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Author: Julia Tortorice (RN, MBA, MSN, NEA-BC, CPHQ)

Overview

Makary and Daniel (2016) identify a medical error as "an unintended act or one that does not achieve its intended outcome, the failure of a planned action to be completed as intended, the use of a wrong plan to achieve an aim, or a deviation from the process of care that may or may not cause harm to the patient."

Medical errors increase expenses in additional patient care and possible litigation costs. Serious medical errors are devastating to the patient, family, and staff. The severe consequences of medical errors are one reason that healthcare is a highly regulated business. All healthcare organizations must be licensed. They also must meet industry standards, building and safety codes, and federal and state statutes.

Healthcare organizations are subject to inspection for compliance with statutes, regulations, and industry standards. Inspections can be scheduled or unscheduled. Scheduled inspections are conducted periodically. Unscheduled inspections can be conducted randomly or conducted for cause, like a patient complaint. One of the most well-known inspection agencies for hospitals is The Joint Commission (TJC). It is an independent organization, meaning that TJC is neither a government agency nor a financial interest in any healthcare organization. If a healthcare organization meets industry standards, TJC accredits that organization for a certain time.

Over the last twenty years, medical errors continue to be a major cause of death in the US. Error reporting is low. When errors are reported, corrective actions are not taken(Anderson & Abrahamson, 2017).

Barriers to reducing medical errors are (Anderson & Abrahamson, 2017):

Information technology to reduce errors is expensive
Healthcare reimbursement does not incentivize facilities and practitioners to invest in patient safety

Table 1: Use of artificial intelligence (AI) to reduce errors (Tremblay, 2020 P 27)
Source Error	How AI can Reduce Errors
Patient experience: Patient fails to convince the provider something is wrong Parents struggle to convince the provider that something is wrong with the child Patient offers an imprecise description of symptoms (vague, generalized) Patient expresses frustration Patient appears doubtful Patient says, "I am feeling different”	Reduce early clinical confusion with AI-enabled tools that prompt the provider to continue questioning or by red-flag symptoms constellations Enable better patient/provider communication and avoid premature diagnostic closure from poor communication through an SI-enabled ambient "listening" (think Alexa-type systems) to detect patterns in patient's use of language and act like a "translation system"
Error in clinical work: Provider takes a poor history Provider does not put symptoms together (poor pattern recognition, lack of familiarity) Provider exhibits poor clinical reasoning Provider thinks the patient looks well and takes no action Provider labels patient as time-consuming Provider uses gender-inappropriate reasoning Provider wrongly correlates symptoms to menopause Provider uses age-related stereotyping Provider labels patient as somatizing The patient lacks classic symptoms Provider is afraid of making an unusual diagnosis (zebra retreat)	AI can act as a "digital second opinion" supporting improved clinical confidence Improved identification of difficult to diagnose conditions, e.g., rare diseases, using AI decision-support tools to reduce clinical confusion concerning mimics, for instance Use computational models of diseases to create clinical patterns and reorder key diagnostic signs and symptoms to predict the correct diagnosis better Predictive case finding of potentially at-risk individuals without the cost of population screening or inappropriate testing Improved guidelines reflecting greater precision in patient identification to reduce diagnostic uncertainty and treatment risk
Errors in Healthcare System: Patient receives treatment but does not get better Patient experiences many clinical encounters with same or different clinicians, therapists, facilities There is no defined clinical pathway, no guidelines, no referral guidelines There is a long journey (in time) to correct diagnosis ("odyssey") Care processes are time-consuming, workflow structure and process overcomplex and tedious (many steps, many people, many facilities) Financial incentives have perverse or inappropriate consequences on organizational behaviors	Realization of "precision medicine" as the reduction intolerance for errors and improvement in diagnostic precision, using computational models to align or optimize treatment and track patient experience across the care system AI models to optimize treatment by matching therapy to a patient, e.g., matching tumor type to a patient to medicines AI-enabled decision-support tools with decision prompts and red flags and computationally enhanced referral criteria to reduce inappropriate referrals to specialists AI enables optimization of the treatment pathway and enhances the ability to anticipate future healthcare resource utilization, e.g., probability of readmission following hospital discharge

Competency

Healthcare organizations must determine an individual's qualifications and ability to do the job. This determination involves checking an individual's education, license, experience, and credentials before hiring an employee. At least annually, staff performance is evaluated. Continued competency, current licensure, and continuing education should also be checked at least once a year. This process is called credentialing and privileging for licensed independent practitioners, such as physicians and nurse practitioners. It should be a high priority for healthcare professionals to ensure that competence is retained to prevent medical errors.

Performance Improvement (PI)

Healthcare organizations have ongoing programs to identify, correct, and prevent medical errors. PI is a way to systematically monitor, analyze, and improve an organization's performance and outcomes. PI should improve an organization's performance by reducing factors that contribute to unanticipated adverse events and outcomes. Unanticipated adverse events and outcomes can be caused by poorly designed systems, system failures, or errors. Decreasing unanticipated adverse events and outcomes requires an environment where patients, families, staff, and leaders can identify and manage safety risks. Such an environment encourages the following:

Recognizing and acknowledging risks and unanticipated adverse events
Initiating actions to reduce these risks and unanticipated adverse events
Reporting internally on risk reduction initiatives and their effectiveness
Focusing on processes and systems, with continuous monitoring of their effectiveness
Minimizing individual blame or retribution for involvement in an unanticipated adverse event
Investigating factors that contribute to unanticipated adverse events and sharing that acquired knowledge both internally and with other hospitals

The following are other concepts related to PI:

Continuous Quality Improvement (CQI) is an approach that ensures that organizations always look for ways to improve processes and practices.
Total Quality Management (TQM) is a management system that encompasses quality planning, quality control, and quality improvement.
Six Sigma, lean management, and change management are performance improvement methodologies that have a systematic approach to dissecting complex safety problems and implementing effective solutions.

These programs are slightly different from PI, but these terms may be used interchangeably.

