CFTF - Consultants for the · PDF fileCFTF 2 Contact Hours This course and Consultants for...

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ThiscourseandConsultantsfortheFuturehavebeenapprovedby:TheFloridaBoards(ProviderNo.50‐435) Nursing, ClinicalSocialWork,Marriage&FamilyTherapy,andMentalHealthCounseling, OccupationalTherapy, Acupuncture SpeechandLanguagePathologyandAudiology MassageTherapy(CourseNo.3344) RespiratoryTherapyand NursingHomeAdministrators ApprovedthroughcomplementaryboardbytheFloridaBoardofMidwifery,DieteticsandNutrition,

Electrolysis,andacceptedbyTheFloridaPhysicalTherapyAssociation(FPTA)(AccreditationofthiscoursedoesnotnecessarilyimplytheFPTAsupportstheviewsofthepresenterorthesponsors.)

TheIowaBoardsof Nursing,ProviderNo.61, BehavioralScienceExaminersforMentalHealthCounselorsandMarital&FamilyTherapists,Sponsor

No.1‐05, SocialWorkExaminers,SponsorNo.334;

TheCaliforniaBoardofNursing,ProviderNo.04422.TheGeorgiaBoardofNursing,ProviderNo.50‐435TheDistrictofColumbiaBoardofNursing,ProviderNo.50‐435TheAlabamaBoardofOccupationalTherapy,ProviderNo.50‐435TheOhioBoardofSpeechTherapy,ProviderNo.50‐435

TheCoursemeetstherequirementsoftheMinnesota,Ohio,Nevada,and KentuckyBoardsofNursing,andotherstatesbyreciprocity.

Dr. Linda S. Greenfield

No portion of this study may be reproduced without permission of the author and Consultants for the Future.

ConsultantsfortheFutureContinuingEducationforHealthcare

Prevention of Medical Errors

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“If you were admitted to a hospital tomorrow in any country… your chances of being subjected to an error in your care would be something like 1 in 10. Your chances of dying due to an error in health care would be 1 in 300,” says Dr. Liam Donaldson, WHO’s envoy for patient safety. “This compared with the risk of dying in an air crash of about 1 in 10 million passengers… It shows that health care generally worldwide has a long way to go.” (Nebehay, July

2011) This course meets the criteria of Florida Statutes 456 that mandates a two-hour course on prevention of medical errors as part of the total hours of continuing education required for initial licensure and biennial renewal for the state of Florida. It provides continuing education credits for those licensed in other states as well.

Please read these IMPORTANT INSTRUCTIONS as they contain answers to many of the questions we are often asked regarding home study.

Once you have downloaded this course, you may save it on your computer, or print all or any part of it. The option to download it disappears once you have completed the course. In this way the document is available to you as a resource for the future. An uncompleted course remains available for 2 years before it becomes outdated.

As you leaf through this study, you will notice that there are questions placed throughout the reading material. At the end is an answer sheet. The answers cannot be submitted from the pdf (the form of the course). As you complete the study, you may record your answers on this answer sheet to help you when entering your answers on the website. Once you are ready to submit your answers and complete the course, you will need to sign in to your record at www.consultantsforthefuture.com, using your username and password. Click on “Pending Courses” to find your list of outstanding courses. Select this course, and on the next page select “Continue To Test”. The questions should be the same as in the course material you just read. Select your answers and then press “Submit.”

A passing score of 75% must be achieved to receive credit. In the event that you do not reach 75% on the first submission, you may try a second time without paying again. You must pay again if you need more than two attempts to pass the course. You may refer to the material at any time and you may also study in groups, if you wish. Once you have successfully completed the course, the next page (the button is on the bottom of the page to go to exit the test) is an evaluation of the course. The page following the evaluation is your certificate, which you can print at any time. You receive credit on the date you successfully pass the course.

For those licensed in Florida, Georgia, Ohio and Alabama, we will report the completion of your courses to CE Broker, with the actual date you completed the course. Hours are reported to CE Broker using only your license number, so please make sure you have listed it correctly, with any beginning letters followed by the numbers. In Florida, there are no spaces between the letters and the numbers.

Initial Printing: January 2002 Current Revision: January 2016


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ABOUT THE AUTHORS Linda S. Greenfield, R.N., Ph.D. After over forty years of experience in health care, Linda has seen many changes. Much of her work history has been in continuing education as the administrator and primary author/instructor for Consultants for the Future, but this has been interspersed with a wide variety of clinical positions. As an author and instructor, she teaches people from many different disciplines within the healthcare system. Renée A. Neville, M.B.A., Mechanical Engineer. Renee is our adjunct consultant for this course, and she comes well qualified. She manages the “Six Sigma” program for a Fortune 500 company, having achieved the highest level in process improvement, known as a “Six Sigma Master Black Belt”. “Six Sigma” is a methodology used in industry to reduce variation in processes -- errors. Her second focus is “Lean”, a program that focuses on waste reduction by streamlining processes. She conducts process-improvement workshops all over the world that incorporate “Six Sigma”, “Lean” and “8 Disciplines for Structured Problem Solving (8D)”. These words mean little to us in healthcare, but the bottom line is that she is an expert in analyzing a system to find errors, and to teach the people working within that system how to find solutions. The 8D process is the underlying structure used to develop her input for this course.

INTRODUCTION It is now well established that medical errors occur too frequently within our healthcare system.

Unlike the early days after the initial Institute of Medicine’s report, “To Err is Human”, when much of the literature argued whether this was really a problem, today’s literature reflects efforts to identify how and where the majority of errors occur and what can be done to change our system and make it a safer place for all of us. Patient safety has become a mandate for all levels of care, from packaging and design of equipment such as syringes, to actual bedside delivery of care, with questions about processes of communication or adequacy of education, effects of stress, and more.

Objective No. 1: Identify the factors that impact the occurrence of medical errors, and reflect on the presence of any of these factors in your place of employment.

Objective No. 2: Consider contraindications and indications for management of errors, recognizing error-prone situations that have been commonly described, and seek to make those situations safer in your own working environment.

Objective No. 3: Specifically identify pharmacological components of error-prone situations respective to your discipline, in the over-all management of patient safety.

Objective No. 4: Explore processes you and others might use to improve patient outcomes, including aspects of medical documentation and communication, and structured problem solving techniques.

Objective No. 5: Become aware of your responsibilities for reporting medical errors and the surrounding controversies.

Objective No. 6: Consider the safety needs of special populations. Objective No. 7: Cite needs for public education and empowerment. As a quick review, To Err is Human reported in 2000 that between 44,000 and 98,000 Americans

die in hospitals each year from medical errors, making this problem the eighth leading cause of death in our country. This was the article that unveiled medical errors as a public issue and lead to the mandate for this course. These estimates were minimums and understated the problem. These estimates did not include deaths from medical errors that happen in outpatient, long-term care, home-health care, or private offices. While there has been much controversy over these original estimates, subsequent studies support the IOM’s call of alarm and provide us with even higher estimates that seem to be more reflective of the problem. “The Institute for Healthcare Improvement estimates there are 15 million incidents of medical harm each year… about 18 percent of patients in hospitals are injured during the course of their care and that many of those injuries are life-threatening, or even fatal. The office of the Inspector General of the US Department of Health and Human Services found that one in seven Medicare patients are injured during hospital stay, and that adverse events during the course of care contribute to the deaths of 180,000 patients every year.” (https://www.justice.org/cps/red/justice/hs.xls/8677, 2013)


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A study reported in the Journal of Patient Safety found that preventable adverse events lead to the death of 210-400,000 hospital patients each year. (Scientific American, 9/20/2013) This would place preventable medical errors as the third leading cause of death behind heart disease and cancer. “…even the 100,000 figure is an estimate,” says Lisa Giffert, co-author of a report by Consumers Union which sited little progress made to reduce the death rate of medical errors, “because there is no centralized system for tracking and monitoring medical harm.” (Web MD, 5/20/2009) In the U.S., it is estimated that 1.7 million infections are acquired in hospitals, leading to 100,000 deaths, which is a number far higher than in Europe where 37,000 deaths are reported, according to the World Health Organziation (WHO). (Nebehay,

2011) Still today, decade and a half after this problem became a public issue, our errors remain high, and even more complicated than at the turn of this century. “Changes in reimbursement models with declining reimbursement rates, a current and projected workforce shortage, and a rising case-mix acuity have combined to create the perfect storm, jeopardizing the delivery of safe and effective care.” (Anthony, 2010)

Most medical errors are a failure of the system, rather than solely the negligence of one person. Most preventable errors are a series of mini-errors made by several people that result in a big problem. It often takes many people to deliver health care. “A heart operation can involve a team of up to 60 people, about the same number needed to run a jumbo jet.” (Donaldson, in Nebehay, 2011) For example, consider one large category of medical errors – hospital-acquired infections. We can try to prove who the culprit carrier was that gave a susceptive patient a life-threatening infection, but the bottom line is that if you ever slacked on hand washing, you created a mini-error that, when multiplied by others, can result in a big problem. This is true whether you are a speech, occupational, respiratory or physical therapist doing a one-time consultation, a marriage and family therapist, counselor, or social worker just visiting a hospitalized client, the dietitian, the nurse or doctor actively providing daily care at the bedside, or an acupuncturist providing private services in an institutional environment.

Each of our professions has its own statistics. We all have a need to pay attention to how our individual job performance and our profession impact this problem. Direct care hospital staff hear about infection control and hand washing, but the same issues apply to disinfecting and hand washing in a school or private clinic. It is obvious that errors made by doctors, nurses and pharmacists account for the majority of fatal errors. But that doesn’t mean that if you are not a nurse, doctor or pharmacist you have no responsibility to this problem. To the patient relying on our expertise, it does not help for a technician to blame a doctor for amputating the wrong limb, when s/he had access to the medical record and could have prevented the error. Nor does it help if the physical therapist blames the nurse for an error in wound management or dressings. Blame blocks effective responsibility. We are all part of all of the problem. The requirement for a course on medical errors applies to every profession under the umbrella of medical quality assurance in Florida. Everyone is a watchdog for everyone else, because patient safety is at risk. So when the mental health counselor observes behaviors that indicate drug therapy is amiss, s/he needs to speak up and collaborate with the doctor, nurse, pharmacist, family caregiver, or whoever has information and power to make the necessary changes. Our professional responsibilities overlap. We need to make the patient’s safety our primary goal. We can learn from each other as well. Those working in long term care might know how to make an environment safe for people who are disabled. That information can help a speech therapist working in a school setting with children in wheelchairs.

