Florida Medical Errors Prevention

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The following course content

This fulfills the continuing education requirement for Medication Errors Prevention for the state of Florida.  

For as long as there have been medical professionals, there have been medical errors.  Medical errors can be small and seemingly insignificant to a catastrophic sentinel event.    

The Joint Commission (TJC) is a healthcare accrediting agency that sets the standard for patient safety.  Each year, TJC publishes a list of national patient safety goals.  These goals are focused on the prevention of medical errors.  In 2019, the World Health Organization (WHO) found that medical errors harmed up to 40% of patients within the global healthcare system.  These medical errors not only cause harm to millions of people worldwide, but they also cost billions of dollars on an annual basis (8). 

There are many different types of medical errors.  They include, but are not limited to: medication errors, healthcare-acquired infections, surgical errors, lab errors, falls, documentation issues, and omitted care.  Healthcare workers must be aware of the possible harm that can be caused by medical errors and the ways in which they can be prevented.   

Introduction   

For as long as there have been medical professionals, there have been medical errors.  Medical errors can be small and seemingly insignificant to a catastrophic sentinel event.    

The Joint Commission (TJC) is a healthcare accrediting agency that sets the standard for patient safety.  Each year, TJC publishes a list of national patient safety goals.  These goals are focused on the prevention of medical errors.  In 2019, the World Health Organization (WHO) found that medical errors harmed up to 40% of patients within the global healthcare system.  These medical errors not only cause harm to millions of people worldwide, but they also cost billions of dollars on an annual basis (8).

There are many different types of medical errors.  They include, but are not limited to: medication errors, healthcare-acquired infections, surgical errors, lab errors, falls, documentation issues, and omitted care.  Healthcare workers must know the possible harm caused by medical errors and how they can be prevented.   

Factors That Impact the Occurrence of Medical Errors 

There are multiple factors that can increase the probability of a medical error occurring.  Healthcare worker behaviors and attitudes, staffing, and communication are among those that have the most significant impact on medical errors. 

In healthcare, a risky behavior is an action that may lead to a compromise in patient safety.  Why would any healthcare worker engage in at-risk behaviors?   Healthcare workers, especially nurses, are generally compassionate and are ultimately looking out for the patients' welfare in their care.  Risky behaviors produce a quick, positive reward without any perceived risk of patient harm.  These risky behaviors can range from a simple short-cut like not checking two patient identifiers to a blatant disregard for hospital/facility policy.  In all instances, the risk for patient harm is real and will eventually occur (13). 

Understaffing in the hospital setting continues to be a factor contributing to medical errors.  Poor nurse-to-patient ratios can lead to a variety of medical errors.  Ordered patient care may go undone, leading to further medical errors adverse patient outcomes (7).  Understaffing leads to fatigue and burnout.  A nurse in this state of mind is prone to committing medical errors. 

Miscommunication between healthcare professionals and patients and miscommunication between healthcare professionals also contribute to the occurrence of medical errors.  As part of their national patient safety goals, TJC has had a communication component almost every year.  They have recognized that effective communication is paramount in the prevention of medical errors.  A lack of effective communication can be a leading cause of every type of medical error. 

In an effort to decrease communication errors, TJC has taken measures to ensure that effective communication is promoted in a variety of different situations.  TJC has instituted a list of unacceptable medical abbreviations.  This list will decrease medication errors by removing confusion when medications are ordered (11).  They also developed a handoff communication protocol for facilities to implement.  The handoff communication occurs anytime that care is passed from one caregiver to another.  In Florida medical errors prevention, this communication protocol is used to ensure that all pertinent patient information is passed on to the next healthcare worker rendering care to the patient.  By using effective handoff communication, all information should be passed on, and mistakes should be avoided (10).  

Recognizing Error-Prone Situations 

 Studies have shown that the majority of medical errors occur in the inpatient setting.  The most common areas for medical errors are the operating room (OR), the emergency room (ER), the intensive care unit (ICU), and the medical/surgical floors (1).   

