Prevention Of Medical

Dana Bartlett, BSN, MSN, MA, CSPI

Dana Bartlett is a professional nurse and author. His clinical experience includes 16 years of ICU and ER experience and over 20 years of as a poison control center information specialist. Dana has published numerous CE and journal articles, written NCLEX material, written textbook chapters, and done editing and reviewing for publishers such as Elsevier, Lippincott, and Thieme. He has written widely about toxicology and was recently named a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Connecticut Poison Control Center and is actively involved in lecturing and mentoring nurses, emergency medical residents and students.

ABSTRACT

The identification and prevention of medical errors requires the participation of all members of the health team, including . The traditional way of coping with medical errors was to assume errors were the result of individual mistakes such as carelessness and inattention, creating a culture of blame. However, it has become clear this approach is not optimal. It does not address the root causes of medical errors, system problems, it discourages disclosure of errors, and without disclosure errors cannot be prevented. Enhancing health team knowledge and the environment of care will help to reduce the risk of a medical .

Policy Statement

This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education

1 nursece4less.com nursece4less.com nursece4less.com nursece4less.com requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities.

Continuing Education Credit Designation

This educational activity is credited for 2 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity.

Statement of Learning Need

The rates of medical errors remain a public health and safety risk. Safe care requires all members of the health team and the public to be educated on how to recognize and prevent a medical error, and to advocate for needed changes to improve the delivery of safe and appropriate healthcare.

Course Purpose

To provide an overview of medical errors in today’s healthcare system and to identify the incidence and risk factors contributing to medical

2 nursece4less.com nursece4less.com nursece4less.com nursece4less.com errors; and, to provide strategies to prevent medical errors including increasing public awareness.

Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Dana Bartlett, BSN, MSN, MA, CSPI, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC -all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. 1. True or False: A medical error and an adverse event are identical.

a. True b. False

3 nursece4less.com nursece4less.com nursece4less.com nursece4less.com

2. Diagnostic errors occur when

a. an incorrect diagnosis is made. b. the diagnosis is changed from the original diagnosis. c. given the available data, the correct diagnosis should have been made. d. the diagnosis was made more than 72 hours after examination.

3. A error is defined in part by the words

a. preventable and patient harm. b. under-dosing and over-dosing. c. and therapeutic intervention. d. avoidable and lack of vigilance.

4. A common cause of medication error is

a. look-alike and sound-alike drug names. b. adult drugs being used for pediatric patients. c. patient refusal to accept the drug . d. undisclosed use of herbal supplements.

5. True or False: Medical errors should be disclosed to the patient.

a. True b. False

Introduction

Medical errors are a significant problem in the healthcare system. The seminal 1999 monograph by The Institute of (IOM) reported

4 nursece4less.com nursece4less.com nursece4less.com nursece4less.com that between 44,000 and 98,000 patients die each year in the as a result of a medical error, and that 7% of all hospital admissions experience a serious medication error,1 and this disturbing situation has not changed since then. This course provides a general overview of medical errors with a discussion on six types of medical errors: 1) Diagnostic errors, 2) Falls, 3) Laboratory errors, 4) Medication errors, 5) Surgical errors, and 6) Treatment errors. The incidence, etiology, and risk factors of each will be examined, and strategies for their prevention will be discussed.

Medical Errors And Terminology

The terminology associated with medical errors can be confusing. Terms such as adverse events, adverse effects, errors of commission, errors of omission, medical errors, near misses, preventable adverse effects, and side effects are all frequently mentioned in discussions of medical errors. All of these have some relevance to the discussion of medical errors, but the terms that are important here are medical error and adverse event. A medical error has been defined as Failure of a planned action to be completed as intended, or, the use of a wrong plan to achieve a goal.1 Since the Institute of Medicine (IOM) released its definition of medical error alongside national statistics at that time, numerous other medical quality experts have reported that the actual statistics on medical errors in the United States are much higher. A recent review of the most common causes of death in the United States reported by the Centers for Control and Prevention (CDC), indicated that past reporting of cause of deaths relied upon the International Classification of Disease (ICD) code. Consequently,

5 nursece4less.com nursece4less.com nursece4less.com nursece4less.com human and system factors were not sufficiently captured. Other studies and news reports suggested that the actual death toll related to medical error was much higher. Additionally, safety factors related to medical error or sentinel events have improved since the IOM report in 1999 on patient harm and death to better identify unsafe processes and systems, such as communication breakdowns, diagnostic errors, poor judgment, and inadequate clinician skill.2

Medical Error

A medical error may result in or it may not, but the potential for injury is present. Medical errors can be errors of execution or planning. An execution error is one in which a plan of action such as a specific therapy is considered appropriate and correct but it was not properly carried out. Execution errors can be errors of commission or errors of omission. In the former, an incorrect action was done unintentionally and, in the latter, the correct action was unintentionally not done. A planning error is one in which the plan of action is not considered appropriate or correct for the patient.2

Adverse Event

An adverse event is defined as a preventable medical error that causes harm to the patient. Not all medical errors are adverse events and not all medical errors become adverse events. The differences between a side effect and an adverse event are predictability, severity, and consequences.

6 nursece4less.com nursece4less.com nursece4less.com nursece4less.com At times the distinction between a side effect and an adverse event can be blurred. A side effect is typically considered to be predictable, minor in severity and often temporary in duration, and it will not cause harm or require treatment. An adverse event is typically considered to be (somewhat) unpredictable, moderate to severe, possibly permanent, and it may cause harm and/or require treatment and stopping the use of a medication suspected to be causing the adverse event.

Interprofessional education and training has been increasingly emphasized in the literature on safety in health systems. The IOM and other researchers advocate that interprofessional awareness of safety issues in healthcare is critical to the delivery of high-quality care, however also point out that while interprofessional awareness of safety issues in healthcare have grown, professionals are still not adequately prepared for this team-based practice.4 There have been barriers to interprofessional training and collaboration due to a variety of factors, such as “logistical challenges, deep-rooted cultural differences among the health care professions, differences in educational curricula and trajectory, and costs … intraprofessional collaboration can be difficult to achieve in practice…”4 Inexperienced or newer clinicians may have difficulty speaking up about unsafe practice and possible medical error when more senior clinicians are involved.

Diagnostic Errors

Diagnostic errors are relatively common, but when compared to other medical errors such as falls and medication errors they have received

7 nursece4less.com nursece4less.com nursece4less.com nursece4less.com much less attention and research.3 Despite the obvious and immediate effects of a medical error, such as a fall, diagnostic errors can be a significant cause of morbidity and mortality and at times more so than other types of medical errors. There is no universally accepted definition of a diagnostic error. This course will define a diagnostic error as follows:5

A diagnostic error has occurred if the wrong diagnosis was made, and 1) there was adequate data to suggest the correct diagnosis, or 2) the clinical findings should have prompted the medical clinician to do further evaluation in order to make the proper diagnosis.

In essence, a diagnostic medical error has happened when it could be reasonably expected that a competent and experienced medical provider should have been able to make the correct diagnosis; or, that further evaluation and testing should have been ordered in order to make a correct diagnosis given the clinical findings.

