Medical Errors Nursing CE Course

Medical Errors Nursing CE Course

5.0 ANCC CONTACT HOURS AACN CATEGORY B

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Syllabus

Overview

Over the past several decades and even more so over the past several years, there has been a strong focus in the medical community and health care industry to reduce medical errors. Medical errors not only increase health care costs, they often also result in costly litigation.

Health care centers, providers, and hospitals are heavily regulated. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is an independent organization accredits and certifies nearly 21,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.

According to John T. James, PhD, patient safety advocate, errors are underreported in studies since the tools used to evaluate data miss errors of omission, those not found in the medical records, diagnostic errors, errors of context, and errors of communication. In addition, there is not even an agreed upon definition of what constitutes a medical error. Healthcare in the United States is complex, with an overwhelming amount of new knowledge becoming available each year. In the Journal of Patient Safety, Dr. James categorized the cause of preventable adverse events in hospitals as: Errors of commission, Errors of omission, Errors of communication, Errors of context, and Diagnostic errors.

This module, Medical Errors, will explore three patient safety concepts: (a) quality control, (b) sentinel events, and (c) root cause analysis as described by the Joint Commission.  Eight common sentinel events will be discussed, followed by the nurse’s role and responsibility in preventing medical errors.

QUALITY CONTROL

Quality control (often called QC) is a procedure/set of procedures followed to ensure that a product or service adheres to a defined set of quality criteria and/or meets the quality requirements of a client or health center.

The Institute of Medicine in 1999 produced a landmark report “To Err is Human; Building a Safer Health System” that made healthcare institutions become acutely aware of the number of medical errors occurring annually and the need to begin to do something about patient safety and quality.   In 2005, the Patient Safety and Quality Improvement Act was created in response to the public’s concern around patient safety. The Act established a voluntary reporting system for data collection in order to assess and resolve patient safety and health care quality issues.

There has been some debate as to the number of deaths attributed to medical errors.  In the 1999 report, the Institute of Medicine identified that up to 98,000 people died annually from preventable medical errors. This is still the number being cited in much of the literature, including publications by the American Hospital Association. However there have been other reports over the years indicating that the number should be much higher, such as a 2013 study published in the Journal of Patient Safety indicating that numbers may be as high as 210,000 to 440,000 hospitalized patients suffer some type of preventable harm contributing to their deaths.  If this number is accurate, it makes preventable medical errors the 3rd leading cause of death in

the United States only falling behind heart disease and cancer. This debate about the prevalence of the problem is fueled by inaccurate reporting methods, voluntary nature of reporting, varying definitions of medical errors, and the fact that many errors occur in multi-step processes rather than as single incidents. Agreement exists about the fact that the risk of a patient experiencing a preventable medical error is not acceptable.

Preventing medical errors has become a priority for health care institutions, regulatory bodies, professional organizations, consumer organizations, and insurance companies, among others. The increase in collection and distribution of knowledge as well as highly-publicized cases of medical errors has led to the establishment of an internal heightened awareness of the incidence of errors and an increased public concern about their safety within the health care delivery system.  Medical errors which are considered preventable are labeled sentinel events. Errors that do not result in harm have been identified in literature as “near misses”.

As a foundation for improving patient safety a hospital needs to establish a culture of safety.  To establish a culture of safety a hospital might consider the five concepts:

  1. Quality begins with the top leadership’s commitment to patient safety and quality;
  2. Teamwork throughout all levels of the organization;
  3. A reporting system that is comprehensive and non-putative;
  4. Appropriate resources being made available; and
  5. Actively engaging the patient and family members in decision making about care.

In response, the Joint Commission has pushed for member organizations to create a Safety Culture. The Patient Safety Systems (PS) chapter of their accreditation manuals defines a safety culture as “the product of individual and group beliefs, values, attitudes, perceptions, competencies, and patterns of behavior that determine the organization’s commitment to quality and patient safety.”

The 11 tenets of a safety culture describe an organizational culture that emphasizes self- assessment, quality and safety improvement, open communication, and freedom to report unsafe conditions and events without intimidation or retaliation. The Joint Commission publishes Sentinel Event Alerts which identifies specific types of sentinel and adverse events and high risk conditions. This publication describes underlying (root) causes and recommended steps to reduce risk and prevent future occurrences. This provides organizations with guidance when designing or redesigning processes.

