ATrain Education


Continuing Education for Health Professionals

FL: Preventing Medical Errors

Module 3

Types of Medical Errors


Error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.

Institute of Medicine, 1999
To Err is Human: Building a Safer Health System


There are many ways that medical care can go wrong. Errors can be related to the administration of medications, laboratory testing, infections occurring within the healthcare setting, surgery, or an environment contributing to a patient fall.

A number of healthcare organizations and government agencies have lists of medical errors on which they focus, but the seven we will discuss appear as hot-button indictors across most oversight organizations and are the ones most commonly encountered:

  1. Medication events (including adverse drug events/reactions)
  2. Healthcare-associated infections
  3. Surgical errors
  4. Laboratory errors
  5. Patient Falls
  6. Pressure sores
  7. Documentation/computer errors (NQF, 2011; AHRQ, 2015; CMS, 2014; Joint Commission, 2015; NHSN, 2015; CDC, 2014)

Medication Events

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, making medication errors the most common of all medical errors.

The report notes a comprehensive study found an administration error rate of 11%. With a typical hospital patient receiving an average of 10 doses of medication each day, he or she could be subjected to at least one administration error per day (IOM, 2007).

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)

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, an aging American population, increase in the use of medications for disease prevention, and increased coverage for prescription medications (CDC, 2012).

Medication Errors

In 2011 the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) 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).

Not all medication errors result in harm to the patient. For example, if the dosage or route were prescribed incorrectly but the error was caught prior to administration (often called a “near miss”), there was no patient harm. That said, any type of medication error must be tracked so preventions can be developed, regardless of whether a patient was harmed or not.

Adverse Drug Events (ADEs)

An adverse drug event (ADE) is “an injury resulting from the use of a drug.” However, not all adverse drug events are the result of errors. According to the VA, “adverse drug events may result from medication errors but most do not” (USDVA, 2006).

ADEs are a serious public health problem, and are a leading cause of injury and death. ADEs account for an estimated one-third of hospital adverse events and approximately 280,000 hospital admissions annually (ODPHP, 2014).

According to the federal Office of Disease Prevention and Health Promotion, ADEs are responsible for a staggering number of harmful patient impacts.

In inpatient settings, ADEs:

  • Account for an estimated 1 in 3 of all hospital adverse events
  • Affect about 2 million hospital stays each year
  • Prolong hospital stays by 1.7 to 4.6 days

In outpatient settings, ADEs account annually for:

  • Over 3.5 million physician office visits
  • An estimated 1 million emergency department visits
  • Approximately 125,000 hospital admissions (ODPHP, 2014)

In addition, the Centers for Disease Control and Prevention (CDC) said ADEs are responsible for $3.5 billion in extra medical expenses as well as 40% of preventable ambulatory care costs (CDC, 2012).

Adverse Drug Reactions (ADRs)

Adverse drug reactions (ADRs) are unintended negative responses or harm caused during the normal use of a medication. ADRs can be an allergic response, such as hives after taking antibiotics, or a side effect such as stomach upset with aspirin (USDVA, 2006).

While all adverse drug reactions are adverse drug events, not all adverse drug events are adverse drug reactions. A patient given the wrong medication is an adverse drug event but not an adverse drug reaction because the medication in question was not used as it was intended. The figure below helps to clarify how the medication-related errors differ and relate to one another.


Adverse Drug Events vs. Reactions

Source: ODPHP, 2014.


Adverse drug reactions are a leading cause of injury and death; it is estimated they cause 100,000 deaths annually in the United States (FDA, 2014).

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, 2014; 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.
  • More than 4 billion prescriptions were filled in 2014 at retail pharmacies alone, nearly 10 prescriptions per person in the United States.
  • The rate of ADRs increases exponentially when a patient is taking four or more medications (FDA, 2014; KFF, 2014).

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 drugs require many more exposures to detect an adverse reaction—particularly reactions that occur with low frequencies.

According to the U.S. Food and Drug Administration (FDA) learning module, “Preventable Adverse Drug Reactions: A Focus on Drug Interactions,” most drugs are approved for use by the FDA with an average of only 1,500 patient exposures and tested for relatively short period of time. A few million patients make take a new drug before the low-frequency adverse reactions are identified. For drugs that cause rare toxicity, the toxicity will only be detected after use by many more thousands of patients (FDA, 2014).

Specific Preventive Measures

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 show 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 right dose of the right drug is given to the right patient at the right time.
  • Error analyses. Reviews about 1,400 reports of med errors every month.
  • Guidances for industry. Three new guidance statements are being reviewed regarding trade name development, pitfalls of drug labeling, and best test practices for drug naming.
  • Public education. Helps educate the public through various models about preventing medical errors. (FDA, 2009)

In 2006 the FDA and Institute for Safe Medication Practices (ISMP) have launched a national education campaign to eliminate the use of ambiguous medical abbreviations that are frequently misinterpreted and lead to mistakes resulting in patient harm. The campaign seeks to promote safe practices among those who communicate medical information (FDA, 2006).

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.


**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 for more information about this Joint Commission requirement.
Source: Institute for Safe Medical Practices (ISMP), 2015.

Dangerous Abbreviations


Intended Meaning





Mistaken as “mg”

Use “mcg”


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”


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”



Mistaken as “BID” (twice daily)

Use “bedtime”


Cubic centimeters

Mistaken as “u” (units)

Use “mL”


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”



Mistaken as “IV” or “intrajugular”

Use “injection”



Mistaken as “IM” or “IV”

Use “intranasal” or “NAS”






At bedtime, hours of sleep

Mistaken as bedtime


Mistaken as half-strength

Use “half-strength” or “bedtime”


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”


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”


Nightly at bedtime

Mistaken as “qhr” or every hour

Use “nightly”


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”



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”

sub q


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”


Sliding scale (insulin) or ½ (apothecary)

Mistaken as “55”

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


Sliding scale regular insulin

Mistaken as selective-serotonin reuptake inhibitor

Spell out “sliding scale (insulin)”


Sliding scale insulin

Mistaken as Strong Solution of Iodine (Lugol’s)

Spell out “sliding scale (insulin)”


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**


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”


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 for more information about this Joint Commission requirement.
Source: Institute for Safe Medical Practices (ISMP), 2015.