The true incidence of diagnostic errors is not known, but it is generally assumed to be approximately 10%-15%.6 Errors have been connected to health clinician overconfidence where there is “positive illusions or to excessive certainty”.7 The tendency to believe that our knowledge is more certain that it really was discussed in a recent (2014) survey estimating the incidence of diagnostic errors in the outpatient setting to be 5.08% or 12 million adults every year in the United States.8 This wide range can be explained by many factors, and some key factors are outlined in the sections to follow.3,6

8 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Patient Population

Consideration of the patient population involves taking into account the demographics of the persons receiving care and the location where healthcare is delivered. Diagnostic errors will clearly be more likely if the patient has a complex medical history and multiple medical problems. Additionally, diagnostic errors will be more likely if diagnostic resources are limited, patient follow-up is sub-optimal and the time available for diagnosis is limited or perceived to be limited.

The setting in which healthcare is delivered is another influencing factor, such as, a setting that is particularly fast-paced and stressful can be predisposed to diagnostic errors. Skill and experience level of the diagnostician is another obvious factor in the accuracy of the diagnostic process.

Data Sources

Autopsy reports, chart reviews, clinical laboratory records and reviews, medical malpractice claims, patient and provider surveys, peer reviews, simulations and standardized patients, and voluntary reporting have all been used to determine the incidence of diagnostic errors. For this purpose, all of these have strengths and weaknesses, and they can all either under-report or over-report the incidence of diagnostic errors. Still, these all reveal an incidence of diagnostic errors that is disturbing. studies show an incidence of diagnostic errors of 10%-20%.6 Most recently, a retrospective study performed at Jackson Memorial Hospital included autopsy reports between 2009 and 2014. There were

9 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 923 performed, and 512 patients (55.5%) were adults. A total of 334 cases were subject to review with some exclusions and restrictions, such as short (<1 day) hospital stays and cases referred from other facilities. A total of 33 of 334 cases (9.9%) were identified as class I discrepancy, “where the autopsy revealed a discrepant diagnosis with a potential impact on survival or treatment”.9 The critical findings reported in the study’s case reports included untreated (15 of 33 cases; 45.5%), pulmonary embolism (8 of 33 cases; 24.2%), and undiagnosed malignancy (6 of 33 cases; 18.2%).9

Some types of diagnoses are much more difficult to make than others. Patients in their early stages of an illness, such as an infection with HIV or tuberculosis, can be very difficult to correctly diagnose. The incidence of these medical errors clearly depends in part on how they are defined.

Causes of Diagnostic Errors

Research into the root causes of diagnostic errors has suggested that these errors occur from either a failure of the ’ intuitive reasoning process (i.e., pattern recognition and memory retrieval) or a failure of their conscious reasoning process.10 Viewed this way, it is possible to understand in a generalized way how diagnostic errors occur. However, it is helpful to look at the specific situational causes of diagnostic errors. Singh, et al., (2013) examined diagnostic errors that were made in primary care settings and five distinct factors of 1) patient-related,

10 nursece4less.com nursece4less.com nursece4less.com nursece4less.com 2) patient-practitioner, 3) diagnostic tests, 4) follow-up and tracking, and 5) referrals were identified as primary causes of diagnostic errors.5

Patient-related

Singh reported that in 16.3% of all cases, patient related factors were the primary causes of diagnostic error. These factors included failure of the patient to provide an accurate medical history, failure of the patient to seek help in a timely manner, a communication barrier between the patient and the practitioner.

Patient-Practitioner

An issue between the patient and the practitioner during the clinical encounter was identified in 78.9% of all cases of diagnostic errors.

Specific problems were errors made by the clinician during the physical examination, failure to review medical records, failure to ask questions needed to make the diagnosis (i.e., data gathering), failure to order the appropriate diagnostic and laboratory tests, and failure to take a comprehensive medical history.

Diagnostic Tests

Incorrect use, incorrect interpretation, and incorrect follow-up of diagnostic tests were identified in 13.7% of all cases of diagnostic errors.

Follow-up and Tracking

11 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Inadequate follow-up and tracking errors such as failure to have a follow-up system in place or failure to follow-up diagnostic tests were identified in 14.5% of all cases of diagnostic errors.

Referrals

In 19.5% of all cases, diagnostic error mistakes in the referral process were identified. These included failure to contact the appropriate expert, failure to identify when a referral was needed, lack of knowledge that would have helped the practitioner identify the need for a referral, failure to consider the patient’s condition serious enough to require a referral, or an error when taking a medical history.

In 43.7% of all cases in which the correct diagnosis was not made, more than one of the five factors identified above was operative. The researchers noted that in 37.9% of all cases the failure to correctly diagnose the patient’s problem could have resulted in considerable harm, and in 14.2% of the cases the patient could have suffered immediate or inevitable death.5 The clinical problems were not highly complex or unusual; pneumonia, congestive heart failure, acute renal failure, and urinary tract were among the diagnoses that were commonly missed.5

The research indicated that practitioner errors involving mistakes in information gathering and synthesis and reasoning are the most common cause of diagnostic errors,5 and this fact could be dismissed as inevitable because people make mistakes. However, the wide variation in the incidence of diagnostic errors clearly shows that they

12 nursece4less.com nursece4less.com nursece4less.com nursece4less.com are not inevitable and that some practitioners are not making cognitive errors during the diagnostic process. The hope is that the habits and techniques of a successful diagnostic process can be identified and taught, and that the incidence of diagnostic errors could be reduced. Several strategies for doing this have been researched and will be discussed later in this study.

Patient Falls In Healthcare

Patient falls are very common medical errors, and they are one of the most common adverse events that happen to hospital in-patients.18,40 It has been estimated that up to 20% of all in- patients suffer a fall at least once during a hospital stay, and the rate of falls in acute care hospitals has been reported to be between 1.3 to 8.9 per 11,12 1000 hospital days.

Falls can be very serious. Between 30%-50% of all patient falls result in an injury, and patients who suffer a fall have longer hospital stays and higher healthcare costs.12,13 The Joint Commission considers a fall that results in death or major permanent loss of function, as a result of sustained in the fall, to be a reviewable sentinel event; and, fall prevention is one of the Joint Commission’s National Goals.14,15 Additionally, the World Health Organization (WHO) defines

13 nursece4less.com nursece4less.com nursece4less.com nursece4less.com fall as an event that results in a person coming to rest inadvertently on the ground or some lower level.16

Several risk factors identified with falling exist, such as being elderly or having urinary frequency. Healthcare teams frequently use assessment tools to identify patients that are at risk for falling and there are many tools and fall risk algorithms available through the Center of Disease Control (CDC) website, a helpful resource with multiple fall prevention patient handouts at: http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html.

