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Prevalence of Medical Errors

Pharmacists and health care professionals became more aware of the serious problem of medication errors with the release of the report by the Institute of Medication, “To Err is Human-Building a Better Health System”. It is estimated that between 44,000 and 98,000 Americans die each year of medical errors in hospitals and as many as 40% of these could have been prevented. This results in an estimated $17 to $29 billion in lost wages, disability payments, additional medical care and other costs.

According to a nationwide survey conducted by NORC at the University of Chicago, 21% of patients report experience with medical errors. The survey also found that these medical errors “often have lasting impact on the patient’s physical health, emotional health, financial well-being, or family relationships.”

Inconsistencies between medication lists maintained by patients and their pharmacy or pharmacies, primary care physician, specialist physicians, and hospital or emergency department are a leading cause of adverse drug events. Frequently, changes made by one provider, and in some cases the patient, are not communicated to the entire patient care team which may result in provider and patient confusion, unintentional errors, or serious harm.

Patient safety is of the utmost importance to any healthcare system, so how can these numbers be so high?

Efforts to Reduce Medical Errors

Steps implemented to reduce errors and increase reporting of such errors:

Federal Effort: Under the new federal health care reform law, starting in 2014, hospitals will receive lower reimbursement from the federal government for Medicare and Medicaid patients who suffer medical mistakes, infections or injuries. And they will also get lower payments for high readmission rates. That’s when a Medicare patients leaves the hospital but has to be readmitted with in 30 days.

State Responses: In response to the IOM report over, NCSL reports that, beginning five years ago, at least 15 states have passed laws aimed at reducing prescription drug errors, including Arizona, Colorado, Delaware, Florida, Idaho, Illinois, Louisiana, Maryland, Massachusetts, Michigan, Montana, South Dakota, Tennessee, Texas and Washington. They address improved legibility, clearer or “common sense” labeling of bottles, regulating telepharmacy and electronic records. In addition, a number of states are supporting expanded use of electronic medical records, which would impact Rx as well as other areas of medical practice.

The Florida state legislature mandated that all licensees must complete a two-hour course​on prevention of medical errors which meets the criteria of Florida Statute 456.013 for initial licensure and biennial renewal.

Twenty-five​states, including Florida, have mandatory or voluntary systems for reporting medical errors in hospitals and other healthcare organizations (National Quality Forum, 2007).

Steps implemented to reduce errors and increase reporting of such errors:

  • The​Joint​Commission​on Accreditation of Healthcare Organizations (JCAHO) requires that healthcare institutions analyze serious medical errors to determine the root cause and develop an action plan to prevent those errors in the future.
  • In December 2000 Congress approved a $50 million annual appropriation for research on patient safety, primarily by the Agency for Healthcare Research and Quality (AHRQ).
  • In July 2005 President Bush signed into law S.544, the Patient Safety and Quality Improvement Act, which established a voluntary confidential reporting system to create a national database of medical errors for analysis and development of evidence-based patient safety measures.

Incentives to Reduce Medical Errors

In 2007 the federal Center for Medicare and Medicaid Services issued a new rule that gave hospitals a powerful incentive to reduce medical errors. This rule denied reimbursement to hospitals for treatment of preventable errors, injuries, and infections (see box below). It also stipulated that hospitals cannot pass these charges along to the beneficiary. This rule was mandated by the Patient Safety and Quality Improvement Act and took effect in October 2008 (Centers for Medicare and Medicaid Services, 2007).

PREVENTABLE COMPLICATIONS NO LONGER COVERED BY MEDICARE

The following preventable complications are no longer reimbursed by Medicare if acquired during an inpatient stay:

  • Object left in patient during surgery
  • Air embolism
  • Blood incompatibility
  • Catheter-associated urinary tract infection
  • Pressure ulcer
  • Vascular catheter–associated infection
  • Mediastinitis after coronary artery bypass grafting
  • Fall from bed

(Source: Federal Register 2007; 72:47379–47428.)

Florida’s Efforts

Florida has taken additional steps to prevent medical errors and improve patient safety. In 2004 legislation was passed requiring the state to inform the public about important performance outcome indicators for healthcare facilities (e.g., volume of cases, average length of stay, complication rates, mortality rates, infection rates for various medical conditions).

This same legislation established the Florida Patient Safety Corporation (FPSC), a voluntary statewide reporting program to track and analyze near misses in healthcare. Two years later, the Florida Academic Patient Safety Centers (2006) reported that “FPSC remains a very young and underdeveloped entity, and much remains to be accomplished by it and the State of Florida in addressing the statutory charges made to the Corporation.“

The principal accomplishment of FPSC was to assess the Code 15 Reporting Program. This assessment found that the Code 15 program “does little to contribute to the safety and welfare of the citizens of Florida. It is largely unusable and unused as a means by which to substantively improve patient safety in Florida.” The assessment recommended that Code 15 “be replaced with a uniform, de-identified anonymous reporting system as recommended in the 2004 legislation, Section 35 and 36 Reports to ACHA and the Legislature.”

In November 2004 voters approved two controversial amendments to the Florida constitution that could reverse many of the patient safety initiatives in the 2004 legislation.

The​Patients’​Right-to-know​About Adverse Medical Incidents Act, also referred to as Amendment 7, allows patients who have been harmed to gain access to all records of their care, including documents of provider deliberation.

The Three Strikes and You Are Out Act directs the Florida Board of Medicine to revoke medical licenses from providers who have had three adjudicated malpractice incidents. An unintended consequence of these amendments has been a chilling effect on reporting and discussion of adverse events, which imperils the research that needs to happen.

The Agency for Healthcare Research and Quality (AHRQ) has shown that medical errors result most frequently from systems errors—the organization of healthcare delivery and the ways resources are provided in the delivery system. Only rarely are medical errors the result of the carelessness or misconduct of a single individual.

Improvement in Quality & Safety

The Joint Commission (JCAHO) reports that accredited U.S. hospitals “continue to show measurable improvements in healthcare quality and patient safety,” but there is still much room for improvement (2007).

In a Commonwealth Fund survey of 12,000 adults in seven countries, U.S. adults were the most likely to report medical errors. One-third of adults with multiple chronic conditions reported either a medical error or a medication error (wrong dosage or wrong drug) during the past year (Schoen et al., 2007). According to the National Quality Forum (NQF).

Errors​can occur at any point in the healthcare delivery system. Acknowledging that errors happen, learning from them, and working to prevent future errors represents a major change in the culture of healthcare—a shift from blame and punishment to analysis of the root causes of errors and creation of strategies to improve. In other words,  healthcare organizations need to create a culture of safety that views medical errors as opportunities to improve the system. Every person on the healthcare team has a role in making healthcare safer for patients and workers.

Types of Medical Errors

Error is defined as “the failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve an aim (i.e., error of planning).“

An adverse event (AE) is an injury caused by medical management rather than the underlying condition of the patient. An​AE attributable to error is a preventable adverse event, because it signals the need to ask why the error occurred and make changes in the system.

Two types of errors: Active and Latent.

  • Active errors tend to occur at the level of the individual, and their effects are felt almost immediately.
  • Latent errors are more likely to be beyond the control of the individual, that is, they are errors in system or process design, faulty installation or maintenance of equipment, or ineffective organizational structure. The effects of latent errors may not appear for months or even years but they can lead to a cascade of active errors, ending in catastrophe.

Close calls or near misses are potential adverse events, errors that could have caused harm but did not, either by chance or because something or someone in the system intervened.

Surgical Errors

Surgical errors, or surgical adverse events include wrong-site, wrong-procedure, or wrong-person surgery and account for a high percentage of all adverse events.

A review by the Joint Commission (JCAHO) found that wrong-site surgery was most common in orthopedic procedures. Risk factors contributing to the error included: more than one surgeon involved in the case, multiple procedures performed during a single operating room visit, and unusual time pressures—particularly pressure to speed up preoperative procedures.

