Define medical error and safe healthcare environment. Appraise the incidence, prevalence, and cost of medical errors.

. Describe the various types of medical errors. Explain how and why medical errors should be reported. Identify risk factors for medical errors. Define sentinel event

 Incidence and Prevalence In 1999, The Institute of Medicine (IOM) released a report, To Err is Human, Building a safer health care According to the 1999 report, one in every 25 patients is injured as a result of medical error(s) annually, and the IOM report data indicate that an estimated 44,000 to 98,000 people die every year as a result. The Agency for Healthcare Research and Quality (AHRQ) research shows that medical errors may be caused most often by systems errors.

 Medication errors occur throughout the entire medication administration process, beginning with the prescription, to medication administration, to patient/family education, and, finally, to assessing patient response The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) reports an alarming increase in surgery on the wrong body parts or on the wrong patient.

 In 1998, there were 15 wrong site cases reported. In just one month, November 2001, 11 cases were reported. 108 cases were reported in the two year span of 2000-2001. 76% involved operating on the wrong body part, 13% operating on the wrong patient, and the remaining 11% involved the wrong surgical procedure. ( Tanner, 2001)

 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, confusion between drugs with similar names, misuse of zeroes and decimal points, confusion of metric and other dosing units, and inappropriate abbreviations; Lack of appropriate labeling as a drug is prepared and repackaged into smaller units; and Environmental factors, such as lighting, heat, noise, and interruptions that can distract health professionals from their medical tasks.

 Collaboration with Food and Drug Administration (FDA) pertaining to such safety issues as lookalike, sound-alike drugs and risk detection. Create a national system of accountability through transparency. Establish a Center for Patient Safety. Physicians and other healthcare professionals must demonstrate competency in patient safety.

 Medical error the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. There are two types of errors to define. Error of planning- Is when the original intended action is not correct Error of execution- Is when the correct action does not proceed as Intended. Medicine error when a patient receives a medication that is not ordered by the physician. Adverse event - an injury caused by medical management rather than by the underlying disease or condition of the patient

Hospitals. Clinics. Outpatient Surgery Centers. Doctors' Offices. Nursing Homes. Pharmacies. Patients' Homes. Errors can involve: Medicines. Surgery. Diagnosis. Equipment. Lab reports.

 Medication Errors, such as a patient receiving the wrong drug Surgical Error, such as amputating the wrong limb. Diagnostic error, such as misdiagnosis leading to an incorrect choice of therapy, failure to use an indicated diagnostic test, misinterpretation of test results, and failure to act on abnormal results. Equipment failure, such as defibrillators with dead batteries or intravenous pumps whose valves are easily dislodged or bumped, causing increased doses of medication over too short a period.

 Infections, such as nosocomial and postsurgical wound infections. Blood transfusion-related injuries, such as a patient receiving an incorrect blood type. Misinterpretation of other medical orders, such as failing to give a patient a salt-free meal, as ordered by a physician.

A Systemic Problem that Harms Patients

DEFENCES
Training Culture Procedures Physical barriers

THE GAPS
Disease manage protocols missing or not actioned Poor compliance, poor supplies Inadequate knowledge, lack of training opportunities

Patient harmed

No clear leadership, no cohesive team structure

 Research shows that about 85% of medical errors are the result of systems failure, and only 15% are the result of job performance errors. Hours worked- Scheduled shifts that are more than 12 hours long and the use of overtime contribute to conditions that jeopardize patient safety Shift rotation- Nurses who rotate from morning, to evening, to night shifts (referred to as forward rotation) generally experience less fatigue than nurses who rotate backward from day, to night, to evening shifts. Research also indicates that changing shifts gradually, for example every one to two weeks, allows the body to adapt to changes in the bodys circadian rhythm. Changing shifts at a more rapid pace (e.g., every few days) interferes with proper adaptation.20

Communication among healthcare professionals -Research shows that disruptive communication patterns such as verbal abuse between colleagues, embarrassing colleagues, or refusal to acknowledge the importance of a colleagues assessment findings lead to high turnover, emotional exhaustion, job dissatisfaction, and reluctance to clarify physicians orders. Distractions Stress Lack of education Lack of common sense Failure to follow policy and procedures

How willing (or how reluctant) are healthcare professionals to report the occurrence of medical errors?

