Prevention of Medical Errors

This course is approved by the the following boards within the State of Florida and the District of Columbia. (CE Provider #:50-4672)

The Florida Board of Registered Nursing

    •         Licensed Practical Nurse 
    •         Florida Board of Respiratory Care
    •         Respiratory Care Practitioner Critical Care 
    •         Respiratory Care Practitioner Non-Critical Care 
    •         Certified Respiratory Therapist 
    •         Registered Respiratory Therapist 
    •         Dietitian/Nutritionist 
    •         Nutrition Counselor 
    •         Licensed Midwife 
    •         Florida Electrolysis Council
    •         Electrologist 
    •         Advanced Registered Nurse Practitioner
      • Florida Board of Nursing - Certified Nursing Assistants
      • District of Columbia Board of Nursing
      • Florida Council of Dietetics and Nutrition

 This course is not approved by the Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling.

For Psychologist credit please take our the Medical Errors course at www.CeUnit.com. Psychologists credit will not be given on this site.

 

Learning Objectives

Upon completion of this course, the health care professional will be able to:

1.      Describe the magnitude of medical errors.

2.      Define the types of medical errors.

3.      Discuss factors that increase the risk of medical errors.

4.      Identify populations of special vulnerability.

5.      Discuss responsibilities for reporting medical errors.

6.      Identify processes to improve patient outcomes.

7.      Describe public education measures related to patient safety.

 

In November 1999, the Institute of Medicine (IOM) revealed a hidden epidemic in the United States: medical errors, which result in injury to 1 in every 25 hospital patients and an estimated 44,000 to 98,000 deaths each year. Even the lower estimate makes medical errors more deadly than breast cancer (42,297), motor vehicle accidents (43,458) or AIDS (16,516). According to the IOM report, To Err is Human: Building a Safer Health System, medical errors cost the economy from $17 to $29 billion each year.

Research funded by the Agency for Healthcare Research and Quality (AHRQ) has shown that medical errors result most frequently from systems errors-organization of health care delivery and how resources are provided in the delivery system. Only rarely are medical errors the result of carelessness or misconduct of a single individual.

As John M. Eisenberg, MD, Director of AHRQ pointed out:

"Mistakes happen in hospitals, they happen in outpatient clinics, they happen in nursing homes and home care, and they happen in self-care. We as clinicians need to acknowledge that they happen. The challenge is to avoid them, and when mistakes do occur, to prevent them from causing harm to our patients." (2000)

Errors can occur at any point in the health care delivery system. Acknowledging that errors happen, learning from those errors, and working to prevent future errors represents a major change in the culture of health care, a shift from blame and punishment to analysis of the root causes of errors and strategies to improve systems and processes. Every person on the healthcare team has a role in making health care safer for patients and workers.

In response to the IOM report, 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.

Types of Medical Errors

The IOM report defines an error 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 is an injury caused by medical management rather than the underlying condition of the patient. An adverse event attributable to error is a preventable adverse event, also called a sentinel event, because it signals the need to ask why the error occurred and make changes in the system.

Research on why humans make errors (Reason, 1990) has identified two types of errors: active errors and latent errors. 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, errors in system design, faulty installation or maintenance of equipment, or ineffective organizational infrastructure. 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. For example, an undetected design flaw in an airplane (a latent error) may cause the pilot to lose control of the plane (an active error) years after the aircraft was built, and cause the plane to crash.

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. For example, a nurse who recognizes a potential drug overdose in a physician's prescription and does not administer the drug but instead calls the error to the physician's attention has prevented an adverse drug event (ADE). Close calls provide opportunities for developing preventive strategies and actions, and should receive the same level of scrutiny as adverse events.

Surgical Errors

Surgical errors, or surgical adverse events, may account for a high percentage of adverse events. A study of hospitals in Colorado and Utah (Gawande, et al, 1999) found that surgical adverse events accounted for two-thirds of all adverse events and 1 of 8 hospital deaths.

A review by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 1998) 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 such as wrong-site surgery are not the sole responsibility of the operating surgeon, however. All operating room personnel have a role in ensuring patient safety by verifying the surgical site and pointing out a possible error. Admittedly, this can be difficult in the presence of an attitude that the surgeon should never be questioned.

