Patient Safety
Evelyn M. Hickson, RN, MSN, CNS, WCC
Objectives
By the end of the presentation, the participant will beable to:
1. Describe the most common causes of medication errors and the actions needed to ensure safe medication administration
2. Be able to state 4 current national patient safety goals
3. Describe the principle of professional, accountable communication
4. Identify perinatal risk management strategies
Patient Safety
1. Are we as nurses responsible for ensuring patient safety?
2. Do nurses have a medical-legal responsibility to provide safe patient care?
3. What methods do nurses have to use to facilitate the provision of safe patient care?
Definition
Patient safety is a discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. Patient safety is also an attribute of health care systems; it minimizes the incidence and impact of, and maximizes recovery from, adverse events.
What Exactly Is Patient Safety? Linda Emanuel, MD, PhD, Don Berwick, MD, MPP, James Conway, MS, John Combes, MD, Martin Hatlie, JD, Lucian
Leape, MD, James Reason, PhD, Paul Schyve, MD, Charles Vincent, MPhil, PhD, and Merrilyn Walton, PhD.*, Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment). Rockville (MD): Agency for Healthcare Research and Quality; 2008 Aug.
2013 Hospital National Patient Safety Goals
Joint Commission of Accredited Health Care Organizations (JCAHO or “Joint”) Changes have been made and since the
mandated implementation of NPSG from the Joint in 2004
Not all of the current safety goals apply to the in-patient acute care setting
Hospital has 15 for 2013 – No new ones were added for this year
www.jointcommision.org
1. NPSG.01.01.01 - Use at least two (2) patient identifiers whenever: Giving medicationsProviding CareGiving any TreatmentsProviding Services
2. NPSG.01.03.01 –Make sure that the correct patient gets the correct blood when they get a blood transfusion
Identify Patients Correctly
Improve the effectiveness of communication among caregivers
3. NPSG.02.03.01 Standardize a list of abbreviations, acronyms,
symbols, and dose designations that are not be used throughout the organization
hs = hour of sleep bid = twice per day
MgSO4 = magnesium sulfate
Improve the effectiveness of communication among caregivers
For verbal or telephone orders or telephone reporting of critical test results, verify the complete order or test result by having the person receiving the information record and “read-back” the complete order or test result
Improve the effectiveness of communication among caregivers
Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.
Improve the effectiveness of communication among caregivers
Implement a standardized approach to “hand- off” communications, including an opportunity to ask and respond to questions.
Clear, concise, factual, appropriate report when patient is transferring within facility, to different level of care or to another facility
Team approach to conflict
Professional Communication
Multiple studies and publications by JCAHO found that health care worker’s inability to communicate effectively contribute to errors and problems within health care that are typically avoidable.
Medication errors
Patient safety
Quality of care
Nursing staffing and turnover
Joint Commission Publications
http://www.jointcommission.org/Advancing_Effective_Communication/
SBAR
Situation-what is going on with the patient at this time
Background-significant medical and obstetrical history
Assessment-vital signs, labs, fetal monitoring assessment
Recommendation-what you want from the MD/provider – order(s), actions,etc.
SBAR
Documentation Patient Hand-off – Report Conversations with MD/Providers
Perinatal SBAR 30-60 Second Report
Before Calling the Provider: 1. Assess the patient 2. Read the most current notes, lab data, orders, etc 3. Have the chart in hand
SBAR Report Obstetric Patient Situation Identify yourself and where you are calling from
Give patient name and reason for call: “Pt was admitted for___________ and/or has recently had a _____________” “I am concerned about____________” FHR pattern Labor Progress Contract Pattern (hyperstim or lack of) BP/Vital signs Vag Bleeding, etc
Background G___ P___ @ _______wks gest OB Attending ______________ Significant med history _____________ Significant OB history __________ Problems with current pregnancy _______ Patient complaints are____________ Patient pain level _____________
Assessment Maternal vital signs Cervical exam Labor progress FHR – Variab, Baseline, Accel, Decels, UC pattern, reassure Vs non-reassuring Lab values that are abnormal or changed Interventions you have had to implement and the patient’s response Your conclusions about the present situation
Recommendation What I would like from you is _________________ (I need you to come now to assess the patient, etc…)
Be specific about the time frame Be specific about interventions (FSE, IUPC, Pit, Terb) Clarify orders, vital signs, labor plans, when to call back, lab work, etc…
Other Methods
Key phrases that stop every member of the team: Huddle “Can I have a moment” “Team Up” Rounds
Seven Areas Where Communication Breaks Down
Broken rules – not following policy/protocols Mistakes Lack of support – from team, peers, administration Incompetence Poor teamwork Disrespect Micromanagement
Actions
What actions can
we as nurses take in order to attend to these 7
essential areas?
