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Prevention of
Medical Errors2011
Mary Mckay DNP, ARNP
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Second Victim
Phenomenon
Source: Scott SD, Hirschinger LE, Cox KR, et al. Caring for our own: deploying a systemwide second victim rapid
response team. Jt Comm J Qual Patient Saf. 2010;36:233-240.
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Is Health Care Safer Today?
Difficult to Assess:
Lack of universal reporting system
Under reporting
Lack of consensus regardingterminology/definitions of whatconstitutes an error
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Why are errors under
reported?1. Historically a punitive approach has been
taken leading to fear :
Loss of reputation
Loss of job Disciplinary action by professional board
Malpractice
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Why are errors under
reported?
2. Difficult to use reporting systems
3. Time constraints
4. Sweep it under the rug mentality
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Is Health Care Safer Today?
Agency for Healthcare Research and
Quality- National Healthcare QualityReport 2008
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National Initiatives
Patient Safety and Quality Improvement
Act of 2005Legislation that establishes a confidentialreporting structure in which hospitals,
health care professional and entities can
voluntarily report information on errors toPatient Safety Organizations to facilitate
development of patient safety strategies.
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Simulation and Safety
What are the benefits of learning through simulation?
Allows for learners to perform in an environment thatis as close as possible to a real patient scenario
Learners acquire and practice skills in a safe
environment Mistakes made while training will not harm a real
patient
An opportunity to improve patient safety thru teamworkand critical event training.( American Society ofAnesthesiologists, 2008).
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Institute for Healthcare Improvement
Adverse Drug Events (ADE) Catheter-Associated Urinary Tract Infections (CAUTI)
Central Line Associated Blood Stream Infections (CLABSI)
Injuries from Falls and Immobility
Obstetrical Adverse Events Pressure Ulcers
Surgical Site Infections
Venous Thromboembolism (VTE)
Ventilator-Associated Pneumonia (VAP)
Other Hospital-Acquired Conditions
Posted on: April 12, 2011
http://www.ihi.org/IHI/Programs/ImprovementMap/
Institute for Health Care Improvement @ IHI.org
http://www.healthcare.gov/center/programs/partnership/safer/ade.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/cauti.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/clabsi.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/injuries.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/obstetrical.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/ulcers_.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/infections_.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/vte.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/vap.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/conditions_.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/conditions_.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/conditions_.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/conditions_.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/vap.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/vap.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/vap.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/vte.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/infections_.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/ulcers_.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/obstetrical.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/injuries.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/clabsi.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/cauti.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/cauti.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/cauti.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/ade.html -
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WHO- Initiatives
Clean Care is Safer Care
Safe Surgery Saves Lives
WHO Safety Check list
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Common Terminology
Medical Error
Adverse Event
Near Miss
Sentinel Event
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What is a Medical Error ?
According to the Institute of
Medicine(1999) a medical error is
defined as the failure of a planned
action to be completed as intended or theuse of a wrong plan to achieve an aim.
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What is an
ADVERSE EVENT ?
An event in which a negativeoutcome occurred as a result ofmedical intervention rather than
from the underlying medicalcondition.
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What is a Near Miss ?
An event or situation that couldhave resulted in an accident, injuryor illness ,but did not, either by
chance or through timelyintervention.
Warning sign
Increased reporting needed
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Case Study
She returned to the patient and hung theDiprivan via the patients central line. The IV
pump alarmed air in line almost immediately.
While removing the air from the line the nursewas once again alerted to the discrepancy she
had noted earlier. She removed the Diprivan
and contacted the pharmacy. Fortunately, the
patient had not received any of the Diprivan yet.
Reference: http://www.ahrq.gov
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What Happened ?
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What is a Sentinel Event? The Joint Commission developed a Sentinel
Event Policy and database in 1996 of allreported events.
Used to analyze events to provideinformation to healthcare organizations todeter future occurrences.
Joint Commission
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What is a Sentinel Event?
A sentinel event is defined as anunexpected occurrence involving deathor serious physical, or psychological
injury, or risk thereof
Sends a signal or warning that requiresimmediate attention
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Agency for Healthcare Research and Quality
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Sentinel Events Alert
In order to communicate information related
to sentinel events to healthcareorganizations in a timely manner the Jointcommission utilizes Sentinel Events Alert.
