Medical Errors and Prevention

Question 1

Types of Medical Errors

Answer 1

• Sentinel Event
• Potential Adverse Event
• Active Error
• Latent Error

Question 2

Sentinel Event (Types of Medical Errors)

Answer 2

Injury as a result of medical management process

e.g. ineffective hand washing that led to spreading MRSA

Question 3

Potential Adverse Event (Types of Medical Errors)

Answer 3

• Event that could have been avoided

e. g. incorrect medication prescription and the pharmacist calls the MD to confirm that the medication was correct

Question 4

Active Error (Types of Medical Errors)

Answer 4

• Caused by an individual

e. g. patient fall risk communicated all involved in the patient’s care

Question 5

Latent Error (Types of Medical Errors)

Answer 5

• Flaw of design or organization of healthcare delivery
  e. g. a lift was installed in the hospital incorrectly so there are risks associated with its use due to the way it was installed

Question 6

Preventing Medical Errors

Answer 6

• Root cause analysis (RCA) for sentinel events (Joint Commission standards)
• Properly functioning and maintained equipment
• Obstacle free, with no congestion in the physical environment
• Adequate availability of personnel
• Maintenance of Material Safety Data Sheets (MSDS) manual
• Awareness of physiologic changes associated with aging- (table 1.6 page 21)
• Vision, hearing, diminished reflexes

Question 7

Adequate Availability of Personnel (Preventing Medical Errors)

Answer 7

Waiting for a second person for a 2-person transfer rather than trying on your own)

Question 8

Maintenance of Material Safety Data Sheets (MSDS) Manual (Preventing Medical Errors)

Answer 8

Discusses all chemicals at the organization and consequences if they are spilled

Question 9

Safety Recommendations

Answer 9

• Perform hand hygiene before and after treatments
• Maintain sufficient space
• Perform transfers in unobstructed areas
• Implement maintenance program for equipment and materials
• Secure equipment, furniture, and assistive aids and store them when not in use
• Keep floors clear
• Attention to patient / client at all times
• Properly protect the patient / client
• Use trained, qualified, and competent personnel
• Avoid storing potentially hazardous materials or equipment