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PME Lecture 2011presentation[1]

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    Prevention of

    Medical Errors2011

    Mary Mckay DNP, ARNP

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    Second Victim

    Phenomenon

    Source: Scott SD, Hirschinger LE, Cox KR, et al. Caring for our own: deploying a systemwide second victim rapid

    response team. Jt Comm J Qual Patient Saf. 2010;36:233-240.

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    Is Health Care Safer Today?

    Difficult to Assess:

    Lack of universal reporting system

    Under reporting

    Lack of consensus regardingterminology/definitions of whatconstitutes an error

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    Why are errors under

    reported?1. Historically a punitive approach has been

    taken leading to fear :

    Loss of reputation

    Loss of job Disciplinary action by professional board

    Malpractice

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    Why are errors under

    reported?

    2. Difficult to use reporting systems

    3. Time constraints

    4. Sweep it under the rug mentality

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    Is Health Care Safer Today?

    Agency for Healthcare Research and

    Quality- National Healthcare QualityReport 2008

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    National Initiatives

    Patient Safety and Quality Improvement

    Act of 2005Legislation that establishes a confidentialreporting structure in which hospitals,

    health care professional and entities can

    voluntarily report information on errors toPatient Safety Organizations to facilitate

    development of patient safety strategies.

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    Simulation and Safety

    What are the benefits of learning through simulation?

    Allows for learners to perform in an environment thatis as close as possible to a real patient scenario

    Learners acquire and practice skills in a safe

    environment Mistakes made while training will not harm a real

    patient

    An opportunity to improve patient safety thru teamworkand critical event training.( American Society ofAnesthesiologists, 2008).

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    Institute for Healthcare Improvement

    Adverse Drug Events (ADE) Catheter-Associated Urinary Tract Infections (CAUTI)

    Central Line Associated Blood Stream Infections (CLABSI)

    Injuries from Falls and Immobility

    Obstetrical Adverse Events Pressure Ulcers

    Surgical Site Infections

    Venous Thromboembolism (VTE)

    Ventilator-Associated Pneumonia (VAP)

    Other Hospital-Acquired Conditions

    Posted on: April 12, 2011

    http://www.ihi.org/IHI/Programs/ImprovementMap/

    Institute for Health Care Improvement @ IHI.org

    http://www.healthcare.gov/center/programs/partnership/safer/ade.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/cauti.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/clabsi.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/injuries.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/obstetrical.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/ulcers_.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/infections_.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/vte.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/vap.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/conditions_.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/conditions_.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/conditions_.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/conditions_.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/vap.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/vap.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/vap.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/vte.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/infections_.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/ulcers_.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/obstetrical.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/injuries.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/clabsi.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/cauti.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/cauti.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/cauti.htmlhttp://www.healthcare.gov/center/programs/partnership/safer/ade.html
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    WHO- Initiatives

    Clean Care is Safer Care

    Safe Surgery Saves Lives

    WHO Safety Check list

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    Common Terminology

    Medical Error

    Adverse Event

    Near Miss

    Sentinel Event

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    What is a Medical Error ?

    According to the Institute of

    Medicine(1999) a medical error is

    defined as the failure of a planned

    action to be completed as intended or theuse of a wrong plan to achieve an aim.

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    What is an

    ADVERSE EVENT ?

    An event in which a negativeoutcome occurred as a result ofmedical intervention rather than

    from the underlying medicalcondition.

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    What is a Near Miss ?

    An event or situation that couldhave resulted in an accident, injuryor illness ,but did not, either by

    chance or through timelyintervention.

    Warning sign

    Increased reporting needed

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    Case Study

    She returned to the patient and hung theDiprivan via the patients central line. The IV

    pump alarmed air in line almost immediately.

    While removing the air from the line the nursewas once again alerted to the discrepancy she

    had noted earlier. She removed the Diprivan

    and contacted the pharmacy. Fortunately, the

    patient had not received any of the Diprivan yet.

    Reference: http://www.ahrq.gov

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    What Happened ?

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    What is a Sentinel Event? The Joint Commission developed a Sentinel

    Event Policy and database in 1996 of allreported events.

    Used to analyze events to provideinformation to healthcare organizations todeter future occurrences.

    Joint Commission

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    What is a Sentinel Event?

