Chapter 2: Prevention of Medical in Nursing

2 Contact Hours

Author: Adrianne Avillion, D.Ed., RN

New Release Date: 2/15/2016 Expiration Date: 2/15/2019

Audience The target audience for this education program is nurses who want to implement best practices to decrease the possibility of medical errors and enhance safety. Purpose statement Medical errors are a silent and largely unseen tragedy. Estimates Health and Human Services (DHHS) identified 180,000 deaths related suggest that medical errors and other instances of preventable harm to medical in 2010, of which 44% were determined clearly at hospitals result in the death of 210,000 to 440,000 Americans each or likely preventable. This course presents the problems as well as year. A 2013 study by the Inspector General of the Department of strategies for Florida nurses.

Learning objectives ŠŠ Define terms important to the concept of medical error. ŠŠ Identify strategies for reducing nine common medical errors. ŠŠ Describe the various categories of medical errors. ŠŠ Explain the Affordable Care Act’s impact on medical error ŠŠ Identify factors that contribute to medical error occurrence. reduction. How to receive credit ●● Read the entire course, which requires a 2-hour commitment of ○○ OR completed the test and submit (a passing score of 70 time. percent is required). ●● Depending on your state requirements you will asked to complete Note: Test questions link content to learning objectives as a either: method to enhance individualized learning and material retention. ○○ An attestation to affirm that you have completed the ●● Provide required personal information and payment information. educational activity. ●● Complete the MANDATORY Self-Assessment, and ●● Print the Certificate of Completion. Accreditation statement Elite is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Designation of credit Elite designates this continuing nursing education activity for 2.0 contact hours.

Faculty Adrianne Avillion, D.Ed., RN Content Reviewer June D. Thompson, DrPH, MSN, RN, FAEN, Activity director June D. Thompson, DrPH, MSN, RN, FAEN, Lead Nurse Planner Disclosures Resolution of Conflict of Interest interest for all individuals in a position to control content of the CME In accordance with the ANCC Standards for Commercial Support activity. for CNE, Elite implemented mechanisms, prior to the planning and implementation of the CNE activity, to identify and resolve conflicts of

Page 10 ANCC.EliteCME.com Planning committee/faculty disclosures Elite staff involved with this activity and any content validation ●● June D Thompson, DrPH, MSN, RN, FAEN, Lead Nurse Planner. reviewers of this activity have reported no relevant financial ●● Tracey Foster, Director of Programming. relationships with commercial interests. Disclaimer The information provided at this activity is for continuing education medical judgment of a healthcare provider relative to diagnostic and purposes only and is not meant to substitute for the independent treatment options of a specific patient’s medical condition. © 2015: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to provide medical, legal, or professional advice. Elite Professional Education, LLC recommends that you consult a medical, legal, or p professional services expert licensed in your state. Elite Professional Education, LLC had made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and are not actual customers. outbreaks of meningitis on college campuses, or as seen in current outbreaks of measles (the most contagious of childhood ) in unvaccinated populations. Healthcare professionals must help and families consider whether the potential side effects of vaccination outweigh the benefits of immunization. With appropriate immunization programs, it is hoped that more and more vaccine-preventable diseases can be eradicated.

Introduction Medical errors are a silent and largely unseen tragedy. Estimates ●● An estimated 86% of total incidents were not reported. suggest that medical errors and other instances of preventable harm ●● Of the unreported incidents, 62% were not reported because staff at hospitals result in the death of 210,000 to 440,000 Americans each members did not perceive them as reportable. year. A 2013 study by the Inspector General of the Department of ●● 25% of the unreported incidents were described as commonly Health and Human Services (DHHS) identified 180,000 deaths related reported but not reported in these cases. to medical error in 2010, of which 44% were determined clearly or ●● Events were most often reported by nurses who identified them as likely preventable[1]. part of the regular course of care. Based on these figures, medical errors are the third leading cause of [2] Evidence based practice (EBP) alert! Research shows that a high death in America, after heart and cancer . Beyond the obvious percentage of medical errors go unreported. This can lead to a emotional toll, unexpected adverse effects related to medical error dangerous environment for patients. Nurses must take the lead in increase personal and institutional financial burdens, adding estimated accurate reporting of medical errors and the promotion of systems billions of dollars to costs annually. To learn more and processes that decrease the potential for error. about how, when, and why medical errors occur, federal regulations established in 2003 required hospitals participating in the Medicare Nurses are essential for developing and maintaining a culture of safety program to, “track medical errors and adverse patient events, analyze within their organizations and are the professionals most likely to their causes, and implement preventive actions and mechanisms that discover and report adverse events[5]. Thus, it is important that nurses include feedback and learning throughout the hospital.” Hospitals work to reduce the risk of medical error and respond appropriately and report this information using a federally-approved Quality Assessment capably to medical error occurrences. and Performance Improvement (QAPI) program[3]. While reporting has been compulsory since 2003, survey data presented Nursing consideration: Nurses are in a position to help educate by the DHHS Office of the Inspector General in 2012 found that[4]: their colleagues, not only in nursing but in other disciplines, about ●● Only about 14% of “patient harm events” experienced by Medicare ways to prevent medical errors and what to do if one is discovered. beneficiaries were captured by hospital incident reporting systems. This will enhance the safety of the patients’ environments.

Definition of terms Medical error is defined as harm to a patient that results from either: [6,7] ●● errors: Medication errors are defined as errors that ●● The failure of a planned action to be completed as intended or occurs due to mistakes made in the processes of the drug’s ●● The use of a wrong plan to achieve an objective. prescribing, transcribing, dispensing, administering, or monitoring. Medical error can be associated with failures in medical practice, ●● Near-miss: An error that is detected and corrected before harm can products, procedures, and/or systems. Medical error requires two critical be done. parts: harm and whether the harm or error could have been prevented[6]. ●● Sentinel event: An unexpected occurrence involving death or serious physical or psychological , or the risk of death or Other terms related to medical error include[6,7,17]: such an injury. ●● Safety: Freedom from accidental injury. ●● Sentinel event: A sentinel event is an unexpected occurrence ●● Adverse drug event: An adverse drug event is injury resulting from involving death, serious physical or psychological injury, or the the use of a drug. An adverse drug event may be caused by an adverse risk thereof. A sentinel event indicates the need for immediate drug reaction, a medication error, or an overdose. An adverse drug investigation and response. event frequently necessitates discontinuation of the drug. ●● : An adverse drug reaction is an unavoidable, Nursing consideration: Nurses must be able to define important appreciably noxious, or unpleasant reaction that occurs during the terms related to medical error in order to adequately promote a normal, proper use of a medical product. Some drug reactions may culture of safety. be minor and temporary; others have the potential to be permanent and serious.

