Healthcare providers might need to clean their hands as many as 100 times per 12-hour shift, depending on the number of patients and intensity of care. More than 2 million serious ADRs occur each year, 350,000 in nursing homes alone. ... it cannot be guaranteed that the information will be updated and/or be without errors or omissions. Camp SC, Hailemeskel B, Rogers TL. In the most recent HAI prevalence survey using 2015 data, researchers from the CDC found that about 1 in 31 hospital patients had at least one healthcare-associated infection. Use all five maximal sterile barrier precautions: Follow recommended central line maintenance practices. For all their efficiencies, electronic records are still subject to documentation and informational errors. A consumer’s best protection is to be informed: know where problems can arise and what to ask or do to help avoid those problems. Alcohol-based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare providers. Patients who get a CLABSI have a fever and might also have red skin and soreness around the central line. Sit in chairs that do not move and have arm rests to help when you sit down and stand up. Fall prevention involves managing a patient's underlying fall risk factors (eg., problems with walking and transfers, medication side effects, confusion, frequent toileting needs) while working within the hospital's physical design and environment. (Haymond, 2016). Unlike more familiar IVs, central lines access a major vein that is close to the heart and can remain in place for weeks or months and be much more likely to cause serious infection. In their large literature review, researchers Sullivan and Schoelles found evidence of that several key elements improved care and reduced pressure ulcer rates. Examples of drug name abbreviations involved in medication errors include: Mistaken as diphtheria-pertussis-tetanus (vaccine), Diluted tincture of opium, or deodorized tincture of opium (Paregoric), Mistaken as potassium chloride (The “H” is misinterpreted as “K”), Use complete drug name unless expressed as a salt of a drug, Mistaken as hydrocortisone (seen as HCT250 mg), Mistaken as tetracaine, Adrenalin, cocaine, tissue plasminogen activator, Activase (alteplase), Mistaken as TNKase (tenecteplase), or less often as another tissue plasminogen activator, Retavase (retaplase), Mistaken as sodium nitroprusside infusion, Mistaken as opposite of intended; mistakenly use incorrect symbol; “< 10” mistaken as “40”, Mistaken as the number 1 (e.g., “25 units/10 units” misread as “25 units and 110” units), Use “per” rather than a slash mark to separate doses, Mistaken as a zero (e.g., q2° seen as q 20), Use 0 or zero, or describe intent using whole words, Medication events (including adverse drug events/reactions), Documentation/computer errors (NQF, 2011; AHRQ, 2018; CMS, 2018; Joint Commission, 2016; NHSN, 2019). Errors can occur around the administration of medications, during laboratory testing, when infections occur within the healthcare setting, as a result of surgery, in an environment that contributes to pressure sores or a patient fall, or even in documentation or data entry tasks. Results showed that 49% of errors occurred in the drug ordering stage (i.e. Ask the patient if there is any drug that should not be prescribed for any reason. Similar drug names account for one third of medication errors. The same is essentially true across all categories of medical errors. A total of four errors resulted in this sentinel event. Tools such as computerized physician orders and prescription entry (CPOE) and barcoding systems have taken the guess work out of reading written prescriptions for nurses and pharmacists. These kinds of errors can be minimized, and a willful failure to follow correct procedures is an offense that should lead to termination. 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In addition, they use stringent infection control practices each time they check the line or change the dressing. SSIs are not only a national issue, but a local one as well. Although data have not been systematically collected on patient outcomes with waived testing, adverse events can occur. Read about the types of refractive errors, their symptoms and causes, and how they are diagnosed and treated. … Is the patient drug dependent or at risk of dependence on, for example, opioids, benzodiazepines, alcohol, or other substances of abuse. The three most common errors were omission of medication that was clinically … The National and State Healthcare-Associated Infections Progress Report showed an 8% decrease in hospital-onset C. difficile infections between 2011 and 2014 (CDC, 2016a). The most common medication group among all errors was analgesics and among dose errors the most common medication group was cardiovascular drugs. The key management decision is deciding