ATrain Education

Continuing Education for Health Professionals

Florida: Medical Errors

Types of Medical Errors

There are many ways that medical care can go wrong. Errors can be related to the administration of medications, adverse drug reactions, laboratory testing, surgery, and improper use or failure of medical devices. The seven main categories of medical errors discussed here are:

  1. Adverse drug reactions
  2. Medication errors
  3. Laboratory errors
  4. Surgical errors
  5. Patient-controlled analgesia
  6. Falls
  7. Healthcare-associated infections

Adverse Drug Reactions

Adverse drug reactions (ADRs) are a leading cause of injury and death—it is estimated that they cause 7,000 deaths annually in the United States. According to the Institute of Medicine, more than 2 million serious ADRs occur each year, 350,000 in nursing homes alone. In recent years the number of medications prescribed to patients has increased dramatically and, not surprisingly, adverse drug reactions have also increased. “Whereas a patient admitted to the hospital typically undergoes one—or even no—surgical procedure, virtually everyone gets bombarded with an array of medications the whole time they’re there” (FDA, 2009; Wachter & Shojania, 2004).

There are three main causes for adverse reactions:

  • As many as two-thirds of all patient visits to a doctor result in a prescription, and there are more drugs and combinations of drugs being used than ever before.
  • There were 2.8 billion outpatient prescriptions filled in 2000, equaling about 10 prescriptions for every person in the United States.
  • The rate of ADRs increases exponentially when a patient is taking four or more medications. (FDA, 2009)

The drug approval process may also play a role in the increase of adverse drug reactions. A drug that is tested in only a few thousand people may have an excellent safety profile in those patients, but some of these drugs require many more exposures to detect an adverse reaction—particularly reactions that occur with low frequencies.

According to the FDA learning module “Preventable Adverse Drug Reactions: A Focus on Drug Interactions,” most drugs are approved for use by the Food and Drug Administration (FDA) with an average of only 1,500 patient exposures and tested for relatively short period of time. Soon after entering the market, the drug may be taken by a few million patients and the low-frequency adverse reactions can become a problem. For drugs that cause rare toxicity, the toxicity will only be detected after use by many more thousands of patients (FDA, 2009).

Systems Intervention

Many adverse drug reactions can be detected and prevented through systems intervention. Tools such as computerized physician orders and prescription entry and bar coding systems have taken the guess work out of reading written prescriptions for nurses and pharmacists. Medication errors can potentially be reduced through the use of computerized medical records as well as drug-interaction screening software that detects and alerts the physician and pharmacist to potentially serious drug interactions.

Clinicians cannot rely solely on technology to prevent errors in prescribing and administering of medications. Incorporation of up-to-date computerized databases is invaluable, as is frequent consultation with other members of the healthcare team. Use of an organized, stepwise approach also helps prevent drug interactions. Use the AVOID mistakes mnemonic to get all necessary information for the medication history (see table).

 

AVOID Mnemonic

Keyword

What to ask

Allergies

Ask the patient if there is any drug that should not be prescribed for any reason.

Vitamins or herbs

Ask the patient whether the patient is taking or has a reaction to any herb, vitamin, or “alternative” or “natural” product.

Old drugs and over the counter (OTC) drugs…in addition to all current drugs

Ask about old drugs (prescription and over the counter) and OTC drugs as well as current drugs the patient is taking. Some of these drugs may have relatively long-lasting effects (either toxicity or potential for drug interactions).

Interactions

Evaluate the potential for adverse drug interactions. Consider a behavioral contract between the physician and the patient in an effort to help the patient reach the therapeutic goal, either in the case of drug dependence or adherence to a therapeutic regimen, with a clear plan.

Dependence potential

Is the patient drug dependent or at risk of dependence on, for example, opioids, benzodiazepines, alcohol, or other substances of abuse. Consider a behavioral contract between the physician and the patient in an effort to help the patient reach the therapeutic goal, both in the case of drug dependence and adherence to a therapeutic regimen.

Mendel (genetics)

Genetics—Is there a family history of benefits from or problems with any drugs?

Anyone taking two or more medications is at risk for drug interactions. Categories of drugs that are considered very high risk for interactions include anticonvulsants, antibiotics, and certain cardiac drugs such as digoxin, warfarin, and amiodarone. When a patient is taking multiple drugs use a systematic approach—such as the Stepwise Approach—to check for possible interactions.

Drug-Drug Interactions: A Stepwise Approach

  1. Take medication history. Avoid mistakes.
  2. Remember high-risk patients.
    • Any patients taking two or more medications
    • Patients taking anticonvulsants, antibiotics, digoxin, warfarin, amiodarone, etc.
  3. Check current pocket reference.
  4. Consult pharmacists/drug information specialists.
  5. Check up-to-date computer program (such as Medical Letter Drug Interaction Program, clinical pharmacology [gsm.com], or www.epocrates.com—programs not endorsed by the FDA) (FDA, 2009).