The purpose of reporting is to protect other patients from a similar occurrence, improve patient care. It is NOT to blame the person making the error.

1. Whether or not patients suffer serious harm. 2. Made for fear of disciplinary action, civil and criminal lawsuits, loss of confidence in clinical ability, and damage to their professional reputations.

1.If it isnt my fault its not an error. 2. If the physician knows, its not an error. 3. If the problem is corrected, there is no error. 4. If an issue more important than medication administration arises, there is no error. 5. Documentation errors are not counted as errors. 6. If I prevent a worse problem, its not an error.

Two Types of Reporting: A)Voluntary B) Mandatory VOLUNTARY -focuses on safety, and improving patient outcome. -deals with potential error or minimal patient harm. MANDATORY - to make the healthcare worker take responsibility for reporting errors/events that result in serious harm or death. ( sentinel event)

Rapport Report Record

 Some healthcare organizations use the data from incident reports to identify and punish those persons who make the mistakes. Disciplinary actions include written or verbal warnings, remedial education, suspension, transfer, demotion or termination.

ALWAYS INFORM YOUR SUPERVISOR FIRST BEFORE TALKING TO A PATIENT OR FAMLY ABOUT AN ERROR OCCURANCE Always follow your facilities policies and procedures for informing patients before you inform them of any mistake. Many patients and families are grateful to be informed and being honest.

According to the Joint Commission, medication errors are one of the most common causes of preventable harm to patients. 1. Medication errors are described as preventable mistakes in prescribing and delivering medication to patients, such as prescribing two or more drugs whose interaction is known to produce side effects, or prescribing a drug to which the patient is known to be allergic. Causes: a)due to mistakes in ordering and administering medicines. b) found that dosage errors were mainly due to the physicians lack of knowledge about the medication, or about the patient who was to receive the drug.

Prescribing of medication Dispensing of medication Administration of medication Monitoring the effects of the medication

In the prescribing stage of medications, many potential problems can arise.

Ordering the incorrect dose Ordering the incorrect drug Ordering the wrong interval or schedule Ordering the wrong route of administration Ordering the wrong rate Ordering the wrong dose form (tabs, liquid) Handwriting that is illegible Incomplete orders Ordering and not being alert to allergies Ordering and not being aware of pre-existing medical conditions Ordering without reviewing and being aware of current medications patient is taking resulting in adverse reactions.

Educating the prescriber, educating the nurse, completing a thorough assessment of the patients history including allergies and current medications, clarifying orders that are illegible, and a review by the consultant pharmacist of medication profiles.

Dispensing the wrong drug Dispensing the wrong dose Inaccurate directions for use of medications Failure to educate patient on use of medication Dispensing an expired medication Failure to assess, review the patient medication profile Dispensing without knowing patient allergies Dispensing without knowing patient conditions, and medical history (such as why the drug is prescribed)

Checking the expiration dates on drugs Checking the integrity of the drug Review patient medication profile Be clear of proper use of the drug Clear concise instructions for medication usage Clarifying all questionable orders Knowing what the drug is used for Know patient allergies Know patient history

 Follow the five rights to medication administration Right patient, right drug, right dose, right route, and right time Educate the patient as to why he is receiving the medication and be aware of the patients right to refuse any medication. Be aware that if a patient refuses a medication, it is not a medical error. If a nurse leaves the medication at the bedside, and it is thrown out without the nurse knowing, this can be considered a medication error. Omitting medications Administering an unauthorized medication Not shaking a medication that should be ( can lead to overdose or under dose) Crushing medications not intended to be crushed