Broken Rules
Shortcuts can be dangerous when it comes to patient care
Policies and procedures are considered institutional standards / guidelines
Mistakes
Important to follow directions Ability to make sound clinical judgments that are
appropriate and individualized for the patient Critical Thinking Skills Assessment skills Triaging and diagnosing Requesting treatment and assistance
Lack of Support
Willingness to help, mentor, precept, answer questions, be a resource
Be an active team player – help out Give emotional support Pats on the back for a job well-done
Incompetence
Precept Mentor Educate Report – at times first line of action, other
times last. Patient safety comes first.
Poor Teamwork
Don’t participate in gossip Participate and lead team building activities Celebrate the things to be grateful for – the
positives Promotion of a culture that is focused on the
patient – improved safety and quality of care
Disrespect
Do not promote or participate in: Insulting others Being condescending Rude behavior Insolent behavior Insubordination to supervisors Portraying yourself and your profession negatively
to the public, students, patients, families and peers
Micromanagement
Do not participate in or allow others to:Abuse authorityPull rankBullyThreaten Force a point of view just to be right
Perspective
“No one can make you feel inferior without your consent”
Eleanor Roosevelt
Improve the safety of using medications
4. NPSG.03.04.01 - Label all medications, medication containers (syringes, medicine cups, basins), or other solutions on and off the sterile field and in the areas where supplies are set up.
Improve the safety of using medications
Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs.
Standardize and limit the number of drug concentrations used by the organization
Improve the safety of using medications
5. NPSG.03.05.01 – Take extra care with patients taking medications to thin their blood
Accurately and completely reconcile medications across the
continuum of care
6. NPSG.03.06.01 Record and pass along correct information
about the patient’s medications Compare any new medications ordered/started
during hospital stay with previously used medications
Make sure the patient knows how to take them – including food and drug interactions
Improve the Safety of High-Alert Medications
Complete lists available on www.ismp.org Anti-arrhythmics Anti-coagulants Chemotherapy Vasopressors Insulin Sedation and Opiates PCA/Epidural Medications Concentrated electrolytes
Other Medication Safety Recommendations
Pumps with alarm systems Distribution Units (i.e. Pyxis) Bar Code Scanning Computerized Physician Order Entry Fostering an environment of safety –
improvement without blame
The American Hospital Association lists the following as some common types of medication errors:
Incomplete patient information (not knowing about patients' allergies, other medicines they are taking, previous diagnoses, and lab results, for example)
Unavailable drug information (such as lack of up-to-date warnings); Miscommunication of drug orders- poor handwriting, confusion
between drugs with similar names, misuse of zeroes 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 medical tasks.
