PREVENTION OF MEDICAL ERRORS Description of Course Designed to inform medical professionals about the widespread problem of medical errors. It was developed to comply with Senate Bill 1558 Section 60 enacted in 2001 that states that all healthcare practitioners complete a two hour continuing education course covering prevention of medical errors. Objectives At the completion of this course, the motivated learner should be able to: • Explain the purpose of the Senate bill for medical errors
• Identify the number of medical errors that lead to death on an annual basis
• List and define the 4 types of medical errors
• Name 6 recommendations for creating safety systems in healthcare
• Discuss how to better design jobs for safety
• List ways to avoid reliance on memory
• Describe how to simplify key processes
• Differentiate between standardized and regular work processes
• Name the purpose of redesigning the workplace
• Define adverse events and name ways to reduce them
• Explain how to track sentinel events
• Define medication errors and state ways to reduce occurrence of them
• List 20 suggestions for patients that reduce errors
• Name 6 ways to take charge of one’s personal health
• Name the impact on massage therapy PRE-TEST Directions: Complete this pre-test before starting the course. 1. T F Senate Bill 1558 Section 60 mandates that all healthcare practitioners complete
a 2 hour CE course covering prevention of medical errors.
2. T F The goal of this mandate is to provide more common sense in the workplace. 3. T F The incidence of death occurring from medical errors is minimal. 4. T F Types of medical errors include medication, surgical, diagnostic and system
5. T F Certain medications when mixed with anesthetics may cause death. 6. T F Reducing automation will help to reduce medication errors. 7. T F Illegible handwriting may lead to medical errors. 8. T F Safety is everyone’s responsibility in healthcare. 9. T F Checklists are designed to reduce our reliance on memory. 10. T F There are 3 rights of drug administration. Answers: 1.T 2.F 3.T 4.T 5.T 6.F 7.T 8.T 9.T 10.F
Introduction The attention paid to the critical issues of medical errors and patient safety has increased since November 1999 when the Institute of Medicine (IOM) released a report estimating that between 44,000 and 98,000 patients die as a consequence of medical errors in hospitals each year. These numbers exceed the annual deaths as a result of vehicle accidents (43,458), breast cancer (42,297) or AIDS (16, 516). These numbers indicate that each and every healthcare practitioner must make a commitment to improve the quality of healthcare and reduce medical errors at the point of care. Our first and foremost goal as healthcare practitioners is to protect and safeguard society. One of the ways we can accomplish this goal is to recognize and prevent medical errors. Our Western society is different from other societies in that we believe in going to the doctor after we encounter a problem. We are quick to visit the doctor when the slightest thing is wrong and we expect to get an immediate cure. Many of the Western treatments are invasive in nature, which contributes to the number of medical errors. Eastern medicine, on the other hand, has for centuries treated the whole person before he/she developed a disease or a problem. Their philosophy has been preventive rather than curative and non-invasive. The Institute of Medicine study found that one million serious medication errors occur each year in U.S. hospitals because of illegible handwriting on prescriptions, misplaced decimal points, and missed drug interactions and allergies. The report prompted a blizzard of patient-safety initiatives that have far-reaching effects. The American public has been informed and now hospitals, home health agencies, clinics, all healthcare settings, and all practitioners are paying attention to errors. If you think that prevention of medical errors is not your concern, think again. Each of us in the medical profession has a duty and responsibility to protect the patient regardless of where the patient is seen. We must be proactive as professionals and individuals to prevent medical errors from occurring. Our patients trust us and we must earn that trust. INCIDENCE Our curative philosophy has led to an abundance of surgical procedures and to “polypharmacy” which has contributed to many medical errors. An Institute of Medicine report entitled “To Err is Human” indicates that 44,000 to 98,000 people each year die from medical errors. Human error and mechanical failure can occur at any time for a variety of reasons. It is reasonable to expect a successful outcome for medical treatments, but this is not always the case. Today there is a heightened focus on quality from healthcare due to:
Pro-active consumer awareness and expectations of reasonable care. Cost containment issues in the wake of staff reductions Our litigious society Trends toward a more sensitive and service-oriented society Heightened awareness of human relations skills Opportunities for a cutting edge in the marketplace
It’s required! Don’t forget about JCAHO and all the other regulations. If we focus our institutions and personnel on quality, then we move toward prevention of medical errors. Errors occur not only in hospitals but in other healthcare settings, such as physician offices, long term care centers, assisted living facilities, pharmacies, urgent care centers, and in patients’ homes. These errors cost approximately $37.6 billion annually and about $17 billion of these costs are associated with preventable errors. About one half of the expenditures for preventable medical errors are for direct healthcare costs. While the prevention of medical errors is not new, the focus on prevention emerged in the early 1990s with the landmark research conducted by Lucien Leape, M.D., and David Bates, M.D., and supported by the Agency for Healthcare Policy and Research, now the Agency for Healthcare Research and Quality (AHRQ). Let us begin to explore the issue of prevention of medical errors by describing the types of medical errors with the hope that cognizance enhances a positive, safe outcome free of medical errors. DEFINING MEDICAL ERRORS The IOM defines medical errors as “the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim.” The IOM emphasized that most medical errors are system related and not intentional acts of wrongdoing. The key to reducing errors is to focus on improving the system of delivering care and not to blame the individual. Healthcare professionals are human and mistakes can occur, but research has shown that system improvements can reduce errors and improve the quality of care. Most people believe that medical errors usually involve drugs, such as a patient getting the wrong drug or the wrong dose, or mishandled surgeries, such as wrong site amputation. However, there are many other types of medical errors, such as:
• Diagnostic errors- misdiagnosis leading to incorrect choice of therapy,
failure to use an indicated diagnostic test, misinterpretation of test results, and failure to act on abnormal results.