Reporting an Adverse Event

Because post-marketing surveillance of new drugs is so important, MedWatch, the FDA Medical Products Reporting Program, was established in 1993. The program has four general goals:

  1. Increase awareness of drug, device, and other medical product-induced disease and the importance of reporting.
  2. Clarify what should not be reported—limit reporting to serious adverse reactions.
  3. Make it easy to report an adverse drug reaction to the FDA.
  4. Provide feedback to health professionals about new safety problems with pharmaceuticals and medical devices.

A postage-paid form is available in the back of the Physicians Desk Reference, from the FDA via the toll-free number 1-800-FDA-1088, or from the FDA/MedWatch website: http://www.fda.gov/Safety/MedWatch/default.htm (FDA, 2009).

Medication Errors

When all types of errors are taken into account, a hospital patient can expect on average to be subjected to more than one medication error each day.

Institute of Medicine, 2006
(reported in NRC, 2007)

According to Preventing Medication Errors—the final report of a joint project involving the Institute of Medicine and others—there are 1.5 million preventable adverse medication events in the United States each year costing as much as $3.5 billion annually. The report notes that of the five steps involved in medication administration—procuring the drug, prescribing it, dispensing it, administering it, and monitoring its impact—errors occur most often during the prescribing and administration phases (NRC, 2007).

Adverse drug events (ADEs) cause an estimated 700,000 emergency department visits each year and the CDC notes that the numbers of ADEs will likely grow due to: development of new medications, discovery of new uses for older medications, aging American population, increase in the use of medications for disease prevention, increased coverage for prescription medications (CDC, 2012).

In 2011 the National Coordinating Council for Medication Error Reporting and Prevention urged medication error researchers, software developers, and institutions to use this standard definition to identify errors:

A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. 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, 2014).

Some of the most common causes of medication errors are:

  • Incomplete patient information, with the healthcare professional not knowing about allergies and other medications the patient is using
  • Miscommunication between physicians, pharmacists, and other healthcare professionals. For example, drug orders can be communicated incorrectly because of poor handwriting.
  • Name confusion from drug names that look or sound alike
  • Confusing drug labeling
  • Identical or similar packaging for different doses
  • Drug abbreviations that can be misinterpreted (FDA, 2012)

Currently, medication errors are reported to the FDA as manufacturer reports (adverse events resulting in serious injury and for which a medication error may be a component), direct contact reports (MedWatch) (FDA, 2014) or reports from the United States Pharmacopeia (USP) or the Institute for Safe Medicine Practices (ISMP).

Naming, Labeling, Packaging, and Abbreviations

The FDA has a seven-part role in reducing and preventing medication errors:

  • Drug Name Review. To minimize confusion between drug names that look or sound alike, the FDA reviews about 400 brand names a year before they are marketed, and about one-third are rejected.
  • Drug Labels. Over the Counter (OTC) medications require “standardized drug facts labels” and improved inserts in prescription medications for healthcare professionals
  • Drug Labeling and Packaging. Works with drug companies to reduce problems stemming from labels and packages that are similar to one another or poor product design
  • Bar Code Label Rule. Since 2004 certain drugs and biologics must have bar codes as part of their labels. When used with scanners and computerized patient information systems these help ensure the 4 Rights.
  • Error Analyses. Reviews about 1,400 reports of med errors every month
  • Guidances for Industry. Three new guidances are in preparation regarding trade name development, pitfalls of drug labeling, and best test practices for drug naming.
  • Public Education. Through various methods helps educate the public about preventing medical errors (FDA, 2009a)

The FDA and ISMP have launched a national education campaign to eliminate the use of ambiguous medical abbreviations that are frequently misinterpreted and lead to mistakes that result in patient harm. The campaign seeks to promote safe practices among those who communicate medical information (FDA, 2013).

The FDA recommends that clinicians review the Institute for Safe Medical Practices’ List of Error-Prone Abbreviations, Symbols and Dose Designation as shown in the following tables. The tables are also available via the ISMP website: http://www.ismp.org.

 

**These abbreviations are included on The Joint Commission’s “minimum list” of dangerous abbreviations, acronyms, and symbols that must be included on an organization’s “Do Not Use” list, effective January 1, 2004. Visit www.jointcommission.org for more information about this Joint Commission requirement.
Source: Institute for Safe Medical Practices (ISMP), 2013.

