Chapter 4: Medical : A Critical Practice Issue

2 Contact Hours

Release Date: 6/1/2016 Expiration Date: 6/1/2019 Faculty Adrianne Avillion, D.Ed., RN is a frequent presenter at conferences and conventions devoted Adrianne is an accomplished nursing professional development to the specialty of continuing education and nursing professional specialist and healthcare author. She earned her doctoral degree in development. Dr. Avillion owns and is the CEO of Strategic Nursing adult education and her M.S. in nursing from Penn State University Professional Development, a business that specializes in continuing and a BSN from Bloomsburg University. Dr. Avillion has held education for healthcare professionals and consulting services in a variety of nursing positions as a staff nurse in critical care and nursing professional development. physical and rehabilitation settings and leadership roles Content reviewer in professional development. She has published extensively and June D. Thompson, DrPH, MSN, RN, FAEN

Audience Each professional nurse has a responsibility to provide a safe errors and strategies for implementation. This is a critical course for environment of care. This course focuses on preventable medical every practicing nurse.

Course overview Medical errors are a silent and largely unseen tragedy. Estimates year. This course addresses preventable medical errors and provides suggest that medical errors and other instances of preventable harm strategies for nurses to use to prevent or reduce common errors. at hospitals result in the death of 210,000 to 440,000 Americans each

Learning objectives ŠŠ Define terms important to the concept of medical . 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 online or in print which requires a 2-hour ○○ A mandatory test (a passing score of 70 percent is required). commitment of time. Test questions link content to learning objectives as a method ●● Depending on your state requirements you will be asked to to enhance individualized learning and material retention. complete either: ●● Provide required personal information and payment information. ○○ An affirmation that you have completed the educational ●● Complete the MANDATORY Self-Assessment and Course activity. Evaluation. ●● Print your Certificate of Completion.

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Activity director June D. Thompson, DrPH, MSN, RN, FAEN, Lead Nurse Planner

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Introduction Medical errors are a silent and largely unseen tragedy. Estimates the obvious emotional toll, unexpected adverse effects related to suggest that medical errors and other instances of preventable harm medical error increase personal and institutional financial burdens, at hospitals result in the death of 210,000 to 440,000 Americans each adding estimated billions of dollars to costs annually. To year. A 2013 study by the Inspector General of the Department of learn more about how, when, and why medical errors occur, federal Health and Human Services (DHHS) identified 180,000 deaths related regulations established in 2003 required hospitals participating in to medical error in 2010, of which 44% were determined clearly or the Medicare program to, “track medical errors and adverse patient likely preventable [1]. events, analyze their causes, and implement preventive actions and Based on these figures, medical errors are the third leading cause mechanisms that include feedback and learning throughout the of death in America, after heart and cancer [2,3]. Beyond hospital.” Hospitals report this information using a federally-approved

Page 131 nursing.elitecme.com Quality Assessment and Performance Improvement (QAPI) program [4]. Evidence based practice (EBP) alert! Research shows that a high percentage of medical errors go unreported. This can lead to a While reporting has been compulsory since 2003, survey data dangerous environment for . Nurses must take the lead in presented by the DHHS Office of the Inspector General in 2012 found accurate reporting of medical errors and the promotion of systems that [5]: and processes that decrease the potential for error. ●● Only about 14% of “patient harm events” experienced by Medicare beneficiaries were captured by hospital incident reporting systems. Nurses are essential for developing and maintaining a culture of safety ●● An estimated 86% of total incidents were not reported. within their organizations and are the professionals most likely to ●● Of the unreported incidents, 62% were not reported because staff discover and report adverse events [6]. Thus, it is important that nurses members did not perceive them as reportable. work to reduce the risk of medical error and respond appropriately and ●● 25% of the unreported incidents were described as commonly capably to medical error occurrences. reported but not reported in these cases. Nursing consideration: Nurses are in a position to help educate ●● Events were most often reported by nurses who identified them as their colleagues, not only in nursing but in other disciplines, about part of the regular course of care. ways to prevent medical errors and what to do if one is discovered. This will enhance the safety of the patients’ environments.

Definition of terms Medical error is defined as harm to a patient that results from ●● Sentinel event: An unexpected occurrence involving death or either [7,8]: serious physical or psychological , or the risk of death or ●● The failure of a planned action to be completed as intended; or such an injury. ●● The use of a wrong plan to achieve an objective. ○○ Sentinel event: A sentinel event is an unexpected occurrence Medical error can be associated with failures in medical practice, involving death, serious physical or psychological injury, products, procedures, and/or systems. Medical error requires two or the risk thereof. A sentinel event indicates the need for critical parts: harm and whether the harm or error could have been immediate investigation and response. prevented [7]. ○○ The terms “sentinel event” and “error” are not synonymous; not all sentinel events occur because of an error, and not all Other terms related to medical error include [7,8,18]: errors result in sentinel events. ●● Safety: Freedom from accidental injury. ●● : Root cause analysis is a process for ●● Adverse drug event: An adverse drug event is injury resulting identifying the factors that underlie variation in performance, from the use of a drug. An adverse drug event may be caused by including the occurrence or possible occurrence of a sentinel event. an , a error, or an overdose. An ○○ A root cause analysis focuses primarily on systems and adverse drug event frequently necessitates discontinuation of the processes, not on individual performance. drug. ○○ The analysis progresses from special causes in clinical ●● Adverse drug reaction: An adverse drug reaction is an processes to common causes in organizational processes unavoidable, appreciably noxious, or unpleasant reaction that and systems and identifies potential improvements in these occurs during the normal, proper use of a medical product. Some processes or systems that would tend to decrease the likelihood drug reactions may be minor and temporary; others have the of such events in the future or determines, after analysis, that potential to be permanent and serious. no such improvement opportunities exist. ●● Medication errors: Medication errors are defined as errors that occurs due to mistakes made in the processes of the drug’s Nursing consideration: Nurses must be able to recognize and prescribing, transcribing, dispensing, administering, or monitoring. report important factors related to medical error or potential medical ●● Near-miss: An error that is detected and corrected before harm can error in order to adequately promote a culture of safety. be done.