SENTINEL EVENT

A sentinel event was introduced by the Joint Commission to help hospitals that have experienced a grave patient safety issue(s) to protect the patient, improve the system, and prevent future harm to patients.  A sentinel event is one type of an adverse event which signals the need for an immediate response.

A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called “sentinel” because they signal the need for immediate investigation and response.  A sentinel event is “not related to the natural course of the patient’s illness or underlying condition”.

Patient acuity, dependence on medical technology, reduced lengths of stay, and the shortage of nurses and other healthcare workers may all contribute to a sentinel event occurring.  Hospitals frequently find a breakdown in communication across disciplines regarding a patient’s plan of care a leading cause to a sentinel event.  Most sentinel events are the result of a system related problem and not a mistake of a single individual. A sentinel event is often the outcome of several root causes.

The Joint Commission requires all accredited hospitals to define sentinel events for their institution.  The definition is expected to be communicated to all departments within the facility and services associated with the institution.  Reporting of a sentinel event by the hospital to the Joint Commission is voluntary.    The Joint Commission also learns about the occurrence of a sentinel events through complaint avenues.  When a sentinel event has been identified, the hospital is expected to respond in the following manner:  stabilization of the patient; communication to the patient and family concerning the event; notification of the hospital leadership; investigate the incidence, complete a route cause analysis, develop a corrective action plan with a time line for implementation and show improvement.

ROOT CAUSE ANAYLSIS

The method for analyzing errors to accurately identify safety improvement measures is called a root cause analysis. The root cause is a problem or factor that, when eliminated in a sequence of problems or faults, prevents the adverse event from occurring. Often this is not the factor identified at the initial examination. The Joint Commission publishes a Framework for Root Cause Analysis and Action Plan in order to provide an example of a comprehensive systematic analysis to health care organizations. The framework provides assistance by outlining the steps and information needed in a root cause analysis in order to analyze an event for quality improvement. Since 1997 Joint Commission has mandated that seminal events be analyzed by using RCA and 27 states have mandated reporting of such events.

The focus of RCA is to determine the underlying problem of systems and processes that lead to an error, which results in temporary or permanent harm or even death of a patient not related to the patient’s illness or primary condition. When a RCA is performed the emphasis focuses on the underlying cause of the event and not the individual. A pre-determined systematic procedure is initiated to collect information and reconstruct the event through questioning the individuals involved, reviewing the records, than analyzing the reason why the event occurred.

The primary aim of RCA is to identify the factors that resulted in the negative outcomes of one or more past events to identify what needs to be changed to prevent future events. RCA is performed by a team systematically as part of an investigation, with conclusions and root cause(s) supported by documented evidence. There may be more than one root cause for an event or a problem. All possible solutions to a problem are identified to prevent future events at the lowest possible cost and in the simplest possible way. The RCA should determine a sequence of events or a timeline to understand the relationships between the root cause(s) and the event to prevent it from happening in the future. Root cause analysis reduces the frequency of events that occur over time within the environment where the RCA process is used. RCA uses the 5 “whys” to get to the bottom of the situation (asking why 5 times to get to the real root of a problem).

In order to reduce the incidence of medical errors, their causes must be correctly identified and fixed, and the success of improvement efforts must be measured. Exact measurements of the problem, must be based on clear and consistent definitions in order to be useful in reducing incidence of these sentinel events. Data collection and subsequently solutions to eliminating related errors is hindered by differing definitions which reflect the variety of purposes for which data is collected and used, such as research, insurance, legal actions, law making, ethics, and quality control. The wide variety of words used to describe errors results in difficulty making a true comparison of error rates in the published literature.  Adding the definition of near misses into the discussion would further complicate the issue, but should not be overlooked as this focus could add to the data on the prevention of errors and quality improvement.

CASE STUDY

Stephen Austin, 51, went to the emergency room with symptoms of anaphylaxis that included facial swelling and thickening of his tongue.  He had eaten walnuts about thirty minutes earlier but had no prior history of a nut allergy. In the emergency room he received 3.0 milligrams of epinephrine.  Following the injection Mr. Austin experienced chest pain and difficulty breathing causing him to collapse and die.

