ATrain Education

 

Continuing Education for Health Professionals

FL: Preventing Medical Errors

Module 6

Reducing Errors and Increasing Patient Safety

 

Health care organizations must develop a culture of safety such that an organization’s care processes and workforce are focused on improving the reliability and safety of care for patients.

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

 

Governments, healthcare personnel, patients, and the public must work together to create a culture of safety, decrease the effects of medical errors, and improve the safety of healthcare. Each has a role to play.

Creating a Culture of Safety

For decades, the healthcare industry, along with a myriad of agencies and stakeholders, has sought a way to curb medical errors. This has resulted in a major shift in philosophy from one of blame to one of changing cultures across the continuum of care.

Garrouste-Orgeas and colleagues (2012) wrote,

Errors are caused by combinations of human factors and system factors, and information must be obtained on how people make errors. . . . Preventive strategies are more likely to be effective if they rely on a systems-based approach, in which organizational flaws are remedied, rather than a human-based approach of encouraging people not to make errors. The development of a safety culture . . . is crucial to effective prevention and should occur before the evaluation of safety programs, which are more likely to be effective when they involve bundles of measures.

While the researchers were speaking in terms of the intensive care unit, the lessons can be applied to many care settings (Garrouste-Orgeas et al., 2012).

Garrouste-Orgeas and colleagues (2012) suggested that

. . . a safety culture arises from a combination of a room-for-improvement model, in which problems are identified, plans are made to resolve them, and the results of the plans are measured; and the monitoring model, in which quality indicators are defined as relevant to potential problems and then monitored periodically. Indicators that reflect structures, processes, or outcomes have been developed by medical societies. Surveillance of these indicators is organized at the hospital or national level. Using a combination of methods improves the results.

Creating a “Just” Culture

Many agencies have adopted some version of the culture of safety, with varying degrees of success. In 2012 the National Association for Healthcare Quality (NAHQ) issued Call to Action: Safeguarding the Integrity of Healthcare Quality and Safety Systems, a document based on wide-ranging research about the efficacy of the culture of safety. Its executive summary, used here by permission, reads in part:

. . . [I]t is widely recognized that there is more work needed to eliminate preventable harm in the U.S. healthcare system. While a strong and just safety culture has been recognized as a key element for improvement, a critical deficit that has not yet been fully addressed is the lack of protective infrastructure to safeguard responsible, accurate reporting of quality and patient safety outcomes and concerns. . . .

Some healthcare providers acknowledge that they fear reporting events or conditions that could endanger quality and patient safety. Some professionals whose direct responsibilities include the monitoring and reporting of quality and patient safety outcomes have experienced pressure, outright harassment, or [have] even experienced serious legal and licensure challenges when they recognize and report events of concern. . . .

The accelerating implementation of new financial models that tie quality outcomes to payment will raise the stakes associated with quality results. The need will be even greater for a protective infrastructure to safeguard accurate reporting of quality data and patient safety concerns.

[These goals] are widely endorsed by leading healthcare and patient advocacy groups: meaningful and measurable improvement in patient outcomes, safety, and quality of care; improvement in the patient experience; and transparency of quality and safety data. These goals can be attained only with impeccable accuracy and trustworthy reporting. In any given situation where quality or patient safety is called into question, the process by which an issue is reported is as important as the query itself. Not every question of concern about patient safety or quality of patient care will ultimately be deemed valid; but every reported concern deserves consideration. A culture that encourages such disclosures is critical to improved patient care. So is the process by which concerns are examined, investigated, and ultimately determined to be valid or not (NAHQ, 2012).

 

Framework for Action: Integrity in Healthcare Quality and Safety

image: framework for action: integrity in healthcare quality and safety

Source: NAHQ, 2012. Used by permission.

 

Implementing Electronic Health Records (EHR)

The report that served as the clarion for efforts to prevent medical errors—IOM’s “To Err is Human”—noted that electronic systems are an “effective remedy” to combat them (IOM, 1999). The use of electronic health records (EHRs) has grown since the IOM report, bolstered by several game-changing pieces of legislation.

HIPAA, 1996

The central theme of the Health Insurance Portability and Accountability Act (HIPAA) was to protect healthcare coverage and privacy for workers and their families as they changed jobs, it also called for the development of health information systems and standards for electronic data interchange, the methodology whereby patient information is transmitted electronically (GPO, 1996).