Identifies specific sentinel events, describes
their common underlying causes, andsuggests steps to prevent occurrences in thefuture.
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What is a Root Cause
and Analysis ?
A process for identifying the
causative factors involved in theoccurrence of a sentinel event
A root cause is the most basicreason for the failure or inefficiency
of a process Focuses primarily on
systems/processes not individuals
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JC Identified Root Causes
of Sentinel Events for AllCategories
Communication
Orientation/Training
Patient Assessment
Availability of information
Staffing levels
Physical environment Issues
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JC Identified Root Causes
of Sentinel Events for AllCategories
Continuum of care
Competency/ Credentialing
Procedural compliance
Alarm systems
Organizational Culture
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FAILURE MODES & EFFECT
ANALYSIS Another method to prevent errors
Process applied prior to actual error
Examines a system/process for possible highrisk points of error
Possibly redesign the process to eliminatechance of failure
Pilot test Implement the process
Reevaluate
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Why Do Errors in Health
Care Occur ?Medical errors most often result from a
complex interplay of multiple factors. Onlyrarely are they due to the carelessness or
misconduct of single individuals
L. Leape, MD.
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WHY DO SYSTEMS FAIL?
COMPLEXITY
VARIABILITY
INCONSISTENCY TIME CONSTRAINT
HUMAN INTERVENTION
HIEARCHICAL CULTURE TIGHT COUPLING
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Types of System
Errors/Failures Active errors/failures involve personnel and
parts of the health care system that are in
direct contact with the patient.
Their actions may result in errors that have adirect impact on patient safety
Referred to as errors occurring at the sharpend. Reason, JT. (1990). Human Error. New York, NY:Cambridge University
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Types of System
Errors/Failures
Latent errors/failures involve individuals such
as managers, administrators and policymakers
Their actions or decisions may lead to anegative impact on patient safety. Tend to be
less obvious. Referred to as errors occurring at the blunt
end
Reason, JT. (1990). Human Error. New York, NY:Cambridge University
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Types of System
Errors/Failures
Blunt End Sharp EndLatent Active
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2011 JC National Patient
Safety GoalsGoal 1: Improve the accuracy of
patient identification
A. Use at least two patientidentifiers(neither to be the patientsroom number) when providing care,treatment or services
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A 47 y/o male who was PCP. Whileundergoing treatment he had several skinlesions biopsied. Several days later an
MD(PCP) noted the results in the EMR werepositive for cancer. This prompted the PCPto recommend Hospice care. Later that daythe hospital MD noted this was an error. The
biopsy results were from another patient.The medical team met with the patient toexplain the error.
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What Happened?
This example involves both active
and latent errors
Reference: http://www.ahrq.gov
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JC Patient Safety 2011
Eliminate Transfusion Errors
2011
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2011
National Patient Safety
Goals
Goal 2- Improve the effectiveness
of communication amongcaregivers
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2011 National Patient Safety
Goals2A. For verbal or telephone orders or for
telephonic reporting of critical test
results,verify read -back of thecomplete order or test result by theperson receiving the order or test
result
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2011 National Patient Safety
Goals
2B. Standardize a list of abbreviations,
acronyms and symbols that are NOT tobe used throughout the organization.
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Case Study
An 81 year old female with a history of
chronic Atrial Fib who was receivingwarfarin developed asymptomatic runsof ventricular Tachycardia
http://www.ahrq.gov
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Case Study
Unit RN contacted MD
who was involved in asterile procedure and
gave a verbal order to
the procedure nurse
Someone in the verbal
order said 40 of K.The unit RN
Wrote the order as
Give 40mg Vit K IVNow
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Case Study
The hospital
pharmacist contacted
The MD concerningThe high dose and the
route
Clarification of order
Was obtained
40 mEq of KCL PO
Simultaneously the unit RN had obtained the Vit K on over ride
From the Pyxis system and given the IV dose
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Case Study
The hospital
pharmacist contacted
The MD concerningThe high dose and the
route
Clarification of order
Was obtained
40 mEq of KCL PO
Simultaneously the unit RN had obtained the Vit K on over ride
From the Pyxis system and given the IV dose
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Case Study
The RN attempted to contact the MD but
Was told he was busy. The MD was not
Notified until the next day. Heparin was
Initiated and warfarin retitrated. No
Long term consequences were suffered.
