medical errors

FAILURE OF A PLANNED ACTION TO BE COMPLETED AS INTENDED OR THE USE OF A WRONG PLAN TO ACHIEVE AN AIM.

THEY ARE CLASSIFIED BY SEVERITY

SENTINEL HEALTH EVENT (SHE)
ADVERSE EVENT
NEAR MISSES

SERIOUS ERROR THAT HAS CAUSED ACTUAL OR POTENTIAL HARM TO A PATIENT.

EX: PATIENT SUICIDE, INFANT ABDUCTION OR DISCHARGE TO WRONG FAMILY, RAPE, HEMOLYTIC TRANSFUSION REACTIONS, SURGERY ON WRONG PT. OR WRONG BODY PART

INJURY CAUSED BY MEDICAL MANAGEMENT RATHER THAN UNDERLYING DISEASE OR CONDITION OF PATIENT

ERROR CAUGHT IN TIME, PREVENTING INJURY

MED ERRORS RANK 5TH AS CAUSE OF DEATH IN USA

COST OF MED ERRORS IS $345 MILLION

6 RIGHTS
AVOID ABBREVIATIONS
NO TRAILING 0'S
USE LEADING 0 FOR DECIMAL DOSES
IF NOT FAMILIAR W/ MED., LOOK IT UP
BEFORE ADM. A NEW MED, CK ALLERGIES, ID BRACELET, MAR
DON'T BORROW MED FROM ANOTHER PT. BIN
NEVER USE PARENTERAL SYRIINGE TO ADMINISTER LIQUID
DOUBLE CHECK HIGH ALERT DRUGS WITH ANOTHER PRACTICIONER
DO NOT RMOVE MED FROM IT'S UNIT-DOSE PACKAGE BEFORE ENTERING PT. ROOM

WRITE DIRECTLY ON PT. CHART AND THEN READ BACK THE ORDER
USE APPROPRIATE ABBREVIATIONS
IF IN THE MIDDLE OF THE NIGHT, HAVE A 2ND NURSE LISTEN IN ON THE CALL
MD. SIGN OFF ON IT W/IN 25 HOURS

DOCUMENT THE REFUSAL AND HAVE PATIENT SIGN THAT HE UNDERSTANDS THE IMPLICATIONS OF THE REFUSAL

CHECK WITH THE PRACTICIONER ?

VERIFY WITH THE PRESCRIBER

LOOK IT UP

IT DOESN'T CHANGE THE ERRORS OF THE SYSTEM

SWISS CHEESE IS A MODEL DESIGNED TO LOOK AT THE SYSTEM. IN THE MODEL, HOLES REPRESENT OPPORTUNITIES FOR FAILURE IN THE SYSTEM. IF HOLES LINE UP, AN ERROR WILL OCCUR.

ROOT CAUSE ANALYSIS IS DONE AFTER THE FACT TO IDENTIFY FUNDAMENTAL CAUSE OF A MED ERROR.

FAILURE MODE EFFECT ANALYSIS REVIEWS HIGH RISK OR NEWLY IMPLEMENTED SERVICES IN ORDER TO ANTICIPATE WHERE THEY MIGHT FAIL (THIS SYSTEM IS MORE PRO-ACTIVE)

PATIENTS/FAMILIES OR THEIR REPRESENTTIVE ARE ENTITLED TO A PROMPT, TRUTHFUL AND COMPASSIONATE EXPLANATION OF WHAT OCCURED, THE REMEDIES PROVIDED AND ITS SHORT-AND LONG TERM EFFECTS.

IN FL.:
IF AN ADVERSE EVENT OCCURS IN PHYSICIANS OFFICE, REPORT TO DEPT. OF HEALTH SERVICES WITHIN 15 DAYS

OCCURING IN A LICENSED FACILITY - REPORT IN 1 BUSINESS DAY AFTER RECEIVING REPORT OF INCIDENT

PERFORMANCE OF SURGICAL PROCEDURE ON WRONG PT..

BRAIN OR SPINAL DAMAGE TO A PT.

Risk management office


examples: design safe systems, simplify standing orders, drug protocals, standardize or standing orders, communicate, adjust environment, rewarding vs. punishing

enhances safety of patients, employees, and visitors through risk detection, evaluation, and prevention

procedure that seeks to prevent med errors through ongoing assessment and updating of every patients list of medications throughout the health care process and the timely communication of such information to both patients and their health care providers

3 steps involved:
verification
clarification
reconciliation

collect pt. med. info with focus on meds currently used (include over the counter meds and supplements)

professional review of the pt. drug info. to ensure that dosages and meds are appropriate for patient

further investigation of any discrepancies and documentation of relevant communications and changes in med orders

U - Units
Q.D. - Every day

phase 1 - ordering/prescribing

phase 2 - dispensing

phase 3 - Administration (most errors occur in this phase due to carelessness regarding 5 rights)

phase 4: monitoring

illegible handwriting
inappropriate abbreviations
failure to note allergies
wrong drug/dose/form

strategies:
have essential info. about client and drugs
develop protocols for high risk meds
implement computerized MD order entry
decreased possibility of confusing orders

improper transcription
failure to verify order
inaccurate drug calculations
labeling errors
storing meds
dispensing meds
inadequate databases
failure to educate patient

strategies:
use of technologies (premixed and filled solutions, pyxis, acudose)
education of product changes
decrease name and package similarities
double check neonatal and ped. meds and high-alert meds
include a clinical pharmacist as part of the pt. care team.

if not familiar w/ med, look it up
ck. allergies, id bracelet, mar, chart
5 rights of med. admin.
if dose missing from pt. bin, do not borrow from another pt. bin
never use parenteral syringe to admin. liquid med
have someone double check when admin. high alert drugs
do not remove dose from unit dose pack before entering room

non-punitive reporting
nurses need to be shielded from personal and professional threats to encourag error reporting of:
near misses, med errors, adverse drug reaction

track, trend, and review
implement changes to improve systems

U - units
mcg - micrograms
Q.D. - every day
Q.O.D. - every other day
D/C - discontinue,discharge
HS - Half Strength
cc - Cubic centemeters
AU, AS, AD - both ears, left ear, right ear