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COURSE CODE
Hours
PRICE
Preventing Medical Errors for Healthcare Professionals (Mandatory)
2 $37 PTFL02ME-H
Evidence-Based Balance Rehabilitation and Fall Prevention 6 $105 PTFL06FP-H
Move Better, Feel Better: A Movement-Based Approach to Soft Tissue Mobilization for the Upper Body
4 $72 PTFL04MU-H
Book Expiration Date: 10/9/2027
INCLUDED IN THIS BOOK
1 Preventing Medical Errors for Healthcare Professionals (Mandatory) [2 contact hours] The purpose of this course is to provide licensed practitioners with information concerning the current state of medical errors, the impact of medical errors on the safety of patients, and the importance of establishing and working in a culture of safety. Contributing causes and types of medical errors are reviewed. Strategies to reduce or prevent medical errors, and improve patient outcomes, are presented. Methods to identify, analyze, and report medical errors are reviewed, populations at risk for medical errors are identified, and patient safety initiatives including education for the public and healthcare professionals are explored. 15 Evidence-Based Balance Rehabilitation and Fall Prevention [6 contact hours] This course is designed to guide professionals through the process of decreasing fall risk through determining the most effective evidence-based treatment plans for patients suffering from balance impairments. The requirements of balance and the sensory modalities of balance are discussed to provide the background for performing a comprehensive assessment. Then the tools to provide a thorough assessment of therapy interventions are explored with specific case studies to assist in applying the knowledge learned through this course. The information provided in this course offers an opportunity for practical application in various healthcare settings. 25 Move Better, Feel Better: A Movement-Based Approach to Soft Tissue Mobilization for the Upper Body [4 contact hours] This course provides an evidence-based approach, combining IASTM, Cupping and Kinesiology Taping by focusing on how we can stimulate the Central Nervous System (CNS) to reduce pain and enhance mobility. This comprehensive treatment philosophy is movement-focused instead of treating the individual muscle, or the fascia, or the joints. The goal is to make overall movement of the affected body part more efficient to allow the body to heal and to become more resilient: “Move Better, Feel Better.”
Colibri Healthcare, LLC’s courses are approved by a component of The American Physical Therapy Association (APTA) and are accepted by the Florida Board of Physical Therapy Practice. Florida Board of Physical Therapy (Provider #50-4007).
FREQUENTLY ASKED QUESTIONS
License Expires
Hours Required
Mandatory Subjects
2 hours - prevention of medical errors 1 hour of HIV/AIDS course required for first renewal only
24 (12 hours are allowed through home study)
Licenses expire November 30 of each odd-numbered year
Are you a Florida board-approved provider? Colibri Healthcare, LLC’s courses are approved by a component of The American Physical Therapy Association (APTA) and are accepted by the Florida Board of Physical Therapy Practice. Florida Board of Physical Therapy (Provider #50-4007). Are my credit hours reported to the Florida board? Yes, the Florida Board of Physical Therapy uses CE Broker to track and verify your compliance. Colibri Healthcare, LLC will report your hours electronically to CE Broker within two business days. Remember, do not forward your CE documentation to the board, keep your certificate in a safe place for your records. What information do I need to provide for course completion and certificate issuance? Please provide your license number on the test sheet to receive course credit. Your state may require additional information such as date of birth and/or last 4 of Social Security number; please provide these, if applicable. Is my information secure? Yes! We use SSL encryption, and we never share your information with third-parties. We are also rated A+ by the National Better Business Bureau. What if I still have questions? What are your business hours? No problem, we have several options for you to choose from! Online at EliteLearning.com/Physical-Therapy you will see our robust FAQ section that answers many of your questions. Simply click FAQs at the top of the page, email us at office@elitelearning.com, or call us toll-free at 1-888-857-6920, Monday - Friday 9:00 am - 6:00 pm EST, Saturday 10:00 am - 4:00 pm EST. Important information for licensees: Always check your state’s board website to determine the number of hours required for renewal, mandatory topics (as these are subject to change), and the amount that may be completed through home-study. Also, make sure that you notify the board of any changes of address. It is important that your most current address is on file. Disclosures: Resolution of conflict of interest Colibri Healthcare, LLC implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity. Sponsorship/commercial support and non-endorsement It is the policy of Colibri Healthcare, LLC not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners. Disclaimer: The information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition. ©2025: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to provide medical, legal, or professional advice. Colibri Healthcare, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and not actual customers.