Categories of medical errors Many preventable adverse events can be associated with more than ●● Medication errors: Medication errors are “any preventable event one type of medical error. There are many different ways to categorize that may cause or lead to inappropriate medication use or patient medical error, and categories may overlap, but the following harm while the medication is in the control of the health care classifications are common. professional, patient, or consumer” [11]. ●● Diagnostic errors: Diagnosis errors are errors that occur when a diagnosis is missed, wrong, or delayed [9]. Nursing consideration: Adhering to the eight “rights” of ●● Systems or process errors: Systems or process errors involve medication administration helps nurses avoid medication errors. predictable human failings in the context of poorly designed These eight rights are [12]: systems [10]. 1. Right patient. ●● Active errors: Active errors nearly always involve frontline staff 2. Right medication. members and occur at the point of contact between a human and 3. Right dose. some part of a larger system [10]. 4. Right route. ●● Latent errors: Sometimes referred to as “accidents waiting to 5. Right time. happen,” latent errors involve failures of organization or design 6. Right documentation. (e.g., systems and processes) that allow active errors to cause 7. Right reason. harm [10]. 8. Right response.

nursing.elitecme.com Page 132 ●● related errors: According to the U.S. Centers for ●● Laboratory errors: Errors made in the laboratory can be Disease Control and Prevention (CDC) there are 1.7 million health technical, procedural, or the result of poor communication. The care-associated every year. Approximately 22% are ECRI Institute evaluated 2,420 mistakes that occurred between infections of surgical wounds; 32% are urinary tract infections 2011 and mid-2013. Only 4% of reported potentially harmful (UTIs); the remainder is infections of the lungs, blood, and other errors occurred in the laboratory itself. Nearly 75% of mistakes parts of the body [13]. It is impossible to estimate the percentage occurred in the pre-analytic stage, defined as the time frame in of hospital acquired infections that are unavoidable, but evidence which tests are selected and ordered, specimens are identified and shows that many of these infections can and should be prevented. transported, and patients are prepared. Such mistakes were more For example, failure to conform to hand hygiene standards can likely to be linked to labels that had the wrong patient’s name, the lead to preventable infections. wrong specimen ordered, and incomplete or mission information. ●● Surgical errors: Wrong-site, wrong-procedure, wrong-patient The other 22% occurred in the post-analytic stage, when results errors (WSPEs) should never occur and indicate serious safety were interpreted, reported, or stored [16]. problems within an organization. Recent studies show that these types of errors occur in about one of 112,000 surgical procedures Nursing consideration: Any discussion of medical errors needs to or that an individual hospital would experience such an error every include clarification of “never ever events.” This term was first used 5 to 10 years. However, these data only include procedures in the in 2001 by Ken Kizer, MD, former CEO of the National Quality operating room. If procedures performed in other settings such as Forum in reference to especially shocking medical errors that should ambulatory centers were to be included, the rate of such never occur. The list of these issues consists of 29 events grouped errors may be significantly higher [14]. into seven categories. The categories are [17]: ●● errors: Pharmacy errors can involve such issues as 1. Surgical events. the preparation or processing of a prescription or giving incorrect 2. Product or device events. directions to patients. Researchers at a tertiary care medical center 3. Patient protection events. in Houston, Texas, recently monitored 1,887,751 medication 4. Care management events. orders, 92 medication error events, and 50 . They 5. Environmental events. determined that the overall error rate was 4.87 errors per 100,000 6. Radiologic events. verified orders. Pharmacy errors were associated with workload, 7. Criminal events. work environment, and number of pharmacists per shift. Factors For a complete list of the 29 events that are part of these categories, such as the type of pharmacy degree, age, experience, and the access https://psnet.ahrq.gov/primers/primer/3/never-events. number of years at an institution may also influence the error rate [15].

Medical error scenarios Which of the following scenarios would be considered medical error? was likely to occur. Blood and tissue levels of the drugs were not Example 1: A nurse is supposed to administer three likely to drop so precipitously that the patient might suffer harm. to a patient once a day, at 8 a.m.: furosemide 40 mg, orally (PO); In certain circumstances, administering medications late would be digoxin 0.25 mg, PO; and potassium chloride, 40 mEq, PO. At 7:55 problematic. While this situation is not a medical error, a similar a.m., another patient the nurse is caring for complains of difficulty action might have resulted in medical error. breathing. The nurse assesses the patient, administers a PRN Example 2 is not an example of medical error. The surgeon’s bronchodilator treatment, and then calls the patient’s . It is assessment and response was appropriate, as some degree of pain now 8:50 a.m., and the nurse gives the patient the furosemide, digoxin, is an expected and unavoidable of joint replacement and potassium chloride. surgery. Example 2: A patient is recovering from total knee arthroplasty, and Example 3 is an example of medical error. Although a very several months after surgery, he is still having slight pain in the joint. unusual occurrence, esophageal injury resulting from alkali The operation and the initial recovery period were uneventful, and exposure can exist even when the patient has no signs or after an examination the surgeon concludes that the prosthesis has not symptoms of external burns. Had an ENT or GI physician been loosened and is in good working order, there is no infection in the area consulted, an endoscopic examination of the child would have and there are no other postoperative complications. been likely. Example 3: A 2-year-old child is brought to an emergency room These scenarios clarify how medical error is determined. In the first because he has swallowed a small amount of drain cleaner; the drain example, no harm or potential harm was possible; and, in the second, cleaner has a pH of 13.5. There are no burns in or around the mouth, the patient complained of an expected side effect that did not result and the child seems relatively comfortable; however, he will not from treatment failure. The third example, however, shows a condition eat, but will occasionally take small sips of fluids. After 2 hours of that should have been detected and treated, causing the patient observation, the child is discharged. Neither the ENT nor GI services further injury and complications that might have been prevented with on-call were consulted. The next day, the parents bring the child back reasonable and appropriate care. because he is crying and will not eat or drink. An endoscopic exam reveals a second-degree burn in the esophagus. The child suffers Nursing consideration: Nurses must follow their organizations’ strictures that need frequent dilations and must receive nutrition policies and procedures regarding medical error reporting. Accurate through a feeding tube. reporting is essential to analysis of errors and making improvements in processes and systems. Example 1 is not an example of medical error. Although there was an alternative action that would have been better for the patient – the nurse could have made arrangements with another RN to administer the medications – no adverse effect occurred and none

