medical errors prevention and safety

8/3/2019 Medical Errors Prevention and Safety

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Medical Errors Prevention and Safety

For the

C.N.A.

A Self-instructional Program

Approved for 1 Contact Hours*

This study was prepared by Linda S. Greenfield, RN, Ph.D.

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Florida now has a defined scope of practice for CNAs that includes a renewal processwith required in-service hours. The Florida Administrative Code 64b9-15.011 and thenurse practice act which governs CNA in-service training state that the CNA must have12hours of training every year that includes the following mandatory subjects every twoyears: HIV, medical record documentation, communication with the cognitively impaired,infection control, resident/patient’s rights, CPR, domestic violence and medical error and

safety. This course has been designed to meet that last requirement.

Please read these IMPORTANT INSTRUCTIONS as they containanswers to many of the questions we are often asked

regarding home study.

If you have downloaded this course, you may save it to your hard drive or print all or any partof it. In this way the document is available to you as a resource. As you leaf through this study,you will notice that there are questions placed throughout the reading material. Please notice thelast two pages and print these if you have downloaded the course. The first is an answer sheet. Asyou complete the study, record your answers on this sheet. A passing score of 75% must beachieved to receive credit. In the event that you do not reach 75% on the first submission, you maytry a second time without paying again. You must pay again if you need more than two attempts topass the course. You may refer to the material at any time and you may also study in groups, if youwish. The second sheet is an evaluation form and is to be filled out and submitted along with your answer sheet. If you find any errors, please note them so we may correct them at the next printing.You may submit your answers online and your certificate will be available upon successful

completion. Or you may fax your answer sheet to 206-600-6268, or mail it to: Nurse LearningCenter 8910 Miramar Pkwy Miramar, FL 33025. Faxed or mailed answer sheets are processedwithin one week of receipt. You receive credit on the date we process your answer sheet. If youput your fax number on the answer sheet, we will fax back a copy of your certificate before we putthe corrected answer sheet and a certificate of completion in the mail to you.

If you have a certification number (C.N.A. number), put it in the space labeled“License or Certificate number” and it will print on your certificate. If you do not have either number, just leave that space blank. Should you decide not to finish the course this year, itcan be applied anytime up to two years from the date of purchase.

Initial printing: June 2006Current Revision May 2010

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More people die from errors within the healthcare system than from vehicle accidents, breastcancer or from AIDS. Errors account for the eighth leading cause of death in our country. This iswhy our legislatures mandated that we all take courses in error prevention and patient safety. A2006 report stated that the incidence of medical errors rose in hospitals between 2002 and 2004,totaling 1.24 million during that three-year period. The number of medical errors for the previous

three-year period was 1.14 million. (Health Day 4/3/06) These estimates are higher than thoseoriginally offered when medical errors first became an issue. Obviously, there is more for us inhealthcare to learn and apply.

Objective No. 1: Identify the factors that contribute to errors and reflect on the presence of any of these factors in your place of employment.

Most errors are a failure of the system, rather than solely the responsibility of one person.Most preventable errors are a series of mini-errors made by several people that result in a bigproblem. For example, consider one large category of medical errors – acquired infections. Wecan try to prove who the carrier was that gave a weakened patient a life-threatening infection, but

the bottom line is that if you ever slacked on hand washing, you created a mini-error that, whenmultiplied by all the others, can result in a big problem.It is obvious that errors made by doctors, nurses and pharmacists account for the majority of

fatal errors. This can’t be denied. To the patient relying on us, it does not help for an aide to blamea nurse for giving a treatment to the wrong patient, when she suspected it was wrong and couldhave prevented the error with a simple question. Everyone is a watchdog for everyone else,because our patient’s safety is at risk. We can learn from each other as well. The nurse working inlong term care might have ideas about how to make an environment safe for disabled people thatcan be used by an aide working in home health with a person in a wheelchair.

The patients themselves contribute to medical errors. Research shows that 20% of patientsare unable to read, understand, or follow their written directions for diet, exercise therapies or other instructions. Patient compliance is part of the problem. Sometimes they don’t cooperate and actdangerously, such as when a patient goes to the bathroom unassisted, even after you told them towait for you. The public, especially our elderly, often do not feel free to question what we do,fearing that they might look stupid, or threaten the healthcare practitioner in some way. They don’trecognize that they need to be involved in the decisions and they fail to monitor their own care. Weneed to teach our patients a new way to interact with us that restores the responsibility for healthback to them. It is their body, their life, and the healthcare decisions and processes are theirs tocontrol. To take care of themselves, they need information, which is our job to supply. Patienteducation is perhaps one of the most effective ways to prevent medical errors. The patient has theright to know, understand and consent to everything that happens to him while in our care. In our team approach to changing the system, we must include the patient as part of that team.