We can find stories that make certain professional groups feel blamed and shamed. That deflects any personal responsibility we don’t want to feel for this issue. For example, wrong-site surgeries are the most common category of sentinel events [“an unexpected occurrence involving death or serious physical or psychological injury, or risk thereof” --- Joint Commission]. Surgeons are highlighted in these cases. But no one acts alone. Instead there has been a series of small but crucial mistakes by several people, including the patient. “Almost all the taxonomies of medical error do not discuss patients’ contribution to error, or they acknowledge this contribution peripherally, perhaps because patient error is a sensitive issue.” (Buetow, 2009) Poor patient compliance, frequently changing providers, not asking for clarification, and other patient-related factors are parts of the problem. The problem of medical errors is huge, systemic and epidemic. Pointing fingers, blaming and shaming will not bring quality back into our system. Our system has good people in it. It is a systems problem. We need a systemic approach in which everyone


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owns the medical errors problem, and everyone works for patient safety. We need the attention of the media and the public to obtain the funding and legal changes necessary to do what needs to be done. Question No. 1: Which of these shifts in attitude or actions would NOT support our efforts to

reduce medical errors? a. Enlisting the help of the media and the public, to obtain the funding and legal support

necessary to make difficult changes possible. b. Finding the individual or profession who should take full responsibility and blame for the

error. c. Recognizing that everyone, including the patient, has a role in patient safety and error

prevention. d. Working together to change the healthcare system’s failures, and build a new system

which prevents, rather than allows errors to occur in such high numbers. Question No. 2: True or False? Given the statistics, it is obvious that the health care system has

successfully made patient safety their primary goal. True. b. False

Question No. 3: The office of the Inspector General of the US Department of Health and Human

Services’ study of Medicare patients found which of these? a. That adverse events during the course of care contributed to the deaths of 180,000 patients every

year. b. That medical errors have become the third leading cause of death – more than heart disease. c. That 37,000 deaths per years in the US are reported to arise from hospital-acquired infections. d. That 44,000 patients die in hospitals each year from medical errors.

FACTORS THAT IMPACT THE OCCURRENCE OF MEDICAL ERRORS:

Identifying the factors that increase errors will give us a starting point. Factors tend to change slowly. We must locate the factors inherent in the problem so that we can build safety nets.

Medical errors happen when something that was planned as a part of medical care doesn’t work out (errors of execution), or when the wrong plan was used in the first place (error of planning). Errors can be major like the improper restraining of a mentally impaired child with inadequate supervision, which resulted in death, or they can be minor like serving a patient a high salt meal when he was on a sodium-restricted diet. An adverse event is an injury or problem that was created because of poor management (error) rather than by the underlying condition of the patient. Thus, there is a factor of prevention that signals the need to ask why the error occurred and make the necessary changes in our systems. Close calls or near misses are potential adverse events. They are errors that didn’t result in an injury or problem, but could have. Close calls provide great opportunities for creating new strategies and these should receive the same attention by our system as actual adverse events. However, most of the time, near misses are overlooked and not mentioned or recorded.

Bad outcomes are not necessarily medical errors. These are unfortunate events that can occur even when everything is done correctly and well.

When considering factors, one obvious one is that limited financial and human resources contribute to a stressful work situation that is error-prone. “A new study suggests that a sleepy surgeon could be every bit as dangerous as a dozing driver, and a nurse in need of a nap can easily give improper doses or medications.” (2007) Our at-risk systems continue because there is not enough time, energy or manpower to change them, or because healthcare professionals feel powerless to challenge those in the system with more power. For example, if the physician is feeling pressure by third-party payors and hospital administrators to increase efficiency, he might push the time factor. This might cause a situation in which clinical protocols are ignored in the interest of time. The healthcare worker might compound the error risk by not speaking up in a calm assertive manner, and instead going along with the rush, festering


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with mistrust and mounting hostility. Who is the source of any error that might occur in this situation? The third-party-payor, or administrators for pushing? The doctor, for yielding to their pressure? The healthcare worker, for not insisting that clinical protocols be followed? It is a systems problem created because of limited resources and compounded by the healthcare workers’ powerlessness.

Don’t think this is a scenario that applies only to doctors or nurses. It takes little work to superimpose this information onto each professional reading this course. Imagine a mental health scenario in which a suicidal patient is hospitalized for treatment of borderline personality disorder, but the doctor is being pressured to discharge the patient to outpatient services. Imagine that you are the therapist, psychiatric nurse, or social worker who has been in deep dialogue with this patient daily and you recognize that he is currently showing good behavior to encourage that discharge, but he has admitted that he has detailed suicidal plans for Christmas, just four days away. Imagine the many excuses why you may not have the time, energy or power to make your point of view heard strongly enough to avert the discharge. “A common error in treatment of patients with BPD is to underestimate the importance of self-injurious behavior or to view suicidal ideation as only likely to lead to non-lethal suicide “gestures”.” (AHRQ WebM&M: Case and Commentary, 2006) It is a system error involving the third party payors, administration, the physician, the healthcare worker, the patient, and even our entire culture.

Our system has lost many who were responsible for staff development and education, or those responsible to assure that healthcare practices and policies were based on the latest research evidence and standards. Management positions have been cut, decreasing the ability to monitor or follow-up on safety issues. There are consequences for not having these safety nets. Those remaining staff carry a greater workload. Understaffing is a factor. Inadequate staffing, insufficient staff training, lack of supervision, and increased use of less skilled unlicensed workers are only some of the changes we have witnessed that do affect quality of care. High workloads, inadequate supervision, poor communication and rapid changeovers do increase the opportunity for errors. Whose “fault” is it if a professional has inadequate knowledge when needed? The individual’s? The educational system? The governing boards? The lack of time, money and energy to seek quality continuing education? It could be all of the above. Usually no one person is to blame, yet all of us are responsible for resolving the problem. It is a systemic problem that requires individual action. Making errors is not, by itself, a measure of competence. Blame doesn’t prevent that same situation from happening again with another person. It just increases stress, anxiety and guilt. Awareness, not blame, allows us to make changes. If we (the system-at-large) would shift our priorities to create patient safety as a high-priority item, we would shift our resources to support our priority. While many healthcare professionals may feel that shifting resources is beyond their immediate control, being able to speak up when we observe a system error in progress is directly our problem. We need to increase our power as healthcare professionals, and this can be accomplished on a personal level. We can only be part of the solution when we have the power and ability to respond and speak up when a situation needs changing.

Power in communication is a factor that is tightly bound to the issue of medical errors. Real power doesn’t depend on your title or position. People don't attack other people who are perceived as confident. They listen to the point of view and ideas of people with power. People don't vent their anger at people who are confident in their own self-definition. Attacks change into collaborative negotiations with win-win solutions. A study conducted with the American Association of Critical Care Nurses reported that, “it’s fairly common for people to see problems and do nothing… People who were confident in their ability to have “crucial conversations” about problem-causing behaviors achieve positive outcomes for patients, the hospital and for themselves.” (Tokarski, 2005) We need power to protect our patients/clients from medical errors. We need our own power before we can empower our patients/clients to act as their own monitors of the care they receive. We need power to change the systems that we work in.

We dis-empower people when we blame them and hold them solely responsible for errors, which has been our history. When we think of errors as an individual’s problem and fail to consider that they might well be systems problems, we create unreasonable expectations: perfection. This leads to denial and covering up of errors rather than a team approach to find a systemic solution or ways to prevent them from happening again. As this mentality usually permeates every level of our healthcare system, it results in management level discipline of individual errors, rather than support for reporting mistakes and


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“near misses.” Here is the disconnect. The IOM and most literature refutes punishment for errors as an effective way to change the system, yet most (93%) healthcare professionals act from their fear of punishment. (AORN, 2005) We are faced with an overwhelming reluctance to admit that any healthcare provider makes mistakes. This strips us of power to negotiate change.

Power has been called the “currency of conflict.” Power is defined as “the ability to get one’s needs met and to further one’s goals.” When needs and goals crash, as in a conflict, the one with the power often wins, yet, as our patients/clients are the least empowered in our healthcare hierarchy, they are often the ones who lose. If you are trying to change a system, you will encounter resistance and conflict. How much power do you have to handle that? Some of the people you want to change may perceive that you are trying to control them. Whenever any of us feel like we are losing control we react with powerlessness, worry, apathy, anger, fear, worthlessness, exhaustion, confusion and defensiveness. Those are common feelings expressed in healthcare today. We respond to those feelings by struggling to regain personal control, and in the process, our goals of patient safety get easily lost. So, control is not an effective way to make systemic changes.

The question is not how to avoid resistance. There is always resistance to change. The question is, will you empower others so that they can be honest and open, or will you control or coerce so that their resistance is closed and overt. And how are they approaching you in their requests for change?

If you control or do not share power to make giving information safe, people will nicely not cooperate. The most common way is to simply smile and say nothing at all. If you empower, you are willing to listen to what others think of your ideas. You must be ready to hear what you do not like to hear. If people had thought that you would like their words, they would have already said them. Learn to reward people for coming forward, especially if the content is not what you want. The reward can be simply an acknowledgement, “I appreciate that you have shared your reasons supporting your point of view. I can feel my resistance to what you told me, so you have obviously given me something to think about. Even though we disagree, I want you to know that I respect you for what you have said. It isn’t easy, I know, and you showed me your own integrity. I honor that. Could we just keep talking until we get to something we can both agree with?”

Acts of empathy let people know that they have a voice and so they have some power to change the things that they see are wrong. Empathy can be as simple as nodding your head and listening while they get through the emotional components of the information they want to share. “Tager calls empathy “the single most effective survival skill in a changing environment,” yet only 6% of executives surveyed saw it as a key trait.” (Seven Steps to Successful Leadership in Stressful Times, 2004) Empathy encourages more honesty, which is valuable information. Any change agent needs a wealth of honest information. Find ways to get it: meetings, informal discussions, anonymous surveys, outside partners collecting information, electronic questions boxes, etc. Four basic truth-finding practices include: Leading with questions, not answers. Engaging in dialogue and debate, no coercion. Conducting a thorough review of issues and/or events without finger-pointing. Building “red flag” mechanisms that turn information, into information that cannot be ignored.