What is it about the inpatient setting that makes it such an error-prone area?  More specifically, why do medical errors occur in the ICU, OR, and ER?  These are all high-stress areas where effective communication between all parties is vital.  Breakdown in communication in these areas will lead to catastrophic medical errors.  When the stress level rises, the probability of medical errors occurring also rises.  These are also fast-paced areas where the condition can change in the blink of an eye.  When we work in such a busy area, we can forget important details.  Effective communication is a big part of Florida medical errors prevention.  Miscommunication in these environments is a recipe for medical errors.  

As the most common type of medical errors is medication errors, we do need to talk about medication administration.  Nurses are taught the five rights of medication administration in nursing school:  

1. Right drug. 
2. Right patient. 
3. Right dose. 
4. Right route. 
5. Right time. 
   

When working in a busy inpatient setting, nurses may fail to perform the five rights in order to save time (5).  Neglecting any one of the five rights of medication administration can cause a medical error.

Processes to Improve Patient Outcomes 

In the technological age in which we live, it is more important than ever before that healthcare facilities consistently demonstrate good patient outcomes.  The Centers for Medicare & Medicaid Services (CMS) places great importance on the patient experience and their perception of their healthcare experience quality.  Every patient who experiences a hospital stay may be asked to complete a Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.  The survey results are published quarterly on the CMS Hospital Compare website.  There, patients can compare the hospital's results and choose a hospital where they would like to have their care rendered (4).  A medical error could very well cause a patient to give a facility a poor rating on the HCAHPS survey. That is why we must take Florida medical errors prevention seriously.

When medical errors have occurred, they will often result in a risk management response to investigate why the error has happened and how it can be prevented in the future – a root cause analysis (RCA).  An RCA will often lead to department-driven performance improvement projects (PIP) to eradicate the problem and improve patient outcomes.  A proactive facility trying to minimize medical errors will have multiple department and facility-wide PIP. 

As previously stated, each year TJC publishes a list of patient safety goals.  These goals will often guide a facility on specific patient outcomes that have required attention for improvement on a national level.  They focus on the prevention of medical errors, and as such, they can steer PIP.  Accreditation hinges on the ability of a facility to improve and consistently deliver positive patient outcomes.  Below is the current list of TJC's patient Safety Goals: 

1. Identify patients correctly.

Use at least two ways to identify patients. For example, use the patient's name and date of birth. This is done to make sure that each patient gets the correct medicine and treatment.

2. Improve staff communication.

Get important test results to the right staff person on time.

3. Use medicines safely.

Before a procedure, label medicines that are not labeled. For example, medicines in syringes, cups, and basins. Do this in the area where medicines and supplies are set up. 

Take extra care with patients who take medicines to thin their blood. 

Record and pass along correct information about a patient's medicines.

Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient.

Give the patient written information about the medicines they need to take. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor.

4. Use alarms safely.

Make improvements to ensure that alarms on medical equipment are heard and responded to on time.

5. Prevent infection.

Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning.

6. Identify patient safety risks.

Reduce the risk for suicide.

7. Prevent mistakes in surgery. 

Make sure that the correct surgery is done on the correct patient and at the correct place on the patient's body. 

Mark the correct place on the patient's body where the surgery is to be done. 

Pause before the surgery to make sure that a mistake is not being made.

(12)

Responsibilities for Reporting as a Part of Florida Medical Errors Prevention

Each individual facility across the nation may have different policies and procedures for the reporting of medical errors within their facilities.  There is, however, a growing trend throughout the healthcare industry of creating a culture of safety.  The culture of safety promotes the reporting of medical errors and "near misses" in an open, transparent and non-punitive manner.  Facilities are taking a stand to ensure patient and staff safety over other competing goals within their system (14).  Near miss reporting allows for issues to be addressed and corrected before an actual error occurs.  Taking a non-punitive approach to self-reporting of medical errors promotes accurate reporting and allows for a true picture of what is happening in the facility. 

The State of Florida has mandated that all licensed healthcare facilities implement an internal risk management program.  In Florida medical errors prevention, it is the responsibility of the risk management team to: 

1. Investigate and analyze the frequency and cause of general and specific types of patient adverse incidents. 
2. Develop measures to minimize the risk of adverse incidents. 
3. Analyze patient grievances that relate to care and quality of services. 
4. The development and implementation of an incident reporting system. 

State law further requires that the Agency for Healthcare Administration (AHCA) post quarterly reports on adverse incidents (9). 