• Equipment failures- defibrillators with dead batteries or IV pumps with
valves that dislodge when bumped, causing increased dosage of medication over a short period of time.
• Infections- nosocomial and post-operative wound infections. • Blood transfusions-related injuries- giving a patient the wrong type.
• Misinterpretation of other medical orders- failure to give the patient a salt-
free type diet, as ordered by the physician
Errors depend on two types of failures: either the correct action does not proceed as intended (error of execution), or the original intended action is not correct (error of planning.) Not all errors result in harm to the patient. Medical errors that result in harm to the patient are called preventable adverse events or sentinel events. Sentinel, because they indicate that there is need for immediate investigation and response.
TYPES OF MEDICAL ERRORS There are four types of medical errors and each of these will be explained below. These are:
1. Medication errors 2. Surgical errors 3. Diagnostic inaccuracies 4. System failures
MEDICATION ERRORS Medication errors occur when the patient has received the wrong medication, when the wrong dose is given, at the wrong time, when the patient is given the medication by the wrong route, when the wrong patient is given medication intended for another, and finally when the wrong documentation is completed. Therefore, there are 6 rights in drug administration: 1. Right drug. 2. Right dose. 3. Right route. 4. Right time. 5. Right patient. 6. Right documentation.
There are many documented incidences of medication errors. All healthcare personnel learn from their first day of education to do no harm and are constantly reminded to avoid medication errors, and are directed to report them immediately if they occur. Failure to report or to act quickly contributes to the high number of deaths as a result of medication errors.
Case Study 1
A 15-year-old patient sustained a chest injury and was taken to an understaffed, busy emergency department in an inner city location. The physician attending to the patient ordered 10 mg IV for pain, but the nurse mistakenly gave hydromorphone. Both drugs were stocked next to each other. The nurse gave the 10 mg hydromorphone which is equivalent to 50 mg to 60 mg of morphine and the patient died.
According to the Annals of Internal Medicine and the Journal of the AmericanMedical Association, medication errors are occurring at the rate of five in every 100 medications administered and accounting for 7,000 deaths annually.
SURGICAL ERRORS Surgical errors can occur from various different sources. The wrong patient may be subjected to the wrong procedure on the wrong body part and be given the wrong medication or anesthesia at the wrong time. There are many horror stories of patients getting their wrong leg or other body part amputated, or the wrong patient subjected to procedures meant for another, or patients dying on the operating room table because of an allergic reaction to the anesthesia, or missed diagnoses or wrong diagnoses due to an error by the physician, pathologist or technician, or equipment failure during a surgical
procedure, or sponges or instruments left in body cavities, or errors committed by surgeons leading to hemorrhage or other life-threatening events, or failure to properly monitor and observe patients, falls, failure to prepare the patient for discharge, or dramatic compromises in sterile fields. This list could go on and on with surgical errors. Therefore, to prevent these errors and safeguard patients, it is imperative that all staff coming into contact with patients thoroughly and accurately identify each patient and make sure that the proper patient is given the proper surgery on the proper body part and that all allergies or medications are clearly identified.
*Follow the rights of patient identification for surgery:
Right patient Right surgery Right location and confirmed by the patient, R.N., surgeon Right anesthesia
Surgical errors may be compounded with medication errors. Consider the necessity for history of concurrent or prior pharmacodynamics to prevent hazards from occurring. The patients’ allergies are extremely important to know and keep in mind. In addition, it is imperative that all healthcare personnel be aware of drug interactions and remains current on pharmacology changes and updates and to make sure drug calculations are accurate. For example, physicians, nurses, pharmacists and all others having a direct impact on the surgical patient must be aware of the interactions of certain drugs with anesthesia. The interaction of certain drugs with anesthetics can lead to arterial hypotension and circulatory collapse. Prior to surgery, the anesthesiologist should be notified if the patient is taking any of the following drugs:
Certain antibiotics: may when combined with muscle relaxants in anesthesia
interrupt nerve transmission causing respiratory paralysis and apnea, e.g., neomycin, streptomycin, dihydrostreptomycin, polymyxin A & B, colistin, kanamycin.
Antidepressants: particularly MAO inhibitors enhance the hypotensive effects
Phenothiazines: increase the hypotensive action of anesthetics. Diuretics: particularly thiazides cause electrolyte imbalance and respiratory Case Study 2
A 65-year-old patient was taken to surgery for amputation of the left leg due to diabetes. When the patient was taken to the recovery room, he and his wife were in horror when they realized that the right leg had mistakenly been amputated. Wrong-site surgery is a surgical error that has been addressed in hospitals. Now it is recommended that each person coming into contact with the patient sign off on the appropriate site for surgery. For amputation of the leg surgery, for example, the doctor and the patient should mark on the appropriate leg with a “yes” and the
healthy one with a “no” with a special surgical pen that does not wear off when the area is sterilized. Using an “X” could be confusing. The most common medical error related to surgery is wrong site surgery. These errors accounted for 11% of sentinel errors reported to JCAHO. Nurses can assist in preventing this type of error by orally confirming with the patient prior to surgery the correct site. Many hospitals require marking the site and involving the patient in the marking.
DIAGNOSTIC INACCURACIES Physicians render medical diagnoses after collecting data from a variety of sources. Errors may occur in many ways, such as:
The physician is unlicensed and may be rendering care without proper
The patient or family fails to provide specific information relative to the
patient’s health status, drug or food allergies, or medication regimen.
