Medical Errors | Copyright © 2008 Ceufast.com

Course Contents

	Purpose    Objectives    Overview    Competency    Performance Improvement (PI)    Risk Management    Sentinel Events    Root Cause Analysis    Human Error    Human Factors Engineering    Reason's Model Inputs    The Cognitive Process        Impact of Design        Interactions with Others    Applying Human Factors Science to      Healthcare    Psychological Human Factors    Medication Errors        High-Alert Medications        Anticoagulants        Pediatric Medication        Infusion Pump Errors    Medication Reconciliation        Disruptive Behavior        Tubing Misconnection        Technology    National Patient Safety Goals    Conclusion    References    Click any section in the index above to browse to the corresponding course section

Purpose

The purpose of this course is to educate healthcare professionals about the performance improvement process, the influence of human factors in errors, how to identify situations where errors commonly occur, and how to apply strategies for prevention.

Objectives

After completing this course, the learner will be able to:

Overview

Preventable events resulting from medical errors are a factor in approximately 43,000 deaths per year. More people die from medical errors than from motor vehicle accidents or breast cancer (BRAUN, 2006). Medical errors increase expenses in additional patient care and in litigation. Serious medical errors are devastating to the patient, family, and staff.

The severe consequence of medical errors is one reason that healthcare is a highly regulated business. All healthcare organizations have to be licensed. They also have to meet industry standards, building and safety codes, Federal statutes, and state statutes.

Healthcare organizations are subject to inspection for compliance with statutes, regulations, and industry standards. Inspections can be scheduled or unscheduled. Scheduled inspections are conducted periodically. Unscheduled inspections can be conducted randomly, or they can be conducted for cause, like a patient complaint. One of the most well know inspection agencies for hospitals, is the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). It is an independent organization, meaning that JCAHO is neither a government agency, nor does it have a financial interested in any healthcare organization. If a healthcare organization meets industry standards, JCAHO accredits that organization.

Competency

Healthcare organizations must determine an individual's qualifications and ability to do the job. This involves checking education, license, experience, and credentials before an employee is hired. At least annually, staff performance is evaluated. Competency, continued licensure, and continuing education should also be checked at least annually. For licensed independent practitioners, like physicians and nurse practitioners, that process is called credentialing and privileging.

Performance Improvement (PI)

Healthcare organizations have ongoing programs to identify, correct and prevent medical errors. PI is a way to systematically monitor, analyze, and improve an organization's performance and outcomes. PI should improve an organization's performance by reducing factors that contribute to unanticipated adverse events and outcomes. Unanticipated adverse events and outcomes can be caused by poorly designed systems, system failures, or errors. Decreasing unanticipated adverse events and outcomes requires an environment where patients, families, staff, and leaders can identify and manage risks to safety. Such an environment encourages the following:

	Recognizing and acknowledging risks and unanticipated adverse events
	Initiating actions to reduce these risks and unanticipated adverse events
	Reporting internally on risk reduction initiatives and their effectiveness
	Focusing on processes and systems
	Minimizing individual blame or retribution for involvement in an unanticipated adverse event
	Investigating factors that contribute to unanticipated adverse events and sharing that acquired knowledge both internally and with other hospitals

The following are other concepts related to PI. Continuous Quality Improvement (CQI) is an approach that ensures that organizations always look for ways to improve processes and practices. Total Quality Management (TQM) is a management system that encompasses quality planning, quality control, and quality improvement. These programs are slightly different from PI, but you may hear the terms used interchangeably.

Quality Control (QC) is an ongoing, systematic measurement to determine compliance and accuracy. It is required for some equipment or measurement tests. Examples are checking the high and low control limits on a glucometer or the temperature of the medication refrigerator. QC is often a component of, or is mentioned in relationship to PI.
 

Risk Management

Risk Management (RM) is a program that is focused on eliminating or minimizing the effects of accidental losses to an organization. RM works closely with and sometimes overlaps functions with PI. The Risk Managers are involved with risk financing, through insurance companies to minimize financial losses. They usually investigate serious medical errors, institute damage control, and consult with legal council as needed.

Incident reports are an important source of information for a Risk Manager. Aggregate data from incident reports is statistically analyzed to identify areas of risk and exposure. Risk control techniques are then applied to those areas of focus. The usual techniques are avoidance, transfer, prevention, reduction, segregation, and duplication.

Avoidance is a technique that eliminates the possibility of a loss. This is also known as a forcing function. This technique involves designing equipment or processes to make it impossible to use it incorrectly. Examples are stocking only one concentration of a medication or removing concentrated Potassium Chloride from floor stock. These functions are effective, but can be inconvenient and time consuming for personnel.

Transfer is the process of negotiating with insurance companies to transfer the financial burden of a loss. This technique assumes that the loss cannot be prevented so we must be insured against those times when it happens.

Loss prevention reduces the probability or frequency of a loss but does not eliminate the chance of loss, nor does it reduce the severity of that loss. This is also known as a constraint function. This means that equipment or a process is designed to make it difficult to use it incorrectly. Examples are limiting floor stock or a policy limiting verbal orders. Constraints can help prevent errors that might be made by less experienced or distracted personnel.