Why would this situation be considered a sentinel event?

Describe the root cause analysis that would have been implemented by the hospital?

Who in the organization should be involved in the effort to correct the situation?

COMMON SENTINEL EVENTS (1)

INFECTIONS

Problem

Healthcare-associated infections (HAIs) are signification causes of infections within all types of healthcare institutions. They are considered to be the most common complication of hospital care. A healthcare-associated infection is an infection that a patient gets while receiving treatment for another medical or surgical condition. These infections are associated with increased health care costs, extended hospital stays, and medical complications and patient deaths.  Several organizations such as the Center for Disease Control (CDC) and the Joint Commission have made significant progress in preventing specific healthcare-associated infections. Catheter-associated urinary tract infections (CAUTIs), surgical site infections (SSIs), and multidrug resistant organisms are three common types of healthcare-associated infections.

Urinary tract infections are the most common type of healthcare-associated infection reported by the Center for Disease Control (CDC).  A catheter-associated urinary tract infection (CAUTI) is an infection that can occur in any part of the urinary system, such as the urethra, bladder, ureters, or kidney. The most important risk factor for developing catheter-associated infections is the prolonged use of a urinary catheter. There are a number of ways an infection can occur, for example: the catheter may become contaminated upon insertion, the drainage bag may not be emptied often enough, or bacteria from a bowel movement may get on the catheter.   The risk of infection can be reduced by using urinary catheters only when needed and removing them as soon as possible; using proper aseptic technique when inserting catheters; and assuring that the closed sterile drainage system is maintained

Surgical site infections (SSIs) occur at the site of surgery.  The Center for Disease Control (CDC) has identified 3 types of surgical site infections (1) Superficial incisional infection, an infection that occurs just in the area where the incision was made; (2) Deep incisional infection, an infection that occurs in the muscle and the tissues surrounding the muscle beneath the incision; (3) Organ infection, an infection in any area of the body, a body organ or a space between organs. Infections following surgery are most commonly caused by bacteria. Bacteria can infect a surgical site through a contaminated caregiver, surgical instruments, and/or bacteria already on the patient’s body.

Multidrug-resistant organisms (MDROs) are bacteria that are resistant to more than one antibiotic. This makes certain healthcare-associated infections difficult to treat. This phenomenon occurs when an individual takes antibiotics for a long period of time or when an individual takes antibiotics that are not necessary. Multidrug-resistant organisms can be spread by hand contact or contact with equipment or surfaces that have been contaminated.  Infections occur most frequently in patients that are older, have a compromised immune system, have repeated hospitalizations, or have had surgery. Although treatment with antibiotics is difficult once the type of multidrug-resistant organism is identified it can be treated with specific antibiotics.

Root-Cause-Analysis

Any of the above healthcare-associated infections can lead to a sentinel event causing the healthcare organization to implement a root-cause-analysis to determine the cause(s).  The following diagram depicts an example of a root-cause-analysis as identified by the Joint Commission Sentinel Event Alert #28 for decreasing healthcare-associated infections.

Prevention

One of the most important ways to prevent healthcare-associated infections is by employing hand hygiene by all healthcare providers regardless of healthcare setting. The National Patient Safety Goals requires compliance with either the Center for Disease Control (CDC) or the World Health Organization (WHO) hand hygiene guidelines.

For pathogens to be transmitted from one patient to another via the hands of the healthcare worker the following chain of events must occur.

  • First the organism must be present on the patient’s skin and the hands of the healthcare worker must come in contact with the organism.
  • Second the organism must be able to survive for several minutes on the hands of the health care worker.
  • Third the handwashing by the healthcare worker was inadequate or omitted, or the type of cleansing agent was unsuitable.
  • Fourth the contaminated hands of the healthcare worker must come in contact with another patient.

Hand hygiene applies to handwashing with soap and water, antiseptic handrubs or surgical hand antisepsis.  Soaps (non-antimicrobial agents) are considered suitable for routine cleansing and removal of most transient microorganisms.  When risk for infection is high alcohol based handrubs (antimicrobial agents) more effectively reduce bacteria.  When the healthcare worker’s hands are minimally soiled alcohol based handrubs are considered suitable to use,

If the healthcare worker’s hands are visually soiled, particularly with body fluids, soap and water should be use for handwashing.