Laboratory Errors

Laboratory medical errors can be divided into three categories: pre- test, testing, and post-test. The incidence of testing performance errors, which are errors that occur with the technical processing of specimens, is comparatively low as standardization of analytical methods, materials, and improved instrumentation have greatly decreased the incidence of in-laboratory analytical error.17,18

Most in-laboratory errors involve specimen mislabeling, and the incidence of inaccurate test performance is very low, estimated at 0.002%. However, pre-test and post-test medical errors involving the clinical laboratory are quite common.17,18

Pre-test and post-test errors during diagnostic testing have been a focus of researchers relative to being more error prone than the

14 nursece4less.com nursece4less.com nursece4less.com nursece4less.com analytical phase of testing. Pre-test errors would involve 1) inappropriate ordering of tests, i.e., ordering a test that has no relevance to the clinical situation, and 2) test performance and specimen collection errors, such as improper site preparation, specimen contamination, improper performance of the test, not using the correct specimen containers or tubes, mislabeling of specimens, and performing a test on the wrong patient. Post-test errors involve 1) errors in receiving, such as test results being incorrectly transmitted by the sender, test results being incorrectly recorded by the receiver, and test results not transmitted to the right person or not transmitted in a timely manner, 2) errors in interpretation, and 3) errors in follow- up, such as failure to check for test results, failure to use test results in a timely manner, failure to order further testing that would be indicated by the previous test results, failure to appropriately use test results to change , and failure to send test results to patients or to contact them about test results.17,19

Earlier researchers, such as Plebani (2010), noted that laboratory errors could result in mistakes in digoxin or heparin therapies, inappropriate admissions, and other clinical problems. Additionally, 24%-30% of laboratory errors had an effect on patient care, and the risk for adverse events from laboratory errors was 2%-12.7%.20 Such studies highlighted the serious harm to patients that can occur as a result of laboratory errors, and paved the way for ongoing research and improved guidelines in the field of laboratory science and medicine.

15 nursece4less.com nursece4less.com nursece4less.com nursece4less.com In a recent report, Plebani (2016) focused on the quality of laboratory medicine, which has become a major cause of concern in terms of adverse clinical outcomes and patient harm. While there exists an interdependence between the pre-analytical phase through to the effect of the post-analytical phase on the quality of data affecting patient care outcomes, researchers focused on patient safety and care outcomes emphasize that “laboratory professionals and clinicians alike should never lose sight of the fact that pre-analytical variables are often responsible for erroneous test results and that quality biospecimens are pre-requisites for a reliable analytical phase”.19 Importantly, test selection and interpretation of test results has increased alongside the increased development and complexity diagnostic laboratory technology.

Medication Errors

A medication error is defined in this section as “Any preventable effect that may cause or lead to inappropriate use or patient harm while the medication is in control of the healthcare professional, patient, or consumer.”21 Two terms in this definition that should be remembered are preventable and patient harm; indicating that the medication error was preventable and may have caused or lead to patient harm.

Medication errors presented here are divided into four categories: 1) Prescribing, 2) Administration or preparation, 3) Dispensing, and 4) Monitoring.

Prescribing Errors

16 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Prescribing errors include but are not limited to: • Wrong drug because of drug-drug interactions and/or drug . • Incorrect dose, concentration, route, or frequency. • Drug prescribed for the wrong patient. • Duplicate drugs prescribed. • The appropriate drug not prescribed. • The prescription was written illegibly or improper abbreviations were used.

Transcribing errors involve a mistake that was made when the order was transcribed, either in the pharmacy or in a clinical setting.

Administration and Preparation Errors

Administration errors are often the same as prescribing errors, and they also include:

• Missed doses or doses given at an incorrect time. • Medication given by someone unauthorized to do so. • Improper administration technique. • Incorrect rate of administration. • Administration of an expired drug. • Drug prematurely discontinued or administered for too long. • Duplicate administration, i.e., a double dose. • Incorrect dosage calculations. • Failure to document administration of a drug or incorrect documentation.

17 nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Failure to use medication administration safeguards, i.e., double checking calculations. • Failure to comply with medication administration policies, i.e., leaving unattended, and not watching a patient take medications. Improper or incomplete administration directions given to a patient.

Preparation errors are typically a drug improperly constituted or incorrectly concentrated.

Dispensing Errors

A dispensing error would involve a drug dispensed to the wrong patient, not dispensed in a timely manner, or the wrong drug was dispensed.

Monitoring Errors

Monitoring is a very important part of medication therapy; it ensures that the medication is effective, tolerated, and to make dose adjustments. Safe use of medications like digoxin, lithium, and warfarin requires periodic laboratory testing of blood levels, and other drugs require measurement of blood glucose, electrolytes, or renal function in order to measure their effectiveness or to detect adverse effects. Monitoring errors include:

• Not ordering the proper laboratory tests.

18 nursece4less.com nursece4less.com nursece4less.com nursece4less.com • Not responding appropriately to laboratory tests. • Ordering a test but the test is not performed. • Failure to monitor for drug effectiveness, adverse effects, and side effects.

Monitoring errors appear to be less common than prescribing, administering, and dispensing errors, but there is limited data and a wide variation in monitoring errors has been reported. In a 2012 study, 6048 prescriptions written by general practitioners showed a 0.9% rate of monitoring errors.22

Clearly, medication errors are not unusual, but for several reasons the exact incidence of medication errors is not known. Firstly, there is no universally used system for detecting and reporting medication errors. Self-reporting, incident reports, chart reviews, direct observation, and trigger tools can and have been used as tools for detecting medical errors, but each one yields different results. Self-reporting appears to greatly underestimate medication errors while direct observation consistently detects a large number of medication errors.23 Secondly, the definition of a medication error is a significant influence on the reported incidence of medication errors.

Keers, et al., (2013) did a systematic review of 91 direct observational studies of medication errors and found a median error rate of 19.6%, but if timing errors (i.e., the medication was not given at the prescribed time) were excluded, the median error rate was 8.0%.23 The issue is further complicated by different definitions of timing error. Some of the studies reviewed by Keers and colleagues defined a timing

19 nursece4less.com nursece4less.com nursece4less.com nursece4less.com error as a delay of 30 minutes or more while some simply reported timing errors but did not provide a definition of what a timing error was considered to be. In addition, 28 of the 91 research papers either did not define a medication error or used a definition that was exclusive to the study.

Despite the difficulty in determining the true incidence of medication errors, the reviews of the literature and the studies of medication errors are very instructive. Regardless of study design or the definition of medical error that was used, the research consistently shows that the incidence of medication errors is disturbingly high and that there are multiple and easily identifiable causes of medication errors.

Baumgart-Huckels (2014), et al., studied the rate of medication errors, and the causes and consequences of medication errors in a large teaching hospital over a four-year period.24 The use of medication was divided into a process of five steps: 1) Prescribing, 2) Transcribing, 3) Preparation, 4) Administration, and 5) Monitoring. Medication errors in the 2014 study were categorized as the wrong patient, wrong dose, wrong drug, wrong dose, wrong quantity, or a medication omitted/not given. Medication errors recorded in the four-year period amounted to 1591 incidents, and most of the errors occurred during the medication preparation and administration steps.