HITECH Act, 2009

Enacted as part of the American Recovery and Reinvestment Act of 2009, it was called the Health Information Technology for Economic and Clinical Health Act (HITECH), and it authorized Medicare and Medicaid to provide incentive payments for eligible professionals, hospitals, and critical access hospitals as they adopt, implement, upgrade, or demonstrate “meaningful use” of EHR technology. Meaningful use is defined as using certified electronic health record (EHR) technology to improve quality, safety, efficiency, and reduce health disparities; engage patients and family; improve care coordination, and population and public health; and maintain privacy and security of patient health to improve patient care (HHS, 2009; ONC, 2015; ONC, 2015a).

Affordable Care Act (ACA), 2010

Perhaps the most broad-reaching piece of healthcare legislation in American history is the Patient Protection and Affordable Care Act of 2010 (ACA). As part of the legislation’s timed roll-out, ACA mandated technologic reforms in 2012 in the use of electronic health records to improve efficiencies (HHS, 2015).

Reducing Medication Errors

Medication errors are the most common of all medical errors, thus requiring additional focus. Even simple medication mistakes can have horrific results. Fortunately, relatively simple approaches can prevent many errors.

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

The HITECH Act’s meaningful use policy has specific medication management measures:

  • Using CPOE systems for medication orders
  • Implementing decision support systems to check for drug–drug and drug–allergy interactions
  • Having the capability to electronically exchange key clinical information (such as medication lists, medication allergies, and test results) with other providers
  • Maintaining an active medication list, and
  • Maintaining an active medication allergy list (Murphy & White, 2014)

Closer to home, a study funded by AHRQ found Florida hospitals that adopted all five core measures of meaningful use for medication management in 2010 had the lowest rate of adverse drug events of all hospitals in the state. Intriguingly, hospitals where physicians objected to adopting HITECH’s meaningful use measures for medication management saw their adverse drug events increase by 14%, compared to a 52% reduction at hospitals where physicians supported the medication management meaningful use measures (Murphy & White, 2014).

The AVOID Mnemonic

Clinicians cannot rely solely on technology to prevent errors in prescribing and administering of medications. Frequent consultation with other members of the healthcare team is just as invaluable.

Use of an organized, step-wise approach also helps prevent drug interactions. The AVOID mistakes mnemonic can be used to collect all necessary information for the medication history (see table below).

 

Source: FDA, 2014.

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 OTC) 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 in adherence to a therapeutic regimen.

Mendel (genetics)

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

 

Six Rights of Medication Administration

When dispensing medications, a systematic approach such as the (DHHS) Six Rights of Medication Administration encourages providers to pause and verify that the medications they are about to give are safe and accurate.

When giving medications, regardless of the type, the following six rights must be followed:

  1. Right individual
  2. Right medication
  3. Right dose
  4. Right time
  5. Right route
  6. Right documentation (NH HHS, 2011)

Reporting an Adverse Drug Event

MedWatch, the FDA Medical Products Reporting Program, was established in 1993 to emphasize the responsibility of providers to identify and report adverse events that may be related to FDA-regulated products (FDA, 2013).

The MedWatch program has three goals:

  • Educate both healthcare providers and patients about the importance of reporting serious adverse events, product quality problems, product use errors, and therapeutic failure or lack of equivalence.
  • Facilitate and support this reporting.
  • Maintain and expand Web-based tools and processes for disseminating the resulting new safety information, ideally delivered to the point of care, for use by providers and their patients in a shared decision-making process. (FDA, 2013)

There are three ways to report an adverse event to MedWatch:

  • Complete the voluntary Form FDA 3500 online
  • Call 800 FDA 1088 to report by telephone.
  • Download a reporting form (Form FDA 3500 or 3500B (a new, consumer-oriented form) and either fax it to 800 FDA 0178 or mail it (For both forms, click this link) (FDA, 2013).

10 Patient Safety Tips for Hospitals (AHRQ)

Medical errors may occur in different healthcare settings, and those that happen in hospitals can have serious consequences. AHRQ, which has sponsored hundreds of patient safety research and implementation projects, offers these 10 evidence-based tips to prevent adverse events from occurring in hospitals:

  1. Prevent central line-associated bloodstream infections.
  2. Re-engineer hospital discharges.
  3. Prevent venous thromboembolism.
  4. Educate patients about using blood thinners safely.
  5. Limit shift durations for medical residents and other hospital staff if possible.
  6. Consider working with a Patient Safety Organization (PSO).
  7. Use good hospital design principles.
  8. Measure your hospital’s patient safety culture.
  9. Build better teams and rapid response systems.
  10. Insert chest tubes safely. (AHRQ, 2009a)

 

Video: Fostering a Culture of Safety (4:03)

This video vignette shows a fictional scenario in which a positive culture of safety overcomes multiple commonly seen barriers to infection prevention in dialysis facilities (AHRQ, 2014).

Source: http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/esrd/fosteringsafetyvid.html

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