Dangerous Abbreviations

Abbreviations

Intended Meaning

Misinterpretation

Correction

µg

Microgram

Mistaken as “mg”

Use “mcg”

AD, AS, AU

Right ear, left ear, each ear

Mistaken as OD, OS, OU (right eye, left eye, each eye)

Use “right ear,” “left ear,” or “each ear”

OD, OS, OU

Right eye, left eye, each eye

Mistaken as AD, AS, AU (right ear, left ear, each ear)

Use “right eye,” “left eye,” or “each eye”

BT

Bedtime

Mistaken as “BID” (twice daily)

Use “bedtime”

cc

Cubic centimeters

Mistaken as “u” (units)

Use “mL”

D/C

Discharge or discontinue

Premature discontinuation of medications if D/C (intended to mean “discharge”) has been misinterpreted as “discontinued” when followed by a list of discharge medications

Use “discharge” and “discontinue”

IJ

Injection

Mistaken as “IV” or “intrajugular”

Use “injection”

IN

Intranasal

Mistaken as “IM” or “IV”

Use “intranasal” or “NAS”

HS

 

hs

Half-strength

 

At bedtime, hours of sleep

Mistaken as bedtime

 

Mistaken as half-strength

Use “half-strength” or “bedtime”

IU**

International unit

Mistaken as IV (intravenous) or 10 (ten)

Use “units”

o.d. or OD

Once daily

Mistaken as “right eye” (OD-oculus dexter), leading to oral liquid medications administered in the eye

Use “daily”

OJ

Orange juice

Mistaken as OD or OS (right or left eye); drugs meant to be diluted in orange juice may be given in the eye

Use “orange juice”

Per os

By mouth, orally

The “os” can be mistaken as “left eye” (OS-oculus sinister)

Use “PO,” “by mouth,” or “orally”

q.d. or QD**

Every day

Mistaken as q.i.d., especially if the period after the “q” or the tail of the “q” is misunderstood as an “i”

Use “daily”

qhs

Nightly at bedtime

Mistaken as “qhr” or every hour

Use “nightly”

qn

Nightly or at bedtime

Mistaken as “qh” (every hour)

Use “nightly” or “at bedtime”

q.o.d. or QOD**

Every other day

Mistaken as “q.d.” (daily) or “q.i.d.” (four times daily) if the “o” is poorly written

Use “every other day”

q1d

Daily

Mistaken as q.i.d. (four times daily)

Use “daily”

q6PM, etc.

Every evening at 6 PM

Mistaken as every 6 hours

Use “daily at 6 PM” or “6 PM daily”

SC, SQ,
sub q

Subcutaneous

SC mistaken as SL (sublingual); SQ mistaken as “5 every;” the “q” in “sub q” has been mistaken as “every” (e.g., a heparin dose ordered “sub q 2 hours before surgery” misunderstood as every 2 hours before surgery)

Use “subcut” or “subcutaneously”

ss

Sliding scale (insulin) or ½ (apothecary)

Mistaken as “55”

Spell out “sliding scale;” use “one-half” or ½

SSRI

Sliding scale regular insulin

Mistaken as selective-serotonin reuptake inhibitor

Spell out “sliding scale (insulin)”

SSI

Sliding scale insulin

Mistaken as Strong Solution of Iodine (Lugol’s)

Spell out “sliding scale (insulin)”

i/d

One daily

Mistaken as “tid”

Use “1 daily”

TIW or tiw

TIW: 3 times a week

TIW mistaken as “3 times a day” or “twice in a week”

Use “3 times weekly”

U or u**

Unit

Mistaken as the number 0 or 4, causing a 10-fold overdose or greater (e.g., 4U seen as “40” or 4u seen as “44”); mistaken as “cc” so dose given in volume instead of units (e.g., 4u seen as 4cc)

Use “unit”

UD

As directed (“ut dictum”)

Mistaken as unit dose (e.g., diltiazem 125 mg IV infusion “UD” misinterpreted as meaning to give the entire infusion as a unit [bolus] dose)

Use “as directed”

 

**These abbreviations are included on The Joint Commission’s “minimum list” of dangerous abbreviations, acronyms, and symbols that must be included on an organization’s “Do Not Use” list, effective January 1, 2004. Visit www.jointcommission.org for more information about this Joint Commission requirement.
Source: Institute for Safe Medical Practices (ISMP), 2013.