The majority of the medication errors, 74.2%, involved more than one-step in the medication use process, and only 25.8% were detected early in the process. The authors report that 84.3% of the errors reached the patients and 8.8% reached the patient and required

20 nursece4less.com nursece4less.com nursece4less.com nursece4less.com monitoring to confirm no harm or intervention to prevent harm. The authors also reported that inattention was the most common cause of the medication errors (60.5%). This was followed by work conditions, such as poor staffing and heavy workload (31.4%).24

Ryan, et al., (2014) also examined the prevalence and causes of prescribing errors made by trainee physicians. A prescribing error was defined as: “One which occurs when, as a result of a prescribing decision or prescription writing process, there is an unintentional significant reduction in the probability of treatment being timely and effective or an increase in the risk of harm when compared with generally accepted practice.’’25

A total of 44,276 prescriptions were examined, and the error rate was 7.5%. The most common prescribing order error was omission, such as, when a medication was not ordered but should have been. Doses that were too low or too high were also common. However, fortunately, prescribing medications that would result in a harmful interaction and prescribing a medication for the wrong patient were uncommon: these accounted respectively for 1.5% and 0.5% of the errors.25 Ryan and colleagues identified that prescribing errors were “of frequent and of complex causation”.25 The authors also found that the work environment and the lack of knowledge of medications by health staff were the most common causes of the medication prescribing errors. It is interesting to note that a potential cause of a prescribing error was due to the physicians’ perception that if they made a prescribing error it was likely to be detected by other

21 nursece4less.com nursece4less.com nursece4less.com nursece4less.com physicians or hospital staff and the error would be corrected before a medication administration error occurred.25

Honey, et al., (2014) studied 2491 prescriptions that were written by medical residents and found a prescribing error rate of 5.88%.26 Doses that were too high, too low, or of unclear quantity were the most common prescribing errors, and these accounted respectively for 17.3%, 13.8%, and 12.7% of the errors made. The study was of pediatric patients, and the relatively high rate of dosage errors was presumed to be because drug dosages for children are more frequently based on body weight than drug dosing for adults so calculating – a process that is susceptible to human error – was an important source of these mistakes.

Beardsley, et al., (2013) examined the medical records of all patients who had been discharged from a general medical practice. Patient records were examined for a period of 60 days prior to discharge to 60 days after discharge.27 The authors found prescribing errors in 34.5% of the pre-discharge records and in 17% of the post-discharge records. Medication omission and dosage errors were the most common, and 3% of the errors were considered to be serious, such as:27

• The route of administration could have led to severe toxicity. • The dose was 4-10 times the normal and the drug had a low therapeutic index. • The dose was too low and the patient had a serious condition.

22 nursece4less.com nursece4less.com nursece4less.com nursece4less.com • The dose was too high and led to a blood level that was potentially toxic.

The risks of medication errors HIGH ALERT MEDICATIONS increase if the patient is very EPINEPHrine, subcutaneous epoprostenol (Flolan), IV young, very old, has complex insulin U-500 (special emphasis) medical problems, or is taking magnesium sulfate injection methotrexate, oral, non-oncologic multiple medications. The risk for use medication errors has also been opium tincture oxytocin, IV associated with specific drugs. The nitroprusside sodium for injection Institute for Safe Medication potassium chloride for injection concentrate Practices (ISMP) has published the potassium phosphates injection List of High-Alert Medications in promethazine, IV vasopressin, IV or intraosseous Acute Care Settings, which are ISMP (2014)28 drugs that clinicians need to be alerted to in terms of the risk of causing significant patient harm when they are used in error, such as epinephrine and insulin. While the drugs published by the ISMP may not necessarily be the more common drugs given in error, the consequences of an error carry significant physical harm and potential morbidity and mortality consequences.

Strategies to avoid medication errors include standardizing the ordering, storage, preparation, and administration of medication, improving access to information about high-alert medication, limiting access to high-alert medications, using auxiliary labels and automated alerts, and employing redundancies such as automated or independent double-checks when necessary. The ISMP recommends that all forms

23 nursece4less.com nursece4less.com nursece4less.com nursece4less.com of insulin, subcutaneous and IV, be considered high-alert medications. Insulin U-500, in particular, is especially emphasized as requiring clear strategies to prevent the types of errors that occur with this concentrated form of insulin.28

Desai, et al., (2013) in a study of medications errors that occurred in nursing homes and residential facilities found that anxiolytics/ sedatives/hypnotics, anti-diabetic agents, anticoagulants, anticonvulsants, and ophthalmic preparations were “frequently and disproportionately involved in errors in nursing homes ...”, and “... certain drug classes are more likely to be involved in medication errors in nursing home patients regardless of the extent of their use.”29

There are other medical errors noted in the literature, which would be outside the scope of this study. This includes a wide body of research and literature on surgical and other treatment errors in healthcare settings, briefly reviewed below. Surgical Errors

Major complications occur can occur in surgical procedures and the rate of permanent disability or death from has been reported to be significant. Each year in the United States there are over 70 million applications of anesthesia and errors are inevitable.30 Equipment failures during anesthesia are relatively uncommon. Most involve a disconnection or misconnection of the breathing circuit and the rate of these errors has been estimated to range from 0.06% to 0.7%; however, these types of errors account for approximately 20% of all critical anesthesia events.31

24 nursece4less.com nursece4less.com nursece4less.com nursece4less.com

While most research on anesthesia-related morbidity and mortality rates consider varying factors, such as length and type of procedure, as well as type of anesthesia, one 2014 study focused on selection of the anesthesia technique based on a clinician’s practice style and consideration of patient-related factors. This study focused on general assumptions of anesthesiologists to select a type of anesthesia based on observational data including factors such as patient age and general health. A common example of a patient-related factor influencing selection of an anesthesia type would be the anticoagulated patient with impaired blood clotting time.

The suggestion of the study authors was that observational data was limited “because of the nonrandom selection of patients for one form of anesthesia or another”.32 The study group evaluated patients undergoing hip surgery between 2004 and 2011, and the study goal was to “go beyond prior observational studies… to address selection bias, multivariable matching, and instrumental variable analysis.”32 The assumption by most anesthesiologists and the research team was that regional anesthesia as compared with general anesthesia would have less risk of adverse outcomes. The study showed, however, that the use of regional anesthesia compared with general anesthesia for a complicated procedure such as hip surgery was not associated with lower 30-day mortality although it did result in a modestly shorter length of hospital stay. The study also considered the residential proximity of patients to specific types of hospitals.