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Preventing Errors for Healthcare Professionals: Summary
Preventing Errors for Healthcare Professionals (Mandatory) 2 Contact Hours
ACCESS THE FULL PRESENTATION Scan the QR CODE ► to start video or visit https://uqr.to/Prevent_HC_Errors
Author Elizabeth D. DeIuliis, OTD, MOT, OTR/L, CLA, FNAP
Ms. Deluliis is currently a clinical associate professor in the Department of Occupational Therapy at Duquesne University, where she has been a core faculty member for over 13 years. Dr. DeIuliis attended Duquesne University and graduated with a Master’s Degree in Occupational Therapy in 2004. In December 2009, she completed a post-professional Doctorate of Occupational Therapy Degree at Chatham University in Pittsburgh, Pennsylvania. She continues to practice clinically on a per- diem basis within the University of Pittsburgh Medical Center (UPMC) Rehabilitation Institute at UPMC Shadyside Hospital. Dr. DeIuliis has had various leadership roles within academia and the occupational therapy profession, such as serving on the Board of Directors within the Pennsylvania Occupational Therapy Association and volunteering within the National Board for Certification in Occupational Therapy. She has published four books and several peer-reviewed publications and has presented at state, national, and international conferences on topics related to experiential learning pedagogies, professionalism and ethics, interprofessional education, and teaching methodologies.
LEARNING OUTCOMES • Define common terminology inclusive in medical errors • Recognize factors that impact the occurrence of medical errors • Identify error-prone scenarios in healthcare settings
• Recall processes to analyze, prevent, and/or reduce medical errors • Recognize safety needs of special patient populations
SELF-ASSESSMENT QUESTIONS
1. A healthcare professional is working with a patient in the hospital setting and forgets to lock the brakes on the wheelchair prior to transferring the client out of bed, which results in a fall. How would you characterize this error? a. Error of omission b. Error of the commission c. Latent error d. Error of compassion 2. A healthcare provider is getting ready to measure vital signs of a patient before beginning treatment. Which of the following mechanisms are appropriate to correctly identify the patient? Choose all that apply. a. Medical Record Number b. Full Name c. Room Number d. Date of Birth
3. A healthcare provider in the State of
Florida has appropriately submitted an incident report for a sentinel event that occurred during their shift on May 1. The risk management department at the facility must investigate the incident and submit their findings to the State of Florida by what deadline? a. May 7
b. May 15 c. May 31 d. June 1
ANSWERS: 1: b 2 : a, b, d 3 : b
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Preventing Errors for Healthcare Professionals: Summary
TERMS USED TO DESCRIBE MEDICAL ERRORS AND PATIENT SAFETY
INTRODUCTION
There are several essential definitions for understanding medical errors and patient safety concepts. Key terms include adverse events (unintended physical injuries from medical care), adverse drug events (medication-related injuries), near misses (potential errors that were prevented), and sentinel events (serious incidents requiring immediate investigation). The section also distinguishes between different types of errors: errors of commission (wrong actions) versus omission (failure to act) and active errors (immediate impact at patient level) versus latent errors (system-level issues that may take time to manifest). Root cause analysis (RCA) is defined as a structured problem-solving method for identifying adverse events to prevent recurrence . These definitions form the fundamental vocabulary for discussing patient safety and medical error prevention in healthcare settings. DEFINING MEDICAL ERRORS Medical errors are defined as either failure in executing planned actions or the implementation of incorrect plans to achieve healthcare goals. According to the Institute of Medicine's report and subsequent studies, despite increased awareness and some improvements since 1999, patient safety remains a critical public health concern. Current statistics show that approximately 1 in 10 hospitalized patients experience some form of adverse event, with over 50% of these incidents being preventable. Globally, there are 421 million hospitalizations resulting in about 42.7 million adverse events annually. Medication errors account for about 50% of all healthcare errors, while diagnostic errors occur in 5-20% of doctor-patient encounters. Importantly, while unsuccessful treatments or varying patient responses to therapy may occur, these are not considered medical errors unless they result from mistakes in planning or execution.
The healthcare industry faces a critical patient safety crisis, with medical errors ranking as the third leading cause of preventable deaths in the United States. Despite initiatives following the “To Err Is Human” report and various safety protocols, the challenge persists. This course aims to equip healthcare professionals with evidence-based knowledge about patient safety practices and error prevention. It focuses on shifting from a blame culture to a safety-oriented approach, covering topics such as types of medical errors, prevention strategies, reporting methods, and identifying at-risk populations. The course meets Florida's licensure renewal requirements and provides practical knowledge for all healthcare team members to promote safer patient care across all practice settings. BACKGROUND AND SCOPE The 2000 “To Err Is Human” report revealed the alarming scope of medical errors in U.S. healthcare, initially estimating 44,000-98,000 preventable deaths annually. More recent studies indicate these numbers have increased significantly, with estimates ranging from 210,000 to 440,000 deaths per year. Current data shows that about 25% of hospitalized patients experience some form of harm, with one-fourth of these incidents being preventable. The COVID-19 pandemic further exacerbated these challenges, particularly regarding hospital- acquired infections (HAIs). Despite some improvements since the initial report, including a 17% decrease in hospital-acquired conditions, medical errors continue to pose a significant challenge, costing approximately $20 billion annually. This emphasizes that healthcare professionals, especially those directly involved in patient care, have a fundamental responsibility to implement systems and processes that reduce medical errors and enhance patient safety.
