Chapter 4: Medical Errors: A Critical Practice Issue 2 Contact Hours Release Date: 6/1/2016 Expiration Date: 6/1/2019 Faculty Adrianne Avillion, D.Ed., RN is a frequent presenter at conferences and conventions devoted Adrianne is an accomplished nursing professional development to the specialty of continuing education and nursing professional specialist and healthcare author. She earned her doctoral degree in development. Dr. Avillion owns and is the CEO of Strategic Nursing adult education and her M.S. in nursing from Penn State University Professional Development, a business that specializes in continuing and a BSN from Bloomsburg University. Dr. Avillion has held education for healthcare professionals and consulting services in a variety of nursing positions as a staff nurse in critical care and nursing professional development. physical medicine and rehabilitation settings and leadership roles Content reviewer in professional development. She has published extensively and June D. Thompson, DrPH, MSN, RN, FAEN Audience Each professional nurse has a responsibility to provide a safe errors and strategies for implementation. This is a critical course for environment of care. This course focuses on preventable medical every practicing nurse. Course overview Medical errors are a silent and largely unseen tragedy. Estimates year. This course addresses preventable medical errors and provides suggest that medical errors and other instances of preventable harm strategies for nurses to use to prevent or reduce common errors. at hospitals result in the death of 210,000 to 440,000 Americans each Learning objectives Define terms important to the concept of medical error. Identify strategies for reducing nine common medical errors. Describe the various categories of medical errors. Explain the Affordable Care Act’s impact on medical error Identify factors that contribute to medical error occurrence. reduction. How to receive credit ● Read the entire course online or in print which requires a 2-hour ○ A mandatory test (a passing score of 70 percent is required). commitment of time. Test questions link content to learning objectives as a method ● Depending on your state requirements you will be asked to to enhance individualized learning and material retention. complete either: ● Provide required personal information and payment information. ○ An affirmation that you have completed the educational ● Complete the MANDATORY Self-Assessment and Course activity. Evaluation. ● Print your Certificate of Completion. Accreditations and approvals Elite is accredited as a provider of continuing education by the American Nurses Credentialing Center’s Commission on Accreditation. Individual state nursing approvals In addition to states that accept ANCC, Elite is an approved provider Nursing, Provider # 50-4007; Florida Board of Nursing, Provider of continuing education in nursing by: Alabama, Provider #ABNP1418 #50-4007; Georgia Board of Nursing, Provider #50-4007; and (valid through April 30, 2017); California Board of Registered Kentucky Board of Nursing, Provider #7-0076 (valid through Nursing, Provider #CEP15022; District of Columbia Board of December 31, 2017). Activity director June D. Thompson, DrPH, MSN, RN, FAEN, Lead Nurse Planner nursing.elitecme.com Page 130 Disclosures Resolution of Conflict of Interest Sponsorship/Commercial Support and Non-Endorsement In accordance with the ANCC Standards for Commercial Support It is the policy of Elite not to accept commercial support. Furthermore, for continuing education, Elite implemented mechanisms prior to the commercial interests are prohibited from distributing or providing planning and implementation of the continuing education activity, to access to this activity to learners. identify and resolve conflicts of interest for all individuals in a position to control content of the course activity. Disclaimer The information provided in this activity is for continuing education medical judgment of a healthcare provider relative to diagnostic and purposes only and is not meant to substitute for the independent treatment options of a specific patient’s medical condition. ©2017: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to provide medical, legal, or professional advice. Elite Professional Education, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state. Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and not actual customers. Introduction Medical errors are a silent and largely unseen tragedy. Estimates the obvious emotional toll, unexpected adverse effects related to suggest that medical errors and other instances of preventable harm medical error increase personal and institutional financial burdens, at hospitals result in the death of 210,000 to 440,000 Americans each adding estimated billions of dollars to health care costs annually. To year. A 2013 study by the Inspector General of the Department of learn more about how, when, and why medical errors occur, federal Health and Human Services (DHHS) identified 180,000 deaths related regulations established in 2003 required hospitals participating in to medical error in 2010, of which 44% were determined clearly or the Medicare program to, “track medical errors and adverse patient likely preventable [1]. events, analyze their causes, and implement preventive actions and Based on these figures, medical errors are the third leading cause mechanisms that include feedback and learning throughout the of death in America, after heart disease and cancer [2,3]. Beyond hospital.” Hospitals report this information using a federally-approved Page 131 nursing.elitecme.com Quality Assessment and Performance Improvement (QAPI) program [4]. Evidence based practice (EBP) alert! Research shows that a high percentage of medical errors go unreported. This can lead to a While reporting has been compulsory since 2003, survey data dangerous environment for patients. Nurses must take the lead in presented by the DHHS Office of the Inspector General in 2012 found accurate reporting of medical errors and the promotion of systems that [5]: and processes that decrease the potential for error. ● Only about 14% of “patient harm events” experienced by Medicare beneficiaries were captured by hospital incident reporting systems. Nurses are essential for developing and maintaining a culture of safety ● An estimated 86% of total incidents were not reported. within their organizations and are the professionals most likely to ● Of the unreported incidents, 62% were not reported because staff discover and report adverse events [6]. Thus, it is important that nurses members did not perceive them as reportable. work to reduce the risk of medical error and respond appropriately and ● 25% of the unreported incidents were described as commonly capably to medical error occurrences. reported but not reported in these cases. Nursing consideration: Nurses are in a position to help educate ● Events were most often reported by nurses who identified them as their colleagues, not only in nursing but in other disciplines, about part of the regular course of care. ways to prevent medical errors and what to do if one is discovered. This will enhance the safety of the patients’ environments. Definition of terms Medical error is defined as harm to a patient that results from ● Sentinel event: An unexpected occurrence involving death or either [7,8]: serious physical or psychological injury, 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: Root cause analysis is a process for ● Adverse drug event: An adverse drug event is injury resulting identifying the factors that underlie variation in performance, from the use of a drug. An adverse drug event may be caused by including the occurrence or possible occurrence of a sentinel event. an adverse drug reaction, a medication error, or an overdose. An ○ A root cause analysis focuses primarily on systems and adverse drug event frequently necessitates discontinuation of the processes, not on individual