Error?

The IOM Committee on Quality of Healthcare in America defines the medical error as a harm caused to the patient as a result of “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim”. Rarely do errors happen in isolation. Usually, one flaw or problem leads to another and then another. This chain of events, involving many healthcare settings and providers, may result in a medical error and a sentinel event. Recognizing error-prone situations and “near misses” can facilitate improvements in the system, lead to a reduction in overall errors and improve patient outcomes.

A “sentinel event” is defined by JCAHO) as “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof”.

Sentinel events include:

  • Operative and post-operative complications
  • Patient suicide
  • Medication errors
  • Wrong site surgery
  • Patient falls

Sentinel event is a preventable adverse event (an injury caused by medical management, rather than from the patient’s underlying condition). It needs assessment of the risk factors in the medical systems.

“Near miss” is a potential error that is found or caught before an actual error or injury occurs. It is a potential adverse event or error that could have caused harm but did not, either by chance or because something or someone in the system intervened. For example, a nurse who recognizes a potential drug overdose in a physician’s prescription and does not administer the drug but instead calls the error to the physician’s attention has prevented an adverse drug event (ADE).

Research on why humans make errors has identified two types of errors: active and latent. Active errors tend to occur at the level of the individual, and their effects are felt almost immediately. Latent errors are more likely to be beyond the control of the individual; that is, they are errors in system design, faulty installation or maintenance of equipment, or ineffective organizational structure. The effects of latent errors may not appear for months or even years, but they can lead to a cascade of active errors, ending in catastrophe.

Types of Medical Errors

Because the healthcare system is very complex, the likelihood of medical errors is high. The following are types of medical errors, arranged according to the order of occurrence.

  • Medication practices
  • Infections
  • Falls
  • Surgical practices
  • Diagnostic inaccuracies
  • Pharmacy practices
  • Laboratory practices
  • Treatment errors

Medication Errors

The 2000 IOM report placed medication errors among the most common preventable mistakes in hospitals. Medication errors are one of the most common areas identified in incident reports and sentinel events. Medications with similar names, but different action classes, effects, and dose ranges further complicate the medication management process. The multiple steps from prescription to administering and monitoring of the effect of the medication are sours of medical errors.According to the U.S. Pharmacopeia (USP), insulin, heparin, warfarin and albuterol are the medications most often associated with errors.

Florida Hospital Association Patient Safety Steering Committee has developed safe medication practices that focus on the ordering, prescribing, dispensing, and monitoring of drug therapies.

1. It directs the ordering healthcare practitioner to gather essential patient data prior to writing any medication orders: diagnoses, allergies and sensitivities, lab values, current medications and other pertinent data.

2. It encourages the practitioner to be involved in reviewing hospital formularies with the Pharmacy and Therapeutics Committee, to have essential medication references on hand when prescribing and to help in developing special protocols for the use of “high risk” medications.

3. Safe medication practices require the practitioner to use the metric system only, to avoid abbreviations and to avoid confusing orders such as “resume same meds” and “resume pre-op medications”. Verbal and telephone orders are being discouraged unless absolutely unavoidable.

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