The study included 56,729 patients of which 15,904 (28%) received

25 nursece4less.com nursece4less.com nursece4less.com nursece4less.com regional anesthesia and 40,825 (72%) received general anesthesia. There were 3032 patients (5.3%) that died. It was found that 583 of 10,757 matched patients (5.4%) who lived near a regional anesthesia–specialized hospital died versus 629 of 10,757 matched patients (5.8%) who lived near a general anesthesia–specialized hospital.32

Future research will be needed however the benefit of this study was to reveal how a widespread assumption by anesthesia specialists based on observational data (in practice) that general anesthesia posed significantly greater risk over regional anesthesia for patients undergoing a lengthy orthopedic procedure of hip surgery did not necessarily hold up in a long-term study. Further, this study added to previous research on anesthesia for hip fracture; a meta-analysis of 8 small trials published between 1978 and 1998 reported lower mortality with regional versus general anesthesia. The present study, however, included groups that were omitted in prior trials, such as patients with dementia. It was also suggested that this study, which extended to 2011, provided more relevance to current practice than historical studies because it also added data showing that anesthesia care varied as a result of patients’ residential proximity to specific types of hospitals rather than being limited to a process of clinical selection.32

Antibiotics, inhalation gases, local anesthetics, muscle relaxers, opiates, and vasoactive drugs are the medications most commonly involved in anesthesia medication errors.56 Failure to read labels or misreading labels, distractions, carelessness and inattention, lack of

26 nursece4less.com nursece4less.com nursece4less.com nursece4less.com vigilance, and stress and poor communication are the root causes of anesthesia medication errors; and, they usually result in a missed dose, an incorrect dose, improper drug substitution, omission, double dosing, or the use of an incorrect route.

Treatment Errors

Other treatment errors are those errors that occur during the performance of an operation, test, or procedure.1 Examples of situations in which treatment errors may occur include administering blood and blood products, advanced monitoring, i.e., intracranial pressure monitoring, intravenous insertions, nasogastric tube insertions, phlebotomy and urinary catheterization. There are other potential treatment errors, such as surgical errors.

Surgical errors have been closely studied to help health teams identify mistakes most likely to happen. The basic types of errors that can be made when clinicians are performing a procedure, such as collecting a specimen or doing a treatment during post-operative care, are errors identified during planning performance and follow-up. The root causes of treatment errors involve human factors and system factors.

Root Cause: Human And System Factors

Human factors and system factors are the root causes of medical errors, but there are certain ways in which people perform and that healthcare systems are organized which are the specific causes of medical errors. The use of multiple medical specialists or medical systems to care for one individual is a large contributor to errors.

27 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Information does not always follow patients; there is no one place that knows all about one patient’s health.

Fragmented health services are largely responsible for healthcare information not being centralized. One medical clinician caring for all of a patient’s medical needs is not the norm in today’s healthcare setting. Fragmentation leads to duplicate medications and services, which is not only costly but increases the risk of a medical error. An individual with diabetes, heart failure, prostate cancer, and depression could see six medical clinicians including in primary care, endocrinology, cardiology, urology, oncology, and psychiatry.

The increasing use of hospitalists is another piece of the healthcare system that leads to fragmentation. The hospitalist is a medical clinician specializing in the care of the patient who is admitted to the hospital. These clinicians are experts in caring for hospitalized patients, but they are not considered primary care clinicians and the lack of familiarity with the patient and (perhaps) incomplete access to a patient’s medical history can be a source of errors. Fragmentation can also be a result of the use of different and hospitals.

Time Constraints

Healthcare takes place at a rapid pace. Each day, healthcare clinicians are seeing a large volume of patients, are filling a large number of prescriptions, and nursing clinicians are often caring for more patients than they should. Many medical and nursing clinicians are overworked. They need to work fast to meet the demands of

28 nursece4less.com nursece4less.com nursece4less.com nursece4less.com administrators, patients and the financial bottom line. When people are working quickly - perhaps too quickly - the risk of errors is increased. Clinicians have often reported that they do not have enough time to properly perform their work.

Poor Communication

Poor communication is often identified as a major cause of medical errors. Communication errors are common and can happen anywhere within the healthcare system. For example, a 2014 study showed a 30% error rate in medical dictation/transcription,34 and poor communication in the form of using non-standard abbreviations and the common use of sound-alike medications has long been known as a cause of medical errors.

Starmer, et al. (2013) wrote that communication errors are a leading cause of sentinel events, and that improving handoff communication (i.e., transferring information about and responsibility for a patient) reduced medical errors from 38.3 per 100 admissions to 18.3.35 Poor communication is also an issue between health clinicians and patients. Good listening requires that the health clinician listen fully and hear the patient. In addition to listening, healthcare providers need to communicate information accurately and simply.

Lack of Knowledge

Both researchers and health clinicians often identify lack of knowledge as a major cause of medical errors, and lack of knowledge affects all

29 nursece4less.com nursece4less.com nursece4less.com nursece4less.com parts of the healthcare delivery process. They also note that there is a lack of resources and/or time for increasing knowledge.

Healthcare Setting

Emergency rooms, intensive care units, and the operating room are high-risk areas for medical errors. The health acuity of the patients (intensive care and emergency room), sudden and unexpected increases in patient census (emergency room), and the use of anesthesia and the need for strict adherence to infection control protocols (operating room) all contribute to an increased incidence of medical errors in these settings of patient care.

Admission and discharge to the hospital are common times in which medical errors occur. A medical clinician who is unfamiliar with the patient’s medical history often admits the patient to the hospital, and the patient is often in his/her most vulnerable condition at the time of admission. Discharge requires patient teaching, perhaps many new medications that the patient must take, and follow-up care; these are multiple opportunities for mistakes to be made and medical errors to occur.

Medical Errors And Reduction Strategies

Reducing the number of medical errors is an important part of improving the American healthcare system. There is a three-tier approach to reducing the number of errors. The first is an overall improvement in the healthcare system. Currently, there is a national focus with healthcare leaders working to collect data, enhance

30 nursece4less.com nursece4less.com nursece4less.com nursece4less.com knowledge to reduce the number of medical errors. The second is an effort on each individual healthcare clinician to provide safe and effective care. Lastly, each patient needs to be an active consumer of healthcare. Some specific interventions that can be used to reduce types of medical errors will be presented first in this section, followed by a short discussion on helping patients prevent medical errors.

Diagnostic Errors and Cognitive Mistakes

Thammasitboon and Cutrer (2013) categorized diagnostic errors and found cognitive mistakes that were common to many diagnostic errors.36 Their strategies to eliminate cognitive error and improve diagnostic accuracy focused on three areas. The first strategy was expanding clinical expertise, which simply involves identifying the gaps in the knowledge base and trying to eliminate them. The second strategy was to avoid cognitive processing errors. This is subtler.

The authors described eight cognitive errors that can cause a diagnostic error and strategies for correcting them. One example of the second strategy to eliminate cognitive errors involves a common error in the diagnostic process known as anchoring, which involves the clinician staying with the original diagnosis despite evidence to the contrary. In order to correct or reduce anchoring, clinicians can be trained to consciously use de-biasing techniques, to periodically re- evaluate evidence, and to pause during the diagnostic process and to re-examine their assumptions. In the third strategy to eliminate cognitive errors, wrong diagnoses can be avoided by reducing the cognitive burden. This can be achieved through appropriate requests

31 nursece4less.com nursece4less.com nursece4less.com nursece4less.com for consultations (i.e., another medical specialist or ancillary health service), the use of checklists, or by team consensus or decision- making. Medication Error Prevention

The causes of medication errors are complex, and there are many possible approaches to the problem. A simple and effective way to avoid medication errors is through the use of the eight rights of medication administration. These eight rights of medication administration are reviewed below.