Loss reduction focuses on reducing the severity of damage. For example, frequent monitoring instituted for conscious sedation procedures does not reduce the risk of the sedation being too deep. However, it allows early intervention to reverse the sedation and provide adequate oxygenation.

Segregation means that a process is totally separated from the rest of a clinical setting to reduce or eliminate errors. For example, changing the medication administration system so the pharmacist fills the order and administers the medication to a patient. This eliminates the potential error at the point the pharmacy usually hands off the medic5ttttation to nursing. However, as with most segregation techniques, it is too expensive and impractical.

Duplication means that there is a backup. For instance, having employees cross-trained. That way, someone is available to perform a job when the person who normally performs that job is unexpectedly unavailable.

Sentinel Events

JCAHO (2007, pg 1) defines a sentinel event as:

	Sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
	Such events are called “sentinel” because they signal the need for immediate investigation and response.
	The terms “sentinel event” and “medical error” are not synonymous; not all sentinel events occur because of an error and not all errors result in sentinel events.

The following events are considered a sentinel event, even if the outcome is not death or major permanent loss of function: suicide; unanticipated death of a full term infant; infant abduction or discharge to the wrong family; rape; hemolytic transfusion reaction; and surgery on the wrong patient or wrong body part (JCAHO, 2007). A near miss is a potential error that fails to cause injury by chance or because it is stopped before it occurs. The natural course of the patient's illness or underlying condition is not considered a sentinel event.

JCAHO requires accredited organizations to identify and respond appropriately to sentinel events. Appropriate response includes conducting a timely and thorough investigation, implementing improvements to reduce risk, and monitoring the effectiveness of the improvements. Healthcare organizations are encouraged to report sentinel events to JCAHO. The information from these reports is evaluated and published in the Sentinel Event Alert. It includes aggregate data, specific examples, and strategies for prevention. The Sentinel Event Alert is available on the Internet at http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/.
 

Root Cause Analysis

JCAHO requires use of root cause analysis (RCA) to investigate the processes and systems that contribute to a sentinel event. RCA is a tool that helps identify and clarify the bottom line factors that precipitate an error or near miss. RCA focuses on systems and processes, not on individual performance.

The RCA process repeatedly digs deeper into an issue by asking “Why” questions until no additional logical answers can be identified. A team of people representing the areas that are involved in an event is brought together to do this analysis. The team begins with a standardized template called an Ishikawa diagram. (Figure 1) This template is also known as a fish bone diagram or cause and effect diagram.

Figure 1, Ishikawa Diagram. The major headings are suggested and can be changed.

The team selects major headings for the diagram that will include categories of possible causes. The headings should be as independent from each other as possible to avoid confusion. The team identifies the potential factors that would cause the problem. These are written along the major branches of the diagram. For each cause listed, the team asks “why?” Those reasons are written down as smaller branches on the diagram. The rule of thumb is to ask “why” five times. When you reach a point where there is no additional logical answer to the question “why,” you have reached what is called a root cause.

Once the Ishikawa diagram is complete, the underlying causes of the event are summarized. Changes that could be made in systems and processes that would reduce the risk of similar adverse events are suggested.

One type of cause is special cause found in clinical processes. Special cause is a factor that is intermittently and unpredictably. This causes a variation that is not inherent in the system. An example is a patient has an allergic reaction to a medication that they have successfully taken in the past. The other type of cause is common cause in organization's process. Common cause is a factor that results from variation that is inherent in the process or system. RCA seeks to identify potential areas for improvement in a process or system that might help reduce the risk of occurrence of an event. An example is allowing only premixed Potassium Chloride solutions on the nursing unit will prevent the possibility of making an error in the dilution.

RCA has a limitation, which is known as the blinder effect. That is the tendency for the team to look only at one part of the process that led to the event, instead of the entire process.
 

Human Error

By nature, humans are fallible. It is unreasonable to expect error-free performance by humans. Human beings have limited mental and information-processing capabilities. Excessive levels of stress or fatigue have a negative impact on performance (ACSQC, 2004).

Every day we all face thousands of interactions with machines, systems, and each other. The vast majority of those interactions goes smoothly and unnoticed. A few interactions that force us to work outside of routine and intuition are simple annoyances with which we have learned to live. Occasionally, one of those interactions leads to an unintended result, an error. While humans can rapidly adapt to impediments blocking their path, and develop compensatory workarounds, these short-term solutions often introduce new risks. Human factors science offers better understanding of the causes of errors, the workarounds already in place, and solutions which are less likely to have negative, unintended consequences.

Human error has been implicated in 60 to 80 percent of accidents that occur in complex systems. Accidents due solely to environmental and mechanical factors have been greatly reduced over the last several years; however, those attributable to human error continue to be a problem.

Healthcare has traditionally regarded error as a moral failing. This places an unsustainable burden of perfection on clinicians (ACSQC, 2004). This attitude impedes efforts to identify errors their frequency, their effects, and how to best protect patients (ACSQC, 2004).