The problem of patient safety is huge. We are all part of the problem and we are all part of the solution. Pointing fingers, blaming and shaming will not bring quality back into our system. Our system has good people in it. We need a systemic approach in which everyone owns the errorsproblem, and everyone works for patient safety.

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FACTORS THAT INCREASE ERRORS:We must identify the factors contributing to the problem so that we can build safety into our

system. We need better ways to double check, or get feedback that something might be wrong.

Here are some definitions of words used to describes problems with patient safety:

*Medical Errors (errors within the healthcare system) happen when something that wasplanned as a part of patient care wasn’t followed, was incorrect, or when the wrong plan was usedin the first place. Errors can be major like a wrong diagnosis that led to the incorrect treatment, or they can be minor like serving a patient a high salt meal when he was on a salt-restricted diet.

*An adverse event is an injury or problem that was created because of an error rather thanby the underlying condition of the patient. These are also called “incidents”. Thus, we all need toask why the error occurred and make the necessary changes in our systems to prevent it fromhappening to someone else in some future time.

*Close calls or near misses are potential adverse events. They are errors that didn’t resultin an injury or problem, but could have. For example, that patient who made it to the bathroomunassisted and didn’t fall, had a close call if you knew he was really unsteady on his feet. It was anerror that didn’t happen, but it could have. Close calls provide great opportunities for creating newstrategies and these should receive the same attention by our system as actual adverse events.However, most of the time, near misses are overlooked and not mentioned or recorded.

*Bad outcomes are not necessarily errors. These are unfortunate events that can occur even when everything is done correctly and well.

When considering why these errors may happen (the “factors”), one obvious one that comesto the mind is the stress of the workload. When you have so much to do in so short of time, thisincreases the rate of mistakes. For example, if the nurse is feeling pressure to increase efficiency,she might rush too fast. This might cause a situation in which clinical protocols or procedures areignored in the interest of time. She cuts corners. She might overlook something important. Theaide might compound the risk of an error by not speaking up, and instead go along with the rush,but feeling a lot of mistrust and hostility. Who is the source of any error that might occur in thissituation? The nurse, for yielding to the pressure she is feeling? The aide, for not questioning whycommon procedures were not followed? Both of these people and the entire system are factors tothe error because of limited resources and the aide’s powerlessness over the nurse. Staffing isdefinitely a factor. Inadequate staffing, insufficient staff training, lack of supervision, and increaseduse of less skilled workers are only some of the changes we have witnessed that do affect qualityof care. High workloads, inadequate supervision, poor communication and rapid changeovers doincrease the opportunity for errors. Making errors is not, by itself, a measure of competence.Blame doesn’t prevent that same situation from happening again with another person. It justincreases stress, anxiety and guilt.

While many healthcare workers recognize that they can’t hire more staff, being able to speakup when we observe a system error in progress, or when the stress is too great, is directly our problem. We need to increase our power, and this can be accomplished on a personal level.Then we can help other people to speak up as well. We can only be part of the solution when wehave the power and ability to respond and speak up when a situation needs changing.

Power in communication is a factor that is very involved in the issue of medical errors. Realpower doesn’t depend on your title or position. People don't attack other people who are perceivedas powerful. They listen to the point of view and ideas of people with power. People don't vent their anger at people who are confident. Attacks change into negotiations with win-win solutions. Weneed power to protect our patients from medical errors. We need our own power before we canempower our patients to act as their own monitors of the care they receive. We need power tochange the systems that we work in.

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The system dis-empowers you when it blames you and holds you solely responsible for errors, which has been our history. When we think of errors as an individual’s problem and fail toconsider that they might well be systems problems, we create unreasonable expectations of perfection. None of us are perfect, so this leads to denial and covering up the errors, rather than ateam approach to find a systemic solution or ways to prevent them from happening again. Whenthe system expects us to be perfect, individuals will be disciplined for errors, rather than supported

for reporting mistakes and “near misses.” A news release in June of 2005 from the Institute of Safe Medication Practices reported that health providers still fear being punished for any medicalerror. We are faced with an overwhelming reluctance to admit that any healthcare worker makesmistakes. This strips us of power to negotiate change and none of us can work together.