Medication Error Stats
2.5 million deaths occur annually in the USA 42% of people believed they had personally
experienced a medical mistake (NPSF survey) 44,000 to 98,000 deaths annually from medical
errors (Institute of Medicine) 225,000 deaths annually from medical errors
including 106,000 deaths due to "non-error adverse events of medications" (Starfield)
Medication Errors
Annual cost of drug-related morbidity and mortality is nearly $177 billion in the United States
180,000 deaths annually from medication errors and adverse reactions (Holland)
2.9 to 3.7 percent of hospitalizations leading to adverse medication reactions
Medication Error Stats
• 7,391 deaths resulted from medication errors (Institute of Medicine)
• 2.4 to 3.6 percent of hospital admissions were due to (prescription) medication events (Australian study)
Medication Error in Perinatal Area
According to the U.S. Pharmacopeia, Center for the Advancement of Patient Safety between 1998-2002 the of the 3,775 medication errors reported in three areas of OB: Labor and Delivery = 49% OB Recovery = 10% Maternity Unit = 41%
Medication Errors
76.7 % of those total errors reached the patient but did not do harm
70% of errors occurred during administration of the medication
3.2 % reached the patient and did significant harm
0.03% caused a death
Medication Errors
Most common errors in Obstetrics Omission of the medication or missed doses Improper dose / quantity Unauthorized (unordered) Wrong drug Knowing absolute contraindications – i.e., an epidural on a
anti-coagulated patient Wrong Timing Extra doses Wrong administration technique
Top 10 Causes of Medication Errors in the Obstetrical Area
Performance Deficit Not following protocol or policy Communication Knowledge deficit Documentation Transcription error / omission Dispensing device System safeguards broke down Improper use of pumps Drug distribution systems
Drugs that are commonly involved
Over 300 total in all three areas Most common: Insulin Antibiotics – Ampicillin, Cefazolin, Gentamycin Magnesium Sulfate Oxytocin – most frequently cited medication with adverse obstetrical events that
lead to professional liability claims Prostaglandins – cervical ripening Narcotics Anticoagulants Asthma Medications
Common Areas of Error
Infusion pumps that are not programmed correctly Misconnected or disconnected IV tubing Administering medications or mainline fluids
through epidural catheter Omission of an antibiotic per protocol or order Lack of allergy information documented and patient
banded at the time of medication administration Incomplete communication and documentation
Prevention
5 Rights – take the time to make sure you do them EVERY time
RIGHT MEDICATION/CONCENTRATION RIGHT DOSE RIGHT PATIENT RIGHT TIME AND FREQUENCY (Even if double sign off) RIGHT ROUTE Evelyn’s 6th Right*** RIGHT INDICATION
Documentation of Medication Errors
Adverse Reaction to Medication Form PRN Quality Improvement/Assurance Forms Chart – just the facts
What you did Who you notified How the patient responded
Prevention of Infections
Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection.
Reduce the risk of health care-associated infection
7. NPSG.07.01.01 -Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.Hospitals in WA now implementing programs were the patients are asking the medical staff if they have washed their hands prior to touching them or giving care and medications.
Reduce the Risk of Health Care-Acquired Infections
8. NPSG.07.03.01 – Use guidelines to prevent infections that are difficult to treat
9. NPSG.07.04.01 – Use guidelines to prevent infection of the blood from central lines
10. NPSG.07.05.01 – Use proven guidelines to prevent infection after surgery
11. NPSG.07.06.01- Use proven guidelines to prevent infections of the urinary tract that are caused by catheters
Reduce the Risk of Health Care-Acquired Infections
According to a report published in 2007 by the CDC, “in American hospitals alone, hospital acquired infections account for an estimated 1.7 million infections and 99,000 associated deaths each year”
Hospital-acquired infections are the sixth leading cause of death nationally, costing the health care industry $6 billion annually
MDRO
Study reported in Consumer Affairs in 2005: Chicago's Northwestern Memorial Hospital swabbed computer keyboards t identify if any dangerous germs were present and for how long they lived.
Contaminated keyboards with three types of bacteria that can cause life-threatening infections in severely ill hospital patients. They found that the bacteria known as VRE (enterococcus) and MRSA survived for at least 24 hours, while PSAE (pseudomonas) bacteria survived for an hour.
When volunteers tapped a key contaminated with MRSA, the bacteria spread to their hands 92 percent of the time. Contamination rates for lower for the other two bacteria -- 50 percent for VRE and 18 percent for PSAE.
