Chapter 4: Medical : A Critical Practice Issue

2 Contact Hours

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.

Introduction Medical errors are a silent and largely unseen tragedy. Estimates medical error increase personal and institutional financial burdens, suggest that medical errors and other instances of preventable harm adding estimated billions of dollars to costs annually. To at hospitals result in the death of 210,000 to 440,000 Americans each learn more about how, when, and why medical errors occur, federal year. A 2013 study by the Inspector General of the Department of regulations established in 2003 required hospitals participating in Health and Human Services (DHHS) identified 180,000 deaths related the Medicare program to, “track medical errors and adverse to medical error in 2010, of which 44% were determined clearly or events, analyze their causes, and implement preventive actions and likely preventable [1]. mechanisms that include feedback and learning throughout the Based on these figures, medical errors are the third leading cause hospital.” Hospitals report this information using a federally-approved of death in America, after heart and cancer [2,3]. Beyond Quality Assessment and Performance Improvement (QAPI) the obvious emotional toll, unexpected adverse effects related to program [4].

CNA.EliteCME.com Page 27 While reporting has been compulsory since 2003, survey data presented by the DHHS Office of the Inspector General in 2012 found Evidence-based practice (EBP) alert! Research shows that a high that [5]: percentage of medical errors go unreported. This can lead to a ●● Only about 14% of “patient harm events” experienced by dangerous environment for . Nurses must take the lead in Medicare beneficiaries were captured by hospital incident accurate reporting of medical errors and the promotion of systems reporting systems. and processes that decrease the potential for error. ●● An estimated 86% of total incidents were not reported. ●● Of the unreported incidents, 62% were not reported because staff Nurses are essential for developing and maintaining a culture of safety members did not perceive them as reportable. within their organizations and are the professionals most likely to ●● 25% of the unreported incidents were described as commonly discover and report adverse events [6]. Thus, it is important that nurses reported but not reported in these cases. work to reduce the risk of medical error and respond appropriately and ●● Events were most often reported by nurses who identified them as capably to medical error occurrences. part of the regular course of care. Nursing consideration: Nurses are in a position to help educate their colleagues, not only in nursing but in other disciplines, about 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 an , a error, or an overdose. An event. adverse drug event frequently necessitates discontinuation of the ○○ A root cause analysis focuses primarily on systems and drug. processes, not on individual performance. ●● Adverse drug reaction: An adverse drug reaction is an unavoidable, ○○ The analysis progresses from special causes in clinical appreciably noxious, or unpleasant reaction that occurs during the processes to common causes in organizational processes normal, proper use of a medical product. Some drug reactions may and systems and identifies potential improvements in be minor and temporary; others have the potential to be permanent these processes or systems that would tend to decrease the and serious. likelihood of such events in the future or determines, after ●● Medication errors: Medication errors are defined as errors that analysis, that no such improvement opportunities exist. occurs due to mistakes made in the processes of the drug’s prescribing, transcribing, dispensing, administering, or monitoring. Nursing consideration: Nurses must be able to recognize and ●● Near-miss: An error that is detected and corrected before harm can report important factors related to medical error or potential medical be done. error in order to adequately promote a culture of safety.

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.