Error-Prone Dose Designations

Dose Designations and Other Information

Intended Meaning



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




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)




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 for more information about this Joint Commission requirement.
Source: Institute for Safe Medical Practices (ISMP), 2015.

Error-Prone Drug Name Abbreviations

Drug Name Abbreviations

Intended Meaning





Not recognized as acetaminophen

Use complete drug name



Mistaken as cytarabine (ARA C)

Use complete drug name


zidovudine (Retrovir)

Mistaken as azathioprine or aztreonam

Use complete drug name


Compazine (prochlorperazine)

Mistaken as chlorpromazine

Use complete drug name



Mistaken as diphtheria-pertussis-tetanus (vaccine)

Use complete drug name


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

Mistaken as tincture of opium

Use complete drug name


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



Mistaken as hydrochlorothiazide

Use complete drug name



Mistaken as hydrocortisone (seen as HCT250 mg)

Use complete drug name


magnesium sulfate

Mistaken as morphine sulfate

Use complete drug name

MS, MSO4**

morphine sulfate

Mistaken as magnesium sulfate

Use complete drug name



Mistaken as mitoxantrone

Use complete drug name



Mistaken as patient controlled analgesia

Use complete drug name



Mistaken as mercaptopurine

Use complete drug name


Tylenol with codeine No. 3

Mistaken as liothyronine

Use complete drug name



Mistaken as tetracaine, Adrenalin, cocaine

Use complete drug name



Mistaken as “TPA”

Use complete drug name


zinc sulfate

Mistaken as morphine sulfate

Use complete drug name

Stemmed Drug Names

Intended Meaning



“Nitro” drip

nitroglycerin infusion

Mistaken as sodium nitroprusside infusion

Use complete drug name



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 for more information about this Joint Commission requirement.
Source: Institute for Safe Medical Practices (ISMP), 2015.

Error-Prone Drug Symbols


Intended Meaning



dram symbol



Symbol for dram mistaken as “3”

Use the metric system

minim symbol


Symbol for minim mistaken as “mL”

Use the metric system


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



Mistaken as “2”

Use “at”



Mistaken as “2”

Use “and”


Plus or and

Mistaken as “4”

Use “and”



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 Warnings and High-Alert Medications

In 1995 the FDA established the Black Box Warning System 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 black box warning 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 & Blegen, 2008).

High-alert medications are those 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, 2015a). 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 & Blegen, 2008).

The National Center for Patient Safety 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, 2015a).

The Center also encourages standardized dosing procedures, careful screening of new products, and creating system redundancies, commonly known as “double checks” (USDVA, 2015a).

Healthcare-Associated Infections (HAIs)

Healthcare-associated infections (HAIs) are some of the most common complications associated with hospital care in the United States.

In the most recent HAI prevalence survey using 2011 data, researchers from the CDC found that about 1 in 25 hospital patients has at least one healthcare-associated infection. There were an estimated 722,000 HAIs in U.S acute care hospitals in 2011 (CDC 2014a).

More than half of all HAIs occurred outside of the intensive care unit and about 75,000 hospital patients with HAIs died during their hospitalization (CDC, 2014a). In fact, a 2013 study found that just five types of infections account for some $9.8 billion annually (Zimlichman et al., 2013).

The federal Office of Disease Prevention and Health Promotion (ODPHP), along with a consortium of other federal agencies including the U.S. Department of Health and Human Services (HHS) and CDC, has selected the following six HAIs as a target of its HAI Action Plan, an outcome of the National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination set by HHS:

  • Surgical site infections
  • Central-line–associated bloodstream infections
  • Ventilator-associated pneumonia
  • Catheter-associated Urinary Tract Infections
  • Hospital-onset Clostridium difficile Infections
  • Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia (ODPHP, 2013).

Surgical Site Infections (SSIs)

Surgical site infections (SSIs) are those that occur after surgery in the part of the body where the surgery took place. SSIs can sometimes be superficial, involving only the skin, but others are more serious and can involve tissues under the skin, organs, or implanted material. 

Common symptoms of a SSI include:

  • Redness and pain around near the surgical wound
  • Drainage of cloudy fluid from the surgical wound
  • Fever (CDC, 2010)

SSIs are the most common hospital-acquired infection, according to the CDC, accounting for more than 30% of all inpatient HAIs (NHSN, 2015). SSIs also account for an additional $22,000 in healthcare costs per case (Zimlichman et al., 2013).

SSIs are not only a national issue, but a local one as well. A 2012 study of 851 patients at nine hospitals in Jacksonville, Florida, found 51 had HAIs, 18 with surgical site infections. These accounted for the largest type of HAI in the study, or 35% among the patients with HAIs (Magill et al., 2012).

Preventing SSIs

To prevent surgical site infections, the CDC recommends:

Before surgery

  • Administer antimicrobial prophylaxis in accordance with evidence-based standards and guidelines.
  • Treat remote infections whenever possible before elective operations.
  • Avoid hair removal at the operative site unless it will interfere with the operation; do not use razors.
  • Use appropriate antiseptic agent and technique for skin preparation.  

During surgery

  • Keep operating room doors closed during surgery except as needed for passage of equipment, personnel, and the patient.

After surgery

  • Maintain immediate postoperative normothermia.
  • Protect primary closure incisions with sterile dressing.
  • Control blood glucose level during the immediate postoperative period for cardiac procedures.
  • Discontinue antibiotics according to evidence-based standards and guidelines.