The laboratory or X-ray equipment fails resulting in incorrect data. The laboratory technician or pathologist fails to correctly analyze or interpret
essential data from tissue, urine or blood samples.
All standard tests are not conducted before making a final diagnosis. These
may include specialized procedures such as CT scan or MRI.
Case Study 3
Dr. S. was employed at a rural hospital in Florida for three years. During this time he made many friends. Physicians and patients liked him very much. Other physicians became worried, however, when he continued to prescribe medications that were not meant for certain diagnoses. Upon checking, it was found that Dr. S. had never been licensed to practice medicine and that the company that placed him in the hospital had neglected to check his credentials. Responsibility for credentialing falls on the hospital and the company that places physicians. Who knows how many errors were made by this impostor.
SYSTEM FAILURES There is a broad spectrum of system failures that lead to medical errors. For the purpose of this study, only a few shall be considered.
a. Physicians, nurses, technicians or other healthcare personnel practicing
without a license or with a falsified license.
b. Foreign-trained physicians or healthcare personnel with inadequate
c. Failure to report information to the Board of Medicine or other licensing
boards that contributes to the continuation of mistakes and errors.
d. Failure of the Boards to take punitive action against members. e. Shielding impaired practitioners.
*Remember our organizations are only as good as those who work in them.
a. Failure to properly identify patients, procedures and orders. b. Departments failing to communicate with each other. c. Physicians, nurses or other healthcare personnel providing misinformation
d. Language barriers leading to misunderstanding
*Remember the medium is the message. Be clear, concrete and concise.
a. Illegible handwriting. b. Documenting on the wrong chart. c. Improper filing of data. d. Offering personal opinions. e. Vague or inaccurate entries or generalizations. f. Omissions. g. Improper abbreviations. h. Late charting. i. Inaccurate record keeping or incorrect spelling. j. Improperly corrected charting errors. k. Improperly signed notes.
*Remember the 3 C’s of good charting:
Clarity Conciseness Consistency *Remember you didn’t do it if you didn’t chart it. Be precise. Be specific. Be thorough.
4. Equipment and supplies:
a. Improperly monitored equipment or supplies. b. Old or outdated equipment or supplies. c. Malfunctioning equipment, inadequate ventilation or lighting. d. Lack of equipment or inadequate supplies. e. Outdated medication, inadequate preparation of medication by
pharmacists of other healthcare personnel, substituting drugs without proper communication with the staff, diluting drugs for personal gain (i.e., the recent chemotherapy scam when the strength of the drug ordered was greatly reduced and the pharmacist took profits for personal gain), and miscalculations of medications.
f. Recognition of fire hazards and training in fire safety and prevention.
*Remember think safety and put the patient first at all times.
a. Reduced staff and inadequate nurse/patient ratios. b. Patient acuity. c. Frequent staff turnover. d. Poorly prepared staff.
e. Failure to orient new staff properly. f. The use of assistive personnel to replace licensed personnel. g. Personnel who are tired or angry as a result of working long shifts. h. Lack of continuing education.
*Remember we are all in this together. Think teamwork.
a. Failure to develop or comply with the standards of care of JCAHO, USP,
ASHP, ASCP, AHCA, OBRA and the many other organizations that establish standards of care.
b. Failure to follow proper policies or protocols and to review these at
c. Failure to practice good, safe and proper technique. d. Failure to pay attention to the results of the quality assurance or risk
management program and make changes as needed.
*Remember that adherence to standards keeps all of us safe and in compliance.
a. Failing to maintain confidentiality. b. Incorrect handling of controlled substances. c. Failure to practice defensive medicine. d. Dispensing the wrong medication. e. Performing the wrong surgical procedure or on the wrong patient. f. Patient falls or injuries as a result of negligence or malpractice. g. Failure to recognize suit-prone patients. h. Failure to obtain informed consent. i. Using restraints without order. j. Failure to obtain proper incident reports. k. Failure to obtain the proper insurance
*Remember risk vs. reward. The best defense is a good offense. Think safety and document, document, document. Case Study 4
When Amaryl was incorrectly given instead of Reminyl, various side effects including hypoglycemia led to death in one patient in a teaching hospital. Reminyl is used to treat mild-to-moderate dementia and Amaryl is used in the treatment of type 2 diabetes. Both drugs are in tablet form, have one dose denomination in common: 4 mg, and are stored next to each other in the pharmacy. What could have prevented this death from occurring is the spelling of the name of the drug correctly and including the indications on the prescription form. Anyone giving medications should be aware of the possibility of errors. There are many drugs that sound alike and are given for different reasons.