High Reliability

High Reliability is an ongoing quality improvement process used in highly technical industries with high risk. The concept of high reliability involves a safety culture of collective mindfulness in which all employees are acutely aware that even small failures in safety protocols or processes can lead to catastrophic adverse outcomes. Therefore, everyone in these organizations is always searching for the smallest indication that the environment or a key safety process has changed somehow, which might lead to failure. Once a deficiency is identified, it is eliminated by improving the processes. There are three requirements for achieving high reliability:

Leadership
Safety Culture
Robust Process Improvement

Quality Control

Quality Control (QC) is an ongoing, systematic measurement to determine compliance and accuracy. It is required for some equipment or measurement tests. Examples are checking the high and low control limits on a glucometer or the medication refrigerator's temperature. QC is often a component of or is mentioned with PI.

Risk Management

Risk Management (RM) is a program focused on eliminating or minimizing the effects of accidental losses on an organization. RM works closely with and sometimes overlaps functions with PI. Risk Managers are involved with risk financing through insurance companies to minimize financial losses. They usually investigate serious medical errors, institute damage control, and consult with legal counsel as needed.

Incident reports are an important source of information for a Risk Manager. Aggregate data from incident reports are statistically analyzed to identify areas of risk and exposure. Risk control techniques are then applied to those areas of focus. The usual techniques are avoidance, transfer, prevention, reduction, segregation, and duplication.

Avoidance is a technique that eliminates the possibility of a loss. This technique is also known as a forcing function. This technique involves designing equipment or processes to make it impossible to misuse it. Examples are stocking only one concentration of medication or removing concentrated Potassium Chloride from floor stock. These functions are effective but can be inconvenient and time-consuming for personnel.

The transfer is the process of negotiating with insurance companies to transfer the financial burden of a loss. This technique assumes that the loss cannot be prevented, so we must be insured against those times when it happens.

Loss prevention reduces the probability or frequency of a loss but does not eliminate the chance of loss, nor does it reduce that loss's severity. This prevention is also known as a constraint function, meaning that equipment or a process is designed to make it difficult to use it incorrectly. Examples are limiting floor stock or a policy limiting verbal orders. Constraints can help prevent errors that might be made by less experienced or distracted personnel.

Loss reduction focuses on reducing the severity of the damage. For example, frequent monitoring instituted for conscious sedation procedures does not reduce the sedation's risk of being too deep. However, it allows early intervention to reverse the sedation and provide adequate oxygenation.

Segregation means that a process is separated from the rest of a clinical setting to reduce or eliminate errors. For example, changing the medication administration system so the pharmacist fills the order and administers it to a patient. This change eliminates the potential error at the point the pharmacy usually hands off the medication to nursing. However, as with most segregation techniques, it is too expensive and impractical.

Duplication means that there is a backup. For example, cross-training employees so that someone is available to perform a job when the person who typically performs that job is unexpectedly unavailable.

Sentinel Events

TJC uses the term sentinel event to describe patient safety events that result in death, severe harm, or permanent harm. These events require an immediate response to ensure they do not reoccur. The appropriate response includes conducting a timely and thorough investigation, implementing improvements to reduce risk, and monitoring the improvements' effectiveness. Healthcare organizations are encouraged to report sentinel events to TJC. The information from these reports is evaluated and published in the Sentinel Event Alert. It includes aggregate data, specific examples, and strategies for prevention. The Sentinel Event Alert is available on the Internet here.

Root Cause Analysis

TJC requires the use of root cause analysis (RCA) to investigate the processes and systems that contribute to a sentinel event. RCA is a tool that helps identify and clarify the bottom-line factors that precipitate an error or near miss. An organization can use this template to conduct a root cause analysis or even as a worksheet in preparation for submitting an analysis through the online form on Joint Commission Connect.

RCA focuses on systems and processes, not on individual performance. The RCA process repeatedly digs deeper into an issue by asking "Why" questions until no additional logical answers can be identified. A team of people representing the areas involved in an event is brought together to do this analysis. There are multiple methods to conduct an RCA; however, TJC recommends a form available at Framework for Root Cause Analysis and Corrective Actions.

RCA has a limitation, which is known as the blinder effect. That is the team's tendency to look only at one part of the process that led to the event instead of the entire process.

Human Error

By nature, humans are fallible. It is unreasonable to expect an error-free performance by humans. Human beings have limited mental and information-processing capabilities. Excessive levels of stress or fatigue harm performance.

Every day we all face thousands of interactions with machines, systems, and each other. The vast majority of those interactions go smoothly and unnoticed. A few interactions that force us to work outside of routine and intuition are simple annoyances with which we have learned to live. Occasionally, one of those interactions leads to an unintended result, an error. While humans can rapidly adapt to impediments blocking their path and develop compensatory workarounds, these short-term solutions often introduce new risks. Human factors science offers a better understanding of the causes of errors, the workarounds already in place, and solutions that are less likely to have unintended negative consequences.

Human error has been implicated in 60 to 80 percent of accidents that occur in complex systems. Accidents due solely to environmental and mechanical factors have been significantly reduced over the last several years; however, those attributable to human error continue to be a problem.

Healthcare has traditionally regarded error as a moral failing. This belief places an unsustainable burden of perfection on clinicians. This attitude impedes efforts to identify errors, frequency, effects, and how to protect patients best.

Solutions reached by trial and error, or workarounds, might simply shift the risk elsewhere. While "fixed by common sense" may often be sufficient, common sense can also benefit science and engineering.

Human factors science discovers and applies information about human behavior, abilities, limitations, and other characteristics to design tools, machines, systems, tasks, jobs, and environments for productive, safe, comfortable, and effective human use. Human factors science is not just applying checklists and guidelines, not just using oneself as the model for designing things, and it is not common sense.

Human Factors Engineering

Human factors engineering uses systems analysis. Humans are considered a critical system component. Human factors analysis focuses on human operators to determine what they are required to do. It combines the scientific methodology familiar to clinicians to explore the causes of error with an engineering approach of task analysis. Human factors analysis goes further than Root Cause Analysis (RCA). This methodology includes:

Systematic observation of procedures
Interviews and focus groups
Activity recording and charting
Analysis of fatigue and distraction factors
Analysis of information flow
Developing and testing models of expected effectiveness

The Reason's(2019) model of human error is based on the premise that adverse outcomes result from a combination of systemic issues such as resource availability, organizational policies and procedures, and human functional errors. Reason's model is called the Swiss cheese model because every layer of defense against errors has holes; the more layers, the smaller the risk of causing harm. There is less chance of the holes lining up to allow an error to occur.