Also consider:

Before surgery

  • Nasal screening and decolonization for Staphylococcus aureus carriers for select procedures (ie, cardiac, orthopedic, neurosurgery procedures with implants)
  • Screening preoperative blood glucose levels and maintaining tight glucose control

During surgery

  • Re-dose antibiotic at the 3-hour interval in procedures with duration >3 hours.
  • Adjust antimicrobial prophylaxis dose for obese patients (body mass index >30).
  • Use at least 50% fraction of inspired oxygen intraoperatively and immediately postoperatively in select procedure(s). (CDC, 2012a)

Central Line-Associated Bloodstream Infections

A central venous catheter, commonly called a “central line,” is an intravascular catheter that terminates at or close to the heart or one of the great vessels and is used for infusion, withdrawal of blood, or hemodynamic monitoring.

Patients who get a central line-associated bloodstream infection (CLABSI) have a fever and might also have red skin and soreness around the central line (CDC, 2011).

According to the National Healthcare Safety Network of the CDC, there are an estimated 30,100 CLABSIs in the United States each year, but other estimate the number of CLABSIs could be as high as 80,000 each year. These infections are usually serious infections typically causing an increase length of stay, increased costs, and risk of mortality (NHSN, 2015; Ranji et al., 2007).

Zimlichman and colleagues found CLABSIs could add as much as $45,814 in care on a per-case basis, making it the costliest HAI on average per case in the study (Zimlichman et al., 2013).

Several types of infections can occur with central lines. 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, can lead to the most serious consequence of CLABSI—a bacteremic infection associated with the presence of a central venous catheter.

Central-line­associated 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 can be as much as $2 billion (Ranji et al., 2007).

The good news is that prevention measures of CLABSIs are having an impact. The CDC’s 2015 HAI Progress Report, based on 2013 data, shows a 46% decrease in CLABSIs between 2008 and 2013 (CDC, 2015b).

Preventing CLABSIs

Healthcare providers can take the following steps to help prevent CLABSIs:

  • Perform hand hygiene.
  • Apply appropriate skin antiseptic.
  • Ensure that the skin prep agent has completely dried before inserting the central line.
  • Use all five maximal sterile barrier precautions:
    • Sterile gloves
    • Sterile gown
    • Cap
    • Mask
    • Large sterile drape
  • Once the central line is in place:
    • Follow recommended central line maintenance practices.
    • Wash their hands with soap and water or an alcohol-based hand rub before and after touching the line.
  • Remove a central line as soon as it is no longer needed. The sooner a catheter is removed, the less likely the chance of infection. (CDC, 2011)

Other interventions 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 insertion site. Also, avoid insertion at the femoral site for nonemergency insertion. Routine removal and replacement of a central venous catheter over guidewire is explicitly discouraged (Ranji et al., 2007).

Ventilator-Associated Pneumonia (VAP)

Studies have estimated that more than 300,000 patients receive mechanical ventilation in the United States each year. These patients are at high risk for complications and poor outcomes, including death (NHSN, 2015).

Among the more serious complications is ventilator-associated pneumonia (VAP). The CDC defines VAP as “a pneumonia where the patient is on mechanical ventilation for >2 calendar days on the date of event, with day of ventilator placement being Day 1, AND the ventilator was in place on the date of event or the day before. If the patient is admitted or transferred into a facility on a ventilator, the day of admission is considered Day 1” (NHSN, 2015).

Patients with VAP can incur an additional $21,000 in costs, on average, and remain hospitalized for 7 to 9 excess days (AHRQ PFP, 2014; Ranji et al., 2007).

In 2011 the CDC said an estimated 157,000 healthcare-associated pneumonias occurred in acute care hospitals in United States (NHSN, 2015).

With statistics like these, we know VAP is an issue. Unfortunately, while there are good protocols to reduce the incidence, the efforts to measure—and therefore reduce—VAP have posed a problem.

The National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination, issued by the Office of Disease Prevention and Health Promotion, an agency of HHS, noted the issue:

The 2009 HAI Action Plan identified ventilator-associated pneumonia (VAP) as a priority area for prevention, however did not specify a related measure and five-year reduction goal for national use due to the lack of an accepted, objective definition that could be used for multiple purposes, including national benchmarking and interfacility comparison. The HAI Action Plan will be shifting its focus to address the issue of ventilator-associated events (VAE) in adult patients.

Subject matter experts at the Critical Care Societies Collaborative, CDC, and other partner organizations have recently developed a new approach to VAE surveillance. Acknowledging the inaccuracies inherent in the diagnosis of VAP, the group focused instead on developing more objectively defined measures, resulting in a new proposed VAE surveillance definition algorithm (ODPHP, 2013).

Consequently, the National Healthcare Safety Network, a division of the CDC, made this statement in the Patient Safety Component Manual (modified April 2015):

A particular difficulty with many commonly-used VAP definitions, including the NHSN PNEU definitions (revised in 2002), is that they require radiographic findings of pneumonia. Evidence suggests that chest radiograph findings do not accurately identify VAP. The subjectivity and variability inherent in chest radiograph technique, interpretation, and reporting make chest imaging ill-suited for inclusion in a definition algorithm to be used for the potential purposes of public reporting, inter-facility comparisons, and pay-for-reporting and pay-for-performance programs. Another major difficulty with available VAP definitions is their reliance on specific clinical signs or symptoms, which are subjective and may be poorly or inconsistently documented in the medical record. . . .

The limitations of VAP surveillance definitions have implications for prevention. Valid and reliable surveillance data are necessary for assessing the effectiveness of prevention strategies. It is notable that some of the most effective measures for improving outcomes of patients on mechanical ventilation do not specifically target pneumonia prevention. (NHSN, 2015)

Preventing VAP

To prevent ventilator-associated pneumonia, 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.
  • Check the patient’s ability to breathe on own every day so that the patient can be taken off of the ventilator as soon as possible.
  • Clean 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, 2010a; Coffin et al., 2008; Krein et al., 2008)

Catheter-Associated Urinary Tract Infections

As many as 25% of hospitalized patients receive urinary catheters during their hospital stay, according to the CDC. Among UTIs acquired in the hospital, approximately 75% are catheter-associated urinary tract infections (CAUTIs) (CDC, 2015c).