Surgical errors are not the sole responsibility of the operating surgeon. All operating room personnel have a role in ensuring patient safety by verifying the surgical site and pointing out a possible error. To reduce the risk of wrong-site, wrong-procedure, or wrong- person surgeries, JCAHO developed a Universal Protocol, which all accredited healthcare organizations were required to implement by July 2004 (JCAHO, 2004).

Competent nursing care, including adequate RN staffing, following surgical procedures is critical in reducing surgical errors.

Misdiagnosis

An accurate diagnosis is the first requirement for correct and effective treatment. Inaccurate diagnosis may delay treatment or result in incorrect, ineffective treatment or unnecessary tests, which can prove costly and invasive. Inexperience with a difficult diagnostic procedure can affect the accuracy of the results.

Misdiagnosis​is a major factor contributing to delays in treatment, according to JCAHO (2002). Hospital emergency departments accounted for just over one-half of all sentinel-event cases of patient death or permanent injury due to delays in treatment.

These serious events also happen in other healthcare settings, including intensive-care units, medical-surgical units, inpatient psychiatric hospitals, the operating room, and the home care setting. Fifty-two of the 55 reported cases of delays in treatment resulted in patient death.

Medication Errors

The National Coordinating Council on Medication Error Reporting and Prevention defines a medication error as: “Any preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the health care professional, patient or consumer. Such events may be related to professional practice, health care products, procedures, and systems including: prescribing, order communication, product labeling, packaging, nomenclature, compounding, dispensing, distribution, administration, education, monitoring and use”. This is a very comprehensive definition of what constitutes a medication error and includes a wide variety of activities that occur during the medication use process. It is also important to note that non-preventable adverse drug events (ADEs) are not considered medication errors because their occurrence cannot be predicted or prevented. For example: A pediatric patient had a gastrointestinal reaction to a medication due to the gluten in it, but did not know they had Celiac Disease. This would not be considered a medication error. However, if the patient had an allergic reaction to penicillin documented in her patient profile and the pharmacist dispensed amoxicillin 250mg, this would be considered a medication error.

Even though pharmacies try to incorporate countermeasures like technology, bar code scanning, and automated dispensing robots to improve patient safety, medication errors still do occur. Even in the best designed systems to maximize patient safety, errors do occur. It is a common misconception that many medication errors are made by incompetent health care professionals that have a history of making several errors over time. In general, it is rare for a health care professional to make multiple medication errors.

More often, a medication error occurs due to a breakdown in the medication use process. This breakdown often occurs at more than one step in this process. The medication use process consists of five major categories all of which have several steps within each including:

  • Prescribing
  • Documenting
  • Dispensing
  • Administering
  • Monitoring

ISMP estimates that the average number of steps in the medication use process is 40. A breakdown in any one of these steps has the potential to cause a medication error. Finally, most health care professionals think that many of the errors that occur in the medication use process happen in dispensing. However, this may not be the case. A study by Bates et al. found that 56% of errors occur during prescribing, 34% during administration, 6% during transcription and only 4% during dispensing. Even though only 4% of medication errors occur during the dispensing part of the medication use process, pharmacists can have a significant impact in reducing medication errors in the other parts and pieces of the process. Pharmacists should always realize that medication error prevention safety needs to     occur at every step of the medication use process. Pharmacists should develop a team approach to achieve this goal with prescribers, Healthcare professionals, patients, and even manufacturers in order to maximize patient safety and minimize patient harm.

Florida’s Effort to Reduce Medication Errors

Florida took a simple but important step to improve patient safety on July 1, 2003, when s.456.42, F.S. went into effect, making handwritten prescriptions illegal. This law requires physicians in Florida to either print legibly or type prescriptions and to include the name and strength of the drug prescribed, the quantity of the drug prescribed in both textual and numerical formats, and the directions for taking the drug.

Preventing Errors in Patient-Controlled Analgesia

  • Include​bar codes on all PCA medications in facilities where point-of-care bar code systems or other item identification technology (e.g., radio frequency identification) are implemented.
  • Conduct a failure modes and effects analysis (FMEA) for existing pumps, as well as for new pumps that are brought into the facility. Consider what default settings are preprogrammed. Consider if the pumps can be programmed by drug (e.g., morphine PCA vs. hydromorphone PCA). Consider if the pump resets to a default (other than “000,” which would require active entry) after it turns off.
  • Perform​double-checks​for​initial​setup​and maintenance, and dose changes/change orders. Double-check clamp (to open position) before closing the pump. Check that the pump is turned on. Check whether connections are to IV or epidural lines to prevent wrong-route errors. Check for kinked tubing in the pump door.
  • Educate​staff​about​sound-alike​and look-alike drugs, especially when bar code technology is not part of the existing system. Many drug errors with PCA pumps are due to name confusion (e.g., morphine, hydromorphone, meperidine).
  • If using preprinted order forms, prohibit writing over information on the form.

Educate patients, family members, and staff (including physical therapists, x-ray technicians) about the use of the pumps. Written instructions should be provided to patients. Instruct family members NOT to administer PCA doses—PCA by definition should be administered at the patient’s perception of need.

Prevention of Medication Errors – Dangerous Abbreviations

There are several techniques that can be used within a health care organization or institution to help prevent and reduce the number of medication errors. One of the major causes of medication errors is the use of dangerous abbreviations. The Joint Commission reviews and writes National Patient Safety Goals. The Joint Commission has identified several dangerous abbreviations that should not be used by health care organizations.

These abbreviations are:

  • “U” should not be used for “units”. It is often misread as “0”, “cc” or “4”. Recommendation: write out “unit”.
  • “IU” should not be used for “International unit(s)”. It is often misread as IV (intravenous) or “10”. Recommendation: write out “international units”.
  • “qd, or QD” should not be used for “every day” or “daily”. It is often misread as four times daily (QID). Recommendation: write out “daily”.
  • “qod, or QOD” should not be used for “every other day”. It is often mistaken for daily (QD) or four times daily (QID). Recommendation: write out “every other day”.
  • “MS” should not be used for “morphine sulfate”. It is can be misinterpreted as “magnesium sulfate”. Recommendation: write out “morphine sulfate”.
  • “MSO4” should not be used for “morphine sulfate”. It can be misinterpreted as “magnesium sulfate”. Recommendation: write out “morphine sulfate”.
  • “MgSo4” should not be used for “magnesium sulfate”. It can be misinterpreted as “morphine sulfate”. Recommendation: write out “magnesium sulfate”.

The improper use of zeros and decimal points continues to be one of the leading causes of medication errors. The rules regarding the use of decimal points and zeros are very simple.

  • Never put a zero after a decimal point. These are called “trailing zeros”. For example: a prescription for morphine sulfate 10mg should never be written “morphine sulfate 10.0mg. The decimal point in this prescription could be overlooked and the patient could receive 100mg instead of 10mg, a ten-fold increase in dose and potentially fatal.
  • Always put a zero in front of a decimal point. These are called “leading zeros”. For example: a prescription written for morphine sulfate .1mg/kg/day could be mistaken for 1mg because the decimal point was not seen. It should be written as 0.1mg.

JCAHO, ISMP, and other patient safety organizations have also identified several other abbreviations that should be avoided to reduce the potential for medication errors and may be added to an official “Do Not Use” list for your pharmacy or institution. These include:

  • the symbols for greater than (“>”) or less than (“<”) which could be mistaken for the number “7” or letter “L”.
  • apothecary units.
  • the “@” symbol which could be mistaken for the number “2”.
  • “μg” for micrograms. Mistaken for “mg”.
  • “H.S” or “h.s.” for half strength or bedtime. These two abbreviations are confused with each other frequently.
  • “T.I.W.” for three times a week. Mistaken for three times daily or twice weekly.
  • “S.C. or S.Q.” for subcutaneously. Mistaken for “sublingual” or “5 every”.
  • “d/c” for discontinue or discharge. This abbreviation is frequently misinterpreted.
  • “c.c.” for cubic centimeters (The more appropriate substitution for c.c. is to use “mL” or write out “milliliters”.),
  • “A.S., A.D., and A.U.” for left, right, and both ears, and “O.S., O.D., and O.U.” for left, right and both eyes.
  • “/” is used to separate doses or strengths. It is often mistaken for the number “1”.
  • “UD” for use as directed. Mistaken for “unit dose”.
  • “+” is used for “plus” or “and”. Mistaken for the number “4”.
  • “q6PM” is used for nightly at 6PM. Mistaken for every 6 hours.
  • “ss” is used for one-half or sliding scale for insulin. Mistaken for “55”.
  • “qn” is used for nightly. Mistaken for “qh” or every hour.
  • “IN” is used for intranasal. Mistaken for “IV” or “IM”.
  • “IT” is used for intrathecal. Mistaken for various other routes of administration such as “intratracheal”.

