Patient Safety

1. Patient Safety Evelyn M. Hickson, RN, MSN, CNS, WCC

2. Objectives By the end of the presentation, the participant will be able to: • Describe the most common causes of medication errors and the actions needed to ensure safe medication administration • Be able to state 4 current national patient safety goals • Describe the principle of professional, accountable communication • Identify perinatal risk management strategies

3. Patient Safety Are we as nurses responsible for ensuring patient safety? Do nurses have a medical-legal responsibility to provide safe patient care? What methods do nurses have to use to facilitate the provision of safe patient care?

4. Definition • Patient safety is a discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. Patient safety is also an attribute of health care systems; it minimizes the incidence and impact of, and maximizes recovery from, adverse events. • What Exactly Is Patient Safety? • Linda Emanuel, MD, PhD, Don Berwick, MD, MPP, James Conway, MS, John Combes, MD, Martin Hatlie, JD, Lucian Leape, MD, James Reason, PhD, Paul Schyve, MD, Charles Vincent, MPhil, PhD, and Merrilyn Walton, PhD.*, Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment). Rockville (MD): Agency for Healthcare Research and Quality; 2008 Aug.

5. 2013 Hospital National Patient Safety Goals • Joint Commission of Accredited Health Care Organizations (JCAHO or “Joint”) • Changes have been made and since the mandated implementation of NPSG from the Joint in 2004 • Not all of the current safety goals apply to the in-patient acute care setting • Hospital has 15 for 2013 – No new ones were added for this year • www.jointcommision.org

6. Identify Patients Correctly 1. NPSG.01.01.01 - Use at least two (2) patient identifiers whenever: • Giving medications • Providing Care • Giving any Treatments • Providing Services 2. NPSG.01.03.01 –Make sure that the correct patient gets the correct blood when they get a blood transfusion

7. Improve the effectiveness of communication among caregivers • NPSG.02.03.01 • Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not be used throughout the organization hs = hour of sleep bid = twice per day MgSO4 = magnesium sulfate

8. Improve the effectiveness of communication among caregivers • For verbal or telephone orders or telephone reporting of critical test results, verify the complete order or test result by having the person receiving the information record and “read-back” the complete order or test result

9. Improve the effectiveness of communication among caregivers • Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.

10. Improve the effectiveness of communication among caregivers • Implement a standardized approach to “hand- off” communications, including an opportunity to ask and respond to questions. • Clear, concise, factual, appropriate report when patient is transferring within facility, to different level of care or to another facility • Team approach to conflict

11. Professional Communication • Multiple studies and publications by JCAHO found that health care worker’s inability to communicate effectively contribute to errors and problems within health care that are typically avoidable. Medication errors Patient safety Quality of care Nursing staffing and turnover

12. Joint Commission Publications http://www.jointcommission.org/Advancing_Effective_Communication/

13. SBAR • Situation-what is going on with the patient at this time • Background-significant medical and obstetrical history • Assessment-vital signs, labs, fetal monitoring assessment • Recommendation-what you want from the MD/provider – order(s), actions,etc.

14. SBAR • Documentation • Patient Hand-off – Report • Conversations with MD/Providers

16. Other Methods • Key phrases that stop every member of the team: • Huddle • “Can I have a moment” • “Team Up” • Rounds

17. Seven Areas Where Communication Breaks Down • Broken rules – not following policy/protocols • Mistakes • Lack of support – from team, peers, administration • Incompetence • Poor teamwork • Disrespect • Micromanagement

18. Actions What actions can we as nurses take in order to attend to these 7 essential areas?

19. Broken Rules • Shortcuts can be dangerous when it comes to patient care • Policies and procedures are considered institutional standards / guidelines

20. Mistakes • Important to follow directions • Ability to make sound clinical judgments that are appropriate and individualized for the patient • Critical Thinking Skills • Assessment skills • Triaging and diagnosing • Requesting treatment and assistance

21. Lack of Support • Willingness to help, mentor, precept, answer questions, be a resource • Be an active team player – help out • Give emotional support • Pats on the back for a job well-done

22. Incompetence • Precept • Mentor • Educate • Report – at times first line of action, other times last. Patient safety comes first.