Some of the common symptoms of a UTI are burning or pain in the lower abdomen, fever, burning during urination, or an increase in the frequency of urination. UTIs are one of the most common types of healthcare-associated infection and are most often caused by the placement or presence of a catheter in the urinary tract (CDC, 2010b).

Partnership for Patients, a public–private program with more than 8,000 partners and coordinated by CMS, found 290,000 CAUTIs in more than 32 million discharges in 2013, for a rate 8.8 per 1,000 discharges (AHRQ PfP, 2014).

We are making headway with this particular HAI; the 2013 findings represent a 28% reduction from the baseline 12.2 per 1,000 discharges in 2010 (AHRQ PfP, 2014).

Preventing CAUTIs

The CDC recommends the following practices to prevent CAUTIs:

  • Insert catheters only for appropriate indications.
  • Leave catheters in place only as long as needed.
  • Ensure that only properly trained persons insert and maintain catheters.
  • Insert catheters using aseptic technique and sterile equipment (acute care setting).
  • Follow aseptic insertion, maintain a closed drainage system.
  • Maintain unobstructed urine flow.
  • Comply with CDC hand hygiene recommendations and Standard Precautions.

Also consider:

  • Alternatives to indwelling urinary catheterization
  • Use of portable ultrasound devices for assessing urine volume to reduce unnecessary catheterizations
  • Use of antimicrobial/antiseptic-impregnated catheters (CDC, 2012a)

More detailed prevention procedures can be found in Guideline for Prevention of Catheter-Associated Urinary Tract Infections, 2009. The guideline emphasizes the proper use, insertion, and maintenance of urinary catheters in various healthcare settings. It also presents effective quality improvement programs that healthcare facilities can use to prevent CAUTIs.

Hospital-Onset C. difficile Infections

Infections caused by Clostridium difficile, a Gram-positive anaerobic bacillus, are characterized by watery diarrhea, fever, loss of appetite, nausea, and abdominal pain/tenderness (CDC, 2010c; CDC, 2015e).

C. difficile infections often occur as secondary infections after antibiotic therapy. It can be contracted in the community as well as in healthcare settings. The severity can range from unpleasant but benign to full-blown sepsis. It is spread through coughing and improper handwashing (NHSN, 2015).

C. difficile is shed in feces. Any surface, device, or material (eg, toilets, bathtubs, electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the spores. C. difficile spores are transferred to patients mainly via the hands of healthcare personnel who have touched a contaminated surface or item. C. difficile can live for long periods on surfaces (CDC, 2015e).

Since many patients in hospitals are immunocompromised, C. difficile poses a severe threat. In 2011 C. difficile was estimated to cause almost half a million infections in the United States, and 29,000 died within 30 days of the initial diagnosis (CDC, 2015f).

A prevalence study by a team of CDC researchers of more than 11,000 patients at 183 hospitals found C. difficile in 12% of the HAIs isolated, making it the most common pathogen found in the study (Magill et al., 2014).

While C. difficile can be deadly, protocols put in place by multiple public and private healthcare organizations are having an effect on the spread of the disease. The National and State Healthcare-Associated Infections Progress Report showed a 10% decrease in hospital-onset C. difficile infections between 2011 and 2013 (CDC, 2015b).

Preventing C. difficile Infections

To prevent C. difficile infections, healthcare providers should:

  • Clean their hands with soap and water or an alcohol-based hand rub before and after caring for every patient. This can prevent C. difficile and other germs from being passed from one patient to another on their hands.
  • Carefully clean hospital rooms and medical equipment that have been used for patients with C. difficile.
  • Use Contact Precautions to prevent C. difficile from spreading to other patients. Contact Precautions mean:
    • Whenever possible, patients with C. difficile will have a single room or share a room only with someone else who also has C. difficile.
    • Healthcare providers will put on gloves and wear a gown over their clothing while taking care of patients with C. difficile.
    • Visitors may also be asked to wear a gown and gloves.
    • When leaving the room, hospital providers and visitors remove their gown and gloves and clean their hands (CDC, n.d.).

The CDC also says healthcare facilities should consider the following:

  • Extend the use of Contact Precautions beyond duration of diarrhea (eg, 48 hours)
  • Presumptive isolation for symptomatic patients pending confirmation of C. difficile infection
  • Evaluate and optimize testing for C. difficile infection
  • Implement soap and water for hand hygiene before exiting room of a patient with C. difficile infection
  • Implement universal glove use on units with high C. difficile infection rates
  • Use EPA-registered disinfectants with sporicidal claim (eg, bleach) or sterilants for environmental disinfection
  • Implement an antimicrobial stewardship program (CDC, 2012a).


Superbugs, bacteria that are difficult to kill and are resistant to most antibiotics, pose a serious threat to healthcare (NIH, 2014).

Each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics and at least 23,000 people die each year as a direct result of these infections. Many more people die from other conditions that were complicated by an antibiotic-resistant infection (CDC, 2013).

Antibiotic-resistant infections can happen anywhere. Data show that most happen in the general community; however, most deaths related to antibiotic resistance happen in healthcare settings such as hospitals and nursing homes (CDC, 2013).

Three superbugs are of particular concern because of their virulence and prevalence:

  1. Methicillin-resistant Staphylococcus aureus
  2. Vancomycin-resistant Enterococcus
  3. Carbapenem-Resistant Enterobacteriaceae

These three have increased in prevalence in U.S. hospitals over the last three decades, and have important implications for patient safety. A primary reason for concern about these multidrug-resistant organisms is that options for treating patients with these infections are often extremely limited, and these types of infections are associated with increased lengths of stay, costs, and mortality (NHSN, 2015).