RECOMMENDATIONS FOR SAFETY The following are recommendations for creating safety systems in health care organizations: 1. Design jobs for safety
a. Decrease work hours b. Decrease workload c. Prevent distractions d. Prevent fatigue e. Hire the right person for the right spot f. Orient thoroughly g. Provide continuing education on safety and scope of responsibility h. Decrease the number of personnel handling medications and sensitive equipment i. Develop policies and procedures with safety in mind
Each and every healthcare practitioner must recognize the safety factor that contributes to medical errors. Safety must remain one of the primary goals of patient care so that we can reduce the number of deaths in Western medicine. At the same time, we must focus on quality and positive patient outcomes. 2. Avoid reliance on memory
a. Establish protocols b. Use checklists c. Use drug interaction software
Since we are only human, errors will continue to happen. If we rely on our memories less and use computers, protocols and checklists, we will enhance the amount of information needed to make good patient decisions and will reduce the need to remember so much and, therefore, reduce medical errors. Today we frequently see physicians using palm pilots with drug information right at their fingertips, pharmacists and nurses using computers containing patient profiles, drug product information, inventory, pricing, and other important data within easy access. The sheer number of available drugs, their different names and costs, multiple prescriptions from different physicians for the same patient, and the involvement of third-party insurers are among the many factors which make the use of prescription drugs a complex area for everyone involved, and especially for patients. Though the environment for dispensing and using drug products is highly complex, computerized systems are used to ensure safety and efficiency. 3. Use constraints and forcing functions
a. Use frameworks and pathways for making decisions b. Utilize decision trees c. Develop protocols to follow d. Decrease the need to consider tremendous amounts of information when forcing
Reduce the number of human errors by utilizing all resources that can assist the healthcare practitioner make appropriate decisions. 4. Avoid reliance on vigilance
a. Use automation whenever possible to reduce human error b. Increase the use of robotics in medication dispensing c. Utilize checklists to reduce the need to remember so much information
d. Rotate staff as appropriate to prevent burnout and increase knowledge and
The fewer number of hands that dispense medications, the fewer errors. Utilize automation whenever possible. 5. Simplify key processes
a. Decrease handoffs b. Implement automated dispensing
Decrease the human element as much as possible or decrease the number of personnel handling medications. 6. Standardize work processes
a. Develop protocols that all can follow b. Follow the standards developed and do not change unless approved
This reduces reliance on memory and allows those unfamiliar with a process to use it safely. Policies and procedures need to be under constant review and scrutiny; they are not static. They can change rapidly because of experience, judgment, and new clinical developments. Standards of care lead to safe, reliable and effective service. PURPOSE OF REDESIGNING THE WORKPLACE The purpose of redesigning the workplace is so errors are more difficult to make. All personnel must have a thorough understanding and appreciation for safety. We also need to stop pointing fingers when an error occurs and think of errors as system defects. Because “the devil is in the details,” nurses and other healthcare personnel must take care to explain everything to the patient and to understand everything they are doing. Most errors are system related not people related. They occur after a chain of events. That is why today we are looking for root cause analysis- not blame- to identify problems (error- prone situations) so that corrective action (systematicerror reduction strategies) can be put into place. Our goal in redesigning the workplace is to improve healthcare safety systems. Every facility must design minimum standards of acceptable care to minimize the possibility of adverse events or outcomes stemming from the process of healthcare itself. Factors that have led to this redesign include: Workload Stress
Relationships between practitioners and managers
Financial forces that create unsafe working conditionsPopulations at special risk for errors include: Children Elderly Pregnant Disability Chronic
Minorities Immigrants UninsuredSince we do not live in a perfect world even in healthcare, some errors are unavoidable. These include allergic reaction to a new medication, risks associated with a treatment intervention, or random errors.
Directions: Complete before continuing the program: Match the following: 1.
Answers: 1 C 2. J 3. A. 4. E 5. G 6. B 7. D 8. F 9. H 10. I Classification of Events An error is any departure from established protocol whether or not the result is
An adverse event results in injury or harm associated with the treatment rather than
A sentinel event occurs during care that results in permanent injury or unanticipated
death. Each of these will be explained below.
Errors Some hospital errors have received much publicity such as wrong site surgery or failure to prevent the abduction of a baby, but others happen as a result of other, less obvious causes. For example, patient falls, delay in initiating treatment, equipment failure, improper use of medical devices, drug interactions, post-op infections or complications, drug interactions, look-alike labels, misinterpretation of test results, illegible handwriting, ambiguous abbreviations, diagnostic errors, and communication errors. Adverse Events Ten powerful concepts for reducing errors were presented to the American Hospital Association by the Institute for Healthcare Improvement. These are:
SIMPLIFY: reduce the number of steps, non-essential elements, and/or
STANDARDIZE: limit unneeded variety of drugs, equipment, supplies,
STRATIFY: avoid “one size fits all” (substitute “Five sizes fit 80%). IMPROVE COMMUNICATIONS: use standard vocabulary, repetition,
SUPPORT “TEAM COMMUNICATION”: use group processes that promote (not discourage) information exchange from bottom to top and vice versa.
USE DEFAULTS PROPERLY. Design processes so that doing the “right”
thing is the easiest thing to do and requires the lowest energy expenditure.
AUTOMATE CAUTIOUSLY: avoid over-automating; but do so in a way
that is operator-friendly and has effective overrides if needed.
USE AFFORDANCES AND NATURAL MAPPING: design equipment
and environment so that physical shapes and flows—and visual controls—guide proper use.
RESPECT HUMAN LIMITS: recognize issues of stress, workload, time
pressure, circadian rhythm, limits to memory and vigilance, etc. Design for human capacity and behavior.
ENCOURAGE REPORTING OF ERRORS AND ERROR PRONE SITUATIONS: use anonymity, reward reports; build a culture that lauds increase of knowledge in mitigating errors. Serious Preventable Adverse Events The Washington based National Quality Forum (NQF) advocates a national strategy for measuring healthcare quality and promoting healthcare safety. The NQF developed a list of serious preventable adverse events that is subdivided into groups according to cause:
1. SURGICAL EVENTS (e.g., wrong body part, wrong patient, wrong
procedure, retention of foreign object, etc.)
2. PRODUCT OR DEVICE EVENTS (e.g., contaminated drugs, wrong
device, use of device other than as intended, product failure, etc.)