ANCC.EliteCME.com Page 11 Categories of medical errors Many preventable adverse events can be associated with more than types of errors occur in about one of 112,000 surgical procedures one type of medical error. There are many different ways to categorize or that an individual hospital would experience such an error every medical error, and categories may overlap, but the following 5 to 10 years. However, these data only include procedures in the classifications are common. operating room. If procedures performed in other settings such as ●● Diagnostic errors: Diagnosis errors are errors that occur when a ambulatory centers were to be included, the rate of such diagnosis is missed, wrong, or delayed[8]. errors may be significantly higher[13]. ●● Systems or process errors: Systems or process errors involve ●● errors: Pharmacy errors can involve such issues as the predictable human failings in the context of poorly designed preparation or processing of a prescription or giving incorrect system[9]. directions to patients. Researchers at a tertiary care medical center in ●● Active errors: Active errors nearly always involve frontline staff Houston, Texas, recently monitored 1,887,751 medication orders, 92 members and occur at the point of contact between a human and medication error events, and 50 . They determined that some part of a larger system[9]. the overall error rate was 4.87 errors per 100,000 verified orders. ●● Latent errors: Sometimes referred to as “accidents waiting to happen,” Pharmacy errors were associated with workload, work environment, latent errors involve failures of organization or design (e.g., systems and number of pharmacists per shift. Factors such as the type of and processes) that allow active errors to cause harm[9]. pharmacy degree, age, experience, and the number of years at an ●● Medication errors: Medication errors are “any preventable event institution may also influence the error rate[14]. that may cause or lead to inappropriate medication use or patient ●● Laboratory errors: Errors made in the laboratory can be technical, harm while the medication is in the control of the health care procedural, or the result of poor communication. The ECRI professional, patient, or consumer [10].” Institute evaluated 2,420 mistakes that occurred between 2011 and mid-2013. Only 4% of reported potentially harmful errors occurred Nursing consideration: Adhering to the eight “rights” of in the laboratory itself. Nearly 75% of mistakes occurred in the medication administration helps nurses avoid medication errors. pre-analytic stage, defined as the time frame in which tests are These eight rights are[11]: selected and ordered, specimens are identified and transported, and ●● Right patient. patients are prepared. Such mistakes were more likely to be linked ●● Right medication. to labels that had the wrong patient’s name, the wrong specimen ●● Right dose. ordered, and incomplete or mission information. The other 22% ●● Right route. occurred in the post-analytic stage, when results were interpreted, ●● Right time. reported, or stored[15]. ●● Right documentation. Nursing consideration: Any discussion of medical errors needs ●● Right reason. ●● Right response. to include clarification of “never ever events.” This term was first used in 2001 by Ken Kizer, MD, former CEO of the National ●● related errors: According to the U.S. Centers for Quality Forum in reference to especially shocking medical errors Disease Control and Prevention (CDC) there are 1.7 million health that should never occur. The list of these issues consists of 29 events [16] care-associated every year. Approximately 22% are grouped into seven categories. The categories are : infections of surgical wounds; 32% are urinary tract infections 1. Surgical events. (UTIs); the remainder is infections of the lungs, blood, and other 2. Product or device events. parts of the body. [12] It is impossible to estimate the percentage 3. Patient protection events. of hospital acquired infections that are unavoidable, but evidence 4. Care management events. shows that many of these infections can and should be prevented. 5. Environmental events. For example, failure to conform to hand hygiene standards can 6. Radiologic events. lead to preventable infections. 7. Criminal events. ●● Surgical errors: Wrong-site, wrong-procedure, wrong-patient For a complete list of the 29 events that are part of these categories, errors (WSPEs) should never occur and indicate serious safety access https://psnet.ahrq.gov/primers/primer/3/never-events. problems within an organization. Recent studies show that these

Medical error scenarios Which of the following scenarios would be considered medical error? Example 3: A 2-year-old child is brought to an emergency room Example 1: A nurse is supposed to administer three because he has swallowed a small amount of drain cleaner; the drain to a patient once a day, at 8 a.m.: furosemide 40 mg, orally (PO); cleaner has a pH of 13.5. There are no burns in or around the mouth, digoxin 0.25 mg, PO; and potassium chloride, 40 mEq, PO. At 7:55 and the child seems relatively comfortable; however, he will not a.m., another patient the nurse is caring for complains of difficulty eat, but will occasionally take small sips of fluids. After 2 hours of breathing. The nurse assesses the patient, administers a PRN observation, the child is discharged. Neither the ENT nor GI services bronchodilator treatment, and then calls the patient’s . It is on-call were consulted. The next day, the parents bring the child back now 8:50 a.m., and the nurse gives the patient the furosemide, digoxin, because he is crying and will not eat or drink. An endoscopic exam and potassium chloride. reveals a second-degree burn in the esophagus. The child suffers Example 2: A patient is recovering from total knee arthroplasty, and strictures that need frequent dilations and must receive nutrition several months after surgery, he is still having slight pain in the joint. through a feeding tube. The operation and the initial recovery period were uneventful, and ●● Example 1 is not an example of medical error. Although there was after an examination the surgeon concludes that the prosthesis has not an alternative action that would have been better for the patient loosened and is in good working order, there is no infection in the area – the nurse could have made arrangements with another RN to and there are no other postoperative complications. administer the medications – no occurred and none was likely to occur. Blood and tissue levels of the drugs were not likely to drop so precipitously that the patient might suffer harm.

Page 12 ANCC.EliteCME.com In certain circumstances, administering medications late would be These scenarios clarify how medical error is determined. In the first problematic. While this situation is not a medical error, a similar example, no harm or potential harm was possible; and, in the second, action might have resulted in medical error. the patient complained of an expected side effect that did not result ●● Example 2 is not an example of medical error. The surgeon’s from treatment failure. The third example, however, shows a condition assessment and response was appropriate, as some degree of pain is an that should have been detected and treated, causing the patient expected and unavoidable adverse effect of joint replacement surgery. further injury and complications that might have been prevented with ●● Example 3 is an example of medical error. Although a very unusual reasonable and appropriate care. occurrence, esophageal injury resulting from alkali exposure can exist even when the patient has no signs or symptoms of external Nursing consideration: Nurses must follow their organizations’ burns. Had an ENT or GI physician been consulted, an endoscopic policies and procedures regarding medical error reporting. Accurate examination of the child would have been likely. reporting is essential to analysis of errors and making improvements in processes and systems.