Image 1: Reason's Swiss Cheese Model

reasons_swiss_cheese_model

Reason's Model Inputs (Reason, 2019)

Culture & Leadership
- Staff shortages
Technical Support
- Inexperienced team member
Training
- Failed to monitor vital signs
Clinical Support
- Poor team

Reason (2019) said that the human condition could not be changed. However, work conditions can be changed. Applying Reason’s model makes it easier to understand that errors reflect problems at the practical and systemic levels. A safe reporting system is used to ensure that system integrity is monitored.

The Cognitive Process

The human cognitive process is how we remember, think, develop, and use motor skills to perform activities individually, in teams, and within organizational systems. Perception equals input: information is perceived through the sensory system. A person cannot take in sensory information with distracted or blurred perception (insufficient light, ambient noise, etc.) and be more prone to misread a label or mishear spoken words.

Long-term memory: information acquired through education and experience is stored in long-term memory. When long-term memory experiences interference (e.g., distraction, multitasking), there is difficulty retrieving and applying previously learned information. Working memory: information from the sensory fields (perception) and long-term memory combine to do the work we label "thinking." Thinking combines sensory input with stored knowledge to call up frequently used patterns and criteria developed through common use to make decisions. When overloaded with physical or emotional demands, there is an increased risk of making incorrect judgments based on confusion or incorrectly applying learned rules.

Impact of Design

The impact of design on human factors has four different types of interactions and a wide variety of applications. The science applies an understanding of physical, cultural, and psychological factors to reduce flawed behavior.

Interaction with machines and objects is the most studied area of human factors problems. Most human errors related to human/machine interactions are either the operator's condition or training, bad design of the machine interface, or both. A bad design is one that does not conform to intuitive application. Design flaws can lead to the incorrect use of equipment. Speed, stress, and fatigue increase the likelihood that bad design will lead to error.

Negative impacts on the work environment exist even with the best-designed objects and machines. Human factors problems are encountered stemming from the physical world around us. Physical space, layout, temperature, light, air quality, noise levels, and visual distractions can all interfere with or alter the ability to perform an activity. When these factors become obstacles, they can manifest as inconveniencies or can be harmful. Fatigue from loss of sleep, circadian rhythm changes, and muscular effort expenditure has been identified as one of the major contributors to errors.

As creatures of habit, humans often seek to "workaround" a new system to maintain an old mindset. For example, matching barcodes were encoded on adjoining components to help technicians correctly assemble devices with multiple components. By swiping each piece, a correct assembly was assured. However, reviewers discovered that the procedure was frustrating for some users who, as a workaround, put matching copies of the barcoding on a paper and scanned the paper instead of the equipment pieces, enabling incorrect assembly. Nurses, too, have found that it is easier to scan the patient label from the medication administration sheet rather than taking the medication cart with a scanner to the patient's bedside to scan the patient identification band on the patient's wrist.

When a system problem is solved in isolation and without considering how it might affect the rest of the system, unintended consequences can undo the fix's benefit. An example of this is an automatic forcing function programmed into a hospital medication system to prevent potassium's over-administration. This change inadvertently prevented the administration of high doses when they were needed. A solution can exacerbate existing minor problems or create new opportunities for errors. This change is an unintended consequence. Piloting and field-testing solutions help identify these "downstream consequences."

Human factors problems related to the practice environment tend to be more transient than design problems. Lighting, noise, temperature, even physical space can change from one patient encounter to the next. If the healthcare provider works in multiple practice settings, the opportunity for environmentally-related problems is equally multiplied. Other issues may include things like:

Equipment models or brands vary
Equipment storage is too high
Equipment is not conveniently located
Equipment is not located in a consistent place
Environment is not set up to allow effective eye contact and discussion

Interactions with Others

In various clinical services, care is provided by changing providers over various timeframes and supported by many administrative personnel. Each person acts in their capacity to attend to the patient's needs through their professional and personal lens of a mental model. Inadequate communication can lead to the misalignment of mental models. Interactions among teams and entire systems of healthcare providers are an important area of human factors study. Handoffs, passing on information or responsibility are a particular patient safety problem areas.

Mental models are deeply ingrained assumptions, generalizations, or even pictures/images that influence how we understand the world and how we act. When two people have different mental models of the same situation or process, they are at risk of misinterpreting each other's directions or intentions.

Teams of people working together need to share a common understanding of what needs to be done and how; for example, the same mental model. Teams need efficient communication that is remembered at least long enough for the recipient to take proper action.

Applying Human Factors Science to Healthcare

Human factors apply wherever humans work. In healthcare, work environments are hazardous. Instruments are potential weapons; drugs are a potential poison, and every worker is a potential killer. The following are human factors problem areas in healthcare:

Equipment changes and upgrades when training is inadequate
Hand-off, when there is poor communication
Infusion pumps when there is poor human interface
Fatigue
Labeling when items look alike and sound alike
Handling Sharps
Retained foreign bodies in surgery
Patient bed alarms when there are false alarms and falls
Physician order entry when orders are illegible, verbal orders are misunderstood, or there are transcription errors
Wrong-site surgery

Accept human factors problems as inevitable, although manageable, part of everyday practice. Shift from a punitive to a creative frame of mind that seeks out and identifies the underlying system failures. Efficient, routine identification of human factors needs to be part of every practice and routine investigation of all human factors problems that cause injuries.

Not all design flaws in healthcare environments are obvious hazards. One of the most subtle mistakes is a failure to realize that the best-motivated and most highly trained professionals are potentially lethal agents. Fatigue management in healthcare is a big challenge. Fatigue resulting from an inadequate amount of sleep or insufficient quality of sleep over an extended period can lead to several problems, including:

Lapses in attention and inability to stay focused
Reduced motivation
Compromised problem solving
Confusion
Irritability
Memory lapses
Impaired communication
Slowed or faulty information processing and judgment
Diminished reaction time
Indifference and loss of empathy

Contributing factors to fatigue and risks to patients include:

Shift length
Work schedule
Quantity and quality of sleep

Recommended actions:

Assess the organization for fatigue-related risks. This assessment includes looking at off-shift hours and consecutive shift work and reviewing staffing and other relevant policies to ensure they address extended work shifts and hours. Invite staff to input into designing work schedules to minimize the potential for fatigue.