With honesty, openness and respectful listening, you can collaborate your way to change. It becomes a team effort in which everyone owns the change. It becomes a joy instead of a burden. Six topic areas that define a healthy environment include: skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition and authentic leadership. Isn’t it great that as we work to make our environments safe and healthy for our patients, we will also be making them healthy for us to work in? Isn’t it sad that as long as we allow our work environments to be punitive, controlling and abusive to those working within the system, they will remain unsafe and full of errors for our patients and clients? “..[M]iscommunications contribute to two of every three “sentinel events.” (Stamer, 2014)

Communication problems within our system are part of the medical error problem, but so are communication problems with our patients/clients. For example, the Agency for Healthcare Research and Quality (AHRQ) found that doctors often do not do enough to help their patient make informed decisions. Without patient involvement in decision-making, there is a higher rate of noncompliance, which can lead to ineffective treatment – an error. We know that many of our patients/clients do not


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understand their third-party payment process. They don’t know how to obtain a needed referral or how to appeal when coverage is denied. Our elderly and mentally ill are particularly dis-empowered as there may not be enough energy, capacity to endure confrontation or cognitive abilities to assert their rights. This, again, can lead to ineffective treatment, mistreatment, or wrong diagnosis. The patient can be a powerful ally in monitoring for untoward effects. An informed patient will know when his pills look different, or when he doesn’t feel like he usually does. If the patient is empowered with adequate knowledge, s/he can provide the feedback we need to reduce the impact of errors or prevent them all together. Even in new situations, if we inform the patient about what to expect and give him or her the power and freedom to question the situation if it differs from that description, we have helped in increasing patient safety and quality of care. Communication can be one of our more powerful ways to reduce medical errors.

Other staff factors that increase the risk of errors include: Substance abuse. It is a rising problem within our system. Illness. Going to work sick when sick compromises our ability to get well, and jeopardizes the health

of our patients, increasing the risk that in our low-energy state the risk of errors is higher. Distraction and Emotional States. Our environments can be noisy, busy, and demanding of our

attention from several sources at the same time. It is difficult to stay focused Equipment design flaws or inadequate or inappropriate labeling or instructions for safe use.

For example, it is dangerous to repackage anything into empty drug-solution or irrigation-solution containers. Some have resorted to poking holes into the containers so that they can’t be used again.

We need to become a team focused on helping each other solve this problem, losing our tendency to define situations in terms of “medicine” “nursing” “administration”, “therapy” etc. This boundary mentality creates blaming, defensiveness, guarding, and power struggles. We are all the system. When our jobs are suffering, the doctor’s ability to do his job will suffer as well. When administration hurts, so will we. Recognizing out interdependence will allow us to work together, becoming collaborative instead of competitive. This process will take time. Understand that the changes that need to be made will happen one person at a time -- one facility at a time. Your decisions and actions are important.

To summarize:

What doesn’t work: Blaming individuals for errors, rather than looking for systemic flaws – punitive approaches. Control, disrespect, abuse. Top down hiercharcies in which only a few are empowered.

What does work: Empowering. Sharing the blame and sharing the gain. Listening, empathy, collaborating, communicating.

Question No. 4: True or False? According to Stamer, miscommunication contributes to two of every three sentinel events. a. True. b. False.

Question No. 5: Which of these empowers people to engage in “crucial conversations” in an effort

to prevent medical errors? a. Acts of empathy to let people know they have a voice, with honesty, openness and respectful listening. b. Expectations of perfectionism that promote denial and a covering up of anything below these perfect expectations. c. System-wide fear that admission of an error will lead to severe punishment. d. Thinking that most errors are an individual’s problem, and then using wide-spread blame and shame to control people.


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Question No. 6: Which of these is NOT a factor to medical errors? a. High-stress work environments. b. High workloads, and/or inadequate supervision. c. Illness, substance abuse, emotional states. d. All of these are factors and more.

CONTRAINDICATIONS & INDICATIONS FOR MANAGEMENT OF ERRORS:

As a result of many reports, error-prone situations have been identified. Some examples include: Those involving medication, including the physician’s order, the pharmacy’s dispensing, and the

healthcare worker’s administration of the medication or the patient’s self-administration. Adverse effects are medicine errors, as are allergic responses. If the patient reacts to a new medicine with an unsuspected allergic response this is not considered an error. However, if the patient receives a drug to which there is a known allergy, this is a preventable error. The Lancet reported in 2011 that medication errors were the most common of medical errors during a hospital stay. Medication errors will be treated in a separate section. Those involving surgery, such as amputation of the wrong limb. Wrong-site surgery was the most

common category of sentinel events reported by the Joint Commission. Those involving errors of diagnosis, leading to incorrect therapy, failure to use indicated diagnostic

tests, misinterpretation of the tests results, and/or failure to act on the abnormal results. Errors in diagnosis are not uncommon and are multi-factorial. For example, one study showed that common blood pressure cuffs often give incorrect readings, which causes doctors to mismanage hypertension. Most errors involve more than just the individual physician involved. It is sometimes very difficult to establish the correct root cause of the patient/client’s problems. The way we present our case to the doctor often becomes a primary influence on his/her diagnosis. We all need to assess our data carefully, and present all of the data, not just that which supports our interpretation. We see that our patient is depressed? Before encouraging the doctor to simply medicate the depression, search for underlying causal factors: pain, loss or grief, medication side effect, loss of primary nutrients, sleep disorder, deeply seated unresolved issues or interpersonal conflicts… Depression doesn’t just “show up” without a cause.

We tend to put errors of diagnoses onto the shoulders of our physicians, yet all professions do assessments. The results of our assessments become the database upon which diagnoses are made. Thus, we are all at risk for errors involving diagnosing. All professions have their “red flag” areas, in which assessments need to be complete and accurate. For physical or occupational therapy, that might involve safety risks in mobilization – the risk of falls. For speech therapy it might be to assess how safely the patient can swallow. For respiratory therapy it might be to evaluate the effectiveness of coughing or deep breathing. For mental health our assessments might determine the patient/client’s potential for violence to self or others. For acupuncture, it might be assessing when medical intervention is needed in addition to acupuncture therapy. For nursing it might be all of these things. Our failure to appropriately assess provides inadequate information upon which the rest of the problem-solving process is based. Errors can compound quickly, and many of these assessed areas can become life-threatening problems.

Those involving equipment failure, such as defibrillators with dead batteries, IV pumps with valves that are easily dislodged creating a change in drip rate, nitrous oxide tanks with defective safety prongs, whirlpools that don’t work. Infections that are picked up in some way because of contact with the healthcare environment.

These are called nosocomial infections. It’s an infection the patient wouldn’t have contacted if he weren’t in our facilities receiving our care. All professions who encounter multiple patient/clients are capable of transmitting organisms from one to another. Any professional involved with wound care or who works around immune-compromised patients, such as ventilated patients, or patients receiving drugs that impair immune functioning (transplant patients), or patients who are elderly, is especially concerned about nosocomial infections. Nosocomial infections are listed in the top four most common medical errors. (Lancet, 2011) Those involving blood transfusions, such as giving a patient the blood of the incorrect type.


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Misinterpretation of medical orders, such as wrong diet or wrong activity plan, or the wrong medication. Illegible hand-writing by our prescribing doctors accounts for many of these errors, but even if our handwriting is poor, someone else might not pick up that the patient has an allergy to the drug just ordered. This can happen in schools and clinics just as easily as in hospitals and healthcare facilities. Medical errors include errors of omission. If you don’t take action to prevent injury, and an injury

occurs, it’s still an error. Falls and other physical injuries often are listed in this category. For some professions such as physical therapy, nursing, and occupational therapy, this is a big category and one that takes creative solutions.

Multiple studies have shown that many, in fact the majority, of medical errors are preventable.

Consider infections as one daunting category of errors. Roughly two-thirds of nosocomial infections (hospital/facility-acquired) occur for reasons we can’t clearly understand. Usually factors like hand-washing, giving antibiotics on time, conducting procedures correctly, etc. aren’t obvious. But research shows that safety efforts can still dramatically reduce the rates of infections. “Northwestern Memorial Hospital in Chicago lowered its infection rate to 43% below the U.S. average by using new technology to closely track infections and taking added precautions.” (Stark et al, 8)

Management of errors begins with the recognition of need to do so. Once this is made a priority, the management process begins, as always, with assessment for safety factors, identification of problem areas, interventions or changes to increase safety and evaluation to assure the interventions are effective. Problem solving as a method of error management becomes a dedicated, conscious effort. However, not all problems require a formal committee to be solved. You can be highly effective by increasing your vigilance of patient safety. Learn to ask yourself if the patient will be safe with your plan of action. If you are to engage your patient in physical therapy, but she is excessively dizzy when you sit her on the edge of the bed, will she be safe with just your physical strength, should she lose her balance? Is exercise at this time contraindicated? If you are assisting your patient to the whirlpool or to a shower, and there is water in your path, take time to consider all of your available options before you guide the patient into a potentially slippery situation. Most of the actual management of error prone situations depends upon the worker who is immediately responsible for direct care of the patient. So, although the nurse or therapist might be solving unit problems through delegation of responsibilities, the assistant at the patient’s side needs to know exactly what to do when patient safety is compromised or care duties are contraindicated.

Question No. 7: Which of these is NOT true of a medical error?

a. Adverse effects to drugs are considered a medical error within the medication category. b. If you don’t do anything to prevent an error, and an error or injury occurs, this is not a

medical error because you didn’t do anything. c. The majority of medical errors are preventable. d. The most common category of sentinel events reported by the Joint Commission was

wrong site surgery.