For example, Joan was called to my unit from another unit because my CNA was sick. It wasa busy shift, so Joan received a quick and sketchy orientation to the patients on this unit. She gotHenry into his Geri-chair, but no one told her how to prop the chair to prevent Henry from archinghis back, causing the chair to recline, which allowed Henry to fall out of the chair over the arm.Because no one told her, she didn’t prop the chair correctly and Henry fell. This wasn’t the firsttime this happened, so the family was really angry. Joan escaped to the break room, crying, asshe tried to figure out where she would get another job. She knew she would be fired for this.

That kind of reaction happens when disciplinary action is the usual response to errors. Wheneveryone concludes that it is all Joan’s fault, they feel better. Joan becomes the scapegoat. Thisincident was no more Joan’s fault than it was my fault for providing a poor orientation to our unit. Itwasn’t my entire fault, because the staffing situation wasn’t resolved before the shift began soeveryone was behind. That meant that administration had a factor, too. And if patient safety wasreally important, why was Henry’s room equipped with such a chair to begin with? Do you see? Byfocusing all the blame on Joan, no one stands back and looks at the big picture to make thenecessary changes so that Henry and others like him won’t fall in the future. They just fill out thepaper work and put a note in Joan’s file that she made an error. The next time Joan makes amistake, do you think she’ll report it if she can hide the evidence? The consequences would beher job. That’s big. So the errors don’t get prevented.

This is what has to change. Joan, and all of us, have to quit taking all the blame. Question thebig picture. Call in all of the factors until somebody sees that lots of people have contributed to theerror situation, and the system needs to respond to this safety issue. It is rare that an error is anyone person’s fault.

When needs and goals crash, as in a conflict, the one with the power often wins, yet, as our patients are the least empowered in our healthcare hierarchy, they are often the ones who lose. If you are trying to change a system, you will encounter resistance and conflict. How much power doyou have to handle that? Some of the people you want to change may perceive that you are tryingto control them or threaten them. Whenever any of us feel like we are losing control we react withpowerlessness, worry, apathy, anger, fear, worthlessness, exhaustion, confusion anddefensiveness. Those are common feelings expressed in healthcare today. For example, if anurse is controlling or does not share power to make giving information safe, people will just nicelynot cooperate. The most common way is to simply smile and say nothing at all. The messagedoesn’t get passed on.

If a nurse empowers, she is willing to listen to what others think of her ideas. She must beready to hear what she does not like to hear. If people had thought that she would like their words,they would have already said them. When the patient’s safety is a risk, you might have to demandto be heard even if she is controlling. Learn to speak without attacking and calmly state what youobserve and what your concerns are, without blaming anyone. Her reaction to you is her problem.Your responsibility is to assert your power to assure the patient will be safe. You can saysomething like, “Mrs. Jones is really weak and unsteady today. I don’t think she is safe getting out of bed and I don’t feel like I can handle her weight alone for her walk.” Imagine that the nurse sayssomething curt like, “Well it’s your job. She has to go for a walk so you figure it out.” You still haveto assert your power to assure that Mrs. Jones will be safe. You might say, “OK. What can I do to

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make her safer? Can I ask for help from the other hall? Can you help me? I do not feel safe to get her up without help, so I have to have another solution.” Stick to your gut feeling. You can evendocument your requests of the nurse in your notes if you can’t negotiate a safe alternative.

There are effective ways that we can communicate with each other, regardless of our positionof the organizational ladder. Being attacking, “in-your-face”, acting superior, or shaming will alwayslose the battle. Four suggestions for communication when you suspect there is a problem include:

Leading with questions, not answers. Saying “Can I get help from the other hall” is better than saying, “I’m not doing this. You’re the nurse.”

Engaging in dialogue and debate, without aggressiveness.

Calling for a review of issues and/or events without finger-pointing. “It’s better to say,“Mrs. Jones is really weak and unsteady,” than to say “You really wiped Mrs. Jones out with thatenema.” It might be true, but the finger-pointing will seem like an attack.

Offering suggestions for building “red flag” mechanisms that change “information”, into“information that cannot be ignored”. You could say something like, “Henry’s chair is really badfor him. Can we write an incident report that emphasizes the chair so that maybe we can get adifferent one for his room?” The incident report might be what you need to get someone’sattention. Since it is usually the nurse who writes up the incident report, and it is usually the aidewho gets Henry into that chair, the aide might need to be the one who initiates the change.