Solutions reached by trial and error or workarounds might simply shift the risk elsewhere. While “fixed by common sense” may often be sufficient, common sense can also benefit from science and engineering.

Human factors science discovers and applies information about human behavior, abilities, limitations, and other characteristics to the design of tools, machines, systems, tasks, jobs, and environments for productive, safe, comfortable, and effective human use. Human factors science is not just applying checklists and guidelines, not just using oneself as the model for designing things, and it is not just common sense.
 

Human Factors Engineering

Human factors engineering uses systems analysis. Humans are considered a critical system component. Human factors analysis focuses on human operators to determine what they are required to do. It combines the scientific methodology familiar to clinicians to explore the causes of error with an engineering approach of task analysis. Human factors analysis goes further than Root Cause Analysis (RCA). This methodology includes:

	Systematic observation of procedures
	Interviews and focus groups
	Activity recording and charting
	Analysis of fatigue and distraction factors
	Analysis of information flow
	Developing and testing models of expected effectiveness

British Psychologist Professor James Reason (1990) developed a model of human error based on the premise that adverse outcomes are the result of a combination of factors of systemic issues such as resource availability, organizational policies and procedures, and human functional errors. Reason's model is called the Swiss cheese model because every layer of defense against errors has it holes; the more layers, the smaller the risk of causing harm (ACSQC, 2004). There is less chance of the holes lining up to allow an error to occur.

Reason's Model Inputs

	Organizational factors

	Excessive cost cutting
	I nadequate promotion policies

	Unsafe supervision

	Deficient training
	I mproper staffing mix

	Preconditions for unsafe acts

	Poor teamwork
	Poor resource management
	Loss of situational awareness

	Unsafe acts

	Incorrect calculation of dosage
	Workarounds
	Using equipment in a way that it was not designed to be used
	Did not communicate all the information
	Quality control checks not done

Reason (1990) said that “we cannot change the human condition, but we can change the conditions under which humans work.” Using his model it is easier to understand that errors reflect problems at the practical level and the systemic level. A safe reporting system is used to ensure system integrity is monitored (ACSQC, 2004).

The Cognitive Process

The human cognitive process is how we remember, think, develop and use motor skills to perform activities individually, in teams and within organizational systems.

	Perception equals input - information perceived through the sensory system. With distracted or blurred perception (insufficient light, ambient noise, etc.) you are unable to take in sensory information, and more prone to misread a label or mishear spoken words.
	Long-term memory information acquired through education and experience are stored in long-term memory. When long-term memory experiences interference (e.g. distraction, multi-tasking) there is difficulty retrieving and applying previously learned information.
	Working memory – information from the sensory fields (perception) and long-term memory combine to do the work we label “thinking.” Thinking combines sensory input with stored knowledge to call up frequently used patterns and criteria that have been developed through common use to make decisions. When overloaded through physical or emotional demands, there is increased risk of making incorrect judgments based on confusion, or applying learned rules incorrectly.

Impact of Design

The impact of design on human factors has four different types of interactions and a wide variety of applications. The science applies an understanding of theories of physical, cultural, and psychological factors to the reduction in flawed behavior.

Interaction with machines and objects is the most studied area of human factors problems. Most human errors related to human/machine interactions are due to either the condition or training of the operator, bad design of the machine interface, or both. A bad design is one that does not conform to intuitive application. Design flaws can lead to incorrect use of equipment. Speed, stress, and fatigue increase the likelihood that bad design will lead to error.

Negative impacts of the work environment exist even with the best designed objects and machines. Human factors problems are encountered, stemming from the physical world around us. Physical space, layout, temperature, light, air quality, noise levels, and visual distractions can all interfere with or alter the ability to perform an activity. When these factors become obstacles they can manifest as inconveniencies or can be harmful. Fatigue from loss of sleep, circadian rhythm changes, and muscular effort expenditure has been identified as one of the major contributors to errors.

As creatures of habit, humans often seek to “workaround” a new system in order to maintain an old mind set. For example, to help technicians correctly assemble devices with multiple components, matching barcodes were encoded on adjoining components. By swiping each piece, correct assembly was assured. However, reviewers discovered that the procedure was frustrating for some users who, as a workaround, put matching copies of the bar coding on a paper and scanned the paper instead of the equipment pieces, enabling incorrect assembly. Nurses, too, have found that it is easier to scan the patient label from the medication administration sheet rather than taking the medication cart with scanner to the patient bedside to scan the patient identification band on the patient's wrist.

When a system problem is solved in isolation and without consideration of how it might affect the rest of the system, unintended consequences can undo the benefit of the fix. An example of this is a computerized forcing function programmed into a hospital medication system to prevent the over-administration of potassium. This inadvertently prevented the administration of high doses when they were needed. A solution can exacerbate existing minor problems or actually create new opportunities for errors. This is the unintended consequence. Piloting and field testing solutions helps identify these “downstream consequences.”