Methicillin-resistant S. aureus (MRSA)

Methicillin-resistant Staphylococcus aureus (MSRA) is the one of the most common HAIs, and there has been a dramatic increase in the number of MRSA-associated hospital stays since 2000. MRSA, often found in intensive care units, is associated with longer hospital stays and a higher likelihood of death (AHRQ, 2014).

MRSA causes a range of illnesses, from skin and wound infections to pneumonia and bloodstream infections that can cause sepsis and death. CDC estimates 80,461 invasive MRSA infections and 11,285 MRSA-related deaths occurred in 2011 (CDC, 2013).

Although MRSA is still a major patient threat, a CDC study published in the Journal of the American Medical Association, Internal Medicine, showed life-threatening MRSA infections that began in hospitals declined 54% between 2005 and 2011, with 30,800 fewer severe MRSA infections. In addition, the study showed 9,000 fewer deaths in hospital patients in 2011 versus 2005 (CDC, 2013).


image: MRSA chart

Source: CDC, 2013. Click here or on the image to view the complete and full-size version.


Vancomycin-resistant Enterococci (VRE)

Vancomycin-resistant enterococci are of great concern because they are not only resistant to one of the most powerful antibiotics available (vancomycin is considered an “antibiotic of last resort”) and therefore have little or no treatment options, but they also have a knack for passing on that resistance to other bacteria. In fact, there is evidence that VRE has passed on its vancomycin resistance to S. aureus, creating an emerging threat of vancomycin-resistant S. aureus (VRSA) (NIAID, 2009).

An estimated 20,000 vancomycin-resistant infections occur among hospitalized patients each year, with approximately 1,300 deaths attributed to these infections (CDC, 2013).

Drug-resistant Enterococci can cause HAIs of the bloodstream, surgical site, and urinary tract (NIAID 2009).

Carbapenem-Resistant Enterobacteriaceae (CRE)

Enterobacteriaceae resistant to carbapenem (an antibiotic of last resort) are particularly virulent. CREs have become resistant to all or nearly all the antibiotics we have today. An estimated 140,000 HAI Enterobacteriaceae infections occur in the United States each year; about 9,300 of these are caused by CRE. Almost half of hospital patients who get bloodstream infections from CRE bacteria die from the infection (CDC, 2013).

Unlike methicillin resistance in Staphylococcus aureus, which represents one resistance mechanism in one species of bacteria, Enterobacteriaceae include more than 70 different genera and many different mechanisms can lead to carbapenem resistance (CDC, 2015d).

Of particular concern are those strains that produce carbapenemase. These are currently believed to be primarily responsible for the increasing spread of CRE in the United States and have therefore been targeted for aggressive prevention (CDC, 2015d).

The CDC considers CRE “an immediate public health threat that requires urgent and aggressive action” (CDC, 2013).

Hand Hygiene: Best Practice to Prevent HAIs

Healthcare-associated infections, as dangerous and even deadly as they are, can be mitigated by one of the simplest methods of infection control—good hand hygiene.

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

In several studies, handwashing with plain soap failed to remove certain pathogens from the hands of healthcare workers. Hand rubs with at least 60% concentration of alcohol were remarkably good at killing most pathogens encountered in healthcare settings (WHO, 2009).

Healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patients. These include:

  • Before patient contact
  • After contact with blood, body fluids, or contaminated surfaces (even if gloves are worn)
  • Before invasive procedures
  • After removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in healthcare settings) (CDC, 2014e)

Surgical Errors

According to an AHRQ-supported study, wrong-site surgery occurred at a rate of approximately 1 per 113,000 operations between 1985 and 2004. In July 2004 the Joint Commission enacted the Universal Protocol, which requires performing a time out prior to beginning surgery, a practice that has been shown to improve teamwork and decrease the overall risk of wrong-site surgery. Developed through expert consensus on principles and steps for preventing wrong-site, wrong-procedure, and wrong-person surgery, the Universal Protocol applies to all accredited hospitals, ambulatory care, and office-based surgery facilities.

Wrong-site, wrong-procedure, and wrong-patient errors are all now considered “never events” (medical errors that should never occur) by the National Quality Forum (NQF) and “sentinel events” (events resulting in death, permanent harm, or severe temporary harm, and intervention required to sustain life, among other events) by the Joint Commission. CMS has not reimbursed healthcare providers for any costs associated with these surgical errors since 2009 (PSNet, n.d.; PSNet 2014; Joint Commission, 2014).

In 2011 NQF and other agencies added “unintended retention of a foreign object in a patient after surgery or other procedure” to its list of never events for surgeries, and this is also among the hospital-acquired conditions for which CMS will not reimburse (CMS, 2014).

Universal Protocol: Best Practice to Prevent Surgical Errors

To address the problem of preventable surgical errors, the Joint Commission issued its Universal Protocol on July 1, 2004, and it has become a mandatory patient safety standard in healthcare ever since. The protocol consists of the following three components:

  1. A pre-procedure verification process
  2. Surgical site marking
  3. Surgical “time out” immediately prior to starting the procedure

The surgical site must be marked and visible after prepping and draping of the patient. Using the surgical time-out as a “reflective pause or a preoperative briefing” involves the surgeons, anesthesiologists, nurse anesthetists, quality control specialists, and administrators. Recent studies show the surgical time-out is an effective quality control measure (Stahel et al., 2009; Joint Commission, 2015a).

Laboratory Errors

An estimated 10 billion laboratory tests are performed each year in the United States, which influence approximately 70% of medical decisions (U.S. Army, 2013; MMWR, 2005). In fact, emergency departments order clinical laboratory tests in more than 41% of all visits, family physicians order tests in 29% of visits, and general internists in 38% of visits (Epner et al., 2013).