With honesty, openness and respectful listening, you can negotiate a change. It becomes ateam effort in which everyone owns the change. It becomes a joy instead of a burden. Six topicareas that define a healthy environment include: skilled communication, true working as a team,effective decision-making, appropriate staffing, meaningful recognition and authentic leadership.Isn’t it great that as we work to make our environments safe and healthy for our patients, we willalso be making them healthy for us to work in? Isn’t it sad that as long as we allow our workenvironments to be punishing, controlling and abusive to those working within the system, they willremain unsafe and full of errors for our patients? “Of the more than 2,900 sentinel events reported to the JCAHO since 1995, more than two-thirds involved communication mishaps.” (Barden, 2005)

Other staff factors that increase the risk of errors include:

Fatigue. Our system is often demanding that the workers carry double loads, or double shifts, or double-back from one shift to the next. Our patients see the same healthcare worker for 16

hours on the same day and don’t question the system about safety. Substance abuse. It is a rising problem within our system.

Illness. How many of us within healthcare have gone to work sick, which not only compromisesour ability to get well, but also jeopardizes the health of our patients and increases the risk that inour low-energy state the risk of errors is higher.

Distraction and Emotional States. Our environments can be noisy, busy, and demanding of our attention from several sources at the same time. It is difficult to stay focused

Equipment design flaws or inadequate or inappropriate labeling or instructions for safeuse. It is dangerous to repackage anything into empty drug-solution or irrigation-solutioncontainers. Some have resorted to poking holes into the containers so that they can’t be re-used.

We need to become a team focused on helping each other solve this problem. We need to

recognize our interdependence and begin to work together. We need to become collaborativeinstead of competitive. This process will take time. Understand that the changes that need to bemade will happen one person at a time -- one facility at a time. Your decisions and actions areimportant.

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To summarize:What doesn’t work:

Blaming individuals for errors, rather than looking for systemic flaws – punishing

approaches.

Control, disrespect, abuse.

Top down power in which only a few are empowered.

What does work:

Empowering, sharing the power with everyone.

Sharing the blame and sharing the gain.

Listening, empathy, collaborating, communicating.

Question No. 1: True/False? When you are blamed and held solely responsible for an error,

this empowers you.

a. True. b. False.

Question No. 2: Factors that increase errors include:

a. Fatigueb. Not having enough internal power to speak up when necessary.

c. Too much stress caused by the workload.

d. All of these are factors.

Question No. 3:Which of these is NOT true of medical errors?

a. Errors within the healthcare system account for the 8th leading cause of death.

b. Most errors are solely the responsibility of one person.

c. Patients can contribute to medical errors by acting dangerously or not following

instructions.

d. The number of errors rose between 2002 and 2004.

Question No. 4: When someone blames only you for an error, what is a healthier response?

a. To encourage the blamer to consider other factors, pointing out that it is rare that

an error is one person’s fault.

b. To recognize that you are not perfect and you should be.

c. To say nothing, but fume with anger.

d. To take all the blame and consider leaving the profession because of your guilt.

Question No. 5: True/False? It is often necessary to share power so that people can feel safe

to share information, or speak up.

a. True. b. False.

Question No. 6: Which of the following is a definition of “bad outcome?”

a. A problem created because of an error, rather than by the underlying condition of

the patient.

b. Errors that didn’t result in injury, but they could have.

c. Something planned wasn’t followed, was incorrect, or the wrong plan was used in

the first place.

d. Unfortunate events that can occur even when everything is done correctly and well.

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Question No. 7: According to the course, one of the most effective ways to prevent medical

errors is:

a. Assigning double shifts.

b. Blaming and shaming accountable individuals if they make any mistake.

c. Only thinking about what you are doing and not considering what someone else isdoing.

d. Patient education.

Question No. 8: Which of the following is an example of “calling for a review of issues and/or

events without finger pointing?”

a. “I’m not doing this. You’re the nurse.”

b. “Mr. Smith is really in a lot of pain today. Can we re-think if we should get him out

of bed right now?”

c. “Well it’s your job, you figure it out.”

d. “You really wiped Mrs. Jones out with that enema.”

Objective No. 2: Specifically identify those factors of error-prone situations that involvemedications respective to your responsibility as a aide, in your over-all efforts to enhance

patient safety.

There are many statistics available showing us how common mistakes are in our system.Many of those statistics involve medications.

The American Society of Health-System Pharmacists found that Americans were veryconcerned about being given the wrong medication (61%) or being given two or more medicinesthat interact in a negative way (58%). (Publication No. AHRQ 00-PO37, 2/2000) Patients can insuretheir own safety by becoming involved in their healthcare. There are several things you can teachpatients or their families that will empower them to ask questions and monitor the process.

• When the doctor writes them a prescription, make sure they can read it. If they can’t, an error ispossible. Teach patients/families to insist that their prescriptions are readable.

• Ensure that patients/families know what medications they are taking, what the pills look like, andwhy they are taking the medication. If they don’t, ask the nurse to teach them.