Human factors problems related to practice environment tend to be more transient than design problems. Lighting, noise, temperature, even physical space, can change from one patient encounter to the next. If the healthcare provider works in multiple practice settings, the opportunity for environmentally-related problems are equally multiplied. Other issues may include things like:

	Equipment models or brands vary
	Equipment storage is too high
	Equipment is not conveniently located
	Equipment is not located in a consistent place
	Environment is not set up to allow effective eye contact and discussion

Interactions with Others

In a variety of clinical services, care is provided through changing teams of providers over various timeframes and supported by many administrative personnel. Each person acts in his or her capacity to attend to the patient's needs through his or her own professional and personal lens of mental model. Inadequate communication can lead to misalignment of mental models. Interactions among teams and entire systems of healthcare providers are an important area of human factors study. Inadequate communication was the second most frequent risk management issue identified in claims made from 1996 to 2000. Handoffs, passing on information or responsibility are a particular patient safety problem area.

Mental models are a deeply ingrained assumption, generalization, or even pictures/images that influence how we understand the world and how we take action. When two people have different mental models of the same situation or process, they are at risk of misinterpreting each other's directions or intentions.

Teams of people working together need to share a common understanding of what needs to be done and how, for example, the same mental model. Teams need efficient communication that is remembered at least long enough for the recipient to take proper action as a result.

Applying Human Factors Science to Healthcare

Human factors apply wherever humans work. In healthcare, work environments are hazardous. Instruments are potential weapons; drugs are a potential poison; and every worker is a potential killer (ACSQC, 2004). The following are human factors problem areas in healthcare:

	Equipment changes and upgrades (training inadequate)
	Handoffs (poor communication)
	Infusion pumps (poor human interface)
	Fatigue
	Labeling (look alike, sound alike)
	Handling sharps
	Retained foreign bodies in surgery
	Patient bed alarms (false alarms and falls)
	Physician order entry (illegible, verbal orders, transcription errors)
	Wrong site surgery

Accept human factors problems as an inevitable, although manageable, part of everyday practice. Shift from a punitive to a creative frame of mind that seeks out and identifies the underlying system failures. Efficient, routine identification of human factors need to be part of every practice, as well as routine investigation of all human factors problems that cause injuries.

Not all design flaws in healthcare environments are obvious hazards. One of the most subtle mistakes is failure to realize that the best-motivated and most highly-trained professionals are potentially lethal agents (ACSQC, 2004). Fatigue management in healthcare is a big challenge. Long before becoming drowsy, fatigue can seriously impair critical thinking ability, often referred to as inattention. Studies show that 24 hours of wakefulness impairs cognitive performance to the same extent as a blood alcohol level of 0.1 percent, affecting the frontal lobe memory processes of: attention, concentration, reasoning, sensory recognition and verbal/nonverbal communication (ACSQC, 2004). The actual onset of fatigue occurs somewhere between well-rested and over-worked (ACSQC, 2004). Fatigue varies between individuals and may have a synergistic effect with other factors, such as state of mind, motivation, and over-the-counter or prescription medication. Negative factors in healthcare that decrease motivation, and therefore, can bring on fatigue at an early stage include (ACSQC04):

	Continuing demands for increased output (heavier patient loads)
	Undervaluing of healthcare workers
	Many inefficiencies which prevent people from working smarter

Psychological Human Factors

Everyone needs some stress; otherwise life would be dull and unexciting. Stress adds flavor, challenge, and opportunity to life. It has also been said that stress is a good motivator, but working when over-stressed, irritated, upset, or shaken will substantially alter one's judgment and can compromise patient safety. Too much stress can seriously affect physical and mental well being. The angry healthcare provider is aggressive, offensive, and careless, and as a result is dangerous. Stressful conditions involving personal or business life will cause distractions that can interfere with the provision of safe patient care. They should be recognized and addressed as negative influences on workplace habits.

The clinician should evaluate his or her state of mind before providing patient care such as medication administration. Providing patient care takes a clear and focused mind, uncluttered by thoughts of aggravation and distress. The healthcare provider with a wandering mind caused by any one of the aforementioned effects has a decreased awareness of the subtle changes in patient status, a slower reaction time, and an overall lack of concentration. The ability to anticipate complications and to determine appropriate responses is also adversely affected. A major challenge in this stress filled world of today is to use stress in a positive way and prevent it from becoming distress.

The emotionally distressed healthcare provider is more apt to make a medical error than is the rested, clear-headed provider. It should be made clear that tired, disturbed, or cluttered minds decreases critical thinking ability. When disturbed by emotions, the healthcare provider is not concentrating on what they are doing; he or she is concentrating on what has him or her upset. This could manifest in increased risk taking behavior such as taking shortcuts, failing to follow policy, and not paying attention to the details. Unsafe behaviors can contribute to increased risk of medical error.

With severe emotional distress, an individual could turn to substance use or abuse to hide emotional pain. Combined with heavy workloads, this increases the likelihood of error. With the increased risk-taking behavior, aggression could result. The clinician is then labeled as “difficult to work with.” Unchecked emotions can lead to aggressive behavior and disciplinary action. The emotionally distressed mind is not capable of rational function or critical thinking required to provide safe patient care. Managers need to recognize the emotionally distressed clinician.