 Laboratory tests need to be monitored and reported Side effects of medication Monitor effectiveness of therapeutic action of medication Complying with a pain management program Assess and monitor vital signs

 insulin opiates and narcotics injectable potassium chloride (or phosphate) concentrate intravenous anticoagulants (heparin) sodium chloride solutions above 0.9%

 operating on the wrong body part, leaving sponges or instruments in the body, or improper antiseptic practices can result in pain, repeating the surgery, scarring, and worse. Types of surgical errors include: Wrong-site surgery - operating in the wrong area of the body. Wrong surgical procedure - this can include removing the wrong part of the body, such as limbs, organs, and tissue. Surgical instrument left in the body - retractors, sponges, and surgical towels can all be left in the body. According to the Center for Disease Control, approximately 15,000 surgical patients have had a surgical instrument left inside their body in the past few years. Surgery unrelated to the patient's diagnosis. Wrong patient surgery Damage from a planned surgery - this can occur when damage is not a risk that was explained to the patient before undergoing surgery.

WHO Surgical Safety Checklist

provides a set of surgical safety standards applicable to all countries and health settings. The checklist covers 3 phases of a surgical procedure: A)before anesthesia is induced, B)before skin incision C)before the patient leaves the operating room. For each phase, a checklist coordinator confirms that the team has completed the designated tasks before the next phase of the operation occurs

 Before induction of anesthesia, key components of the checklist, using the mnemonic "Sign In," are as follows: Check that the patient has confirmed their identity, the surgical site, and the procedure to be done and that the patient has given informed consent. The surgical site should be marked, if applicable. The anesthesia safety check should be completed. The pulse oximeter should be placed on the patient and functioning. Check to see if the patient has (1) A known allergy. If so, these should be documented. (2) An anatomically difficult airway to intubate or aspiration risk. If so, additional equipment and assistance should be available. (3) Risk of more than 500-mL blood loss in adults or 7 mL/kg in children. If so, provision should be made for adequate intravenous access and fluids.

 Before skin incision, the checklist uses the mnemonic "Time Out" for the following components: Confirm that all team members have introduced themselves both by name and by their role on the surgical team. The surgeon, anesthesia professional, and nurse should verbally confirm the patient's identity, surgical site, and procedure to be performed. Anticipated critical events to be reviewed by the surgeon are any critical or unexpected steps, estimated operative duration, and anticipated blood loss. Anticipated critical events to be reviewed by the anesthesia team are whether there are any patient-specific concerns. Anticipated critical events to be reviewed by the nursing team are confirmation of sterility of the tools, supplies, and field (including indicator results); documentation and discussion of any equipment issues or concerns; whether antibiotic prophylaxis has been given within the last 60 minutes, if applicable; and whether essential imaging is displayed, if applicable.

 Before the patient leaves the operating room, the checklist uses the mnemonic "Sign Out" for the following components: The nurse verbally confirms with the team the name of the procedure to be recorded and verifies instrument, sponge, and needle counts, if applicable; labeling for the surgical specimen, including patient name; and whether there are any equipment problems to be addressed. The surgeon, anesthesia professional, and nurse review the key concerns regarding recovery and management of the specific patient.

 Incorrect diagnoses can lead to inaccurate, ineffective, or unnecessary testing and/or treatments. An extensive body of research has examined the causes of diagnostic error at the individual clinician level. This work has been informed by the field of cognitive psychology, which studies how individuals process information and subsequently develop plans. As applied to health care, we have learned that clinicians frequently use heuristics (shortcuts or "rules of thumb") to come up with a provisional diagnosis, especially when faced with a patient with common symptoms. While heuristics are ubiquitous and useful, researchers have used categories developed in cognitive psychology to classify several types of errors that clinicians commonly make due to incorrect applications of heuristics:

Cognitive Bias

Definition

Example

Availability heuristic

Diagnosis of current patient biased by experience with past cases

A patient with crushing chest pain was incorrectly treated for a myocardial infarction, despite indications that an aortic dissection was present.

Anchoring heuristic (premature closure)

Relying on initial diagnostic impression, despite subsequent information to the contrary

Repeated positive blood cultures with Corynebacterium were dismissed as contaminants; the patient was eventually diagnosed with Corynebacterium endocarditis.

Framing effects

Diagnostic decision-making unduly biased A heroin-addicted patient with abdominal by subtle cues and collateral information pain was treated for opiate withdrawal, but proved to have a bowel perforation.