Factors that contribute to medical errors The causes and prevention of medical errors are the focus of considerable address the three most common causes of medical errors, communication, academic and professional attention. Prevention strategies typically planning and knowledge, and systemic or institutional failure.

Communication Accurate communication is vital for diagnosing; treating; dispensing by communication breakdowns[18]. Such breakdowns can include and administering medications; maintaining ; following inadequate patient handoffs, interpersonal communication failures, and policies and procedures; and ensuring treatment instructions are reluctance to admit a lack of knowledge or failure to seek clarification. carefully followed. Communication errors can be verbal or written, and occur in every part of the process of delivery of care. Nursing consideration: One often overlooked aspect of communication that can be a cause of medical errors is lack of Breakdowns in communication are one of the leading causes of communication. No communication, as well as poor and inaccurate medical errors. The Joint Commission reports that, according to a communication, clearly contributes to medical error. of over 4,000 adverse events, 70% were caused

Planning and knowledge Planning and knowledge failures can encompass virtually every aspect professionals work together to establish the most effective plan of care of the delivery of care, and the different types of errors that can be for each patient, to ensure that all members of the health care team have caused by failure in planning and failure in knowledge are almost the necessary knowledge and skills to implement the plan of care, and to limitless[6,7]. It is therefore essential that nurses and other health care evaluate the effectiveness and safety of the plan as it is implemented.

Systemic or institutional failures The Institute of (IOM) reports medical errors are more often due shame culture of health care is counterproductive if the goal is reducing to poor systems than negligent practitioners. System failures involve poor error. First, it discourages voluntary reporting; second, it does not assess planning and execution, inappropriate or absent policies and procedures, whether there was a system contribution to the error; and third, it focuses failure to procure and maintain equipment, failure to hire and retain staff, on assigning blame and punishment, not on why the error occurred, or failure to maintain safe staffing levels, failure to monitor care, and failure on error prevention[6,7]. to recognize errors and correct the conditions that caused the errors. Some suggest health care medical error reporting would be more [6,7] While systemic failures in communication, infection control, and effective if modeled on alternative reporting systems, such as medication prescribing, dispensing and administration have contributed those used in the aviation industry, which has a very high level of considerably to medical error, entrenched health care traditions (e.g., safety. Aviation reporting guidelines do not absolve individuals of using blame and shame, closing ranks, and strategies that minimize legal responsibility and punishment for errors, but treat each incident as a liability) have played a major role in discouraging disclosure necessary to complex event with many possible causes and contributing factors[6,7]. reducing the risk of medical error. Personal behavior is in one sense the least changeable aspect of medical Nursing consideration: Many health care professionals are afraid error prevention. Health care professionals are not motivated to disclose to report errors because of the fear of being reprimanded. It is part medical error if policies and procedures focus on punishment rather than of a true culture of safety for an organization’s leaders to look at the timely reporting and prevention. While individuals bear responsibility entire system or process involved in an error, and avoid rushing to for their actions when a medical error occurs, the traditional blame and cast blame on a particular individual.

CAUSES OF, AND STRATEGIES FOR, REDUCING COMMON MEDICAL ERRORS Studies of medical error show the potential risk of some errors is far 6. Pressure ulcers. greater than others, with some likely to happen repeatedly. A 2014 7. Surgical site infections. Partnership for Patients study described the most common medical 8. Venous thromboembolism (VTE). errors in the . Nine core patient safety areas of focus were 9. Ventilator-associated events. [19] identified : Let’s examine what strategies might be used to enhance safety and 1. Adverse drug events (medication errors). decrease the occurrence of these core safety issues. 2. CAUTIs. 3. Central line-associated bloodstream infections. 4. from falls and immobility. 5. Obstetrical adverse effects.

ANCC.EliteCME.com Page 13 Adverse drug events (medication errors) Medication errors have received a huge amount of attention, especially ●● Oxytocin, IV. in nursing practice. The incidence of medication errors is an issue of ●● Nitroprusside sodium for injection. contention. Because definitions of medication errors can differ, many ●● Potassium chloride for injection concentrate. medication errors must be self-reported to be recorded (and data ●● Potassium phosphates injection. suggest a significant percentage of medication errors are not reported), ●● Promethazine, IV. and there is no central agency or institution that is responsible for ●● Vasopressin, IV or intraosseous. collecting reports of medication errors, no one knows how many In an effort to identify root causes, there has been a lot of attention medication errors actually occur. focused on why medication errors occur. Nurses surveyed about A medication error is defined as “any preventable event that my cause medication errors listed a variety of reason for their mistakes, or lead to inappropriate medication use or patient harm while the including poor staffing, unskilled/new nurses, stress, personal error, mediation is in the control of the health care professional, patient, or and distraction. These data suggest the most common medication consumer[23]”. Medication errors are the most common type of medical errors are related to: error. About 1.3 million people are injured annually in the United ●● Wrong dose. States following such errors[24]. ●● Wrong diluent. The incidence of medication errors varies according to patient ●● Calculation errors. population and clinical setting. Pediatric patients and the elderly are ●● Extra dose. more likely to be harmed by medication error than other segments of ●● Too-rapid administration rate. the population; children are more susceptible to harm from dosing ●● Wrong concentration. errors due to their small size, while older individuals tend to take more ●● Drug (contraindicated drug administered). medications, increasing their potential for medical error and adverse ●● Avoidable drug interaction. drug interactions. Medication errors are more likely to occur in fast- ●● Contraindicated drug. paced, stressful environments such as intensive care units, emergency ●● Incorrect order transcription. departments, and certain clinical areas[20,21.22]. ●● Missed dose. ●● Wrong route. Data from the U.S. Food and Drug Administration (FDA) show that ●● Administration too early or too late. the most common error involving medications was related to the administration of an improper dose of medicine, accounting for 41% Poor staffing is often cited as a reason for medication errors, as are of fatal medication errors. Administering the wrong drug and using the interruptions or lack of attention during the processes of medication wrong route of administration each accounted for 16% of the errors[24]. preparation or administration. Other reasons cited are considered to be system or institution-based. Tracking research by the FDA concluded these factors were the most common causes of medication error: EBP alert! Almost 50% of fatal medication errors occur in people 1. Incomplete patient information (e.g., not being aware of drug over the age of 60. The older population may be at particularly or not being aware of other currently prescribed medications). high risk for such errors because they frequently take multiple 2. Unavailable or out-of-date drug information. prescription medications[24]. Thus, nurses must be especially 3. Miscommunication of drug orders. careful when administering medications and providing patient/ 4. Lack of appropriate labeling. family education to this population. 5. Environmental factors that contribute to medication errors.