Since patient hand-off is a time of high risk – especially for tired staff – assess the organization's hand-off processes and procedures to ensure that they adequately protect patients.

Create and implement a fatigue management plan that includes scientific strategies for fighting fatigue. These strategies can include: engaging in conversations with others (not just listening and nodding); doing something that involves physical action (even if it is just stretching); strategic caffeine consumption (do not use caffeine when you are already alert and avoid caffeine near bedtime); taking short naps (less than 45 minutes).

Educate staff about sleep hygiene and the effects of fatigue on patient safety. Sleep hygiene includes getting enough sleep and taking naps, practicing good sleep habits (for example, engaging in a relaxing pre-sleep routine, such as yoga or reading), and avoiding food, alcohol, or stimulants (such as caffeine) can impact sleep.

Psychological Human Factors

Everyone needs some stress; otherwise, life would be dull and unexciting. Good stress is also known as "eustress." Stress adds flavor, challenge, and opportunity to life. It has also been said that stress is a good motivator, but working when over-stressed, irritated, upset, or shaken will substantially alter one's judgment and can compromise patient safety. Too much stress can seriously affect physical and mental well-being and becomes known as "distress." The angry healthcare provider is aggressive, offensive, and careless, and as a result, is dangerous. Stressful conditions involving personal or business life will cause distractions that can interfere with the provision of safe patient care. They should be recognized and addressed as negative influences on workplace habits.

The clinician should evaluate his or her state of mind before providing patient care, such as medication administration. Providing patient care takes a clear and focused mind, uncluttered by thoughts of aggravation and distress. As mentioned earlier, the healthcare provider with a wandering mind caused by any one of the effects has a decreased awareness of the subtle changes in patient status, a slower reaction time, and an overall lack of concentration. The ability to anticipate complications and to determine appropriate responses is also adversely affected. A major challenge in today's stress-filled world is using stress positively and preventing it from becoming distressed.

The emotionally distressed healthcare provider is more apt to make a medical error than is the rested, clear-headed provider. It should be made clear that tired, disturbed, or cluttered minds decreases critical thinking ability. When disturbed by emotions, the healthcare provider does not concentrate on what they are doing; they concentrate on what has them upset. This distraction could manifest in increased risk-taking behavior such as taking shortcuts, failing to follow policy, and not paying attention to the details. Unsafe behaviors can contribute to an increased risk of medical error.

With severe emotional distress, an individual could turn to substance use or abuse to hide emotional pain. Combined with heavy workloads, this increases the likelihood of error. With the increased risk-taking behavior, aggression could result. The clinician is then labeled as "difficult to work with." Unchecked emotions can lead to aggressive behavior and disciplinary action. The emotionally distressed mind cannot function rationally, or critical thinking is required to provide safe patient care. Managers need to recognize emotionally distressed clinicians.

Standards of practice and hospital policies are instituted and established for patient safety. A policy may not specifically cover special situations, but most clinicians agree that policies and practice standards are needed. The unsupervised and uncontrolled practice would lead to chaos. Some healthcare providers despise the increase in the number of "rules." They stress the negative side of policies rather than the goal of increased patient safety. It must be understood that policies and standards of care can benefit them and be supported and followed.

Healthcare providers should be aware that circumstances and attitude changes could dramatically affect practice habits. Some attitudes that predispose to risk-taking behavior and increase the risk of errors are:

Enjoying the thrill of crises
Enjoying impressing coworkers
Disregarding personal safety
The illusion of control or overestimating abilities
Justifying risks because they are taken in a noble cause

Design work to minimize the requirements for particularly fallible human functions such as short-term memory and tasks requiring prolonged attention. For instance, do not rely on memory to retrieve a laboratory test result or when a medication is due. Systemizing these tasks reduce memory-related errors.

Reduce reliance on memory for high-risk procedures or multi-step processes by using checklists. Review the checklists to ensure appropriateness and avoid increasing errors through workarounds that make more errors. While surgical areas generally use preoperative checklists already, it may be wise to use checklists in handoff situations couple brief, useful protocols with procedures developed by the healthcare teams who provide the services. Standardize color match items used together to prevent slips, such as clinicians combining items that should not be used together. Pre-package component items into kits.

As the volume of information increases, there is a need for creative ways to make it more readily available, displaying it where clinicians need it when needed. Making information available at the point of care will make a significant impact on error reduction. Many medication-related claims result from clinicians making decisions about treatment without having all of the appropriate information available. Create forms to promote accurate documentation and electronic ticklers for tracking test results. Block avenues to workarounds that cut out the important transmission of information.

Complexity increases the opportunity for errors. Where possible, critical tasks should be structured so that errors cannot be made. A system's reliability can be improved by perfecting its parts and handoffs, but reducing complexity is even more powerful.

Disruptive Behavior

Intimidating and disruptive behaviors foster medical errors. When these behaviors are left unchecked, it can lead to increased turnover, interfere with communication, and interfere with teamwork. Intimidating behaviors can cause a hostile work environment, and numerous errors can occur under these distressful conditions.

Most healthcare providers have experienced or witnessed intimidating or disruptive behaviors. Intimidating and disruptive behaviors include active and passive behavior, such as:

Verbal outbursts
Physical threats
Refusing to perform assigned tasks
Quietly exhibiting uncooperative attitudes during routine activities

When manifested by healthcare professionals in positions of power, these behaviors include:

Reluctance or refusal to communicate (i.e., answer questions, return phone calls or pages)
Condescending language or voice intonation
Impatience with questions

Disruptive behaviors are often not addressed because the behavior is not reported. Disruptive behaviors may go unreported due to a fear of retaliation, the stigma of whistleblowing, and reluctance to confront an intimidator.