Page 133 nursing.elitecme.com Factors that contribute to medical errors The causes and prevention of medical errors are the focus of involve poor planning and execution, inappropriate or absent policies considerable academic and professional attention. Prevention strategies and procedures, failure to procure and maintain equipment, failure to typically address the three most common causes of medical errors, hire and retain staff, failure to maintain safe staffing levels, failure to communication, planning and knowledge, and systemic or institutional monitor care, and failure to recognize errors and correct the conditions failure. that caused the errors [7,8]. While systemic failures in communication, Communication infection control, and medication prescribing, dispensing and Accurate communication is vital for diagnosing; treating; dispensing administration have contributed considerably to medical error, and administering medications; maintaining ; following entrenched health care traditions (e.g., using blame and shame, closing policies and procedures; and ensuring treatment instructions are ranks, and strategies that minimize legal liability) have played a carefully followed. Communication errors can be verbal or written, major role in discouraging disclosure necessary to reducing the risk of and occur in every part of the process of delivery of care. medical error. Breakdowns in communication are one of the leading causes of Personal behavior is in one sense the least changeable aspect medical errors. The Joint Commission reports that, according to a of medical error prevention. Health care professionals are not root cause analysis of over 4,000 adverse events, 70% were caused motivated to disclose medical error if policies and procedures focus by communication breakdowns [19]. Such breakdowns can include on punishment rather than timely reporting and prevention. While inadequate patient handoffs, interpersonal communication failures, and individuals bear responsibility for their actions when a medical error reluctance to admit a lack of knowledge or failure to seek clarification. occurs, the traditional blame and shame culture of health care is counterproductive if the goal is reducing error. First, it discourages Nursing consideration: One often overlooked aspect of voluntary reporting; second, it does not assess whether there was a communication that can be a cause of medical errors is lack of system contribution to the error; and third, it focuses on assigning communication. No communication, as well as poor and inaccurate blame and punishment, not on why the error occurred, or on error communication, clearly contributes to medical error. prevention [7,8]. Some suggest health care medical error reporting would be more Planning and knowledge effective if modeled on alternative reporting systems, such as Planning and knowledge failures can encompass virtually every aspect those used in the aviation industry, which has a very high level of of the delivery of care, and the different types of errors that can be safety. Aviation reporting guidelines do not absolve individuals of caused by failure in planning and failure in knowledge are almost responsibility and punishment for errors, but treat each incident limitless [7,8]. It is therefore essential that nurses and other health as a complex event with many possible causes and contributing factors care professionals work together to establish the most effective plan [7,8]. of care for each patient, to ensure that all members of the health care team have the necessary knowledge and skills to implement the plan Nursing consideration: Many health care professionals are afraid of care, and to evaluate the effectiveness and safety of the plan as it is to report errors because of the fear of being reprimanded. It is part implemented. of a true culture of safety for an organization’s leaders to look at the Systemic or institutional failures entire system or process involved in an error, and avoid rushing to The Institute of Medicine (IOM) reports medical errors are more often cast blame on a particular individual. due to poor systems than negligent practitioners. System failures

Causes of, and strategies for, reducing common medical errors Human error is inevitable. Although we cannot eliminate human error, visible when they occur so their effects can be intercepted; having we can better measure the problem to design safer systems mitigating remedies at hand to rescue patients; and making errors less frequent by its frequency, visibility, and consequences. Strategies to reduce death following principles that take human limitations into account [20]. from medical care should include three steps: Making errors more

nursing.elitecme.com Page 134 The identification of errors needs to become more transparent. There 2. CAUTIs. needs to be standardized data collection and evaluation of the root 3. Central line-associated bloodstream infections. cause of each error. Punishment is not helpful as it leads to the non- 4. from falls and immobility. disclosure of errors or risk of error. Both individuals and hospital 5. Obstetrical adverse effects. systems have unique responsibilities in the reduction of medical errors. 6. Pressure ulcers. Studies of medical error show the potential risk of some errors is far 7. Surgical site infections. greater than others, with some likely to happen repeatedly. A 2014 8. Venous thromboembolism (VTE). Partnership for Patients study described the most common medical 9. Ventilator-associated events. errors in the . Nine core patient safety areas of focus were Let’s examine what strategies might be used to enhance safety and identified [21]: decrease the occurrence of these core safety issues. 1. Adverse drug events (medication errors).

Adverse drug events (medication errors) Medication errors have received a huge amount of attention, especially The Institute of for Safe Medication Practices (ISMP) has identified in nursing practice. The incidence of medication errors is an issue of some specific medications classified as high-risk, meaning that these contention. Because definitions of medication errors can differ, many medications bear a heightened risk of causing significant patient harm medication errors must be self-reported to be recorded (and data when used in error [28]: suggest a significant percentage of medication errors are not reported), ●● Ephinephrine subcutaneous. and there is no central agency or institution that is responsible for ●● Epoprostenol (Flolan) IV. collecting reports of medication errors, no one knows how many ●● Insulin U-500 (All forms of insulin are considered high-risk. medication errors actually occur. Insulin U-500 has been singled out for special emphasis to bring A medication error is defined as “any preventable event that my cause attention to the need for distinct strategies to prevent the types of or lead to inappropriate medication use or patient harm while the errors that occur with this concentrated form of insulin). mediation is in the control of the health care professional, patient, ●● Magnesium sulfate injection. or consumer” [25]. Medication errors are the most common type of ●● Methotrexate, oral, non-oncologic use. medical error. About 1.3 million people are injured annually in the ●● Opium tincture. United States following such errors [26]. ●● Oxytocin, IV. ●● Nitroprusside sodium for injection. The incidence of medication errors varies according to patient ●● Potassium chloride for injection concentrate. population and clinical setting. Pediatric patients and the elderly are ●● Potassium phosphates injection. more likely to be harmed by medication error than other segments of ●● Promethazine, IV. the population; children are more susceptible to harm from dosing ●● Vasopressin, IV or intraosseous. errors due to their small size, while older individuals tend to take more medications, increasing their potential for medical error and adverse In an effort to identify root causes, there has been a lot of attention drug interactions. Medication errors are more likely to occur in fast- focused on why medication errors occur. Nurses surveyed about paced, stressful environments such as intensive care units, emergency medication errors listed a variety of reason for their mistakes, departments, and certain clinical areas [22,23,24]. including poor staffing, unskilled/new nurses, stress, personal error, and distraction. These data suggest the most common medication Data from the U.S. Food and Drug Administration (FDA) show that errors are related to: the most common error involving medications was related to the ●● Wrong dose. administration of an improper dose of medicine, accounting for 41% ●● Wrong diluent. of fatal medication errors. Administering the wrong drug and using the ●● Calculation errors. wrong route of administration each accounted for 16% of the errors [26]. ●● Extra dose. ●● Too-rapid administration rate. Evidence based practice (EBP) alert! Almost 50% of fatal ●● Wrong concentration. medication errors occur in people over the age of 60. The older ●● Drug (contraindicated drug administered). population may be at particularly high risk for such errors because ●● Avoidable drug interaction. they frequently take multiple prescription medications [26]. Thus, ●● Contraindicated drug. nurses must be especially careful when administering medications ●● Incorrect order transcription. and providing patient/family education to this population. ●● Missed dose. ●● Wrong route. ●● Administration too early or too late. The medications/classes of medications most likely to be involved Poor staffing is often cited as a reason for medication errors, as are in medication errors are insulin, antibiotics, cardiovascular drugs, interruptions or lack of attention during the processes of medication anticoagulants, diuretics, nonsteroidal anti-inflammatories (NSAIDs), preparation or administration. Other reasons cited are considered to be inhaled medications, narcotics, and ophthalmic preparations [27]. system or institution-based. Tracking research by the FDA concluded Some of these drugs are a frequent cause of medication errors because these factors were the most common causes of medication error: they are commonly used (e.g., insulin and antibiotics). Others are 1. Incomplete patient information (e.g., not being aware of drug sufficiently potent and there is little room for therapeutic error and or not being aware of other currently prescribed substantial potential for harm from seemingly small mistakes (e.g., medications). the cardiovascular drug nitroprusside, heparin, warfarin, insulin, or 2. Unavailable or out-of-date drug information. colchicine). 3. Miscommunication of drug orders. Another set of drugs are common causes of medication errors 4. Lack of appropriate labeling. because they can be easily confused (e.g., Percocet® [acetaminophen 5. Environmental factors that contribute to medication errors. and oxycodone] confused with Vicodin® [acetaminophen and hydrocodone]).

