Preventing Medical Errors: Specifically for the Registered Dietitian in all Health Care Settings

1. Preventing Medical Errors: Specifically for the Registered Dietitian in all Health Care Settings Barbara Truitt, RD, LD/N

2. Welcome This is a two hour requirement for our Registered Dietitian Licensure “in some states”. This webinar will pose challenging questions to you and at some points we will have interactions with each other. We will review basics of medical errors with examples and how we can avoid making medical errors ourselves. We will discuss most healthcare disciplines, including dietitians!

3. Objectives • Define Institute of Medicine (IOM) definition for “Error” • Describe the interplay between medical systems and individuals that can lead to medical errors • Distinguish a bad outcome from a medical error • Describe looks alike, sound alike medications • Describe The Joint Commission (TJC) “do not use list of abbreviations”

4. Who can make a medical error?

6. According to IOM: Hospital errors rank between the fifth and eighth leading cause of death (44,000 to 100,000), killing more Americans than breast cancer (42,297), traffic accidents (43,458) orAIDS (16,516)

7. Who pays the price?

8. me, you

9. my family, friends, your family and friends

10. Institute of Medicine (IOM)Definition Error: “ The failure to complete a planned action as intended or the use of a wrong plan to achieve an aim”

11. IOMs list of “General Categories for Medical Errors” • Diagnostic errors • Treatment errors • Prevention • Other

12. Diagnostic errors • Error or delay in diagnosis • Failure to employ indicated tests • Use of outmoded tests or therapy • Failure to act on results of monitoring or testing https://www.premierinc.com/quality-safety/tools-services/safety/topics/patient_safety/index_1.jsp#IOM-1 definitions of key terms

13. Treatment • Error in the performance of an operation, procedure, or test • Error in administering the treatment • Error in the dose or method of using a drug • Avoidable delay in treatment or in responding to an abnormal test • Inappropriate (not indicated) https://www.premierinc.com/quality-safety/tools-services/safety/topics/patient_safety/index_1.jsp#IOM-1 definitions of key terms

14. Prevention • Failure to provide prophylactic treatment • Inadequate monitoring or follow-up of treatment https://www.premierinc.com/quality-safety/tools-services/safety/topics/patient_safety/index_1.jsp#IOM-1 definitions of key terms

15. Other • Failure of communication • Equipment failure • Other system failure https://www.premierinc.com/quality-safety/tools-services/safety/topics/patient_safety/index_1.jsp#IOM-1 definitions of key terms

16. How many medical error-related deaths do you think occur each year? • 50,000? • 75,000? • Over 90,000?

17. Medical errors account for ∼98,000 deaths per year in the United States

18. Medical errors can lead to death-not everyone walks away

21. Medication mistakes are a leading cause of death after traffic accidents and the largest percentage of medical errors (CDC, LA times)

22. 5 deadly medication errors http://wellness1.knoji.com/five-deadly-medication-errors/

23. Avoid removing medication labels from Rx and OTC bottles AND do not mix medications in the same bottle Follow directions on the bottle EXACTLY how prescribed Take medications either with or without food and water Do not mix Rx medications with herbal supplements Read labels when taking an OTC medication with an Rx

25. Easy to make? You decide!

27. IOM-1 Medication errors: A large percentage of medical errors are associated with medications. The National Coordinating Council for Medication Error and Prevention (NCCMERP) has approved the following working definitions specifically for medication errors: • Medication error: 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, or systems including prescribing; order communication; product labeling, packaging and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use. • Adverse drug event: An adverse drug event is any injury resulting from a medical intervention related to a drug. Examples of such injuries include heart rhythm disturbances, diarrhea, fever, nausea and vomiting, renal failure, mental confusion, rash, low blood pressure, and bleeding. https://www.premierinc.com/quality-safety/tools-services/safety/topics/patient_safety/index_1.jsp#IOM-1 definitions of key terms