Medical Record Documentation

Documentation in the patient chart provides a means by which health professionals can communicate information to each other. Notes on what each health professional observes and how they respond with interventions, or the formations of care plans, are entered into this repository of information centered upon the patient.

Healthcare facilities are tasked by organizations such as The Joint Commission (TJC) or the Centers for Medicare and Medicaid Services (CMS) to effectively manage health information collection using uniform data sets and policies that guide record creation and handling. While the health record components may differ somewhat in each facility, certain minimum standards are expected for both paper and electronic documentation systems (TJC, 2018).

Table 2: Documentation Do's & Don'ts (AHIMA, 2018)
Documentation Do's	Documentation Don'ts
Be timely with chart notes Be accurate with information Be complete in what you write Be legible Be objective and provide facts Be clear about pertinent negative findings Be observant to report unusual interactions between patients and others Be correct in spelling, grammar, and use of approved abbreviations Be sure patient identifying information is on each page of the written chart	Avoid criticism Avoid erasing or obliterating unwanted chart entries Avoid gaps in your written notes Avoid sarcasm, slurs, use of humor, and profanity Avoid concluding – give the facts instead Avoid removing parts of the chart to work on elsewhere Avoid asking others to document for you Avoid documenting for others Avoid mentioning incident reports within the patient chart

Progress notes are essential medical records based on the nursing profession process: assessment, nursing diagnosis, planning with goal setting, implementation/ interventions, and evaluation. Progress notes serve to:

Establish a communicated baseline
Record relevant data at regular intervals
Provide snap-shot summaries of a patient's condition
Document changes in condition
Document response, or lack of response, to treatment

Each care setting tends to specify the patient data format or chart note style they prefer for progress notes. Follow the facility's documentation policies. There are many charting styles currently available. Each notation format has advantages as well as disadvantages. Some have been around for a long time, while others are rather new. Many institutions blend format systems to get just the right record-keeping style that works for their unique needs. Whichever style is used, clearly communicate while avoiding potential legal problems. Careful forethought and practice using a charting strategy will lead to consistently clear and legally defensible documentation.

Medication Errors

Nurses are most likely to be blamed for medication errors because they are involved at the administration point. However, medication errors are complex and are rarely the result of one person's actions. The medication system in hospitals is complicated. There are multiple steps and many individuals involved. Every time a document or medication changes hands, there is an increased potential for error.

Administering medication is a crucial nursing responsibility. To ensure safe and effective drug therapy, the nurse must be familiar with indications, usual dosages, and the drugs' intended effects. Remember the five rights: right patient, right drug, right dose, right route, and the right time. Each patient must be assessed before administration, and the medication should be delayed or withheld if indicated.

Nurses' medication error interception practices are associated with lower rates of medication errors. One study defines these interceptive practices as:

Independent comparisons between the medication administration record and patient record at the beginning of a nurse's shift
Determining the rationale for each ordered medication
Requesting that physicians rewrite orders when improper abbreviations are used
Ensuring that patients and families are knowledgeable regarding the medication regimen so that they can question unexplained variances

The types of medication errors include prescribing, omission, wrong time, unauthorized drugs, improper doses, wrong drug preparation, wrong administration techniques, deteriorated drugs, improper monitoring and compliance, product errors, process errors, and human errors. Particularly error-prone areas are:

Verbal orders
Handwritten orders
High-alert drugs
Infusion pump errors
Confusing drugs names

Handwritten and manually transcribed physician orders leave much opportunity for errors. A computerized physician order entry, where the physician must enter all computer orders, eliminates handwriting and transcription errors. It also makes it possible to automatically check doses, drug-drug interactions, allergies, and significant patient characteristics, like allergies and impaired renal function.

A computerized order entry system presents its own set of problems. There is a significant expense that smaller facilities may not be able to afford. Cost prohibitions or lack of space may limit the number of PCs to the point that practitioners have long wait times for computer access. It seems slow and inconvenient at times. Also, physicians who are less computer-savvy may be resistant to change. A listing and resource for confusing drug names (look alike/sound alike) can be found at the following link.

High-Alert Medications

The Institute for Safe Medication Practices (ISMP) is a nonprofit organization devoted entirely to medication error prevention and safe medication use. ISMP represents over 35 years of experience in helping healthcare practitioners keep patients safe and lead efforts to improve the medication use process (ISMP, 2018). The organization is known and respected worldwide as the premier resource for impartial, timely, and accurate medication safety information.

High-alert medications are drugs that bear a heightened risk of causing significant patient harm when used in error. Although mistakes may or may not be more common with these drugs, an error's consequences are more devastating to patients. Use this list to determine which medications require special safeguards to reduce the risk of errors and minimize harm. This error reduction may include strategies like providing mandatory patient education, improving access to information about these drugs, using auxiliary labels and automated alerts; employing automated or independent double checks when necessary; and standardizing the prescribing, storage, dispensing, and administration of these products. A list of high-alert medications is available at ISMP List of High-Alert Medications.

Drug Specific Strategies for the Prevention of Medication Errors

Insulin:

Establish a check system where one nurse prepares the dose and another nurse reviews it
Do not store insulin and heparin near each other
Spell out the word unit instead of using the abbreviation U
Build-in an independent check system for infusion pump rates and concentration settings

Opiates and Narcotics:

Limit the opiates and narcotics available in floor stock
Educate staff about hydromorphone and morphine
Implement PCA protocols that include double checks of the drug, pump settings, and dosage

Injectable Potassium Chloride (KCL) (or Phosphate):

Remove concentrated KCL from floor stock
Move the drug preparation of the units and use commercially available premixed IV solutions
Standardize and limit drug concentrations

Intravenous Anticoagulants:

Standardize concentrations and use premixed solutions
Use only single-dose containers
Seperate heparin and insulin
Remove heparin from the top of medication carts

Sodium Chloride Solutions Concentration above 0.9%:

Remove sodium chloride concentration solutions above 0.9% from nursing units
Standardize and limit drug concentrations
Double-check pump rate, drug concentration, and line attachments

Anticoagulants

The anticoagulants most commonly used and most frequently involved in medication errors are unfractionated heparin, warfarin, and enoxaparin. Contributing factors to medication error with the use of anticoagulants include:

Inadequate screening of patients for contraindications and drug interactions
Lack of standardized naming, labeling, and packaging
Keeping up with the changes to the different dosing regimens, drug interactions, and reversal agents is difficult, particularly for a practitioner who does not routinely prescribe anticoagulants
Failure to document or communicate individualized instructions and current lab results during handoffs
Pediatric administration errors because anticoagulants are formulated and packaged for adults

Risk reduction strategies (TJC, 2021e):

Patient education is vital
Use approved protocols and evidence-based practice guidelines for:
- Initiation and maintenance of anticoagulant therapy
- Reversal of anticoagulation
- Management of bleeding events related to anticoagulant
- Perioperative management of all patients on oral anticoagulants
- Need for baseline and ongoing laboratory tests to monitor and adjust anticoagulant
Establish a process to identify, respond to, and report adverse drug events
Use only oral unit-dose products, prefilled syringes, or premixed infusion bags

Pediatric Medications

Patient weight is the basis for calculating a lot of dosing of pediatric medications. Therefore, an accurate weight should be done before administering any weight-based medications, except in emergencies. The kilogram should be the standard for all pediatric weights. Pediatric patients are more prone to medication errors and more likely to be harmed by medication errors.

Most medications used in the care of children are formulated and packaged primarily for adults. Therefore, medications must be prepared in different volumes or concentrations within the health care setting before being administered to children. The need to alter the original medication dosage requires a series of pediatric-specific calculations and tasks, each significantly increasing the possibility of error.

Most healthcare settings are primarily built around the needs of adults. Many settings lack trained staff oriented to pediatric care, pediatric care protocols and safeguards, or up-to-date and easily accessible pediatric reference materials, especially concerning medications. Emergency departments may be particularly risk-prone environments for children.

Children, especially young, small, and sick children, are usually less able to tolerate a medication error physiologically due to still-developing renal, immune, and hepatic functions.

Many children, especially the very young, cannot communicate effectively with providers regarding any adverse effects that medications may be causing.

Pediatric-specific strategies for reducing medication errors:

Standardize and identify medications effectively, as well as the processes for drug administration.
Establish and maintain a functional pediatric formulary system with drug evaluation policies, selection, and therapeutic use.
To prevent timing errors in medication administration, standardize how days are counted in all protocols by deciding upon a protocol start date (e.g., Day 0 or Day 1).
Limit the number of concentrations and dose strengths of high alert medications to the minimum needed to provide safe care.
For pediatric patients who are receiving compounded oral medications and total parenteral nutrition at home, ensure that the doses are equivalent to those prepared in the hospital (i.e., the home dose volume should be the same as the volume of the hospital prepared products).
Use oral syringes to administer oral medications. The pharmacy should use oral syringes when preparing oral liquid medications. Make oral syringes available on patient care units when "as needed" medications are prepared. Educate staff about the benefits of oral syringes in preventing inadvertent intravenous administration of oral medications.

Ensure full pharmacy oversight and other appropriate staff's involvement—in the verifying, dispensing, and administering of both neonatal and pediatric medications.

Assign a practitioner trained in pediatrics to any committee that is responsible for the oversight of medication management.
Provide ready access, including website access, to up-to-date pediatric-specific information for all hospital staff. This information should include pediatric research study data, pediatric growth charts, normal vital sign ranges for children, emergency dosage calculations, and drug reference materials with information about minimum effective doses and maximum dose limits.
Orient all pharmacy staff to specialized neonatal/pediatric pharmacy services in the organization.
Provide a dosage calculation sheet for each pediatric critical care patient, including emergency and commonly used medications.
Develop preprinted medication order forms and clinical pathways or protocols to reflect a standardized approach to care. Include reminders and information about monitoring parameters.
Create pediatric satellite pharmacies or assign pharmacists and technicians with pediatric expertise to areas or services such as neonatal/pediatric critical care units and pediatric oncology units. At a minimum, pediatric medications should be stored and prepared in areas separate from those where adult medications are stored and prepared.

Use Technology Judiciously

Use methods to ensure the technology's accuracy that measures and delivers additives for intravenous solutions, such as total parenteral nutrition.
If dose and dose range checking software programs are available in hospital or pharmacy information systems, they can provide alerts for potentially incorrect doses.
Medications in automated dispensing cabinets that do not undergo appropriate pharmacist review should be limited to those needed for emergency use or to those medications under the control of a licensed independent prescriber, as specified in Joint Commission standard MM 4.10.
Recognize that the use of infusion pumps, or smart pumps, is not a guarantee against medication errors. An appropriate education for nurses, pharmacists, and other caregivers regarding these technologies is important for all institutions caring for pediatric patients.
To prevent adverse outcomes or oversedation, use consistent physiological monitoring, particularly pulse oximetry, while children are under sedation during office-based procedures. Use age and size-appropriate monitoring equipment and follow uniform procedures under the guidance of staff appropriately trained in sedation, monitoring, and resuscitation.
Providers are encouraged to develop barcoding technology with pediatric capability. Potential errors should be carefully considered while adapting this technology to pediatric processes and systems. For example, a pediatric barcoding solution must provide readable code for small-volume, patient-specific dose labels.

Infusion Pump Errors

The types of infusion pump errors seen are pumps that do not protect from the free flow of fluids to the patient, the wrong drug concentration, or the wrong rate is set.

Free flow of fluids occurs when the infusate flows freely, under the force of gravity, without being controlled by the infusion pump. Infusion pump tubing needs a built-in, anti-free-flow mechanism. This prevents gravity-free flow by closing off the tubing to prohibit flow when the pump's administration set is removed. If an infusion pump does not have free-flow protection, devices attached to the administration set are available. However, they are not recommended because they are packaged separately and must be manually attached to a set. Clinicians may forget to use the mechanism or may accidentally remove it.

Training and education are important in the prevention of infusion pump administration errors. Be sure to provide in-service to staff who may not be administering medication but may handle the infusion pumps, such as aides, radiology technicians, and transporters. Another concern is that patients, family members, or visitors may mishandle pumps.