Standards of practice and hospital policies are instituted and established for patient safety. Policy may not specifically cover special situations; but, most clinicians agree there is a need for policies and standards of practice. Unsupervised and uncontrolled practice would lead to chaos. Some healthcare providers despise the increase in the number of “rules.” They stress the negative side of policies rather than the goal for increased patient safety. It must be understood that policies and standards of care can benefit them and should be supported and followed.

Patient safety focus by the following groups has increased the number of policies and standards of practice that decrease medical errors.

	Joint Commission on Healthcare Accreditation Organization (JCAHO)
	Agency for Healthcare Research and Quality (AHRQ)
	Leap-Frog Group
	National Quality Forum (NQF)
	National Patient Safety Foundation (NPSF)
	Institute for Safe Medication Practices (ISMP)

Healthcare providers should be aware that circumstances and attitude changes could dramatically affect practice habits. Some attitudes that predispose to risk taking behavior and increase the risk of errors are:

	Enjoying the thrill of crisis situations
	Enjoying impressing coworkers
	Disregarding personal safety
	The illusion of control or overestimating abilities
	Justifying risks because they are taken in a noble cause

Design work to minimize the requirements for particularly fallible human functions such as short-term memory and tasks requiring prolonged attention. For instance, don't rely on memory to retrieve a laboratory test result or the time a medication is due. Systemizing these tasks reduces memory related errors.

Reduce reliance on memory for high-risk procedures, or multi-step processes, by using checklists. Review checklists to insure appropriateness and avoid increasing error through workarounds that make more errors. While surgical areas generally use preoperative checklists already, it may be wise to use checklists in handoff situations as well. Couple brief, useful protocols with procedures developed by the healthcare teams who provide the services. Standardize color match items that are used together to prevent slips such as clinicians combining items that should not be used together. Pre-package component items into kits.

As the volume of information increases you need creative ways for making it more readily available, displaying it where clinicians need it when it is needed. Making information available at the point of care will make a significant impact on error reduction. Many medication-related claims are the result of clinicians making decisions about treatment without having all of the appropriate information available. Create forms to promote accurate documentation and electronic ticklers for tracking test results. Block avenues to workarounds that cut out important transmission of information.

Complexity increases the opportunity for errors. Where possible, critical tasks should be structured so that errors cannot be made. The reliability of a system can be improved by perfecting its parts and handoffs, but reducing complexity is even more powerful.

Medication Errors

Nurses are most likely to be blamed for medication errors because they are involved at the administration point. However, medication errors are complex and are rarely the result of one person's actions. The medication system in hospitals is complicated. There are multiple steps and many individuals involved. Every time a document or medication changes hands, there is an increased potential for error.

Administering medication is a crucial nursing responsibility. To ensure safe and effective drug therapy, the nurse must to be familiar with indications, usual dosages, and intended effects of drugs. Remember the 5 rights: right patient, right drug, right dose, right route, and right time. Each patient must be assessed before administration and medication should be delayed or withheld if indicated.

The types of medication errors include: prescribing, omission, wrong time, unauthorized drug, improper dose, wrong drug preparation, wrong administration techniques, deteriorated drugs, improper monitoring and compliance, product errors, process errors and human errors. Areas that are particularly error prone are:

	Verbal orders
	Handwritten orders
	High-alert drugs
	Infusion pump errors
	Look alike, sound alike drugs names

Handwritten and manually transcribed physician orders leave a lot of opportunity for errors. A computerized physician order entry, in which the physician must enter all orders by computer, eliminates handwriting and transcription errors. It also makes it possible to automatically check doses, drug-drug interactions, allergies and significant patient characteristics, like allergies and impaired renal function.

A computerized order entry system presents its own set of problems. There is a significant expense that smaller facilities may not be able to afford. Cost prohibitions or lack of space may limit the number of PCs to the point that practitioners have long wait times for computer access. It seems slow and inconvenient at times. In addition, physicians who are less computer savvy may be resistant to change.

A listing and resource for look alike, sound alike drugs can be found at the following website http://www.jointcommission.org/NR/rdonlyres/C92AAB3F-A9BD-431C-8628-11DD2D1D53CC/0/LASA.pdf.

High-Alert Medications

Study has shown that the majority of medication errors resulting in death or serious injury were caused by a list of specific medications. The top 5 high–alert medications were: insulin; opiates and narcotics; injectable potassium chloride (or phosphate); intravenous anticoagulants, and sodium chloride solutions above 0.9% (JCAHO, 2007). The following are drug specific strategies for prevention of medication errors.

Insulin:
	Establish a check system where one nurse prepares the dose and another nurse reviews it.
	Do not store insulin and heparin near each other.
	Spell out the word unit instead of using the abbreviation U.
	Build in an independent check system for infusion pump rates and concentration settings.

Opiates and Narcotics:
	Limit the opiates and narcotics available in floor stock.
	Educate staff about hydromorphone and morphine.
	Implement PCA protocols that include double checks of the drug, pump settings, and dosage.

Injectable Potassium Chloride (KCL) (or Phosphate):
	Remove concentrated KCL from floor stock.
	Move the drug preparation off the units and use commercially available premixed IV solutions.
	Standardize and limit drug concentrations.