MDRO
**A CDC study published in the current issue of the Journal of the American Medical Association : MRSA - is much more prevalent than previously thought. The study found MRSA cases tripled in the United States between 2000 and 2005, and estimated 94,360 people are infected and 18,650 die annually, killing more people annually than HIV.
***A 2003 Centers for Disease Control and Prevention study: 52 percent of doctors did not clean their hands between patients.Doctor's lab coat picked up MRSA bacteria 65 percent of the time when leaning over an infected patient (1997) 77 percent of blood pressure cuffs on rolling carts were contaminated with MRSA. (2007 study)
MDRO
According to the Centers for Disease Control, recent studies place hand hygiene adherence in hospitals at between 29 percent and 48 percent.
Methicillin-resistant Staphylococcus aureus (MRSA), can cost hospitals roughly $30,000 per case.
Brad Sokol, CEO of Fast Track Technologies, a health care consulting firm, has estimated that our nation suffers 13,000 to 26,000 thousand deaths annually from infection caused by contaminated medical devices and instruments.
Reduce Risk of Patient Harm Resulting from Falls
NPSG 09.02.01 – Reduce the risk of falls Implement a fall reduction program including an
evaluation of the effectiveness of the program
Identify Patient Safety Risks
12. NPSG.15.01.01 – Find out which patients are likely to try to commit suicidePost partum depression = Post partum ComplicationsWithout treatment, depression can last for many months and may have long-term consequences. Research suggests that postpartum depression can interfere with bonding between mother and child, which can lead to behavior problems and developmental delays when the child gets older.
Identify When there is a change in the Patient’s Condition
Develops criteria for calling additional assistance to respond to a change in the patient’s condition or a perception of change by the staff, the patient and/or family Rapid Response Codes
Staff seek additional assistance when they have concerns about a patient’s condition
Formal education is done for urgent response policies and practices Mock Codes
Prevent Mistakes in Surgery
13. UP.01.01.01- Make sure that the correct surgery is done on the correct patient at the correct place on their body
14. UP.01.02.01 – Mark the correct place on the patient’s body where the surgery is done
15. UP.01.03.01 – Pause before the surgery to make sure that a mistake is not being made
The organization Meets the Expectation of the Universal
Protocol Verification of the correct person, site and procedure occurs
at the following times: When the procedure is scheduled Preadmission testing and assessment Admission or entry for procedure whether it is scheduled or
emergent Before leaves the pre-procedural area or enters the
procedure room Anytime responsibility for the care of the patient is
transferred to another member of the procedural care team at the time of, and during, the procedure
With the patient involved, awake and aware if possible
Pre-procedural Checklist
Relevant documentation H&P Nursing assessment Pre-anesthesia assessment
Accurately completed and signed consent form Correct diagnostic and radiology test results Any blood products, implants, devices and or
special equipment for the procedure
Pre-Procedural Time Out
Conducted prior to starting the procedure and ideally, prior to induction of anesthesia, unless contraindicated
Standardized Initiated by a designated member of the team Involves the immediate members of the procedure team Involves interactive verbal communication between all
team members
Pre-Procedural Time Out
Includes a defined process for reconciling differences in responses
During time out all other activities are suspended (as long as it does not compromise patient safety)
If two or more procedures are being performed on the same patient, a time out is performed to confirm each subsequent procedure before it is initiated
Pre-Procedural Time Out
Addresses the following: Correct patient Confirmation that side and site are marked Accurate procedure consent Agreement of procedure to be performed Correct patient position Relevant images, diagnostic tests and results are properly
labeled and displayed The need to administer antibiotics or fluids Special equipment or supplies Safety precautions based on the patients current
medications or history
Marking the Procedure Site
Performed by a Licensed Independent Provider credentialed to perform procedure
Marked while patient is awake if possible Marked prior to going into procedural room
Marking of the Side and Site for OB
OB is excepted on most side and site marking: C-sections D & C and D & E Vaginal Delivery Cerclage Hysterectomy Bilateral Tubal Ligation Circumcisions
*** Exception – UNILATERAL tubal or ovary surgery
Sentinel Events
Organization is placed on an “Accreditation Watch” when a sentinel event has occurred and has come to the Joint’s attention
Adverse Drug Event Adverse Event
Death of a patient (unexpected) Retained foreign object Patient Falls Perforation, hemorrhage, bacteremia, complications to anesthesia or
sedation Any complication that leads to undesirable outcomes Any adverse/undesirable outcomes that result from providers or health care
staff that result in an illness or injury Errors of commission or omission that result in patient severe or
permanent injury
Bariatric Patients
Special Population that has additional safety risks for Obstetrics
Body Mass Index (BMI)
Correlates but does not directly measure body fat
Calculated from weight and height Correlates with body fat that is measured by
underwater and x-ray absorptiometry methods
Cheaper, more efficient and more readily available method of measurement to the medical practitioner
BMI
BMIBMI Weight CategoryWeight Category
<18.5 Underweight
18.5-24.9 Normal
25.0-29.9 Overweight
30-39.9 Obese
> 40 Extremely (Morbidly) Obese
Statistics
More than one-third of U.S. adults (35.7%) are obese.