The medications/classes of medications most likely to be involved In general, medication error occurs when health care professionals: in medication errors are insulin, antibiotics, cardiovascular drugs, ●● Do not have the proper knowledge. anticoagulants, diuretics, nonsteroidal anti-inflammatories (NSAIDs), ●● Do not follow rules or are using bad rules. inhaled medications, narcotics, and ophthalmic preparations[25]. Some ●● Forget to perform a task or forgot important patient information. of these drugs are a frequent cause of medication errors because they ●● Simply make a mistake in the performance of medication are commonly used (e.g., insulin and antibiotics). Others are sufficiently administration. potent and there is little room for therapeutic error and substantial The five main causes of medication errors are action-based, knowledge- potential for harm from seemingly small mistakes (e.g., the cardiovascular based, rule-based, memory-based, and knowledge-based[24].: drug nitroprusside, heparin, warfarin, insulin, or colchicine). An action-based medication error is defined as the performance of an Another set of drugs are common causes of medication errors unintended. Examples of action-based medication errors would include because they can be easily confused (e.g., Percocet® [acetaminophen selecting the wrong medication or administering an incorrect dose. and oxycodone] confused with Vicodin® [acetaminophen and A rule-based medication error occurs because the nurse did not follow hydrocodone]). proper rules or procedures for medication administration. Examples could The Institute of for Safe Medication Practices (ISMP) has identified include a good rule that was not applied (e.g., checking with another nurse some specific medications classified as high-risk, meaning that these when performing a dose calculation for a high-risk drug such as insulin), medications bear a heightened risk of causing significant patient harm or the application of a bad rule (e.g., the health care facility does not when used in error[26]: require nurses to double-check dose calculations for high-risk drugs). ●● Ephinephrine subcutaneous. A memory-based medication error occurs when a nurse simply forgets ●● Epoprostenol (Flolan) IV. to perform a task or forgets important information about the patient. The ●● Insulin U-500 (All forms of insulin are considered high-risk. nurse may forget to give a dose of a medication, that the medication has Insulin U-500 has been singled out for special emphasis to bring been discontinued, or that the patient is allergic to the medication. attention to the need for distinct strategies to prevent the types of errors that occur with this concentrated form of insulin). Knowledge-based medication errors are errors that could be avoided ●● Magnesium sulfate injection. with a reasonable and appropriate level of professional knowledge. If ●● Methotrexate, oral, non-oncologic use. the nurse is familiar with the drug and the patient, knowledge-based ●● Opium tincture. medication errors are avoidable.

Page 14 ANCC.EliteCME.com Knowledge-based medication errors can be general, specific, or expert: [24] Strategies to decrease the risk of medication error include: ●● A general knowledge-based error occurs when someone makes ●● Adhere to the eight rights of medication administration[11]. an error because of lack of or disregard for information that is ●● Ensure that handoffs involve the transfer of essential information considered general knowledge (e.g., warfarin can cause bleeding). when the responsibility for care of the patient shifts from one ●● A specific knowledge-based error occurs when someone makes health care provider to another[18]. an error because of lack of or disregard of information that would ●● Use barcode technologies and electronic health records with be considered specific knowledge (e.g., a patient is given warfarin computerized prescriber order entry[27]. even though the INR is very high). ●● Involve pharmacists throughout a patient’s hospitalization. ●● An expert knowledge-based error occurs when someone makes ●● Require nurses who are administering medicine to wear a colored an error because of lack of or disregard of information that would sash or vest to prevent interruptions. be considered expert knowledge (e.g., the failure to use genetic ●● Have two clinicians independently verify doses prior to testing to check for variations in patient response prior to initiating administering medication. with warfarin).

Catheter-Associated Urinary Tract Infections (CAUTIs) Experts recommend the following actions to prevent CAUTIs[28,29]: [28] EBP alert! Research shows that : ●● Establish policies and procedures for catheter use including ●● 70% to 80% of CAUTIs are due to the presence of an indications for urinary catheterization, insertion guidelines, and indwelling urethral catheter. criteria for urinary catheterization. Nurses and other members ●● 12% to 16% of adult hospitalized patients will have a urinary of the health care team should be sure that catheter placement is catheter at some time during hospitalization. limited to those patients who meet criteria for use. ●● When an indwelling urethral catheter remains in place the daily ●● Be sure that only trained, competent personnel insert urinary risk of acquiring bacteria in the urinary tract varies from 3% to catheters. Provide education and training as needed. 7%. ●● Ensure that supplies and equipment necessary for aseptic Nurses must do everything possible to find alternatives to insertion catheterization technique are readily available. of indwelling catheters and, if such catheterization cannot be ●● Review the necessity of continuing indwelling catheters on a daily avoided, to facilitate its removal as soon as possible. basis. Such catheters should be removed as soon as possible. ●● Implement infection control surveillance programs. Include the development of any CAUTIs. Develop appropriate action plans to Additional research findings show that[29]: reduce/prevent CAUTI occurrence. ●● The major risk factor for CAUTIs is prolonged catheterization. ●● 25% of hospital inpatients and up to 90% of patients in a critical care Nursing consideration: Nurses should ensure that indwelling unit have a urinary catheter at some point during hospitalization. catheters are properly secured to prevent movement and urethral Unfortunately, such catheters are often inserted without an appropriate traction. They must also ensure that a sterile, continuously closed indication or remain in place after the need is no longer present. drainage system is maintained[28,29]. ●● Most hospitals do not have effective strategies for preventing CAUTIs.