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Do Not Use AbbreviationsAbbreviation Mistaken for Suggestion
U for unit Zero, four, cc Unit
IUInternationalunit
IV or 10 Internationalunit
Q.D.Q.O.D.
Each other Daily orevery otherday
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Abbreviation Mistaken for Suggestion
Trailing zero(1.0mg)
Lack of aleading ero(.1mg)
Decimal point ismissedRead as 10 mg
Read as1 mg
Never write a zerafter a decimalpoint and alwaysuse a zero beforea decimal point
MSMSO4MgSO4
ConfusionMorphine sulfatevsMagnesiumsulfate
Write out name ofdrug
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Abbreviation Mistaken for Suggestion
mcg Milligram Write outmicrogram
TIW Three times
a week
HS Multiple
meaning
Write out
meaningbedtime halfstrength
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2011 JC National Patient
Safety Goals
2C. Measure, assess and, if appropriate
take action to improve the timeliness ofreporting and timeliness of receipt bythe responsible licensed caregiver of
critical test result and values.
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A 91-year-old female was transferred to a hospital-based skilled
nursing unit from the acute care hospital for continued woundcare and intravenous (IV) antibiotics for (MRSA) osteomyelitisof the heel. She was on IV vancomycin and began to havefrequent, large stools.
The attending physician ordered a test for Clostridium difficileon Friday, and was then off for the weekend. That night, the testresult came back positive. The lab called infection control, whoin turn notified the float nurse caring for the patient. The nursedid not notify the physician on call or the regular nursing staff.
Isolation signs were posted on the patient's door and chart, andthe result was noted in the patient's nursing record.
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On Monday, the physician who originally ordered the C. difficile
test returned to assess the patient and found the isolation signson her door. He asked why he was never notified and why thepatient was not being treated. The nurse on duty at that timetold him that the patient was on IV vancomycin. The float nurse,who had received the original notification from infection control,
stated that she had assumed the physician would check theresults of the test he had ordered. Due to the lack of follow-up,the patient went three days without treatment for C. difficile, andcontinued to have more than 10 loose stools daily. Given heradvanced age, this degree of gastrointestinal loss undoubtedlyplayed a role in her decline in functional status and extended
hospital stay.
AHRQ
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How Important is
Communication and PatientSafety?
70-80% of health care errors are caused
by human factors associated withinterpersonal interactions(Schaefer,1994)
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CASE STUDY
An 83 y/o male with a history of COPD,
GERD, and atrial fib was admitted to a large
teaching hospital for placement of a pacemakervia the left subclavian vein. Following the
procedure the patient had an CXR which
showed no pneumothorax. He was sent torecovery for overnight monitoring.
Reference: http://www.ahrq.gov
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Case Study
The patient had shortness of breath andcomplained of left sided back pain. The
nurse informed the on call intern who
examined the patient (for the first time)and ordered a chest x-ray. When the nurse
called the intern at 8 pm to check for results, the
Intern stated he was signing out the x-ray to the
night float resident. In the meantime the patientwas feeling a little better with oxygen.
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Case Study
At 10 pm the nurse called the float resident who
had been too busy with an emergency to check the
x-ray results. At midnight the nurse gave report
to the next shift noting that the resident had notcalled with any bad news. The next morning
the radiologist called to inform the nurse the
patient had a large left pneumothorax. A chest
tube was inserted nearly 23 hours following thex-ray. Fortunately the patient did not suffer any long
term harm.
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What Happened?
After further follow up it was discoveredthat the night float resident hadmistakenly examined the CXR that had
been taken immediately following thesurgery instead of the later one.
This case illustrates how a handoff canjeopardize patient safety. A standardized
method for communicating transfer ofcare can decrease the risk.