Blind obedience

Placing undue reliance on test results or "expert" opinion

A false-negative rapid test for Streptococcus pharyngitis resulted in a delay in diagnosis.

1. Explicitly describe heuristics and how they affect clinical reasoning. 2. Promote the use of diagnostic timeouts. 3. Promote the practice of worst case scenario medicine. 4. Promote the use of a systematic approach to common problems. 5. Ask why. 6. Teach and emphasize the value of the clinical exam. 7. Teach Bayesian theory as a way to direct the clinical evaluation and avoid premature closure. 8. Acknowledge how the patient makes the clinician feel. 9. Encourage learners to nd clinical data that doesnt t with a provisional diagnosis; Ask What cant we explain? 10. Embrace Zebras. 11. Encourage learners to slow down. 12. Admit ones own mistakes.

1. Thou shalt reect on how you think and decide. 2. Thou shalt not rely on your memory when making critical decisions. 3. Thou shalt make your working environment information-friendly by using the latest wireless technology such as the Tablet PC and PDA. 4. Thou shalt consider other possibilities even though you are sure of your rst diagnosis. 5. Thou shalt know Bayesian probability and the epidemiology of the diseases in your differential diagnosis. 6. Thou shalt mentally rehearse common and serious conditions that you expect to see in your specialty. 7. Thou shalt ask yourself if you are the right person to make the nal decision or a specialist after considering the patients values and wishes. 8. Thou shalt take time to decide and not be pressured by anyone. 9. Thou shalt create accountability procedures and follow up for decisions made. 10. Thou shalt record in a relational data base software your patients problems and decisions for review and improvement.

 fall varies among healthcare organizations. Some definitions include lowering the patient to the floor, while others state that a fall is strictly an uncontrolled event. Regardless of the definition, falls are a common adverse event with potentially devastating consequences. The Joint Commission Patient Safety Goals stress the importance of assessing and re-assessing each patients fall risk and recommend the implementation of a fall reduction program

Dim lighting, or lighting that glares into eyes when walking Inappropriate or poorly maintained seating Lack of full-length side rails on beds Uneven flooring Bed height too to easily get in or out Loose carpets or rugs Assistive devices not suited to the person's condition Wet and/or slippery floors Inappropriate footwear Lack of handrails in rooms and hallways Malfunctioning emergency call systems Lack of grab bars in bathrooms Poorly fitting or prescribed eye wear Poorly positioned storage areas

Indoor Lighting-Make sure stairways and hallways have bright light. Clutter-When objects are out of their normal place, they can be overlooked and tripped over. Extension cords-Find a way to arrange your furniture so that the extension cords are out of the way.

Scatter rugs-Be sure all throw rugs or scatter rugs have a non skid backing. Use handrails on all steps no matter how easy the steps are to climb or how many times youve been up and down them before. Get up from a laying down position slowly if you have heart problems or high blood pressure. Educate patients on their medication can cause side effects such as dizziness or drowsiness

 reflects the clients perspective, identifies the caregiver and promotes continuity of care by allowing other partners in care to access the information; communicates to all health care providers the plan of care, the assessment, the interventions necessary based on the clients history and the effectiveness of those interventions;

 Poor record-keeping; Poor planning of care; Incomplete admission records; Inconsistent/lack of documented care planning; Failing systems of communication; Compromised fluid management; Lack of reported care evaluation; Lack of patient involvement in documentation of care; Lack of training documented care planning for student nurses; Poor time management.

Do:
Check that you have the correct chart before you write. Chart a patient's refusal to allow treatment. Be sure to report this to the patient's physician. Write "late entry" and the date and time if you forgot to document something. Write often enough to tell the whole story. Chart preventive measures. Chart contemporaneously (contemporaneous notes are credible). Write legibly, offering concise, clear notes reflecting facts. Chart what you report to other healthcare providers. Chart solutions as well as problems.

Document your observations. Write only what you see, hear, feel, or smell. Encourage others to document relevant information that they share with you. Document circumstances and handling of errors. Chart your efforts to answer your patients' questions. Chart patient/family teaching and response.