Error-Prone Dose Designations

Dose Designations and Other Information

Intended Meaning

Misinterpretation

Correction

Trailing zero after decimal point (e.g., 1.0 mg)**

1 mg

Mistaken as 10 mg if the decimal point is not seen

Do not use trailing zeros for doses expressed in whole numbers

“Naked” decimal point (e.g., .5 mg)**

0.5 mg

Mistaken as 5 mg if the decimal point is not seen

Use zero before a decimal point when the dose is less than a whole unit

Abbreviations such as mg. or mL. with a period following the abbreviation

mg

 

mL

The period is unnecessary and could be mistaken as the number 1 if written poorly

Use mg, mL, etc. 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)

Inderal 40 mg

Mistaken as Inderal 140 mg

Place adequate space between the drug name, dose, and unit of measure

Tegretol 300 mg

Mistaken as Tegretol 1300 mg

Numerical dose and unit of measure run together (e.g., 10mg, 100mL)

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)

100,000 units

100000 has been mistaken as 10,000 or 1,000,000

Use commas for dosing units at or above 1,000, or use words such as 100 “thousand” or 1 “million” to improve readability

1,000,000 units

1000000 has been mistaken as 100,000

 

**These abbreviations are included on The Joint Commission’s “minimum list” of dangerous abbreviations, acronyms, and symbols that must be included on an organization’s “Do Not Use” list, effective January 1, 2004. Visit www.jointcommission.org for more information about this Joint Commission requirement.
Source: Institute for Safe Medical Practices (ISMP), 2013.

Error-Prone Drug Name Abbreviations

Drug Name Abbreviations

Intended Meaning

Misinterpretation

Correction

APAP

acetaminophen

Not recognized as acetaminophen

Use complete drug name

ARA A

vidarabine

Mistaken as cytarabine (ARA C)

Use complete drug name

AZT

zidovudine (Retrovir)

Mistaken as azathioprine or aztreonam

Use complete drug name

CPZ

Compazine (prochlorperazine)

Mistaken as chlorpromazine

Use complete drug name

DPT

Demerol-Phenergan-Thorazine

Mistaken as diphtheria-pertussis-tetanus (vaccine)

Use complete drug name

DTO

Diluted tincture of opium, or deodorized tincture of opium (Paregoric)

Mistaken as tincture of opium

Use complete drug name

HCl

hydrochloric acid or hydrochloride

Mistaken as potassium chloride (The “H” is misinterpreted as “K”)

Use complete drug name unless expressed as a salt of a drug

HCT

hydrocortisone

Mistaken as hydrochlorothiazide

Use complete drug name

HCTZ

hydrochlorothiazide

Mistaken as hydrocortisone (seen as HCT250 mg)

Use complete drug name

MgSO4**

magnesium sulfate

Mistaken as morphine sulfate

Use complete drug name

MS, MSO4**

morphine sulfate

Mistaken as magnesium sulfate

Use complete drug name

MTX

methotrexate

Mistaken as mitoxantrone

Use complete drug name

PCA

procainamide

Mistaken as patient controlled analgesia

Use complete drug name

PTU

propylthiouracil

Mistaken as mercaptopurine

Use complete drug name

T3

Tylenol with codeine No. 3

Mistaken as liothyronine

Use complete drug name

TAC

triamcinolone

Mistaken as tetracaine, Adrenalin, cocaine

Use complete drug name

TNK

TNKase

Mistaken as “TPA”

Use complete drug name

ZnSO4

zinc sulfate

Mistaken as morphine sulfate

Use complete drug name

Stemmed Drug Names

Intended Meaning

Misinterpretation

Correction

“Nitro” drip

nitroglycerin infusion

Mistaken as sodium nitroprusside infusion

Use complete drug name

“Norflox”

norfloxacin

Mistaken as Norflex

Use complete drug name

“IV Vanc”

intravenous vancomycin

Mistaken as Invanz

Use complete drug name

 

**These abbreviations are included on The Joint Commission’s “minimum list” of dangerous abbreviations, acronyms, and symbols that must be included on an organization’s “Do Not Use” list, effective January 1, 2004. Visit www.jointcommission.org for more information about this Joint Commission requirement.
Source: Institute for Safe Medical Practices (ISMP), 2013.

Error-Prone Drug Symbols

Symbols

Intended Meaning

Misinterpretation

Correction

dram symbol

Dram

 

Symbol for dram mistaken as “3”

Use the metric system

minim symbol

Minim

Symbol for minim mistaken as “mL”

Use the metric system

x3d

For three days

Mistaken as “3 doses”

Use “for three days”

> and <

Greater than and less than

Mistaken as opposite of intended; mistakenly use incorrect symbol; “< 10” mistaken as “40”

Use “greater than” or “less than”

/ (slash mark)

Separates two doses or indicates “per”

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

@

At

Mistaken as “2”

Use “at”

&

And

Mistaken as “2”

Use “and”

+

Plus or and

Mistaken as “4”

Use “and”

°

Hour

Mistaken as a zero (e.g., q2° seen as q 20

Use “hr,” “h,” or “hour”

Φ or Ø

zero, null sign

Mistaken as the numerals 4, 6, 8, and 9

Use 0 or zero, or describe intent using whole words

Black Box and High-Alert Medications

In 1995 the Food and Drug Administration established the Black Box Warning System (BBW) to alert healthcare providers to drugs with increased risk for patients. These warnings are meant to be the strongest labeling requirement for drugs and drug products that can have serious adverse reactions or potential safety hazards, especially those that may result in death or injury. The black box warning appears on the label of a prescription to alert the patient and the provider about safety concerns, such as serious side effects or life-threatening risks. Some BBW drugs are Celebrex, warfarin, Avandia, Ritalin, estrogen-containing contraceptives, and most antidepressants. Although a large percentage of patients are prescribed medications with black box warnings, many do not receive the advised laboratory monitoring (Hughes, 2008).

