________________________________________________ Medical Error Prevention and Root Cause Analysis
PATIENT SUICIDE It is estimated that between 48 and 65 hospital inpatient sui- cides occur per year in the United States. Most of these cases (31 to 52) occur in psychiatric units or involve psychiatric inpatients. The most common method is hanging [50]. Times of care transition are particularly risky, with a 200% increase in risk in the week after discharge from a psychiatric facility; the elevated risk continues for four years [18]. Other risk fac- tors include previous suicide attempt or self-injury, mental or emotional disorders, history of trauma or loss, serious illness or chronic pain, substance use disorder, social isolation, and access to lethal means. The most common root cause documented for patient suicide reported between 2010 and 2014 was shortcomings in assess- ment, most commonly psychiatric assessment [18]. In addition, nearly 25% of behavioral health facilities accredited by the Joint Commission were found noncompliant with the requirement to conduct an adequate suicide risk assessment in 2014. The Joint Commission has recommended a number of suicide risk reduction strategies, including [18]: • Review each patient’s personal and family medical history for suicide risk factors. • Screen all patients for suicide ideation, using a brief, standardized, evidence-based screening tool. • Review screening questionnaires before the patient leaves the appointment or is discharged. • Establish a collaborative, ongoing, and systematic assessment and treatment process with the patient involving the patient’s other providers, family, and friends, as appropriate. • To improve outcomes for at-risk patients, develop treatment and discharge plans that directly target suicidality. • Educate all staff in patient care settings about how to identify and respond to patients with suicide ideation. • Document decisions regarding the care and referral of patients with suicide risk. A simple review of these measures demonstrates that healthcare providers can avoid the devastating impact of an inpatient suicide by implementing routine preventative strategies, such as removing harmful items and careful screening through the admission and discharge processes.
gery, and thoracic surgery [17]. The majority of the reporting healthcare facilities cited miscommunication as the primary root cause. Other identified causes include failure to follow established procedures, incomplete preoperative assessment, inconsistent postoperative monitoring procedures, and failure to question inappropriate orders. In order to reduce the risk, reporting facilities have identified a number of strategies, including improving staff orientation and training, increas- ing educational opportunities for physicians, clearly defining expected channels of communication, and monitoring con- sistency of compliance with procedures. Healthcare facilities should review postoperative patient monitoring procedures to ensure an adequate level appropriate to the needs of the patient, regardless of the setting (e.g., operating room, endos- copy suite, radiology department) [17]. Based upon these find- ings, it is clear that direct communication among healthcare providers is key to preventing operative and postoperative complications. Healthcare facilities should provide more staff education regarding preventative measures, and healthcare providers can do their part by engaging in a healthy and mutual respect for all of the members of the healthcare team [17]. MEDICATION ERRORS Unquestionably, medication errors are one of the most com- mon causes of avoidable harm to patients. These errors may occur at any of these critical points: when ordered or prescribed by a physician; during documentation; while transcribing; when dispensed by a pharmacist; when administered by a nurse; or during monitoring. The National Coordinating Council for Medication Error Reporting and Prevention defines a medication error as [20]: 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, and systems, including pre- scribing: order communication; product labeling; packaging, and nomenclature; compounding; dis- pensing; distribution; administration; education; monitoring; and use. It has been estimated that up to 50% of medication errors are caused by a provider writing the wrong medication, the wrong route or dose, or the wrong frequency, and nearly 75% of medication errors have been attributed to distraction of the care provider [24]. In addition, a number of medication errors can be linked to the prescriber who continually uses potentially dangerous abbreviations and dose expressions. Despite repeated warnings by the Institute for Safe Medica- tion Practices about the dangers associated with using certain abbreviations when prescribing medications, this practice continues. To eliminate this factor, there are fairly simple steps that can eliminate much confusion. Prescribers should [21]:
OPERATIVE AND POSTOPERATIVE COMPLICATIONS
Many of the sentinel events reported to the Joint Commission regarding operative and postoperative complications occurred in relation to nonemergent procedures, such as interventional imaging and/or endoscopy, tube or catheter insertion, open abdominal surgery, head and neck surgery, orthopedic sur-
20
EliteLearning.com/Dental
Powered by FlippingBook