3. PATIENT PROTECTION EVENTS (e.g., infant discharged to wrong
person, patient suicide or attempted suicide, patient elopement—disappearing for more than hours, etc.)
4. CARE MANAGEMENT EVENTS (e.g., medication errors, transfusion
errors, maternal death or disability during low risk labor and delivery, stage 3 or 4 pressure ulcers acquired after admission, etc.)
5. ENVIRONMENTAL EVENTS (e.g., falls, burns, electric shock, injuries
related to restraints or side rails, problems with oxygen lines or other gases, etc.)
6. CRIMINAL EVENTS (e.g., impersonating a physician or nurse, abduction, Tracking Sentinel Events The Joint Commission began tracking sentinel events in JCAHO accredited healthcare settings and identified the top 4 sentinel events, along with their root causes, and made recommendations for corrective action. The top 4 were: 1. Inpatient suicide 2. Intra- and post-operative complications 3. Medication errors 4. Wrong site surgery INPATIENT SUICIDE
75% OF THE 245 PATIENT SUICIDES RESULTED FROM HANGING IN A BATHROOM, BEDROOM OR CLOSET. Jumping from the roof occurred in 20% of the time. Root cause analysis was determined to be: 1. The care environment: lack of non-breakaway bars, rods, or safety rails;
failure to test safety hardware; and inadequate security.
2. Assessment issues: incomplete suicide risk assessment at intake and
reassessment; incomplete exam of the patient (failure to identify contraband).
3. Staffing factors: insufficient orientation or training; incomplete competency
4. Level of care: incomplete or infrequent patient observations. 5. Communication: incomplete among caregivers, and data unavailable when
6. Care planning: assignment of the patient to an inappropriate unit or location.
Some of the recommended risk reduction strategies included:
Revising risk assessment strategies Updating the staffing model Enhancing orientation and staff development Updating policies and procedures for patient observation Monitoring consistency of implementation of observation procedures Revising information transfer procedures Redesigning security measures, including testing safety equipment Implementing education for family/support group re. Suicide risk factors
Intra- and Post-operative Complications
The types of procedures most frequently associated with these complications include interventional imaging/ and or endoscopy, tube or catheter insertion, open abdominal surgery, thoracic surgery. The most frequent complications included:
Nasogastric or feeding tube insertion into the trachea or bronchus
Massive fluid overload from absorption of irrigation
Open orthopedic procedures associated with respiratory failure, including
Endoscopic procedures with perforation of adjacent organs. Liver lacerations
Central venous catheter insertion in an artery
Imaging-directed percutaneous biopsy or tube placement resulting in liver
laceration, peritonitis, or respiratory arrest while temporarily off prescribed oxygen.
Burns from electrocautery used with flammable prep solution
Hospitals identified 8 root causes:
1. Incomplete communication among caregivers. 2. Failure to follow established procedures
3. Necessary personnel not being available when needed. 4. Pre-op assessment incomplete. 5. Deficiencies in credentialing and privileging. 6. Inadequate supervision of house staff. 7. Inconsistent post-op monitoring procedures. 8. Failure to question inappropriate orders.
Root cause analysis as defined by JCAHO is “a process for identifying the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event.
Medication Errors The Institute for Safe Medication Practices documents that 30% of medication errors occur due to deficient drug knowledge; 20% due to limited patient knowledge; and the remaining 50% due to poor labeling or drug nomenclature errors. In spite of the five rights (right medication, dose, patient, route and time), potential breaks in the system have been identified that offer opportunities for error. These include:
Inadequate patient information Inadequate drug knowledge Lack of protocols for high alert drugs (chemotherapy) Verbal/telephone orders Transcription Correct patient Incorrect dose Rate errors Missed doses Borrowing doses from a patient or using floor stock Double checks Needle sticks
Nearly 5% of the errors reported to the MEDMARX national database from 2004 to 2006 were attributed to misinterpretation of abbreviations. JCAHO is adding drug names; stem abbreviations, such as amps, nitro, succs, mcg, mL; and dose scheduling to the list. The most common abbreviation errors include “qd” in place of “once daily,” accounting for 43.1% of the errors. Other common errors were the use of “u” for units, “cc” for mL and “MSO4” or “MS” for morphine sulfate, plus decimal errors.