• If they have any questions about the instructions on their medicine labels, dietary sheets,exercise instructions, etc. encourage them to ask, and specify who they can ask along withappropriate telephone numbers. Medication labels can be particularly hard to understand. For example, does four doses daily mean every six hours around the clock or just four times duringwaking hours?

• If they are treated by various physicians, they should keep a list of all the medicines from all thedifferent doctors, as well as herbs from the health food store and vitamins from the grocery. Listall over-the-counter drugs, all allergies, and any other helpful information.

• They should read the warning labels on their prescriptions, checking specifically for foods toavoid, timing of the drug with meals, etc. If there are concerns, encourage them to ask.

• They should get the results of any tests or procedures done. Instruct them to ask when theresults are expected, and if they haven’t heard, to contact the physician.

• Doctors need feedback. Encourage patients to tell doctors when treatments or medication areworking or not working, and to inform them of all changes they’ve observed from constipation tosexual functioning and everything in between. Teach patients not to assume that a newsymptom is because of age or stress. There might be a connection.

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Perhaps the type of error most familiar to nurses is medication administration errors.However, nurses are not the only profession that administers medications. Sometimes CNAsadminister medications, and sometimes the patient self-administers his own medication. TheAmerican Hospital Association has listed the common types of medicine errors:

• Incomplete patient information (not knowing about patients’ allergies, other medicines

they are taking, previous diagnoses, and lab results, for example.)• Unavailable drug information (such as lack of up-to-date warnings.)

• Miscommunication of drug orders, which can involve poor handwriting, confusionbetween drugs with similar names, misuse of zeros and decimal points, confusion of metric andother dosing units, and inappropriate abbreviations.

• Lack of appropriate labeling as a drug is prepared and repackaged into smaller units.

• Environmental factors, such as lighting, heat, noise, and interruptions that can distracthealth professionals from their tasks.

Drug names can be very confusing. Name confusion is among the most common causes of drug-related errors. For example, the arthritis drug, Celebrex, the anticonvulsant drug Cerebyx ,and the antidepressant drug Celexa, all look alike. So if you are involved in giving or monitoring

drugs, you need to pay very close attention to the name of the drug.Liquid medications are associated with many errors. These are the least likely to be

dispensed in unit doses, and the most commonly prescribed form for highly vulnerable patients –children and the elderly. Parents of children often confuse milliliters and teaspoons. If you aremonitoring a home situation that involves the patient or family administering their own medication,be alert to this type of error and watch closely to be sure they are doing it right.

Decimal points are another potential source of error. One solution is to never use a trailingzero after a decimal point, as in “1.0”. If the decimal point isn’t noticed, the dose could be read as“10”. There should always be a leading zero to alert us that a decimal point is present. Thus, “.1”should be written “0.1”

It is important to assure safe drug delivery when you are responsible for administering anydrugs, and also important to know what safety concerns apply when your patient/client is self-

administering a variety of drugs. Safe drug therapy goes beyond making sure that the right patientis getting the right drug at the right dose at the right time and in the right way. You need to beaware of what drugs the patient is taking that might change his ability to be safe and for you towork safely with him. Many of the drugs that patients take to control blood pressure can increasethe risk of falls and injuries. Certainly, narcotic painkillers are known to make people drowsy andunsteady on their feet, yet we often want the patient to be medicated before we try to get them outof bed or walking. Our concern for comfort creates another concern for safety that calls for our attention and close monitoring. Often people with Parkinson’s can’t move as freely until their drugsreach peak effect. Those who ambulate patients on these drugs need to be aware of the need for greater vigilance and constant assessment of safety risk. You can routinely ask the nurse to tellyou if there are any drug concerns you should know before you give care. You have a right and aresponsibility to gather this kind of information.

You don’t have to directly give medications to be involved in preventing medication errors.We are all monitors. Most of us deal daily with patients taking some kind of drug therapy. Howdoes their therapy increase their risk for injury? How can you prevent adverse effects? Consider the ways your medication system may contribute to increased errors and look for other ways thatmight work better, or consider safeguards, double checks, equipment safety-checks, etc. that mightresolve some error-prone situations. Begin to think in terms of safety. Use this course as aspringboard for talk with others.

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Question No. 9: Examples of drug information that you should be told to help you keep your

patients safe include all but one. Which is NOT something that will help you with

patient safety?

a. Knowing that an elderly patient is receiving a drug such as cortisone that may

make his skin become very thin and tear easily if he should bump against things.

b. Knowing that the patient is taking a medication that stops working if he eatsgrapefruit, and you often feed the patient.

c. Knowing that the patient is unable to pay for his drugs and is receiving financial

aid.

d. Knowing when they have received a narcotic pain reliever drug that might make

them dizzy if you get them out of bed.