Page 135 nursing.elitecme.com In general, medication error occurs when health care professionals: knowledge-based medication errors are avoidable. Knowledge- ●● Do not have the proper knowledge. based medication errors can be general, specific, or expert [26]: ●● Do not follow rules or are using bad rules. ○○ A general knowledge-based error occurs when someone makes ●● Forget to perform a task or forgot important patient information. an error because of lack of or disregard for information that ●● Simply make a mistake in the performance of medication is considered general knowledge (e.g., warfarin can cause administration. bleeding). The four main causes of medication errors are action-based, ○○ A specific knowledge-based error occurs when someone makes rule-based, memory-based, and knowledge-based [26]: an error because of lack of or disregard of information that ●● An action-based medication error is defined as the performance would be considered specific knowledge (e.g., a patient is of an unintended. Examples of action-based medication errors given warfarin even though the INR is very high). would include selecting the wrong medication or administering an ○○ An expert knowledge-based error occurs when someone makes incorrect dose. an error because of lack of or disregard of information that ●● A rule-based medication error occurs because the nurse did not would be considered expert knowledge (e.g., the failure to use follow proper rules or procedures for medication administration. genetic testing to check for variations in patient response prior Examples could include a good rule that was not applied (e.g., to initiating with warfarin). checking with another nurse when performing a dose calculation Strategies to decrease the risk of medication error include: for a high-risk drug such as insulin), or the application of a bad ●● Adhere to the eight rights of medication administration [12]. rule (e.g., the health care facility does not require nurses to double- ●● Ensure that handoffs involve the transfer of essential information check dose calculations for high-risk drugs). when the responsibility for care of the patient shifts from one ●● A memory-based medication error occurs when a nurse simply health care provider to another [19]. forgets to perform a task or forgets important information about ●● Use barcode technologies and electronic health records with the patient. The nurse may forget to give a dose of a medication, computerized prescriber order entry [29]. that the medication has been discontinued, or that the patient is ●● Involve pharmacists throughout a patient’s hospitalization. allergic to the medication. ●● Require nurses who are administering medicine to wear a colored ●● Knowledge-based medication errors are errors that could be sash or vest to prevent interruptions. avoided with a reasonable and appropriate level of professional ●● Have two clinicians independently verify doses prior to knowledge. If the nurse is familiar with the drug and the patient, administering medication. Catheter-associated urinary tract infections (CAUTIs) ●● Most hospitals do not have effective strategies for preventing Evidence based practice (EBP) alert! Research shows that [30]: CAUTIs. ○○ 70% to 80% of CAUTIs are due to the presence of an indwelling urethral catheter. Experts recommend the following actions to prevent CAUTIs [30,31]: ○○ 12% to 16% of adult hospitalized patients will have a urinary ●● Establish policies and procedures for catheter use including catheter at some time during hospitalization. indications for urinary catheterization, insertion guidelines, and ○○ When an indwelling urethral catheter remains in place the criteria for urinary catheterization. Nurses and other members daily risk of acquiring bacteria in the urinary tract varies from of the health care team should be sure that catheter placement is 3% to 7%. limited to those patients who meet criteria for use. ●● Be sure that only trained, competent personnel insert urinary Nurses must do everything possible to find alternatives to insertion catheters. Provide education and training as needed. of indwelling catheters and, if such catheterization cannot be ●● Ensure that supplies and equipment necessary for aseptic avoided, to facilitate its removal as soon as possible. catheterization technique are readily available. ●● Review the necessity of continuing indwelling catheters on a daily Additional research findings show that [31]: basis. Such catheters should be removed as soon as possible. ●● The major risk factor for CAUTIs is prolonged catheterization. ●● Implement infection control surveillance programs. Include the ●● 25% of hospital inpatients and up to 90% of patients in a development of any CAUTIs. Develop appropriate action plans to critical care unit have a urinary catheter at some point during reduce/prevent CAUTI occurrence. hospitalization. Unfortunately, such catheters are often inserted Nursing consideration: Nurses should ensure that indwelling without an appropriate indication or remain in place after the need catheters are properly secured to prevent movement and urethral is no longer present. traction. They must also ensure that a sterile, continuously closed drainage system is maintained [30, 31]. Central-line associated bloodstream infections More than 5 million patients require central venous access every year, Nursing consideration: Patients and families should be taught to and infection is the main if intravascular catheters are observe whether health care workers are washing their hands before used in critically ill patients [32]. Every year, an estimated 250,000 and after providing patient care. They should be told to ask their cases of central venous catheter-associated bloodstream infections health care providers to wash their hands if they have not done so. occur in the United States. The cost per infection is estimated to be between $34,508 and $56,000 [33]. Nurses and their interdisciplinary The CDC and the Institute for Healthcare Improvement (IHI) both colleagues must make every effort to prevent such infections. advocate that hand hygiene be performed “before and after palpating Hand hygiene the catheter insertion site; before and after inserting; replacing, Proper hand hygiene is the most important infection control measure accessing, repairing or dressing a venous access device; before and the most effective way to prevent the transmission of health care- donning and after removing gloves; when hands are visibly soiled or associated infections [32,33,34]. contaminated; before and after invasive procedures; and after using