    A sentinel event is defined as anunexpected occurrence involving deathor serious physical, or psychological

    injury, or risk thereof

    Sends a signal or warning that requiresimmediate attention

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    Agency for Healthcare Research and Quality

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    Sentinel Events Alert

    In order to communicate information related

    to sentinel events to healthcareorganizations in a timely manner the Jointcommission utilizes Sentinel Events Alert.

    Identifies specific sentinel events, describes

    their common underlying causes, andsuggests steps to prevent occurrences in thefuture.

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    What is a Root Cause

    and Analysis ?

    A process for identifying the

    causative factors involved in theoccurrence of a sentinel event

    A root cause is the most basicreason for the failure or inefficiency

    of a process Focuses primarily on

    systems/processes not individuals

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    JC Identified Root Causes

    of Sentinel Events for AllCategories

    Communication

    Orientation/Training

    Patient Assessment

    Availability of information

    Staffing levels

    Physical environment Issues

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    JC Identified Root Causes

    of Sentinel Events for AllCategories

    Continuum of care

    Competency/ Credentialing

    Procedural compliance

    Alarm systems

    Organizational Culture

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    FAILURE MODES & EFFECT

    ANALYSIS Another method to prevent errors

    Process applied prior to actual error

    Examines a system/process for possible highrisk points of error

    Possibly redesign the process to eliminatechance of failure

    Pilot test Implement the process

    Reevaluate

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    Why Do Errors in Health

    Care Occur ?Medical errors most often result from a

    complex interplay of multiple factors. Onlyrarely are they due to the carelessness or

    misconduct of single individuals

    L. Leape, MD.

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    WHY DO SYSTEMS FAIL?

    COMPLEXITY

    VARIABILITY

    INCONSISTENCY TIME CONSTRAINT

    HUMAN INTERVENTION

    HIEARCHICAL CULTURE TIGHT COUPLING

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    Types of System

    Errors/Failures Active errors/failures involve personnel and

    parts of the health care system that are in

    direct contact with the patient.

    Their actions may result in errors that have adirect impact on patient safety

    Referred to as errors occurring at the sharpend. Reason, JT. (1990). Human Error. New York, NY:Cambridge University

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    Types of System

    Errors/Failures

    Latent errors/failures involve individuals such

    as managers, administrators and policymakers

    Their actions or decisions may lead to anegative impact on patient safety. Tend to be

    less obvious. Referred to as errors occurring at the blunt

    end

    Reason, JT. (1990). Human Error. New York, NY:Cambridge University

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    Types of System

    Errors/Failures

    Blunt End Sharp EndLatent Active

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    2011 JC National Patient

    Safety GoalsGoal 1: Improve the accuracy of

    patient identification

    A. Use at least two patientidentifiers(neither to be the patientsroom number) when providing care,treatment or services

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    A 47 y/o male who was PCP. Whileundergoing treatment he had several skinlesions biopsied. Several days later an

    MD(PCP) noted the results in the EMR werepositive for cancer. This prompted the PCPto recommend Hospice care. Later that daythe hospital MD noted this was an error. The

    biopsy results were from another patient.The medical team met with the patient toexplain the error.

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    What Happened?

    This example involves both active

    and latent errors

    Reference: http://www.ahrq.gov

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    JC Patient Safety 2011

    Eliminate Transfusion Errors

    2011

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    2011

    National Patient Safety

    Goals

    Goal 2- Improve the effectiveness

    of communication amongcaregivers

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    2011 National Patient Safety

    Goals2A. For verbal or telephone orders or for

    telephonic reporting of critical test

    results,verify read -back of thecomplete order or test result by theperson receiving the order or test

    result

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    2011 National Patient Safety

    Goals

    2B. Standardize a list of abbreviations,

    acronyms and symbols that are NOT tobe used throughout the organization.

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    Case Study

    An 81 year old female with a history of

    chronic Atrial Fib who was receivingwarfarin developed asymptomatic runsof ventricular Tachycardia

    http://www.ahrq.gov

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    Case Study

    Unit RN contacted MD

    who was involved in asterile procedure and

    gave a verbal order to

    the procedure nurse

    Someone in the verbal

    order said 40 of K.The unit RN

    Wrote the order as

    Give 40mg Vit K IVNow

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    Case Study

    The hospital

    pharmacist contacted

    The MD concerningThe high dose and the

    route

    Clarification of order

    Was obtained

    40 mEq of KCL PO

    Simultaneously the unit RN had obtained the Vit K on over ride

    From the Pyxis system and given the IV dose

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    Case Study

    The hospital

    pharmacist contacted

    The MD concerningThe high dose and the

    route

    Clarification of order

    Was obtained

    40 mEq of KCL PO

    Simultaneously the unit RN had obtained the Vit K on over ride

    From the Pyxis system and given the IV dose

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    Case Study

    The RN attempted to contact the MD but

    Was told he was busy. The MD was not

    Notified until the next day. Heparin was

    Initiated and warfarin retitrated. No

    Long term consequences were suffered.