To reduce the risk of wrong-site surgeries, JCAHO recommends the following strategies:

  • Clearly mark the operative site, involving the patient (or the family when appropriate) in the marking process
  • Require oral verification of the correct site in the operating room by each member of the surgical team
  • Develop a verification checklist that lists all documents referencing the intended surgical procedure and site

Diagnostic Inaccuracies

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. For example, a study of colposcopy, a test used to follow up on abnormal Pap smear results, showed that physicians who performed 100 or more colposcopies annually had more accurate findings than those who performed the procedure less often (Gordon, 1996).

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. However, these serious events also happen in other healthcare settings, including intensive care units, medical-surgical units, inpatient psychiatric hospitals, the operating room, and in the home care setting. Of the 55 reported cases of delays in treatment, 52 resulted in patient death.

Medication Errors

Medication-related error is one of the most common types of error, and of primary concern to nurses who administer medications, as well as to the practitioner who prescribes medications, and the pharmacist who dispenses medications. Medication errors are called preventable adverse drug events (ADEs).

According to the U.S. Pharmacopeia (USP) (2000), the three most frequently reported types of medication errors were:

  • Omission errors (failure to administer an ordered medication dose).
  • Improper dose/quantity errors (any medication dose, strength or quantity that differs from that prescribed).
  • Unauthorized drug errors (the medication dispensed and/or administered was not authorized by the prescriber); this category includes dispensing or administering the wrong drug.

Other findings of the USP report included:

  • Of the five phases of the medication process, errors reported originated primarily in administering and documenting. (The other phases include ordering, dispensing, and monitoring.)
  • The primary contributing factors to medication errors were distractions and workload increases, many of which may result from efforts at cost containment.
  • Insulin, heparin and warfarin were the medications most often associated with errors.
  • In 32% of the records where documented action was taken due to a medication error, the personnel involved with initiating or perpetuating the error were reportedly not informed of their involvement in the medication error event.

One study funded by AHRQ in two tertiary care hospitals (Bates, et al, 1995) found that errors in ordering medications accounted for 56 percent of preventable ADEs, while errors in administering medication accounted for 34 percent of preventable ADEs. A second study (Leape, 1995) showed that dosage errors, in particular, were primarily due to the physician's lack of knowledge about the drug or about the patient for whom it was prescribed.

A later study attempting to identify risk factors for preventable ADEs among patients admitted to medical and surgical units at two large hospitals (Bates, et al, 1999), found few such factors, suggesting that focusing on improving medication systems would prove more effective.

Even though nurses 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. Nurses administering medication should observe the following six "rights:"

  • Right patient
  • Right drug
  • Right dose
  • Right dosage form
  • Right route
  • Right time

In 1999, The National Patient Safety Partnership, a coalition of healthcare organizations, released a list of 16 best practices in medication safety. (Box 1) If hospitals implemented all of these practices, it could markedly reduce medication errors.

Box 1: Best Practices for Medication Safety

  • To reduce the occurrence of adverse drug events (events that can cause, or lead to, inappropriate medication use and patient harm),
  • Patients can:
  • Tell physicians about all medications they are taking and responses/reactions to them
  • Ask for information in terms they understand before accepting medications
  • Providing Organizations and Practitioners can:
  • Educate patients
  • Put allergies and medications on patient records
  • Stress dose adjustment in children and older persons
  • Limit access to high hazard drugs
  • Use protocols for high hazard drugs
  • Computerize drug order entry
  • Use pharmacy-based IV and drug mixing programs
  • Avoid abbreviations
  • Use "unit dose" drug systems (packaged and labeled in standard patient doses)
  • Use "unit dose" drug systems (packaged and labeled in standard patient doses)
  • Purchasers can:
  • Require machine-readable labeling (barcoding)
  • Buy drugs with prominent display on name, strength, warnings
  • Buy "unit of use" packaging ("unit dose")
  • Buy IV solutions with two sided labeling
  • To reduce the potential for taking a medication that was not prescribed for them or cannot be safely taken by them, patients should ask the following five sets of questions before accepting prescription drugs.
  • Is this the drug my doctor (or other health care provider) ordered? What is the trade and generic name of the medication?
  • What is the drug for? What is it supposed to do?
  • How and when am I supposed to take it and for how long?
  • What are the likely side effects? What do I do if they occur?
  • Is this medication safe to take with other over-the-counter or prescription medications, or dietary supplements, that I am already taking? What food, drink, activities, dietary supplements or other medication should be avoided while taking this medication?
  • National Patient Safety Partnership, May 12, 1999

System Failures

Analysis of medical errors continues to show that human fallibility is only part of the picture; system failures are also guilty. A major study (Leape et al, 1995) showed that failures at the system level - in disseminating pharmaceutical information, in checking drug dosages and patient identities, and in making patient information available - were the real culprits in more than 75 percent of adverse drug events.