High-alert medications are medications that have a higher likelihood of causing injury if misused. Some of these medications also have a higher volume of use than other medications. Though medication mishaps with these high-alert drugs are no more frequent than other drugs, the consequences can be devastating (USDVA, 2013b). The top five high-alert medications are:

  • Insulin
  • Opiates and narcotics
  • Injectable potassium chloride concentrate
  • Intravenous anticoagulants
  • Sodium chloride solutions above 0.9 percent (Hughes, 2008)

The National Center for Patient Safety (NCPS) promotes three principals to improve high-alert medication administration and distribution:

  • Eliminate the possibility of errors. Reduce the number of drugs on a facility’s formulary and the number of concentrations and volumes; remove high-alert drugs from critical areas.
  • Make errors visible. Have two individuals independently check the product to ensure it is correct, particularly when received in bulk; and have two individuals independently check equipment settings, as applicable, since some drugs are administered intravenously.
  • Minimize the consequence of errors. Minimize the size of vials or ampules in patient care areas to the dose commonly needed; reduce the total dose of drugs in a continuous IV drip bag; and reduce the concentration of the drugs when possible (USDVA, 2013b).

The NCPS also encourages standardized dosing procedures, careful screening of new products, and creating system redundancies—commonly known as “double checks” (USDVA, 2013b).

Laboratory Errors

There are an estimated 7 to 10 billion laboratory tests performed each year in the United States, which influence approximately seventy percent of medical decisions. Any efforts to improve the quality of healthcare must consider laboratory medicine, its workforce, and its systems for ensuring quality and managing information (MMWR, 2005). The CDC currently has several ongoing projects aimed at improving laboratory medicine practice in the face of a recent estimate that 15% to 54% of primary care medical errors reported by primary care physicians and staff are related to the testing process (CDC, 2013a; Smith et al., 2013).

The laboratory testing process consists of the pre-analytic, analytic, and post-analytic phases. Errors occur in all three phases and the distribution among phases varies according to setting and institution, but the highest rates of error overall occur in the pre-analytic phase of testing. The CDC recommends a more comprehensive quality management system (QMS), which has traditionally focused on the analytic phase, with insufficient attention given to the pre- and post-analytic phases (Wolcott et al., 2008).

Poor communication between laboratory and healthcare professionals is the main issue affecting quality in the pre- and post-analytic phases, and it has been noted that few in either group receive specific training in good communication techniques. 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).

Recommendations for improvement of laboratory testing and error reduction include the implementation of systematic approaches such as CQI (continuous quality improvement), Toyota “lean” production, Six Sigma, and FMEA (failure mode and effects analysis), which are being used in small and large labs and have contributed to financial savings, improved test quality, and reduced errors. There is also a need to standardize pre- and post-analytic performance measures, data collection, analysis, and reporting methods (Wolcott et al., 2008).

Computerized, hand-held medical devices allow many tests—once exclusively performed by trained healthcare personnel—to be done outside of the laboratory or clinic by people with limited experience and training. Known as point-of-care testing, the devices used are often not covered by the regulations that govern tests done in a laboratory setting (Wolcott et al., 2008).

Frequently, the personnel performing point-of-care tests are not required to undergo training and there is little quality control, proficiency testing, or routine quality assessment. Although by law these “waived” tests should have a small risk for erroneous results, this is not always the case. Errors can occur anywhere in the testing process, particularly when manufacturer’s instructions are not followed and when personnel lack proper training. Errors in point-of-care testing (eg, glucose, prothrombin time) can have serious consequences because medication dosages are frequently determined by test results (Wolcott et al., 2008).

Surgical Errors

During the mid-1980s, Congress passed a law mandating that the Department of Veterans Affairs (VA) report surgical outcomes annually and compare them to national averages. The VA created the National VA Surgical Risk Study in forty-four Veteran’s Administration medical centers. Using data collected from thousands of major operations, risk models were developed for the first time for 30-day mortality and morbidity following selected major surgeries (Khuri et al., 2002).