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Preventing Errors for Healthcare Professionals: Summary
HISTORY OF MEDICAL ERROR ISSUES The systematic study of medical errors dates back to 1954, beginning with research on anesthesia-related deaths . A significant milestone was the 1962 report revealing 16 errors per 100 medication doses in hospitals, which sparked ongoing research initiatives. The 1970s and 1980s saw expanded research into various healthcare settings and improved monitoring systems. The issue gained major public attention in the 1990s, particularly with the economic impact of adverse drug events, estimated at $76 billion annually. The watershed moment came with the 1999 publication of "To Err Is Human," which revealed that 44,000-98,000 Americans died annually due to medical errors. This report, building on the work of physicians Lucian Leape and David Bates, catalyzed national efforts to improve patient safety and remains a pivotal moment in healthcare quality improvement. Contributing Causes of Medical Errors Medical errors stem from eight primary categories of contributing factors: 1. Communication Factors : Miscommunication is the most common cause of errors, affecting both healthcare team interactions and patient-provider communication. 2. Inadequate Information Flow : Poor information transfer during patient transitions and fragmented healthcare systems can lead to lost or incomplete medical information, while health information technology can both help and potentially create new risks. 3. Human Factors : Issues like fatigue, illness,
LEARNING TIP! 4. Patient-Related Factors: These include improper patient identification, incomplete assessments, and inadequate
patient education. Currently, the Joint Commission lists Goal 1 as “to identify patients correctly.” Proper patient identification using at least two identifiers is crucial. 5. Organizational Transfer of Knowledge : Deficiencies in staff orientation and education, particularly affecting new, temporary, or floating staff members. 6. Workforce Issues : Inadequate staffing 7. Technology Failures : While technology can prevent errors, equipment failures and inadequate training on medical devices can lead to serious injuries. levels and supervision can lead to increased error rates and compromised patient care. 8. Inadequate Policies and Procedures : The lack of standardized, updated policies and procedures can lead to inconsistent care and medical errors. Identifying and Analyzing Medical Errors The accurate measurement of medical errors presents significant challenges, primarily because most data relies on self-reporting systems, which typically capture only a small fraction of actual incidents. Healthcare professionals must first recognize an error, understand that it is reportable, and feel safe reporting it without fear of consequences. To improve error detection, two major tools have been developed: 1. AHRQ's Patient Safety Indicators (PSIs) : ○ Includes 20 hospital-level and 7 area-level indicators ○ Used with hospital discharge data to screen for potential errors
and drug use can impair healthcare providers' ability to follow protocols and best practices.
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Preventing Errors for Healthcare Professionals: Summary
2. IHI's Trigger Tool : ○ Contains 53 triggers to identify potential adverse events during hospitalization ○ Widely used for adverse event identification and analysis However, both tools have limitations: ○ They are retrospective (identifying events after harm occurs) ○ Require additional review to confirm preventable adverse events ○ May not capture all preventable adverse events This highlights the ongoing challenge of comprehensive error identification and the need for multiple approaches to capture and analyze medical errors effectively. Sentinel Event LEARNING TIP!
• Maternal complications : ○ Maternal death during birth ○ Severe maternal morbidity requiring intensive intervention • Other serious events : ○ Severe neonatal hyperbilirubinemia ○ Fire/smoke during patient care ○ Equipment-related incidents Importantly, not all sentinel events result from errors, and not all errors lead to sentinel events. MANDATES WITHIN THE STATE OF FLORIDA Florida has specific requirements for medical error prevention and reporting: Continuing Education: All healthcare professionals must complete 2 hours of approved training on Prevention of Medical Errors for license renewal. Mandatory Reporting: • Sentinel events must be reported (unlike voluntary TJC reporting) • Hospitals must implement risk management programs with state oversight • The Florida Comprehensive Medical Malpractice Act of 1985 mandates that each licensed hospital must implement a risk management program with state oversight and an internal incident-reporting system. Oversight is provided by the State of Florida Agency for Health Care Administration (AHCA). Each licensed hospital is required to hire a risk manager who is responsible for the implementation and management of the risk management program. Reportable Adverse Incidents Include: • Death or serious injury (brain/spinal damage, permanent disfigurement) • Wrong-site/patient/procedure surgeries • Unplanned surgical repairs • Retained surgical objects • Conditions requiring transfer to higher levels of care
A sentinel event, as defined by The Joint Commission (TJC), is any unexpected occurrence in a healthcare setting that results in death or serious physical/ psychological injury unrelated to the natural course of a patient's illness.