Key bump errors can cause errors in the volume or infusion rate. These should be double-checked after entry and before starting the pump. Having a second nurse check calculations and settings for infusion pumps when high-alert drugs are used is recommended.

Medication Reconciliation

Medication reconciliation is when healthcare professionals resolve discrepancies when comparing the medications a patient should be using, actually using, and new medications that are ordered (TJC, 2021e). Medication reconciliation is done to avoid medication errors. Handoff situations are prone to errors. Errors can be due to omission, duplication, contraindications, prescription errors, and administration errors. Therefore, the process should be done every time a patient has a handoff or transition in care. A handoff includes a change in setting, service, practitioner, or level of care. Medication reconciliation has five steps:

develop a list of current medications
develop a list of medications to be prescribed
compare the medications on the two lists
make clinical decisions based on the comparison
communicate the new list to appropriate caregivers and the patient

When the patient has difficulty with the instructions, someone (family member or caregiver) must be designated and taught about their medications.

Risk reduction strategies include:

Collect a complete list of current medications for each patient on admission, including dose, frequency, and other key information.
Validate the home medication list with the patient whenever possible.
Assign primary responsibility for collecting the home list to someone with sufficient expertise within a context of shared accountability.
Use the home medication list when writing orders.
Place the reconciling form in a consistent, highly visible location within the patient chart, easily accessible by clinicians writing orders.
Assign responsibility for comparing admission orders to the home medication list, identifying discrepancies, and reconciling variances to someone with sufficient expertise.
Reconcile medications within specified time frames, within 24 hours of admission; shorter time frames for high-risk drugs, potentially serious dosage variances, or upcoming administration times.
Adopt a standardized form to collect the home medication list and reconcile the variances, including electronic and paper-based forms.
Develop clear policies and procedures for each step in the reconciliation process.
Provide access to drug information and pharmacist advice at each step in the reconciliation process.
Improve access to complete medication lists at admission.
Provide orientation and ongoing education on procedures for reconciling medications to all health care providers.
Provide feedback, and ongoing monitoring.

Place the medication list in a highly visible location in the patient's chart and include dosage, drug schedules, immunizations, and allergies or drug intolerances on the list. Create a process for reconciling medications at all care interfaces (admission, transfer, discharge) and determining reasonable time frames for reconciling medications. Patients and responsible physicians, nurses, and pharmacists should be involved in the medication reconciliation process.

On discharge from the facility, in addition to communicating an updated list to the next provider of care, provide the patient with the complete list of medications that he or she will be taking after discharge from the facility, as well as instructions on how and how long to continue taking any newly prescribed medications. Encourage the patient to carry the list with them and share it with any care providers, including primary care and specialist physicians, nurses, pharmacists, and other caregivers.

Tubing Misconnection

Misconnection of tubing can lead to patient deaths. Causative factors include:

Luer connectors enable functionally dissimilar tubes or catheters to be connected
The routine use of tubes or catheters for unintended purposes
The positioning of functionally dissimilar tubes used in patient care near one another
Movement of the patient from one setting or service to another
Staff fatigue associated with working consecutive shifts

Error reduction recommendations include:

Do not purchase non-intravenous equipment 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 origin point before connecting any new device or infusion.
Recheck connections and trace all patient tubes and catheters to their sources upon the patient's arrival to a new setting or service as part of the handoff 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.
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.
Certain high-risk catheters (e.g., epidural, intrathecal, arterial) label the catheter and do not use catheters with 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.

Technology

Health information technology and converging technologies have been found to contribute to medical errors. Care must be taken when implementing new technology. Contributing factors include:

Inadequate technology planning can result in poor product selection, a solution that does not adapt well to the local clinical environment, or insufficient testing or training
Failing to include front-line clinicians in the planning process
Failing to consider the costs and resources needed for ongoing maintenance
Failure to consult product safety reviews or alerts or the previous experience of others
Implementing new clinical information systems can expose latent problems or flawed processes with existing manual systems
An over-reliance on vendor advice can lead to problems
Learning to use new technologies takes time and attention, sometimes placing strain on demanding schedules
Failure to quickly fix technology when it becomes counterproductive can lead to dangerous workarounds
Excessive alerts lead to alert fatigue, where staff overlook important alerts

Examine workflow processes and procedures for risks and inefficiencies and resolve these issues before any technology implementation. Whether they are clinical, clerical, or technical, involving all disciplines will help examine and resolve these issues.

Actively involve clinicians and staff who will ultimately use or be affected by the technology and IT staff with strong clinical experience in the planning, selection, design, reassessment, and ongoing quality improvement of technology solutions, including the system selection process. Involve a pharmacist in the planning and implementation of any technology that involves medication.

Assess the organization's technology needs beforehand (e.g., supporting infrastructure, communication of admissions, discharges, transfers, etc.). Investigate how best to meet those needs by requiring IT staff to interact with users outside their facility to learn about potential systems' real-world capabilities, including those of various vendors; conduct field trips; and look at integrated systems to minimize reliance on interfaces between various vendor systems.

When introducing new technology, continuously monitor for problems, and address any issues as quickly as possible, particularly problems obscured by workarounds or incomplete error reporting. During the early post-live phase, consider implementing an emergent issues desk staffed with project experts and champions to help rapidly resolve critical problems. Use interdisciplinary brainstorming methods for improving system quality and giving feedback to vendors.

Establish a training program for all types of clinicians and operations staff using the technology and provide frequent refresher courses. Training should be appropriately designed for the local staff. Training programs should focus on how the technology will benefit patients and staff, i.e., less inefficiency, fewer delays, and less repetitive work. Do not allow long delays between orientation and system implementation.

Develop and communicate policies delineating staff authorized and responsible for technology implementation, use, oversight, and safety review. Before taking a technology live, ensure that all standardized order sets and guidelines are developed, tested on paper, and approved by the Pharmacy and Therapeutics Committee or institutional equivalent.