CLIA and Laboratory Errors

Nearly 30 years ago, the CDC, CMS and the FDA developed the Clinical Laboratory Improvement Amendments of 1988 (CLIA), a sweeping set of regulations for all U.S. facilities or sites that test human specimens for health assessment or to diagnose, prevent, or treat disease. A critical component of these regulations was quality control. Final regulations were published in 2003 (CDC, 2015g).

CLIA urges laboratories to develop an individualized quality control plan addressing five areas for assessing risk: specimen, test system, reagents, environment, and testing personnel (see table below) (CLIA, 2014).


Source: CLIA, 2014. Go to the CLIA brochure to view the original.

Potential Sources of Error for the five
Risk Assessment Components


  • Patient preparation
  • Specimen collection
  • Specimen labeling
  • Specimen storage, preservation, and stability
  • Specimen transportation
  • Specimen processing
  • Specimen acceptability and rejection
  • Specimen referral


  • Inadequate sampling
  • Clot detection capabilities
  • Capabilities for detection of interfering substances (e.g., hemolysis, lipemia, icterus, turbidity)
  • Calibration associated issues
  • Mechanical/electronic failure of test system
  • Optics
  • Pipettes or pipettors
  • Barcode readers
  • Failure of system controls and function checks
  • Built-in procedural and electronic controls (internal controls)
  • External or internal liquid quality control (assayed vs. unassayed)
  • Temperature monitors and controllers
  • Software/Hardware
  • Transmission of data to LIS
  • Result reporting


  • Shipping/Receiving
  • Storage condition requirements
  • Expiration Date (may differ based on storage requirements)
  • Preparation


  • Temperature
  • Airflow/ventilation
  • Light intensity
  • Noise and vibration
  • Humidity
  • Altitude
  • Dust
  • Water
  • Utilities (Electrical failure/power supply variance or surge)
  • space


  • Training
  • Competency
  • Education and experience
  • Staffing


Laboratory testing is often broken into three stages: pre-analytic, analytic, and post-analytic (CLIA, 2014). Studies have shown nearly 70% of errors occur in the pre-analytic phase encompassing test requests, patient and specimen identification, specimen collection, transport, accessioning or processing (Kaushik & Green, 2014).

Poor communication between laboratory and healthcare professionals is the main issue affecting quality in the pre- and post-analytic phases, and researchers note 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).

Impact of Waived Tests on Laboratory Testing

As part of CLIA, some simple, low-risk tests were waived from laboratory quality requirements and performed with no routine regulatory oversight in physicians’ offices and various other locations (MMWR, 2005).

In 1993 CLIA waived nine such tests; today there are more than 5,400 waived test systems and 119 analytes, according to the Commission on Office Laboratory Accreditation (COLA), an independent laboratory accreditation agency recognized by both CMS and the Joint Commission (COLA, 2013).

Although by law waived tests should have insignificant risk for erroneous results, these tests are not completely error-proof and are not always used in settings that employ a systems approach to quality and patient safety. Errors can occur anywhere in the testing process, particularly when the manufacturer’s instructions are not followed, and when testing personnel are not familiar with all aspects of the test system and how testing is integrated into the facility’s workflow (COLA, 2013; MMWR, 2005).

Although data have not been systematically collected on patient outcomes with waived testing, adverse events can occur. Some waived tests have potential for serious health impacts if performed incorrectly. For example, results from waived tests can be used to adjust medication dosages, such as prothrombin time testing in patients undergoing anticoagulant therapy or glucose monitoring in diabetics. In addition, erroneous results from diagnostic tests, such as those for human immunodeficiency virus (HIV) antibody, can have unintended consequences (MMWR, 2005).

In its white paper, “Federal Government Questions Quality in Waived Testing,” COLA wrote regarding the CDC’s 2005 Morbidity & Mortality Weekly Report, “Good Laboratory Practices” survey:

According to a report from the Centers for Disease Control and Prevention, 31% to 43% of waived labs do not follow manufacturer’s instructions.

Some other examples of notable problems among the more than 150,000 waived testing sites in the U.S. include:

  • More than 20% do not routinely check the product insert or instructions for changes to the information (consider the implications of an ignored new sampling technique for a Rapid HIV test)
  • More than 20% do not perform quality control testing as specified by manufacturer’s instructions (consider the implications of an uncontrolled prothrombin time test)
  • Nearly half do not document the name, lot number, and expiration dates for tests performed (consider the implications of a massive recall of problematic test kits). (COLA, 2013)

What’s more, the Morbidity & Mortality report also found that some 5% were performing tests that were not waived (MMWR, 2005).

Preventing Laboratory Errors

Although laboratory medicine has had long a history of formalized approaches of mitigating errors, most laboratory quality control programs focus on reducing testing errors as opposed to a systems approach preventing diagnostic harm to patients (Epner et al., 2013).

Several studies are reviewing an outcomes-based approach to reducing and preventing errors. Epner and colleagues suggest five causes that, taken together, may explain all-important sources of diagnostic error and harm related to the testing process (see box below). “While occurrences of the five causes will not always result in diagnostic error, patient harm related to diagnostic testing is highly likely to stem from one of these five causes” (Epner et al., 2013).


Five Causes of Diagnostic Error and Harm

Five causes taxonomy of testing-related diagnostic error:

  • An inappropriate test is ordered.
  • An appropriate test is not ordered.
  • An appropriate test result is misapplied.
  • An appropriate test is ordered, but a delay occurs somewhere in the total testing process.
  • The result of an appropriately ordered test is inaccurate.

Source: Epner, Gans, & Graber, 2013.