Safety Needs of Special Populations 

There are certain groups of people that are especially vulnerable to experience a medical error.   

Elderly 

The elderly are especially susceptible to medical errors.  Generally, as we get older, we tend to start taking more medications.  Complex medication regimens offer a greater opportunity for medication errors.  Many medications require close monitoring of vital signs and/or blood levels.  Drug-related issues are a major driving force for both ER visits and nursing home admissions among the elderly (3).  Declining cognition, poor vision, and increased forgetfulness associated with aging can also play a part in medication errors.  Education with frequent reinforcement and the use of support people are crucial to help prevent medication errors.   

The elderly are also at a higher risk for falls.  Falls within a medical facility can lead to further medical complications, increased length of stay, and serious injury.  Patients at risk for falls need to be identified and place on a fall prevention protocol. 

 Children 

 Children are on the other side of the spectrum and are also another group that are at higher risk for medical errors.  Younger children may be unable to accurately voice exactly their problem is, or what symptoms they are experiencing.  They must rely on both parents and other caregivers for the coordination of their care.  Though a parent may know their child well, they may not be able to properly convey their child's issues to the healthcare professional.  It is also important to realize that children are not little adults.  Care plans must be catered to their specific phase of life. 

Limited Health Literacy/Education

Another population that is vulnerable to medical errors are patients with limited health care literacy or education.  These patients may have difficulty obtaining, retaining, and implementing health information to make proper decisions for their healthcare needs.  Populations within this group may include the elderly, low-income populations, immigrants, and minorities.  There is also a strong correlation between limited health literacy and the uninsured, undereducated, and unemployed populations.  It is important that information be presented to this group at a level that they can understand.  The use of interpreters can also be helpful if the patient does not have a good grasp of the English language (6). 

Public Education 

Now, more than ever before, the general public has greater access to information of all sorts.  This includes access to health information, specifically, patient outcomes.  The public is able to make informed decisions on where they would like to be cared for by comparing healthcare facilities.   

The public is seeking information not only on which facility is the safest with the best outcomes but also on ways that they can actively prevent medical errors from happening to them.  There are many resources that patients can find online to help them recognize scenarios that may place them at risk for the occurrence of medical errors.  The Agency for Healthcare Research and Quality (AHRQ) has published a list of 20 tips patients can use to help prevent medical errors: 

Medicines 

1.    Make sure that all of your doctors know about every medicine you are taking.
This includes prescription and over-the-counter medicines and dietary supplements, such as vitamins and herbs. 

2.    Bring all of your medicines and supplements to your doctor visits.
"Brown bagging" your medicines can help you and your doctor talk about them and find out if there are any problems. It can also help your doctor keep your records up to date and help you get better quality care. 

3.    Make sure your doctor knows about any allergies and adverse reactions you have had to medicines.
This can help you to avoid getting a medicine that could harm you. 

4.    When your doctor writes a prescription for you, make sure you can read it.
If you cannot read your doctor's handwriting, your pharmacist might not be able to either. 

5.    Ask for information about your medicines in terms you can understand—both when your medicines are prescribed and when you get them: 

• What is the medicine for? 
• How am I supposed to take it, and for how long? 
• What side effects are likely? What do I do if they occur? 
• Is this medicine safe to take with other medicines or dietary supplements I am taking? 
• What food, drink, or activities should I avoid while taking this medicine? 

6.    When you pick up your medicine from the pharmacy, ask: Is this the medicine that my doctor prescribed? 

7.    If you have any questions about the directions on your medicine labels, ask.
Medicine labels can be hard to understand. For example, ask if "four times daily" means taking a dose every 6 hours around the clock or just during regular waking hours. 

8.    Ask your pharmacist for the best device to measure your liquid medicine.
For example, many people use household teaspoons, which often do not hold a true teaspoon of liquid. Special devices, like marked syringes, help people measure the right dose. 

9.    Ask for written information about the side effects your medicine could cause.
If you know what might happen, you will be better prepared if it does or if something unexpected happens. 

Hospital Stays 

10. If you are in a hospital, consider asking all health care workers who will touch you whether they have washed their hands.
Handwashing can prevent the spread of infections in hospitals. 