23. Poor Teamwork • Don’t participate in gossip • Participate and lead team building activities • Celebrate the things to be grateful for – the positives • Promotion of a culture that is focused on the patient – improved safety and quality of care

24. Disrespect • Do not promote or participate in: • Insulting others • Being condescending • Rude behavior • Insolent behavior • Insubordination to supervisors • Portraying yourself and your profession negatively to the public, students, patients, families and peers

25. Micromanagement • Do not participate in or allow others to: • Abuse authority • Pull rank • Bully • Threaten • Force a point of view just to be right

26. Perspective “No one can make you feel inferior without your consent” Eleanor Roosevelt

27. Improve the safety of using medications 4. NPSG.03.04.01 - Label all medications, medication containers (syringes, medicine cups, basins), or other solutions on and off the sterile field and in the areas where supplies are set up.

28. Improve the safety of using medications • Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs. • Standardize and limit the number of drug concentrations used by the organization

29. Improve the safety of using medications • 5. NPSG.03.05.01 – Take extra care with patients taking medications to thin their blood

30. Accurately and completely reconcile medications across the continuum of care • NPSG.03.06.01 • Record and pass along correct information about the patient’s medications • Compare any new medications ordered/started during hospital stay with previously used medications • Make sure the patient knows how to take them – including food and drug interactions

31. Improve the Safety of High-Alert Medications Complete lists available on www.ismp.org • Anti-arrhythmics • Anti-coagulants • Chemotherapy • Vasopressors • Insulin • Sedation and Opiates • PCA/Epidural Medications • Concentrated electrolytes

32. Other Medication Safety Recommendations • Pumps with alarm systems • Distribution Units (i.e. Pyxis) • Bar Code Scanning • Computerized Physician Order Entry • Fostering an environment of safety – improvement without blame

33. The American Hospital Association lists the following as some common types of medication errors: • Incomplete patient information (not knowing about patients' allergies, other medicines they are taking, previous diagnoses, and lab results, for example) • Unavailable drug information (such as lack of up-to-date warnings); • Miscommunication of drug orders- poor handwriting, confusion between drugs with similar names, misuse of zeroes and decimal points, confusion of metric and other dosing units, and inappropriate abbreviations • Lack of appropriate labeling as a drug is prepared and repackaged into smaller units • Environmental factors, such as lighting, heat, noise, and interruptions, that can distract health professionals from their medical tasks.

34. Medication Error Stats • 2.5 million deaths occur annually in the USA • 42% of people believed they had personally experienced a medical mistake (NPSF survey) • 44,000 to 98,000 deaths annually from medical errors (Institute of Medicine) • 225,000 deaths annually from medical errors including 106,000 deaths due to "non-error adverse events of medications" (Starfield)

35. Medication Errors • Annual cost of drug-related morbidity and mortality is nearly $177 billion in the United States • 180,000 deaths annually from medication errors and adverse reactions (Holland) • 2.9 to 3.7 percent of hospitalizations leading to adverse medication reactions

36. Medication Error Stats 7,391 deaths resulted from medication errors (Institute of Medicine) 2.4 to 3.6 percent of hospital admissions were due to (prescription) medication events (Australian study)

37. Medication Error in Perinatal Area • According to the U.S. Pharmacopeia, Center for the Advancement of Patient Safety between 1998-2002 the of the 3,775 medication errors reported in three areas of OB: • Labor and Delivery = 49% • OB Recovery = 10% • Maternity Unit = 41%

38. Medication Errors • 76.7 % of those total errors reached the patient but did not do harm • 70% of errors occurred during administration of the medication • 3.2 % reached the patient and did significant harm • 0.03% caused a death