nursing.elitecme.com Page 136 the bathroom. Palpation of the insertion site should not be performed dressing that covers the catheter insertion site. Topical antibiotic after the application of skin antiseptics, unless aseptic technique is ointments or creams should not be applied to the insertion site maintained” [33]. because of the possibility of promoting fungal infections or pathogen Maximum sterile barrier precautions resistance. Dressings are changed when they become wet, loose, or Maximum sterile barrier precautions must be taken when inserting soiled. Central Venous Access Device (CVAD) dressing are generally the venous catheter. These precautions include, not only the person changed weekly for a transparent semipermeable dressing, and every inserting the catheter, but anyone assisting with the procedure and the 48 hours for a gauze dressing [33]. patient as well [32,33]. Assessment and removal Skin antisepsis The catheter should be removed as soon as it is no longer needed. The The IHI advocates the use of chlorhexidine skin antisepsis. The CDC risk for infection increases with the length of time the device is left in prefers the use of a 2% chlorhexidine solution, but a tincture of iodine place and decreases when the catheter is removed [33]. or 70% alcohol can be used [33]. Skin antisepsis should be performed Evidence based practice (EBP) alert! The risk for infection has at the time of insertion and with every dressing change [33,34]. declined with the standardization of aseptic care and insertion and Selection of catheter site maintenance of catheters being performed by experienced staff The site of insertion is important to optimal outcomes. The use of the members. Education of staff in the insertion and maintenance of subclavian site is preferred to the jugular or femoral sites in adults to intravascular catheters is required and staff competency must be minimize infection risk [33,34]. periodically evaluated. Nurses must demonstrate competency in [33, 34] Dressing change the care of patients with vascular catheters . Dressings for insertion sites must be impermeable to water vapor. They can be either sterile gauze or sterile transparent, semipermeable

Injuries from falls and immobility Patient falls with serious injury are among the top 10 sentinel events Suggestions for fall prevention include the following nursing reported to The Joint Commission Sentinel Even Database. Since intervention [35,36]: 2009, The Joint Commission has received 465 reports of patient falls ●● Establish an interdisciplinary fall team with representatives from with injuries. About 65% of those falls caused fatalities [33]. all disciplines. The Joint Commission reports that from January 2009 through October ●● Develop and implement policies and procedures to enhance safety 2014, the most common contributing factors contributing to reported and prevent falls. falls included [35]: ●● Implement a fall risk assessment. Assess patients on ●● Communication failures. admission and periodically throughout hospitalization. ●● Deficiencies in the physical environment. ●● Determine if the patients’ medications may cause dizziness, ●● Failure to adhere to protocols and safety practices. coordination problems, or other issues that may contribute to falls. ●● Inadequate assessment. ●● Initiate fall prevention interventions such as providing the patients ●● Inadequate staff orientation, supervision, staffing levels, or skill with no-slip socks, teaching them about the use of (and supervising mix. the use of) mobility assistive devices, and making sure that the call ●● Lack of leadership. bell is within reach and that patients know how to use it. ●● Create a culture of safety in which systems and process issues are evaluated as the primary causes of adverse effects and in which Evidence based practice (EBP) alert! Research shows that open communication is supported. major factors to reduce falls and other adverse events focus on ●● Initiate rounds at least hourly to evaluate the safety of the patients effective communication and interdisciplinary work [36]. Thus, and their environments. nurses must work with their interdisciplinary colleagues to reduce/prevent falls. Nursing consideration: If and when a fall does occur, a post-fall huddle should be conducted. This is done to evaluate what risk 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 huddle is not conducted to cast blame but to improve the culture of safety within the organization. Obstetrical adverse events Obstetrical medical errors can harm the mother by increasing the Suggestions to reduce obstetrical events include [29]: 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 delivers for first-time mothers. Pressure ulcers General recommendations for the reduction of pressure ulcers ●● Employ a wound care team. include [29]: ●● Use logs and schedules to remind nurses to reposition patients. ●● Assess all patients for pressure ulcers before and during admission. Stages III and IV pressure ulcers present particular problems and ●● Have nurses discuss pressure ulcers during shift reports. deserve detailed discussion.