11. When you are being discharged from the hospital, ask your doctor to explain the treatment plan you will follow at home.
This includes learning about your new medicines, making sure you know when to schedule follow-up appointments, and finding out when you can get back to your regular activities.
It is important to know whether or not you should keep taking the medicines you were taking before your hospital stay. Getting clear instructions may help prevent an unexpected return trip to the hospital. 

Surgery 

12. If you are having surgery, make sure that you, your doctor, and your surgeon all agree on exactly what will be done.
Having surgery at the wrong site (for example, operating on the left knee instead of the right) is rare. But even once is too often. The good news is that wrong-site surgery is 100 percent preventable. Surgeons are expected to sign their initials directly on the site to be operated on before the surgery. 

13. If you have a choice, choose a hospital where many patients have had the procedure or surgery you need.
Research shows that patients tend to have better results when they are treated in hospitals that have a great deal of experience with their condition. 

Other Steps in Florida Medical Errors Prevention

14. Speak up if you have questions or concerns.
You have a right to question anyone who is involved with your care. 

15. Make sure that someone, such as your primary care doctor, coordinates your care.
This is especially important if you have any health problems or are in the hospital. 

16. Make sure that all your doctors have your important health information.
Do not assume that everyone has all the information they need. 

17. Ask a family member or friend to go to appointments with you.
Even if you do not need help now, you might need it later. 

18. Know that "more" is not always better.
It is a good idea to find out why a test or treatment is needed and how it can help you. You could be better off without it. 

19. If you have a test, do not assume that no news is good news.
Ask how and when you will get the results. 

20. Learn about your condition and treatments by asking your doctor and nurse and by using other reliable sources.
For example, treatment options based on the latest scientific evidence are available from the Effective Health Care Web site. Ask your doctor if your treatment is based on the latest evidence (2). 

Case Studies 

Mr. Smith is a 68-year-old male with diabetes type 2, hypertension, and chronic renal failure stage 4.  He takes both long-acting and short-acting insulin for his diabetes and a beta-blocker for his high blood pressure.  He is also taking a diuretic to help regulate his fluids.  Mr. Smith was recently admitted to the hospital for a hypoglycemic event.  Once in the hospital, Mr. Smith expressed to his nurse that he has been having difficulty reading his medication labels.  He also confided that he feels dizzy when he stands up and has fallen back onto his bed on more than 1 occasion.   

After two days, Mr. Smith was ready to be discharged.  The diabetic educator brought him some pamphlets and educated him on proper blood glucose monitoring and insulin administration.  His blood pressure medicines were also changed, and Mr. Smith was given a new prescription to be filled once he left the hospital.  He was alone when discharge instructions were given, and his current medications were not removed from his medicine bag.   

Two days later, Mr. Smith was readmitted to the hospital with hypoglycemia and hypotension (BP 87/52).

Exercise

1. What are some factors that lead to the occurrence of medical errors with Mr. Smith? 

2. What are the medical errors that occurred? 

3. What could the nurse/educator have done differently to prevent further medical errors, using steps addressed in this Florida medical errors prevention course? 

Bernice is a staff nurse working in a busy ICU.  Due to the COVID-19 pandemic, the unit has been short-staffed, with each nurse taking care of 3-4 patients.  This is Bernice's fifth day in a row, working fourteen plus hours.  There have been multiple "code blue" situations in the ICU over the course of Bernice's workweek, some involving her patients.  She was only able to have a full lunch hour on her second day, and she has not been able to sleep much during the night.   

One of her patients was having severe abdominal pain, 9/10 on the pain scale.  Bernice went in to administer the ordered narcotic and injected the wrong patient. 

Exercise 

1. What factors lead to Bernice's medical error? 

2. What could have been done to prevent the error? 

3. Is this a situation that could happen in a unit where you work?

Conclusion  

Medical errors are an ongoing problem in the healthcare setting.  They affect patients in all phases of life and come with a large price tag of both money and medical resources.  It is everyone's responsibility to help prevent the occurrence of medical errors.  Though we may not be able to totally eradicate them, we can all play a big part in Florida medical errors prevention by learning from previous mistakes and taking measures to ensure that they do not happen again. 

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