PHARMACOLOGICAL COMPONENTS OF ERROR-PRONE SITUATIONS Perhaps the type of error most familiar to nurses is the error involving medication. This includes

both prescription and non-prescription medications, over-the-counter-drugs, and supplements. Nurses are not the only profession that administers medications. Pharmacists, physical therapists, respiratory therapists, and doctors also administer medications. Acupuncturists often suggest herbs or oriental medicine. In schools and residential facilities, the medications are administered by other groups as well. Add to this the patient self-administration and you have involved much of our society involved with this factor of medical errors. The American Hospital Association (AHA) has listed the common factors of medicine errors: Incomplete patient information (not knowing about a patient’s established allergies, other medicines they

are taking, previous diagnoses, and lab results, for example.)


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Unavailable drug/product information (such as lack of up-to-date warnings.) Miscommunication of drug orders, which can involve poor handwriting, confusion between drugs with

similar names, misuse of zeros and decimal points, confusion of metric and other dosing units, and inappropriate abbreviations.

Lack of appropriate labeling as a drug is prepared and repackaged into smaller units. Environmental factors, such as lighting, heat, noise, and interruptions that can distract health

professionals from their tasks.

An Institute of Medicine Report Brief cites one study which estimated 380,000 preventable adverse drug events in hospitals each year, and another study estimated 450,000. The committee belied that both were likely underestimates. They cited another study which calculated preventable adverse events from drugs in long term care facilities at 800,000. “When all type of errors are taken into account, a hospital patient can expect on average to be subjected to more than one medication error each day.” (Institute of Medicine, July 2006)

It is dangerous to keep bottles of any multidose drug on the counter in any patient environment. It is too easy to grab the wrong bottle, thinking that it is something else. Bottles look alike. Physical therapists often use multi-dose vials for iontophoresis, a method to deliver drugs to localized tissue that uses electrical current applied to a solution. There is a significant difference between dexamethasone, a steroidal anti-inflammatory, and sodium chloride.

Not only do bottles look-alike, but drug names can be very confusing. Name confusion is among the most common causes of drug-related errors. As a result, the FDA is developing standards to prevent such name mix-ups and to prevent confusion between similar looking drug packaging. Still, drug companies resist changing drug names because they have invested in marketing them. “While the FDA reviews new drug names for confusion, few are actually changed.” (Doheny, 2009)

The packaging is confusing; the drug names are confusing; and even the drug orders can be mis-leading. The system should be preventing errors, not encouraging them. For example the orders printed on pharmacy-generated medication administration records (MARs) often list the drug name and strength on the top line in bold, with the patient’s actual dose in plain type below. It is very easy to make a mistake and give the patient the dosage listed in bold print. This can result in under-dosing or over-dosing. For example, the drug strength is 25 mg, but the patient’s dose is 50 mg. He should receive two pills. If the bolded “25 mg” is given instead, the patient doesn’t receive enough medication.

Liquid medications are associated with many errors. These are the least likely to be dispensed in unit doses, and the most commonly prescribed form for highly vulnerable patients – children and the elderly. Parents of children often confuse milliliters and teaspoons. One error involved Augmentin, an antibiotic. It was prescribed at a dose of 2½ ml, but the directions on the bottle were incorrectly written as 2½ teaspoons, which equals 12.5 ml. It is a good safety habit to independently calculate the dose of liquid medications to be sure the instructions are correct. This is possible if the bottle includes both the calculated dose and the milligram per kilograms upon which the dose is based. In facilities, pharmacies can help assure patient safety by dispensing unit dose liquid medications in oral syringes.

Any medication that is administered by syringe is a top concern, especially for nurses. Injectable medication errors carry concerns affecting both the patient and the person giving the injection. Any syringe should be labeled after the solution is prepared in the syringe. As an example of how systemic changes have evolved to make our environment safe, newer syringes now have a write-on stripe that does not interfere with the visibility of the syringe content or gradations. As another example, 81% of nurses in an ANA study reported that safety syringes are used in most or all departments. (Business Wire,

2007) However, that same study reported that 55% of nurses have experienced needlestick injuries from needles contaminated by blood or body fluids.

IV drug administration has become safer due to “smart” pumps; an IV pump with infusion-safety software that checks the process against data from comprehensive drug libraries, especially checking dose limits and alerting the clinician when the situation is off-standard. “It is estimated that more than 50% of hospitals in the United States now have a version of smart IV pumps, including general-purpose syringe, and patient-controlled analgesia pumps with DERS.” [dose error reduction software]. (Vanderveen, 2009)


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Decimal points are another potential source of error, especially of dosages. Joint Commission advocates to never use a trailing zero after a decimal point, as in “1.0”. If the decimal point isn’t noticed, the dose could be read as “10”. There should always be a leading zero to alert us that a decimal point is present. For example, “.1” should be written “0.1”

Assure safe drug delivery when you are responsible for administering any drugs, and also important to know what safety concerns apply when your patient/client is self-administering a variety of drugs. For example, whether your patient is taking a steroidal anti-inflammatory drug, you need to be aware that these drugs can disrupt fluid balance and alter glucose/insulin levels. These factors become important if you are ambulating or exercising this patient as both of these situations can make people feel dizzy or change levels of consciousness. Even many of the drugs that patients take to control blood pressure can potentiate falls and injuries, and those related to Inderal (beta-blockers)can create an intolerance to exercise. Certainly, narcotic pain killers are known to make people drowsy and unsteady on their feet, yet we often want the patient to be medicated before they engage in any therapy that might create pain. Our concern for comfort creates another concern for safety that calls for our attention and close monitoring. Drugs in the family of benzodiazapines (e.g. Xanax, Ativan) are associated with falls and loss of balance. Those who ambulate patients on these drugs (e.g. nursing, physical therapy) need to be aware of the need for greater vigilance and constant assessment of safety risk.

In mental health we encounter patients taking psychotropic drugs, some of which may alter the patient’s temperature regulating mechanism. Situations in which the patient may become too hot (hyperthermia) or too cold (hypothermia) become dangerous. Should these patients have physical therapy that is vigorous, it carries a greater risk for safety. In long-term care facilities there is concern that demented patients taking these drugs might elope from the building into freezing winter temperatures, a risk that can be life-threatening.

How does this generalized information apply specifically to your professional domain? You don’t have to directly give medications to be involved in preventing medication errors. Each profession encounters its own common drugs, of which you should be knowledgeable. We are all monitors. Most of us deal daily with patients taking some kind of drug therapy. How does their therapy increase their risk for injury or medical error? How can you prevent adverse effects? Consider the ways your medication system may contribute to increased errors and look for other ways that might work better, or consider safeguards, double checks, equipment safety-checks, etc. that might resolve some error-prone situations. Begin to think in terms of safety. Use this course as a springboard for dialogue within your specific departments.

One helpful source to use as we learn more about medication risks is the Institute For Safe Medication Practices (ISMP). It is a non-profit organization working closely with healthcare professionals and institutions, regulatory agencies, professional organizations and the pharmaceutical industry. Their website at www.ismp.org provides a wealth of information about safe medication practices. Question No. 8: You may be responsible for ambulating with a patient, but not responsible for drug

administration. Which drug-related issues would be important in order for you to keep the patients safe? a. Blood sugar deviations or medication expected to change blood sugar in a short time. b. The use of narcotic pain killers. c. The use of psychotropic drugs that may alter temperature regulation, if exercise is

planned. d. All of these would be important for you to know.

Question No. 9: Which of these was not mentioned as a common factor of medicine errors by the

AHA? a. Labeling a syringe before the solution is prepared in the syringe. b. Misuse of zeros and decimal points. c. Not checking if a medication is safe to use in pregnancy, and the patient is pregnant. d. Not knowing about a patient’s allergies, and a new medication has been added.


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PROCESSES TO IMPROVE PATIENT OUTCOMES: We can reduce medical errors. Our anesthesiologists have already proven that. Anesthesia used

to be one of the most dangerous areas of medical care. Over these last three decades, anesthesiologists have transformed this problem so that now anesthesia is one of the safest arenas of care. “Mortality has fallen from 2 deaths per 10,000 anesthetized patients to 1 death per 200,000 to 300,000 patients.” (Stark, 12) We can follow that example, but it will take a united effort at every level of care within our system and support from governmental and regulatory agencies outside of our system.

The Joint Commission (Joint Commission, TJC) adopted standards for patient safety and error reduction, implemented in July of 2001. Facilities are required to implement an integrated, organization-wide patient safety program that provides on-going, proactive identification of potential errors and remedial steps to reduce the likelihood that errors will occur. There are provisions for immediately responding to medical errors and for reporting them. The facility must have a patient safety program that focuses on improvement and not blame, in order to maintain accreditation. In addition, facilities are now required to inform patients and families concerning the outcomes of care, including adverse events.

TJC’s activities are becoming very specific, including even a list of abbreviations that facilities cannot use. For example, QD (daily) and QID (four times a day) are often confused. Thus the directive must be spelled out, as in “take this medication daily.” “20U” often looks like “200”, and so, “units” must be spelled out. “CC” means one thing if you are measuring volume in cubic centimeters, another thing if you are writing the chief complaint on a history and physical, and still another thing if you are a cardiologist who just completed a cardiac catheterization. When reading these entries after the fact it is not always clear what the writer is talking about. Greater than > and less than < signs can easily be misinterpreted as the number 7 or the letter L. The @ sign can be mistaken for the number 2. The symbol for micrograms “g” is often mistaken for mg (milligrams), which is one thousand times more. It is safer to write “mcg” or “micrograms”.

TJC has created several goals relative to different clinical environments, each with evidence-based or expert-based requirements that will be reviewed annually as a part of their survey of all of their facilities. The 2014 National Patient Safety Goals for a Behavioral Health Care Program are provided here as an example. Other lists for other programs are similar.

For a review of the specific differences, go to www.jointcommission.org/patientsafety and click on National Patient Safety Goals. This website provides a wealth of specific information that can be helpful for any environment in which patient care is provided.