These events require a root cause analysis (RCA) and include: • Critical incidents : ○ Patient suicide (in facility or within 72 hours of discharge) ○ Unexpected full-term infant death ○ Patient abduction or elopement leading to harm ○ Wrong family infant discharge ○ On-site violence (rape, assault, homicide) ○ Major medical errors: ■ Wrong blood transfusion reactions ■ Wrong procedure/patient/site surgeries ■ Retained surgical objects ■ Radiation errors
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Preventing Errors for Healthcare Professionals: Summary
Risk Management System Requirements: • Investigation and analysis of adverse incidents • Development of risk minimization measures • Analysis of patient grievances • Patient notification system • 3-day incident reporting requirement State Reporting Requirements: • Annual Report: All adverse incidents in a calendar year • Code 15 Report: Detailed report of serious injuries within 15 days • Reporting extends to various healthcare settings (nursing homes, assisted living, etc.) The system is overseen by the State of Florida Agency for Health Care Administration (AHCA). ROOT CAUSE ANALYSIS PROCESS Root Cause Analysis (RCA) serves as both a reactive and proactive tool in addressing medical errors. Originally developed for industrial accidents, RCA has become mandatory for investigating sentinel events in accredited hospitals since 1997. The process involves systematic data collection through interviews, document reviews, and field
observations, followed by detailed analysis to identify underlying factors. RCA emphasizes finding effective solutions rather than simply identifying causes, following a structured approach that includes problem definition, data gathering, identifying relationships, determining preventable causes, developing solutions, and implementing recommendations. Principles of RCA • Improving performance measures the root cause in a more effective manner than merely treating the symptoms of a problem • To be effective, RCA must be performed systematically with conclusions and causes backed up by documented evidence • There is usually more than one potential root cause for any given problem • To be effective, the analysis must establish all known pieces of the puzzle between the root cause(s) and the actual problem(s) • Root cause analysis transforms an old culture that reacts to problems to a new culture that solves problems before they escalate, creating a focus on variability reduction and risk avoidance
Applying the Process of RCA When people discover problems, the most frequent response is to rush to find a solution. Finding an immediate fix to a problem may be very satisfying for the moment but is not a long- term effective decision. The purpose and goal of applying RCA to medical errors that occur or that might occur is to find effective solutions rather than only discovering root causes. Root causes are secondary to the goal of prevention and are only revealed after deciding which solutions to implement. 1. Define the problem: The therapist can ask the following questions: What does the medical facility want to prevent? When and where did it occur? What is the significance of the problem? Is it possible to close the gap between patient safety and the accurate or effective process that defines the problem? 2. Gather data/evidence: This part of the process requires a collection, or a sample of data related to the problem. This will assist in conducting a root cause analysis to identify the reasons why the problem exists. Gathering data and evidence will form the basis for determining solutions to prevent a recurrence of the causes and ultimately lead to preventing the problem in the future.
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Preventing Errors for Healthcare Professionals: Summary
Applying the Process of RCA (continued) 3. Identify the fundamental relationships associated with the defined problem: The most common element of RCA methods includes asking why the error occurred, recording the answers and considering the possible cause behind each of these answers. RCA attempts to identify contributing factors and all causes, proceeding until the desired goal of finding the “root” cause is reached. 4. Identify which causes, when removed or changed, will prevent recurrence: Finding root causes will lead to the next step of evaluating the best method to change the root cause. This will allow for developing a more efficient procedure to put in place. This is commonly known as corrective and preventive action. 5. Identify effective solutions: An effective solution is one that prevents recurrence, is within one’s control, meets the goals and objectives that have been set forth, and does not cause other problems. 6. Implement and observe the recommendations: When the recommendations are implemented and subsequently observed for a specific period of time, it will become more obvious what the real solutions are to ensure effectiveness.
account for $3.5 billion yearly. National hospital expenses to treat patients who suffer ADEs during hospitalization are estimated at between $1.56 and $5.6 billion annually. COST OF MEDICAL ERRORS Hospital costs for patients experiencing medical errors are significantly higher than for those who don't, with specific increases noted: • 33% more for nursing care (pressure ulcers, hip fractures) - $12,196 • 32% more for metabolic problems (kidney failure, blood sugar issues) - $11,797 • 25% more for blood clots and pulmonary problems - $7,838 • 6% more for wound complications - $1,426 A study of 24 hospitals examining 14,732 medical records revealed 465 medical injuries, including 127 negligent injuries. Hospitals absorbed approximately $238 per admission in injury-related costs while passing on $1,775 per admission to other parties. Malpractice premiums averaged $123 per patient. These figures underscore the significant financial impact of medical errors on healthcare institutions and the importance of preventive measures.
LEARNING TIP! Complementing RCA, the Failure Mode and Effects Analysis (FMEA) is a systematic, proactive method for evaluating a process to identify where and how it might fail and to assess the relative impact of different failures, in order to identify the parts of the process that are most in need of change.