Cost containment is a system-level factor that can affect medical errors. For example, inadequate staffing levels of nurses increased the incidence of postoperative adverse events, such as urinary tract infections, pneumonia, thrombosis, and pulmonary compromise (Kovner and Gergen, 1998).

Research on system failures that have led to major industrial disasters (Peterson, 1996) 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 ability 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 and Situations that Increase the Risk of Errors

As the IOM acknowledges, "to err is human." However, research has shown that certain factors can increase the error rate (Reason, 1990), such as:

  • Fatigue - Working a double shift, for example, can increase the likelihood of errors. Medical residents on call for 36 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, nurses, and other health 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 - Nurses 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 - Doctors' 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.

Focusing on the multi-causal nature of errors does not alter the role of individual accountability for safe practice. In fact, the National Council of State Boards of Nursing has testified as follows:

"Both systems liability for mistakes and individual accountability are important to protect the public. Absent individual accountability standards, practitioners who leave organizations after serious errors occur and are employed elsewhere will never receive necessary remediation or education to address human factors, thus compromising the safety of the patient." (Ridenour, 2000)

Populations of Special Vulnerability

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 health care team, most commonly related to communication issues. Nurses 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 for medication errors, which can have life-threatening or even fatal effects, due to the declining ability of the aging body to metabolize drugs. Visual, hearing or cognitive problems may lead to misunderstanding of instructions or failure to question an incorrect or unfamiliar drug. When caring for older patients, communication with a responsible family member or other patient advocate is essential.

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. Florida Nursing CEUs in Prevention of Medical Errors. Automatic CE Broker Reporting. Board Approved Course for Nurses.

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 pharmacists often must dilute stock solutions.

One research study in two urban teaching hospitals found that errors occurred in 5.7 percent of medication orders during the care of 1,120 pediatric patients admitted during 1999 (Kaushal, et al, 2001). In addition, the rate of potential adverse drug events - close calls/near misses - was three times the rate of potential ADEs found in a similar study of hospitalized adults.

The researchers noted that physicians at both hospitals handwrote medication orders, copies of which were sent to the pharmacy. According to the researchers, computerized medication order entry and decision support (with automatic checks on patient drug allergies, drug dosage, and drug-drug interaction) could have prevented 93 percent of potential ADEs, as could the participation of ward-based clinical pharmacists in ward rounds. Nearly 80 percent of potential ADEs occurred in drug ordering, and 34 percent involved incorrect dosing.

Infants and young children do not have the communication abilities needed to alert clinicians about potential drug errors or 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.

Persons with Limited English Language Skills and/or Limited 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 non-English speaking patients. 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 nurses caring for patients from 23 different cultural groups can be found in Culture and Nursing Care: A Pocket Guide (Lipson, Dibble, and Minarik, 1996). Each chapter outlines issues related to health and illness, symptom expression, self-care, birth, death, religion, family participation in care, and other topics.

When caring for patients whose verbal abilities are limited either by education, development, or neurological impairment, assistive devices such as an alphabet board, a picture board or 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 (Adkins, 1991).

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 in Box 2.

Box 2: Risk Factors for Falls

  • Age 65 or over
  • History of falling
  • Impaired mobility or difficulty walking
  • Need for assistance in getting out of bed or transferring to and from a 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, anti-depressants, tranquilizers.

Reporting Errors

Improving patient safety begins with prompt reporting of errors followed by analysis of the root causes and contributing factors and developing a plan of action to prevent similar errors in the future. Only in this way can a health care organization assess the safety of care delivered and 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. 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 10 to 20 fold (Leape, 2000).

Joint Commission on Accreditation of Healthcare Organizations

Each accredited healthcare organization must have two systems in place for reporting errors: an internal system and an external system. The Joint

Joint Commission on Accreditation of Healthcare Organizations, 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.