Page 28 CNA.EliteCME.com ●● 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? administer the – no occurred and none Example 1: A nurse is supposed to administer three medications was likely to occur. Blood and tissue levels of the drugs were not to a patient once a day, at 8 a.m.: furosemide 40 mg, orally (PO); likely to drop so precipitously that the patient might suffer harm. digoxin 0.25 mg, PO; and potassium chloride, 40 mEq, PO. At 7:55 In certain circumstances, administering medications late would be a.m., another patient the nurse is caring for complains of difficulty problematic. While this situation is not a medical error, a similar breathing. The nurse assesses the patient, administers a PRN action might have resulted in medical error. bronchodilator treatment, and then calls the patient’s . It is Example 2 is not an example of medical error. The surgeon’s now 8:50 a.m., and the nurse gives the patient the furosemide, digoxin, assessment and response was appropriate, as some degree of pain and potassium chloride. is an expected and unavoidable adverse effect of joint replacement Example 2: A patient is recovering from total knee arthroplasty, and surgery. several months after surgery, he is still having slight pain in the joint. Example 3 is an example of medical error. Although a very The operation and the initial recovery period were uneventful, and unusual occurrence, esophageal injury resulting from alkali after an examination the surgeon concludes that the prosthesis has not exposure can exist even when the patient has no signs or loosened and is in good working order, there is no infection in the area symptoms of external burns. Had an ENT or GI physician been and there are no other postoperative complications. consulted, an endoscopic examination of the child would have Example 3: A 2-year-old child is brought to an emergency room been likely. because he has swallowed a small amount of drain cleaner; the drain These scenarios clarify how medical error is determined. In the first cleaner has a pH of 13.5. There are no burns in or around the mouth, example, no harm or potential harm was possible; and, in the second, and the child seems relatively comfortable; however, he will not the patient complained of an expected side effect that did not result eat, but will occasionally take small sips of fluids. After 2 hours of from treatment failure. The third example, however, shows a condition observation, the child is discharged. Neither the ENT nor GI services that should have been detected and treated, causing the patient on-call were consulted. The next day, the parents bring the child back further injury and complications that might have been prevented with because he is crying and will not eat or drink. An endoscopic exam reasonable and appropriate care. reveals a second-degree burn in the esophagus. The child suffers strictures that need frequent dilations and must receive nutrition Nursing consideration: Nurses must follow their organizations’ through a feeding tube. policies and procedures regarding medical error reporting. Accurate reporting is essential to analysis of errors and making improvements Example 1 is not an example of medical error. Although there was in processes and systems. an alternative action that would have been better for the patient – the nurse could have made arrangements with another RN to

CNA.EliteCME.com Page 29 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 (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

Page 30 CNA.EliteCME.com The identification of errors needs to become more transparent. There 3. Central line-associated bloodstream infections. needs to be standardized data collection and evaluation of the root 4. from falls and immobility. cause of each error. Punishment is not helpful as it leads to the non- 5. Obstetrical adverse effects. disclosure of errors or risk of error. Both individuals and hospital 6. Pressure ulcers. systems have unique responsibilities in the reduction of medical errors. 7. Surgical site infections. Studies of medical error show the potential risk of some errors is far 8. Venous thromboembolism (VTE). greater than others, with some likely to happen repeatedly. A 2014 9. Ventilator-associated events. Partnership for Patients study described the most common medical Let’s examine what strategies might be used to enhance safety and errors in the . Nine core patient safety areas of focus were decrease the occurrence of these core safety issues. identified [21]: 1. Adverse drug events (medication errors). 2. CAUTIs.

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

CNA.EliteCME.com Page 31 3. Miscommunication of drug orders. knowledge. If the nurse is familiar with the drug and the patient, 4. Lack of appropriate labeling. knowledge-based medication errors are avoidable. Knowledge- 5. Environmental factors that contribute to medication errors. based medication errors can be general, specific, or expert [26]: In general, medication error occurs when health care professionals: ○○ A general knowledge-based error occurs when someone makes ●● Do not have the proper knowledge. an error because of lack of or disregard for information that ●● Do not follow rules or are using bad rules. is considered general knowledge (e.g., warfarin can cause ●● Forget to perform a task or forgot important patient information. bleeding). ●● Simply make a mistake in the performance of medication ○○ A specific knowledge-based error occurs when someone makes administration. an error because of lack of or disregard of information that would be considered specific knowledge (e.g., a patient is The four main causes of medication errors are action-based, given warfarin even though the INR is very high). rule-based, memory-based, and knowledge-based [26]: ○○ An expert knowledge-based error occurs when someone makes ●● An action-based medication error is defined as the performance an error because of lack of or disregard of information that of an unintended. Examples of action-based medication errors would be considered expert knowledge (e.g., the failure to use would include selecting the wrong medication or administering an genetic testing to check for variations in patient response prior incorrect dose. to initiating with warfarin). ●● A rule-based medication error occurs because the nurse did not follow proper rules or procedures for medication administration. Strategies to decrease the risk of medication error include: Examples could include a good rule that was not applied (e.g., ●● Adhere to the eight rights of medication administration [12]. checking with another nurse when performing a dose calculation ●● Ensure that handoffs involve the transfer of essential information for a high-risk drug such as insulin), or the application of a bad when the responsibility for care of the patient shifts from one rule (e.g., the health care facility does not require nurses to double- health care provider to another [19]. check dose calculations for high-risk drugs). ●● Use barcode technologies and electronic health records with ●● A memory-based medication error occurs when a nurse simply computerized prescriber order entry [29]. forgets to perform a task or forgets important information about ●● Involve pharmacists throughout a patient’s hospitalization. the patient. The nurse may forget to give a dose of a medication, ●● Require nurses who are administering medicine to wear a colored that the medication has been discontinued, or that the patient is sash or vest to prevent interruptions. allergic to the medication. ●● Have two clinicians independently verify doses prior to ●● Knowledge-based medication errors are errors that could be administering medication. avoided with a reasonable and appropriate level of professional