Originally developed for military systems in the 1950s, FMEA has been adapted for healthcare settings to assess risk and prioritize process improvements. This comprehensive approach to error analysis and prevention reflects the healthcare industry's commitment to creating a culture of safety that emphasizes prevention, learning, and continuous improvement rather than blame. Medical errors impose substantial financial burdens on the healthcare system and society. According to the Institute of Medicine, preventable adverse events cost the nation approximately $37.6 billion annually, with $17 billion directly linked to preventable errors. Drug-related injuries in hospitals alone
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Preventing Errors for Healthcare Professionals: Summary
PREVENTION OF MEDICAL ERRORS The prevention of medical errors requires a comprehensive systems approach rather than isolated interventions. The National Patient Safety Foundation (NPSF) outlined eight key recommendations for this approach: 1. Establish and maintain a safety culture through leadership 2. Implement centralized safety oversight 3. Develop meaningful safety metrics 4. Increase safety research funding 5. Address safety across all care settings 6. Support the healthcare workforce 7. Partner with patients and families 8. Ensure safe technology implementation Public concern about medical errors remains significant, with surveys showing: • 42% of Americans have been affected by medical errors personally or through someone they know • 61% worry about receiving wrong medications • 58% fear negative drug interactions • 56% are concerned about procedure complications • An estimated 1.5 million preventable injuries occur annually Regarding hospital accountability, research shows that hospitals currently bear only about 22% of injury-related costs, while externalizing 78%. This cost distribution provides limited financial incentive for hospitals to invest in safety improvements. Patient safety advocates are working to demonstrate that investments in safer practices can lead to reduced malpractice costs and other expenses, making a business case for safety improvements. TYPES OF MEDICAL ERRORS Medical errors can be categorized into several major types: 1. Diagnostic Errors : ○ Misdiagnosis of symptoms ○ Under-diagnosis of conditions
○ Failure to use indicated diagnostic tests ○ Misreading of test results ○ Failure to act on abnormal tests 2. Medication Errors : ○ Occurs across four stages: ordering, transcribing, dispensing, and administration ○ Causes at least one death daily and 1.5 million injuries annually ○ Includes adverse drug events (ADEs) and reactions and can result in a number of different physical consequences, raging from allergic reactions to death ○ Results from poor handwriting, confusion with similar drug names, poor packaging design, and dosing confusion 3. Treatment Errors : ○ Incorrect choice of therapy ○ Misdiagnosis leading to inappropriate treatment ○ Failure to prevent injury ○ Inadequate follow-up or monitoring 4. Surgical Errors : ○ Wrong-site surgery ○ Retained surgical instruments/failure to remove foreign object ○ Wrong-patient operative procedures ○ Anesthesia-related erro rs 5. Systems Errors : ○ Poor system design ○ Organizational factors ○ Healthcare professional fatigue (24-hour shifts) ○ Complex processes increasing error probability ○ Inadequate technology utilization The Institute of Medicine (IOM) notes that most errors stem from system design and organizational factors rather than individual negligence or lack of training . Prevention requires addressing both human and system factors while maintaining focus on patient safety.
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Preventing Errors for Healthcare Professionals: Summary
MEDICAL ERRORS AND ETHICS Medical errors and ethics in healthcare revolve around several key concepts: 1. Adverse Events and Error Types : ○ Adverse events are injuries from medical interventions rather than underlying conditions: ■ Errors of Commission : This refers to those injuries arising as a direct consequence of treatment when the medical professional is prescribing a medication or a treatment plan that has harmful interactions with another medication the patient is taking ■ Errors of Omission : This refers to failing to act or failing to perform a specific treatment that was determined for a patient. An example of an error of omission would be a medical professional failing to prescribe a medication from which the patient would likely have benefited • Both types require systematic reporting and classification for prevention 2. Core Ethical Principles : ○ Nonmaleficence : The fundamental "do no harm" principle ○ Beneficence : Duty to produce positive outcomes ○ Autonomy : Patient's right to make informed decisions ○ Paternalism : Protection of patient interests (weak vs. strong) ○ Privacy/Confidentiality : Protecting patient information ○ Justice : Ensuring fair treatment and resource allocation
MEDICAL ERRORS PREVENTION The 1999 Institute of Medicine report, "To Err Is Human," sparked a nationwide focus on medical error prevention, revealing that up to 98,000 annual hospital deaths resulted from medical errors, with over 7,000 specifically related to medications. This revelation prompted the U.S. healthcare system to strengthen its prevention strategies, emphasizing solutions rather than just identifying problems. A key approach to prevention involves creating partnerships between medical professionals and patients to jointly engage in ensuring that the appropriate care is provided in the following manner at the right place, at the right time, to the correct person, and in the safest and most efficient manner possible . Knowledge plays a crucial role in error prevention, with both healthcare providers and patients needing proper education about treatments, medications, and potential risks. The challenge often lies in maintaining up- to-date information, particularly given the vast number of pharmaceutical products and constantly evolving safety guidelines. To address medication errors, which account for nearly 50% of dosing and prescription mistakes, healthcare facilities have implemented automated systems such as bar code medication administration (BCMA). These systems verify the "5 rights" of medication administration: right patient, dose, drug, time, and route. Understanding pharmacological components is essential for error prevention, encompassing three main areas: pharmacodynamics (how drugs affect the body), pharmacokinetics (how drugs move through the body), and therapeutics (drug application in treatment). Healthcare professionals must maintain comprehensive knowledge of these aspects to effectively manage medications, monitor patient responses, and document relevant information. This knowledge enables them to serve as patient advocates and ensure proper medication usage while implementing appropriate rehabilitation interventions and programs.