DENNIS QUAID DELIMMA Dennis Quaid, a Hollywood actor, and his wife gave birth to twins late in 2007. The twins were doing well and were scheduled to be discharged from the nursery when an R.N. gave an incorrect dose of Heparin. The babies were given 1000 times the dosage ordered by the physician and spent 11 days in the pediatric ICU. How does this happen? Look-alike drugs are the answer. The R.N. did not intend to give this incorrect dose and cause a life-threatening problem. Upon investigation it was found that the Pharmacy delivered 100 vials of the wrong medication and the nurse did not look carefully at the label. It is easy to confuse HEP-LOCK U/P 10 units/ml with Heparin Sodium injection 10,000 units/ml. Baxter has admitted that this confusion has resulted in the death of three infants and is addressing the problem. The Quaid twins, fortunately, have continued to progress at normal levels. Baxter, together with the FDA, has issued the following suggestions to prevent administration errors:
• Encourage staff to read drug labels prior to administering any
• Never rely on color to differentiate products • Stock the vials in separate areas of the refrigerator
• Verify current inventory to ensure that there is no stocking mix up Wrong Site Surgery Factors contributing to these errors include:
Emergency situations Unusual physical characteristics, such as morbid obesity or physical deformity Unusual time pressures to start or complete in the OR Multiple surgeons Multiple procedures being performed during a single surgical visit
The actual root causes identifies involved more than one factor, but the majority involved a breakdown in communication between the surgical team and the patient and family. The causes of preventable surgical errors included:
Marking of the surgical site not required Verification in the OR was not required No verification checklist Patient assessment incomplete Staffing issues Distraction factors Organizational culture issues
Recommendations for risk reduction strategies by JCAHO include:
Patients, family members, primary care physician, and surgeon agree on
Mark the surgical site and involve the patient. Use a verification checklist. Obtain oral verification of the patient, site, and procedure in the OR by each
Flaws in the System An average of 195,000 people in the U.S. die annually as a result of in-hospital medical mistakes. These errors are only the “tip of the iceberg” according to Paul C. Tang, M.D. who chaired a committee on patient safety for the Institute of Medicine in Washington, D.C. He states that there are probably more errors of omission than commission. These mistakes of neglect or follow-through happen in all healthcare settings, not just hospitals. He speculates that omission errors could be responsible for the loss of hundreds or thousands more lives each year. Every story is tragic, but that of Owen Gardner, age 2 from South Dakota, is even sadder than some: Owen’s Story
Owen Gardner began vomiting two days after his second birthday and than he developed diarrhea. The next morning his family physician told his mother that
Owen had lost 4 of his 34 pounds. “The doctor said he was moderately dehydrated”, said his mom. He needed an IV line to supply fluid. In the meantime, the mother was instructed to give him fluids to drink. His mother was concerned about Owen’s uncharacteristic weakness. He often rode horses on the family’s horse farm and he couldn’t get the energy to ride or do anything else. When his mother placed him in his bath, he began to drink shower water in his cup and drank it. She called the doctor and the doctor said he didn’t think anyone in the nearest rural hospital could start an IV on Owen and directed her to take him to a large city hospital two hours away. The parents drove rapidly to the city hospital and during the trip Owen’s breathing became labored. After arriving at the hospital, there was no place to park, so the father left the car idling in the parking lot and ran into the emergency department with Owen in his arms. He was directed to take Owen to the pediatric unit where things were “moving in slow motion.” Their first encounter was with a nurse who wanted to instruct them how to use the TV and the phone. The parents kept repeating that they didn’t care about that because their son needed an IV right now. The nurses finally gave him two ounces of fluid and said doctor’s orders said no more. Owen had a death grip on the bottle and it had to be forcefully pulled from his mouth. When the nurse finally tried to insert the IV, Owen was so dehydrated that his blood vessels had decreased in size and the nurse was unable to insert the much -needed fluid. A physician arrived 30 minutes later and began his laborious examination. Owen never got his IV. The physician tried to start the IV on his arms, but gave up and moved on to a vein in his head. Owen vomited and began to suffocate. A Code Blue was called, and one of the doctors on the team tried to insert a breathing tube into his windpipe, but instead put it into his esophagus. Now the air Owen needed flowed into his stomach instead of his lungs. He died several minutes later, about two hours after Owen arrived at the hospital on January 24, 2001. The official cause of death was dehydration, insufficient fluid, caused by infection. The unofficial cause was due to two species of medical errors. Some were mistakes of omission- of unnecessary delays and failures to call for backup help for procedures beyond the competency of his caretakers. One was a catastrophic error of commission, the inept insertion of a breathing tube. The parents won an undisclosed sum in a settlement.
72 Year Old Woman’s Story
A patient-controlled analgesia (PCA) is a device with push-button control of pain relievers such as morphine. It is delivered through an IV line and allows patients in hospital beds to get immediate pain relief without calling for a nurse’s help.
Nurses hooked up a 72 year old woman to a PCA unit after cancer surgery. She was allowed a maximum of one dose of morphine every 10 minutes- based on a physician order. Agitated and restless after surgery, she soon became listless, quiet and unable to tell nurses how much her pain had increased. With good intentions, the nurses guessed that her pain had increased, so they pushed the PCA button for her. Through the next two days the nurses continued to trigger morphine doses while the patient slept. They apparently had no idea that they had tripped an overriding backup safety feature: Even when a physician errs in estimating a safe dosage, a sedated patient stops pressing the button and avoids danger. The nurses did not realize that morphine was building up to life-threatening levels in the patient’s system. They kept delivering the drug even when her breathing became shallow and her blood pressure dropped to dangerously low levels. The signals that should have sounded to tell them to discontinue the morphine were not functioning. The resulting overload of painkiller caused a breakdown in her normal heart and lung function and the patient died several months later of a seizure and irreversible brain damage. “PCA by proxy” can occur also by families or visitors who keep pushing the buttons for patients after they fall asleep, not wanting them to wake up in pain.
Patient Fact Sheet The Agency for Healthcare Research and Quality has developed a “Patient Fact Sheet” that outlines 20 suggestions for patients to prevent medical errors. We as professionals must be sure that our patients know these guidelines:
1. The single most important way that a patient can help to prevent errors is to be
an active member of the healthcare team. We should encourage each of our patients to take an active role in every healthcare decision.
2. The patient should ensure that all doctors know about every medication that
the patient is taking. This includes prescription and over-the-counter medications, and dietary supplements such as vitamins and herbs. We should ask each of out patients about their medications to ensure that they are familiar with them.
3. The patient must ensure that all healthcare providers know about any allergies
and adverse reactions to any medications.
4. The patient should ensure that when a healthcare provider writes a
prescription, it is legible. If a patient can’t read the handwriting, it is likely that the pharmacist will not be able to. We should confirm that the patient can read the handwriting by asking them to read it aloud.