Epner and colleagues suggest research into new interventions is needed, and should take into account the following questions:

  • What specific measures can be developed and validated to assess and monitor the harm of testing-related diagnostic error?
  • How often and under what circumstances do the five types of errors proposed lead to harm associated with an erroneous diagnosis, a missed diagnosis, or a delay in diagnosis?
  • What practices would optimize the appropriate ordering of laboratory tests and application of laboratory test results to improve patient outcomes?

“Clearly, laboratorians and clinicians should forge stronger links between diagnostic testing and patient outcomes. Without those links, the clinical laboratory will continue to be driven primarily by cost, volume, and process measures, similar to the way a factory manages inputs and outputs,” the researchers wrote (Epner et al., 2013).

Patient Falls

Falls among older Americans are a serious issue. The CDC reports falls by older adults incur $34 billion in direct medical costs. Annually, emergency departments treat about 2.5 million nonfatal fall injuries among older adults; more than 30%, or about 734,000 of these patients, have to be hospitalized (CDC, 2015h).

Falls within care settings are especially concerning. One study found that patients whose falls resulted in serious injury added more than $13,000 in care costs per episode and had a length of stay increased by more than 6 days (Wong et al., 2011).

By far the most alarming, the Joint Commission Center for Transforming Healthcare said that some 11,000 fatalities result from patient falls inside hospitals (DuPree, 2014).

Injuries can occur in as many as 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 falls and fall-related injuries should never occur while a patient is under hospital care (Hughes & Blegen, 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 & Blegen, 2008).

Preventing Patient Falls

Inpatient fall prevention has been an area of concern for almost 50 years. Traditional hospital-based incident reports consider all inpatient falls to be avoidable, and therefore falls are classified as adverse events (Hughes & Blegen, 2008).

Despite volumes of research and prevention protocols, some have concluded that falls are never completely unavoidable (Waters et al., 2015; Champaneria et al, 2014; Lohse et al., 2012). Indeed, eldercare expert Dr. Sharon Inouye concluded that perhaps just 20% of falls could be mitigated and that quality measures should focus on safe mobility rather than just patient falls (Inouye et al., 2009).

Despite these grim perspectives, all researchers noted that falls prevention of some kind must continue. To aid patient care centers, several large agencies have developed comprehensive fall prevention protocols.

Joint Commission Center for Transforming Healthcare

The Joint Commission released its Targeted Solutions Tool for Patient Falls with Injury, in August 2015. The tool is an innovative application that guides healthcare organizations through a step-by-step process to accurately measure their organization’s actual performance, identify their barriers to excellent performance, and direct them to proven solutions that are customized to address their particular barriers. According to the Commission, organizations that followed its standardized approach reduced the rate of patient falls by 35% and falls with injury by 62% (JCC, 2015).

Agency for Healthcare Research and Quality

AHRQ released in 2008 its mammoth text, Patient Safety and Quality: An Evidence-Based Handbook for Nurses. The guide includes a chapter specific to patient falls in different care settings, with a discussion of fall risk assessment tools and prevention strategies, such as floor mats (see table below).


Source: Hughes & Blegen, 2008.

Recommendations for Acute and Long-Term Care

Evidence-based practice recommendations

Research implications

Fall Prevention

Educate staff about safety care.

Train medical team, including students and residents, for fall-injury risk assessment and post fall assessment.

Examine impact of safety education across interdisciplinary team.


Use alarm devices.

Examine impact of alarms on caregiver satisfaction.

Monitor medication side effects and adjust as needed.

Examine effect of computerized decision support for medication management.

Adjust environment (eg, design rooms to promote safe patient movement).

Examine cost effectiveness of environmental adjustments.

Provide exercise interventions (eg, Tai Chi) for long-term care patients.

Examine usefulness of exercise interventions for acute care patients.

Provide toileting regimen for confused patients (eg, check patients every 2 hours).

Study barriers to maintaining and sustaining monitoring activities.

Monitor and treat calcium and vitamin D levels for long-term care patients.

Examine effects of calcium and vitamin D management for acute care patients.

Treat underlying disorders such as syncope, diabetes, and anemia.

Examine constellations of disorders that might precipitate falls.


Injury Prevention

Limit restraints use.

Identify methods to overcome barriers to restraints reduction.

Lower bedrails.

Study efficacy of environmental changes.

In addition to fall rates, monitor injury rates.

Establish fatal fall rates across settings.

Use hip protectors for geriatrics and long-term care.

Identify methods to overcome barriers to use of hip protectors.

Use floor mats.

Examine effect of safety flooring.

Monitor prothrombin time, international normalized ration (PT/INR) for patients at risk for falling.

Identify safety measures for bleeding-injury prevention.

Ensure post fall assessment.

Examine barriers to post fall assessment.

Use bisphosphonates for patients with documented osteoporosis.

Explore safety of long-term use of bisphosphonates.


AHRQ also published its “2013 Preventing Falls in Hospitals: A Toolkit for Improving Quality of Care,” which discusses the development of a complete program for hospitals, including such practices rounding protocols (AHRQ, 2013).

Other Approaches to Preventing Falls

Stemming from a study of seven participating acute-care centers, methods to reduce falls included adopting an organizational culture of commitment to fall safety, engaging patients and families in the fall safety process, utilizing a validated falls assessment tool, hourly rounding, among other protocols. Targeted solutions included implementing a standardized assessment tool and video monitoring on non-compliant patients (DuPree et al., 2014).

Tens of thousands of patients fall in healthcare facilities every year and many of these falls result in moderate to severe injuries. Find out how the participants in the Center for Transforming Healthcare’s seventh project are working to keep patients safe from falls.


Keeping Patients Safe From Falls (3:58)

The Joint Commission (2012).


Pressure Ulcers

Pressure ulcers, sometimes called decubitus ulcers, pressure sores or bedsores, are areas of damaged skin caused by staying in one position for too long. They commonly form where bones are close to the skin, such as ankles, back, elbows, heels, and hips. Patients are at risk if they are bedridden, use a wheelchair, or are unable to change their position. Pressure sores can cause serious infections, some of which are life-threatening (MedLine Plus, 2014).