1. Identify individuals served correctly.

a. Utilization of two patient identifiers when providing care, treatment or services. 2. Use medicines safely

Official “Do Not Use” List Do Not Use Potential Problem Use Instead U (unit) Mistaken for “0” (zero), the Write “unit”. Number “4” (four) or “cc” IU (International Unit) Mistaken for IV (intravenous) Write “International or the number 10 (ten). Unit.” Q.D. QD, q.d., qd (daily) Mistaken for each other. Write “daily”. Q.O.D., QOD, q.o.d. Period after the Q mistaken for Write “every qod (every other day) “I” and the “O” mistaken for “I” other day.” Trailing zero (X.0 mg)* Decimal point is missed. Write x mg Lack of leading zero (.Xmg) Write 0.X mg MS Can mean morphine sulfate or Write “morphine magnesium sulfate. sulfate.” MSO4 and MgSO4 Confused for one another. Write “magnesium sulfate.” *Exception: A “trailing zero” may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.


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a. Record and pass along correct information about an individual’s medicine. b. Find out what medicines the individual is taking. c. Compare current medicines to new medicines given to the individual served. d. Make sure the individual served knows which medicines to take when they are at home. e. Tell the individual served it is important to bring their up-to-date list of medicines every time they

visit a doctor.

3. Prevent Infections. a. Comply with current World Health Organization (WHO) Hand Hygiene Guidelines or Centers for

Disease Control and Prevention (CDC) hand hygiene guidelines when providing services to a high-risk population, or administering physical care.

b. Set goals for improving hand cleaning. Use the goals to improve hand cleaning.

4. Identify individuals served safety risks. a. The organization identifies clients at risk for suicide. Business incentives that would support safety standards may involve including safety parameters in

the contracts made. Our various state and federal legislators are working hard on the problem of medical errors, introducing multiple bills. Florida established a Commission on Excellence in Health Care and gave it the responsibility to develop recommendations on ways to improve healthcare delivery systems and reduce medical errors. Everyone is concerned with this public issue. While top administration/government is setting standards, policies and expectations, the ability to prevent and reduce errors remains at the frontline. The real question to be answered is how are our facilities and our professionals going to impact this problem? What can be done at the grass roots level?

More staff is an obvious solution to the problem, but for now the availability of more people is limited. This cannot become an excuse to relax our efforts in recruitment, but it is a reality. While more effort will need to be made to attract more people into the healthcare field, some of our problems can be solved with technology. Hand-held computers and computerized charting to record medications and dosage instructions can help decrease problems associated with illegible handwriting. Electronic prescribing can merge patient and drug information to determine drug interactions, possible contra-indications, and possible adverse events. The doctor’s order is compared to information with upper dose limits for the drug and other pre-programmed guidelines. When the doctor seems to have made a mistake, the computer signals the error. The computer systems available are becoming more affordable

The VA system established the first bar coding system to prevent and track medical errors. ID strips are worn by nurses and patients and attached to medications. Before giving a patient a drug, the nurse scans all three ID strips into a computer, which verifies that the drug is being given correctly and will not cause drug interactions. If the program identifies a potential problem, it flashes a warning. Otherwise, it keeps a record of the activity. Currently only 10% of hospitals and very few other facilities have this system in place, but there is mounting pressure to use it, as the statistics show the system’s effectiveness.

The physician need not wait until the facilities provide sophisticated computerized systems for diagnosis and order entry. The National Guideline Clearinghouse (NGC) provides nearly 700 evidence-based guidelines to help clinicians find and better understand the best, evidence-based treatment strategies. It can be accessed from the Internet at http://www.guideline.gov

Computerized systems can be a source of mistakes as well. If the wrong bar code is on the drug, the system will cause errors. As more facilities have implemented automated systems for administering drugs, the number of errors associated with them has risen. The USE study by the nonprofit drug standards organization found that one in five errors identified by the Medmarx medication error program involved some form of computerization or automated dispensing system. (Health Management Technology,

2005). The human factor of monitoring cannot be ignored. Vigilance of healthcare practitioners cannot slack just because systems are improved.

Our documentation and communication is vital to patient safety and in our rush, we sometimes don’t document what we should, or fail to communicate a potential risk with appropriate emphasis.


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Errors are increasing when professional copy and paste data into electronic records, without reviewing what is there to assure it is accurate and applies to this patient. Documentation needs to be timely in order to be meaningful to those others also providing services to the patient/client. For example, if the nurse notices the patient is unsteady and his blood pressure is low today, but fails to document those changes before his physical therapy treatments, the patient is at a greater risk for a fall that may be prevented with a greater effort to communicate the situation. But if the therapist doesn’t usually check the chart before working with the patient, then documentation has to be augmented, perhaps with verbal communication, or instructions to the patient to let people know he is dizzy and may fall.

Real time computerized documentation systems and voice activated systems are being developed to allow immediate charting, yet mistakes can still occur even in highly technical systems. Some have reported that when errors are made in charting, it is very difficult to get it corrected without help, and at other times the computers go down. Question No. 10: Which are possible errors that support the need for constant vigilance when working with

computers? a. Errors involving copy/pasting incorrect data into a record, without review. b. Errors made in charting are usually slow to get corrected. c. Wrong bar codes on the drugs. d. All of these are reasons to be constantly monitoring.

Question No. 11: Which of these is NOT a violation of TJC standards”

a. An insulin order was hand written as 20U. b. A patient safety program focusing on improvement is in place and active. c. A trailing zero, such as x.0 was used with medication-related documentation. d. Documentation used the abbreviation q.o.d.

Question No. 12: With each survey TJC reviews that facility’s ability to meet National Patient Safety

Goals relative to that clinical environment. For a Behavioral Healthcare Program, which does NOT correctly address the goal: Prevent Infections? a. Comply with WHO or CDC hand hygiene guidelines when caring for high-risk populations or

administering care. b. Use gloves when providing mental consultation. c. Use goals to improve hand cleaning.

Question No. 13: True or False? The majority of hospitals in the US use a bar-coding system to prevent and

track medication errors. a. True. b. False.

USING THE STRUCTURED PROBLEM SOLVING PROCESS (SPS) TO ANALYSE YOUR SYSTEM.

Industry has been successful in using a structured problem solving process (SPS) to locate and reduce errors. This same approach can be easily adapted to our healthcare system as a method of root cause analysis. There are 8 steps to SPS. This course will summarize this approach briefly and refer you to the literature if your find an opportunity to apply this process.

The source for identifying a systemic error that needs attention often comes from incident reports. Our example scenario involves an increase in the rate of falls, but it takes little work to imagine a scenario in which incident reports in a mental health environment show an increase in losing contact with abused children who were active cases, or an increase in aspiration pneumonia among clients of speech or respiratory therapists, or weight loss among a group of long-term residents under the guidance of a registered dietitian.

We’ll show how the process works with falls. Imagine that a facility’s incident reports showed that the number of patient falls and injuries have been rising during the third quarter. The latest report occurred when the patient tried to ambulate from the bed to the bathroom in his hospital room. It resulted in an extensive workup to check for possible fractures, and days of pain for the patient. The family was


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very upset when notified, mostly because this same patient had fallen just one week earlier when in physical therapy. After the administrator read this last report, he decided to tackle in-house error rates, and has called various other staff to consider their approach to this problem. While this example is derived from a facility approach to the issue of falls, the same structure can be adapted to a “unit’s” or “center’s” concern for their specific error rates.

THE FIRST STEP: FORMING THE TEAM:

A small, diverse group of people with process knowledge, skill in the appropriate disciplines, and time and authority to take the needed actions to solve the problem becomes the team that will orchestrate the problem solving process. THE SECOND STEP: DEFINE THE PROBLEM:

This begins by describing the problem in quantifiable terms. The tool used is called “4W2H”.: Who, What, Where, When, How and How many. Notice this list did not include “why”. You do not want to assume that you know why during the defining phase. This tool is used to narrow the scope of the project. The answers to the questions come from the various incident reports, and other related sources. These questions create a narrower focus for containment and cause-finding efforts.

The following analysis can be used to define the problem. The brief definition of the data collected in the table (expanded) would read: “Twenty-two patients in hospital YZ have been injured from falls and accidents during ambulation in the third quarter of 2014. The factors associated are multifactorial and involve nursing, physical therapy, occupational therapy, the physicians, and the patient. The falls and injuries occur around the clock, but 67% happen after dark. The majority (73%) occurred in the first three days following surgery.”

Question Example (Input coming from the incident reports.)

Who Who are injured? Patients ambulating during their rehabilitative process. What What are the factors

associated with the errors? Possibly medication side effects. Possibly unsafe supportive structures. Possibly inadequate supervision when ambulating. Possibly patient noncompliance.

Where Where is the error occurring? In PT, in the patient’s rooms, in the bathrooms. When When has the defect been

occurring? At 2:00 in the afternoon, at 8:30 at night, at 3:00 am… In terms of patient recovery timing, 3 were on the third post-op day, 5 were on the second post-op day, etc. The rise in falls/injuries is occurring during the third quarter.

How How did the defect occur? (During…)

During a patient attempt to get to the bathroom. The patient’s left leg did not support his weight, and he lost his balance. He fell on his left hip against the edge of the bed. An aide was assisting him. (Plus data from other reports.)

How Many

How many errors were observed?

During the third quarter, administration has received 22 reports of falls and injuries in the facility.

THE THIRD STEP: IMPLEMENT CONTAINMENT ACTIONS:

Containment actions shield the patients from the effect of an error until the true root cause can be identified and a corrective action can be put into place. Even though this is step 3, many times we put a containment action in place first. We want to shield the patients from the effects of the error as soon as possible. Therefore, we implement the containment actions immediately, and then form the team (step 1) and define the problem (Step 2). The containment action is revisited when you arrive at the 3rd step. Example 1 An injury occurred. A possible containment could be to request that two staff members assist high-risk patients during ambulation in the first two post-operative days until other safety features could be added.


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THE FOURTH STEP: IDENTIFY THE ROOT CAUSE:

In this step the team will identify and test all possible causes, using the problem description and test data, to isolate and verify potential root causes, in order of priority established in team meetings.

There are two sources of root causes: the specific local cause that resulted in the problem, and the systematic cause that is part of the existing system that allowed the specific local cause to occur. During this step, you will concentrate on finding specific local causes. System causes are addressed in Step 7: Preventing Problem Recurrence.

Here is the strategy used for determining the root cause.

A. Review the problem definition and existing data, looking for clues to potential causes. You will systematically compare a potential root cause for each case to the definition developed during step 2, and determine if the potential root cause could have occurred, given the definition. Then look for common patterns among the cases.