JCAHO 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. Reportable JCAHO sentinel events are summarized in Box 3.

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:

Box 3: JCAHO Reportable Sentinel Events

  • Suicides
  • Infant abduction or discharge to the wrong family
  • Rape
  • Transfusion reaction
  • Surgery on the wrong body part

Accredited facilities are to report not only actual sentinel events but potential sentinel events, the close calls/near misses that afford valuable learning opportunities for prevention of future errors. JCAHO also encourages facilities to submit the findings of their root cause analyses and corrective action plans. This information can be included in JCAHO's review of sentinel events, helping track national trends and develop strategies for improving patient safety.

Since 1995, JCAHO has reviewed 1,609 sentinel events. Of these, the most common are patient suicide (16.7percent), operative/postoperative complications (12.2 percent), medication errors (11.4 percent), and wrong-site surgery (11.3 percent).

JCAHO published an online newsletter, Sentinel Event Alert, which identifies specific sentinel events, describes their common underlying causes and suggests actions to prevent these occurrences. Accredited organizations are expected to:

  • Review and consider relevant information, if appropriate to the organization's services, from each Sentinel Event Alert.
  • Consider information in an alert when designing or redesigning relevant processes.
  • Evaluate systems in light of information in an alert.
  • Consider standard-specific concerns.
  • Implement relevant suggestions or reasonable alternatives or provide a reasonable explanation for not implementing relevant changes

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 implement a risk-management program with state oversight and an internal incident-reporting system. State oversight is provided by the Florida Agency for Health Care 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 health care 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:

(a) 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 neurological, 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;

(b) 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;

(c) 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; or

(d) Was a procedure to remove unplanned foreign objects remaining from a surgical procedure."

The risk-management reporting system must:

  • Investigate and analyze the frequency and causes of adverse incidents to patients
  • Educate facility staff and agents
  • 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 3 days after the event occurred. Following receipt of the report, the risk manager in turn must report the event to the Florida Agency for Health Care Administration (AHCA). Certain adverse incidents (sentinel events), referred to as Code 24 events, must be reported to AHCA within 24 hours of the occurrence (See Box 4).

Box 4: Code 24 Sentinel Events

Report to AHCA within 24 hours of occurrence:

  • Death of a patient
  • Brain or spinal damage to a patient
  • Performance of a surgical procedure on the wrong patient
  • Performance of a wrong-site surgical procedure
  • Performance of a wrong surgical procedure

In addition to their internal reporting system, Florida hospitals and ambulatory surgical centers also must submit to the Florida Agency for Health Care Administration (ACHA) an annual report of all adverse incidents and malpractice actions (new, pending, and closed). They are also required to report any injuries of which they are aware that occur through any health care service, including nursing homes, home health organizations, doctors' offices, dentists' offices, or any other purveyor of health care service. Florida Statute 641.55 requires similar reporting of patient injury incidents by HMOs.

Three types of reports are required by ACHA:

  • The Annual Report, which includes all adverse incidents that occur in the facility in the course of a calendar year. These reports are due after the first of each year for the previous year.
  • 24-Hour Urgent Issue Report, a preliminary report of serious patient injuries of a more complicated nature, within 24 hours of the occurrence of the injury. (See Box 4)
  • 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.

Moving Beyond Blame: Improving Patient Outcomes

"The medical imperative is clear: to make health care safe we need to redesign our systems to make errors difficult to commit, and create a culture in which the existence of risk is acknowledged and injury prevention is recognized as everyone's responsibility." (Leape et al, 1998)

Root Cause Analysis (RCA)

JCAHO requires that a thorough, credible root cause analysis (RCA) be performed for each reported sentinel event. The goal of a Root Cause Analysis is to find out:

  • What happened
  • Why did it happen
  • What do you do to prevent it from happening again

VA National Center for Patient Safety

Root Cause Analysis (RCA) is a tool for identifying error prevention strategies. It is a process for discovering basic and contributing causes of error with the continuing goal of preventing recurrence.