5. The patient should ask for information about medications in terms that can be
understood. They should ask the following important questions: What is the medication for? How am I supposed to take it, and for how long? What side effects are likely, and what to do if they occur? Is this medicine safe to take with other medicines or dietary supplements that I am taking? What food, drink, or activities should I avoid while taking this medicine?
6. When a patient picks up medication from the pharmacy, they should ask the
pharmacist the name of the drug and what it is for. This will clarify and ensure that the medication is what the physician prescribed.
7. If a patient has any questions about the directions on any medication labels,
ask either the physician or the pharmacist. In some instances, medication labels may be confusing. For example,, does “four doses daily” mean taking a dose every 6 hours around the clock, or only four times during waking hours? We can obviously preempt any confusion by giving thorough instructions, and asking the patient to verbally review their understanding?
8. A patient should ask the pharmacist for the best device to measure liquid
medicine. For example, if the instruction is to take a “teaspoon” of medication, is that a household teaspoon?
9. A patient should ask for written information about the possible side effects of
all medications. The patient should also share that information with family members so they will know what side effects are possible, and how to prepare for dealing with a side effect if one occurs. We should strongly encourage active participation by family members in all aspects of healthcare, but it is very important that they understand the possible implications for the medications that the patient is taking.
10. When a patient is to be hospitalized, if possible, the patient should choose a
hospital at which many patients have had the procedure or surgery.
11. When hospitalized, a patient should ensure that all healthcare workers who
come in direct contact have washed their hands. The patient should actually observe the handwashing, and if not, should ask.
12. Prior to being discharged from the hospital, a patient should ask the doctor or
nurse about the treatment plan that should be used at home. Again, family members should be available to hear the instructions and have the opportunity to ask questions. We should involve family members in the discharge planning process from the outset.
13. If a patient is having surgery, the patient, the referring doctor, and the surgeon
should all be in agreement about the surgical procedure to be performed.
14. A patient should not be afraid to ask questions and express concerns to any
healthcare provider, and should be encouraged to do so.
15. A patient should ensure that one healthcare provider is in charge of their care.
This will avoid miscommunication and confusion.
16. A patient should ensure that all healthcare professionals involved in their care
have access to all of their pertinent healthcare information. If it is important, it should be repeated to every member of the healthcare team.
17. All patients should have a family member or friend available during important
encounters with healthcare professionals. This will ensure that another person has the opportunity to ask questions, and seek clarification of confusing information. We should encourage this participation, rather than asking family members to wait outside the exam room.
18. Every patient should know that “more” is not always better. The patient
should ask the doctor why an additional treatment or test is being ordered.
19. If a test is done, the patient should ask for the results, and not assume that “no
20. Every patient should learn as much about their condition as possible. In
addition to asking the healthcare providers, they should utilize other reliable sources. We should also be familiar with these sources so that, if asked, we can provide this information to the patient and their family.
6 Ways to Take Charge of your Health Use doctors’ appointments to plan ahead, not just to get help for a current problem.
“When should I see you again?” or “How often should I have my blood pressure checked?” are great questions to help prevent you or your physician from forgetting crucial details.
Ask your doctor to make sure the medication label displays the reason why you’re
taking a medication. The extra information will help prevent mix-ups at the pharmacy and in your medicine cabinet. Cancer patients, for example, may take the drug methotrexate daily. But it'’ also prescribed in smaller doses to be taken only once or twice a week for other conditions like rheumatoid arthritis. Daily doses, if you're not a cancer patient, can be harmful, even fatal. If your pharmacist knows why you’re taking a drug, he’s more likely to give you safe directions.
Peruse prescription labels before you leave the pharmacy. Ask your doctor to give you copies of any lab reports and ask what the results mean.
In addition to your results, most reports provide information on normal ranges for cholesterol, blood sugar and other markers of health. Most also highlight your numbers when they stray out of normal limits. Don’t assume your doctor has noticed the anomalies.
If a physician prescribes a major procedure or operation, get a second opinion. Take more responsibility for your own health. It is up to you to adopt healthy
lifestyle lifesavers such as a low-fat diet and exercising regularly.
FLORIDA LAW As healthcare professionals, we have a duty and an obligation to report these types of errors to leadership to ensure that JCAHO standards are met. Also in Florida, certain serious adverse events must be reported to Florida’s Agency for Health Care Administration (AHCA). Florida law requires that licensed facilities, such as hospitals, establish an internal risk management program and an incident reporting system, which imposes an affirmative duty on all healthcare providers and employees of the facility to report adverse incidents to the risk manager. The risk manager must receive these incident reports within three days of the incident and, depending on the type of incident, the risk manager may have to report the incident to AHCA within 24 hours of receipt of the report. Florida law specifically defines an adverse incident as: “An event over which healthcare personnel could exercise control and which is associated in whole or in part with medical intervention rather than the condition for which such intervention occurred, and which also satisfies one of the following requirements:
• Results in one of the following injuries:
2. Brain or spinal damage 3. Permanent disfigurement 4. Fracture or dislocation of bones or joints 5. A resulting limitation of neurological, physical, or sensory function
which continues after discharge from the facility
6. Any condition that required specialized medical attention or surgical
intervention resulting from non-emergency medical intervention, other than an emergency medical condition, to which the patient has not given his or her informed consent.
7. Any condition that required the transfer of the patient, within or
outside the facility, to a unit providing a more acute level of care due to the adverse incident, rather than the patient’s condition prior to the adverse incident.