Central-line associated bloodstream infections More than 5 million patients require central venous access every year, Maximum sterile barrier precautions and infection is the main if intravascular catheters are Maximum sterile barrier precautions must be taken when inserting used in critically ill patients[30]. Every year, an estimated 250,000 cases the venous catheter. These precautions include, not only the person of central venous catheter-associated bloodstream infections occur in inserting the catheter, but anyone assisting with the procedure and the the United States. The cost per infection is estimated to be between patient as well[30,31]. [31] $34,508 and $56,000 . Nurses and their interdisciplinary colleagues Skin antisepsis must make every effort to prevent such infections. The IHI advocates the use of chlorhexidine skin antisepsis. The CDC Hand hygiene prefers the use of a 2% chlorhexidine solution, but a tincture of iodine Proper hand hygiene is the most important infection control measure or 70% alcohol can be used[31]. Skin antisepsis should be performed at and the most effective way to prevent the transmission of health care- the time of insertion and with every dressing change[31,32]. [30,31,32] associated infections . Selection of catheter site Nursing consideration: Patients and families should be taught to The site of insertion is important to optimal outcomes. The use of the observe whether health care workers are washing their hands before subclavian site is preferred to the jugular or femoral sites in adults to [31,32] and after providing patient care. They should be told to ask their minimize infection risk . health care providers to wash their hands if they have not done so. Dressing change Dressings for insertion sites must be impermeable to water vapor. The CDC and the Institute for Healthcare Improvement (IHI) both They can be either sterile gauze or sterile transparent, semipermeable advocate that hand hygiene be performed “before and after palpating the dressing that covers the catheter insertion site. Topical antibiotic catheter insertion site; before and after inserting; replacing, accessing, ointments or creams should not be applied to the insertion site repairing or dressing a venous access device; before donning and after because of the possibility of promoting fungal infections or pathogen removing gloves; when hands are visibly soiled or contaminated; before resistance. Dressings are changed when they become wet, loose, or and after invasive procedures; and after using the bathroom. Palpation soiled. Central Venous Access Device (CVAD) dressing are generally of the insertion site should not be performed after the application of skin changed weekly for a transparent semipermeable dressing, and every antiseptics, unless aseptic technique is maintained [31].” 48 hours for a gauze dressing[31].

ANCC.EliteCME.com Page 15 Assessment and removal EBP alert! The risk for infection has declined with the The catheter should be removed as soon as it is no longer needed. The standardization of aseptic care and insertion and maintenance of risk for infection increases with the length of time the device is left in catheters being performed by experienced staff members. Education place and decreases when the catheter is removed[31]. of staff in the insertion and maintenance of intravascular catheters is required and staff competency must be periodically evaluated. Nurses must demonstrate competency in the care of patients with vascular catheters[31,32].

Injuries from falls and immobility Patient falls with serious injury are among the top 10 sentinel events ●● Develop and implement policies and procedures to enhance safety reported to The Joint Commission Sentinel Even Database. Since and prevent falls. 2009, The Joint Commission has received 465 reports of patient falls ●● Implement a fall risk assessment. Assess patients on with injuries. About 65% of those falls caused fatalities[33]. admission and periodically throughout hospitalization. The Joint Commission reports that from January 2009 through October ●● Determine if the patients’ medications may cause dizziness, 2014, the most common contributing factors contributing to reported coordination problems, or other issues that may contribute to falls. falls included[33]: ●● Initiate fall prevention interventions such as providing the patients ●● Communication failures. with no-slip socks, teaching them about the use of (and supervising ●● Deficiencies in the physical environment. the use of) mobility assistive devices, and making sure that the call ●● Failure to adhere to protocols and safety practices. bell is within reach and that patients know how to use it. ●● Inadequate assessment. ●● Create a culture of safety in which systems and process issues are ●● Inadequate staff orientation, supervision, staffing levels, or skill mix. evaluated as the primary causes of adverse effects and in which ●● Lack of leadership. open communication is supported. ●● Initiate rounds at least hourly to evaluate the safety of the patients and their environments. EBP alert! Research shows that major factors to reduce falls and other adverse events focus on effective communication and Nursing consideration: If and when a fall does occur, a post-fall interdisciplinary work[34]. Thus, nurses must work with their huddle should be conducted. This is done to evaluate what risk interdisciplinary colleagues to reduce/prevent falls. factors for fall existed, the circumstances surrounding the fall, and what measures should be taken to prevent future falls, including the review and revision of existing policies and procedures. Such a Suggestions for fall prevention include the following nursing huddle is not conducted to cast blame but to improve the culture of intervention[33,34]: safety within the organization. ●● Establish an interdisciplinary fall team with representatives from all disciplines.

Obstetrical adverse events Obstetrical medical errors can harm the mother by increasing the Suggestions to reduce obstetrical events include[27]: potential for caesarean section and its associated risks, and higher ●● Establish a “hard-stop” policy, like 39 weeks, to reduce rate of risk of postpartum complications, such as anemia and endometriosis. early elective deliveries. Babies born at 37 to 38 weeks are at much higher risk of death, and ●● Conduct emergency drills for critical situations such as postpartum increased risk for respiratory problems, and greater likelihood of hemorrhage. admission to the neonatal intensive care unit (NICU). ●● Hold a multidisciplinary debriefing after emergency situations. ●● Reduce C-section deliveries for first-time mothers.

Pressure ulcers General recommendations for the reduction of pressure ulcers include[27]: ulcer depends on the anatomical location. For example, the bridge ●● Assess all patients for pressure ulcers before and during admission. of the nose or the ear does not have (adipose) subcutaneous tissue ●● Have nurses discuss pressure ulcers during shift reports. and Stage III ulcers in such locations can be shallow. However, areas ●● Employ a wound care team. where there is significant adipose tissue can be very deep. Bone and/ ●● Use logs and schedules to remind nurses to reposition patients. or tendon are not seen or directly palpable. Stages III and IV pressure ulcers present particular problems and ●● Category/Stage IV: Full thickness tissue loss. Bone, tendon, or deserve detailed discussion. muscle is exposed. Slough or eschar may be present. There is often undermining and tunneling. The depth varies according to anatomical In addition to the physical and emotional toll on patients, Stages III position. Ulcers may be shallow in areas that do not have (adipose) and IV pressure ulcers carry with them a significant monetary burden subcutaneous tissue (e.g., nose, ear). These types of pressure ulcers as well. It is estimated that the cost of one Stage III or Stage IV can extend into muscle and/or supporting structures such as fascia, pressure ulcer may be between $5,000 and $50,000[35]. tendon, or joint capsule, thus making osteomyelitis or osteitis likely to How are Stages III and IV pressure ulcers described? Here are their occur. Exposed bone or muscle is visible or directly palpable. determining characteristics[36]: Which patients are at risk for the development of pressure ulcers? Here ●● Category/Stage III: Full thickness skin loss. Although subcutaneous are some factors that increase such risk[35,37]: fat may be seen, bone, tendon, or muscles are not exposed. Slough ●● Advanced age: The elderly person’s skin has less subcutaneous fat, may be present, but it does not obscure the depth of tissue loss. which leads to decreased protection from pressure. There may be undermining and tunneling. The depth of this pressure