The best way to avoid any of these types of errors is to always write the words out on any prescription or oral order.

In addition to dangerous abbreviations for directions and doses, inappropriate abbreviations and shortcuts regarding drug names are also potentially just as serious. Many physicians and pharmacists devise their own abbreviations in an attempt to save time and improve efficiency. The way to prevent these types of errors is very simple. Don’t abbreviate drug names. Take the extra time and write the entire name of the drug.

Listed below are some common drug name abbreviations and what they might be mistaken for:

  • “AZT” for zidovudine, but mistaken for azathioprine
  • “MTX” for methotrexate, but mistaken for mitoxantrone
  • “TAC” for triamcinolone, but mistaken for tetracaine, adrenalin, or cocaine
  • “CPZ” for Compazine, but mistaken for chlorpromazine
  • “HCTZ” for hydroclorothiazide, but mistaken for hydrocortisone
  • “PIT” for Pitocin, but mistaken for Pitressin
  • “HCT” for hydrocortisone, but mistaken for hydrochlorothiazide
  • “ASA” for aspirin, but mistaken for Ascol
  • “HCl” for hydrochloric acid, but mistaken for potassium chloride
  • “NITRO Drip” for Nitrorpusside, but mistaken for nitroglycerin
  • “NORFLOX” for norfloxacin, but mistaken for Norflex
  • “APAP” is not recognized as being the abbreviation for acetaminophen

It is always good advice for the prescriber to include the indication with the prescription to help prevent look-alike and sound-alike drug names. It is also a good idea to use both brand and generic names when issuing a prescription to a patient.

Verbal/oral prescriptions or orders that are communicated via the telephone are particularly prone to medications errors. These types of prescriptions have multiple steps where a medication error could likely occur. Each oral prescription requires the pharmacist to hear the order correctly, understand what is being communicated, process the information mentally, and write down the correct information. There are many things that can interrupt or interfere with this process. Bad pronunciation by the nurse or doctor, voice inflections, a noisy environment, distractions, interruptions during the process, lack of knowledge of the drug being called-in, etc. can all affect the accuracy of the oral prescription.

Here are a few tips to help prevent medication errors with oral prescriptions:

  • If the oral prescription or order is being communicated too quickly, ask the person to please slow down and speak more clearly. Also, ask the person to enunciate the information slowly and clearly. It is not rude to ask someone to please speak-up.
  • Many times the nurse cannot read the doctor’s handwriting and will try to make an educated guess. A common occurrence is the nurse saying “Well, it looks like Nexium® 40mg”. Ask the nurse to verify the drug with physician and call you back.
  • Never rely on the patient’s profile to help decipher a drug name, strength, or directions. Many times if a nurse cannot read the doctor’s handwriting she will ask the pharmacist, “How did the patient take it the last time?” Then she will tell the pharmacist to use the same directions on the new prescription.
  • If someone is communicating a prescription to a pharmacist and cannot be understood, shows a lack of knowledge of the drug, or seems unsure of what they are calling-in, ask to speak to someone else.
  • Ask the person to spell drug names that may be similar to others. Sometimes an “S” sounds like an “F” and a “D” sounds like a “B”.
  • Pronounce digits separately when providing a strength or dose. For example: Lisinopril 20mg should be communicated, “Lisinopril twenty milligrams… that’s two zero milligrams”.
  • When receiving an oral prescription, go to a quiet place in the pharmacy free from distractions. Also, tell your technicians never to interrupt you in the middle of taking an oral prescription. If you do get interrupted, have the person giving you the oral prescription over the phone start over.
  • Finally, once the pharmacist completes the transcription of a verbal or oral prescription, take the time to verify the information with the person calling-in the prescription.

General tips to help prevent medication errors from inappropriate abbreviations:

  • Pharmacists and other health care providers should become familiar with error-prone abbreviations. They should recognize patterns in the use of these types of abbreviations and use that as a point to educate the health care provider who is using them about their potential danger.
  • It is never justified to use abbreviations as a “short-cut” to reduce workload or improve efficiency. Patient safety should never be compromised in an attempt to accomplish either of these goals.
  • Never abbreviate any drug name when taking an oral prescription or order over the phone. Many pharmacists will use abbreviations for drug names and directions in order  to “keep-up” with the fast pace of the person giving the prescription over the phone. If the oral prescription or order is being communicated too quickly, ask the person to please slow down and speak more clearly.
  • Verify any prescription you receive from a prescriber that contains problematic abbreviations or one the physician has “made-up” themselves. Do not try to make it a game among the pharmacists to try to decipher what the drug name or directions actually are.

These suggestions can be used within the pharmacy, health care institution, or as a tool for practitioners in the community.

  • Provide pocket-sized cards with the list of dangerous abbreviations.
  • Place articles regarding dangerous abbreviations in employee and staff newsletters.
  • Conduct a mock survey to test staff knowledge.
  • Develop a “Do Not Use” abbreviation of the month.
  • Develop medical chart inserts with the list of dangerous abbreviations.
  • Create post-it notes, stickers, posters, magnets, and flyers in patient service areas.
  • Offer to conduct an educational talk on this topic at a local physician’s office combined with lunch.
  • Send professional letters to physicians who routinely use these abbreviations.
  • Empower the nursing and office staff to help their physicians avoid these abbreviations through the use of contests, rewards, and incentives for participation.

Medication Error Reduction Tips

The Institute for Safe Medication Practices (ISMP) has a number of resources that pharmacists and health care practitioners can use to help reduce medication errors. Their website has several educational tools to assist in this process. It is definitely worth the time to browse their website at www.ismp.organd see what they have to offer.

Some of their suggestions for pharmacists to use to reduce medication errors along with others are:

  • Use the same process or workflow every time you fill or check a prescription. If you become interrupted in the middle of checking a prescription, start over from the beginning.
  • Check the prescription against the label at least three times.
  • Have another pharmacist verify any calculations you do. Make that person do the calculation from scratch and on their own. Do not give them your math work and have them verify it.
  • Keep the original prescription order, label, and stock medication container together during the entire process from start to finish.
  • Monitor the medical literature for information on newly discovered medication errors that have occurred in your practice setting.
  • Pharmacists should use auxiliary labels and stickers on the prescription bottle more prudently when it may prevent a medication error such as “shake well”, “for the eye”, “for the ear”, “rectally”, “refrigerate”, etc.. However, pharmacists should not overuse auxiliary labels or use more than three per bottle if possible.
  • Develop, implement, and follow a medication error avoidance plan.
  • Establish a quality control procedure for double-checking prescriptions waiting to be picked up with the information in the computer and on the original prescription.
  • Create shelf “tags” or “red flags” for look-alike or sound-alike drugs on inventory shelves.
  • Create a formal process to document and evaluate medication errors and “near-misses”.
  • Request resources from your employer that will facilitate error reduction.
  • Constantly evaluate new technologies or dispensing processes for medication error potential.
  • Make regular follow-up phone calls to patients to assess how their drug therapy is going and inquire about adverse events, side effects, and/or any changes in the patient’s medication or medical history.
  • Report errors and near misses to both internal and external medication error reporting systems to help others learn how to avoid similar problems and situations.
  • Use the following websites www.ismp.org,www.nccmerp.org,www.safemedication.com,​and www.ahrq.govto learn more about medication error reduction tips and techniques.
  • Patients not being properly taught how to use dosing cups, droppers, and measuring spoons. They need to be educated by the pharmacist on how to measure the correct volume of liquid in these measuring devices, so patients do not overdose or under-dose the medication.
  • The work area should be kept free from clutter.
  • Area for final verification should be kept away from high traffic areas in the prescription department.
  • Drug bottles that are no longer used should be discarded or returned to the shelves.
  • Telephones should be located in an area where they cannot be a distraction to a pharmacist verifying prescriptions before dispensing.
  • Pharmacists should only fill one prescription at a time before switching containers or drugs.
  • Complete the entire process for each prescription (counting, checking, labeling, verifying) before moving on to the next one.
  • Make sure the dispensing area has adequate space to perform all activities.
  • Train all staff who answer the phone.
  • Avoid interruptions while entering prescriptions into the computer and/or verifying prescriptions.
  • Keep the fax machine in an area away from the final verification area.
  • Make sure all areas of the pharmacy are well-lit. Some studies have suggested that light levels need to be increased for workers over the age of 45. Also, clean lighting fixtures on a regular basis. Lighting levels can be decreased by as much as 25% in fixtures that have not been cleaned for two years.
  • Create “break-periods” where pharmacists can step away from the dispensing process for a short time to avoid fatigue. It is better to make a patient wait a few minutes then have a pharmacist make a mistake due to eye-strain.
  • Make sure everyone in the pharmacy is properly trained on the system of how a prescription flows through the work flow system.
  • All staff should conform to a consistent work flow.
  • Never overstep your professional boundaries and risk patient safety.
  • Always read the label, prescription, and drug container at least three times. This is called Verification.
  • Have monthly meetings to discuss how work flow could be improved to reduce congestion, distractions, and improve patient safety.
  • Provide magnifying lens to aid in the reading of labels with very small print.
  • Make sure the lighting in the pharmacy is not casting a glare on computer screens used for data entry.
  • Store medication stock bottles in an organized and uncluttered area with at least one inch between bottles sitting side-by-side on the shelf.

The Pharmacy Technician’s Role in Preventing Errors

In addition to conducting medication reconciliation, technicians in outpatient or “retail” pharmacies can help prevent future discrepancies by avoiding errors resulting from poor communication between prescribers, pharmacies, and patients. Frequently the pharmacy is not informed by the provider or patient when a chronic medication is discontinued. This lack of communication is a large contributor to errors within the medication regimen.

  • Do not “fill everything”: It is not uncommon for patients to request the pharmacy fill all medications available for refill. Understandably, they would like to avoid unnecessary trips to the pharmacy, however complying with this request risks providing the patient with a medication that may have been changed or discontinued entirely. Kindly request that for their own safety, the patient requests the specific medications they need, either verbally or using a medication list. If a patient is unable to comply with this request, it may indicate confusion within their medication regimen and requires pharmacist review.
  • Verify all medications on autofill are necessary: Periodically verifying all medications placed on autofill is still necessary. Avoid placing medications on autofill without direct instruction by the patient.
  • Encourage patients to use one pharmacy: Medication errors and discrepancies are more likely to occur if patients are using multiple pharmacies. Use of multiple pharmacies increases the risk of duplications in therapy or drug-drug interactions. If a patient must use two pharmacies, encourage them to stay within a single chain of stores where prescription profiles are available in “central view” (i.e. view medication filled at all pharmacies within the chain).

Electronic Prescribing

Electronic prescribing or e-prescribing has been touted as a significant advance towards preventing medication errors. E-prescribing can accomplish this by effectively dealing with many potential medication errors such as bad handwriting, ambiguous prescriptions, omitted information, and improper terminology. Some e-prescribing systems come equipped with clinical-decision support systems that are linked to comprehensive drug databases that aid in appropriate prescribing.

Some of the most sophisticated systems can:

  • Help prescribers stay up to date on formulary changes and insurance coverage issues.
  • Alert prescribers of the most appropriate treatment options based on evidence based medicine, current clinical guidelines and best practices.​
  • Facilitate data exchange between health care providers.
  • Maintain up-to-date, accurate and unbiased drug databases for drug therapy selection.
  • Provide prescribers with computer screen alerts and prompts to be careful of look-alike drugs and dosages that exceed clinical guidelines.
  • Provide prescribers with patient specific allergy and drug interaction alerts to help avoid potential adverse drug reactions.
  • Flag pre-existing conditions that would preclude the use of certain therapeutic options.
  • Expedite refill requests from both patients and pharmacists.

There is no doubt that electronic prescribing can be very beneficial in preventing many types of medication errors. However, this new technology is also causing a new generation of medication errors that pharmacists and practitioners must become aware.

Some of these include:

  • One of the biggest shortcuts being used is when a physician writes the prescriptions in the patient’s chart or on a sheet of paper and then has his/her nurse or medical assistant enter the drugs into the electronic prescribing system. The physician reviews all the entries at the end of the day and verifies they are correct. This is a recipe for disaster.
  • If a prescriber misspells the patient’s name, the system may bring up the wrong patient. This can result in the prescriber ordering a prescription for the wrong patient.
  • A physician may forget to close one patient’s record on the system before e-prescribing medications for the next patient. This could result in the first patient receiving prescriptions intended for the second patient.
  • Physicians may design their own “short-cuts” and enter them into the system to speed- up e-prescribing. For example: When prescribing amoxicillin 500mg, the physician only has to enter “Amox” and the system automatically brings up amoxicillin 500mg. Errors occur when the physician types Amox… and the system brings up the 500mg strength when actually the physician wanted the 875mg strength.
  • Physicians design their own “short-codes” for medication directions to speed-up prescribing. For example: The physician creates a short-code in the system called “CTID”. Whenever this is typed into the system, the directions for the medication automatically inserted are “Take one capsule by mouth three times a day”. Errors can occur when the wrong short-codes are chosen or misspelled.
  • Physicians setting “defaults” within the system. For example: A physician knows that 90% of his patients started on an ACE inhibitor are given enalapril 5mg, QD. This is set in the system as the default and automatically comes up on the prescribing screen. An error occurs when a patient is supposed to get a different strength of enalapril.
  • Like some pharmacists, prescribers turn-off some safety features of the system, such as drug interaction alerts or they get in the habit of just “entering” past them because many are clinically insignificant. This is sometimes referred to as “work-arounds”.
  • A physician may inadvertently order laboratory tests instead of medications when options on the screen look like drug names.
  • The system is not kept properly updated with new clinical information as new clinical guidelines are introduced, new ADRs are discovered, and new drugs become available.
  • Individual prescribers can access the system’s programming and can create overrides within the system. For example: A prescriber gets into the system and can override maximum dosage alert messages or delete them altogether.

“Six Rights”

Even though some healthcare professionals do not write the prescription or dispense the drug from the pharmacy, they are in a position to identify potential errors in prescribing and dispensing and thereby protect the patient.

Healthcare professionals administering medication should always observe the following six “Rights”:

?         Right patient

?         Right drug

?         Right dose

?         Right dosage form

?         Right route

?         Right time

The IOM report Preventing Medication Errors (2006) found that medication errors are “surprisingly common and costly to the nation,” and outlines a comprehensive approach to decreasing the prevalence of these errors.

Basic steps in achieving this goal include:

?         Move toward a model of healthcare that is more of a partnership with patients: educate consult with and listen to patients.

?         Use information technologies to reduce medication errors:

?         Computerize drug order entry.

?         Use “unit dose” drug systems (packaged and labeled in standard patient doses).

?         Use e-prescriptions tied in with patients’ medical records

?         Standardize drug packaging, labeling, storage.

System Failures

Cost containment is a system-level factor that can affect medical errors. According to researchers at AHRQ, financial pressure at hospitals is associated with increases in the rate of adverse events. Using the Healthcare Cost and Utilization Project (HCUP) State Inpatient Data for Florida, they found that patients have significantly higher odds of experiencing adverse events (AEs) when hospital profit margins decline over time. These include nursing-related AEs, surgery-related AEs, and all likely preventable AEs. Cost containment measures that reduce staffing, particularly RN staffing, and thereby increase AEs, may prove to be a false economy.