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, Hand hygiene and infection is the main if intravascular catheters are Proper hand hygiene is the most important infection control measure used in critically ill patients [32]. Every year, an estimated 250,000 and the most effective way to prevent the transmission of health care- cases of central venous catheter-associated bloodstream infections associated infections [32,33,34]. occur in the United States. The cost per infection is estimated to be between $34,508 and $56,000 [33]. Nurses and their interdisciplinary Nursing consideration: Patients and families should be taught to colleagues must make every effort to prevent such infections. observe whether health care workers are washing their hands before and after providing patient care. They should be told to ask their health care providers to wash their hands if they have not done so.

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

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 risk ●● Establish a “hard-stop” policy, like 39 weeks, to reduce rate of of postpartum complications, such as anemia and endometriosis. Babies early elective deliveries. born at 37 to 38 weeks are at much higher risk of death, and increased ●● Conduct emergency drills for critical situations such as postpartum risk for respiratory problems, and greater likelihood of admission to the hemorrhage. neonatal intensive care unit (NICU). ●● Hold a multidisciplinary debriefing after emergency situations. ●● Reduce C-section delivers for first-time mothers.

CNA.EliteCME.com Page 33 Pressure ulcers General recommendations for the reduction of pressure ulcers with decreased mobility and position change and increased shear include [29]: force, all of which increase the risk for skin breakdown. ●● Assess all patients for pressure ulcers before and during admission. ●● Length of time on mechanical ventilation: Indicates inadequate ●● Have nurses discuss pressure ulcers during shift reports. oxygenation and the need to provide ventilation mechanically. ●● Employ a wound care team. ●● Decreased oxygen levels means decreased oxygen to body tissues, ●● Use logs and schedules to remind nurses to reposition patients. including the skin. Stages III and IV pressure ulcers present particular problems and ●● Moisture: Moisture (e.g., incontinence, sweat, failure to dry skin deserve detailed discussion. after bathing) contributes to skin breakdown. ●● Nutrition: Inadequate nutrition alters the proper state of the skin, In addition to the physical and emotional toll on patients, Stages III contributing to skin breakdown. and IV pressure ulcers carry with them a significant monetary burden ●● Pressure: The longer pressure is sustained, the more likely is local as well. It is estimated that the cost of one Stage III or Stage IV tissue ischemia, edema, and tissue death. pressure ulcer may be between $5,000 and $50,000 [37]. ●● Pressure scale risk scores: The higher the score on a pressure scale How are Stages III and IV pressure ulcers described? Here are their score, the greater the risk of pressure ulcer development. determining characteristics [38]: ●● Vasoactive medications: Vasoactive medications given to improve ●● Category/Stage III: Full thickness skin loss. Although subcutaneous blood pressure increase vasoconstriction. This may decrease fat may be seen, bone, tendon, or muscles are not exposed. Slough perfusion of skin tissue. may be present, but it does not obscure the depth of tissue loss. Nursing measures to decrease the risk for pressure ulcer development There may be undermining and tunneling. The depth of this pressure include [37,38,39]: ulcer depends on the anatomical location. For example, the bridge ●● Perform skin assessment upon admission and at least once per shift of the nose or the ear does not have (adipose) subcutaneous tissue thereafter. Skin inspection should be done more often on patients and Stage III ulcers in such locations can be shallow. However, areas at high risk for pressure ulcer development. Document results of where there is significant adipose tissue can be very deep. Bone and/ all skin assessments. or tendon are not seen or directly palpable. ●● Identify patients at high risk for pressure ulcer development using ●● Category/Stage IV: Full thickness tissue loss. Bone, tendon, or a risk-identification scale. muscle is exposed. Slough or eschar may be present. There is often ●● Incorporate results of skin assessment in change-of-shift report and undermining and tunneling. The depth varies according to anatomical at any handoffs and signoffs. position. Ulcers may be shallow in areas that do not have (adipose) ●● Incorporate a schedule of turning and body repositioning and subcutaneous tissue (e.g., nose, ear). These types of pressure ulcers document these actions. can extend into muscle and/or supporting structures such as fascia, tendon, or joint capsule, thus making osteomyelitis or osteitis likely Evidence-based practice (EBP) alert! Research shows that to occur. Exposed bone or muscle is visible or directly palpable. shearing forces can be reduced by keeping the head of the bed Which patients are at risk for the development of pressure ulcers? Here lower than 45 degrees [38]. are some factors that increase such risk [37,39]: ●● Advanced age: The elderly person’s skin has less subcutaneous fat, ●● Use appropriate positioning devices according to hospital policy which leads to decreased protection from pressure. and procedure. ●● Friction/shear: Decreases the epidermal layer, reducing protection ●● Keep skin warm and dry. Dry thoroughly after bathing. Remove of the skin. skin secretions such as sweat. Use non-irritating, non-drying ●● Hypotension: Increases the response of local tissues, making skin cleansing agents. Use moisturizers as appropriate. Keep bed more vulnerable to breakdown. sheets, clothing, etc. dry and wrinkle-free. ●● Immobility: Lack of mobility can lead to sustained pressure on ●● Take measures to avoid spasticity and contracture prevention. bony prominences. ●● Ensure proper nutritional intake. ●● Length of stay in critical care units: The longer the stay indicates ●● Promote mobility and self-position change as appropriate. a more critical condition. Such conditions are generally associated ●● Remain alert to any skin changes (such as redness) that may suggest impending skin breakdown. Surgical site infections According to the CDC, a recent study found that surgical site ●● 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) DVT affects about 350,000 Americans every year [44]. In the hospital and pulmonary embolism (PE). DVT is the formation of a blood clot setting, DVT is listed as a preventable hospital acquired complications. in a deep vein, usually in the leg or pelvis. The most serious potential Nurses and other health care providers must be aware of factors that place complication of a DVT is the possibility that the clot could dislodge patients at higher risk for the development of DVT. These include [43]: and travel to the lungs, becoming a PE [41]. According to Agency for ●● Using birth control pills or hormone therapy. Healthcare Research and Quality (AHRQ), VTE is the most common ●● Having blood clotting disorders. preventable cause of hospital death [42]. ●● Some malignancies.