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Interviewing and Documentation Effective patient care begins with comprehensive interviewing and documentation processes. A thorough subjective history must be collected for each new patient, including all previous and current medical problems, medications, dosages, and side effects. Although this process may seem repetitive, especially when a healthcare provider is not the first point of contact, such repetition serves as a crucial safeguard against medical errors. This information is complemented by objective data collection, which includes assessing all potential pharmacological side effects associated with the patient's medications. The development of safe and effective rehabilitation programs requires careful consideration of pharmaceutical effects and potential interactions. Healthcare providers must be particularly vigilant about medication details, studying and becoming familiar with the specific drugs their patients are taking and their potential side effects. Continuous monitoring and documentation are essential, as rehabilitation professionals often see patients more frequently than physicians and must serve as additional eyes and ears regarding pharmaceutical management. They should immediately notify physicians of any concerns about incomplete information, inaccurate details, medication side effects, or treatment ineffectiveness. LEARNING TIP! A contraindication is a specific situation in which a drug, procedure,
by the Food and Drug Administration. They routinely include them in the package insert under the phrase “Indications and Usage.” What do the terms contraindication and indication have to do with the prevention of medical errors? Contraindication on a medication for a particular patient is a red flag signaling that a pharmacological combination will not work in this instance. On the other hand, an indication allows that the medication is appropriate for the patient. Professional judgment plays a crucial role in patient care, built on a foundation of training, information gathering, wisdom, and ethical integrity. Clear communication with patients about diagnoses, treatment plans, and ongoing results helps to build trust and ensures better outcomes. Healthcare professionals must maintain continuous professional development beyond mandatory requirements, staying current with new treatments and conditions. Throughout all interactions, maintaining professionalism and integrity is paramount, from initial evaluation through diagnosis and treatment planning, ensuring that all information is conveyed clearly and comprehensively to patients. Medical Documentation and Communication Communication failures represent the leading cause of serious medical errors in healthcare settings, making effective communication crucial for error prevention and litigation risk reduction. Critical attention must be paid to transition points in care, where handoffs between different care settings or providers often lead to errors. A key strategy involves medication reconciliation between transition points, comparing medications across settings to avoid transcription errors, omissions, or dangerous drug interactions. Documentation plays a vital role in this process, requiring consistent verification and thorough recording of all procedures, dosage administrations, and treatments.
or surgery should not be used, because it may be harmful to the patient.
Some treatments may even cause unwanted or dangerous reactions in people with allergies, high blood pressure, or pregnancy. Indication is a term describing a valid reason to use a certain test, medication, procedure, or surgery. Indications for medications are strictly regulated
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Preventing Errors for Healthcare Professionals: Summary
To improve patient safety, healthcare systems are implementing various technological solutions and standardized protocols. LEARNING TIP! Computerized adverse drug event (ADE) monitoring systems use
proficiency (requiring medical interpreters), and those with low health literacy. Healthcare providers must be particularly vigilant when treating these populations, implementing additional safeguards and communication strategies to ensure safe and effective care delivery. CONCLUSION Protecting patients is the responsibility of all healthcare professionals. Leaders of healthcare organizations have made concerted progress toward attaining an environment that embraces teamwork, engagement of patients in their care, and standardization of practices. However, patients continue to suffer the harmful consequences of medical errors. All members of the healthcare team share joint responsibility for ensuring safe care of patients through the care continuum. Occupational therapists and occupational therapist assistants play a vital role in the field of patient safety because of holistic, client-centered approaches, and the development of unique relationships. This position in the care delivery system places occupational therapy professionals at the forefront for advocating, guiding, and leading patient safety initiatives and working collaboratively with other healthcare professionals for the benefit of keeping all patients and the public safe.
electronic medical records to track parameters and alert healthcare providers to potential issues, with one organization reporting annual savings of $900,000 through reduced adverse events. Computerized ADE monitoring works by setting an application called an event monitor over the clinical database.
Standardized protocols have shown significant improvements in patient outcomes, such as a four-fold increase in survival rates for patients with severe respiratory disease. The FDA maintains oversight of drug safety through rigorous approval processes and guidelines. Special attention must be given to populations at increased risk for medical errors, as mandated by Florida Statute 64B9-5.011. These vulnerable groups include infants and children (due to complex dosage calculations), older adults (affected by communication barriers and polypharmacy), individuals with limited English
CASE STUDIES
Failure to Act on an Abnormal Test Louise (pronouns she/her/hers) went to her primary care physician after discovering some irregularities in her left breast. Dr. Breem did not think it was of any consequence but sent her for a mammogram even though she had just had one 5 months previously. The mammogram report was sent to Dr. Breem, who noted that there was some irregularity in the breast. However, Dr. Breem made the decision to ignore the irregularity. One year later Louise died of breast cancer.