Question. No 10: How can you help prevent errors involving medications?

a. If patients have questions about their medications, you can encourage them to ask

by giving contact information for their nurse.

b. If patients have a question, you can tell them not to worry, but to just do what the

nurse says.c. This isn’t your job, so there’s nothing you can do.

d. You can imply that everyone is too busy to be bothered with little questions.

Objective No. 3: Become aware of your responsibilities for reporting medical errorsand the obstacles that exist in our healthcare systems .

Not all problems require a formal committee to be solved. You can be highly effective byincreasing a watchful eye to patient safety. Learn to ask yourself if the patient will be safe withyour plan of action. If you are to ambulate your patient, but she is excessively dizzy when you sither on the edge of the bed, will she be safe with just your physical strength, should she lose her balance? Is exercise at this time a good thing? If you are assisting your patient to the whirlpool or to a shower, and there is water in your path, take time to consider all of your available optionsbefore you guide the patient into a potentially slippery situation. Most of the actual management of error prone situations depends upon the worker who is immediately responsible for direct care of the patient. So, although the nurse or therapist might be solving unit problems through delegationof responsibilities, the aide at the patient’s side needs to know exactly what to do when patientsafety is questionable or care duties may be unsafe. Get used to asking questions when you feelunsafe. Get used to trusting your own instincts. You have valuable information and you carry agreat deal of responsibility for patient safety. You deserve to be listened to.

“You got to come feel this bump,” one of my CNAs said to me. “She fell yesterday and she’s pretty sore, but I don’t remember her hip ever feeling like this. I can’t tell if it’s normal or not. I know they didn’t send her for X-rays when she fell, so I’m a little worried.” The problem was that Icouldn’t tell if it were normal or not either. It was pretty hard to decide if this was just a bruise,normal bone or a break. I called the doctor who ordered the X-rays. It was a full day event to gether to the clinic to get the X-rays, and the doctor was a little upset when the X-rays were normal.Still, I thanked the aide for bringing this to my attention. This kind of close observation is exactlywhat is needed. I will relax when working with her, knowing that she’s watching, and she’ll bringher questions to me. She can relax working with me knowing that I will listen to her concerns. Wewere lucky that nothing was broken this time.

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INCIDENT REPORTS AND DOCUMENTATIONThe most common method of reporting used by facilities is the incident report. Incident

reports are used with almost any patient or staff mishap. These are not part of the patient'spermanent record, and although most lawyers are very much aware they exist, it is not correct towrite in the patient's record that an incident form was completed. An incident report is an in-house

administrative tool, used in risk assessment and reduction programs. They are used to monitor, for example, the number of falls in the last quarter, or the number of pressure ulcers in the last year,etc. They are used to monitor errors.

These tools can help us communicate with administration. Policies or procedures won'tchange if we don't provide adequate communication of problem areas, and incident reports getattention. If you are ever asked to fill out or to sign an incident report, here are some safesuggestions. If we have an attitude that reflects a belief that filling out an incident report alwaysmeans we erred, we may try to rationalize or explain away mistakes when we chart. This is legallydangerous, and lawyers quickly recognize words that imply this. Some bad examples are"accidentally" or "somehow", or "unintentionally". Don't offer your opinion, draw any conclusions,place any blame or make accusations, or even guess about the situation. Don’t let the nurse (whomight be filling out an incident report about something you were involved with) do this either.Whoever is completing the incident report and documenting the incident in the patient’s chartshould just state the facts. Report what the patient said in quotes, exactly as he said it. Tell whatyou did or the patient did; what you did about it; who you notified; and any assessed data whichwould indicate outcome. For example, if you found the patient on the floor next to a puddle of urine, the patient’s chart should not say “The patient apparently slipped on the wet floor thatsomeone didn’t clean up.” It would be better to say, “The patient was found lying on his back onthe floor. A puddle of urine-spelling liquid was at his feet, but he himself was not incontinent." Thisentry provides the patient centered details, without "red flags". The incident report will providefurther details. Avoid being subjective. If you come to a conclusion, state the objective facts thatled you to that conclusion. Patient doesn’t like his shake", is stating your conclusion. It is better togive just the facts with “Patient tries to eat most foods, but clamps his mouth tight when the shakeis offered.”

In general, incident reports should be completed by the person who first witnessed or discovered the event (even if the person did not commit or contribute to the error) or by the personmost closely involved in the occurrence. In Florida, anyone can fill out an incident report.

