Med Errors Flashcards
The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.
Two kinds?
Medical error
Error in execution
Error in planning
Medical errors result in injury to how many hospitalized patients per year?
44,000-98,000 per year
1 in every 25
What are the three leading causes of death in America?
Heart disease
cancer
medical errors
Healthcare system decentralized and fragmented. Results in lost info on lab and diagnostic test, or medical information. Hand-off communication
Inadequate information flow
Human problems in medical errors
Fatigue, illness, drug use. Long shifts, interruptions.
Patient-related issues: inadequate ID
Deficiencies in orientation and training
Organizational transfer of knowledge
Inadequate staffing, lack of supervision
Staffing patterns
Equipment failures in medical errors?
Implants, poorly designed equipment, inadequate instruction
Inadequate policies and procedures
Poorly documented, non-existent, or clinical inadequate procedures
Factors include poor design system and inadequate organizational strategies
System-based errors
Medication, surgical, healthcare-associated, diagnostic
Failure to administer ordered medication
Omission errors
Any dose, strength, or quantity that is inappropriate for patient or different than prescribed
Improper dose/quantity erros
Medication dispensed and/or administered that was not authorized by the prescriber
Unauthorized drug errors
Medication medical errors?
Brand names look or sound alike, labels are hard to read, look-alike packaging, lack of standards in contents display, inconsistent warnings
What are some prescribing errors?
Decline in renal or hepatic function History of allergy Wrong drug, dosage form/abbreviation Incorrect dosage calculation Illegible handwriting or incomplete orders Use of error-prone terms
What are vulnerable patients when it comes to medical errors?
Elderly: polypharmacy, falls, slow metabolism
Children: dose calculations, communication
ICU patients: medication erros, complexity of care
Language barriers
An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.
Sentinel event. Requires immediate investigation and response.
A process for identifying the basic or casual factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event
Root cause analysis. Who was involved, when it happened, what happened, why is happened, and what to do to prevent it from happening again
What are basic types of root causes?
Physical causes: material items failed in some way
Human causes: someone did something incorrectly
Organizational causes: a system, policy, or process is faulty
Analyze the data from the review of sentinel event, root cause analysis, and risk reduction measures
The Joint Commission
Non-profit with mission to educate healthcare community and consumers about safe med practices
Institute for Safe Medication Practices
Directs the medication error reporting system
What can be done to prevent medical errors?
Clarify order, question medication, document immediately, learn your meds, report all errors/near misses, med reconciliation, pharmacist participation, med standardization, marking incision site, time-out before procedure
How to take verbal orders?
Verify the full name of patient and person giving the order. Obtain verbal/telephone order and write it on the physician’s order from, read back the entire order to verify, ensure legibility, flag and highlight verbal order
How to prevent catheter-assocaited urinary tract infections (CAUTI)?
Limit use and duration, use aseptic technique, secure for unobstructed urine flow, maintain sterility of urine collection system, replace collection system when required, collecting urine samples
Evidence-based, scientifically-researched standard of care which has been shown to result in improved clinical outcomes
Core measure
Why are core measures important?
Core measure care is the right care every time. Reduces morbidity, reduces mortality, reduces complications and readmissions.
It is the best evidenced-based care for your patients.
What does HCAHPS stand for?
Hospital consumer assessment of healthcare providers and systems
A nationally standardized patient satisfaction survey from the Center for Medicare and Medicaid Services (CMS)
HCAHPS
Measures and publicly reports patient’s experiences in our country’s hospitals
What number and types of questions does HCAHPS include?
27 survey items
Communication with doctors and nurses, responsiveness of the hospital staff, pain control, communication about meds, physical environment, discharge information
What are common sentinel events?
Retention of foreign body, wrong patient/site/procedure, delay in treatment, OP/Post-OP complications, suicide, falls, criminal events, med errors, perinatal death/injury, other unanticipated events