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Preventing Errors for Healthcare Professionals: Summary
Error in the Medication Process A 41-year-old female was ordered 160 mg daily of Temodar. The dosage was 20 mg in each capsule, so she was instructed to take eight capsules daily. However, the medication that the patient received from the pharmacy was a 250 mg capsule rather than the intended 20 mg capsules, and she administered eight capsules for a total daily dose of 2,000 mg. The patient presented with pancytopenia and died 10 days following administration of the last dose. Lucinda Lucinda and her husband were at an initial appointment with Dr. Richards, a chiropractor, after Lucinda had continued to have low back discomfort following the birth of their daughter. Dr. Richards did a subjective history, took X-rays, and performed a manual examination. Then he called Lucinda and her husband into his office. He informed Lucinda of the problems that she had in her lower back and recommended a plan of care. The plan of care extended over a 6-month period, consisting of heat therapy and manipulation along with repeated X-rays. By the second month, office visits were required every other day. Lucinda did not have health insurance and could not cover the $10,000 medical bill. Lucinda attempted to negotiate a payment plan with Dr. Richards, but the doctor was unwilling to work with her. He advised Lucinda that treatment could not continue until payment was received. Sue Sue is an occupational therapist at Gulf Coast Therapy Associates, located in Bates County, Missouri. She has just completed an intake on Frank Simons for therapy after a work-related accident at Exxon Mobil Refinery. The Bates County public health agency receives information that a person infected with a contagious bacterium by the name of Frank Simons is being treated at Sue’s facility. On the one hand, Sue and the facility have a duty to respect Frank’s right to confidentiality and freedom of movement. However, the occupational therapist and Gulf Coast Therapy Associates have a greater duty to prevent the spread of the bacterium to other people. In the utilitarianism approach to ethics this is known as “doing the greatest good for the largest number of people.” Thus, more good would be achieved by protecting the public health of all the other patients treated at Gulf Coast Therapy Associates. This can be accomplished only by breaching Frank Simon’s Sheralyn Sheralyn walked into the emergency department (ED) one Monday morning in October unable to breathe. Preliminary tests were performed, objective data were collected, and a detailed subjective history was taken. Time went by, but a diagnosis eluded the attending physician. She was given a dose of Lasix as a preventative measure, in case her shortness of breath was related to congestive heart failure. Finally, all the tests were returned and the physician was able to determine that Sheralyn had two massive pulmonary embolisms (one lodged in each lung). But why? She was overweight and had a sedentary lifestyle but was otherwise in average health. Throughout the day, various doctors, nurses, and other medical staff had taken a subjective history on Sherlyn in the ER as well as collecting objective data. They all missed one key item. She had been prescribed Megace, a coagulant, 18 months earlier. Sherlyn had faithfully itemized medications she was on to every medical professional for the last 24 hours, but no one caught it.
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Preventing Errors for Healthcare Professionals: Summary
FINAL EXAM QUESTIONS
1. One of the earliest studies of a medical error was an analysis of causes of death during anesthesia administration in what year?
5. Which of the following can result in a number of different physical consequences, ranging from allergic reactions to death? a. Causal drug events b. Medication events c. Adverse medical causes d. Adverse drug events 6. Which of the following terms refers to when a medical professional fails to prescribe a medication from which the patient would likely have benefited? a. Error of omission b. Error of commission c. Adverse medical decision d. Beneficence 7. Which of the following ethical principles refers to doing no harm? a. Justice b. Autonomy c. Beneficence d. Non-maleficence 8. A partnership needs to be developed between the patient and medical professional to jointly engage in ensuring that the appropriate care is provided in the following manner: a. At the right place and time b. To the correct person c. In the safest and most efficient manner d. All of the above (BCMA) systems reduce medication errors by electronically verifying the “5 rights” of medication administration, which include which of the following? a. Right patient, right dose, right drug, right time, right route b. Right prescription, right drug class, right time, right route 9. Bar code medication administration c. Right type of medication, right person, right medication, right time, right route, right taste d. Right pace and time, correct person, safest and most efficient manner
a. 1954 b. 1944 c. 1964 d. 1974
2.