Intravenous Anticoagulants:
	Standardize concentrations and use premixed solutions.
	Use only single-dose containers.
	Separate heparin and insulin.
	Remove heparin from the top of medication carts.

Sodium Chloride Solutions Concentration above 0.9%:
	Remove sodium Chloride concentration solutions above 0.9% from nursing units.
	Standardize and limit drug concentrations.
	Double check pump rate, drug concentration and line attachments.

Anticoagulants

The anticoagulants most commonly used and most frequently involved in medication error are unfractionated heparin, warfarin and enoxaparin (JCAHO, September 08). Contributing factors to medication error with the use of anticoagulants include (JCAHO, September 08, pg 1):

	Inadequate screening of patients for contraindications and drug interactions.
	Lack of standardized naming, labeling and packaging
	Keeping up the changes to the different dosing regimens, drug interactions and reversal agents is difficult, particularly for practitioner who not routinely prescribe anticoagulants
	Failure to document or communicate individualized instructions and current lab results during hand-offs
	Pediatric administration errors because anticoagulants are formulated and packaged for adults,

Risk reduction strategies (JCAHO, September 08, pg 1):

	Improve staff communication and information access
	Involve the patient in the management of anticoagulation therapy
	Implement a pharmacist managed anticoagulation service
	Use computerized provider order entry or barcoding technology

Other JCAHO recommendations (JCAHO, September, pg 1):
For all anticoagulants:

For heparin:

For warfarin:

Pediatric Medication

Patient weight is the basis for calculating a lot of dosing of pediatric medications. Therefore an accurate weight should be done before administering any weight based medications, except in emergencies. The kilogram should be the standard for all pediatric weights. Pediatric patients are more prone to medication errors and more likely to be harmed from medication errors because (JCAHO, April 2008, pg 1):

	Most medications used in the care of children are formulated and packaged primarily for adults. Therefore, medications often must be prepared in different volumes or concentrations within the health care setting before being administered to children. The need to alter the original medication dosage requires a series of pediatric-specific calculations and tasks, each significantly increasing the possibility of error.
	Most health care settings are primarily built around the needs of adults. Many settings lack trained staff oriented to pediatric care, pediatric care protocols and safeguards, and/or up-to-date and easily accessible pediatric reference materials, especially with regard to medications. Emergency departments may be particularly risk-prone environments for children.
	Children - especially young, small and sick children - are usually less able to physiologically tolerate a medication error due to still developing renal, immune and hepatic functions.
	Many children, especially very young children, cannot communicate effectively to providers regarding any adverse effects that medications may be causing.

JCAHO (April 2008, pg 1) recommends the following pediatric-specific strategies for reducing medication errors:

Standardize and identify medications effectively, as well as the processes for drug administration.

	Establish and maintain a functional pediatric formulary system with policies for drug evaluation, selection and therapeutic use.
	To prevent timing errors in medication administration, standardize how days are counted in all protocols by deciding upon a protocol start date (e.g., Day 0 or Day 1).
	Limit the number of concentrations and dose strengths of high alert medications to the minimum needed to provide safe care.
	For pediatric patients who are receiving compounded oral medications and total parenteral nutrition at home, ensure that the doses are equivalent to those prepared in the hospital (i.e., the volume of the home dose should be the same as the volume of the hospital prepared products).
	Use oral syringes to administer oral medications. The pharmacy should use oral syringes when preparing oral liquid medications. Make oral syringes available on patient care units when “as needed” medications are prepared. Educate staff about the benefits of oral syringes in preventing inadvertent intravenous administration of oral medications.

Ensure full pharmacy oversight - as well as the involvement of other appropriate staff - in the verifying, dispensing and administering of both neonatal and pediatric medications.

	Assign a practitioner trained in pediatrics to any committee that is responsible for the oversight of medication management.
	Provide ready access, including website access, to up-to-date pediatric-specific information for all hospital staff. This information should include pediatric research study data, pediatric growth charts, normal vital sign ranges for children, emergency dosage calculations, and drug reference materials with information about minimum effective doses and maximum dose limits.
	Orient all pharmacy staff to specialized neonatal/pediatric pharmacy services in your organization.
	Provide a dosage calculation sheet for each pediatric critical care patient, including both emergency and commonly used medications.
	Develop preprinted medication order forms and clinical pathways or protocols to reflect a standardized approach to care. Include reminders and information about monitoring parameters.
	Create pediatric satellite pharmacies or assign pharmacists and technicians with pediatric expertise to areas or services such as neonatal/pediatric critical care units and pediatric oncology units. At a minimum, pediatric medications should be stored and prepared in areas separate from those where adult medications are stored and prepared.

Use technology judiciously.