Research on system failures that have led to major industrial disasters found that the systems had nine characteristics in common:

?         Diffuse responsibilities

?         Underestimation of the severity of risks

?         Belief that compliance with the rules was sufficient to achieve safety

?         Lack of acceptability for team members to speak up

?         Failure to share and implement lessons learned in other facilities

?         Subordination of safety to other performance goals

?         Persistence of flawed design features

?         Failure to use risk management techniques

?         Poorly defined responsibility for safety within the organization

?         Healthcare systems with these characteristics create an unsafe environment for both

patients and staff.

Factors That Increases Risk of Errors

Fatigue. Working a double shift, can increase the likelihood of errors. Medical residents on call for 24 hours or more are also at high risk for errors.

Alcohol and/or other drugs. Use of alcohol and/or drugs is incompatible with competent, professional, safe patient care. Unfortunately, the combination of high stress and easy access to medications has led to substance abuse by physicians, Healthcare professionals, and other healthcare professionals.

  • Illness. Coming to work when you aren’t well jeopardizes your health and the health and safety of patients.
  • Inattention/distraction. A noisy, busy emergency department can make it difficult to concentrate on one patient’s care, especially if you know that other patients are waiting to see you.
  • Emotional states. Anger, anxiety, fear, and boredom can all impair job performance and lead to errors. A heavy workload, conflict with other staff or with patients, and other sources of stress increase the likelihood of errors.
  • Unfamiliar​situations​or problems. Healthcare professionals who “float” from one hospital department to another may not have the expertise needed for all situations.
  • Equipment​design​flaws.Here​again, training and experience with equipment are key to avoiding errors.
  • Inadequate​labeling or instructions on medication or equipment. Look-alike or sound-alike drugs can lead to errors. Incomplete or confusing instructions on equipment can result in inappropriate use.
  • Communication problems. Lack of clear communication among staff or between providers and patients is one of the most common reasons for error.
  • Hard-to-read handwriting. Physicians’ handwriting has long been criticized for its illegibility, particularly on prescriptions. Fortunately, computerized medication ordering has eliminated this problem in many healthcare organizations.
  • Unsafe working conditions. Poor lighting and/or slippery floors can lead to errors, especially falls—a costly hazard in every hospital.

Populations of Special Vulnerabilities

The safety of all patients is of paramount concern for all care providers. However, some patients—for example, the very young and the very old—are particularly vulnerable to the effects of medical errors, often due to their inability to participate actively as a member of the healthcare team, most commonly related to communication issues. Healthcare professionals and other care providers need to recognize the special needs of these patients and act accordingly.

Older Patients

The normal aging process commonly includes some degree of impairment in vision and hearing. Older people may also suffer varying degrees of cognitive impairment. Alone or in combination, these problems contribute to difficulties in communication between patients and care providers. Serious illness, accidents, or trauma such as surgery that require hospitalization add another layer of anxiety and possible confusion that can further interfere with communication between patients and care providers, potentially leading to errors.

Older patients are at special risk from medication errors, which can have life-threatening or even fatal effects due to the declining ability of the aging body to metabolize drugs.

According to researchers from AHRQ and the National Center for Health Statistics, women 65 to 74 years of age had the highest incidence of ADEs. Visual, hearing, or cognitive problems may lead to misunderstanding of instructions or failure to question an incorrect or unfamiliar drug.

Older patients are also at high risk of falling. Reasons include medication effects, existing health problems such as arthritis, confusion or other cognitive deficit, or postural hypotension. Many older people need to use the bathroom during the night and need assistance to avoid falls.

Fall Risk – Falls are a commonly reported sentinel event, and can be fatal. Older patients are not the only population at risk. Any patient who has had excessive blood loss may experience postural hypotension, increasing the risk of falling. Maternity patients or other patients who have epidural anesthesia are at risk for falls due to decreased lower-body sensation. Factors that increase the risk of falls are summarized below.

Factors that increase risk of falls:

?         Age 65 or over

?         History of falling

?         Impaired mobility or difficulty walking

?         Need for assistance in getting out of bed or transferring to/from chair

?         History of dizziness or seizures

?         Impaired vision, hearing, or speech

?         Need for mobility-assistive devices (cane, walker, wheelchair, crutches or braces)

?         Weakness or fatigue

?         Confusion, disorientation, impaired cognitive function

?         Use of medications such as diuretics, laxatives, or consciousness-altering drugs including sedatives, analgesics, hypnotics, antidepressants, tranquilizers.

Infants and Children

The younger the patient, the greater the risk of serious medication errors with devastating effects. Weight-based dosing is required for almost all pediatric drugs, and errors often occur when physicians or pharmacists convert dosage from pounds (for adults) to kilograms (for children). The USP advises that parents should know their child’s weight in kilograms and reconfirm with the doctor that the dosage is correct for that weight.

Infants and young children do not have the communication abilities needed to alert clinicians about adverse effects that they experience. Infants, particularly newborns, are physiologically ill-equipped to deal with drug errors. Parents of infants and children need to be fully informed and involved in their child’s care during hospitalization and must be educated to question caregivers about medications and procedures.

Patients in Intensive Care Units

Intensive care units (ICUs) host the sickest patients whose conditions require extraordinarily complex care. These patients are more vulnerable to medical errors and more prone to injury. AHRQ researchers reported that more than 20 percent of patients admitted to two ICUs at a teaching hospital experienced an adverse event, almost half of which were preventable. A significant number of the AEs involved medication errors, most commonly a wrong-dose error. Most of the AEs occurred during routine care, not at admission or during an emergency (AHRQ, 2005b).

Patients in the ICU often have feeding tubes, chest drainage tubes, and central venous catheters, all of which require invasive procedures for placement. The most common types of adverse events in the ICU involve these lines, tubes, and drains. One study found that nearly two-thirds of these line, tube and drain adverse events are preventable, and that they occur more often during holidays, among children ages 1 to 9, and among patients with medically complex conditions.

Tubing Misconnections

According to JCAHO (2006), tubing and catheter misconnections are “a persistent and potentially deadly occurrence.” Although misconnections are often caught and corrected before the patient is injured, these AEs can have life-threatening consequences. Nine sentinel events involving tubing misconnections have been reported to JCAHO, eight of which resulted in death, and the other in permanent loss of function. Patients affected included seven adults and two infants.

Reducing or eliminating tube misconnections will require changes in purchasing, equipment design, and staff education. JCAHO recommends the steps outlined below.

  • Do not purchase non-intravenous equipment that is equipped with connectors that can physically mate with a female luer IV line connector.
  • Conduct​acceptance​testing​(for​performance,​safety, and usability) and, as appropriate, risk assessment (e.g., failure mode and effect analysis) on new tubing and catheter purchases to identify the potential for misconnections and take appropriate preventive measures.
  • Always trace a tube or catheter from the patient to the point of origin before connecting any new device or infusion.
  • Recheck connections and trace all patient tubes and catheters to their source upon the patient’s arrival to a new setting or service as part of the hand-off process. Standardize this “line reconciliation” process.
  • Route​tubes​and​catheters​having​different​purposes​in different, standardized directions (e.g., IV lines routed toward the head; enteric lines toward the feet). This is especially important in the care of neonates.

Reducing or eliminating tube misconnections will require changes in purchasing, equipment design, and staff education. JCAHO recommends the steps outlined below (additional steps):

  • inform non-clinical staff, patients and their families that they must get help from clinical staff whenever there is a real or perceived need to connect or disconnect devices or infusions.
  • For certain high-risk catheters (e.g., epidural, intrathecal, arterial), label the catheter and do not use catheters that have injection ports.
  • Never use a standard luer syringe for oral medications or enteric feedings.
  • Emphasize the risk of tubing misconnections in orientation and training curricula.
  • Identify and manage conditions and practices that may contribute to healthcare worker fatigue, and take appropriate action.
  • In addition, the Joint Commission urges product manufacturers to implement “designed incompatability,” as appropriate, to prevent dangerous misconnections of tubes and catheters.