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    Do Not Use AbbreviationsAbbreviation Mistaken for Suggestion

    U for unit Zero, four, cc Unit

    IUInternationalunit

    IV or 10 Internationalunit

    Q.D.Q.O.D.

    Each other Daily orevery otherday

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    Abbreviation Mistaken for Suggestion

    Trailing zero(1.0mg)

    Lack of aleading ero(.1mg)

    Decimal point ismissedRead as 10 mg

    Read as1 mg

    Never write a zerafter a decimalpoint and alwaysuse a zero beforea decimal point

    MSMSO4MgSO4

    ConfusionMorphine sulfatevsMagnesiumsulfate

    Write out name ofdrug

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    Abbreviation Mistaken for Suggestion

    mcg Milligram Write outmicrogram

    TIW Three times

    a week

    HS Multiple

    meaning

    Write out

    meaningbedtime halfstrength

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    2011 JC National Patient

    Safety Goals

    2C. Measure, assess and, if appropriate

    take action to improve the timeliness ofreporting and timeliness of receipt bythe responsible licensed caregiver of

    critical test result and values.

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    A 91-year-old female was transferred to a hospital-based skilled

    nursing unit from the acute care hospital for continued woundcare and intravenous (IV) antibiotics for (MRSA) osteomyelitisof the heel. She was on IV vancomycin and began to havefrequent, large stools.

    The attending physician ordered a test for Clostridium difficileon Friday, and was then off for the weekend. That night, the testresult came back positive. The lab called infection control, whoin turn notified the float nurse caring for the patient. The nursedid not notify the physician on call or the regular nursing staff.

    Isolation signs were posted on the patient's door and chart, andthe result was noted in the patient's nursing record.

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    On Monday, the physician who originally ordered the C. difficile

    test returned to assess the patient and found the isolation signson her door. He asked why he was never notified and why thepatient was not being treated. The nurse on duty at that timetold him that the patient was on IV vancomycin. The float nurse,who had received the original notification from infection control,

    stated that she had assumed the physician would check theresults of the test he had ordered. Due to the lack of follow-up,the patient went three days without treatment for C. difficile, andcontinued to have more than 10 loose stools daily. Given heradvanced age, this degree of gastrointestinal loss undoubtedlyplayed a role in her decline in functional status and extended

    hospital stay.

    AHRQ

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    How Important is

    Communication and PatientSafety?

    70-80% of health care errors are caused

    by human factors associated withinterpersonal interactions(Schaefer,1994)

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    CASE STUDY

    An 83 y/o male with a history of COPD,

    GERD, and atrial fib was admitted to a large

    teaching hospital for placement of a pacemakervia the left subclavian vein. Following the

    procedure the patient had an CXR which

    showed no pneumothorax. He was sent torecovery for overnight monitoring.

    Reference: http://www.ahrq.gov

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    Case Study

    The patient had shortness of breath andcomplained of left sided back pain. The

    nurse informed the on call intern who

    examined the patient (for the first time)and ordered a chest x-ray. When the nurse

    called the intern at 8 pm to check for results, the

    Intern stated he was signing out the x-ray to the

    night float resident. In the meantime the patientwas feeling a little better with oxygen.

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    Case Study

    At 10 pm the nurse called the float resident who

    had been too busy with an emergency to check the

    x-ray results. At midnight the nurse gave report

    to the next shift noting that the resident had notcalled with any bad news. The next morning

    the radiologist called to inform the nurse the

    patient had a large left pneumothorax. A chest

    tube was inserted nearly 23 hours following thex-ray. Fortunately the patient did not suffer any long

    term harm.

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    What Happened?

    After further follow up it was discoveredthat the night float resident hadmistakenly examined the CXR that had

    been taken immediately following thesurgery instead of the later one.

    This case illustrates how a handoff canjeopardize patient safety. A standardized

    method for communicating transfer ofcare can decrease the risk.