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Behaviors That Impede
Patient Safety Reluctance or refusal to answer
questions- avoidance
Rude or condescending comments
Threatening body language
Verbal abuse I am in charge. Just do it
Threats to reputation
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Behaviors That Support A
Culture of Safety
Collaboration
Respect Interdisciplinary rounds/conferences
Open, honest and direct communication
Supportive non-punitive reporting
Goal directed interactions
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Agency for Healthcare Research andQuality
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2011 National Patient
Safety GoalsGoal 3 Improve the safety of using medications
Identify and, at a minimum, annually review a list oflook-alike/sound-alike drugs used in theorganization, and take action to prevent errors
involving the interchange of these drugs
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Case Study
A 36 y/o woman with chronic renal failure
& diabetes was transferred from a nursing
home to the hospital for treatment of an
infection. Bicitra (citric acid)30ml four times a
day was ordered on admission. The
pharmacist filled the order with Polycitra
instead ( contains citric acid & Potassium
citrate). The patient drank the entire dose.
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Case Study
The nurse on the next shift noted the
empty container. The MD was notified
and a STAT potassium level was > 8mEq/L.
(Normal is 3.5-5) and her blood glucose was
600mg/dl. The patient was treated
with Kayexalate and insulin withoutcomplications.
Reference: http://www.ahrq.gov
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What Happened?
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2011 National Patient
Safety Goals
- Label all medications, medication
containers(syringes, medicine cups,etc)or other solutions on & off the sterilefield
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Case Study
A woman was injected with chlorhexidine
(topical anti microbial) instead of the intended
contrast media during a cerebral angiogramprocedure. The clear pink tinged chlorhexidine
solution was placed in a basin identical to that
used to hold clear colored contrast media.
Neither basin was labeled so both solutions
looked very similar.ISMP Medication Safety Alert! August 2005 Vol3 Issue 8
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Case Study
The patient experienced an acute severe
chemical injury to the blood vessels in her leg.Within two weeks her leg was amputated. She
then suffered a stroke and organ failure leading
to her death.
ISMP Medication Safety Alert! August 2005 Vol3 Issue 8
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What Happened ?
Is this an example of an active or
latent failure?
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What Happened ?
It is an example of both.
The lack of labeling on the basins is an
active failure. The change in cleaning solutions is a
latent failure.
Blunt End Sharp End
Addi i l M di i
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Additional MedicationSafety Issues
The National Coordinating Council for Medication ErrorReporting & Prevention defines a medication error asfollows:
A medication error is any preventable event that maycause or lead to inappropriate medication use or patientharm while the medication is in the control of the healthcare professional, patient or consumer. Such eventsmay be related to professional practice, health care
products, procedures and systems, includingprescribing; order communication; product labeling,packing, and nomenclature; compounding; dispensing;distribution, administration; education;monitoring;anduse.
H Oft D M di ti
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How Often Do MedicationErrors Really Occur ?
According to the IOM study more than7000 deaths occur each year related tomedication errors.
Another study found that as many as 1 inevery 5 medications reach the patient inerror.
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Medication Errors
Keep in mind that the reporting ofmedication errors is thought to be
grossly under reported !
Reporting agencies include the FDA, US
Pharmacopeia via Medmarx , ISMP andJCAHO
Wh i th P d
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Where in the Process doMedication Errors Occur?
Reference: http://www.ahrq.gov
Wh i h P d
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Where in the Process doMedication Errors Occur?
Most errors occur during the prescribing/ordering process.
About 50% of those prescribing errors arecaught prior to reaching the patient.
Greater than one third of errors occur during
administration but only 2% of these errorsare caught prior to reaching the patient.ISMP Medication Safety Alert, November 2005
P ti t i th L t Li f
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Patient is the Last Line ofDefense
Errors made during the administration
process are much more likely to reach thepatient and are associated with those errorsthat cause harm.
Encourage patient and families to askquestions.
ISMP Medication Safety Alert, November 2005
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TYPES OF ERRORS
Unauthorized drug
Improper dose Omission
Prescribing
Wrong time Wrong Patient
Extra dose
Wrong administration
technique Wrong method of
preparation
Wrong dosage form
Wrong route
Failure to monitor
D All M di ti E
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Do All Medication ErrorsResult in Harm to Patient?