Page 16 ANCC.EliteCME.com ●● Friction/Shear: Decreases the epidermal layer, reducing protection Nursing measures to decrease the risk for pressure ulcer development of the skin. include[35-37]: ●● Hypotension: Increases the response of local tissues, making skin ●● Perform skin assessment upon admission and at least once per shift more vulnerable to breakdown. thereafter. Skin inspection should be done more often on patients ●● Immobility: Lack of mobility can lead to sustained pressure on at high risk for pressure ulcer development. Document results of bony prominences. all skin assessments. ●● Length of stay in critical care units: The longer the stay indicates ●● Identify patients at high risk for pressure ulcer development using a more critical condition. Such conditions are generally associated a risk-identification scale. with decreased mobility and position change and increased shear ●● Incorporate results of skin assessment in change-of-shift report and force, all of which increase the risk for skin breakdown. at any handoffs and signoffs. ●● Length of time on mechanical ventilation: Indicates inadequate ●● Incorporate a schedule of turning and body repositioning and oxygenation and the need to provide ventilation mechanically. document these actions. Decreased oxygen levels means decreased oxygen to body tissues, including the skin. EBP alert! Research shows that shearing forces can be reduced by ●● Moisture: Moisture (e.g., incontinence, sweat, failure to dry skin keeping the head of the bed lower than 45 degrees[36]. after bathing) contributes to skin breakdown. ●● Nutrition: Inadequate nutrition alters the proper state of the skin, contributing to skin breakdown. ●● Use appropriate positioning devices according to hospital policy ●● Pressure: The longer pressure is sustained, the more likely is local and procedure. tissue ischemia, edema, and tissue death. ●● Keep skin warm and dry. Dry thoroughly after bathing. Remove ●● Pressure scale risk scores: The higher the score on a pressure scale skin secretions such as sweat. Use non-irritating, non-drying score, the greater the risk of pressure ulcer development. cleansing agents. Use moisturizers as appropriate. Keep bed ●● Vasoactive medications: Vasoactive medications given to improve sheets, clothing, etc. dry and wrinkle-free. blood pressure increase vasoconstriction. This may decrease ●● Take measures to avoid spasticity and contracture prevention. perfusion of skin tissue. ●● Ensure proper nutritional intake. ●● Promote mobility and self-position change as appropriate. ●● Remain alert to any skin changes (such as redness) that may suggest impending skin breakdown.

Surgical site infections According to the CDC, a recent study found that surgical site Recommendations to decrease the risk of surgical site infections infections were the most common health care-associated infection, include[27,38]: accounting for 31% of all of these infections among hospitalized ●● Use chlorhexidine baths or showers. patients. In addition, one study found 16,147 surgical site infections ●● Use proper hair removal techniques. following 849,659 operative procedures[38]. ●● Do not allow staff with open wounds, bandages, or casts to scrub into surgical cases. ●● Conduct random black light inspections of operating room suites after cleaning. ●● Monitor hand hygiene practices.

Venous thromboembolism (VTE) VTE is a condition that includes both deep vein thrombosis (DVT) ●● Smoking. and pulmonary embolism (PE). DVT is the formation of a blood clot ●● Having vein disease(s). in a deep vein, usually in the leg or pelvis. The most serious potential Strategies for the prevention of DVT include[41,42]: complication of a DVT is the possibility that the clot could dislodge ●● Administrating anticoagulant therapy as indicated. [39]. According to Agency for and travel to the lungs, becoming a PE ●● Promoting early movement and physical therapy. Healthcare Research and Quality (AHRQ), VTE is the most common ●● Facilitating position change in patients who have difficulty moving preventable cause of hospital death[40]. themselves. DVT affects about 350,000 Americans every year[42]. In the hospital ●● Applying compression stockings or pneumatic compression setting, DVT is listed as a preventable hospital acquired complications. devices as ordered and indicated. Nurses and other health care providers must be aware of factors that place ●● Teaching patients and families about the importance of early patients at higher risk for the development of DVT. These include[41]: movement and position change. ●● Using birth control pills or hormone therapy. Nursing consideration: Most of the interventions to prevent DVT ●● Having blood clotting disorders. are easily implemented. However, busy nurses and other health care ●● Some malignancies. professionals may forget to implement things as simple as position ●● Increasing age. change and teaching patients the importance of early movement and ●● Being overweight or obese. position changes. They must remain alert to the possibility of DVT ●● Personal or family history of DVT or PE. development and how to prevent it. ●● Pregnancy.

Ventilator-associated pneumonia (VAP) The CDC states, “VAP is a lung infection that develops in a person breathe by giving oxygen through a tube placed in a patient’s mouth or using a ventilator. A ventilator is a machine used to help a patient

ANCC.EliteCME.com Page 17 nose, or through a hole in the front of the neck. An infection may occur Prevention strategies for VAP include[27,44]: if germs enter through the tube and get into the patient’s lungs[43].” ●● Elevate patient’s head 30 to 45 degrees. ●● Maintain good oral hygiene. VAP is one of the top three infection concerns in the health care ●● Wean ICU patients from the ventilator more quickly by using a environment. VAP may account for up to 60% of all deaths from health percussion vest. care-associated infections in the United States. ●● Assess patient readiness to extubate daily. Other important data include[44]: ●● Perform hand hygiene before and after patient contact, before ●● VAP is the most common and deadly health care-associated infection. aseptic procedures, when having contact with the care environment ●● VAP affects up to 28% of ventilated patients. or body fluids regardless of glove use. ●● Health care-associated pneumonia patients have a mortality rate of ●● Follow Standard Precaution guidelines. up to 33%. ●● Minimize saline lavage. ●● VAP increases length of stay in the intensive care unit (ICU) by 4 ●● Use a closed-suction system or sterile single-use suction catheter. to 6 days. ●● Prevent patient contamination from ventilator circuit condensate. ●● Each incidence of VAP leads to an increased cost of about $20,000 ●● Maintain optimal pressure in endotracheal tube (EDT) cuff while to $40,000. patients are intubated. ●● Avoid unnecessary manipulation of EDT. ●● Vaccinate staff and patients against influenza. ●● Utilize methods for early diagnosis of VAP. ●● Provide staff members with continuing education regarding VAP.