Cather-related Infections:

Central venous catheter-related bloodstream infections are not only potentially fatal but also cost the healthcare system an estimated $2.3 billion each year . Preventing these dangerous oversights may have a low-cost, high-yield solution such as a simple checklist of evidence-based practices in infection control like hand washing and other fundamental procedures. Provonost and colleagues (2006) demonstrated the dramatic value of using a checklist in ICU to ensure that basic protocols are followed. In a study of large and small hospitals in Michigan, researchers found that using the checklist of five evidence-based practices recommended by CDC reduced the infection rate by two-thirds. These practices included hand washing, using full-barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site if possible, and removing any unnecessary catheters.

Respiratory Complications:

Patients on ventilators are prone to bacterial pneumonia as well as development of stomach ulcers. Resar and colleagues (2005) found that use of a checklist that included a “bundle” of evidence-based care processes, such as propping up the patient’s bed at least 30 degrees (to prevent aspiration of oral secretions) and administering antacid medications (to prevent stomach ulcers) reduced the incidence of pneumonias in ventilator patients by one-fourth and reduced length of stay in ICU by one half.

Patients with Language Barrier and/or Limited Health Literacy

“Health literacy” is defined as the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions. A U.S. Department of Education (2003) assessment found that more than one-third of the U.S. population has only basic or below basic health literacy.

Meeting the healthcare needs of Florida’s culturally and ethnically diverse population may require bilingual care providers, translators or interpreters, or other communication experts. Without these experts available, communication of vital information between patient and provider can lead to misunderstanding and errors.

Many hospitals have translators or interpreters available for patients who do not speak English. If translation assistance is not available, communicating with a family member or other support person is essential. It is important to keep your words simple and concrete, and to use pictures or diagrams to explain procedures.

General guidelines to assist Healthcare professionals caring for patients from thirty-five different cultural groups can be found in Culture and Nursing Care: A Pocket Guide (Lipson, Dibble & Minarik, 2005). Each chapter outlines issues related to health and illness, symptom expression, self-care, birth, death, religion, family participation in care, and other topics.

According to the Partnership for Clear Health Communication (2007), “the average American reads at the eighth or ninth grade level” while health information is usually written at a higher reading level. In addition, fear, vulnerability, shock concerning a diagnosis, family stresses, and multiple health problems can interfere with patients’ ability to understand medical information.

The Partnership’s Ask Me 3 initiative promotes three basic questions that patients should ask their providers in every healthcare interaction:

?        What is my main problem?

?        What do I need to do?

?        Why is it important for me to do this?

When caring for patients whose verbal abilities are limited either by education, development, or neurologic impairment, assistive devices such as an alphabet board, a picture board, or a magic slate may prove helpful. Patients who are unable to speak because of a tracheostomy or other surgical procedure should also have these devices available, along with pencil and paper.

Reporting Errors

Improving patient safety begins with prompt reporting of errors, followed by analysis of the root causes and contributing factors and development of a plan of action to prevent similar errors in the future. Only in this way can a healthcare organization assess the safety of care delivered and determine whether safety is improving.

The mistaken attitude in healthcare that errors are solely the fault of individual practitioners has proved a major barrier to reporting. A survey of 1600 physicians found that 93 percent of them said doctors should report all significant medical errors they observe, but less than half of them did so.

Instead of analyzing the multiple factors that contribute to errors, efforts have focused almost entirely on making providers more careful, reinforced by fear of punishment when they fail. Until the mid-1990s, this punitive attitude severely limited the reporting of errors. In fact, research shows that when the fear of punishment is removed, reporting of errors increases by as much as ten- to twenty-fold.

Joint Commission Error Reporting Requirements

Each accredited healthcare organization must have two systems in place for reporting errors: an internal system and an external system. The Joint Commission, whose mission is “to continuously improve the safety and quality of care provided to the public,” requires that healthcare organizations:

  • Have a process in place to recognize sentinel events.
  • Conduct thorough and credible root cause analyses that focus on process and system factors, not on individual blame.
  • Document a risk-reduction strategy and internal corrective action plan within 45 days of the organization becoming aware of the sentinel event .
  • The Joint Commission defines a sentinel event as any unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Including the words “or the risk thereof” broadens the definition to include potential sentinel events (close calls/near misses). In other words, if similar circumstances recurred, a serious adverse outcome would be likely.

Joint Commission Reportable Sentinel Events:

The Joint Commission encourages, but does not require, reporting of any sentinel event meeting the criteria below.

Unanticipated death or major permanent loss of function, unrelated to the natural course of the patient’s illness or underlying condition, or one of the following (even if the outcome was not death or major permanent loss of function unrelated to the natural course of the patient’s illness or underlying condition):

  • Suicide of any individual receiving care, treatment, or services in a staffed around-the- clock care setting or within 72 hours of discharge
  • Unanticipated death of a full-term infant
  • Abduction of any individual receiving care, treatment, or services
  • Discharge of an infant to the wrong family
  • Rape
  • Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities
  • Surgery on the wrong individual or wrong body part
  • Unintended retention of a foreign object in an individual after surgery or other procedure
  • Severe neonatal hyperbilirubinemia (bilirubin >30 milligrams/deciliter)
  • Prolonged fluoroscopy with cumulative dose >1500 rads to a single field, or any delivery of radiotherapy to the wrong body region or >25% above the planned radiotherapy dose

Root Cause Analysis (RCA)

The Joint Commission requires that a thorough, credible root cause analysis (RCA) and corrective action plan be performed for each reported sentinel event within 45 days of the event’s occurrence or of the organization’s becoming aware of the event.

According to JCAHO (2007) research:

  • Inadequate communication between care providers or between care providers and patients/families is consistently the main root cause of sentinel events. Other leading root causes include incorrect assessment of a patient’s physical or behavioral conditions and inadequate leadership, orientation or training.
  • The U.S. Department of Veterans Affairs, National Center for Patient Safety, offers the following guidance in root cause analysis.

?         What happened

?         Why it happened

?         What to do to prevent it from happening again

Root cause analysis is a tool for identifying prevention strategies. It is a process that is part of the effort to build a culture of safety and move beyond the culture of blame.

In RCA, basic and/or contributing causes underlying variations in performance associated with Adverse Events (AE) or Close Calls (CC) are discovered in a focused review process similar to diagnosis of disease—with the goal always in mind of preventing recurrence.

Root cause analysis is:

  • Interdisciplinary, involving those knowledgeable about the processes involved in the event
  • Focused primarily on systems and processes rather than individual performance situation
  • Continually digging deeper by asking what and why until all aspects of the process are reviewed and contributing factors are considered
  • A process that identifies changes that could be made to systems and processes to improve performance and reduce risk of recurrence of the AE or CC.

When developing root cause statements, the following five guidelines need to be considered:

  • Root cause statements need to include the cause and effect.
  • Negative descriptions are not to be used in root cause statements.
  • Each human error has a preceding cause.
  • Violations of procedure are not root causes, but must have a preceding cause.
  • Failure to act is only a root cause when there is a pre-existing duty to act.

To be thorough, RCA must include:

  • Determination of human and other factors most directly associated with the AE or CC
  • Analysis of underlying cause and effect systems through a series of why​questions to determine where redesigns might reduce risk.
  • Identification of risks and their potential contributions to the AE or CC
  • Determination of potential improvement in processes or systems that would decrease the likelihood of such events in the future, or a determination, after analysis, that no such improvement opportunities exist.

To be credible, RCA must:

  • Include participation by the leadership of the organization and those most closely involved in the processes and systems under review.
  • Be internally consistent.
  • Include consideration of relevant literature.
    Include corrective outcome measures, and top management approval.
  • Meet the JCAHO requirements. (U.S. Dept. Veterans Affairs, 2005)

Florida Law

Reporting sentinel events to JCAHO is voluntary. However, Florida law makes such reporting mandatory. Florida’s Comprehensive Medical Malpractice Reform Act of 1985 (F.S.395.0197) mandates that each licensed hospital and ambulatory surgery center implement a risk-management program with state oversight and an internal incident- reporting system. State oversight is provided by the Florida Agency for Healthcare Administration (AHCA). Each licensed facility is required to hire a risk manager, licensed under F.S. 395–10974, who is responsible for implementation and oversight of the risk management program.