This quality improvement program has been adopted by many private-sector hospitals. In 1999 the American College of Surgeons collaborated with the VA to create the National Surgical Quality Improvement Program to identify opportunities and actions for improvement. During the first nine years of data collection by the VA hospitals, there was a 27% reduction in 30-day postoperative mortality and a 45% reduction in 30-day morbidity for noncardiac surgery performed at 128 VA hospitals (Khuri et al., 2002).

To address the problem of preventable surgical errors, the Joint Commission issued two National Patient Safety Goals in 2003 to target wrong-site surgery (Hughes, 2008):

  1. Improve the accuracy of patient identification by using two patient identifiers and a timeout before invasive procedures.
  2. Eliminate wrong-site, wrong-patient, and wrong-procedure surgery using a preoperative verification process to confirm documents and to implement a process to mark the surgical site and involve the patient and family.

Both of these goals are ongoing priorities for the Joint Commission and are mandated for use in all hospitals. The surgical timeout (STO) is done immediately prior to the start of the procedure to conduct a final verification of the correct patient, procedure, site, and implant. The surgical site must be marked and visible after prepping and draping of the patient. Using the STO as a “reflective pause or a preoperative briefing” involves the surgeons, anesthesiologists, nurse anesthetists, quality control specialists, and administrators. The STO has been shown in recent studies to be an effective quality control measure.

The Joint Commission’s 2014 National Patient Safety Goals for all settings and institutions within its purview have the appropriate elements of Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery incorporated within them, and they are downloadable from the Joint Commission’s website at http://www.jointcommission.org/standards_information/npsgs.aspx.

Current Universal Protocol for surgery and invasive procedures in hospitals, ambulatory care facilities, and office-based facilities involves the following three elements (each is accompanied by specific steps to follow):

  • Conduct a preprocedure verification process.
  • Mark the procedure site.
  • A timeout is performed before the procedure.

In 2010 the Joint Commission made adjustments to the Universal Protocol to incorporate feedback it had received from healthcare facilities and other relevant sources. The changes were designed “to address patient safety issues while allowing organizations flexibility in applying the requirements within existing work processes, given the diversity of organizations that need to follow the Universal Protocol” (Joint Commission, 2014a,b).

Patient-Controlled Analgesia

Patient-controlled analgesia (PCA) has become a popular option for pain control since it was first introduced into hospitals in the 1970s for control of postoperative pain. A PCA pump is a computerized machine attached to a patient’s IV line that dispenses a predetermined amount of pain medication when the patient presses a button. In addition to its popularity and ease-of-use with patients and staff, PCA has been shown to have other medical benefits:

  • Steady serum levels of medication
  • Easier coughing and deep breathing
  • Early ambulation
  • Improved pain relief
  • Shortened hospital stays (D’Arcy, 2007)

Despite the benefits associated with the use of PCA, it is not without its problems. Errors related to its use are 4 times more likely to result in patient harm than errors associated with other medications. In a review of 9,500 PCA errors over a 5-year period in the United States, patient harm occurred in 6.5% of incidents, compared with 1.5% for general medication errors (Joint Commission Resources, 2008).

Persistent safety concerns have led the Joint Commission and the Institute for Safe Medication Practices (ISMP) to identify three areas where PCA errors are most likely to occur:

  • Patient selection
  • Pump and human errors
  • PCA by proxy

Patient selection is a critical safety issue with patient-controlled analgesia. Some patients are not suitable for PCA because of their age, level of consciousness, psychological state, or intellectual capacity. When deciding on the use of a PCA pump for pain management, the patient’s medical condition and ability to use the PCA machine must be considered.

Each facility should develop protocols and standardized order sets for PCA devices that address type of medication, dosing, concentration, and frequency. Because opiates are the primary medications used with PCA protocols, respiration, heart rate, and blood pressure must be observed and monitored. The first 24 hours are important, since the effects of opiates on intellectual functioning can be unpredictable. Also monitor and observe the patient at night, since nocturnal hypoxia can be a serious side effect.

To avoid pump and human errors associated with patient-controlled analgesia, an easily programmable pump should be selected and the same model of pump should be used throughout the facility. Providers prescribing PCA should use standard order sets, pre-filled syringes with standard concentrations, and separate hydromorphone and morphine to different areas of the pharmacy. Providers must monitor for symptoms of opioid overdose and withdrawal and be provided with ongoing education and annual proficiency testing (D’Arcy, 2007; see also Hicks, 2008).

Serious adverse events can result when medication is administered by caregivers, family members, or clinicians who are not authorized or trained in the use of PCAs or the drug being dispensed. These adverse events are known as PCA-by-proxy errors. These errors are the result of family members, friends, and even healthcare professionals hoping to assist the patient with pain control. This can result in over sedation, respiratory depression, and sometimes death (FDA, 2002).

