92% of participants will understand process improvement, root cause analysis, patient safety, correct medical record documentation, and methods to avoid medical errors in any practice area.
After completing this course, the learner will be able to:
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):
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Patient experience:
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Error in clinical work:
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Errors in Healthcare System:
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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.
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:
The following are other concepts related to PI:
These programs are slightly different from PI, but these terms may be used interchangeably.
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:
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 (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.
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.
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.
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 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:
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.
Reason's Model Inputs (Reason, 2019)
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 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.
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:
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.
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:
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:
Contributing factors to fatigue and risks to patients include:
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 handoffs are a time of high risk – especially for tired staff – assess the organization's handoff 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.
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:
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.
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:
When manifested by healthcare professionals in positions of power, these behaviors include:
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.
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.
Health care 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).
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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;
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.
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:
The types of medication errors include prescribing, omission, wrong time, unauthorized drug, improper dose, wrong drug preparation, wrong administration techniques, deteriorated drugs, improper monitoring and compliance, product errors, process errors, and human errors. Particularly error-prone areas are:
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 here.
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 is of high-alert medications is available at ISMP List of High-Alert Medications.
Insulin:
Opiates and Narcotics:
Injectable Potassium Chloride (KCL) (or Phosphate):
Intravenous Anticoagulants:
Sodium Chloride Solutions Concentration above 0.9%:
The anticoagulants most commonly used and most frequently involved in medication error are unfractionated heparin, warfarin, and enoxaparin. Contributing factors to medication error with the use of anticoagulants include:
Risk reduction strategies (TJC, 2021e):
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 health care 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 very young children, cannot communicate effectively to providers regarding any adverse effects that medications may be causing.
Pediatric-specific strategies for reducing medication errors:
Ensure full pharmacy oversight and other appropriate staff's involvement—in the verifying, dispensing, and administering of both neonatal and pediatric medications.
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 in-service 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 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 (transition in care). A handoff includes a change in setting, service, practitioner, or level of care. Medication reconciliation has five steps:
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:
Place the medication list in a highly visible location in the patient's chart and including 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 for instructions on how and how long to continue taking any newly prescribed medications. Encourage the patient to carry the list with them and share the list with any care providers, including primary care and specialist physicians, nurses, pharmacists, and other caregivers.
Misconnection of tubing can lead to patient deaths. Causative factors include:
Error reduction recommendations include:
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:
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 who will be 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 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 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.
Alarm-equipped devices are essential to providing safe care to patients in many health care 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 and 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):
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.
(TJC, 2021a)(TJC, 2021b)(TJC, 2021c)(TJC, 2021d)(TJC, 2021e)(TJC, 2021f)(TJC, 2021g)(TJC, 2021h)
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 that 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, fog-brain, 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.
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.
