These data suggest the most common medication errors are related to an improper dose of medication, administering the wrong dose of medication or the wrong drug, or administering medication via the wrong route. 34 The FDA has also commented on common causes of medication errors as follows: poor communication; ambiguities in product names, directions for use, medical abbreviations, or writing; poor procedures or techniques; patient misuse because of poor understanding of the directions for use of the product; job stress; lack of knowledge or training; similar labeling or packaging. 38 The following list describes the most common causes of medication errors according to specific definitions: 37 • An action-based medication error is defined as the performance of an unintended. Examples of action-based medication errors would include selecting the wrong medication or administering an incorrect dose. • A rule-based medication error occurs because the provider did not follow proper rules or procedures for medication administration. • A memory-based medication error occurs
• Ensure that handoffs involve the transfer of essential information when the responsibility for care shifts from one provider to another. • Use barcode technologies and electronic health records with computerized prescriber order entry. • Involve pharmacists throughout a patient’s hospitalization. • Require providers who are administering medicine to wear a colored sash or vest to prevent interruptions. • Have two providers independently verify doses prior to administering medication. Central-Line Associated Bloodstream Infections: In 2020, 3,687 general acute care hospitals in the US reported 21,399 central-line associated blood stream infections, which represent a significant increase in infections between 2019 and 2020. 40 Strategies to reduce the incidence of central-line associated bloodstream infections are outlined below. Hand Hygiene: Proper hand hygiene is the most important infection control measure and the most effective way to prevent the transmission of healthcare-associated infections. 41 Maximum Sterile Barrier Precautions: Maximum sterile barrier precautions must be taken when inserting the venous catheter. These precautions include, not only the person inserting the catheter, but anyone assisting with the procedure and the patient as well. 42 Skin Antisepsis; An alcoholic chlorhexidine antiseptic should be used for skin preparation that contains more than 0.5% CHG in patients over 2 months of age. 42 Povidone- iodine or alcohol may be used in patients 2 months or younger. Skin antisepsis should be performed at the time of insertion and with every dressing change 43 Busby et al., 2015). Selection of Catheter Site: The site of insertion is important to optimal outcomes. The use of the subclavian site is preferred to the jugular or femoral sites in adults to minimize infection risk. 43 Dressing Change: Dressings for insertion sites must be impermeable to water vapor. They can be either sterile gauze or sterile transparent, which is semipermeable dressing that covers the catheter insertion site. Topical antibiotic ointments or creams should not be applied to the insertion site because of the possibility of promoting fungal infections or pathogen resistance. Dressings are changed when they become wet, loose, or soiled. 42 43 Assessment and Removal: The catheter should be removed as soon as it is no longer needed. The risk for infection increases with the length of time the device is left in place and decreases when the catheter is removed. 42, 43 Injuries from Falls and Immobility: Patient falls that cause serious injury are among the top 10 sentinel events reported to The Joint Commission Sentinel Even Database. 44 Falls are among the leading causes of injury and death among Americans older than 65 years .
Almost one-third of adults in this age group report a fall every year, and the annual cost of falls to Medicare is approximately $31 billion. 45 A study found that rates of falls were even higher in patients with chronic kidney disease, which is common in older adults with comorbidities. 46 The Joint Commission reports that from January 2009 through October 2014, the most common contributing factors contributing to reported falls included. 44 • Communication failures. • Deficiencies in the physical environment. • Failure to adhere to protocols and safety practices. • Inadequate assessment. • Inadequate staff orientation, supervision, staffing levels, or skill mix. • Lack of leadership. Pressure Ulcers: Although most hospital- acquired pressure ulcers area reasonably preventable, approximately 2.5 million Americans develop a pressure ulcer in US acute care facilities every year. 47 These injuries can result in extensive harm, including chronic wounds, and as many as 60,000 deaths annually. 47 Hospital-acquired pressure ulcers are responsible for a huge financial burden. According to a recent estimate, based on 2016 dollars, the national burden of hospital-acquired pressure ulcers could exceed $26.8 billion. The cost of treatment was estimated to be approximately $10,708 per person. 47 Approximately 59% of the costs associated with these ulcers are attributable to a small number of patients with stage 3 and 4 full-thickness wounds. 47 There are a number of factors that increase risk for pressure ulcers 48, 49 : • Advanced age: An elderly person’s skin has less subcutaneous fat, which leads to decreased protection from pressure. • Friction/Shear: Decreases the epidermal layer, reducing protection of the skin. • Hypotension: Increases the response of local tissues, making skin more vulnerable to breakdown. • Immobility: Lack of mobility can lead to sustained pressure on bony prominences. • Length of stay in critical care units: Longer stays are indicative of more critical conditions. Such conditions are generally associated with decreased mobility and position change and increased shear force, all of which increase the risk for skin breakdown. • Length of time on mechanical ventilation: Indicates inadequate oxygenation and the need to provide ventilation mechanically. Decreased oxygen levels mean decreased oxygen to body tissues, including the skin. • Moisture: Moisture (e.g., incontinence, sweat, failure to dry skin after bathing) contributes to skin breakdown. • Nutrition: Inadequate nutrition alters the proper state of the skin, contributing to skin breakdown.
when a provider forgets to perform a task or forgets important information about the patient. The provider may forget to give a dose of a medication, that the medication has been discontinued, or that the patient is allergic to the medication. Knowledge-based medication errors are errors that could be avoided with a reasonable and appropriate level of professional knowledge. If the provider is familiar with the drug and the patient, knowledge-based medication errors are avoidable. Knowledge-based medication errors can be general, specific, or expert : 37 °
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A general knowledge-based error occurs when someone makes an error because of lack of or disregard for information that is considered general knowledge (e.g., warfarin can cause bleeding). A specific knowledge-based error occurs when someone makes an error because of lack of or disregard of information that would be considered specific knowledge (e.g., a patient is given warfarin even though the INR is high).
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° An expert knowledge-based error occurs when someone makes an error because of lack of, or disregard, for information that would be considered expert knowledge (e.g., the failure to use genetic testing to check for variations in patient response prior to initiating therapy with warfarin). Strategies to decrease the risk of medication error include 28, 34, 39 : • Adhere to the eight rights of medication administration: right patient, right medication, right time, right dose, right route, right position, right documentation, and right to refuse.
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