Non-Hispanic blacks have the highest age-adjusted rates of obesity (49.5%) compared with Mexican Americans (40.4%), all Hispanics (39.1%) and non-Hispanic whites (34.3%) JAMA. 2012;307(5):491-497. doi:10.1001/jama.2012.39.
US Statistics
In 2008, medical costs associated with obesity were estimated at $147 billion
Medical costs for people who are obese were $1,429 higher than those of normal weight
1998
Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1998, 2006
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
2006
1990
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
United States 2011 Obesity Rates
Adult Women Affected by Obesity
49% of Non-Hispanic African American Women 38% of Hispanic Women 31% Non-Hispanic Caucasian Women
National Health and Nutrition Examination Survey (NHANES) 2002
Medical Conditions and Obesity
Sleep Apnea Hypertension Malnutrition Type II Diabetes Coronary Heart Disease Strokes Gallbladder Disease Osteoarthritis Cancer
Endometrial Breast Colon
Obstetrical Risk Factors and Obesity
Diabetes Type II Gestational
Spontaneous AbortionPreclampsiaGestational HypertensionFetal Macrosomia
Obstetrical Risk Factors and Obesity
Cesarean Birth (related to failure to progress) 20.7% if BMI <30 33.8% if BMI 30-34.9 47.4% if BMI 35-39.9
Shoulder dystocia
Prenatal Assessment
Early Diabetes Screening On first or second OB visit Again at 24-28 weeks Use 50 Gram glucose tolerance test (GTT)
Nutrition consult Assessment for vitamins, nutrients Weight management during pregnancy
Normal weight gain 25-35 lbs for the “normal” weight patient Overweight patient gain 15-25 lbs 15 lbs for the obese patient
Intrapartum Issues
May be difficult to:
Obtain accurate estimated fetal weight
Perform Leopold's maneuver
Monitor fetal well being and uterine activity
Find the right equipment – size, fit, weight restrictions
Hill-Rom Affinity bed = 500 lbs
Foot of the bed = 400 lbs
Find medical staff members with knowledge of how to care for patient with her particular needs
Nursing Care Issues
Sue Yager 1600 lbs
Nursing Care Issues
Prejudice Require EARLY anesthesia consult regarding pain management and
surgical planning Medication Management
May require more antibiotics per kilogram weight – need to check with pharmacy
Require antibiotics 30 minutes PRIOR to surgery Requires longer needles for IM injections – 2 inch to 2 ½
inch May react to pain medications differently – take longer to
clear (due to increased fat storage)
Surgical Management Considerations
Airway management Preoperative showering for c-section with chlorhexidine (48
hour kill rate) Potential for excessive blood loss Anesthesia challenges for induction Increased operative time
Large panis Increased time to close
Operative Beds Regular beds – 400 lbs “Hercules” table – 800-1000 lbs (better hydraulics)
Surgical Management Considerations
5-15% Complication Wound dehiscence Wound infection Poor wound healing Endometritis Deep Vein Thrombosis (DVT) Pulmonary Edema Pulmonary Emboli Pneumonia Sleep apnea – respiratory depression
Surgical Wound
Surgical Wound
Post Operative Issues
Wounds may be left openVertical exterior wounds JP drainsConsideration of whether need PACU
recovery and ICU stay
Moving Bariatric Patients
Good body mechanics