Clearly document the patient's refusal to give information or to accept care. It is best if youuse his words. Chart all noncompliance. For example, if you told a patient to call for assistancebefore getting up, and later found him on the floor, be sure you chart the previous instructions tothe patient, so any governing body knows that you told him what to do. When you suspect anoncompliant patient, chart your instructions even if no injury occurred. This helps to clarify errorsfrom noncompliance. For example: "9:00 Assisted patient with transfer to toilet. Patient dizzy and

pivoting difficult. Instructed to ring the bathroom bell for assistance when finished. 9:15 Found patient in chair. Stated she returned to chair unassisted. Reminded her to call for assistance.Nodded assent." Although it is all we can do to remember to chart the things which go wrong, inthese types of circumstances, it will provide protection if we remember to chart these incidentswhich did not end in mishap. If several hours, or several days later, the patient was found on thefloor, careful charting of noncompliance earlier would be a safeguard, would perhaps bringattention to a risky patient pattern, and would generally be much more effective than if you chartedthe noncompliance at the same time you are charting the incident. When you have recognized thispattern of noncompliance, increase your monitoring. Don’t leave the patient and depend upon himto call you. You recognized a potential for injury. Act on that knowledge. This detail to chartingalso provides more accurate information to those assessing the system for error prevention.

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Not all uses of incident reports have been constructive, as history and prevailing attitudesattest. For example, in a study of nurses, “Twenty percent of nurses believed that supervisors useincident reports against employees, and 17% reported that their supervisor used incident reportsagainst them in their evaluations. Twenty-five percent of nurses reported they were afraid that supervisors would have a negative view of their skills when they reported an incident.” (Dunn, 2003)

Incident reporting will not provide valuable data as long as they are used to punish or asdisciplinary devices.

We need systems in which errors are difficult to commit, and in which the existence of anerror is openly acknowledged and patient safety is everyone’s obligation. Truth telling for all of usshould not be unique. It should be the expected norm. It is a sign of a healthier system.

Question No. 11: What is an incident report?

a. An administrative tool to monitor errors.

b. An important part of a patient’s chart that tells who is to blame for an error.

c. An insurance form.

d. A way to gather information for your annual review of how well you are doing.

Question No. 12: Most of the actual attention to error-prone situations depends on the direct

care worker, who is often an aide. Therefore you have a responsibility to:

a. Ask questions if you feel unsafe, until you do feel safe.

b. Assume patient safety is someone else’s job.

c. Distrust your own instincts and assume you don’t know enough.

d. Hold your tongue and don’t say anything when in the presence of someone with

more education.

Question No. 13: True/False. Words you should not use on the patient’s record include,

“accidentally”, “unintentionally,” or “somehow.”

a. True. b. False.

Objective No. 4: Consider the safety needs of special populations.

Certainly there are patient populations and situations that require closer monitoring to preventerrors. Obvious situations include the use of restraints, patients who experience degrees of sedation, delirium or dementia, those with sensory loss, children, handicapped and elderlypatients.

For example, the use of restraints makes that patient completely dependent upon us for safety. Part of your facility’s approach to reduce medical errors will be to define the standards andprocedures of restraint use, and develop ways to use alternatives to restraints or to use the least

restrictive type of restraint. Each healthcare worker will be held responsible to know what thoseprocedures of restraint use are, to know what documentation is required for the restrained patientand to know how often these patients have to be assessed. Evidence will be required to show thatyou have considered carefully various alternatives to each patient’s situation and have chosen therestraint type to assure the least danger. All dangers will have to be considered. If you argue, “Hemight fall and hurt himself,” you have not considered the dangers inherent in restraint use, whichare considerable. For example, restraints often cause a person to struggle, which might causeharm as well. Restraints cause a person to lose muscle strength, which will increase his risk of fallswhen he does get up. All of this and more has to be considered. Forms need to be created to

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document restraint use, and various alternatives can be listed on those forms as suggestions for alternatives to the restraint, such as decreasing sensory stimuli, moving the patient so he can bebetter observed, or using alarms. As the needs to assure safety for a patient increase, so will theneed for attention to detail increase. You can expect surveying agencies to focus on suchsituations precisely for this reason.

Put safety on the agenda and most of your patients will have approaches written into their

plans of care to meet their safety needs. Consider such common situations as skin tears for elderly patients and the need to minimize sharp corners, tight spots, and generally make it easier for these patients to move without injury. While it is impossible to put your patients in a plasticbubble to protect them from harm, much more can be done than is being done.