• Was the performance of a surgical procedure on the wrong patient, a
wrong surgical procedure, a wrong-site surgical procedure, or a surgical procedure otherwise unrelated to the patient’s diagnosis or medical condition.
• Required the surgical repair of damage resulting to a patient from a
planned surgical procedure, where the damage was not a recognized specific risk, as disclosed to the patient and documented through informed-consent process.
• Was a procedure to remove unplanned foreign objects remaining from a
If the adverse incident resulted in death, brain or spinal damage, the performance of a surgical procedure on the wrong patient, the performance of a wrong-site surgical procedure, or the performance of a wrong surgical procedure, the facility must report the incident within 14 hours to AHCA. For all other adverse events, Florida law requires that the facility investigate the event and report the findings to AHCA within 15 days of the incident. Failure to comply may result in fines up to as much as $25,000 per occurrence. JCAHO recommends that healthcare organizations voluntarily report sentinel events, and it encourages facilities to communicate the results of their root cause analyses and their corrective action plans. Conclusion The number of medical errors is high. Consequences of mistakes in healthcare are higher than other industries because these mistakes can lead to death or serious long term disability. Each healthcare practitioner must take an active part in reduction of medical errors and assist with the improvement of quality of care. Impact on Massage Therapy How does this impact massage therapy? First of all, all healthcare professionals should do no harm. Since massage therapists are healthcare professionals, it is imperative to learn more about medical errors and practice the profession as safely as possible so that the patients (clients) are protected. All of us in the healthcare profession have a duty to prevent errors. Massage therapists are no different from other healthcare professionals when it comes to performing the right treatment on the right patient at the right time.
Errors occur when we become complacent, are too much in a rush, or when we fail to care for each patient as an individual with individualized needs. Massage therapists are no different from other healthcare professionals when it comes to documentation and communication, which often lead to medical errors. In medical litigation, there is an old saying that says, "If you didn't document it, you didn't do it." Proper documentation and therefore communication are important for the practitioner and the patient. Proper documentation is essential in designing a workplace that is safe from errors. Use forms that are easy to use and understand. Review all intake forms with the patient. Ask the patient for feedback during each session and keep them apprised of their progress throughout the course of treatment. Refer out, if you have any doubt. Document clearly, concretely and concisely and in a timely fashion. To avoid mistaken identity, place the client’s name at the top of each page. Record any information you gave to the client before they made any decision to sign any consent form. This helps to ensure informed consent. Record any adverse events. Do not remove case notes or send original notes to any outsider unless the client has given consent. Respect confidentiality and HIPAA. Know and respect contraindications for massage therapy. Get trained in modalities that you are unfamiliar with and do not attempt any hands-on treatment unless you have been specifically trained in that modality. Today with the increasing fear of our litigious society, massage therapists and other healthcare professionals are practicing “defensive medicine.” If an error does occur, we are obliged to complete an incident report that outlines occurrence and responsibility. There must be honesty in these reports. Many practitioners are afraid to complete these reports for fear of losing their jobs. Unfortunately, these incident reports have become a means of punishment instead of a means of communication. The sad fact is that many of these errors could have been prevented in the future if the communication existed to alert other staff. Many fear the blaming and shaming of their character and reputation, so they choose to hide these errors. This causes the ongoing “sweeping under the rug” or cover up of errors. Therefore, communication and documentation suffer. The goal in prevention of medical errors is to educate personnel and improve patient safety so that errors can be reduced. Massage therapists can help prevent errors by admitting their mistakes and looking for the reasons they occurred. Another area that is important for massage therapists to address is medication safety for their patients. We cannot live in a vacuum today and not be aware of the impact of massage on the medications and herbs that the client is taking. As healthcare professionals, it is imperative to know and understand the patient’s medication profile. One important area for knowledge and understanding is the patient in pain and to know what medications the patient is taking. Patients who have their pain under control heal faster and rehab better. On the other hand, the use of medications such as laxatives, diuretics, or consciousness-altering drugs, including sedatives, analgesics, hypnotics, antidepressants and tranquilizers, is a major risk factor for patient falls. (Harkreader, H. 2000). Falls can
easily occur as the patient is getting off the table. Therefore, massage therapists must be aware of the risk and assist those clients who may be vulnerable to falls. It is important for massage therapists to be aware of the medications that the patient is taking, their actions, side effects and contraindications. This can help prevent errors and improve patient outcome.
Conclusion Safety in healthcare is a primary objective in preventing errors. Because there have been so many deaths and injuries as a result of unsafe medical care, it is now important that all healthcare practitioners focus on safety and improve our quality of medical care at the same time. The redesigned workplace will make it more difficult to make errors. Therefore, medication errors, surgical errors, diagnostic inaccuracies, and system failures will improve. References
• Allen, M. “Medical Error Prevention and Root Cause Analysis.” CME
Resource. Sacramento CA. January 1, 2007.
• Becher, C. and Chassin, M. “Improving Quality, Minimizing Error: Making it
Happen.” Health Affairs. May/June 2001.
• Berwick, D. “Examining Errors in Health Care.” Institute for Healthcare
Improvement. Boston MA. Presentation to the American Hospital Association Centennial Regional Leadership Forum. June 24, 1998.
• Gordon, I. “Medical Errors. The Scope of the Problem.” Jan. 2002.
• Penny, J. “That’s Not Supposed to Happen.” Vital Signs. October 2002.
• Phillips, D. “New Look Reflects Changing Style of Patient Safety
Enhancement. Journal of the American Medical Association. 2006.
• AHRQ Publication No. 00-P011, March 2000.
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