To avoid PCA-by-proxy errors, educate patients, staff, and family members about the proper use of PCA. Advise visitors not to push the PCA button, even if the patient asks them to. Ensure that they fully understand the hazards of using analgesics. Consider posting warning signs that state, “Only the patient should press the button” (Marders, 2004).

Falls

Inpatient fall prevention has been an area of concern for almost fifty years. Traditional hospital-based incident reports consider all inpatient falls to be avoidable, and therefore falls are classified as adverse events. Indeed, falls are the most frequently reported adverse events in the adult inpatient setting. But under-reporting of fall events is possible, so injury reporting is likely a more consistent quality measure over time and organizations should consider judging the effects of interventions based on injury rates, not only fall rates (Hughes, 2008).

Injuries are reported to occur in 6% to 44% of acute inpatient falls. Serious injuries from falls, such as head injuries or fractures, occur less frequently (2% to 8%), but result in approximately 90,000 serious injuries across the United States each year. Fall-related deaths in the inpatient environment are a relatively rare occurrence. Although less than 1% of inpatient falls result in death, this translates to approximately 11,000 fatal falls in the hospital environment per year nationwide. Since falls are considered preventable, fatal fall-related injuries should never occur while a patient is under hospital care (Hughes, 2008).

In the long-term care setting, 29% to 55% of residents are reported to fall during their stay. In this group, injury rates are reported to be as high as 20%, twice that of community-dwelling elders. The increase in injury rates is likely because long-term care residents are more vulnerable than those who can function in the community. The current number of long-term care fatal falls has not been estimated; however, there were 16,000 nursing homes in the United States caring for 1.5 million residents in 2004. This population will likely grow in the coming years, thus fall and injury prevention remains of utmost concern (Hughes, 2008).

Healthcare-Associated Infections

Healthcare-associated infections (HAIs) are the most common complication associated with hospital care in the United States. Each year 1.7 million patients develop HAIs, resulting in 99,000 deaths and an estimated $28 to $33 billion in related costs.

Four areas associated with HAIs have been targeted for improvement by the Agency for Healthcare Quality and Research (AHRQ). These four types account for more than 80% of all HAIs:

  • Bloodstream infections (BSIs)
  • Catheter-associated urinary tract infections (CAUTIs)
  • Surgical site infections (SSIs)
  • Ventilator-associated pneumonia (VAP) (AHRQ, 2009)

Methicillin-resistant Staphylococcus aureus (MSRA) is the most common HAI, and there has been a dramatic increase in the number of MRSA-associated hospital stays since 2000, reaching 386,600 in 2005. MRSA is associated with longer hospital stays and a higher likelihood of death. MRSA infections are especially common in intensive care units (ICUs) (AHRQ, 2009).

Another important focus for the AHRQ is on central-line-associated bloodstream infections (CLABSIs), which account for an estimated 250,000 cases each year, and the CDC reports that as many as 25% of those patients die from the infection (AHRQ, 2009).

Hand hygiene is considered the best preventive measure for all HAIs and is universally recommended as a key strategy to prevent HAIs of all types. Current recommendations encourage use of waterless, alcohol-based hand rubs (Ranji et al., 2007).

Surgical Site Infections

[This section is taken largely from cdc.gov, 2012c, 2011, and n.d.]

Surgical site infections (SSIs) are those that occur after surgery in the part of the body where the surgery took place. Surgical site infections can sometimes be superficial involving only the skin. Other SSIs are more serious and can involve tissues under the skin, organs, or implanted material. Most patients who have surgery do not develop an infection; however, infections develop in about 1 to 3 out of every 100 patients who have surgery. Common symptoms of a surgical site infection include:

  • Redness and pain around the area where you had surgery
  • Drainage of cloudy fluid from your surgical wound
  • Fever 

Most surgical site infections can be treated with antibiotics, and the antibiotic given depends on the bacteria causing the infection. Sometimes patients with SSIs also need another surgery to treat the infection.

Healthcare professionals should follow CDC and facility guidelines for cleaning their hands and arms before surgery; properly preparing the patient, including correct hair removal procedures and appropriate use of gowns, gloves, and hair coverings during surgery.

Recommended interventions for prevention of surgical site infections include appropriate use of perioperative antibiotics, avoidance of shaving of the operative site, and perioperative glucose control (Ranji et al., 2007).

Bloodstream Infections

Bloodstream infections are a leading infectious complication among critically ill patients. They represent about 15% of all healthcare-acquired infections and affect approximately one percent of all hospitalized patients. The impact on patient outcome is tremendous—bloodstream infections increase mortality rates, prolong patient stay in an intensive care unit and in the hospital, and generate substantial extra costs (Hugonnet et al., 2004).

More than 5 million central venous catheters (CVC) are inserted into U.S. patients every year; CVCs can cause several types of infections. The skin at the insertion site of the catheter may become infected (this is called an exit-site infection), or the internal surface of the device itself may become colonized with bacteria, which occurs in 25% of catheters left in place for 5 days (Ranji et al., 2007).