	Use methods to ensure the accuracy of technology that measures and delivers additives for intravenous solutions, such as for total parenteral nutrition.
	If dose and dose range checking software programs are available in hospital or pharmacy information systems, enable them to provide alerts for potentially incorrect doses.
	Medications in automated dispensing cabinets that do not undergo appropriate pharmacist review should be limited to those needed for emergency use and/or to those medications under the control of a licensed independent prescriber, as specified in Joint Commission standard MM 4.10.
	Recognize that the use of infusion pumps, or smart pumps, is not a guarantee against medication errors. Appropriate education for nurses, pharmacists and other caregivers regarding these technologies is important for all institutions caring for pediatric patients.
	To prevent adverse outcomes or oversedation, use consistent physiological monitoring – particularly pulse oximetry – while children are under sedation during office-based procedures. Use age- and size-appropriate monitoring equipment and follow uniform procedures under the guidance of staff appropriately trained in sedation, monitoring and resuscitation.
	Providers are encouraged to develop bar-coding technology with pediatric capability. Potential errors should be carefully considered while adapting this technology to pediatric processes and systems. For example, a pediatric bar-coding solution must be able to provide readable code for small-volume, patient-specific dose labels.

Infusion Pump Errors

The types of infusion pump errors seen are the use of pumps that do not protect from free–flow of fluids to the patient, the wrong drug concentration, or the wrong rate is set.

Free-flow of fluids occurs when the infusate flows freely, under the force of gravity, without being controlled by the infusion pump. Infusion pump tubing needs a built in, anti-free-flow mechanism. This prevents gravity free-flow by closing off the tubing to prohibit flow when the administration set is removed from the pump. If an infusion pump does not have free-flow protection, devices that attach to the administration set are available. However, they are not recommended, because the mechanisms are packaged separately and must be manually attached to a set. Clinicians may forget to use the mechanism or may accidentally remove them.

Training and education are important in the prevention of infusion pump administration errors. Be sure to inservice staff who may not be administering medication, but may be handling the infusion pumps, such as aides, radiology technicians and transporters. Another concern is that patients, family members or visitors may mishandle pumps.

Key bump errors can cause errors in the volume or infusion rate. These should be double checked after entry and before starting the pump. Having a second nurse check calculations and settings for infusion pumps when high-alert drugs are used is recommended.

Medication Reconciliation

Medication reconciliation is done to avoid medication errors. Hand-off situations are prone to errors. Errors can be omission, duplication, contraindications, prescription errors and administration errors. Therefore, the process should be done every time a patient has a hand off (transition in care). A hand-off includes change in setting, service, practitioner, or level of care (JCAHO, January 2006). Medication reconciliation has five steps (JCAHO, January, 2006, pg 1):

	develop a list of current medications
	develop a list of medications to be prescribed
	compare the medications on the two lists
	make clinical decisions based on the comparison
	Communicate the new list to appropriate caregivers and to the patient.

When the patient has difficulty with the instructions, someone must be designated and taught about the patient's medications.

Risk reduction strategies include (JCAHO, January, 2006, pg 1):

	Collect a complete list of current medications (including dose and frequency along with other key information) for each patient on admission.
	Validate the home medication list with the patient (whenever possible).
	Assign primary responsibility for collecting the home list to someone with sufficient expertise, within a context of shared accountability.
	Use the home medication list when writing orders.

Place the reconciling form in a consistent, highly visible location within the patient chart (easily accessible by clinicians writing orders).

	Assign responsibility for comparing admission orders to the home medication list, identifying discrepancies, and reconciling variances to someone with sufficient expertise.
	Reconcile medications within specified time frames (within 24 hours of admission; shorter time frames for high-risk drugs, potentially serious dosage variances, and/or upcoming administration times).
	Adopt a standardized form to use for collecting the home medication list and for reconciling the variances (includes both electronic and paper-based forms).
	Develop clear policies and procedures for each step in the reconciliation process.
	Provide access to drug information and pharmacist advice at each step in the reconciliation process.
	Improve access to complete medication lists at admission.
	Provide orientation and ongoing education on procedures for reconciling medications to all health care providers.
	Provide feedback, on-going monitoring.

JCAHO recommendations include (JCAHO, January, 2006, pg 1):

Disruptive Behavior

Medical errors are fostered by intimidating and disruptive behaviors. Left unchecked, these behaviors lead to increased turnover, interfere with communication, and interfere with teamwork. “It is important that organizations recognize that it is the behaviors that threaten patient safety, irrespective of who engages in them” (JCAHO, July 08, pg 1)..

Most healthcare providers have experienced or witnessed intimidating or disruptive behaviors. One survey reported that “40 percent of clinicians have kept quiet or remained passive during patient care events rather than question a known intimidator” (JCAHO, July 08, pg 1). Intimidating and disruptive behaviors include active and passive behavior such as (JCAHO, July 08, pg 1):

When manifested by health care professionals in positions of power, these behaviors include (JCAHO, July 08, pg 1):

Disruptive behaviors are often not address because the behavior is not reported. There is fear of retaliation, the stigma of whistle blowing, and reluctance to confront an intimidator. In one survey, almost 39 % of physician acknowledged that physicians who generate high revenue are treated more leniently concerning behavior problems (JCAHO, July 08).