Example 2 Given our earlier example definition: “Twenty-two patients in hospital YZ have been injured from falls and accidents during ambulation in the third quarter of 2014. The factors associated are multifactorial and involve nursing, physical therapy, the physicians, and the patient. The falls and injuries occur around the clock, but 67% happen after dark. The majority (73%) occurred in the first three days following surgery.” Does it make sense that the root cause could be the new pain protocol used by doctor X, which was put in place in the first quarter? No, because the rise in errors didn’t begin until the end of the second quarter, and the pain protocol used by doctor Z is not different and he has about the same number of injured patients as doctor X. What happened in the third quarter? What changed? Did staffing change? Did we quit following procedures in the second quarter? Were there new procedures implemented then? B. Ask, “What changed, when? And ask, “WHY? WHY? WHY? WHY? WHY? We ask “Why?”

until we don’t know the answer to the question any more. At this point we brainstorm a list of possible causes and test for the true root cause.

Example 3 Why did this last injured patient’s leg give way? Answer: because it has been weakened and atrophied from months of disuse. Why was he ambulating on a weakened leg, supervised with just one aide who weighed several pounds less than he did? Answer: Because there was pressure from payors to get him ambulatory in order for him to be re-admitted to his residential care facility. Because adequate time was not available or taken to strengthen the leg before ambulation was attempted. Because this aide was the only one available at the time he asked to be helped to the bathroom. Why did the PT or nursing staff, or the physician not determine that ambulation would be unsafe, given these factors? Answer – We don’t know the answer. In this case it took us 3 “whys” to get to a place where we did not know the answer. We can ask more questions, we can gather more data, but when the data runs outs, we need to brainstorm. C. Brainstorm all potential causes using a cause and effect diagram.

There are several ways to brainstorm, but one method that puts structure in the process is to list possible factors for each major category contributing to the outcome, which in our example is patients falling. All possible categories are included, and all possible factors in each category are considered.. Example 4 Human (both (a)staff and (b)patient): (a) Poor utilization of available staff, lack of focus to task, (b) age,

noncompliance. Methods (procedures): No safety belt when transferring, Bed position not at lowest level. Medications/Disease: Pain controlling drugs and others, Weakness from bed rest and surgery. Environmental: Room cold=need to rush. Hospital environment creating some confusion for the patient.


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Equipment: Bed wheels didn’t lock completely. Whole bed side-rails. Diagnosis: Wrong diagnosis. Inadequate assessment.

Categories of this example for medical errors are listed below in bold, with the contributing factors

that were brainstormed listed in italics.

D. Select the most likely causes: compare them to the project definition.

This is a team-negotiated weighing of possible causes with recognition of which factors/causes carry the most potential for being significant. One method is to give each team member 5 votes.

Example 5

For our example case, the team member representing nursing placed two votes on drugs, two votes on no safety belt, and one vote on staffing assignment. The physical therapy team member placed one vote on age, one vote on drugs, one vote on weakness, one vote on confusion, and one vote on inadequate assessment. When all votes from all members were tallied, the factors of medications and disease received the most votes, and the human factors came in second. Also significant was the diagnostic factor of assessing risk for falls.

E. Conduct parallel, fact-based investigations of the most likely causes.

Team members accept responsibility for investigating specific areas to obtain further data about these two important categories.

Example 6

The physician and nursing team members studied the drug and disease effects of those patients who had fallen during this quarter. The physical therapy representative would investigate falls relative to age parameters, evidence of noncompliance, evidence of stress/anxiety or other impediments to focusing on task. Others team members had further assignments.

F. Verify root causes

As the evidence is presented and compared to the definition of the problem, the root causes are identified as such.

THE FIFTH STEP: DEVELOP AND VERIFY SOLUTION:

Through a testing process, the team will confirm that the selected corrective actions will resolve the problem, without causing undesirable side effects. This is one of the most critical steps in the problem solving process, and frequently is the most difficult.

Wrong Way: A common method for evaluating a problem solution is to implement the solution and determine if the problem goes away. This attempt is high risk to the customer/patient and is inefficient, since excessive time passes before conclusive evidence is available.

Right Way: The team must show that the corrective actions will eliminate/reduce the problem by conducting verification tests. THE SIXTH STEP: IMPLEMENT CORRECTIVE ACTIONS

Corrective actions work at the root cause of the problem, not just on the effect. Document everything that is done. Sometimes corrective actions result in additional problems in this or a related process. Brainstorm all possible side effects and watch for their potential occurrence. Verification should be both an immediate action (part of implementation) and also a step that assesses trend type information over time. Verification is an important sub-step that must be performed on an ongoing basis.


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Questions to Ask:

From the patient’s viewpoint, are the proposed actions a feasible means of increasing safety? Does the cost exceed the benefit? Are the proposed actions permanent? Will the proposed actions cause changes elsewhere in the system? For the actions planned, are everyone’s responsibilities clear? For the actions planned, has timing been established? For the actions planned, has support been defined and approved? What indicators will be used to verify effectiveness of the actions? At what level of each indicator will we consider the problem solved? Are ongoing controls in place, permanent and effective? Can we remove the containment actions without risk to the process patient?

THE SEVENTH STEP: PREVENT PROBLEM RECURRENCE:

This step acts at the systems level to modify the methods, equipment, materials, process procedures, operating systems, and management systems and practices to prevent related problems from occurring. This level might consider factors such as over-all staffing ratios, departmental accountability for certain issues of error, changing facility attitudes to reporting incidents and errors, etc. At this level standards and procedures would be evaluated, removing those that are obsolete and implementing those that reflect current requirements. The changes to the system would be implemented with communication/training and with assignments for follow-up responsibilities.

THE EIGHTH STEP: RECOGNITION This step recognizes all the team members for their individual and collective efforts and develops a

climate for ongoing improvements. If recognition is not given, team members are less willing to participate and are likely to become discouraged. Recognition and feedback is the most effective method available to shape behavior. Recognition can come in the form of a top management letter, an enclosure in the performance review, as food, or other ways of showing recognition.

Answers will come from administrative and team efforts, but don’t forget your power and ability to impact this problem in your own local domain. Surveyors may ask you, wherever you fit into the hierarchal structure of your facility, what you have been doing to improve the patient safety in your department Develop a habit of visually inspecting your work area, looking for safety factors. Look for mishandled items, such as syringes left in inappropriate places. Medications that require dilution before administration should be stored in a distinctive way that reminds the practitioner of this need. Make sure that supply cabinets and crash carts are locked. Ensure that cabinets and storage areas are clean and items are stored in appropriate places. Inspect blackboards; bulletin boards and assignment boards to be sure there are no breaches of confidentiality. Make sure checklists are up to date and followed. No day should be missed on the lists. Questions regarding how the hospital is improving patient safety by doing proactive risk identification and reduction activities will be an important part of future unit surveys. Question No. 14: Which of these is not part of the second step of the SPS process?

a. Use incident reports or other data collection processes to determine the need for changes. b. Answer who, what where, when, how and how many related questions about the data. c. Answer why these errors happened. d. Define and summarize the results of the data analysis.


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Question No. 15: Since many errors have significant systemic factors, reducing errors has to have a solid process of addressing the problems systemically. Which is NOT valid? a. It is helpful to follow a problem solving process with defined steps: e.g. the SPS. b. It is logical to think that systemic problems will resolve by punishing the individual who

was with the patient when the error caused injury. c. Someone with the ability to makes changes in procedures needs to start the process. d. The process works better if a team representing key departments determines corrective

actions/procedure changes.

RESPONSIBILITIES FOR REPORTING: One of the most controversial recommendations initiated by the IOM report was mandatory

reporting of medical errors. How can anyone create a system that reduces errors unless the nature and frequency of specific errors is known? The National Patient Safety Database now exists in addition to other reporting systems already in place. For example, as a part of TJC’s set of patient safety standards, healthcare facilities are required to report “sentinel events”, which involve unexpected, unanticipated death or permanent loss of function. At least 21 states have some type of reporting system for medical errors. Four states have laws in place that requires facilities to publicly admit if they commit any of 24 types of sentinel events – also called “never events” – or events that should never have happened: surgery on wrong body parts or the wrong patient, foreign objects left in the patient after surgery, patient death or serious disability from contaminated drugs or devices, infant discharged to the wrong person, patient death or disability after the patient disappears for more than four hours, patient suicide or attempted suicide resulting in serious disability, patient death or serious disability from medication error or wrong blood type, patient death from fall, care provided by someone impersonating a doctor, nurse, or pharmacist, abduction of a patient, sexual assault on a patient, or physical assault on a patient resulting in death or serious disability.

Other new laws in various states may require hospitals to report infection rates, nurse staffing, and mortality rates, and information on 30 common procedures, including costs, infection rates and deaths. There is significant pressure to bring transparency into healthcare. There is still debate about whether or not to make medical errors reportable and available on the Internet with names of facilities and/or physicians. “Despite the fact that patients uniformly endorse the disclosure of harmful errors, such disclosure currently seems to be uncommon…In one study, 76% of housestaff reported that they had made a serious medical error that they had not disclosed to the patient or a family member.” (White, 2008)

While most agree that such information is needed for change, reporting errors is frightening for many reasons. In our present system, the person who made the error is identified, and then action is taken against him/her. This action may include reprimand, remedial training, suspension or firing, disciplinary actions by state licensing boards, malpractice suits, and rarely, criminal prosecution. These are heavy consequences that very strongly encourage people to hide their errors. In the past, healthcare professionals learned to deal with medical errors and possible malpractice lawsuits by saying as little as possible, denying everything, and never apologizing or acknowledging the error. Thus apologizing has become a controversy within the scope of medical errors. An apology is considered an “admission against interest,” and as such was considered admissible in a court as evidence of acknowledgment of fault. However, silence and denial creates anger and resentment, and a sense of betrayal in our clients/patients. An apology restores the aggrieved person’s respect and dignity, and allows more reconciliation and open dialogue. Legislatures are beginning to protect the making of apologies. California and Florida have already passed laws “excluding from admissibility in court proceedings apologetic expressions of sympathy, but not fault-admitting apologies after accidents.” (Sparkman, 2005)

The development of voluntary reporting needs to be encouraged, by creating a “culture of safety”. In this culture, there would be no retribution for reporting errors or near misses. Our system must support error recognition, accountability, honesty, and rapid settlement of injuries, viewing those injuries as systems problems. You can already imagine what this change in paradigm might mean in terms of malpractice insurance. Most health-care practitioners are competent professionals who are vulnerable to error simply by virtue of being human.


