Medical Errors _V2 March 31, 2020 Medical Errors _V2 March 31, 2020
18 Another set of drugs are common causes of medication errors because they can be easily confused (e.g., Percocet ® [acetaminophen and oxycodone] confused with Vicodin ® [acetaminophen and hydrocodone]). The Institute of for Safe Medication Practices (ISMP) identified some specific medications classified as high-risk, meaning that they are associated with a heightened risk of causing significant patient harm when used inappropriately: 37 • Ephinephrine subcutaneous. • Epoprostenol (Flolan) IV. • Insulin U-500 (All forms of insulin are considered high-risk. Insulin U-500 has been singled out for special emphasis to bring attention to the need for distinct strategies to prevent the types of errors that occur with this concentrated form of insulin). the mediation is in the control of the healthcare professional, patient, or consumer.” 19 Medication errors are the most common type of medical error. About 1.3 million people are injured annually in the United States following such errors. 34 The incidence of medication errors varies according to patient population and clinical setting. Children and the elderly are more likely to be harmed by medication errors than other segments of the population; children are more susceptible to harm from dosing errors due to their small size, while older individuals tend to take more medications, increasing their potential for medical error and adverse drug interactions. Polypharmacy is not uncommon is patients older than 62 years. 35 Medication errors are more likely to occur in fast- paced, stressful environments such as intensive care units, where errors are more likely to be more severe and cause harm. 36 Data from the FDA show that the most common error involving medications was related to the administration of an improper dose of medicine, accounting for 41% of fatal medication errors. Administering the wrong drug and using the wrong route of administration each accounted for 16% of the errors. 34 Some drugs that are frequent causes of medication errors are commonly used (e.g., insulin and antibiotics). Others are sufficiently potent and there is little room for therapeutic error and substantial potential for harm from seemingly small mistakes (e.g., the cardiovascular drug nitroprusside, heparin, warfarin, insulin, or colchicine). • Magnesium sulfate injection. • Methotrexate, oral, nononcologic use. • Opium tincture. • Oxytocin, IV. • Nitroprusside sodium for injection. • Potassium chloride for injection concentrate. • Potassium phosphates injection. • Promethazine, IV. • Vasopressin, IV or intraosseous. In an effort to identify root causes, a great deal of attention focused on why medication errors occur. Among a variety of reasons or these mistakes are poor staffing, unskilled/new nurses, stress, personal error, and distraction.
Figure 2. Injury Severity of all RCA Cases
The authors noted that identifying the most severe ED adverse events and their preceding causes permits the development of action plans aligned to address root causes and the prioritization of action plan implementation. 27 Human error is inevitable. Although we cannot eliminate human error, we can better measure the problem to design safer systems mitigating its frequency, visibility, and consequences. Strategies to reduce death from medical care should include three steps: 1. Making errors more visible when they occur so their effects can be intercepted. 2. Having remedies at hand to rescue patients. 3. Making errors less frequent by following principles that take human limitations into account. 28 ADDRESSING ROOT CAUSES: STRATEGIES FOR REDUCING COMMON MEDICAL ERRORS Figure 3. Individual and System Responsibilities
The identification of errors needs to become more transparent. There needs to be standardized data collection and evaluation of the root cause of each error. Punishment is not helpful as it leads to the nondisclosure of errors or risk of error. Both individuals and hospital systems have unique responsibilities in the reduction of medical errors. 28 The identification of errors needs to become more transparent. There needs to be standardized data collection and evaluation of the root cause of each error. Punishment is not helpful as it leads to the nondisclosure of errors or risk of error. Both individuals and hospital systems have unique responsibilities in the reduction of medical errors. 30
A Partnership for Patients study described the most common medical errors in the United States. Nine core patient safety areas of focus were identified: 32 Adverse Drug Events (Medication Errors); Catheter Associated Urinary Tract Infections (CAUTIs); Central Line-Associated Bloodstream Infections; Injuries from Falls and Immobility; Obstetrical Adverse Effects; Pressure Ulcers; Surgical Site Infections; Venous Thromboembolism; Ventilator-Associated Events. The following are strategies might be used to enhance safety and decrease the occurrence of some of these core safety issues. Adverse Drug Events/Medication Errors: A medication error is an error, of commission or omission, at any step along the pathway that begins when a clinician prescribes a medication and ends when the patient actually receives the medication. An adverse drug event is defined as harm experienced by a patient as a result of exposure to a medication. The occurrence of an adverse drug event does not necessarily indicate an error or poor-quality care. It is estimated that approximately 50% of adverse drug events are preventable. 33 In some cases, an adverse drug event is an unseen consequence of a medication reaction with therapeutic intent. The incidence of medication errors is an issue of contention. Because definitions of medication errors can differ, many medication errors must be self-reported to be recorded, and data suggest a significant percentage of medication errors are not reported. 19 In addition, there is no central agency or institution responsible for collecting reports of medication errors, so no one knows how many medication errors actually occur. A medication error is defined as “any preventable event that my cause or lead to inappropriate medication use or patient harm while
Wrong-Site Surgery Wrong-Site Surgery Three primary strategies have been identified to reduce the likelihood of wrong-site surgery. 31 Preoperative Verification and Reconciliation. The verification and reconciliation process is typically initiated by the admitting nurse in the preoperative area, but ultimately includes all staff members. The process includes the verification of the procedure to be performed with the patient or patient representative and allows for review of all relevant documents. Any discrepancies are immediately resolved with the attending surgeon. Site Marking. The marking of the surgical site is a preoperative procedure that allows the surgeon to mark the surgical site after a verbal confirmation with the patient or patient representative, and the attending nurse. The site mark acts as a visual confirmation to not only the surgeon, but the entire surgical team. Timeout and Intraoperative Verification. The timeout is the final pause prior to initiating a surgical procedure and should include all staff participating in the procedure. Intraoperatively, a verification process should be utilized to ensure accuracy (site and side) for the consented procedure. Partnership for Patients Core Safety Measures Studies show the potential risk of some errors is far greater than others, with some likely to happen repeatedly.
Three primary strategies have been identified to reduce the likelihood of wrong-site surgery. 29 Preoperative Verification and Reconciliation . The verification and reconciliation process is typically initiated by the admitting nurse in the preoperative area, but ultimately
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