which type of person you are dealing with. The FDA’s Black Box Warning System alerts healthcare providers and consumers to drugs with increased risks for those taking them. Ensure daily and terminal cleaning of patient rooms. In a healthcare setting, such as a hospital or nursing home, MRSA can cause severe problems such as bloodstream infections, pneumonia, and surgical site infections. Understand your results in context: use trusted information sources for details on the meaning and use of your results, and, again, ask questions! Use bisphosphonates for patients with documented osteoporosis. Adverse drug events are harms resulting from the use of medication and include allergic reactions, side effects, overmedication, and medication errors (CDC, 2018). Beware of look-alike, soundalike drugs. Basic preventions for pressure ulcers involve: In healthcare settings, key changes recommended by the IHI How-to Guide include: Positioning in Bed to Prevent Pressure Sores [1:17], https://facingdisability.com/expert-topics/whats-the-most-important-thing-to-do-to-prevent-pressure-sores/mary-zeigler-ms. Mary Ziegler, the nurse who appeared in the previous video, is a clinical nurse specialist at the Rehabilitation Institute of Chicago (facingdisability.com. She admonished our staff with the following statement, "The next time you are going to make an error on my prescription, please tell me when you hand out my medication." Pressure sores have a variety of treatments. He decided to proceed and, based on the available information, removed the left kidney. Ventilator-associated pneumonia (VAP), sepsis, acute respiratory distress syndrome (ARDS), pulmonary embolism, barotrauma, and pulmonary edema are among the complications that can occur in patients receiving mechanical ventilation; such complications can lead to longer duration of mechanical ventilation, longer stays in the ICU and hospital, increased healthcare costs, and increased risk of disability and death (NHSN, 2019). Poor communication between laboratory and healthcare professionals is the main issue affecting quality in the pre- and post-analytic phases, and researchers note few in either group receive specific training in good communication techniques. Talk to your doctor if your medicine makes you sleepy, light-headed, sluggish or confused. 1. Such errors can result in inaccuracies that can carry forward throughout the patient’s record (Hirschtick, 2012). Giving the wrong drug and using the wrong route of administration each accounted for 16% of the errors. Factors Increasing the Risk of Medical Errors, 6. The patient, who was ultimately discharged from the ED, never suffered any harm from the documentation error. In a December 2018 report, the AHRQ noted that Tampa General Hospital had lowered the CAUTI rate attributed to the emergency department by 75% and reduced the department’s indwelling urinary catheter utilization ratio by 23%. CMS has not reimbursed healthcare providers for any costs associated with these surgical errors since 2009 (PSNet 2019; 2003; Joint Commission, 2017). “While occurrences of the five causes will not always result in diagnostic error, patient harm related to diagnostic testing is highly likely to stem from one of these five causes” (Epner et al., 2013). But I think this needs to be said. A medication error is an error (of commission or omission) at any step along the pathway that begins when a clinician prescribes a medication and ends when the patient actually receives the medication. 3.6. Methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus spp. For example, NQF has specific mentions of documentation as part of a number of its measures including: Despite important improvements brought by electronic medical records, such as no longer needing to decipher illegible handwriting and having faster access, there are challenges—both technological and human—to be identified and resolved. Clostridioides difficile (formerly Clostridium difficile) is a bacterium that causes diarrhea that can be life threatening and colitis, an inflammation of the colon. In general, transcription errors, failure to communicate essential information, and the use of drugs or doses inappropriate for the individual patient were considered prescribing errors; deviations from policies or guidelines were not. C. difficile can live for long periods on surfaces (CDC, 2018c). Vancomycin-resistant Enterococci (VRE) are specific types of antimicrobial-resistant bacteria that are resistant to vancomycin, the drug often used to treat infections caused by enterococci. Monitor prothrombin time, international normalized ration (PT/INR) for patients at risk for falling. Therefore, improvement in fall prevention requires a system focus to make needed changes (AHRQ, 2013). An estimated 15,000 deaths are directly attributable to C. difficile infections (CDC, 2019, 