39. Medication Errors • Most common errors in Obstetrics • Omission of the medication or missed doses • Improper dose / quantity • Unauthorized (unordered) • Wrong drug • Knowing absolute contraindications – i.e., an epidural on a anti-coagulated patient • Wrong Timing • Extra doses • Wrong administration technique

40. Top 10 Causes of Medication Errors in the Obstetrical Area • Performance Deficit • Not following protocol or policy • Communication • Knowledge deficit • Documentation • Transcription error / omission • Dispensing device • System safeguards broke down • Improper use of pumps • Drug distribution systems

41. Drugs that are commonly involved • Over 300 total in all three areas • Most common: • Insulin • Antibiotics – Ampicillin, Cefazolin, Gentamycin • Magnesium Sulfate • Oxytocin – most frequently cited medication with adverse obstetrical events that lead to professional liability claims • Prostaglandins – cervical ripening • Narcotics • Anticoagulants • Asthma Medications

42. Common Areas of Error • Infusion pumps that are not programmed correctly • Misconnected or disconnected IV tubing • Administering medications or mainline fluids through epidural catheter • Omission of an antibiotic per protocol or order • Lack of allergy information documented and patient banded at the time of medication administration • Incomplete communication and documentation

43. Prevention • 5 Rights – take the time to make sure you do them EVERY time • RIGHT MEDICATION/CONCENTRATION • RIGHT DOSE • RIGHT PATIENT • RIGHT TIME AND FREQUENCY (Even if double sign off) • RIGHT ROUTE • Evelyn’s 6th Right*** RIGHT INDICATION

44. Documentation of Medication Errors • Adverse Reaction to Medication Form PRN • Quality Improvement/Assurance Forms • Chart – just the facts • What you did • Who you notified • How the patient responded

45. Prevention of Infections • Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection.

46. Reduce the risk of health care-associated infection 7. NPSG.07.01.01 -Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. • Hospitals in WA now implementing programs were the patients are asking the medical staff if they have washed their hands prior to touching them or giving care and medications.

47. Reduce the Risk of Health Care-Acquired Infections 8. NPSG.07.03.01 – Use guidelines to prevent infections that are difficult to treat 9. NPSG.07.04.01 – Use guidelines to prevent infection of the blood from central lines 10. NPSG.07.05.01 – Use proven guidelines to prevent infection after surgery 11. NPSG.07.06.01- Use proven guidelines to prevent infections of the urinary tract that are caused by catheters

48. Reduce the Risk of Health Care-Acquired Infections • According to a report published in 2007 by the CDC, “in American hospitals alone, hospital acquired infections account for an estimated 1.7 million infections and 99,000 associated deaths each year” • Hospital-acquired infections are the sixth leading cause of death nationally, costing the health care industry $6 billion annually

49. MDRO • Study reported in Consumer Affairs in 2005: Chicago's Northwestern Memorial Hospital swabbed computer keyboards t identify if any dangerous germs were present and for how long they lived. • Contaminated keyboards with three types of bacteria that can cause life-threatening infections in severely ill hospital patients. They found that the bacteria known as VRE (enterococcus) and MRSA survived for at least 24 hours, while PSAE (pseudomonas) bacteria survived for an hour. • When volunteers tapped a key contaminated with MRSA, the bacteria spread to their hands 92 percent of the time. Contamination rates for lower for the other two bacteria -- 50 percent for VRE and 18 percent for PSAE.

50. MDRO • **A CDC study published in the current issue of the Journal of the American Medical Association : MRSA - is much more prevalent than previously thought. The study found MRSA cases tripled in the United States between 2000 and 2005, and estimated 94,360 people are infected and 18,650 die annually, killing more people annually than HIV. • ***A 2003 Centers for Disease Control and Prevention study: • 52 percent of doctors did not clean their hands between patients. • Doctor's lab coat picked up MRSA bacteria 65 percent of the time when leaning over an infected patient (1997) • 77 percent of blood pressure cuffs on rolling carts were contaminated with MRSA. (2007 study)