Which of the following defines a sentinel event? a. Any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness b. A series of unfortunate events that may or may not result in a serious or psychological injury to a patient c. An avoidable event in which a healthcare provider failed to follow a treatment protocol that resulted in a serious physical or psychological injury to a patient d. A specific situation in which a drug,
procedure, or surgery should not be used, because it may be harmful to the patient 3. Which of the following problem-solving methods aims to identify the root causes of problems or events? a. Initiation cause method b. Root cause analysis c. Root method problems d. Initiation root analysis 4. Not all errors lead to injury or death, but the number of preventable injuries that do occur are estimated at least at ________ million each year. a. 17
b. 2.5 c. 1.5 d. 500,000
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Preventing Errors for Healthcare Professionals: Summary
10. Which of the following refers to a specific situation in which a drug, procedure, or surgery should not be used because it may be harmful to the patient? a. Adverse drug event b. Indication c. Contraindication d. Medical error 11. Which of the following uses works by setting an application called an event monitor over a clinical database? a. Computerized RCA b. Computerized MDE c. Computerized CTS d. Computerized ADE 12. Which of the following are components of the root cause analysis process? a. Define the problem b. Gather data/evidence c. Identify the fundamental relationships associated with the defined problem d. All of the above 13. Which of the following is a type of medical error that can occur? a. Misdiagnosis of symptoms b. Errors in medication c. Surgical errors d. All of these are medical errors that can occur 14. When a medical professional fails to use an indicated diagnostic test, he or she is not acting in the best interest of the patient, and the result will be a faulty diagnosis which ultimately means the patient will not heal or improve. This phenomenon is known as what? a. Failure to use an indicated diagnostic test b. Misreading of test results c. Adverse drug reaction d. Beneficence
15. Which of the following outlines the four stages and sequence of the medication process? a. Physician ordering, transcription, pharmacy dispensing, nursing administration b. Pharmacy dispensing, transcription, nursing administration, patient adherence c. Nurses ordering, transcription, pharmacy dispending, physician assistant administration d. Physician ordering, pharmacy dispensing, nursing administration, documentation 16. Studies show that over how many people are injured or die each year in hospitals from adverse drug events? a. 250,000 b. 500,000 c. 770,000 d. 1 million 17. Hospital expenses to treat patients who suffer ADEs during hospitalization are estimated at between how many dollars annually? a. $ 770,000 and $ 1 million
b. $1.56 and $5.6 million c. $1.56 and $5.6 billion d. $6.2 and $7 billion 18. Medication errors cause at least
________ death(s) every day and injure approximately 1.5 million people annually in the United States.
a. One b. Two
c. Three d. Seven 19. Which of the following can contribute to a medication error? a. Poor handwriting b. Confusion with drugs with similar names c. Poor packaging design d. All of the above can contribute to a medication error 20. What occurs when a wrong operative procedure occurs, a professional fails to remove a foreign object, or an operation happens on the wrong site? a. Adverse drug reaction b. Surgical error c. Medication errors d. Hospital acquired infection
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Preventing Errors for Healthcare Professionals: Summary
21. The IOM determined that more errors occur in the health care systems due to what? a. Poor systems design, organizational factors b. Short staffing, lack of training c. Lack of control by staff related to poor system designs d. Not using a root cause analysis 22. Errors of _______refers to those injuries arising as a direct consequence of treatment when the medical professional is prescribing a medication or a treatment plan that has harmful interactions with another medication the patient is taking. a. Dismission b. Commission c. Omission d. Justice 23. Which of the following is an example of an error of omission? a. Leaving a surgical instrument in a patient during surgery b. Prescribing a medication that is too costly for the patient that does not have health insurance c. Failing to prescribe a medication from which the patient would likely have benefited d. Not providing a client access to their medical record 24. Which of the following defines failure mode and effects analysis (FMEA)? a. A systematic, proactive method for evaluating a process to identify where and how it might fail and to assess the relative impact of different failures b. A way to retroactively evaluate a process to determine where the system failed c. A real-time system to calculate the susceptibility of a process to potential failures d. Failing to disclose a medical error to a patient 25. Which of the components of the root cause analysis process is known as corrective and preventive action? a. Defining the problem b. Gathering the data/evidence c. Identifying solutions d. Identifying what will prevent recurrence
26. A rehabilitation professional should always notify the physician immediately if he or she suspects which of the following during an interaction with a patient? a. That the patient has not provided the
doctor with complete information b. That the patient has not provided accurate information c. That the patient is experiencing side effects from a medication
d. All of the above should be monitored, documented, and communicated to the physician 27. During an initial encounter with a patient, which of the following should the provider do prior to beginning examination and/or treatment? a. Check the medical insurance of the client b. Verify patient identity c. Inquire who the next of kin is d. Ask if they have had a recent surgery minimum number of approved training hours required for license renewal on the topic of preventing medical errors? a. One b. Two c. Three d. Four 29. Per Florida’s Comprehensive Medical Malpractice Act of 1985 (F.S. 395.0917), every licensed hospital in the State of Florida is required to hire what kind of personnel? a. Lawyer b. Risk manager c. Human resource designee d. Continuing education director 28. In the State of Florida, what is the
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Course content code: PTFL02ME-H
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