RCA is an interdisciplinary process involving:

  • Experts from all services involved
  • Those who are the most familiar with the situation
  • Asking why at each level of cause and effect
  • Identification of changes needed
  • As great a degree of impartiality as possibility

According to the VA National Center for Patient Safety (2002), a thorough RCA must include:

  • Determination of human and other factors
  • Determination of related processes and systems
  • Analysis of underlying cause and effect systems through a series of WHY questions
  • Identification of risks and their potential contributions*
  • Determination of potential improvement in processes or systems

One step in the RCA of both actual adverse events and close calls is determining the Safety Assessment Code (SAC) score of the event. The Severity and Probability Categories and the SAC Matrix are shown in Figure 3. (VHA Handbook 1050.1, Appendix D-1 and D-2).

A credible RCA must:

  • Include participation by the leadership of the organization and those most closely involved in the processes and systems.
  • Be internally consistent.
  • Include consideration of relevant literature.

In July 2001, the Agency for Healthcare Research and Quality released a report outlining evidenced-based clinical recommendations for improving patient safety. Titled "Making Health Care Safer: A Critical Analysis of Patient Safety Practices," the report reviews 79 practices to prevent adverse events and improve patient safety, based on current research. The 11 most highly rated practices are listed in Box 5. The authors of this report emphasized that this list should not be considered complete, and that it was weighted toward care of the very ill, rather than the mildly or chronically ill. Other measures to improve patient safety are summarized in Box 1.

A complete summary of the AHRQ report is available at http://www.ahrq.gov/clinic/ptsafety/summary.htm  - required reading

Box 5 - Clinical Opportunities for Safety Improvement

  1. Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk.
  2. Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality.
  3. Use of maximum sterile barriers while placing central intravenous catheters to prevent infections.
  4. Appropriate use of antibiotic prophylaxis in surgical patients to prevent perioperative infections.
  5. Asking that patients recall and restate what they have been told during the informed consent process.
  6. Continuous aspiration of subglottic secretions (CASS) to prevent ventilator-associated pneumonia.
  7. Use of pressure relieving bedding materials to prevent pressure ulcers.
  8. Use of real-time ultrasound guidance during central line insertion to prevent complications.
  9. Patient self-management for warfarin (Coumadin™) to achieve appropriate outpatient anticoagulation and prevent complications.
  10. Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients.
  11. Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections.

In July 2002, The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) issued new mandatory goals and recommendations to improve patient safety, to take effect in January 2003. Hospitals and other organizations will be evaluated by accreditation representatives to see whether these recommendations or acceptable alternative measures are being implemented. Failure to implement the recommendations could result in loss of accreditation and federal funding. The 2003 National Patient Safety Goals and Recommendations are summarized in Box 6.

Box 6. 2003 National Patient Safety Goals and Recommendations

  • 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 taking blood samples or administering medications or blood products.
  • Prior to the start of any surgical or invasive procedure, conduct a final verification process, such as a "time out," to confirm the correct patient, procedure, and site, using active - not passive - communication techniques
  • Goal 2. Improve the effectiveness of communication among caregivers.
  • Recommendations:
  • Implement a process for taking verbal or telephone orders that requires a verification "read-back" of the complete order by the person receiving the order.
  • Standardize the abbreviations, acronyms and symbols used throughout the organization, including a list of abbreviations, acronyms and symbols not to use.
  • Goal 3. Improve the safety of using high-alert medications.
  • Recommendations:
  • Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >.9%) from patient care units.
  • Standardize and lmit the number of drug concentrations available in the organization.
  • Goal 4. Eliminate wrong-site, wrong-patient and wrong-procedure surgery.
  • Recommendations:
  • Create and use a preoperative verification process, such as a checklist, to confirm that appropriate documents (e.g., medical records, imaging studies) are available.
  • Implement a process to mark the surgical site and involve the patient in the marking process.
  • Goal 5. Improve the safety of using infusion pumps.
  • Recommendations:
  • Ensure-free-flow protection on all general-use and PCA intravenous infusion pumps used in the organization.
  • Goal 6. Improve the effectiveness of clinical alarm systems.
  • Recommendations:
  • Implement regular preventive maintenance and testing of alarm systems.
  • Assure that alarms are activated with appropriate settings and are sufficiently audible with respect to distances and competing noise within the unit.

References

Making Health Care Safer: A Critical Analysis of Patient Safety Practices July 2001. Agency for Healthcare Research and QualitySource:

Joint Commission on the Accreditation of Healthcare Organizations.

U.S. Department of Health and Human Services; Agency for Health Care Research and Quality

Prevention of Medical Errors

 

 

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