Don't:
Chart a verbal order unless you have received one. Chart a symptom (for instance: c/o excessive thirst), without also charting what you did about it. Wait until the end of the day and rely on memory. Ever alter a record. If you make an error, do mark through it with one line, indicate you are making a correction, and initial (or sign) and date. Document what someone else said they heard, saw, or felt (unless the information is critical -- then quote and attribute). Write trivia: "a good day." (What does that mean?) Be imprecise. Avoid terms like "large amounts" and "appears." Write your opinions. Blanket chart or pre-chart. It is considered fraud to chart that you've done something you didn't do.

Negligence vs Malpractice
Negligence as a failure to use such care as a reasonably prudent and careful person would use under similar circumstances. Malpractice is defined as improper or unethical conduct or unreasonable lack of skill by a holder of a professional or official position; often applied to physicians, dentists, lawyers, and public officers to denote negligent or unskillful performance of duties when professional skills are obligatory. Malpractice is a cause of action for which damages are allowed.

Six major categories of negligence that result in malpractice lawsuits:

1. Failure to follow standards of care. 2. Failure to use equipment in a proper, responsible manner. 3. Failure to communicate, including inadequate transfer of information. 4. Failure to document properly. 5. Failure to accurately assess and monitor. 6. Failure to act as an advocate for the patient.

 is to promote specific improvements in patient safety. Recognizing that sound system design is intrinsic to the delivery of safe, high quality health care, the goals generally focus on systemwide solutions Patient Safety Solutions are defined as: "Any system design or intervention that has demonstrated the ability to prevent or mitigate patient harm stemming from the processes of health care."

1. Look-Alike, Sound-Alike Medication Names 2. Patient Identification 3. Communication During Patient Hand Overs 4. Performance of Correct Procedure at Correct Body Site 5. Control of Concentrated Electrolyte Solutions 6. Assuring Medication Accuracy at Transitions in Care 7. Avoiding Catheter and Tubing Mis-Connections 8. Single Use of Injection Devices 9. Improved Hand Hygiene to Prevent Health CareAssociated Infection

The Official "Do Not Use" List of Abbreviations

The symbols ">" and "<" - All abbreviations for drug names - Apothecary units - The symbol "@" - The abbreviation "cc" - The abbreviation "?g"

30 Safe Practices for Improving Patient Safety

Creating a Culture of Safety 1. Create a health care culture of safety. Matching Health Care Needs with Service Delivery Capability 2. Patients should be clearly informed of the likely reduced risk of an adverse outcome at treatment facilities that have demonstrated superior outcomes and should be referred to such facilities in accordance with the patient's stated preference.

 3. Specify an explicit protocol to be used to ensure an adequate level of nursing based on the institution's usual patient mix and the experience and training of its nursing staff. 4. All patients in general intensive care units (both adult and pediatric) should be managed by physicians having specific training and certification in critical care medicine ("critical care certified"). 5. Pharmacists should actively participate in the medication-use process, including, at a minimum, being available for consultation with prescribers on medication ordering, interpretation and review of medication orders, preparation of medications, dispensing of medications, and administration and monitoring of medications.

 Facilitating Information Transfer and Clear Communication 6. Verbal orders should be recorded whenever possible and immediately read back to the prescriber; that is, a health care provider receiving a verbal order should read or repeat back the information that the prescriber conveys in order to verify the accuracy of what was heard. 7. Use only standardized abbreviations and dose designations. 8. Patient care summaries or other similar records should not be prepared from memory.

 9. Ensure that care information, especially changes in orders and new diagnostic information, is transmitted in a timely and clearly understandable form to all of the patient's current health care providers who need that information to provide care. 10. Ask each patient or legal surrogate to recount what he or she has been told during the informed consent discussion. 11. Ensure that written documentation of the patient's preference for life-sustaining treatments is prominently displayed in his or her chart.

 12. Implement a computerized prescriberorder entry system. 13. Implement a standardized protocol to prevent the mislabeling of radiographs. 14. Implement standardized protocols to prevent the occurrence of wrong-site or wrong-patient procedures.