Page 137 nursing.elitecme.com In addition to the physical and emotional toll on patients, Stages III ●● Moisture: Moisture (e.g., incontinence, sweat, failure to dry skin and IV pressure ulcers carry with them a significant monetary burden after bathing) contributes to skin breakdown. as well. It is estimated that the cost of one Stage III or Stage IV ●● Nutrition: Inadequate nutrition alters the proper state of the skin, pressure ulcer may be between $5,000 and $50,000 [37]. contributing to skin breakdown. How are Stages III and IV pressure ulcers described? Here are their ●● Pressure: The longer pressure is sustained, the more likely is local determining characteristics [38]: tissue ischemia, edema, and tissue death. ●● Category/Stage III: Full thickness skin loss. Although subcutaneous ●● Pressure scale risk scores: The higher the score on a pressure scale fat may be seen, bone, tendon, or muscles are not exposed. Slough score, the greater the risk of pressure ulcer development. may be present, but it does not obscure the depth of tissue loss. ●● Vasoactive medications: Vasoactive medications given to improve There may be undermining and tunneling. The depth of this pressure blood pressure increase vasoconstriction. This may decrease ulcer depends on the anatomical location. For example, the bridge perfusion of skin tissue. of the nose or the ear does not have (adipose) subcutaneous tissue Nursing measures to decrease the risk for pressure ulcer development and Stage III ulcers in such locations can be shallow. However, areas include [37,38,39]: where there is significant adipose tissue can be very deep. Bone and/ ●● Perform skin assessment upon admission and at least once per shift or tendon are not seen or directly palpable. thereafter. Skin inspection should be done more often on patients ●● Category/Stage IV: Full thickness tissue loss. Bone, tendon, or at high risk for pressure ulcer development. Document results of muscle is exposed. Slough or eschar may be present. There is often all skin assessments. undermining and tunneling. The depth varies according to anatomical ●● Identify patients at high risk for pressure ulcer development using position. Ulcers may be shallow in areas that do not have (adipose) a risk-identification scale. subcutaneous tissue (e.g., nose, ear). These types of pressure ulcers ●● Incorporate results of skin assessment in change-of-shift report and can extend into muscle and/or supporting structures such as fascia, at any handoffs and signoffs. tendon, or joint capsule, thus making osteomyelitis or osteitis likely ●● Incorporate a schedule of turning and body repositioning and to occur. Exposed bone or muscle is visible or directly palpable. document these actions. Which patients are at risk for the development of pressure ulcers? Here are some factors that increase such risk [37,39]: Evidence based practice (EBP) alert! Research shows that ●● Advanced age: The elderly person’s skin has less subcutaneous fat, shearing forces can be reduced by keeping the head of the bed [38] which leads to decreased protection from pressure. lower than 45 degrees . ●● Friction/shear: Decreases the epidermal layer, reducing protection of the skin. ●● Use appropriate positioning devices according to hospital policy ●● Hypotension: Increases the response of local tissues, making skin and procedure. more vulnerable to breakdown. ●● Keep skin warm and dry. Dry thoroughly after bathing. Remove ●● Immobility: Lack of mobility can lead to sustained pressure on skin secretions such as sweat. Use non-irritating, non-drying bony prominences. cleansing agents. Use moisturizers as appropriate. Keep bed ●● Length of stay in critical care units: The longer the stay indicates sheets, clothing, etc. dry and wrinkle-free. a more critical condition. Such conditions are generally associated ●● Take measures to avoid spasticity and contracture prevention. with decreased mobility and position change and increased shear ●● Ensure proper nutritional intake. force, all of which increase the risk for skin breakdown. ●● Promote mobility and self-position change as appropriate. ●● Length of time on mechanical ventilation: Indicates inadequate ●● Remain alert to any skin changes (such as redness) that may oxygenation and the need to provide ventilation mechanically. suggest impending skin breakdown. ●● Decreased oxygen levels means decreased oxygen to body tissues, including the skin. Surgical site infections According to the CDC, a recent study found that surgical site ●● Use chlorhexidine baths or showers. infections were the most common health care-associated infection, ●● Use proper hair removal techniques. accounting for 31% of all of these infections among hospitalized ●● Do not allow staff with open wounds, bandages, or casts to scrub patients. In addition, one study found 16,147 surgical site infections into surgical cases. following 849,659 operative procedures [40]. ●● Conduct random black light inspections of operating room suites Recommendations to decrease the risk of surgical site infections after cleaning. include [29, 40]: ●● Monitor hand hygiene practices. Venous thromboembolism (VTE) VTE is a condition that includes both deep vein thrombosis (DVT) ●● Having blood clotting disorders. and pulmonary embolism (PE). DVT is the formation of a blood clot ●● Some malignancies. in a deep vein, usually in the leg or pelvis. The most serious potential ●● Increasing age. complication of a DVT is the possibility that the clot could dislodge ●● Being overweight or obese. and travel to the lungs, becoming a PE [41]. According to Agency for ●● Personal or family history of DVT or PE. Healthcare Research and Quality (AHRQ), VTE is the most common ●● Pregnancy. preventable cause of hospital death [42]. ●● Smoking. DVT affects about 350,000 Americans every year [44]. In the hospital ●● Having vein disease(s). setting, DVT is listed as a preventable hospital acquired complications. Strategies for the prevention of DVT include [43,44]: Nurses and other health care providers must be aware of factors that place ●● Administrating anticoagulant therapy as indicated. patients at higher risk for the development of DVT. These include [43]: ●● Promoting early movement and physical therapy. ●● Using birth control pills or hormone therapy. ●● Facilitating position change in patients who have difficulty moving themselves. nursing.elitecme.com Page 138 ●● Applying compression stockings or pneumatic compression Nursing consideration: Most of the interventions to prevent DVT devices as ordered and indicated. are easily implemented. However, busy nurses and other health care ●● Teaching patients and families about the importance of early professionals may forget to implement things as simple as position movement and position change. change and teaching patients the importance of early movement and position changes. They must remain alert to the possibility of DVT development and how to prevent it.

Ventilator-associated pneumonia (VAP) The CDC states, “VAP is a lung infection that develops in a person Prevention strategies for VAP include [27,44]: using a ventilator. A ventilator is a machine used to help a patient ●● Elevate patient’s head 30 to 45 degrees. breathe by giving oxygen through a tube placed in a patient’s ●● Maintain good oral hygiene. mouth or nose, or through a hole in the front of the neck. An infection ●● Wean ICU patients from the ventilator more quickly by using a may occur if germs enter through the tube and get into the patient’s percussion vest. lungs” [45]. ●● Assess patient readiness to extubate daily. VAP is one of the top three infection concerns in the health care ●● Perform hand hygiene before and after patient contact, before environment. VAP may account for up to 60% of all deaths from health aseptic procedures, when having contact with the care environment care-associated infections in the United States. Other important data or body fluids regardless of glove use. include [46]: ●● Follow standard precaution guidelines. ●● VAP is the most common and deadly health care-associated ●● Minimize saline lavage. infection. ●● Use a closed-suction system or sterile single-use suction catheter. ●● VAP affects up to 28% of ventilated patients. ●● Prevent patient contamination from ventilator circuit condensate. ●● Health care-associated pneumonia patients have a mortality rate of ●● Maintain optimal pressure in endotracheal tube (EDT) cuff while up to 33%. patients are intubated. ●● VAP increases length of stay in the intensive care unit (ICU) by 4 ●● Avoid unnecessary manipulation of EDT. to 6 days. ●● Vaccinate staff and patients against influenza. ●● Each incidence of VAP leads to an increased cost of about $20,000 ●● Utilize methods for early diagnosis of VAP. to $40,000. ●● Provide staff members with continuing education regarding VAP.

Affordable care act and medical error reduction Nursing professionals employed in participating institutions should ●● The Patient Safety and Quality Improvement Act of 2005 also be aware that the Patient Protection and Affordable Care Act (ACA) authorized AHRQ to promulgate “Common Formats” so that contains three pay-for-performance programs that reward hospitals hospitals can report adverse events in a uniform, unambiguous delivering high quality care and penalize those failing to reduce manner [47]. The goal of Common Formats is to allow for the medical errors. “apples to apples” comparison of medical errors across multiple The following Congressional actions and ACA policies have been hospital systems. developed with the objective of reducing medical error: ●● The Patient Protection and Affordable Care Act also authorized ●● In 2011, the Centers for Medicare and Medicare Services (CMS) three pay-for- performance programs that will adjust Medicare launched the Hospital Patient Safety initiative, which pilots new payments to hospitals based on the quality of care delivered. The surveyor tools for assessing compliance with federal regulations [47]. Hospital Readmission Reduction Program began in October 2012 ●● Under the Hospital Inpatient Quality Reporting (HIQR) and penalizes hospitals with higher-than-expected readmissions for program, CMS pays hospitals that successfully report designated beneficiaries initially admitted for selected conditions. The Value quality measures a higher annual update, and failure to report Based Purchasing Program began in October 2012 and provides the measures results in a payment reduction. Once received penalties as well as incentive payments based on hospitals’ from hospitals, CMS publicly reports the data on its “Hospital performance on quality measures, including reducing surgical site Compare” website. infections [47]. ●● The Deficit Reduction Act of 2005 required CMS to select at least ●● The Hospital-Acquired Condition Reduction Program reduces two hospital-acquired conditions for which hospitals would not payments to hospitals that are in the top quartile for hospital- be paid higher Medicare reimbursement [47]. Since 2008, CMS acquired conditions; the program started on October 1, 2014 [47]. has maintained a list of hospital-acquired conditions that includes CMS has adopted AHRQ safety indicators encompassing pressure catheter-associated UTIs, falls and trauma, late-stage pressure ulcer rate and DVT rate, among others, as well as measures from ulcers, surgical site infections, and DVT [48]. Under the Patient the CDC, such as central line-associated bloodstream infection and Protection and Affordable Care Act of 2009, starting in 2011, CAUTIs. CMS has applied this payment policy to the Medicaid program to ●● The Office of the National Coordinator is developing a system encourage hospitals to actively prevent these conditions. for reporting medical errors, similar to the method of Common ●● The Patient Safety and Quality Improvement Act of 2005 Formats established by AHRQ, allowing hospitals to more easily established Patient Safety Organizations under supervision of the and accurately collect data on errors, including critical information AHRQ. Patient Safety Organizations receive reports of patient about where and when they occur. safety events from health care providers and provide analyses In summary, the problems associated with medical errors are significant of these events [47]. They also operate under federal privacy and require that nurses and other health care professionals be ever- protections to encourage providers to report medical errors and to vigilant about protecting patients’ safety. There is some good news, work with health care systems to resolve systemic issues. however. According to a report published by the AHRQ, from 2010 to 2013, the United States saw 1.3 million fewer hospital-acquired