Page 34 CNA.EliteCME.com ●● Increasing age. ●● Applying compression stockings or pneumatic compression ●● Being overweight or obese. devices as ordered and indicated. ●● Personal or family history of DVT or PE. ●● Teaching patients and families about the importance of early ●● Pregnancy. movement and position change. ●● Smoking. ●● Having vein disease(s). Nursing consideration: Most of the interventions to prevent DVT are easily implemented. However, busy nurses and other health care Strategies for the prevention of DVT include [43,44]: professionals may forget to implement things as simple as position ●● Administrating anticoagulant therapy as indicated. change and teaching patients the importance of early movement and ●● Promoting early movement and physical therapy. position changes. They must remain alert to the possibility of DVT ●● Facilitating position change in patients who have difficulty moving development and how to prevent it. themselves.

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

CNA.EliteCME.com Page 35 In summary, the problems associated with medical errors are significant assume the lead in educating their patients and colleagues about ways and require that nurses and other health care professionals be ever- to prevent harm and keep the health care environment safe for all. vigilant about protecting patients’ safety. There is some good news, Nurses also have a professional obligation to become involved in however. According to a report published by the AHRQ, from 2010 how their employing organizations address safety issues. They should to 2013, the United States saw 1.3 million fewer hospital-acquired volunteer for committees and task forces and act as patient advocates at conditions. This is a 17% decrease and a savings of $12 billion dollars all times. during this 3-year period. These data also indicated that 50,000 lives were saved due to this reduction in hospital-acquired conditions [48]. Nurses must support their organization’s efforts to enhance the safety and well-being of patients, visitors, and employees. In addition to Much work still needs to be done. Research shows that nearly one adhering to safety mandates, they should help teach their colleagues in 10 hospitalized patients will still become sick or harmed while in how to establish and maintain a culture of safety. All employees are the hospital [48]. Nurses are among the health care leaders who can responsible for patient safety. Nurses are on the front-line of all safety make a significant difference in reducing medical errors. They should 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. 28. Institute for Safe Medication Practices. (ISMP) (2014). ISMP list of high-alert medications in acute Retrieved January 30, 2016 from http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_06.pdf. care settings. Retrieved February 4, 2016 from https://www.ismp.org/tools/highalertmedications.pdf. 2. McCann, E. (2014). Deaths by medical mistakes hit records. Retrieved January 30, 2016 from http:// 29. Beckers Hospital Review. (2014). 36 approaches to reducing 9 common medical errors. Retrieved www.healthcareitnews.com/news/deaths-by-medical-mistakes-hit-records. February 3, 2016 from http://www.beckershospitalreview.com/quality/36-approaches-to-reducing-9- 3. Medical errors now third leading cause of death in the United States May 10, 2016 from https://www. common-medical-errors.html. washingtonpost.com/news/to-your-health/wp/2016/05/03/researchers-medical-errors-now-third- 30. Evelyn, L. et al. (2014). Strategies to prevent catheter-associated urinary tract infections in leading-cause-of-death-in-united-states/. 