Affordable Care Act and Medical Error Reduction Nursing professionals employed in participating institutions should October 2012 and provides penalties as well as incentive be aware that the Patient Protection and Affordable Care Act (ACA) payments based on hospitals’ performance on quality measures, contains three pay-for-performance programs that reward hospitals including reducing surgical site infections[45]. delivering high quality care and penalize those failing to reduce ●● The Hospital-Acquired Condition Reduction Program reduces medical errors. The following Congressional actions and ACA policies payments to hospitals that are in the top quartile for hospital-acquired have been developed with the objective of reducing medical error: conditions; the program started on October 1, 2014[45]. CMS has ●● In 2011, the Centers for Medicare and Medicare Services (CMS) adopted AHRQ safety indicators encompassing pressure ulcer rate and launched the Hospital Patient Safety initiative, which pilots new DVT rate, among others, as well as measures from the CDC, such as surveyor tools for assessing compliance with federal regulations[45]. central line-associated bloodstream infection and CAUTIs. ●● Under the Hospital Inpatient Quality Reporting (HIQR) program, ●● The Office of the National Coordinator is developing a system CMS pays hospitals that successfully report designated quality for reporting medical errors, similar to the method of Common measures a higher annual update, and failure to report the measures Formats established by AHRQ, allowing hospitals to more easily results in a payment reduction. Once received from hospitals, CMS and accurately collect data on errors, including critical information publicly reports the data on its “Hospital Compare” website. about where and when they occur. ●● The Deficit Reduction Act of 2005 required CMS to select at least In summary, the problems associated with medical errors are significant two hospital-acquired conditions for which hospitals would not and require that nurses and other health care professionals be ever- be paid higher Medicare reimbursement[45]. Since 2008, CMS has vigilant about protecting patients’ safety. There is some good news, maintained a list of hospital-acquired conditions that includes however. According to a report published by the AHRQ, from 2010 catheter-associated UTIs, falls and trauma, late-stage pressure to 2013, the United States saw 1.3 million fewer hospital-acquired ulcers, surgical site infections, and DVT[46]. Under the Patient conditions. This is a 17% decrease and a savings of $12 billion dollars Protection and Affordable Care Act of 2009, starting in 2011, during this 3-year period. These data also indicated that 50,000 lives CMS has applied this payment policy to the Medicaid program to were saved due to this reduction in hospital-acquired conditions[46]. encourage hospitals to actively prevent these conditions. ●● The Patient Safety and Quality Improvement Act of 2005 Much work still needs to be done. Research shows that nearly one in established Patient Safety Organizations under supervision of the 10 hospitalized patients will still become sick or harmed while in the AHRQ. Patient Safety Organizations receive reports of patient hospital[46]. Nurses are among the health care leaders who can make a safety events from health care providers and provide analyses of significant difference in reducing medical errors. They should assume these events[45]. They also operate under federal privacy protections the lead in educating their patients and colleagues about ways to to encourage providers to report medical errors and to work with prevent harm and keep the health care environment safe for all. health care systems to resolve systemic issues. Nurses also have a professional obligation to become involved in ●● The Patient Safety and Quality Improvement Act of 2005 also how their employing organizations address safety issues. They should authorized AHRQ to promulgate “Common Formats” so that hospitals volunteer for committees and task forces and act as patient advocates [45] can report adverse events in a uniform, unambiguous manner . at all times. The goal of Common Formats is to allow for the “apples to apples” comparison of medical errors across multiple hospital systems. Nurses must support their organization’s efforts to enhance the safety ●● The Patient Protection and Affordable Care Act also authorized and well-being of patients, visitors, and employees. In addition to three pay-for- performance programs that will adjust Medicare adhering to safety mandates, they should help teach their colleagues payments to hospitals based on the quality of care delivered. how to establish and maintain a culture of safety. All employees are The Hospital Readmission Reduction Program began in responsible for patient safety. Nurses are on the front-line of all safety October 2012 and penalizes hospitals with higher-than-expected initiatives and should act as leaders in the safety process. readmissions for beneficiaries initially admitted for selected conditions. The Value Based Purchasing Program began in