 In Specific Settings or Processes of Care 15. Evaluate each patient undergoing elective surgery for risk of an acute ischemic cardiac event during surgery, and provide prophylactic treatment for high-risk patients with beta blockers. 16. Evaluate each patient upon admission, and regularly thereafter, for the risk of developing pressure ulcers. This evaluation should be repeated at regular intervals during care. Clinically appropriate preventive methods should be implemented consequent to the evaluation.

17. Evaluate each patient upon admission, and regularly thereafter, for the risk of developing deep vein thrombosis/venous thromboembolism. 18. Utilize dedicated anti-thrombotic (anticoagulation) services that facilitate coordinated care management. 19. Upon admission, and regularly thereafter, evaluate each patient for the risk of aspiration. 20. Adhere to effective methods of preventing central venous catheter-associated bloodstream infections.

21. Evaluate each pre-operative patient in light of his or her planned surgical procedure for the risk of surgical site infection, and implement appropriate antibiotic prophylaxis and other preventive measures based on that evaluation. 22. Utilize validated protocols to evaluate patients who are at risk for contrast media-induced renal failure, and utilize a clinically appropriate method for reducing risk of renal injury based on the patient's kidney function evaluation. 23. Evaluate each patient upon admission, and regularly thereafter, for risk of malnutrition. Employ clinically appropriate strategies to prevent malnutrition. 24. Whenever a pneumatic tourniquet is used, evaluate the patient for the risk of an ischemic and/or thrombotic complication, and utilize appropriate prophylactic measures.

 25. Decontaminate hands with either a hygienic hand rub or by washing with a disinfectant soap prior to, and after, direct contact with the patient or objects immediately around the patient. 26. Vaccinate health care workers against influenza to protect both them and patients.

 Increasing Safe Medication Use 27. Keep workspaces where medications are prepared clean, orderly, well lit, and free of clutter, distraction, and noise. 28. Standardize the methods for labelling, packaging, and storing medications 29. Identify all "high alert" drugs (for example, intravenous adrenergic agonists and antagonists, chemotherapy agents, anticoagulants and antithrombotics, concentrated parenteral electrolytes, general anesthetics, neuromuscular blockers, insulin and oral hypoglycemics, narcotics, and opiates). 30. Dispense medications in unit-dose or, when appropriate, unit-of-use form, whenever possible.

1. Look-Alike, Sound-Alike Medication Names Confusing drug names is one of the most common causes of medication errors and is a worldwide concern. With tens of thousands of drugs currently on the market, the potential for error created by confusing brand or generic drug names and packaging is significant. 2. Patient Identification The widespread and continuing failures to correctly identify patients often leads to medication, transfusion and testing errors; wrong person procedures; and the discharge of infants to the wrong families. 3. Communication During Patient Hand Overs Gaps in hand-over (or hand-off) communication between patient care units, and between and among care teams, can cause serious breakdowns in the continuity of care, inappropriate treatment, and potential harm for the patient.

4. Performance of Correct Procedure at Correct Body Site Considered totally preventable, cases of wrong procedure or wrong site surgery are largely the result of miscommunication and unavailable, or incorrect, information. A major contributing factor to these types of errors is the lack of a standardized preoperative process. 5. Control of Concentrated Electrolyte Solutions While all drugs, biologics, vaccines and contrast media have a defined risk profile, concentrated electrolyte solutions that are used for injection are especially dangerous. 6. Assuring Medication Accuracy at Transitions in Care Medication errors occur most commonly at transitions. Medication reconciliation is a process designed to prevent medication errors at patient transition points.