Right Patient

All healthcare facilities have a procedure for identifying patients. The minimum number of identifiers is two, and the patient must be correctly identified in person and on all medication orders. Making sure the clinician is giving a medication to the right patient is largely a matter of communication.

Right Drug

The medication and the order must be checked against one another to make sure that the right drug will be given. Also, before giving a drug that is new for a patient, the clinician should re-check drug allergies, re-check possible drug-drug-interactions, and make sure that at some time the patient has been asked about the use of herbal supplements.

Right Dose

32 nursece4less.com nursece4less.com nursece4less.com nursece4less.com The right dose should be checked using current references, with the pharmacy or an appropriate staff member as secondary resources. All medical and nursing clinicians should be aware of common dosing errors such as a 10-fold increase in dose, and calculations should be double-checked.

Right Route

There are important questions a prudent clinician would want to consider related to patient status and the right route. The clinician should always check to see that the route is correct.

Right Time

The clinician should always check to see when the last medication dose was given to make sure that it is not being administered too early or too late.

Right Documentation

Proper documentation should include the time and route of administration, and, if needed, the patient’s vital signs before and after medication administration.

Right Reason

A medication should be appropriate for the patient and for the clinical condition it is supposed to treat, and clinicians have a responsibility to check this information before giving a drug.

33 nursece4less.com nursece4less.com nursece4less.com nursece4less.com

Right Response

The definition of a drug is a substance that is given to prevent or treat an illness, and which has a measurable effect. In order to avoid medication errors clinicians should have a basic understanding of how a drug works, and how its effectiveness can be measured or monitored. Two other preventive strategies for avoiding medication errors are: 1) awareness of look-alike and sound-alike drugs, and 2) using abbreviations properly. A significant number of medication errors that occur in the United States involve name confusion, and these errors have the potential to cause great harm. Several websites include The United States Pharmcopeia and the ISM, which can be accessed by clinicians. Regarding proper use of abbreviations, each healthcare facility should have a list of acceptable abbreviations and clinicians should know where the list is and what it contains.

Commonly used abbreviations related to medication administration that can be used mistakenly or misidentified are ones, such as: U (or u) intended to mean unit but easily mistaken for a 0 or 4, SC intended to mean subcutaneous but easily mistaken for SL (sublingual), and QOD intended to mean every other day but easily mistaken as QD (every day) if it is written sloppily. The ISM has a list of dangerous abbreviations and dose designations on its website as noted earlier.

Preventing Surgical Errors

34 nursece4less.com nursece4less.com nursece4less.com nursece4less.com There are many approaches to avoiding medical errors involving surgery, but one of the simplest and most commonly used is the World Health Organization (WHO) Surgical Safety Checklist, which is online at http://www.who.int/patientsafety/safesurgery/ss_checklist/en/. The Surgical Safety Checklist has three components: the sign in, the time out, and, the sign out. These three components correspond to before anesthesia, before skin incision, and the post-operative period.37,38

Preventing Treatment Errors

Methods for preventing treatment errors are essentially the same as those used for preventing the other medical errors that been discussed previously. These methods include healthcare team members having a good knowledge base, effective communication, and team adherence to the healthcare facility’s protocols.

Patient Awareness Of Medical Error Prevention

Medical errors by patients, especially medication errors, are very common and may cause serious harm. Acetaminophen is very popular and very safe when taken in therapeutic amounts. However, recently acetaminophen overdose has been the leading cause of acute liver injury in the United States, and many of these cases are not deliberate overdoses done with the intent to cause self-harm but therapeutic mistakes made by the lay public. Teaching patients about medication safety is an important part of preventing medication errors. Physicians, nurses, and pharmacists should spend time teaching patients about their medications. Clinicians providing teaching about medication to patients should encourage them to write this information down. Key

35 nursece4less.com nursece4less.com nursece4less.com nursece4less.com points of patient teaching and medication administration and safety should include such concerns as the purpose for taking a medication and common side effects, interactions, and risks that require ongoing monitoring.

Disclosure of Medical Errors

Medical errors should be disclosed to the patient and, if appropriate, to family members. Disclosure of an error is difficult, but it is vital for the patient’s physical and emotional wellbeing. Disclosure of errors is also vital for the wellbeing of healthcare systems, as acknowledging errors is the first step in correcting them. In many jurisdictions the disclosure of medical errors is mandatory and most health facilities have, or should have, a policy that outlines how and by who a medical error should be disclosed. This policy should be reviewed before a medical error is disclosed.41

Summary

The prevention of medical errors is not easy. Hospitals and other healthcare facilities are complex organizations and the work environment is fast-paced. There is significant external and internal pressure on staff to perform the work correctly, which requires experience and specialized knowledge. A medical error, defined as failure of a planned action to be completed as intended, or, the use of a wrong plan to achieve a goal has been discussed. The Institute of Medicine (IOM) released its definition of medical error alongside national statistics at the time of publication, however since that time

36 nursece4less.com nursece4less.com nursece4less.com nursece4less.com numerous medical quality experts have reported much higher statistics on medical errors in the United States.

A recent review of the most common causes of death in the United States reported by the Centers for Disease Control and Prevention indicated that past reporting of cause of deaths relied upon the International Classification of Disease (ICD) code. Consequently, human and system factors were not sufficiently captured. Other studies and health news reports have suggested that the actual death toll related to medical error has been much higher.

Quality studies and newer national guidelines focused on patient harm and death related to medical errors have grown. Such reports are developed to better identify unsafe processes and systems, such as communication breakdowns, diagnostic errors, poor judgment, and inadequate clinician skill. Future studies are needed on proactive, preventive strategies to reduce unsafe medical practices related to the diagnosis and treatment of patient conditions.

Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the

37 nursece4less.com nursece4less.com nursece4less.com nursece4less.com article, and providing feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course requirement.

1. True or False: A medical error and an adverse event are identical.

a. True b. False

2. Diagnostic errors occur when

a. an incorrect diagnosis is made. b. the diagnosis is changed from the original diagnosis. c. given the available data, the correct diagnosis should have been made. d. the diagnosis was made more than 72 hours after examination.

3. A medication error is defined in part by the words

a. preventable and patient harm. b. under-dosing and over-dosing. c. adverse effect and therapeutic intervention. d. avoidable and lack of vigilance.

4. A common cause of medication error is

a. look-alike and sound-alike drug names. b. adult drugs being used for pediatric patients. c. patient refusal to accept the drug therapy. d. undisclosed use of herbal supplements.