According to MEDMARX 2002 Datareport (USP) out of 192,477 reported
med errors-82 % were classified asnon-harmful.
However, a reported 3,193 were
classified as harmful and 20 as fatalerrors.
C ld f l t ib
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Could you safely transcribethis order ?
Reference: http://www.ahrq.gov
Co ld o safel transcribe
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Could you safely transcribethis order ?
Reference: http://www.ahrq.gov
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Key Points Written orders must be clear and legible !
Clarify any order that is questionable
including sound alike/ look alike drugs. Patients age, sex,current medications,
diagnosis, co morbidities, concurrent
conditions, laboratory values, allergiesand past sensitivities must be available toprescriber
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Case Study
A patient was admitted to a teaching hospital withsuspected vasculitis. During rounds the senior residentinstructed the intern to give the patient one gram ofsteroids. Following rounds the interns orderedPrednisone 20mg tabs 50 pills PO x 1 now. The
pharmacist contacted the intern to clarify the order. Shesuggested to the intern that the order should probablybe given in an IV form. The intern refused to change theOrder despite the pharmacists suggestion to contact thesenior resident for clarification. The intern added to give
Maalox with the steroids. The patient reluctantly took the fifty20 mg pills and developed mild nausea and heartburn. Thefollowing day the senior resident found the error andchanged the order to the IV form.
Reference: http://www.ahrq.gov
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What Happened?
The intern did not seek clarification as suggested bythe pharmacist, who is an expert in pharmacology.Lack of interdisciplinary approach to patient care.The intern may have been fearful of the seniorresidences reaction to seeking clarification.
The pharmacist did not follow the chain of commandby calling the senior resident when the discrepancywas not addressed by the intern.
QUESTION INCONSISTENCIES-YOUR PATIENTSSAFETY IS IN YOUR HANDS
Medication Errors :
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Medication Errors :Prevention Strategies
Adhere to standards of medication
administration -8 Rights Communicate with the patient /family
Identify medications with high risk for
error and institute specific protocols
Medication Errors :
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Medication Errors :
Prevention Strategies Training & competency assessment
Decrease distractions
Computerized order entry
Automated dispensing devices
Medication Errors :
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Medication Errors :
Prevention Strategies
Proper storage & labeling
Bar coding-decreases errors inadministration
Increased clinical Pharmacists
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2011 Patient Safety Goals
Reduce the likelihood of patient harm
associated with the use ofanticoagulation therapy.
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Case Study
Three neonates died at a hospital as aresult of accidental heparin overdoses.A pharmacy technician inadvertently filled
the automated dispensing cabinet with1ml vials of heparin containing10,000 units/ml instead of the1ml vials ofheparin10 units/ml. The nurses did not notice
the discrepancy and the heparin wasadministered to the neonates.
ISMP Medication Safety Alert Oct 2006 4/10
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RecommendationsIn order to prevent this tragedy from happening again
the following recommendations have been made:
1. Eliminate 10, 000 units/ml concentration vialsstocked in the hospital. If this concentrationremains in the pharmacy, keep the vials separatefrom other concentrations.
2. Require an independent double check of drug.3. Reduce look alike/ sound alike drug packaging
The vials of heparin had similarities that may have
contributed to the error.For all recommendations see reference
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Unintended Medication Discrepancies at the
Time of
Hospital Admission
6% Severe harm potential
61%
No harm potential
33%
Moderate harm potential
More than half of patient have 1 unintended medication discrepancy at
hospital admission
Reference: http://www.ahrq.gov
Unintended Medication Discrepancies at the
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Unintended Medication Discrepancies at the
Time of
Hospital Admission
Cornish,Knowles & Marchensano(2005)found
greater than 50% of patients had at least 1medication discrepancy upon hospitaladmission. The most common error wasomission of a regularly used medication.
Obtaining an accurate medication history atthe time of admission is critical to preventsuch errors.