Statute 395.0197 mandates internal reporting of any adverse incident (event) over which healthcare personnel could exercise control, and which is associated in whole or in part with medical intervention, rather than the condition for which such intervention occurred, and which:

Results in one of the following injuries:

  • Death. Brain or spinal damage. Permanent disfigurement. Fracture or dislocation of bones or joints
  • A resulting limitation of neurologic, physical, or sensory function which continues after discharge from the facility
  • Any condition that required specialized medical attention or surgical intervention resulting from non-emergency medical intervention, other than an emergency medical condition, to which the patient has not given his or her informed consent, or
  • Any condition that required the transfer of the patient, within or outside the facility, to a unit providing a more acute level of care due to the adverse incident, rather than the patient’s condition prior to the adverse incident;
  • Was the performance of a surgical procedure on the wrong patient, a wrong surgical procedure, a wrong-side surgical procedure, or a surgical procedure otherwise unrelated to the patient’s diagnosis or medical condition.
  • Required the surgical repair of damage resulting to a patient from a planned surgical procedure, where the damage was not a recognized specific risk, as disclosed to the patient and documented through the informed-consent process.
  • Was a procedure to remove unplanned foreign objects remaining from a surgical procedure (F.S.395.0197).

The risk-management system must:

  • Investigate and analyze the frequency and causes of adverse incidents to patients
  • Educate all non-physician personnel in risk management and risk prevention as part of their initial orientation
  • Provide at least 1 hour of such education and training annually for all personnel of the facility working in clinical areas and providing patient care, except for licensed healthcare practitioners who are required to complete continuing education coursework pursuant to chapter 456 or their respective practice act
  • Analyze patient grievances related to patient care.

All incident reports must be filed with the risk manager of the healthcare organization or his or her designee within three days after the event occurred. Following receipt of the report, the risk manager in turn must report the event to the Florida Agency for Healthcare Administration (AHCA).

In addition to their internal reporting system, Florida hospitals and ambulatory surgical centers also must submit two types of reports to the Florida AHCA:

  • Code 15 reports, which report in detail on each serious patient injury, the facility’s investigation of the injury, and whether the factors causing or resulting in the adverse incident represent a potential risk to other patients. The findings of that investigation must be reported to AHCA within 15 days of an adverse incident. Failure to comply with this mandate may result in fines of as much as $25,000.
  • The annual report, which includes all adverse incidents that occur in the facility and malpractice actions (new, pending, and closed) in the course of a calendar year. Facilities are also required to report any injuries of which they are aware that occur through any healthcare service, including nursing homes, home health organizations, doctors’ offices, dentists’ offices, or any other purveyor of healthcare service. Florida Statute 641.55 requires similar reporting of patient injury incidents by HMOs. These reports are due after the first of each year for the previous year.

Florida law (F.S. 395.051) also requires that hospitals and other healthcare facilities notify each patient—or an individual identified pursuant to s.765.401(1)—in person about adverse incidents that result in serious harm to the patient. Such notification shall be given by an appropriately trained person designated by the facility as soon as practicable to allow the patient an opportunity to minimize damage or injury. “Notification of outcomes of care that result in harm to the patient under this section shall not constitute an acknowledgment or admission of liability, nor can it be introduced as evidence.”

JACHO’s Patient Safety Goals 2012

Joint Commission National Patient Safety Goals

JCAHO set the first National Patient Safety Goals (NPSGs) in January 2003. Since that time these NPSGs have undergone many revisions, with the last one in 2012. The new goal for the hospital and critical hospital accreditation programs that JCAHO has approved for 2012 focuses on the prevention of catheter-associated urinary tract infection (CAUTI). The 2012 National Patient Safety Goals and Recommendations are summarized below.

New goals are in boldface type.

Goal​1. Improve the accuracy of patient identification.

Recommendations: Use at least two patient identifiers (neither of which is the patient’s room number) whenever administering medications or blood products, taking blood samples or other specimens for clinical testing, or providing any other treatments or procedures.

Goal 2. Improve the effectiveness of communication among caregivers. Recommendations:

  • For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the order or test result “read-back” the complete order or test result.
  • Standardize a list of abbreviations, acronyms and symbols that are not to be used throughout the organization.
  • 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.
  • Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.

Goal​3. Improve the safety of using medications.

  • Standardize and limit the number of drug concentrations available in the organization.
  • Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs.
  • Label all medications, medication containers (e.g., syringes, medicine cups, basins), or other solutions on and off the sterile field.
  • Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.

Goal 4. Eliminate wrong-site, wrong-patient, wrong-procedure surgery Goal 5. Improve the safety of using infusion pumps

Goal​6. Improve the effectiveness of clinical alarm systems

Goal​7. Reduce the risk of healthcare-associated infections.

  • Comply with current World Health Organization (WHO) Hand Hygiene Guidelines or CDC hand hygiene guidelines.
  • Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a healthcare-associated infection.

Goal 8. Accurately and completely reconcile medications across the continuum of care.

  • Implement a process for comparing the patient’s current medications with those ordered for the patient while under care of the organization.
  • A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred to or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility.

Goal 9. Reduce the risk of patient harm resulting from falls.

  • Implement a fall reduction program including an evaluation of the effectiveness of the program.

Goal 10.
Not applicable

Goal 11.
Not applicable

Goal 12.
Not applicable

Goal 13. Encourage patients’ active involvement in their own care as a patient safety​strategy.

  • Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so.

Goal 14. The organization identifies safety risks inherent in its patient population.

  • Identify patients at risk for suicide (applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals—NOT APPLICABLE TO CRITICAL ACCESS HOSPITALS).

Goal 15. Improve recognition and response to changes in a patient’s condition.

  • The organization selects a suitable method that enables healthcare staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening. [Critical Access Hospital, Hospital]

Electronic Medical Records (EMR)

Electronic medical records (EMRs) and other information technology can improve communication and patient safety if fully implemented in hospitals and other healthcare facilities. For example, EMRs can help reduce medication errors, avoid the need to repeat laboratory tests, and improve continuity of care across the healthcare system. All healthcare providers within a system have access to accurate and complete information when they need it.

One barrier to adoption of EMRs is the cost. According to the Leapfrog Group, a national coalition of large healthcare providers, a purchase and implementation of EMRs in a 200- bed hospital can cost from $1-7 million. However, the return on investment in terms of increased efficiency and improved patient safety can be substantial (Joint Commission, 2005).

One of the largest HMOs, Kaiser Permanente, which serves 3.2 million people in Northern California, has implemented a sophisticated EMR system to help improve patient safety and quality of care. Every doctor in every Kaiser hospital, clinic, and ambulatory care center has instant access to each of their patient’s charts. According to Robert Pearl, the Executive Director and CEO of Kaiser Permanente, the use of EMRs has helped reduce the death rate from heart disease among Kaiser members 30% below the rate in the general population, adjusted for age and sex.

Patient Safety Tips for Hospitals

In February 2007 the Agency for Healthcare Research and Quality published 10 Patient Safety Tips for Hospitals, evidenced-based clinical recommendations for improving patient safety.

  • Assess and improve your patient safety culture.
  • Build teamwork—train hospital staff to communicate effectively as a team.
  • Limit​shifts​for​hospital​staff,​if possible—minimize shifts of more than 16 consecutive hours by residents, interns, and Healthcare professionals.
  • Insert chest tubes safely using UWET protocol
    • Universal Precautions (w/sterile cap, mask, gown, and gloves)
    • Wider skin prep
    • Extensive draping
    • Tray positioning
  • Prevent central line-related bloodstream infections through vigilance and using five evidence-based procedures: hand washing, full-barrier-precautions during insertion of central venous catheters, cleaning skin with chlorhexidine, avoiding the femoral site, and removing unnecessary catheters. This practice reduced fatal infections to zero in a study at more than 100 large and small hospitals.
  • Make good use of senior ICU Healthcare professionals—Use RNs and maintain appropriate round-the-clock staffing levels in ICUs to prevent airway tube complications.
  • Use reliable decision-support tools at the point of care, such as computerized physician order entry or personal digital-assistant based drug information.
  • Set up a safety reporting system.
  • Limit​urinary catheter use to 3 days to reduce the risk of urinary tract infections (UTIs).
  • Minimize unnecessary interruptions and distractions, such as establishing a “zone of silence” near medication carts and other areas where concentration is essential.