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    Behaviors That Impede

    Patient Safety Reluctance or refusal to answer

    questions- avoidance

    Rude or condescending comments

    Threatening body language

    Verbal abuse I am in charge. Just do it

    Threats to reputation

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    Behaviors That Support A

    Culture of Safety

    Collaboration

    Respect Interdisciplinary rounds/conferences

    Open, honest and direct communication

    Supportive non-punitive reporting

    Goal directed interactions

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    Agency for Healthcare Research andQuality

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    2011 National Patient

    Safety GoalsGoal 3 Improve the safety of using medications

    Identify and, at a minimum, annually review a list oflook-alike/sound-alike drugs used in theorganization, and take action to prevent errors

    involving the interchange of these drugs

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    Case Study

    A 36 y/o woman with chronic renal failure

    & diabetes was transferred from a nursing

    home to the hospital for treatment of an

    infection. Bicitra (citric acid)30ml four times a

    day was ordered on admission. The

    pharmacist filled the order with Polycitra

    instead ( contains citric acid & Potassium

    citrate). The patient drank the entire dose.

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    Case Study

    The nurse on the next shift noted the

    empty container. The MD was notified

    and a STAT potassium level was > 8mEq/L.

    (Normal is 3.5-5) and her blood glucose was

    600mg/dl. The patient was treated

    with Kayexalate and insulin withoutcomplications.

    Reference: http://www.ahrq.gov

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    What Happened?

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    2011 National Patient

    Safety Goals

    - Label all medications, medication

    containers(syringes, medicine cups,etc)or other solutions on & off the sterilefield

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    Case Study

    A woman was injected with chlorhexidine

    (topical anti microbial) instead of the intended

    contrast media during a cerebral angiogramprocedure. The clear pink tinged chlorhexidine

    solution was placed in a basin identical to that

    used to hold clear colored contrast media.

    Neither basin was labeled so both solutions

    looked very similar.ISMP Medication Safety Alert! August 2005 Vol3 Issue 8

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    Case Study

    The patient experienced an acute severe

    chemical injury to the blood vessels in her leg.Within two weeks her leg was amputated. She

    then suffered a stroke and organ failure leading

    to her death.

    ISMP Medication Safety Alert! August 2005 Vol3 Issue 8

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    What Happened ?

    Is this an example of an active or

    latent failure?

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    What Happened ?

    It is an example of both.

    The lack of labeling on the basins is an

    active failure. The change in cleaning solutions is a

    latent failure.

    Blunt End Sharp End

    Addi i l M di i

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    Additional MedicationSafety Issues

    The National Coordinating Council for Medication ErrorReporting & Prevention defines a medication error asfollows:

    A medication error is any preventable event that maycause or lead to inappropriate medication use or patientharm while the medication is in the control of the healthcare professional, patient or consumer. Such eventsmay be related to professional practice, health care

    products, procedures and systems, includingprescribing; order communication; product labeling,packing, and nomenclature; compounding; dispensing;distribution, administration; education;monitoring;anduse.

    H Oft D M di ti

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    How Often Do MedicationErrors Really Occur ?

    According to the IOM study more than7000 deaths occur each year related tomedication errors.

    Another study found that as many as 1 inevery 5 medications reach the patient inerror.

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    Medication Errors

    Keep in mind that the reporting ofmedication errors is thought to be

    grossly under reported !

    Reporting agencies include the FDA, US

    Pharmacopeia via Medmarx , ISMP andJCAHO

    Wh i th P d

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    Where in the Process doMedication Errors Occur?

    Reference: http://www.ahrq.gov

    Wh i h P d

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    Where in the Process doMedication Errors Occur?

    Most errors occur during the prescribing/ordering process.

    About 50% of those prescribing errors arecaught prior to reaching the patient.

    Greater than one third of errors occur during

    administration but only 2% of these errorsare caught prior to reaching the patient.ISMP Medication Safety Alert, November 2005

    P ti t i th L t Li f

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    Patient is the Last Line ofDefense

    Errors made during the administration

    process are much more likely to reach thepatient and are associated with those errorsthat cause harm.

    Encourage patient and families to askquestions.

    ISMP Medication Safety Alert, November 2005

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    TYPES OF ERRORS

    Unauthorized drug

    Improper dose Omission

    Prescribing

    Wrong time Wrong Patient

    Extra dose

    Wrong administration

    technique Wrong method of

    preparation

    Wrong dosage form

    Wrong route

    Failure to monitor

    D All M di ti E

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    Do All Medication ErrorsResult in Harm to Patient?