Pressure ulcers, which can occur in healthcare settings or at home, affect more than 2.5 million people annually (CDC, 2011a).

Pressures ulcers are often associated with nursing homes and long-term skilled care facilities, but some 60,000 deaths occur each year from complications due to hospital-acquired pressure ulcers (Sullivan & Schoelles, 2013; NQMC, 2012).

The estimated cost of managing a single full-thickness pressure ulcer is as high as $70,000, and the total cost for treatment of pressure ulcers in the United States is estimated at $11 billion per year. Within care settings, pressure ulcer incidence rates vary considerably, ranging from 0.4% to 38% in acute care, from 2.2% to 23.9% in long-term care, and from 0% to 17% in home care (NQMC, 2012).

But unlike many other medical errors, the incidence of pressure ulcers is climbing—perhaps by as much as 80% from 1995 to 2008 (Sullivan & Schoelles, 2013).

The prevention of pressure ulcers is on the NQF’s list of Serious Reportable Events and encompasses several nationally endorsed measures (NQF, n.d.).

Preventing Pressure Ulcers

Basic preventions for pressure ulcers involve:

  • Keeping skin clean and dry
  • Changing position every two hours
  • Using pillows and products that relieve pressure (MedLine Plus, 2014)

In their large literature review, Sullivan and Schoelles suggested prevention measures include simplification and standardization of pressure ulcer interventions and documentation, involvement of multidisciplinary teams and leadership, use of designated skin champions, ongoing staff education, and sustained audit and feedback (Sullivan & Schoelles 2013).

In ARHQ’s “Preventing Pressure Ulcers in Hospitals Tool Kit,” the agency presents a broad scope plan, and recommends a multi-disciplinary approach:

No individual clinician working alone, regardless of how talented, can prevent all pressure ulcers from developing. Rather, pressure ulcer prevention requires activities among many individuals, including the multiple disciplines and multiple teams involved in developing and implementing the care plan. To accomplish this coordination, high-quality prevention requires an organizational culture and operational practices that promote teamwork and communication, as well as individual expertise. Therefore, improvement in pressure ulcer prevention calls for a system focus to make needed changes.

More specifically, ARHQ recommends a protocol that includes:

  • Comprehensive skin assessment
  • Standardized pressure ulcer risk assessment
  • Care planning and implementation to address areas of risk (ARHQ, 2014a)

Documentation Errors

Central to many types of medical errors are issues with documentation. While illegible physician handwriting is often regarded as a humorous cliché, it can have ramifications that are anything but humorous. Charting errors or omissions can have serious consequences.

Electronic medical records (EMRs) and more comprehensive systems known as electronic health records (EHRs) have grown exponentially in the last two decades, bolstered by several game-changing pieces of legislation. For all their efficiencies, electronic records are still subject to documentation and informational errors.

High-risk copy-and-paste errors, which are defined as mistakes with high potential risk for patient harm, fraud, or tort claim, have been reported in 10% of patient EMRs. Such errors can result in inaccuracies that can carry forward throughout the patient’s record (Hirschtick, 2012).

Cho and colleagues found that more than 50% medication orders entered through a computerized physician order/entry system had at least one error in a study at a 950-bed teaching hospital. Further, documentation errors occurred in 205 (82.7%) of 248 correctly performed administrations. When tracking incorrectly entered prescriptions, 93% of the errors were intercepted by nurses, but two-thirds of them were recorded as prescribed rather than administered (Cho et al., 2014).

Another study found a small but concerning error rate of as much as 0.05% in patient-note mismatches, where a clinical note pertaining to one patient was included in the electronic record of another patient (Wilcox et al., 2011).

Preventing Documentation Errors

Accurate documentation—written or electronic—is one of the most fundamental components in the medical record and is threaded through all quality indicators. For example, NQF has specific mentions of documentation as part of a number of its measures including:

  • 0045. Communication with the physician or other clinician managing on-going care post fracture for men and women aged 50 years and older
  • 0092. Emergency Medicine: Aspirin at Arrival for Acute Myocardial Infarction
  • 0419. Documentation of Current Medications in the Medical Record (NQF, n.d.-a)

There is a growing body of evidence of what errors can occur with electronic records, but there appears to be little research on a systems approach to preventing them as of yet.

What research there is calls for preventions to include application prompts, screens or warnings built into the system itself as well as barcode system for medications and supplies. Other studies recommend a variety of techniques including patient pictures; using a room number “watermark” on the electronic record display in busy emergency rooms to assist providers with patient identification; and even changes to the physical environment to make charting easier (Hyman et al., 2012; Yamamoto, 2014; Mahmood et al., 2009).



A 78-year-old man with hypertension and diabetes presented to an emergency department (ED) with new-onset chest pain. The ED physician reviewed the patient’s electronic medical record (EMR) and noted “PE” listed under past medical history, which raised his suspicion for the possibility of a new pulmonary embolus (PE). After initial testing excluded a cardiac etiology, a computed tomography (CT) scan of the chest was ordered to rule out a PE. When the physician approached the patient to explain why he was ordering the diagnostic test, the patient denied ever having a PE or being treated with blood thinners.

Puzzled by the conflicting reports, the ED physician returned to the EMR and noted that this mistaken history of PE dated back several years. It even appeared in the “problem list” section of his EMR. Investigating further back, the ED physician discovered that the letters “PE” were first noted nearly a decade earlier where it was clearly intended to reflect a “physical examination” rather than a “pulmonary embolus.” A physician likely copied and mistakenly pasted “PE” under “past medical history,” after which this history of pulmonary embolism was carried forward time and time again.

The patient, who was ultimately discharged from the ED, never suffered any harm from the documentation error. The EMR was updated to say “This patient never had a pulmonary embolism.”

Source: Hirschtick, 2012.

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