Monitor the environment the patient is in to make sure it is safe. This becomes even moreimportant for those who are cognitively impaired. Make sure that at-risk cabinets are locked if necessary. Ensure that cabinets and storage areas are clean and items are stored in appropriateplaces. Make sure checklists are up to date and followed. No day should be missed on the lists.

Questions regarding how your employer is improving patient safety will be an important partof future surveys. Your surveyor may ask you for specific answers. Think about what answers youcould provide. You have important insights. You are on the front lines. You have the knowledgethat your supervisors need in order to make the changes that will keep the patient safe. Iencourage you to communicate what you have observed. Trust how important you are to theprocess. Sometimes it is difficult to get people to listen to you, but keep trying. Your patients needyour commitment to their safety.

Question No. 14: People who require closer monitoring include:

a. Those with drug-induced sedation, or sleepiness.

b. Those who are handicapped.

c. Those who can’t see or hear.

d. All of these require close monitoring to ensure safety.

Question No. 15: Those with dementia require closer attention to safety. Which of the

following examples could cause more harm than good and is the riskiest example?

a. Lowering the temperature in the hot water heater so that the patient can’t burn

himself.b. Restraining the patient to his chair daily, with two short walks during the day, so

that it is easier to watch him.

c. Taking the knobs off of the kitchen stove so the patient can’t turn on the gas (but

the caregiver could still use the stove.)

d. Using locks on the doors so that the patient can’t get lost outside.

For additional information on patient safety and prevention of medical errors, refer towww.allheathnet.com/Patient-Safety.htm. This site links you to multiple associations, centers and articles

that can keep you quickly informed.

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http://www.allheathnet.com/Patient-Safety.htm

http://www.allheathnet.com/Patient-Safety.htm




BIBLIOGRAPHY

Barden, Connie, “Toward a Healthy Work Environment,” Health Progress, Nov./Dec 2005.Beyea, Suzanne, “Implications of the 2004 National Patient Safety Goals,” AORN Journal ,

November 2003.

Carroll, Patricia, “Medication Errors,” RN, January 2003, pg. 52-57.“Crossing the Quality chasm: A New Health System for the 21st Century,” Institute of Medicine, 2001.

“Documentation Errors are Easy to Avoid and Correct,” Same-Day Surgery , August 2003.Doheny, Kathleen, “Deadly Medical Errors Still Plague U.S.”, WebMD Health News, May 20, 2009,

www.medscape.com/viewarticle/703092Dunn, Debra, “Incident Reports,” AORN Journal , July, 2003.Hakin, Amin, “JCAHO Standards Up the Ante for Leadership,” Physician Executive, July-August

2006.“Health Care Practitioners Expect Punishment for Errors,” AORN Journal , Sept. 2005.

Holland, Julie, “Professionals and Patient Safety: How to Positively Influence Change,”http://www.ahima.org/journal/features/feature.0104.4.html .

“JCAHO Urges Passage of Patient Safety Regs,” Hospital Infection Control , August 2003.“Medical Errors: The Scope of the Problem,” Publication No. AHRQ 00-PO37 , February 2000.“More than 40% of Nurse Errors not From Medication: Procedural Errors, Charting Errors also

Significant,” HealthCare Benchmarks and Quality Improvement, April 2005.“Nurses Report Lion’s Share of Medical Errors,” Health Management Technology , March 2006.

O’Connor, Edward, “Resistance to Patient Safety Initiatives,” Physician Executive, Nov/Dec 2005.Preidt, Robert, “Number of Medical Errors Rose,” Health Day , April 3, 2006.“Reducing Medication Mistakes,” http://backandneck.about.com/library/weekly/aa052300a.htm . .

Solnik, Claude, “Healthcare Group Seeking to Reduce Medical Errors,” Long Island BusinessNews, Jan. 5, 2007.

Spalding, Katrina, “Medication Errors Become Problematic,” Arizona Nurse, July 2006.Sparkman, Catherine, “Focus on Health Care Delivery, Quality, and Nursing,” AORN Journal ,

October 2005.“Survey Finds American Still Worry About Medical Errors,” AORN Journal , April 2005.“To Err Is Human: Building a Safer Health System”, Washington, DC: Institute of Medicine,

National Academy Press: 1999.“What You Must know About New Patient Safety Standards,” RN, June 2001, pg. 24hf1-24hf4.

Zuckerman, Susan, “In Conflict Resolution, What’s Power Got to Do With It?” Dispute ResolutionJournal , August-October 2001.

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http://backandneck.about.com/library/weekly/aa052300a.htm


http://www.medscape.com/viewarticle/703092

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