Page 18 ANCC.EliteCME.com References 1. Heron, M. (2013). Deaths: Leading Causes for 2010. National Vital Statistics Reports, 62(6), 1-97. 27. Beckers Hospital Review. (2014). 36 approaches to reducing 9 common medical errors. Retrieved Retrieved January 30, 2016 from http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_06.pdf. February 3, 2016 from http://www.beckershospitalreview.com/quality/36-approaches-to-reducing-9- 2. McCann, E. (2014). Deaths by medical mistakes hit records. Retrieved January 30, 2016 from http:// common-medical-errors.html. www.healthcareitnews.com/news/deaths-by-medical-mistakes-hit-records. 28. Evelyn, L. et al. (2014). Strategies to prevent catheter-associated urinary tract infections in acute 3. Department of Health and Human Services Office of Inspector General. (2012). Hospital incident care hospitals. Retrieved November 8, 2015 from http://www.medscape.com/viewarticle/824790. report systems do not capture most patient harm. 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Siegel, M., & Kramer-Cain, J. (2013). Vascular catheter-associated infections. Retrieved November 8, 6. Institute of Medicine (IOM). (2000). To err is human: Building a safer health system. Retrieved 2015 from http://nursing.advanceweb.com/Article/Vascular-Catheter-Associated-Infections-2.aspx. February 18, 2011 from http://www.iom.edu/~/media/Files/Report percent20Files/1999/To-Err-is- 32. Busby, S. R. et al. (2015). Assessing patient awareness of proper hand hygiene. Nursing2015, May, Human/To percent20Err percent20is percent20Human percent201999 percent20 percent20report 2015, 27-30. percent20brief.ashx. 33. The Joint Commission. (2015). New sentinel event alert focuses on preventing falls. Retrieved 7. National Academies/Institute of Medicine (IOM). (2000). To err is human: building a safer health November 7, 2015 from http://www.jointcommission.org/new_sentinel_event_alert_focuses_on_ system (summary). 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Cooper, K. L. (2013). Evidence-based prevention of pressure ulcers in the intensive care unit. 10. National Coordinating Council for Medication Error Reporting and Prevention. (2016). What is a Critical Care Nurse, 33(6), 57-67. medication error? Retrieved February 2, 2016 from http://www.nccmerp.org/about-medication-errors. 36. National Pressure Ulcer Advisory Panel (NPUAP). (2015). NPUAP pressure ulcer stages/ 11. Lippincott Nursing Center. (2011). 8 rights of medication administration. Retrieved February 2, categories. Retrieved November 4, 2015 from http://www.npuap.org/resources/educational-and- 2016 https://www.nursingcenter.com/ncblog/may-2011/8-rights-of-medication-administration. clinical-resources/npuap-pressure-ulcer-stagescategories/. 12. Griffin, R. M. (2009). Common problems patients face in the hospital. Retrieved February 2, 37. Kirman, C. N., et al. (2015). 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Retrieved February 3, 2016 from infections_complications/dvt/what_is_dvt_vte.html http://www.pharmacytimes.com/news/what-makes-pharmacist-mistakes-more-likely. 40. Agency for Healthcare Research and Quality. Preventing Hospital-Acquired Venous 15. Rice, S. (2014). Most laboratory errors happen outside the lab, ECRI report finds. Retrieved Thromboembolism: A Guide for Effective Quality Improvement. Available at: http://www.ahrq.gov/ February 3, 2016 from http://www.modernhealthcare.com/article/20140417/NEWS/304179961. professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/index.html 16. Patient Safety Network. (2014). Never events. Retrieved February 3, 2016 from https://psnet.ahrq. 41. American Academy of Orthopaedic Surgeons. (2015). Deep vein thrombosis. Retrieved December 9, gov/primers/primer/3/never-events. 2015 from http://orthoinfo.aaos.org/topic.cfm?topic=a00219. 17. Joint Commission. (2015). Sentinel events (SE). Retrieved February 3, 2016 from http://www. 42. WebMD. (no date given). How to prevent deep vein thrombosis (DVT). Retrieved December jointcommission.org/assets/1/6/camh_2012_update2_24_se.pdf. 10, 2015 from http://www.webmd.com/dvt/deep-vein-thrombosis-prevent-dvt?page=2 18. Wheeler, K. K. (2014). Effective handoff communication. OR Nurse, 8(1), 22-26. 43. Centers for Disease Control and Prevention. Ventilator-associated Pneumonia (VAP). Available at: 19. Centers for Medicare & Medicaid Services. (2014). Patient safety areas of focus. Retrieved February http://www.cdc.gov/hai/vap/vap.html 3, 2016 from https://partnershipforpatients.cms.gov/about-the-partnership/what-is-the-partnership- 44. Halyard Health. (no date given). Ventilator associated pneumonia. Retrieved February 4, 2016 from about/lpwhat-the-partnership-is-about.html. http://www.halyardhealth.com/hai-watch/hai-threats-solutions/ventilator-associated-pneumonia.aspx. 20. Kothari, D., et al. (2010). Medication error in anesthesia and critical care: A cause for concern. 45. Cornell University Law School. (no date given). Public health service act. Retrieved February 4, Indian Journal of Anesthesia, 54, 187-192. 2016 from https://www.law.cornell.edu/uscode/text/42/chapter-6A. 21. Ghaleb, M. A., Barber, N., & Wong, F. B.D. (2010). The incidence and nature of prescribing and 46. Health US News. (2014). 50,000 fewer deaths caused by hospitals. Retrieved February 4, 2016 from administration errors in pediatric patients. Archives of Disease in Childhood, 95, 113-118. http://health.usnews.com/health-news/hospital-of-tomorrow/articles/2014/12/02/fewer-americans- 22. Garrouste-Orgeas, M., et al. (2010). Selected medical errors in the intensive care units: Results of the harmed-or-killed-by-hospital-errors. IATRORF study: parts I and II. American Journal of Respiratory Critical Care Medicine, 181, 134-142. 23. National Coordinating Council for Medication Error Reporting and Prevention. 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ANCC.EliteCME.com Page 19 PREVENTION OF Medical Errors IN NURSING Choose the best answer for questions 11 through 20 and mark your answers on the Final Examination Sheet found on Page 125 or take your test online at ANCC.EliteCME.com.

11. Medical error requires that: 17. To prevent central line-associated bloodstream infections: a. The patient involved must complain about a health care worker. a. Use soap and water for skin antisepsis. b. A physician must confirm that a medical error occurred. b. Use the femoral site for catheter insertion. c. An attorney must be notified of the medical error’s occurrence. c. Choose dressings that are permeable to water. d. Harm or error must have occurred that could have been prevented. d. Avoid applying topical antibiotic creams and ointments to the 12. An adverse drug reaction: insertion site. a. Involves death or serious physical injury. 18. To decrease surgical site infections it is important to: b. Is unavoidable. a. Avoid using chlorhexidine. c. Is an error that is detected and corrected before harm occurs. b. Prevent staff members with casts from scrubbing into d. Involves the need for immediate investigation and response. surgical cases. 13. Which of the following statements about factors that contribute to c. Conduct black light inspections on a regular basis. medical error occurrence is accurate? d. Understand that surgical site infections are rare. a. The Joint Commission reports that analysis of 4,000 adverse 19. Deep vein thrombosis (DVT): effects showed that 70% were due to communication breakdowns. a. Is more likely to occur in someone is underweight. b. Planning and knowledge refers to analysis of sentinel events. b. Has the potential to cause a serious complication of pulmonary c. The IOM reports that medical errors are most often due to embolism (PE). negligent practitioners. c. Is unpreventable in the hospital setting. d. Personal behavior is the most changeable aspect of medical d. Affects less than 100,000 Americans annually. error prevention. 20. The Patient Protection and Affordable Care Act: 14. Strategies to reduce the risk of medication error include: a. Has authorized three pay-for-performance programs. a. Adhere to the five rights of medication administration. b. Reduces payments to hospitals that fail to comply with Joint b. Ensure that handoffs at discharge receive the most attention Commission standards. compared to other handoffs. c. Has developed a system for reporting medical errors. c. Use barcode technologies. d. Sends surveyors to hospitals to determine their medical error rate. d. Have three clinicians independently verify doses prior to administering medication. 15. When teaching colleagues about preventing catheter-associated urinary tract infections (CAUTIs), a nurse should explain that: a. The majority of CAUTIs occur when a patient is catheterized for a urine specimen. b. The major risk for CAUTIs has not been identified. c. Most hospitals have effective strategies for the prevention of CAUTIs. d. Indwelling catheters should be properly secured to prevent urethral traction. 16. The most effective way to prevent transmission of health care- associated infections is: a. Sterile barrier precautions. b. Adherence to personal protective equipment policies. c. Proper hand hygiene. d. Wearing gloves.

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