5. True or False: Medical errors should be disclosed to the patient.

a. True b. False

6. Diagnostic errors are more likely EXCEPT when

38 nursece4less.com nursece4less.com nursece4less.com nursece4less.com a. the patient has a complex medical history. b. more diagnostic resources are available. c. patient follow-up is sub-optimal. d. time available for diagnosis is limited or perceived to be limited. 7. True or False. The healthcare setting is an influencing factor for diagnostic errors, such as one that is fast-paced and stressful.

a. True b. False

8. A 2014 study showed a ______error rate in medical dictation/transcription, and poor communication in the form of using non-standard abbreviations and the common use of sound-alike medications has long been known as a cause of medical errors.

a. 15% b. 25% c. 30% d. 44%

9. Nurses providing teaching about medication to patients should include key points of points, such as

a. the purpose for taking a medication. b. common side effects interactions. c. risk factors of taking the medication. d. All of the above

10. Starmer, et al., (2013) wrote that communication errors are a leading cause of

a. sentinel events. b. poor team dynamics. c. medication errors. d. documentation errors.

11. True or False: It has been reported that and that improving handoff communication (i.e., transferring information

39 nursece4less.com nursece4less.com nursece4less.com nursece4less.com about and responsibility for a patient) reduced medical errors from 38.3 per 100 admissions to 28.

a. True b. False

12. Patient discharge is

a. a time when medical errors commonly occur. b. less of a risk factor than admission for a medical error. c. less of a risk factor for a medical error than patient follow-up. d. Both b., and c., above

13. True or False: Equipment failures during anesthesia are relatively uncommon.

a. True b. False

14. One example of the second strategy to eliminate cognitive errors involves a common error in the diagnostic process known as

a. time out. b. It-Takes-Two. c. anchoring. d. pause.

40 nursece4less.com nursece4less.com nursece4less.com nursece4less.com

CORRECT ANSWERS:

1. True or False: A medical error and an adverse event are identical.

b. False

“An adverse event is defined as a preventable medical error that causes harm to the patient. Not all medical errors are adverse events and not all medical errors become adverse events. The differences between a side effect and an adverse event are predictability, severity, and consequences.”

2. Diagnostic errors occur when

c. given the available data, the correct diagnosis should have been made.

“A diagnostic error has occurred if the wrong diagnosis was made; and, 1) there was adequate data to suggest the correct diagnosis, or, 2) the clinical findings should have prompted the medical provider to do further evaluation in order to make the proper diagnosis.”

3. A medication error is defined in part by the words

a. preventable and patient harm.

“A medication error is defined in this section as follows: ‘Any preventable effect that may cause or lead to inappropriate use or patient harm while the medication is in control of the healthcare professional, patient, or consumer.’”

4. A common cause of medication error is

a. look-alike and sound-alike drug names.

41 nursece4less.com nursece4less.com nursece4less.com nursece4less.com

“Two other preventive strategies for avoiding medication errors are: 1) awareness of look-alike and sound-alike drugs; and, 2) using abbreviations properly.”

5. True or False: Medical errors should be disclosed to the patient.

a. True

“Medical errors should be disclosed to the patient and, if appropriate, to family members.”

6. Diagnostic errors are more likely EXCEPT when

b. more diagnostic resources are available.

“Additionally, diagnostic errors will be more likely if diagnostic resources are limited, patient follow-up is suboptimal and the time available for diagnosis is limited or perceived to be limited.”

7. True or False. The healthcare setting is an influencing factor for diagnostic errors, such as one that is fast-paced and stressful.

a. True

“The setting in which healthcare is delivered is another influencing factor, such as, a setting that is particularly fast- paced and stressful can be predisposed to diagnostic errors.”

8. A 2014 study showed an ______error rate in medical dictation/transcription, and poor communication in the form of using non-standard abbreviations and the common use of sound-alike medications has long been known as a cause of medical errors.

c. 30%

“Communication errors are common and can happen anywhere within the healthcare system. For example, a 2014

42 nursece4less.com nursece4less.com nursece4less.com nursece4less.com study showed a 30% error rate in medical dictation/transcription, and poor communication in the form of using non-standard abbreviations and the common use of sound-alike medications has long been known as a cause of medical errors.” 9. Clinicians providing teaching about medication to patients should include key points of points, such as

a. the purpose for taking a medication. b. common side effects interactions. c. risk factors of taking the medication. d. All of the above [correct answer]

“Key points of patient teaching and medication administration and safety should include such concerns as the purpose for taking a medication and common side effects, interactions and risks that require ongoing monitoring.”

10. Starmer, et al., (2013) wrote that communication errors are a leading cause of

a. sentinel events.

“Starmer, et al. (2013) wrote that communication errors are a leading cause of sentinel events, ....”

11. True or False: It has been reported that and that improving handoff communication (i.e., transferring information about and responsibility for a patient) reduced medical errors from 38.3 per 100 admissions to 28.

b. False

“Starmer, et al. (2013) wrote ... that improving handoff communication (i.e., transferring information about and responsibility for a patient) reduced medical errors from 38.3 per 100 admissions to 18.3.”

12. Patient discharge is

a. a time when medical errors commonly occur.

43 nursece4less.com nursece4less.com nursece4less.com nursece4less.com “Admission and discharge to the hospital are common times in which medical errors occur.”

13. True or False: Equipment failures during anesthesia are relatively uncommon.

a. True

“Equipment failures during anesthesia are relatively uncommon.”

14. One example of the second strategy to eliminate cognitive errors involves a common error in the diagnostic process known as

c. anchoring.

“One example of the second strategy to eliminate cognitive errors involves a common error in the diagnostic process known as anchoring, which involves the clinician staying with the original diagnosis despite evidence to the contrary.”

44 nursece4less.com nursece4less.com nursece4less.com nursece4less.com

Reference Section

The References below include published works and in-text citations of published works that are intended as helpful material for your further reading.

1. Kohn LT, Corrigan JM, Donaldson, MS, eds. To err is human. Building a safer health system. Committee on Quality Health Care in America. Institute of Medicine. National Academy press, Washington, D.C. 2000. 2. Martin A Makara and Michael Daniel (2016). Medical error—the third leading cause of death in the US. BMJ 2016;353:i2139. Retrieved online at http://www.bmj.com/content/353/bmj.i2139. 3. Zwaan, L., Schiff GD, and Singh H. (2013). Advancing the research agenda for diagnostic error reduction. BMJ Quality & Safety. 2013;22:ii52-ii57. 4. Balogh EP, Miller BT, and Ball JR (2015). Improving Diagnosis in Health Care. Committee on Diagnostic Error in Health Care; Board on Health Care Services. Institute of Medicine; The National Academies of Sciences, Engineering, and Medicine. Washington (DC): National Academies Press (US); 2015 Dec 29. 5. Singh H, et al. (2013). Types and origins of diagnostic errors in primary care settings. JAMA Internal Medicine. 2013;173:418- 425. 6. Graber ML. (2013). The incidence of diagnostic error in medicine. BMJ Quality & Safety. 2013;22:ii21-ii27. 7. Cassam, Q (2017). Diagnostic error, overconfidence and self- knowledge. Palgrave Communications 3, Article number: 17025 (2017). 2017.25 8. Singh H, Meyer AN, and Thomas EJ. (2014). The frequency of diagnostic errors in outpatient care: observational studies involving US adult populations. BMJ Quality & Safety. 2014;Sept 23 (9): 727-731. 9. Marshall, H.S. and Milikowski, C. (2017). Comparison of clinical diagnoses and autopsy findings: Six-year retrospective study.