7. Avoiding Catheter and Tubing Mis-Connections The design of tubing, catheters, and syringes currently in use is such that it is possible to inadvertently cause patient harm through connecting the wrong syringes and tubing and then delivering medication or fluids through an unintended wrong route. 8. Single Use of Injection Devices One of the biggest global concerns is the spread of Human Immunodeficiency Virus (HIV), the Hepatitis B Virus (HBV), and the Hepatitis C Virus (HCV) because of the reuse of injection needles. 9. Improved Hand Hygiene to Prevent Health Care-Associated Infection It is estimated that at any point in time more than 1.4 million people worldwide are suffering from infections acquired in hospitals. Effective hand hygiene is the primary preventive measure for avoiding this problem.

 create a national center for patient safety, this center would be responsible for setting national safety goals, and to serve as a clearinghouse for the latest reliable information regarding patient safety. All evaluations performed by those regulating or accrediting healthcare organizations should emphasize patient safety. leaders of healthcare organizations must be deeply involved in patient safety initiatives. This includes creating and adequately funding processes to monitor patient safety. The FDA must initiate aggressive oversight to address safety issues pertaining to drug packaging and labeling, look-alike, sound-alike drugs, and surveillance conducted by physicians and pharmacists concerning marketing of drugs. Both mandatory and voluntary reporting systems should be established pertaining to medical errors. Data should be used to help healthcare professionals learn from mistakes and improve safety. There should be a national system established to track patient safety. Standards for demonstrating competency in patient safety must be raised and documented for healthcare professionals.

Safety of medication administration:

Insulin
a double-check must be in place so that one nurse prepares the injection and another nurse checks it for accuracy avoid storing heparin and insulin in close proximity do not use U instead of units; spell out the word units establish an independent check system for infusion pump rates and concentration settings

Opiates and Narcotics

strictly limit opiates and narcotics kept on the unit as stock make sure that staff receives education about the differences between hydromorphone and morphine, and how to avoid mistaking one for the other

establish PCA protocols, including double-checks of the medication, pump setting, and dose

 Injectable Potassium Chloride or Phosphate Concentrate

remove these drugs from unit stock do not prepare solutions on the units; use commercially premixed IV solutions drug concentrations should be standardized and limited

Intravenous Anticoagulants (Heparin)

concentrations must be standardized; premixed solutions should be used only single-dose containers should be used do not store heparin and insulin in close proximity to each other

Sodium Chloride Solutions above 0.9%

there should be limited access to sodium chloride solutions above 0.9%; such solutions should not be stored on the units drug concentrations should be standardized and limited pump rates, drug, concentration, and line attachments must be doublechecked

 Q.D., Q.O.D. for once daily and every other day. Write out the words daily and every other day. Avoid trailing zeros. A zero must never be written by itself after a decimal point (e.g., 5.0). Always use a zero before a decimal point (e.g., 0.25). MS, MSO4, and MgSO4 are frequently mistaken for one another. Write out morphine sulfate and magnesium sulfate.

 H.S. for half-strength or at bedtime. Write halfstrength or at bedtime. T.I.W. for three times a week. Write out three times weekly. S.C., or S.Q. for subcutaneously. Write out Sub-Q, subQ, or subcutaneously. D/C for discharge. May be mistaken for discontinue. Write out discharge. cc for cubic centimeter. Write ml for milliliters. A.S., A.D., and A.U. for left, right, or both ears. Write left ear, right ear, and both ears.

 A standardized approach to hand-off communications must be implemented that includes an opportunity to ask and respond to questions. All medications, medication containers, or other solutions on and off the sterile field in perioperative and other procedural settings must be labeled. All concentrated electrolytes must be removed from patient units. All general-use and patient-controlled analgesia intravenous infusion pumps must have free-flow protection.

 Establish a fall prevention program. Establish a task force or committee that reviews, revises, and develops the fall prevention program. Formulate a standardized definition of a fall. Fall prevention protocol should include procedures for consistently evaluating a patients fall risk. Provide ongoing continuing education pertaining to fall prevention

Correcting Handwritten Documents

Never obliterate the mistaken entry. Do not use correction fluid, black marker, erasures, tape, or any technique that hides a documentation error. The correction must be made in a way that preserves the original entry. Draw a single line through the entry accompanied by the time, date, and name of the person making the correction. Explain why the correction is being made. For example mistaken entry or mistaken date. Never try to squeeze information between lines or in margins.

Never alter words or numbers. For instance, do not try to change a 10 into a 17. Correct mistakes in documentation immediately.