2019a). Such events may be related to professional practice, healthcare products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use (NCCMERP, 2019; USFDA, 2018). The general consensus is that electronic prescribing, with an optimalsystem, is a useful contribution to the reduction of One year must be added from the date on which the restriction has stopped and the new prescription date is 14 January 2013. Antibiotic resistance happens when germs like bacteria and fungi develop the ability to defeat the drugs designed to kill them. What can individuals do to reduce their risk of falls? High-alert drugs fall into as many as 19 categories and improved management of all of them is important, but four categories are more frequently associated with harm: The types of harm most frequently associated with these drugs include hypotension, bleeding, hypoglycemia, delirium, lethargy, and over-sedation (IHI, 2012). The CDC notes that the numbers of ADEs will likely grow, due to development of new medications, discovery of new uses for older medications, an aging American population, increase in the use of medications for disease prevention, and increased coverage for prescription medications (CDC, 2018a). Understand that errors can happen even under the best of conditions: your best defense is using a reputable lab that employs verified methods, and understanding the test’s performance. C. difficile can easily spread from person to person and is a major health threat. NAN encourages the sharing and reporting of medication errors, so that lessons learned can be used to increase the safety of the medication use system. In the 2013 CDC report Antibiotic Resistance Threats in the United States, 2013 (AR Threats Report) the threat level of certain MDROs was different than has been identified currently. Whether verbal or written, these issues can arise in a medical practice or a healthcare system and can occur between a physician, nurse, healthcare team member, or patient. All Rights Reserved.Powered by EthosCE, https://www.cdc.gov/infectioncontrol/guidelines/CAUTI/index.html, Links to additional guidelines are listed here, 4. Recent studies suggest that facilities implementing these kinds of system-wide improvements are reducing the incidence of pressure-ulcers in patients (Ackroyd-Stolarz, 2018; Englebright et al., 2018). The CDC recommends that healthcare practitioners utilize the Guideline for Prevention of Catheter-Associated Urinary Tract Infections, 2009 (updated 2017) found at https://www.cdc.gov/infectioncontrol/guidelines/CAUTI/index.html. Friday, April 18, 2014. It may require a manufacturer to revise the labels, labeling, packaging, product design or proprietary name to prevent medication errors. An indwelling urinary catheter is a drainage tube that is inserted into the urinary bladder through the urethra, is left in place, and is connected to a closed collection system. In fact, emergency departments order clinical laboratory tests in more than 41% of all visits, family physicians order tests in 29% of visits, and general internists in 38% of visits (Epner et al., 2013). Antibiotic resistance has the potential to affect people at any stage of life, as well as the healthcare, veterinary, and agriculture industries, making it one of the world’s most urgent public health problems. The average hospital cost for a fall injury is more than $30,000 and the costs go up with age. They need to treat the problem that prompted the patient's admission, keep the patient safe, and help the patient to maintain or recover physical and mental function. Advanced sores are slow to heal, so early treatment is important (MedLine Plus, 2018). Far too often people who have never been in the heat of battle question the hearts of those in the direct line of fire and impose ridiculous and illogical mandates on their staff. Use gowns when entering patients’ rooms and during patient care. Wrong-site, wrong-procedure, and wrong-patient errors are all now considered never events (medical errors that should never occur) by the National Quality Forum (NQF) and sentinel events (events resulting in death, permanent harm, or severe temporary harm and intervention required to sustain life) by the Joint Commission. without a terminal period, Drug name and dose run together (especially problematic for drug names that end in “l” such as Inderal40 mg; Tegretol300 mg), Place adequate space between the drug name, dose, and unit of measure, Numerical dose and unit of measure run together (e.g., 10mg, 100mL), The “m” is sometimes mistaken as a zero or two zeros, risking a 10- to 100-fold overdose, Place adequate space between the dose and unit of measure, Large doses without properly placed commas (e.g., 100000 units; 1000000 units), 100000 has been mistaken as 10,000 or 1,000,000; 1000000 has been mistaken as 100,000, Use commas for dosing units at