    According to MEDMARX 2002 Datareport (USP) out of 192,477 reported

    med errors-82 % were classified asnon-harmful.

    However, a reported 3,193 were

    classified as harmful and 20 as fatalerrors.

    C ld f l t ib

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    Could you safely transcribethis order ?

    Reference: http://www.ahrq.gov

    Co ld o safel transcribe

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    Could you safely transcribethis order ?

    Reference: http://www.ahrq.gov

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    Key Points Written orders must be clear and legible !

    Clarify any order that is questionable

    including sound alike/ look alike drugs. Patients age, sex,current medications,

    diagnosis, co morbidities, concurrent

    conditions, laboratory values, allergiesand past sensitivities must be available toprescriber

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    Case Study

    A patient was admitted to a teaching hospital withsuspected vasculitis. During rounds the senior residentinstructed the intern to give the patient one gram ofsteroids. Following rounds the interns orderedPrednisone 20mg tabs 50 pills PO x 1 now. The

    pharmacist contacted the intern to clarify the order. Shesuggested to the intern that the order should probablybe given in an IV form. The intern refused to change theOrder despite the pharmacists suggestion to contact thesenior resident for clarification. The intern added to give

    Maalox with the steroids. The patient reluctantly took the fifty20 mg pills and developed mild nausea and heartburn. Thefollowing day the senior resident found the error andchanged the order to the IV form.

    Reference: http://www.ahrq.gov

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    What Happened?

    The intern did not seek clarification as suggested bythe pharmacist, who is an expert in pharmacology.Lack of interdisciplinary approach to patient care.The intern may have been fearful of the seniorresidences reaction to seeking clarification.

    The pharmacist did not follow the chain of commandby calling the senior resident when the discrepancywas not addressed by the intern.

    QUESTION INCONSISTENCIES-YOUR PATIENTSSAFETY IS IN YOUR HANDS

    Medication Errors :

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    Medication Errors :Prevention Strategies

    Adhere to standards of medication

    administration -8 Rights Communicate with the patient /family

    Identify medications with high risk for

    error and institute specific protocols

    Medication Errors :

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    Medication Errors :

    Prevention Strategies Training & competency assessment

    Decrease distractions

    Computerized order entry

    Automated dispensing devices

    Medication Errors :

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    Medication Errors :

    Prevention Strategies

    Proper storage & labeling

    Bar coding-decreases errors inadministration

    Increased clinical Pharmacists

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    2011 Patient Safety Goals

    Reduce the likelihood of patient harm

    associated with the use ofanticoagulation therapy.

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    Case Study

    Three neonates died at a hospital as aresult of accidental heparin overdoses.A pharmacy technician inadvertently filled

    the automated dispensing cabinet with1ml vials of heparin containing10,000 units/ml instead of the1ml vials ofheparin10 units/ml. The nurses did not notice

    the discrepancy and the heparin wasadministered to the neonates.

    ISMP Medication Safety Alert Oct 2006 4/10

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    RecommendationsIn order to prevent this tragedy from happening again

    the following recommendations have been made:

    1. Eliminate 10, 000 units/ml concentration vialsstocked in the hospital. If this concentrationremains in the pharmacy, keep the vials separatefrom other concentrations.

    2. Require an independent double check of drug.3. Reduce look alike/ sound alike drug packaging

    The vials of heparin had similarities that may have

    contributed to the error.For all recommendations see reference

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    Unintended Medication Discrepancies at the

    Time of

    Hospital Admission

    6% Severe harm potential

    61%

    No harm potential

    33%

    Moderate harm potential

    More than half of patient have 1 unintended medication discrepancy at

    hospital admission

    Reference: http://www.ahrq.gov

    Unintended Medication Discrepancies at the

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    Unintended Medication Discrepancies at the

    Time of

    Hospital Admission

    Cornish,Knowles & Marchensano(2005)found

    greater than 50% of patients had at least 1medication discrepancy upon hospitaladmission. The most common error wasomission of a regularly used medication.

    Obtaining an accurate medication history atthe time of admission is critical to preventsuch errors.