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Just because reporting is “mandatory” will not in itself solve the data collection problem. Even with mandatory reporting, state officials state that under-reporting persists. Just consider the frequent medical error that occurs when any health professional fails to comply with mandatory abuse reporting laws. Confidentiality must be a critical component of any system of reporting. Practitioners do not want to damage their reputations. But any incentives or promises that reports would be kept out of litigation may undermine public trust and create concerns about accountability and protection from true negligence. Specifically, data could be protected on medical mistakes that have no serious consequences, in which the data is collected solely for the purpose of improving safety and quality of care. Should there be consequences for failure to report when reporting is mandatory? Where is the trade off between detecting and preventing errors, and confidentiality? The current trend is that reporting systems have to be educational, rather than punitive. There is also the “hassle factor” to consider. How much time will filing these new reports take from the task of caring for the patient? It is hoped that those creating the mechanisms for mandatory or voluntary reporting of medical errors will standardize and streamline the process so that the investment of time and effort is worth it.

In 2005 TJC developed and endorsed a voluntary system for classifying patient safety incidents, creating a standard for taxonomy that will allow users to compare information across many different systems. It is called PSET: Patient Safety Event Taxonomy and, as TJC developed it, it may well be incorporated into that organization’s standards. PSET categorizes safety issues into five primary classifications: Impact –The outcome or effects of the error, e.g. harm to the patient. Type – The processes that failed, e.g. communication, clinical performance, etc. Domain – Setting in which the error occurred and type of individual involved, e.g. patient. Cause – Factors and agents that led to the incident, e.g. human factors. Prevention and Mitigation – Measures taken to reduce incidence and effects.

The most common method of reporting used by facilities is the incident report. Incident reports are used with almost any patient or staff mishap. These are not part of the patient's permanent record, and although most lawyers are very much aware they exist, it is not correct to write in the patient's record that an incident form was completed. An incident report is an in-house, administrative tool, used in risk assessment and reduction programs. They are used to monitor, for example, the number of falls in the last quarter, or the number of pressure ulcers in the last year, etc. They are used to monitor errors.

These tools can help us communicate with administration. Policies or procedures won't change if we don't provide adequate communication of problem areas, and incident reports get attention. Provide any input to the various questions that the team will need answered in order to discover the root cause. Who, What, Where, When, How, How Many, AND WHY. It is important that we keep incident report type information out of the patient's charts. If we have an attitude that reflects a belief that filling out an incident report always means we erred, we may try to rationalize or explain away mistakes. This is legally dangerous, and lawyers quickly recognize words that imply this. Some bad examples are "accidentally" or "somehow", or "unintentionally". Don't offer your opinion, draw any conclusions, place any blame or make accusations, or even speculate about the situation. Just state the facts. Tell what you did or the patient did; what you did about it; who you notified; and any assessed data which would indicate outcome. "IV of 1/2 NS with 40 mEq of potassium chloride started at 1:30 p.m. At 3:00 p.m., IV was changed to 1/2 NS with 20 mEq of potassium chloride. Doctor notified, but no orders given. Pt's urinary output is good, vital signs are stable." The correct order was 20 mEq of potassium. It was a med error that the IV had 40 mEq added, as the incident report will clarify. This entry provides the patient centered details, without "red flags". The incident report will provide further details. If you come to a conclusion, state the objective facts that led you to that conclusion. "Wound appears infected." is legally dangerous. "Wound discharge is green and foul-smelling", is much safer legally.

It is not always clear whether reports of errors are “discoverable” (that is, obtainable as legal evidence) by patients or other third parties. To protect yourself if you file a medical error or incident report, assume that third parties may access it.


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In general, incident reports should be completed by the person who first witnessed or discovered the event (even if the person did not commit or contribute to the error) or by the person most closely involved in the occurrence. In Florida, anyone can fill out an incident report.

Clearly document the patient's refusal to give information or to accept care. It is best if you use his words. Chart all noncompliance. For example, if you told a patient to call for assistance before getting up, and later found him on the floor, be sure you chart the previous instructions to the patient, so any governing body knows that you told him what to do. When you suspect a noncompliant patient, chart your instructions even if no injury occurred. This helps to clarify errors from noncompliance. For example: "9:00 Assisted patient with transfer to toilet. Patient dizzy and pivoting difficult. Instructed to ring the bathroom bell for assistance when finished. 9:15 Found patient in chair. Stated she returned to chair unassisted. Reminded her to call for assistance. Nodded assent." Although it is all we can do to remember to chart the things which go wrong, in these types of circumstances, it will provide protection if we remember to chart these incidents which did not end in mishap. If several hours, or several days later, the patient was found on the floor, careful charting of noncompliance earlier would be a safeguard, would perhaps bring attention to a risky patient pattern, and would generally be much more effective than if you charted the noncompliance at the same time you are charting the incident. When you have recognized this pattern of noncompliance, increase your monitoring. Don’t leave the patient and depend upon him to call you. You recognized a potential for injury. Act on that knowledge. This detail to charting also provides more accurate information to those assessing the system for error prevention.

Perhaps more important to the reporting of medical errors to systems data banks is the need to report the error to the patient. Recently, pressure to disclose is receiving more attention. Ethical obligations strongly support a mandate to disclose harmful errors to patients. The ethical principles of fiduciary duty, patient autonomy and equity are all involved. More and more states have passed laws mandating disclosure. These laws are different than the “I’m sorry” laws first passed. Thus, is it likely that disclosure will increase in the future.

It is important that the disclosure includes an aplogy, along with information about the error that is explicit, sincere and honest. The disclosure needs to be given as soon as the error is identified, and ongoing as information changes. Yet, even if the disclosure is conducted under optimal circumstances, it is important to recognize that not all patients will immediately, if ever, forgive the physician or the health care system for the mistake. “Moreover, physicians and other providers can also be tough on themselves when evaluating their own actions. The period following an error can be emotionally trying for patients and providers alike. The desire to avoid these strong and trying responses should not be underestimated and is thought to be another barrier to disclosure. To deal with these challenges, all available resources, including social workers, chaplains, support groups, and counselors, should be sought. The goal is to improve delivery of disclosure and better address the emotional impact of harmful error to foster disclosure efforts.” (Kachalia, 1/2009)

The Florida Statute 456.0575 defines our duty to notify patients. “Every licensed health care practitioner shall inform each patient, or an individual identified pursuant to s.765.401(1), in person about adverse incidents that result in serious harm to the patient. Notification of outcomes of care that result in harm to the patient under this section shall not constitute an acknowledgment of admission of liability, nor can such notifications be introduced as evidence.”

There are ethical issues that surround the reporting issue. The American Medical Association’s Errors do not necessarily constitute improper, negligent, or unethical behavior, but failure to disclose them may. Studies show that the majority of hospitals have formal, board-approved policies to disclose medical errors to patients. Errors occur in other settings as well, such as in clinics, centers, long term care facilities, offices, schools and homes.

If you become aware of an error that was not properly disclosed, by doctor, nurse, therapist, or anyone, you should first share your observations with that person. “Be a Team Member. You may feel compelled to “tell” on the attending physician or resident who committed the error, but this will not only undermine your relationship with the patient, it will also create distrust and lack of confidence within the whole medical team…One way is to respect the authority of the attending physician by asking for their assistance. For example, you might say, “I spoke with Mrs. Jones and she is very concerned about X. I would like your help discussing it with her.” (Fix, 2008) Put the patient first. You might say to a fellow


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healthcare worker who committed an error, “I was concerned about our patient when I saw Y. I’d like to talk to the attending physician (supervisor, whoever is the authority). Will you join me?” The supervisor/doctor then can re-approach the healthcare professional for clarification. Supervisors should also report suspected error non-disclosure to administration. This process will be easier when peer error committees or discussion groups have been formed to adopt non-punitive responses to error reporting and to support the physician and other professionals in the act of reporting. We need systems in which errors are difficult to commit, and in which the existence of an error is openly acknowledged and patient safety is everyone’s obligation. Truth telling for all of us should not be unique. It should be the norm.

Question No. 16: Which of these is NOT an example of a “Never” event?

a. An allergic response to a new medication, which was not a recognized allergy in the past. b. An infant discharged to the wrong person. c. Patient death or disability after the patient disappears for more than four hours. d. Surgery on the wrong body part or the wrong patient.

Question No. 17: Which of these statements about incident reports is incorrect?

a. Do not offer opinion, draw conclusions or place blame. b. Everything in the incident report should be recorded in the patient’s record as well. c. Tell what you did, the patient did, what you did about it, who you notified, and any

assessed data. d. You should provide the answers to who, what, where, how, how many and why to give

adequate information to the problem solving team.

Question No. 18: You observed an error, and now you learn that your patient/client is confused about why symptoms are occurring, and that the error had never been disclosed to her. Which of these is the most appropriate FIRST step? a. Ignore it. You didn’t make the mistake, so you have no further responsibilities. b. Go to the supervisor or administrator and file a complaint. c. Go to the person who made the error, and offer to help with the disclosure… “I spoke

with Mrs. Smith, and she is very confused about her recent condition. I would like your help in discussing this with her.”

d. Tell the patient yourself that, in your opinion, an error had been made.

Question No. 19: True or False? Florida has a law that excludes from admissibility in court proceedings apologetic expressions of sympathy, but not fault-admitting apologies after accidents. a. True. b. False.

SAFETY NEEDS OF SPECIAL POPULATIONS:

Certainly there are patient populations and situations that require closer monitoring to prevent medical errors. As your facility develops its response to provide a higher degree of safety, these populations will have to be identified within your facility. Obvious situations include the use of restraints, patients who experience degrees of sedation, delirium or dementia, those with sensory loss, children, handicapped and elderly patients.