 

MEDICATION ERRORS

Problem

Medication errors can occur in any healthcare setting as well as the home. Medication errors may result from errors in prescribing, transcribing, communication, packaging and labelling, distribution and other practices.

Nurses have a pivotal role in optimizing individual performance and controlling environmental factors to reduce medication errors. Medication management is an important responsibility that has been said to involve approximately 40% of a nurse’s time. It not only involves the nurse preparing, calculating, checking and administering medications but also updating her/his knowledge about medications, monitoring the effectiveness of the treatment, observing if any drug reactions, interactions or adverse events might have occurred, and educating patients about their medications

There are three medication safety issues identified by the Joint Commission, National Patient Safety Goals as a concern: labeling of medications, anticoagulant therapy, and medication reconciliation.

The way medications are labeled and packaged can lead to medication errors.  Labels may cause confusion leading to errors when the following situations occur: (a) marketing distractions, (b) labels or drug names look alike, (c) drug names are the same but the drugs have different purposes, (d) information on the label maybe difficult to find, and (e) warning information may be hidden.  A manufacture may want to draw attention to its product by using eye catching adjectives or phrases causing distractions for the consumer.  Drugs may come in different forms (ex: capsules, gel tabs) and in different strengths, however, the drug companies often package them in containers that look alike. At times when a drug company has a well-known brand name for one product they will introduce a new product under the same name. The two products may treat different medical conditions (ex: stool softener vs laxative).  Important information about a drug may be located underneath the label.  The label reads “peel back” causing individuals not to notice the instructions or to think they cannot peel back the label without buying the drug.  Finally, warning information regarding a fact about a drug, such as allergic ingredients, might be located in a less obvious place on the medication container leading individuals to miss the information or become confused.

Anticoagulant drugs (ex: Pradaxa®, Xarelto®, Eliquis® and Coumadin®) are widely used for both treatment and prophylaxis of thrombotic and are some of the drugs that most frequently cause adverse medication incidents in hospitals.  Admission, discharge and surgery were found to be the times adverse incidents frequently occurred.  Studies have shown that during admission and surgery, prescribing excess anticoagulant was the most frequent problem. During discharge, prescribing insufficient anticoagulant was the most frequent problem. Management of anticoagulant therapy involves being aware of the difference between bleeding caused by over-dosing and clotting caused by under-dosing. Both conditions can be fatal.

Medication reconciliation is the process of creating an accurate list of all medications a patient is taking to avoid errors.  The medication list needs to include drug name, dosage, frequency and route.  To assure the correct medications are administered the medication list needs to be compared to the physician’s orders at the time of admissions, when transferred from one hospital unit to another, and at the time of discharge. Errors that have the potential of occurring when medication reconciliation is implemented are: omitting a particular medication, giving the medication more than once, giving an incorrect dose and/or causing a drug interaction.

Root-Cause-Analysis

Any of the above medication errors can lead to a sentinel event causing the healthcare organization to implement a root-cause-analysis to determine the cause(s).  The following diagram depicts an example of a root-cause-analysis as identified by the Joint Commission Sentinel Event Alert #41 for safety of using medications.

Prevention

Every medication has the potential to cause adverse effects. These are undesired, inadvertent, and harmful effects of the medication. Adverse effects can range from mild to severe, and some can be life‑threatening. Medications are chemicals that affect the body. With concurrent use of medications, there is a potential for an interaction. Medications can also interact with foods and dietary supplements. Contraindications and precautions for specific medications are conditions (diseases, age, pregnancy, lactation) that make it risky or completely unsafe for clients to take them.

Nurse Responsibilities:

  •  Having knowledge of federal, state (nurse practice acts), and local laws, and facilities’ policies that govern the prescribing, dispensing, and administration of medications
  • Preparing, administering, and evaluating clients’ responses to medications
  • Developing and maintaining an up‑to‑date knowledge base of medications they administer, including uses, mechanisms of action, routes of administration, safe dosage range, adverse and side effects, precautions, contraindications, and interactions
  • Maintaining knowledge of acceptable practice and skills competency
  • Determining the accuracy of medication prescriptions
  • Reporting all medication errors
  • Safeguarding and storing medications

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