Page 139 nursing.elitecme.com conditions. This is a 17% decrease and a savings of $12 billion dollars Nurses also have a professional obligation to become involved in during this 3-year period. These data also indicated that 50,000 lives how their employing organizations address safety issues. They should were saved due to this reduction in hospital-acquired conditions [48]. volunteer for committees and task forces and act as patient advocates at Much work still needs to be done. Research shows that nearly one all times. in 10 hospitalized patients will still become sick or harmed while in Nurses must support their organization’s efforts to enhance the safety the hospital [48]. Nurses are among the health care leaders who can and well-being of patients, visitors, and employees. In addition to make a significant difference in reducing medical errors. They should adhering to safety mandates, they should help teach their colleagues assume the lead in educating their patients and colleagues about ways how to establish and maintain a culture of safety. All employees are to prevent harm and keep the health care environment safe for all. responsible for patient safety. Nurses are on the front-line of all safety initiatives and should act as leaders in the safety process. References 1. Heron, M. (2013). Deaths: Leading Causes for 2010. National Vital Statistics Reports, 62(6), 1-97. 22. Kothari, D., et al. (2010). Medication error in anesthesia and critical care: A cause for concern. Indian Retrieved January 30, 2016 from http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_06.pdf. Journal of Anesthesia, 54, 187-192. 2. McCann, E. (2014). Deaths by medical mistakes hit records. Retrieved January 30, 2016 from http:// 23. 23. Ghaleb, M. A., Barber, N., & Wong, F. B.D. (2010). The incidence and nature of prescribing and www.healthcareitnews.com/news/deaths-by-medical-mistakes-hit-records. administration errors in pediatric patients. Archives of Disease in Childhood, 95, 113-118. 3. Medical errors now third leading cause of death in the United States May 10, 2016 from https://www. 24. Garrouste-Orgeas, M., et al. (2010). Selected medical errors in the intensive care units: Results of the washingtonpost.com/news/to-your-health/wp/2016/05/03/researchers-medical-errors-now-third- IATRORF study: parts I and II. American Journal of Respiratory Critical Care Medicine, 181, 134-142. leading-cause-of-death-in-united-states/. 25. National Coordinating Council for Medication Error Reporting and Prevention. (2016). About 4. Department of Health and Human Services Office of Inspector General. (2012). Hospital incident medication error. Retrieved February 3, 2016 from http://www.nccmerp.org/about-medication-errors. report systems do not capture most patient harm. Retrieved January 30, 2016 from http://oig.hhs.gov/ 26. Stoppler, M. C. (2014). The most common medication errors. Retrieved February 3, 2016 from http:// oei/reports/oei-06-09-00091.pdf. www.medicinenet.com/script/main/art.asp?articlekey=55234. 5. Morran, C. (2012). Study: Only 14% of medical errors reported by hospitals. Retrieved January 31, 27. Aronson, J. K. (2009). Medication errors: Definitions and classification. British Journal of Clinical 2016 from http://consumerist.com/2012/01/06/study-only-14-of-medical-errors-reported-by-hospitals/. , 67, 599-604. 6. Garrouste-Orgeas, M., et al. (20120. Overview of medical errors and adverse events. Annals of 28. Institute for Safe Medication Practices. (ISMP) (2014). ISMP list of high-alert medications in acute Intensive Care, February, 2012. Retrieved February 1, 2016 from http://annalsofintensivecare. care settings. Retrieved February 4, 2016 from https://www.ismp.org/tools/highalertmedications.pdf. springeropen.com/articles/10.1186/2110-5820-2-2. 29. Beckers Hospital Review. (2014). 36 approaches to reducing 9 common medical errors. Retrieved 7. Institute of Medicine (IOM). (2000). To err is human: Building a safer health system. Retrieved February 3, 2016 from http://www.beckershospitalreview.com/quality/36-approaches-to-reducing-9- February 18, 2011 from http://www.iom.edu/~/media/Files/Report percent20Files/1999/To-Err-is- common-medical-errors.html. Human/To percent20Err percent20is percent20Human percent201999 percent20 percent20report 30. Evelyn, L. et al. (2014). Strategies to prevent catheter-associated urinary tract infections in percent20brief.ashx. 31. American Association of Critical Care Nurses (AACN). (2011). Catheter-associated urinary tract 8. National Academies/Institute of Medicine (IOM). (2000). To err is human: building a safer health infections. Retrieved November 7, 2015 from system (summary). Retrieved February 1, 2016 from https://iom.nationalacademies.org/~/media/Files/ 32. Frasca, D., Dahyot-Fizelier, C., & Mimoz, O. (2010). Prevention of central venous catheter-related Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%. infection in the intensive care unit. Retrieved November 8, 2015 from 9. Johns Hopkins Medicine. (2013). Diagnostic errors more common, costly, and harmful than treatment 33. Siegel, M., & Kramer-Cain, J. (2013). Vascular catheter-associated infections. Retrieved mistakes. Retrieved February 1, 2016 from http://www.hopkinsmedicine.org/news/media/releases/ 34. Busby, S. R. et al. (2015). Assessing patient awareness of proper hand hygiene. diagnostic_errors_more_common_costly_and_harmful_than_treatment_mistakes. 35. The Joint Commission. (2015). New sentinel event alert focuses on preventing falls. 10. Agency for Healthcare Research and Quality. (2015). Systems approach. Retrieved February 2, 2016 36. Quigley, P. A., & White, S. V. (2013). Hospital-based fall program measurement and from https://psnet.ahrq.gov/primers/primer/21/systems-approach. 37. Cooper, K. L. (2013). Evidence-based prevention of pressure ulcers in the intensive care 11. National Coordinating Council for Medication Error Reporting and Prevention. (2016). What is a 38. National Pressure Ulcer Advisory Panel (NPUAP). (2015). NPUAP pressure ulcer medication error? Retrieved February 2, 2016 from http://www.nccmerp.org/about-medication-errors. 39. 39. Kirman, C. N., et al. (2015). Pressure ulcers and wound care treatment & management. 12. Lippincott Nursing Center. (2011). 