28. Medication errors can occur at any stage of medication administration. These include: Ordering: wrong dose, wrong choice of drug, Transcribing: wrong frequency of drug administration, missed dose because medication is not transcribed Dispensing: drug not sent in time to be administered at the time ordered, wrong drug, wrong dose Administering: wrong dose of drug administered, wrong technique used to administer the drug, and Monitoring: not noting the effects of the given medication https://www.premierinc.com/quality-safety/tools-services/safety/topics/patient_safety/index_1.jsp#IOM-1 definitions of key terms

31. medical and medication errors can happen anywhere • In the care of healthcare professionals • Pharmacy • Family • Friends • Neighbors • Babysitters

32. Can you tell the difference? Which one is red hots and which one is Sudafed?

33. Answer The first one is Sudafed Look how closely they resemble each other, could they be mistaken in YOUR house?

34. More …. Which one are mints and which are medications?

35. Answer The first one are the mints Once again, look how closely they resemble each other See how easily an error can occur in your home?

36. Do you know about ….? Sound-alike Look-alike

37. Sound alike, look alike

38. Patient brochure/website page: “Ways You Can Help Your Family Prevent Medical Errors!”

39. Other ways we and other health care professionals can advise patients we come into contact with, suggest they: Voice concerns and all questions to the appropriate professional if it is out of your scope 2. Question side effects of medications, especially new ones 3. Prepare a list of all medicines they currently take and keep it on them and/or bring it to all doctors and ER visits 4. Request copies of labs and all test results

40. Question Have you PERSONALLY encountered any medical errors while a patient in a hospital or doctors office? ____ I have ____ I have not

41. Dietitians !

43. Here’s what the lawyers are saying …. Doctor or Hospital Liability for Negligence “When a patient is under the care of a physician while in a hospital or other facility, there is a duty owed to the patient by the physician and the institution for reasonable medical care.  If a patient must follow a specific diet plan, failure to adhere to the diet can result in medical malpractice.  Frequently, this type of malpractice occurs when there is an error on the part of the facility.  For instance, if a person must receive a diabetic, diet plan the wrong meal may be provided to the patient, resulting in serious injury.  Additionally, providing food and drink to a patient where there is an order not to do so prior to surgery can result in malpractice if the patient aspirates during the surgery.  Other ways that liability may result from failure of a physician or health facility to provide a specific diet, is by the physician or health care provider to properly obtain a full medical history.  If there is no note made to a patient’s chart about the restricted diet, a typical meal [REGULAR DIET]may be served to the patient, causing injury.  Finally, simple neglect of the patient’s dietary requirements and restrictions may result in medical malpractice.”

44. Patient Safety:Preventing Medical Errors – course for nurses “Transcription errors which can cause a patient to receive an incorrect or unordered treatment such as an erroneous procedure, medication, activity, or diet” http://www.orlandohealth.com/pdf%20folder/patient%20safety.pdf

45. Medical error “potentials” for the nutrition department: 1. Diet orders 2. Food/drug interactions 3. Fluid restrictions 4. Food allergies 5. Religious dietary restrictions 6. Patient preferences 7. Change in location/facility

46. 1. Diet order scenario Order received for Puree, thickened liquids. The kitchen gets the order, does not clarify which level of thickened is correct and gives the least restrictive: Nectar. The actual diet order was for Honey and the patient aspirates, who is responsible? Error!

47. All parties hold some level of responsibility, however, the kitchen will take the most punishment since they directly provided the inappropriate order and did not clarify. Train all staff to double check incomplete orders.

48. Risks for incorrect diet orders There are different risks for diet error, depending upon the nature of the patient’s diet plan.  For a diabetic, failure to adhere to a medically required diet plan can result in the following: • hyperglycemia • kidney problems • ketoacidosis • death

49. Risks for diet errors (continued) For a person on a low sodium or sodium free diet, failure to follow the plan can result in the following: •hypertension •stroke •heart attack •death

50. Risks for diet errors (continued) For individuals taking blood thinning medications, failure to adhere to a specific diet plan can cause: •uncontrolled bleeding •stroke •death