31. American Association of Critical Care Nurses (AACN). (2011). Catheter-associated urinary tract 4. Department of Health and Human Services Office of Inspector General. (2012). Hospital incident infections. Retrieved November 7, 2015 from report systems do not capture most patient harm. Retrieved January 30, 2016 from http://oig.hhs.gov/ 32. Frasca, D., Dahyot-Fizelier, C., & Mimoz, O. (2010). Prevention of central venous catheter-related oei/reports/oei-06-09-00091.pdf. infection in the intensive care unit. Retrieved November 8, 2015 from 5. Morran, C. (2012). Study: Only 14% of medical errors reported by hospitals. Retrieved January 31, 33. Siegel, M., & Kramer-Cain, J. (2013). Vascular catheter-associated infections. Retrieved 2016 from http://consumerist.com/2012/01/06/study-only-14-of-medical-errors-reported-by-hospitals/. 34. Busby, S. R. et al. (2015). Assessing patient awareness of proper hand hygiene. 6. Garrouste-Orgeas, M., et al. (20120. Overview of medical errors and adverse events. Annals of 35. The Joint Commission. (2015). New sentinel event alert focuses on preventing falls. Intensive Care, February, 2012. Retrieved February 1, 2016 from http://annalsofintensivecare. 36. Quigley, P. A., & White, S. V. (2013). Hospital-based fall program measurement and springeropen.com/articles/10.1186/2110-5820-2-2. 37. Cooper, K. L. (2013). Evidence-based prevention of pressure ulcers in the intensive care 7. Institute of Medicine (IOM). (2000). To err is human: Building a safer health system. Retrieved 38. National Pressure Ulcer Advisory Panel (NPUAP). (2015). NPUAP pressure ulcer February 18, 2011 from http://www.iom.edu/~/media/Files/Report percent20Files/1999/To-Err-is- 39. 39. Kirman, C. N., et al. (2015). Pressure ulcers and wound care treatment & management. Human/To percent20Err percent20is percent20Human percent201999 percent20 percent20report 40. Centers for Disease Control and Prevention. (2016). Surgical site infection event. Retrieved February percent20brief.ashx. 4, 2016 from http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf. 8. National Academies/Institute of Medicine (IOM). (2000). To err is human: building a safer health 41. Johns Hopkins Medicine, Center for Innovation in Quality Patient Care. What is DVT/ VTE? Available system (summary). Retrieved February 1, 2016 from https://iom.nationalacademies.org/~/media/Files/ at: http://www.hopkinsmedicine.org/innovation_quality_patient_care/areas_expertise/ infections_ Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%. complications/dvt/what_is_dvt_vte.html 9. Johns Hopkins Medicine. (2013). Diagnostic errors more common, costly, and harmful than treatment 42. Agency for Healthcare Research and Quality. Preventing Hospital-Acquired Venous mistakes. Retrieved February 1, 2016 from http://www.hopkinsmedicine.org/news/media/releases/ Thromboembolism: A Guide for Effective Quality Improvement. Available at: http://www.ahrq.gov/ diagnostic_errors_more_common_costly_and_harmful_than_treatment_mistakes. professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/index.html 10. Agency for Healthcare Research and Quality. (2015). Systems approach. Retrieved February 2, 2016 43. American Academy of Orthopaedic Surgeons. (2015). Deep vein thrombosis. Retrieved from https://psnet.ahrq.gov/primers/primer/21/systems-approach. 44. WebMD. (no date given). How to prevent deep vein thrombosis (DVT). Retrieved February 19, 2016 11. National Coordinating Council for Medication Error Reporting and Prevention. (2016). What is a from http://www.webmd.com/dvt/deep-vein-thrombosis-prevent-dvt medication error? Retrieved February 2, 2016 from http://www.nccmerp.org/about-medication-errors. 45. Centers for Disease Control and Prevention. Ventilator-associated Pneumonia (VAP). Available at: 12. Lippincott Nursing Center. (2011). 8 rights of medication administration. Retrieved February 2, 2016 http://www.cdc.gov/hai/vap/vap.html https://www.nursingcenter.com/ncblog/may-2011/8-rights-of-medication-administration. 