January 1, 2009, JCAHO implemented a new Leadership standard (LD.03.01.01) that addresses disruptive and inappropriate behaviors in two elements of performance (JCAHO, July 08, pg 1):

Tubing Misconnection

Misconnection of tubing can lead to patient deaths. Causative factors include (JCAHO, April, 06, pg 1)::

	Luer connectors enable functionally dissimilar tubes or catheters to be connected
	the routine use of tubes or catheters for unintended purposes
	the positioning of functionally dissimilar tubes used in patient care in close proximity to one another
	movement of the patient from one setting or service to another
	staff fatigue associated with working consecutive shifts

Error reduction recommendations include (JCAHO, April, 06, pg 1):

Technology

Health information technology and converging technologies have been found to contribute to medical errors. Care must be taken when implementing new technology. Contributing factors include (JCAHO, December 08, pg 1)::

	Inadequate technology planning can result in poor product selection, a solution that does not adapt well to the local clinical environment, or insufficient testing or training
	Failing to include front-line clinicians in the planning process,
	Failing to consider the costs and resources needed for ongoing maintenance
	Failure to consult product safety reviews or alerts or the previous experience of others
	Implementing new clinical information systems can expose latent problems or flawed processes with existing manual systems
	An over-reliance on vendor advice can lead to problems
	Learning to use new technologies takes time and attention, sometimes placing strain on demanding schedules
	Failure to quickly fix technology when it becomes counterproductive can lead to dangerous workarounds
	Excessive alerts leads to alert fatigue, where staff overlook important alerts

Recommended actions include (JCAHO, December 08, pg 1):

Training should be appropriately designed for the local staff. Focus training on how the technology will benefit patients and staff, i.e. less inefficiency, fewer delays and less repeated work. Do not allow long delays between orientation and system implementation.

National Patient Safety Goals

JCAHO has made patient safety a priority and is seeking to promote specific improvements in patient safety. The mechanism for doing this is the use of National Patient Safety Goals (NPSGs) as a major focus for accreditation visits (JCAHO, 2007). The NPSGs highlight problematic areas and seek system wide solutions and are being updated annually. The following are links to NPSGs for other healthcare settings that are available at http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/.

Click on a name in the list below to be taken to the website.

	Ambulatory Care and Office-Based Surgery
	Assisted Living
	Behavioral Healthcare
	Critical Access Hospital and Hospital
	Disease-Specific Care
	Home Care
	Laboratory
	Long Term Care
	Networks

The following are the 2010 NPSGs applicable to acute care hospitals and the Universal Protocol (JCAHO, 2010 pg1):

I. Goal 1 - Improve the accuracy of patient identification.   A. Use of Two Patient Identifiers (NPSG.01.01.01)       C. Eliminating Transfusion Errors (NPSG.01.03.01) II. Goal 2 - Improve the effectiveness of communication among caregivers.   C. Timely Reporting of Critical Tests and Critical Results (NPSG.02.03.01) III. Goal 3 - Improve the safety of using medications.   D. Labeling Medications (NPSG.03.04.01)       E. Reducing Harm from Anticoagulation Therapy (NPSG.03.05.01) VII. Goal 7 - Reduce the risk of health care–associated infections.   A. Meeting Hand Hygiene Guidelines (NPSG.07.01.01)       C. Preventing Multidrug-Resistant Organism Infections (NPSG.07.03.01)       D. Preventing Central Line–Associated Blood Stream Infections (NPSG.07.04.01)       E. Preventing Surgical Site Infections (NPSG.07.05.01) VIII. Goal 8 - Accurately and completely reconcile medications across the continuum of care. Note: All requirements for Goal 8 are not in effect at this time.   A. Comparing Current and Newly Ordered Medications (NPSG.08.01.01)       B. Communicating Medications to the Next Provider (NPSG.08.02.01)       C. Providing a Reconciled Medication List to the Patient (NPSG.08.03.01)       D. Settings in which Medications Are Minimally Used (NPSG.08.04.01) IX. Goal 9 - Reduce the risk of patient harm resulting from falls. XIV. Goal 14 - Prevent health care–associated pressure ulcers (decubitus ulcers). XV. Goal 15 - The organization identifies safety risks inherent in its patient population.   A. Identifying Individuals at Risk for Suicide (NPSG.15.01.01) Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™ I. Universal Protocol   A. Conducting a Pre-Procedure Verification Process (UP.01.01.01)       B. Marking the Procedure Site (UP.01.02.01)       C. Performing a Time-Out (UP.01.03.01)

Do Not Use Abbreviations are also a focus of JCAHO accreditation visits. The following is the official list (JCAHO, 07).).

Conclusion

Healthcare professionals have a responsibility to be knowledgeable about the PI process and to participate as opportunity presents. Healthcare professionals also have a responsibility to be aware of clinical situation that are prone to error, and to participate in procedures to prevent those errors.

Systems redesign to prevent all such errors should be based on a balanced utilization of evidenced-based technology, training, on-going education, standards of practice and best practices, keeping in mind each human's inherent cognitive and physical limitations.

Human factors lead to medical errors. Human factors errors can be reduced through the application of scientific method. Human errors are inevitable within healthcare settings. Human factors analysis needs to be part of every medical error investigation.

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