Develop a graduated system of safety alerts in the new technology that helps clinicians determine urgency and relevancy. Carefully review skipped or rejected alerts as important insight into clinical practice. Decide which alerts need to be hard stops when using the technology and provide appropriate supporting documentation. Develop a system that mitigates potential harmful Computerized Provider Order Entry (CPOE) drug orders by requiring departmental or pharmacy review and sign-off on orders created outside the usual parameters. Use the Pharmacy and Therapeutics Committee (or institutional equivalent) to oversee and approve all electronic order sets and clinical decision support alerts. Assure proper nomenclature and printed label design, eliminate dangerous abbreviations and dose designations, and ensure Medication Administration Record (MAR) acceptance by nurses.

To improve safety, provide an environment that protects staff involved in data entry from undue distractions when using the technology. After implementation, continually reassess and enhance safety effectiveness and error-detection capability, including error tracking tools and the evaluation of near-miss events. Maximize the potential of technology to maximize safety benefits.

After implementation, continually monitor and report errors and near misses or close calls caused by technology through manual or automated surveillance techniques. Pursue system errors and multiple causations through the root cause analysis process11 or other forms of failure-mode analysis. Consider reporting significant issues to well-recognized external reporting systems.

Re-evaluate the applicability of security and confidentiality protocols as more medical devices interface with the IT network. Reassess HIPAA compliance periodically to ensure that medical devices' addition to the IT network and the IT department's growing responsibilities have not introduced new security and compliance risks.

Medical Device Alarm Safety

Alarm-equipped devices are essential to providing safe care to patients in many healthcare settings. The number of alarm signals per day can reach several hundred, depending on the unit. Healthcare professionals begin to ignore alarms when there are too many false alarms which is called alarm fatigue. Problems can be the conditions are set too tight, default settings are not adjusted for the individual patient or the patient population, ECG electrodes have dried out, or sensors are mispositioned.

Recommendations for alarm systems are (TJC, 2021e):

Make alarm system safety a priority
Identify the most important alarm signals to manage based on the following:
- Input from staff
- Risk to patients if the alarm signal is not attended to or if it malfunctions
- Whether specific alarm signals are needed or unnecessary
Establish policies and procedures for managing the alarms
- Clinically appropriate settings for alarm signals
- When alarm signals can be disabled
- When alarm parameters can be changed
- Who has the authority to set or change alarm parameters

National Patient Safety Goals

TJC has made patient safety a priority and is seeking to promote specific improvements in patient safety. The mechanism for doing this is National Patient Safety Goals (NPSGs) as a major focus for accreditation visits. The NPSGs highlight problematic areas and seek system-wide solutions, and are being updated annually. The following is the link to NPSGs www.jointcommission.org/standards/national-patient-safety-goals/. The following are the links to the NPSGs by practice locations:

patient_safety_goals

^{(TJC, 2021a)(TJC, 2021b)(TJC, 2021c)(TJC, 2021d)(TJC, 2021e)(TJC, 2021f)(TJC, 2021g)(TJC, 2021h)}

Case Scenario

Scenario/Situation/Patient Description

Nurse Jane has been struggling with financial issues for the past six months. To help her family out of it, she has been volunteering to work alternating shifts and overtime consistently at the local hospital. She is on her fifth 12-hour night shift this week alone on the pediatric unit. It is time to pass medications. The CNA recently helped her admit a new pediatric patient (20-day-old neonate, male) and has recorded the weight as 9.6 lbs. Nurse Jane is preparing to administer acetaminophen 10 mg/kg for a fever. As she begins to calculate the dose, she calculates 9.6 x 10 = 96 mg. The bottle indicates 80 mg/mL, so she then calculates a total acetaminophen dose to be administered of 1.2 mL and proceeds to administer this to the neonate.

Interventions/Strategies

Upon scanning the medication and entering the dose to be given, the computer software alerts her to check the dosage for potential errors. It auto-populates the patient's weight, medication ordered, and medication dosage ordered. The computer system defaults to expressing weight in kilograms. At this point, the nurse realizes her potential error. She calculated the dose in pounds rather than in kilograms and almost administered double the appropriate dose for this patient. The dose should have been calculated as 9.6 pounds / 2.2 kg per pound = 4.36 kg. 4.36 kg x 10 mg = 43.6 mg. 43.6 mg / 80 mg = .54 mL to be administered.

Discussion of Outcomes

The hospital's EMR is calibrated to alert to potential errors when used with scanning barcodes before administering medications. The weight default to kilograms avoided a potential overdose of acetaminophen on a young neonate.

Strengths/Weaknesses

This scenario's strengths are the EMR which notifies staff of potential errors and shows weight in the appropriate kilogram format for medication dosing. Weaknesses include not having a two-person check system for pediatric patient medications, not having a pharmacist calculate individual pediatric doses, sending the appropriate amount to the floor, and allowing a nurse to work five 12-hour shifts in a week. Excessive workload has led to exhaustion, brain fog, and potential or actual medical errors, including an incorrect dosage of medication or administering the wrong medication. The hospital should implement a policy that limits the number of shifts or hours staff can work weekly to reduce medical errors. They should also consider annual or semi-annual continuing education for any staff member who must manually calculate medication dosages or a two-person sign-off system for manually calculated medication doses.

Conclusion

Healthcare professionals have a responsibility to be knowledgeable about the PI process and to participate as opportunity presents. Healthcare professionals also have a responsibility to be aware of clinical situations prone to error and participate in procedures to prevent those errors.

Systems redesign to prevent all such errors should be based on a balanced utilization of evidenced-based technology, training, ongoing education, standards of practice, and best practices, keeping in mind each human's inherent cognitive and physical limitations.

Human factors lead to medical errors. Human factors errors can be reduced through the application of the scientific method. Human errors are inevitable in healthcare settings. Human factors analysis needs to be part of every medical error investigation.

Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.

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TJC (2021a). Ambulatory Health Care: 2021 National Patient Safety Goals | The Joint Commission. TJC. Visit Source.
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TJC. (2021c). Critical Access Hospital: 2021 National Patient Safety Goals | The Joint Commission. Joint Commission. Visit Source.
TJC. (2021d). Home Care: 2021 National Patient Safety Goals | The Joint Commission. Joint Commission. Visit Source.
TJC. (2021e). Hospital: 2021 National Patient Safety Goals | The Joint Commission. Joint Commission. Visit Source.
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