46. Halyard Health. (no date given). Ventilator associated pneumonia. Retrieved February 4, 2016 from 13. Griffin, R. M. (2009). Common problems patients face in the hospital. Retrieved February 2, http://www.halyardhealth.com/hai-watch/hai-threats-solutions/ventilator-associated-pneumonia.aspx. 2016 from http://www.webmd.com/a-to-z-guides/features/before-surgery-your-top-six-hospital- 47. Cornell University Law School. (no date given). Public health service act. Retrieved February 4, 2016 risks?page=2. from https://www.law.cornell.edu/uscode/text/42/chapter-6A. 14. Agency for Healthcare Research and Quality. (2015). Wrong-site, wrong-procedure, and wrong-patient 48. Health US News. (2014). 50,000 fewer deaths caused by hospitals. Retrieved February 4, 2016 from surgery. Retrieved February 3,2 016 from https://psnet.ahrq.gov/primers/primer/18/wrong-site-wrong- http://health.usnews.com/health-news/hospital-of-tomorrow/articles/2014/12/02/fewer-americans- procedure-and-wrong-patient-surgery. harmed-or-killed-by-hospital-errors. 15. Ross, M. (2015). What makes mistakes more likely? Retrieved February 3, 2016 from http://www.pharmacytimes.com/news/what-makes-pharmacist-mistakes-more-likely. 16. Rice, S. (2014). Most laboratory errors happen outside the lab, ECRI report finds. Retrieved February 3, 2016 from http://www.modernhealthcare.com/article/20140417/NEWS/304179961. 17. Patient Safety Network. (2014). Never events. Retrieved February 3, 2016 from https://psnet.ahrq.gov/ primers/primer/3/never-events. 18. Joint Commission. (2015). Sentinel events (SE). Retrieved February 3, 2016 from http://www. jointcommission.org/assets/1/6/camh_2012_update2_24_se.pdf. 19. Wheeler, K. K. (2014). Effective handoff communication. OR Nurse, 8(1), 22-26. 20. Makary, Martin and Daniel, Michael. Analysis: Medical error–the third leading cause of death in the US. The British Medical Journal. BMJ 2016;353:i2139 doi: 10.1136/bmj.i2139 (Published 3 May 2016). 21. Centers for Medicare & Medicaid Services. (2014). Patient safety areas of focus. Retrieved February 3, 2016 from https://partnershipforpatients.cms.gov/about-the-partnership/what-is-the-partnership-about/ lpwhat-the-partnership-is-about.html. 22. Kothari, D., et al. (2010). Medication error in anesthesia and critical care: A cause for concern. Indian Journal of Anesthesia, 54, 187-192. 23. 23. Ghaleb, M. A., Barber, N., & Wong, F. B.D. (2010). The incidence and nature of prescribing and administration errors in pediatric patients. Archives of Disease in Childhood, 95, 113-118. 24. Garrouste-Orgeas, M., et al. (2010). Selected medical errors in the intensive care units: Results of the IATRORF study: parts I and II. American Journal of Respiratory Critical Care Medicine, 181, 134-142. 25. National Coordinating Council for Medication Error Reporting and Prevention. (2016). About medication error. Retrieved February 3, 2016 from http://www.nccmerp.org/about-medication-errors. 26. Stoppler, M. C. (2014). The most common medication errors. Retrieved February 3, 2016 from http:// www.medicinenet.com/script/main/art.asp?articlekey=55234. 27. Aronson, J. K. (2009). Medication errors: Definitions and classification. British Journal of Clinical , 67, 599-604.

Page 36 CNA.EliteCME.com MEDICAL ERRORS: A CRITICAL PRACTICE ISSUE Final Examination Questions Choose the best answer for questions 1 through 10 and mark your answers online at CNA.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. c. An attorney must be notified of the medical error’s occurrence. 5. Deep vein thrombosis (DVT): d. Harm or error must have occurred that could have been a. Is more likely to occur in someone is underweight. prevented. b. Has the potential to cause a serious complication of pulmonary 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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