For example, the use of restraints makes that patient completely dependent upon us for safety. Part of your facility’s approach to reduce medical errors will be to define the standards of restraint use, and develop ways to use alternatives to restraints or to use the least restrictive type of restraint. Each professional will be held responsible to know what those standards of restraint use are, to know what documentation is required for the restrained patient and to know how often these patients have to be assessed. Evidence will be required to show that you have considered carefully various alternatives to


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each patient’s situation and have chosen the restraint type to assure the least danger. All dangers will have to be considered. If you argue, “He might fall and hurt himself,” you have not considered the dangers inherent in restraint use, which are considerable. Forms need to be created to document restraint use, and various alternatives can be listed on those forms as suggestions for alternatives to the restraint, such as decreasing sensory stimuli, moving the patient closer to the station, or using alarms. As the needs to assure safety for a patient escalate, so will the attention to detail escalate. You can expect surveying agencies to focus on such situations precisely for this reason.

Patients become delirious for a variety of reasons, only one of which is conscious sedation for procedures and surgery. These patients require closer monitoring to assure safety. A plan of care needs to be in place that details those safety needs and provides appropriate interventions. Safety plans should be standard throughout your facility for similar populations.

Put safety on the agenda and most of your patients will have approaches written into their plans of care to meet their safety needs. Consider such common situations as skin tears for elderly patients and the need to minimize sharp corners, tight spots, and generally make it easier for these patients to move without injury. While it is impossible to put your patients in a plastic bubble to protect them from harm, much more can be done than is being done.

PUBLIC EDUCATION:

Patients can insure their own safety by becoming involved in their healthcare. There are several things you can teach patients that will empower them to ask questions and monitor the process. When the doctor writes them a prescription, make sure they can read it. If not, an error is

possible. Ensure that they know what medications they are taking, what the pills look like, and why they

are taking the medication. If they have any questions about the instructions on their medicine labels, dietary sheets,

exercise instructions, etc. encourage them to ask, and specify who they can ask along with appropriate telephone numbers. Medication labels can be particularly hard to understand. For example, does four doses daily mean every six hours around the clock or just four times during waking hours.

It is appropriate for them to ask all healthcare workers who have direct contact with them whether they have washed their hands.

Before surgery, patients can sign their initials near the site to be operated on to assure that this will be the area the surgeon will work.

If they are treated by various physicians, they should keep a list of all the medicines from all the different doctors, as well as herbs from the health food store and vitamins from the grocery. List all over-the-counter drugs, all allergies, and any other helpful information.

They should read the warning labels on their prescriptions, checking specifically for foods to avoid, timing of the drug with meals, etc. If there are concerns, encourage them to ask.

They should get the results of any tests or procedures done. Instruct them to ask when the results are expected, and if they haven’t heard, contact the physician.

Doctors need feedback. Encourage patients to tell doctors when treatments or medication are working or not working, and to inform them of all changes they’ve observed from constipation to sexual functioning and everything in between. Teach patients not to assume that a new symptom is because of age or stress. There might be a connection.

The public, especially our elderly, often do not feel at liberty to question what we do, fearing that they might look stupid, or threaten the healthcare practitioner in some way. We need to teach our patients/clients a new way to interact with us that restores the responsibility for health back to them. It is their body, their life, and the healthcare decisions and processes are in their domain of power. To act with self-responsibility, they need access to information, which is our responsibility to provide. Patient education is perhaps one of the most effective ways to prevent medical errors. The patient/client has the right to know, understand and consent to everything that happens to him/her while in our care. In our team approach to changing the system, it is vital that we include the patient/client as part of that team.


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Question No. 20: How can you empower patients to insure their own safety?

a. Encourage patients to ask any questions they may have. b. Teach patients that it is appropriate to ask all healthcare workers giving them direct care

whether they have washed their hands. c. Teach patients to insist on being able to read their prescriptions. d. All of these and more.

For additional information on patient safety and prevention of medical errors, refer to

www.allheathnet.com/Patient-Safety.htm. This site links you to multiple associations, centers and articles that can keep you quickly informed.


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BIBLIOGRAPHY Abushaiqa, M. et al, “Educational Interventions to Reduce Use of Unsafe Abbreviations,” American Journal of Health-System Pharmacy, 64(11), 2007. Allen, M. “How Many Die From Medical Mistakes in US Hospitals?” Scientific American, September 20, 2013. Anthony, M, and Vidal, K., “Mindful Communication: A Novel Approach to Improving Delegation and Increasing Patient Safety,” The Online Journal of Issues in Nursing, 15(2), 2010. Barclay, Laurie, “Copied and Pated and Misdiagnosed (or Cloned Notes and Blind Alleys,” American College of Physicians Ethics Case Studies, http://www.medscape.org/viewarticle/763617, May 16, 2012. Buetow, S. et al, “Patient Error: A Preliminary Toxonomy,” Annals of Family Medicine, 7(3), 2009. “Case and Commentary: Crossing the Borderline,” AHRQ: WebM&M, webmm.ahrq.gov/case.aspx?caseID=141, December 2006. “Confronting a Colleague Who Covers Up a Medical Error,” American Family Physician, April 1, 2006. “Crossing the Quality chasm: A New Health System for the 21st Century,” Institute of Medicine, 2001. Doheny, Kathleen, “Deadly Medical Errors Still Plague U.S.”, WebMD Health News, May 20, 2009, www.medscape.com/viewarticle/703092 Fix, Megan, “What Should I Do If I Witness a Medical Error?” MedScape Med Students, 11/13/2008, http://medscape.com/viewarticle/582861 Hakin, Amin, “JCAHO Standards Up the Ante for Leadership,” Physician Executive, July-August 2006. Henneman, E. et al, “Strategies Used by Critical Care Nurses to Identify, Interrupt, and Correct medical Errors,” American Journal of Critical Care, 19, (6), http://ajcc.aacnjournals.org/content/19/6/500, November 2010. Holland, Julie, “Professionals and Patient Safety: How to Positively Influence Change,”

http://www.ahima.org/journal/features/feature.0104.4.html. Kachalia, Allen, “Disclosure of Medical Error, https://psnet.ahrq.gov/perspectives/perspective/70, January 2009. Keefe, Sandy, “Living LEAN,” Advance for Nurses, October 16, 2006. Levinson, William, “Medical Tragedy Can Be Easily Prevented by Error Proofing,” Quality Digest, www.qualitydigest.com, 2011. Mazor, K. et al, “Disclosure of Medical Errors,” Journal of General Internal Medicine, 21(7), pg. 704-710, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924693, July 2006. “Medical Errors in the USA: Human or Systemic?”, The Lancet, Volume 377, NO. 9774, pg 1289, http://thelancet.com/journals/lancet/article/PIIS0140-6736(11)60520-5, April 16, 2011. “Medication Errors and Syringe Safety are Top Concerns for Nurses According to New National Study,” Business

Wire, June 18, 2007. “More than 40% of Nurse Errors not From Medication: Procedural Errors, Charting Errors also Significant,”

HealthCare Benchmarks and Quality Improvement, April 2005. Nebehay, Stephanie, “Health Care is “High-Risk” Business, “ Reuters Health Information,

www.medscape.com/viewarticle/746848 July 2011. “Nurses Report Lion’s Share of Medical Errors,” Health Management Technology, March 2006. Preidt, Robert, “Number of Medical Errors Rose,” Health Day, April 3, 2006. “Preventable Medical Errors – the Sixth Biggest Killer in America,”

https://www.justice.org/cps/red/justice/hs,xls/8677, 2013. “Reducing Medication Mistakes,” http://backandneck.about.com/library/weekly/aa052300a.htm. Solnik, Claude, “Healthcare Group Seeking to Reduce Medical Errors,” Long Island Business News, Jan. 5, 2007. Spalding, Katrina, “Medication Errors Become Problematic,” Arizona Nurse, July 2006. Sparkman, Catherine, “Legislating Apology in the Context of Medical Mistakes,” AORN Journal, August 2005. Starmer, A. et al, “Changes in Medical Errors after Implementation of a Handoff Program,” The New England

Journal of Medicine, 371: 1803-1812. http://www.nejm.org/doi/full/10.1056/NEJMsa1405556 , Nov. 6, 2014. “To Err Is Human: Building a Safer Health System”, Washington, DC: Institute of Medicine, National Academy

Press: 2000. Tokarski, Cathy, “Better Communication Needed to Reduce Medical Errors,” Medscape Medical News, January 27,

2005, www.medscape.com/viewarticle/498276 Tokuda, U., et al, “Cognitive Error as the Most Frequent Contributory Factor in Cases of Medical Errors,” Journal of

Hospital Medicine, March 2011, pg. 109-114. Topol, Eric, “Medical Errors: Still Made in One out of Four Hospitalized Patients,”

http://www.medscape.com/viewarticle/802276, April 19, 2011. Vanderveen, T., “Intravenous Medication Delivery,” http://www.medscape.org/viewarticle/590420 April 8, 2009. White, A. et al, “The Attitudes and Experiences of Trainees Regarding Disclosing Medical Errors to Patients,”

Academic Medicine, 83(3), 2008.


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Use this answer sheet as a guide when you submit your answers on the website. Once you are ready to submit your answers and complete the course, you will need to sign in to your record at www.consultantsforthefuture.com, using your username and password. Click on “Pending Courses” to find your list of outstanding courses. Select this course, and on the next page select “Continue To Test”. The questions should be the same as in the course material you just read. Select your answers and then press “Submit.” Online submission is immediate. After successful completion, the next page is the evaluation, and the page after that is your certificate, which you can print. There is only one correct answer for each question. 1. (a) (b) (c) (d) 11. (a) (b) (c) (d) 2. (a) (b) 12. (a) (b) (c) 3. (a) (b) (c) (d) 13. (a) (b) 4. (a) (b) 14. (a) (b) (c) (d) 5. (a) (b) (c) (d) 15. (a) (b) (c) (d) 6. (a) (b) (c) (d) 16. (a) (b) (c) (d) 7. (a) (b) (c) (d) 17. (a) (b) (c) (d) 8. (a) (b) (c) (d) 18. (a) (b) (c) (d) 9. (a) (b) (c) (d) 19. (a) (b) 10. (a) (b) (c) (d) 20. (a) (b) (c) (d) 1120A 1/16

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