45 nursece4less.com nursece4less.com nursece4less.com nursece4less.com Arch Pathol Lab Med. 2017 Jun 28. doi: 10.5858/arpa.2016- 0488-OA. [Epub ahead of print]/ 10. Norman G, Sherbino J, Dore K, et al. (2014). The etiology of diagnostic errors: A controlled trial of System 1 versus System 2 reasoning. Academic Medicine. 2014;89(2):277-284. 11. Tung EE, Newman JS. (2014) Fall prevention in hospitalized patients. Hospital Medicine Clinics. 2014;3 (2):e189-e201. 12. Miake-Lye IM, Hempel S, Ganz DA, Shekelle PG. (2013). Inpatient fall prevention programs as a patient safety strategy: a systematic review. Ann Intl Med. 2013;158 (5 Pt 2):390-396. 13. Tzeng H-M, Yin C-Y. ( 2 0 1 5). Perceived top 10 highly effective interventions to prevent adult inpatient fall injuries by specialty area: A multihospital nurse survey. Appl Nurs Res. 2015;28(1):10-17. 14. Joint Commission. Sentinel Events. (2013). Obtained online at http://www.jointcommission.org/assets/1/6/CAMCAH_2012_Upd ate2_23_SE.pdf. 15. Joint Commission (2014). National Patient Safety Goals. Obtained online at http://www.jointcommission.org/standards_information/npsgs.a spx. 16. World Health Organization. (2014). Violence and Injury Prevention. Falls. Obtained online at http://www.who.int/violence_injury_prevention/other_injury/fall s/en/ 17. Thammasitboon S, Thammasitbon S, Singhal G. (2013). System- related factors contributing to diagnostic errors. Curr Probl Pediatr Adolesc Health Care. 2013;43(9):242-247. 18. Plebani M, et al. (2014). Quality indicators to detect pre- analytical errors in laboratory testing. Clini Chim Acta. 2014;432:44-48. 19. Plebani, M. (2016). Toward a new paradigm in laboratory medicine: the five rights. Clin Chem Lab Med. 2016;54(12):1881-1891. 20. Plebani M. The detection and prevention of errors in laboratory medicine. Ann Clin Biochem. 2010;47(Pts 2):101-110. 21. Food and Drug Administration. Medication errors. Obtained online at http://www.fda.gov/Drugs/DrugSafety/MedicationErrors/default. htm. 22. Avery AA, Ghaleb M, Barber N, et al. (2013). The prevalence and nature of prescribing and monitoring errors in English general

46 nursece4less.com nursece4less.com nursece4less.com nursece4less.com practice: a retrospective case note review. Br J Gen Pract. 2013;63(613):e543-e553. 23. Keers RN, et al. (2013). Prevalence of medication administration errors in healthcare settings: A systematic review of direct observation studies. Ann Pharmacother. 2013;47(2):237-256. 24. Baumgart-Huckels, S. and Manser, T. (2014). Identifying medication error chains from critical incident reports: A new analytic approach. J Clin Pharmacol. 2014;20(10):1-10. 25. Ryan C, Ross S, Davey P, et al. (2014). Prevalence and causes of prescribing errors: The Prescribing Outcomes for Trainee Doctors Engaged in Clinical Training (PROTECT) Study. PLOS ONE. 2014- 9;e79802:1-19. 26. Honey BL, Bray WMJ, Gomez MR, Condren M. (2015).Frequency of prescribing errors by medical residents in various training programs. J Patient Safe. 2015;11(2):100-104. 27. Beardsley JR, et al. (2013). Implementation of a standardized time out process to reduce the prescribing errors at discharge. Hosp Pharm. 2013;48(1):39-47. 28. Institute for Safe Medication Practices (2014). ISMP List of High- Alert Medications in Acute Care Settings. ISMP. Retrieved online at http://www.ismp.org/Tools/highalertmedications.pdf. 29. Desai RJ, et al. (2013). Exploratory evaluation of medication classes most commonly involved in nursing home errors. J Amer Med Dir Assoc. 2013;14(6):403-408. 30. Anderson, DE and Watts, BV. (2013). Application of an engineering problem solving methodology to address persistent problems in patient safety: a case study on retained surgical sponges after surgery. J Patient Safe. 2013;9(3):134-139. 31. Mehta, S.P., et al. (2013). Patient injuries from anesthesia gas delivery equipment: a closed claims update. . 2013;119(4):788-795. 32. Neuman, M., et al. (2014). Anesthesia technique, mortality, and length of stay after hip fracture surgery. JAMA. 2014;311(24):2508-2517. 33. Cooper, L. and Nossaman, B. (2013). Medication errors in anesthesia: A review. Int Anesthesiol Clin. 2013;51(1):1-12. 34. David, G.C., et al. (2014). Error rates in dictation: quality assurance and medical record production. Int J Health Care Qual Assur. 2014;27(2):99-110. 35. Starmer, A.J., et al. (2013). Rates of medical errors and preventable adverse events among hospitalized children

47 nursece4less.com nursece4less.com nursece4less.com nursece4less.com following implementation of a resident handoff bundle. JAMA. 2013;310(21):2262-2270. 36. Thammasitboon, S and Cutrer, WB. (2013). Diagnostic decision- making strategies to improve diagnosis. Curr Probl Pediatr Adolesc Health Care. 2013;43(9):232-241. 37. Vishwanath S, et al. (2014). Wrong site surgery! How can we stop it? Urol Ann. 2014;6(1):57-62. 38. Collins, SJ., et al. (2014). Effectiveness of the surgical safety checklist in correcting errors: A literature review applying Reason’s Swiss Cheese Model. AORN J. 2014;(1)100:65-79. 39. Hempel, S., et al. (2013). Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness. J Am Geriatr Soc. 2013;61(4):483-494. 40. Shi, C. (2014). Interventions for preventing falls in older people in care facilities and hospitals. Orthop Nurs. 2014;33(1):48-49. 41. Lipira, L.E. and Gallagher, T.H. (2014). Disclosure of adverse events and errors in surgical care: Challenges and strategies for improvement. World J Surg. 2014;38(7);1614-1621.

The information presented in this course is intended solely for the use of healthcare professionals taking this course, for credit, from NurseCe4Less.com.

The information is designed to assist healthcare professionals, including nurses, in addressing issues associated with healthcare.

The information provided in this course is general in nature, and is not designed to address any specific situation. This publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals.

Hospitals or other organizations using this publication as a part of their own orientation processes should review the contents of this publication to ensure accuracy and compliance before using this publication.

Hospitals and facilities that use this publication agree to defend and indemnify, and shall hold NurseCe4Less.com, including its parent(s), subsidiaries, affiliates, officers/directors, and employees from liability resulting from the use of this publication.

The contents of this publication may not be reproduced without written permission from NurseCe4Less.com.

48 nursece4less.com nursece4less.com nursece4less.com nursece4less.com