Reference: http://www.ahrq.gov
2011 National Patient
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2011 National PatientSafety Goals
Goal 8- Accurately and completely
Reconcile Medications across thecontinuum of care
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2011 Patient Safety Goals
Comparing Current and Newly OrderedMedications (NPSG.08.01.01)
B. Communicating Medications to theNext Provider (NPSG.08.02.01)
C. Providing a Reconciled Medication
List to the Patient (NPSG.08.03.01) D. Settings in which Medications Are
Minimally Used (NPSG.08.04.01)
2011 National Patient
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2011 National PatientSafety Goals
Goal 7- Reduce the risk of health care
associated infections
A. Meeting Hand Hygiene Guidelines
B. Preventing Multidrug-Resistant OrganismInfections
C. Preventing Central LineAssociated Blood StreamInfections
D. Preventing Surgical Site Infections
TEST YOUR KNOWLEDGE
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TEST YOUR KNOWLEDGE
Which is the most
frequently occurring
nosocomial
infection?A. Urinary tract infection
B. Pneumonia
C. Vascular Catheterrelated
Which of these are riskfactors for development
of nosocomial infections?
A. AgeB. Urinary catheter >24hrs
C. Mechanical ventilation
D. Severe underlying disease
E. Extended stay in acute orchronic care facility
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Additional considerations include:
Overuse of antimicrobials
Contaminated equipment-instruments
Poor HANDWASHING
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Additional Safety Concerns
Reduce the Potential of Patient Harmresulting from falls
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Falls in the Elderly
Falls are a leading cause of death in people 65 andolder.
Approximately 50% of those that fall suffer injuriesthat reduce mobility and independence. One third ofthose that sustain hip fractures require nursing homeplacement
Ten percent of fatal falls for older adults occur inhospitals.
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Fall Risk Factors
>65 years of age
Inability tounderstand or follow
directions Confusion
Altered level ofconsciousness/
delirium
Inability to use calllight
Impaired vision ormobility
Unsteady gait
Dizziness/fainting
Recent history offalls
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Fall Risk Factors
Medication Therapy
Hx ofnocturnal/urgency/frequency inelimination
Hx of seizures
Surgical Procedure
Orthostatic
hypotension orhypertension
Children in cribs
Use of assistivedevices
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Meds Requiring Fall Alert
Tricyclic Antidepressants
Antipsychotics
Sedative-Hypnotics
Antihypertensives
Antihistamine/Anticholinergics
Hypoglycemic agents
Diuretics/Laxatives
Anticonvulsants
Muscle Relaxants
Narcotic Analgesics
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Fall Assessment-High Risk
Identify high risk patients and communicate
to staff-Morse Fall Scale
Place yellow fall identification band onpatients wrist
Observe patients identified at risk for fallsevery 2 hours
Review patients medications that may
increase the risk of falls on a daily basis.
Interventions- Initiate Safety
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Interventions Initiate SafetyMeasures
Dangle feet from bedprior tositting/ambulation
Assist with ambulation Apply fall alert ID
armband
Place bed/chair in low
position Ensure correct use of
least restraint
Free environment ofclutter
Review medications
Considerinterdisciplinary consult
Document assessment,interventions, response
Educate patient &significant others
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Reporting Falls: SBARD
A method of communication used toreport a critical situation to a physicianincluding falls
S = Situation B = Background
A = Assessment
R = Recommendation D = Document
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Additional Safety Concerns
Prevent health careassociated pressure
ulcers
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2011 Patient Safety Goals
The organization identifies safety risks inherent
in its patient population.
High Risk Patient
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High Risk PatientPopulations
Elderly
Pediatric
Language Barriers Vision Impairment
C S d
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Case Study
An elderly blind patient was hospitalizedfor treatment of a deep vein thrombosis(clot).
His discharge medications included injections
of a anti coagulate. A nurse and pharmacistprovided the patient with written information
sheets and counseling regarding self
administration of his medications. Neithernoticed that the patient was blind.
Reference: http://www.ahrq.gov
C S d
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Case Study
Several days following discharge the
patient called the office and told the nurse
he had a bag full of medications including
injections, but he had not taken any of
them since he could not read the
instructions. The patient had to be
readmitted to the hospital for continuation
of anticoagulate therapy.
Wh H d?
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What Happened?
False assumptions regarding the patientsvisual acuity
Inadequate discharge teaching. Written
information is insufficient. They did not have the patient return
demonstrate the injection procedure.