8 rights of medication administration. Retrieved February 2, 2016 40. Centers for Disease Control and Prevention. (2016). Surgical site infection event. Retrieved February https://www.nursingcenter.com/ncblog/may-2011/8-rights-of-medication-administration. 4, 2016 from http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf. 13. Griffin, R. M. (2009). Common problems patients face in the hospital. Retrieved February 2, 41. Johns Hopkins Medicine, Center for Innovation in Quality Patient Care. What is DVT/ VTE? Available 2016 from http://www.webmd.com/a-to-z-guides/features/before-surgery-your-top-six-hospital- at: http://www.hopkinsmedicine.org/innovation_quality_patient_care/areas_expertise/ infections_ risks?page=2. complications/dvt/what_is_dvt_vte.html 14. Agency for Healthcare Research and Quality. (2015). Wrong-site, wrong-procedure, and wrong-patient 42. Agency for Healthcare Research and Quality. Preventing Hospital-Acquired Venous surgery. Retrieved February 3,2 016 from https://psnet.ahrq.gov/primers/primer/18/wrong-site-wrong- Thromboembolism: A Guide for Effective Quality Improvement. Available at: http://www.ahrq.gov/ procedure-and-wrong-patient-surgery. professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/index.html 15. Ross, M. (2015). What makes mistakes more likely? Retrieved February 3, 2016 from 43. American Academy of Orthopaedic Surgeons. (2015). Deep vein thrombosis. Retrieved http://www.pharmacytimes.com/news/what-makes-pharmacist-mistakes-more-likely. 44. WebMD. (no date given). How to prevent deep vein thrombosis (DVT). Retrieved February 19, 2016 16. Rice, S. (2014). Most laboratory errors happen outside the lab, ECRI report finds. Retrieved February from http://www.webmd.com/dvt/deep-vein-thrombosis-prevent-dvt 3, 2016 from http://www.modernhealthcare.com/article/20140417/NEWS/304179961. 45. Centers for Disease Control and Prevention. Ventilator-associated Pneumonia (VAP). Available at: 17. Patient Safety Network. (2014). Never events. Retrieved February 3, 2016 from https://psnet.ahrq.gov/ http://www.cdc.gov/hai/vap/vap.html primers/primer/3/never-events. 46. Halyard Health. (no date given). Ventilator associated pneumonia. Retrieved February 4, 2016 from 18. Joint Commission. (2015). Sentinel events (SE). Retrieved February 3, 2016 from http://www. http://www.halyardhealth.com/hai-watch/hai-threats-solutions/ventilator-associated-pneumonia.aspx. jointcommission.org/assets/1/6/camh_2012_update2_24_se.pdf. 47. Cornell University Law School. (no date given). Public health service act. Retrieved February 4, 2016 19. Wheeler, K. K. (2014). Effective handoff communication. OR Nurse, 8(1), 22-26. from https://www.law.cornell.edu/uscode/text/42/chapter-6A. 20. Makary, Martin and Daniel, Michael. Analysis: Medical error–the third leading cause of death in the 48. Health US News. (2014). 50,000 fewer deaths caused by hospitals. Retrieved February 4, 2016 from US. The British Medical Journal. 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nursing.elitecme.com Page 140 MEDICAL ERRORS: A CriTICAL PRACTICE ISSUE Final Examination Questions Choose the best answer for questions 1 through 10 and mark your answers online at nursing.elitecme.com. 1. To prevent central line-associated bloodstream infections: 7. Strategies to reduce the risk of medication error include: a. Use soap and water for skin antisepsis. a. Adhere to the five rights of medication administration. b. Use the femoral site for catheter insertion. b. Ensure that handoffs at discharge receive the most attention c. Choose dressings that are permeable to water. compared to other handoffs. d. Avoid applying topical antibiotic creams and ointments to the c. Use barcode technologies. insertion site. d. Have three clinicians independently verify doses prior to administering medication. 2. An adverse drug reaction: a. Involves death or serious physical injury. 8. When teaching colleagues about preventing catheter-associated b. Is unavoidable. urinary tract infections (CAUTIs), a nurse should explain that: c. Is an error that is detected and corrected before harm occurs. a. The majority of CAUTIs occur when a patient is catheterized d. Involves the need for immediate investigation and response. for a urine specimen. b. The major risk for CAUTIs has not been identified. 3. The Patient Protection and Affordable Care Act: c. Most hospitals have effective strategies for the prevention of a. Has authorized three pay-for-performance programs. CAUTIs. b. Reduces payments to hospitals that fail to comply with Joint d. Indwelling catheters should be properly secured to prevent Commission standards. urethral traction. c. Has developed a system for reporting medical errors. d. Sends surveyors to hospitals to determine their medical error 9. The most effective way to prevent transmission of health care- rate. associated infections is: a. Sterile barrier precautions. 4. Which of the following statements about ventilator-associated b. Adherence to personal protective equipment policies. pneumonia (VAP) is accurate? c. Proper hand hygiene. a. VAP affects up to 50% of ventilated patients. d. Wearing gloves. b. VAP seldom leads to death. c. To help prevent VAP, saline lavage should be performed 10. Medical error requires that: frequently. a. The patient involved must complain about a health care d. To help prevent VAP ,the patient’s head should be elevated 30 worker. to 45 degrees. b. A physician must confirm that a medical error occurred. 5. Deep vein thrombosis (DVT): c. An attorney must be notified of the medical error’s occurrence. a. Is more likely to occur in someone is underweight. d. Harm or error must have occurred that could have been b. Has the potential to cause a serious complication of pulmonary prevented. embolism (PE). c. Is unpreventable in the hospital setting. d. Affects less than 100,000 Americans annually.

6. Which of the following statements about factors that contribute to medical error occurrence is accurate? a. The Joint Commission reports that analysis of 4,000 adverse effects showed that 70% were due to communication breakdowns. b. Planning and knowledge refers to analysis of sentinel events. c. The IOM reports that medical errors are most often due to negligent practitioners. d. Personal behavior is the most changeable aspect of medical error prevention.

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