No holding legs for 2nd stage!!!! Team approach – 3-4 Lift team Right Equipment
Hover mats Lifts – KCI 1000 lbs Stretchers
Stryker 1710 = 500 lbs
Wyeast = 600 lbs
Stryker Bariatric = 660 lbs
Other Equipment
Hill-Rom VersaCare Bed – Up to 600 Lbs and can convert to a chair (costs about $7,500)
Other Equipment
Wall mounted toilets only hold 250-300 lbs Commodes – regular commode holds 250 lbs
Bariatric commode 750-800 lbs and need to provide privacy measures (costs about $300)
Bariatric Weight Loss Procedures
Bariatric Weight Loss Procedures
Multiple Bariatric Weight Loss Procedures are surgically available now.
Some will impact pregnancy more than others
Adjustable Gastric Banding
Roux-en-Y Stomach Bypass
Biliopancreatic Diversion (BPD)
Biliopancreatic Diversion with Duodenal Switch
Dumping Syndrome
Post Bariatric Surgery and Pregnancy
Nutrition Absorption Fetal growth and development Recommendation is to wait 12-24 months after surgery Pregnancy less likely to be complicated by:
Gestational or Type II Diabetes Hypertension Fetal Macrosomia Cesarean birth
Patient Satisfaction Surveys
Working toward the JCAHO Safety Goals The Ideal Patient Experience:Positive AttitudeSense of Ownership & AccountabilityCollaboration & Participation-Pt centered
care
Organizational/Nursing Actions That Lead to Improved Patient
Outcomes Positive Attitude Sense of Ownership and Accountability Collaboration & Participation in Patient &
Family Centered Care Information sharing – keeping the patient informed
in a language that they understand Follow up and see if they have any other questions
or needs
Opportunities for Improvement in Patient Care
Increase trust Increase confidence Continuity of care Explaining procedures Emotional support Treating patients with respect and dignity
Ideal Patient Experience
Hospitals are now looking at patient satisfaction surveys as part of their Continuous Quality Improvement (CQI) process
Looking for ways to improve the patient care experience
Organizational/Nursing Actions That Lead to Improved Patient
Outcomes
Practice good telephone etiquette Have professional and appropriate appearance Perform random acts of kindness Provide smooth transitions – patient handoffs Provide safe, age appropriate, and comfortable care Appreciate and celebrate staff for jobs well done
References
BRFSS, Behavioral Risk Factor Surveillance System http: //www.cdc.gov/brfss/
Mokdad AH, et al. The spread of the obesity epidemic in the United States, 1991—1998 JAMA 1999; 282:16:1519–1522.
Mokdad AH, et al. The continuing epidemics of obesity and diabetes in the United States. JAMA. 2001; 286:10:1519–22.
Mokdad AH, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA 2003: 289:1: 76–79
CDC. State-Specific Prevalence of Obesity Among Adults — United States, 2005; MMWR 2006; 55(36);985–988
References
JCAHO 2013 National Patient Safety Goals JCAHO News release 1/27/2005, “Speak Up: New National
Campaign Offers America To Prevent Medication Mistakes”
Maxfield, D., Grenny, J., McMillan, R., Patterson, K., & Switzer, A. Vitalsmarts Industry Watch, Executive Summary (2005). Silence Kills: The Seven Crucial Conversations in Healthcare.
U.S. Pharmacopeia, edited version of AWHONN Lifelines (April/May 2004) Errors in Obstetrics.
Top Related