Over 1 million persons living in the US are
legally blind. Proper assessment is essentialto patient education.
Interventions For High Risk
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Interventions For High RiskPatients
Medication training/competency
Interpreter use Available patient education materials
Large print
Available outside resources
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Case Study
Following an overdose a 26 year old
woman was admitted for observation with
a 72 hour hold by psychiatry. A 24 - hour
attendant was placed with the patient. The
patient was to go to x-ray but requested to go to
the bathroom first. She was left in the bathroom
alone. The attendant and transporter began totalk.
Reference: http://www.ahrq.gov
C St d
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Case Study
Upon return to patients room, the nurse
became concerned and found patient with her
gown tied around her neck, standing on the
upside down garbage can. She was seconds
from stepping off and hanging herself.
Fortunately no harm came to the patient.
NEVER LEAVE PATIENT UNATTENDED
P hi t i P ti t
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Psychiatric Patients
According to other resources the number isunder reported. Approximately 1500 suicideshave occurred in hospitals.
Review of 76 cases found only 40% ofinpatients who committed suicide wereadmitted for suicidal ideation.
Prevention Strategies
2011 P ti t S f t G l
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2011 Patient Safety Goal
Conduct a pre procedure verificationProcess
A. Conducting a Pre-Procedure
Verification Process
B. Marking the Procedure Site
C. Performing a Time-Out
Patient Safety
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at e t Sa etyConsiderations
Encourage patients active involvement in theirown care as a patient safety strategy.
Improve recognition and response to changein a patients condition.
R id R T
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Rapid Response Teams
Team Composition
Goals- Early intervention Process
Outcomes
P ti t/F il
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Patient/Family
Patients and family members can provideadditional safety checks.
Encourage patients and families to ask
questions. Inform patients of their rights.
Educate patients and family members on allaspects of their care.
Provide written material as well as verbal.
Available Resources for
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Patient Education include
Institute for Safe Medication Practices
access www.ismp.org Agency for Healthcare Research & Quality -
access www.ahrq.govhttp://www.ihi.org/IHI/
Institute for Healthcare Improvement access:http://www.ihi.org/IHI/
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TEAM WORK IS THE KEY
Moving pains
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Moving pains
A 90-year-old woman was admitted to the acute careward of the school's teaching hospital with a urinarytract infection and pneumonia. After developinghypoxemia, on hospital day 2, she was placed on 2L/min oxygen by nasal cannula. On hospital day 3,
her hypoxemia worsened, as did her mental status.A head CT was ordered. She was placed on a non-rebreather mask (NRM) at 15 L/min to maintain heroxygen saturations. This change in respiratory status
occurred while the primary nurse was occupied bythe critical needs of another patient, so anothernurse and the respiratory therapist placed the patienton the NRM.
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The primary nurse completed the transport stability
scale (TSS
a local instrument used to assess apatient's stability for transport and to determine theneed for a nurse or physician to travel with thepatient) at the nurses' station in preparing her patientfor transport to the CT scanner. Because the nursewas unaware of the change in her patient'srespiratory status, she recorded that the patientrequired only 2 L/min oxygen by nasal cannula.Accordingly, the TSS score did not signal a need for
a nurse or physician to accompany the patient.Therefore, the patient was taken to the CT scannerby two transport personnel/escorts.
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As the transporters prepared to leave the floor with the patient
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As the transporters prepared to leave the floor with the patient,one of them noticed that the patient had labored breathing. Hesuspected that a nurse should travel with them but did notquestion the nurse's assessment on the transport stability form.During transport, the patient continued breathing through herNRM, which was connected to an oxygen tank.
Once the patient arrived in radiology, the CT technician noticedthat NRM bag was deflated and the oxygen tank had a
regulator that limited oxygen delivery to 4 L/min. The technicianconnected the NRM to the wall oxygen source at 15 L/min forthe study and located an appropriate tank (that would allowhigher-flow oxygen) for the trip back to the unit. After the study,the patient was switched to this new tank at 15 L/min and
awaited transport. The two transporters arrived, and the patientleft radiology to return to her room.
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