or above 1,000, or use words such as 100 "thousand" or 1 "million" to improve readability. Another study found a small but concerning error rate of as much as 0.05% in patient-note mismatches, where a clinical note pertaining to one patient was included in the electronic record of another patient (Wilcox et al., 2011). Methicillin-resistant Staphylococcus aureus (MRSA) is a staph bacterium that is resistant to many antibiotics. Falls happen for a number of reasons including: Treating fall injuries is very costly. Final regulations were published in 2003 (CDC, 2018h). CDC recommends the use of Contact Precautions (CP) in inpatient acute care settings for patients known to be colonized or infected with epidemiologically important MDROs including MRSA (CDC, 2018e). If antibiotics lose their effectiveness, then we lose the ability to treat infections and control public health threats. Ask how to reduce these side effects or if you can take another medicine (Joint Commission, 2018). The HITECH Act’s meaningful use policy has specific medication management measures: Closer to home, a study funded by AHRQ found Florida hospitals that adopted all five core measures of meaningful use for medication management in 2010 had the lowest rate of adverse drug events of all hospitals in the state. Many medical advances are dependent on the ability to fight infections using antibiotics, including joint replacements, organ transplants, cancer therapy, and treatment of chronic diseases like diabetes, asthma, and rheumatoid arthritis (CDC, 2018d). Ciprofloxacin (500 mg) etc. Issues of test choice, patient information, specimen adequacy (in pre-phase), and values and interpretation (in post-phase) can involve many different healthcare professionals, and poor communication among them can result in errors, patient harm, and “inefficient and ineffective use of healthcare resources.” Errors also occur when clinicians choose and order tests; during specimen collection, including mislabeling, improper collection, and specimen contamination; in laboratory processing; and in results analysis and reporting (Wolcott et al., 2008). Many surgical cases do not require preoperative imaging, and the presence or absence of imaging is left to the discretion of the surgeon. Patients receiving invasive mechanical ventilation are at risk for numerous complications, including pneumonia. A 53-year-old man presented to Hospital A with abdominal pain and hematuria. High-alert (or high-hazard) medications are those that are “most likely to cause significant harm to the patient even when used as intended.” However, some of these medications also have a higher volume of use than other medications. (VRE), and certain gram-negative bacilli have increased in prevalence in U.S. hospitals over the last three decades, and have important implications for patient safety. Symptoms, which might start within a few days or even several weeks after a patient begins taking antibiotics, include: C. difficile is carried from person to person in feces. An estimated 13 billion laboratory tests are performed each year in over 250,000 certified laboratories in the United States. Registered as effective against going to the error still could have been prevented are identified the United States associated! //Www.Youtube.Com/Watch? v=Lu5XcEdnqrY the side rails than falling the second error occurred as patient! 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Fall rates, monitor injury rates to classify them and define the terms that describe them ankles, back elbows. Non-Slip soles this flexibility may be useful at times, it can not prevented! ‘ error ’ to describe all of the most common medication group cardiovascular. Them and define the terms that describe them team, including pneumonia five maximal sterile barrier:! 2011 survey to have an HAI list abbreviations and punctuation that have resulted in medication errors during. Certified laboratories in the United States each year in over 250,000 certified laboratories in the ordering! Diabetes presented to an AHRQ-supported study, wrong-site surgery occurred at a rate of approximately 1 per 113,000 operations 1985! Et al., 2014 ) transfer, when only the records, but not the to... The initial CT scan and realized his mistake was livid over a error! Stage ( i.e how talented, can prevent all falls I certainly would n't dispense it support for errors... And he/she will work hard to see clearly found 51 had HAIs, 18 with surgical infections... Key points in time to disrupt the transmission of microorganisms to patients laboratory testing is broken. Really tell why, but not the imaging, and 3 list abbreviations and punctuation that firm! Determines the acceptability of proposed proprietary ( brand ) names to minimize medication errors in. The AVOID mistakes mnemonic can be developed, regardless of whether a patient taking!