    Reference: http://www.ahrq.gov

    2011 National Patient

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    2011 National PatientSafety Goals

    Goal 8- Accurately and completely

    Reconcile Medications across thecontinuum of care

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    2011 Patient Safety Goals

    Comparing Current and Newly OrderedMedications (NPSG.08.01.01)

    B. Communicating Medications to theNext Provider (NPSG.08.02.01)

    C. Providing a Reconciled Medication

    List to the Patient (NPSG.08.03.01) D. Settings in which Medications Are

    Minimally Used (NPSG.08.04.01)

    2011 National Patient

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    2011 National PatientSafety Goals

    Goal 7- Reduce the risk of health care

    associated infections

    A. Meeting Hand Hygiene Guidelines

    B. Preventing Multidrug-Resistant OrganismInfections

    C. Preventing Central LineAssociated Blood StreamInfections

    D. Preventing Surgical Site Infections

    TEST YOUR KNOWLEDGE

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    TEST YOUR KNOWLEDGE

    Which is the most

    frequently occurring

    nosocomial

    infection?A. Urinary tract infection

    B. Pneumonia

    C. Vascular Catheterrelated

    Which of these are riskfactors for development

    of nosocomial infections?

    A. AgeB. Urinary catheter >24hrs

    C. Mechanical ventilation

    D. Severe underlying disease

    E. Extended stay in acute orchronic care facility

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    Additional considerations include:

    Overuse of antimicrobials

    Contaminated equipment-instruments

    Poor HANDWASHING

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    Additional Safety Concerns

    Reduce the Potential of Patient Harmresulting from falls

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    Falls in the Elderly

    Falls are a leading cause of death in people 65 andolder.

    Approximately 50% of those that fall suffer injuriesthat reduce mobility and independence. One third ofthose that sustain hip fractures require nursing homeplacement

    Ten percent of fatal falls for older adults occur inhospitals.

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    Fall Risk Factors

    >65 years of age

    Inability tounderstand or follow

    directions Confusion

    Altered level ofconsciousness/

    delirium

    Inability to use calllight

    Impaired vision ormobility

    Unsteady gait

    Dizziness/fainting

    Recent history offalls

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    Fall Risk Factors

    Medication Therapy

    Hx ofnocturnal/urgency/frequency inelimination

    Hx of seizures

    Surgical Procedure

    Orthostatic

    hypotension orhypertension

    Children in cribs

    Use of assistivedevices

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    Meds Requiring Fall Alert

    Tricyclic Antidepressants

    Antipsychotics

    Sedative-Hypnotics

    Antihypertensives

    Antihistamine/Anticholinergics

    Hypoglycemic agents

    Diuretics/Laxatives

    Anticonvulsants

    Muscle Relaxants

    Narcotic Analgesics

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    Fall Assessment-High Risk

    Identify high risk patients and communicate

    to staff-Morse Fall Scale

    Place yellow fall identification band onpatients wrist

    Observe patients identified at risk for fallsevery 2 hours

    Review patients medications that may

    increase the risk of falls on a daily basis.

    Interventions- Initiate Safety

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    Interventions Initiate SafetyMeasures

    Dangle feet from bedprior tositting/ambulation

    Assist with ambulation Apply fall alert ID

    armband

    Place bed/chair in low

    position Ensure correct use of

    least restraint

    Free environment ofclutter

    Review medications

    Considerinterdisciplinary consult

    Document assessment,interventions, response

    Educate patient &significant others

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    Reporting Falls: SBARD

    A method of communication used toreport a critical situation to a physicianincluding falls

    S = Situation B = Background

    A = Assessment

    R = Recommendation D = Document

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    Additional Safety Concerns

    Prevent health careassociated pressure

    ulcers

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    2011 Patient Safety Goals

    The organization identifies safety risks inherent

    in its patient population.

    High Risk Patient

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    High Risk PatientPopulations

    Elderly

    Pediatric

    Language Barriers Vision Impairment

    C S d

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    Case Study

    An elderly blind patient was hospitalizedfor treatment of a deep vein thrombosis(clot).

    His discharge medications included injections

    of a anti coagulate. A nurse and pharmacistprovided the patient with written information

    sheets and counseling regarding self

    administration of his medications. Neithernoticed that the patient was blind.

    Reference: http://www.ahrq.gov

    C S d

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    Case Study

    Several days following discharge the

    patient called the office and told the nurse

    he had a bag full of medications including

    injections, but he had not taken any of

    them since he could not read the

    instructions. The patient had to be

    readmitted to the hospital for continuation

    of anticoagulate therapy.

    Wh H d?

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    What Happened?

    False assumptions regarding the patientsvisual acuity

    Inadequate discharge teaching. Written

    information is insufficient. They did not have the patient return

    demonstrate the injection procedure.