The clinical significance of colonization, along with migration of skin flora along the external surface of the catheter, predisposes to the most serious consequence of catheter-related infection-central-line-associated bloodstream infection (CLABSI). This occurs when a patient develops bacteremic infection associated with the presence of a central venous catheter. It is estimated that one of the two types of infection above (exit-site infection or CLABSI) occurs in 3% to 7% of catheters, resulting in approximately 80,000 episodes of CLABSI in the United States every year. Most of these infections occur in patients with temporary central venous catheters, often placed in ICU patients. Central-line associated bloodstream infections are estimated to result in an absolute increase in mortality of 10% to 30% for ICU patients, and the total yearly costs to the U.S. healthcare system are between $300 million and $2 billion (Ranji et al., 2007).

Recommended interventions for prevention of central-line-associated bloodstream infections include use of aseptic technique for the insertion of all central venous catheters and use of 2% chlorhexidine gluconate solution for skin disinfection at the CVC insertion site. Also, avoid insertion at the femoral site for nonemergency CVC insertion and remove CVCs that are no longer essential for care. Routine removal and replacement of a CVC over guidewire is explicitly discouraged (Ranji et al., 2007).

Ventilator-Associated Pneumonia

Ventilator-associated pneumonia (VAP) is one of the most common infections acquired by both adults and children in intensive care units (Coffin et al., 2008). Ventilator-associated pneumonia (VAP) is estimated to occur in 9% to 27% of patients intubated for more than 48 hours. Patients with VAP have a higher risk of dying in the ICU than similar patients without VAP, though the magnitude of this risk is controversial. Patients with VAP remain hospitalized for 7 to 9 excess days, and costs are estimated to be between $12,000 and $40,000 per patient (Ranji et al., 2007).

To prevent ventilator-associated pneumonia, doctors, nurses, and other healthcare providers can do the following things:

  • Keep the head of the patient’s bed raised between 30 and 45 degrees unless other medical conditions do not allow this to occur.
  • Check the patient’s ability to breathe on his or her own every day so that the patient can be taken off of the ventilator as soon as possible.
  • Clean their hands with soap and water or an alcohol-based hand rub before and after touching the patient or the ventilator.
  • Clean the inside of the patient’s mouth on a regular basis.
  • Clean or replace equipment between use on different patients. (CDC, 2010b; Coffin et al., 2008; Krein et al., 2008)

Recommended interventions for prevention of ventilator-associated pneumonia include semi-recumbent positioning, minimizing the duration of mechanical ventilation by minimizing sedative administration (including daily “sedation holidays”), and use of weaning protocols (Ranji et al., 2007).

Catheter-Associated Urinary Tract Infections (CAUTIs)

Urinary tract infections (UTIs) are the most common type of healthcare-associated infection reported to the National Healthcare Safety Network (NHSN). Among UTIs acquired in the hospital, approximately 75% are associated with a urinary catheter. Between 15% and 25% of hospitalized patients receive urinary catheters during their hospital stay. The most important risk factor for developing a catheter-associated UTI (CAUTI) is prolonged use of the urinary catheter (CDC, 2012b).

An estimated 17% to 69% of CAUTI may be preventable with recommended infection control measures, which means that up to 380,000 infections and 9000 deaths related to CAUTI per year could be prevented (CDC, 2009).

CAUTIs have been associated with increased morbidity, mortality, healthcare costs, and length of stay. The risk of CAUTI can be reduced by ensuring that catheters are used only when needed and removed as soon as possible, that catheters are placed using proper aseptic technique, and that the closed sterile drainage system is maintained (CDC, 2010a).

Hospitals should follow the recommendations in the 2009 CDC Guideline for Prevention of Catheter-associated Urinary Tract Infections (see References). The guideline emphasizes the proper use, insertion, and maintenance of urinary catheters in different healthcare settings. It also presents effective quality improvement programs that healthcare facilities can use to prevent CAUTIs (CDC, 2010a). Additional training and evaluation resources are available from the CDC website.

CDC evidence review: When is urinary catheterization necessary?

  • Use urinary catheters in operative patients only as necessary, rather than routinely.
  • Avoid use of urinary catheters in patients and nursing home residents for management of incontinence.
    • Further research is needed on periodic (eg, nighttime) use of external catheters in incontinent patients or residents and the use of catheters to prevent skin breakdown.
  • Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction.
  • Consider alternatives to chronic indwelling catheters, such as intermittent catheterization, in spinal cord injury patients.
  • Consider intermittent catheterization in children with myelomeningocele and neurogenic bladder to reduce the risk of urinary tract deterioration.

Source: CDC, 2009.