Public Education Measures

Making the patient and the family part of the healthcare team is an important strategy in improving patient safety and reducing medical errors. Several organizations have materials available to educate patients about their role on the healthcare team. The AHRQ has developed a simple message for patients called Five Steps to Safer Healthcare, as well a comprehensive patient fact sheet that hospitals are encouraged to make available to patients.

The single most important way patients can help to prevent errors is to be active members

of the healthcare team. That means taking part in every decision about their healthcare. Research shows that patients who are personally involved with their care tend to get better results. Some specific tips, based on the latest scientific evidence about what works best, are listed below.

Educate Patients about the following to help prevent medical errors:

Medicines

  • Make sure that patients inform doctors about everything they are taking. This includes prescription and over-the-counter medicines, and dietary supplements such as vitamins and herbs.
  • At least once a year, patients should bring their medicines and supplements to their doctor. “Brown bagging” the medicines can help the patient and the doctor find out if there are any problems. It can also help the doctor keep patient records up to date, which can help the patient get better quality care.
  • Make sure the doctor knows about any allergies and adverse reactions the patient may have to medicines. This can avoid getting a medicine that can harm the patient.
  • When the doctor writes a prescription, make sure the patient can read it. If the patient can’t read the doctor’s handwriting, the pharmacist might not be able to either read it
  • Ask for information about the medicines in terms the patient can understand—both when medicines are prescribed and when the patient receives them. What is the medicine for? How should the patient take it, and for how long? What side effects are likely? What does the patient do if they occur? Is this medicine safe to take with other medicines or dietary supplements the patient is taking? What food, drink, or activities should the patient avoid while taking this medicine?
  • When the patient picks up the medicine from the pharmacy, they should ask: Is this the medicine that my doctor prescribed? A study by the Massachusetts College of Pharmacy and Allied Health Sciences found that 88% of medicine errors involved the wrong drug or the wrong dose.
  • If patients have any questions about the directions on medicine labels, they should ask questions. Medicine labels can be hard to understand. For example, ask if “four doses daily” means taking a dose every 6 hours around the clock or just during regular waking hours.
  • Ask the pharmacist for the best device to measure the liquid medicine. Also, ask questions if the patient is not sure how to use it. Research shows that many people do not understand the right way to measure liquid medicines. For example, many use household teaspoons, which often do not hold a true teaspoon of liquid. Special devices, like marked syringes, help people to measure the right dose. Being told how to use the devices helps even more.
  • Ask for written information about the side effects the medicine could cause. If the patient knows what might happened, they will be better prepared if it does—or if something unexpected happens instead. That way, the patient can report the problem right away and get help before it gets worse. A study found that written information about medicines can help patients recognize problem side effects and then give that information to their doctor or pharmacist.

Hospital Stays

If the patients have a choice, choose a hospital at which many patients had the procedure or surgery. 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.

If the patient is in a hospital, consider asking all healthcare workers who have direct contact with the patient whether they have washed their hands. Hand washing is an important way to prevent the spread of infections in hospitals. Yet, it is not done regularly or thoroughly enough. A recent study found that when the patients checked whether healthcare workers washed their hands, the workers washed their hands more often and used more soap.

When the patient is being discharged from the hospital, ask the doctor to explain the treatment plan the patient will use at home. This includes learning about the medicines and finding out when to get back to your regular activities. Research shows that at discharge time the doctors think their patients understand more than they really do about what they should or should not do when they return home.

Surgery

If the patient is having surgery, make sure that the doctor, and surgeon all agree and are clear on exactly what will be done. Doing 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% preventable. The American Academy of Orthopedic Surgeons urges its members to sign their initials directly on the site to be operated on before the surgery.

Other Steps Patient Can Take

  • Speak up if they have questions or concerns. Patients have a right to question anyone who is involved with their care.
  • Make sure that someone, such as their personal doctor, is in charge of their care. This is especially important if the patient has many health problems or is in a hospital.
  • Make sure that all health professionals involved in patient care have important health information about the patient. Do not assume that everyone knows everything they need to know.
  • Ask a family member or friend to be there with the patient and to be their advocate (someone who can help get things done and speak up for patient if they can’t). Even if patients think that they don’t need help now, they might need it later.
  • 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 them. The patient could be better off without it.
  • If the patient has a test done, don’t assume that no news is good news. Ask about the results.
  • Learn about the condition and treatments by asking the doctor and the nurse and by using other reliable sources.

Tips for Patients to Help Prevent Medication Errors

While medication errors can happen to any patient at any age, the consequences may be far more devastating when children are involved. With this in mind, USP offers parents the following tips to help prevent medication errors from happening to their children:

  • On admittance to the hospital, provide the healthcare practitioner (HCP) with an up-to- date list of all medicines (prescription and over-the-counter) and dietary supplements that your child is taking. This will help minimize medication errors and prevent drug interactions during your child’s hospital stay.
  • Make sure your child’s HCP is aware of any allergies your child may have. For life- threatening allergies, be sure that your child wears a MedicAlert bracelet at all times.
  • Medications administered to children are based on the child’s weight in kilograms. For purposes of preparing appropriate dosages of medicines, your child’s weight in pounds must be divided by 2.2 to convert it into kilograms. Be aware of this calculation and/or your child’s weight in kilograms, and reconfirm the correct dosage with your child’s HCP if you have concerns.
  • Be sure that you are provided with verbal and written information about your child’s medications, the common side effects, and the adverse events that should be reported to your child’s HCP.
  • Pay close attention to how your child is feeling while in the hospital. Notify the HCP immediately if you notice any negative side effects from the administered medications, such as sudden difficulty in swallowing or breathing.
  • If your child is given a liquid medication to take after release from the hospital, be sure you are provided with an appropriate measuring device and instructions to ensure proper medication doses.
  • In case of an emergency, be sure that your child’s school has a list of any medical conditions or allergies your child may have.

Conclusion

Since the IOM’s To Err Is Human presented its dramatic findings of preventable death and injury in US hospitals in 2000, notable advances have been made. They include the development of performance standards, an increase in error reporting, integration of information technology and improved safety systems. However, more is still needed to improve safety and reduce errors, including the development of data standards for patient safety information, the establishment of a national health information infrastructure and a need for comprehensive patient safety programs in healthcare organizations. The reduction of medical errors must remain a top priority for all healthcare professionals.

Resources

  • Agency for Healthcare Administration (Florida) http://www.floridahealthfinder.gov
  • Florida State Board of Nursing, Department of Health  http://www.doh.state.fl.us/mqa/nursing/

4052 Bald Cyprus Way, Bin C10

Tallahassee FL 32399-3257

850-488-0595

  • Agency for Healthcare Research and Quality (AHRQ)

Free toolkits for health professionals, hospital managers and patients  http://www.ahrq.gov/qual/pips

  • Association of Operating Room Healthcare professionals http://www.aorn.org
  • Institute for Healthcare Improvement (IHI)  http://www.ihi.org
  • Institute for Safe Medication Practices  http://www.ismp.org
  • Joint Commission on Accreditation of Healthcare Organizations (JCAHO)  http://www.jcaho.org
  • The Leapfrog Group  http://www.leapfroggroup.org
  • National Center for Patient Safety (Veterans Administration)  http://www.va.gov/ncps
  • National Patient Safety Foundation  http://www.npsf.org
  • National Quality Forum  http://www.qualityforum.org
  • Patient Safety Network

http://psnet.ahrq.gov

  • Society of Pediatric Healthcare professionals  https://www.pedsHealthcare professionals.org

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