    Over 1 million persons living in the US are

    legally blind. Proper assessment is essentialto patient education.

    Interventions For High Risk

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    Interventions For High RiskPatients

    Medication training/competency

    Interpreter use Available patient education materials

    Large print

    Available outside resources

    C St d

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    Case Study

    Following an overdose a 26 year old

    woman was admitted for observation with

    a 72 hour hold by psychiatry. A 24 - hour

    attendant was placed with the patient. The

    patient was to go to x-ray but requested to go to

    the bathroom first. She was left in the bathroom

    alone. The attendant and transporter began totalk.

    Reference: http://www.ahrq.gov

    C St d

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    Case Study

    Upon return to patients room, the nurse

    became concerned and found patient with her

    gown tied around her neck, standing on the

    upside down garbage can. She was seconds

    from stepping off and hanging herself.

    Fortunately no harm came to the patient.

    NEVER LEAVE PATIENT UNATTENDED

    P hi t i P ti t

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    Psychiatric Patients

    According to other resources the number isunder reported. Approximately 1500 suicideshave occurred in hospitals.

    Review of 76 cases found only 40% ofinpatients who committed suicide wereadmitted for suicidal ideation.

    Prevention Strategies

    2011 P ti t S f t G l

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    2011 Patient Safety Goal

    Conduct a pre procedure verificationProcess

    A. Conducting a Pre-Procedure

    Verification Process

    B. Marking the Procedure Site

    C. Performing a Time-Out

    Patient Safety

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    at e t Sa etyConsiderations

    Encourage patients active involvement in theirown care as a patient safety strategy.

    Improve recognition and response to changein a patients condition.

    R id R T

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    Rapid Response Teams

    Team Composition

    Goals- Early intervention Process

    Outcomes

    P ti t/F il

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    Patient/Family

    Patients and family members can provideadditional safety checks.

    Encourage patients and families to ask

    questions. Inform patients of their rights.

    Educate patients and family members on allaspects of their care.

    Provide written material as well as verbal.

    Available Resources for

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    Patient Education include

    Institute for Safe Medication Practices

    access www.ismp.org Agency for Healthcare Research & Quality -

    access www.ahrq.govhttp://www.ihi.org/IHI/

    Institute for Healthcare Improvement access:http://www.ihi.org/IHI/

    http://www.ahrq.gov/http://www.ahrq.gov/
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    TEAM WORK IS THE KEY

    Moving pains

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    Moving pains

    A 90-year-old woman was admitted to the acute careward of the school's teaching hospital with a urinarytract infection and pneumonia. After developinghypoxemia, on hospital day 2, she was placed on 2L/min oxygen by nasal cannula. On hospital day 3,

    her hypoxemia worsened, as did her mental status.A head CT was ordered. She was placed on a non-rebreather mask (NRM) at 15 L/min to maintain heroxygen saturations. This change in respiratory status

    occurred while the primary nurse was occupied bythe critical needs of another patient, so anothernurse and the respiratory therapist placed the patienton the NRM.

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    The primary nurse completed the transport stability

    scale (TSS

    a local instrument used to assess apatient's stability for transport and to determine theneed for a nurse or physician to travel with thepatient) at the nurses' station in preparing her patientfor transport to the CT scanner. Because the nursewas unaware of the change in her patient'srespiratory status, she recorded that the patientrequired only 2 L/min oxygen by nasal cannula.Accordingly, the TSS score did not signal a need for

    a nurse or physician to accompany the patient.Therefore, the patient was taken to the CT scannerby two transport personnel/escorts.

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    As the transporters prepared to leave the floor with the patient

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    As the transporters prepared to leave the floor with the patient,one of them noticed that the patient had labored breathing. Hesuspected that a nurse should travel with them but did notquestion the nurse's assessment on the transport stability form.During transport, the patient continued breathing through herNRM, which was connected to an oxygen tank.

    Once the patient arrived in radiology, the CT technician noticedthat NRM bag was deflated and the oxygen tank had a

    regulator that limited oxygen delivery to 4 L/min. The technicianconnected the NRM to the wall oxygen source at 15 L/min forthe study and located an appropriate tank (that would allowhigher-flow oxygen) for the trip back to the unit. After the study,the patient was switched to this new tank at 15 L/min and

    awaited transport. The two transporters arrived, and the patientleft radiology to return to her room.

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