Chapter 4: Preventing Medical Errors for Healthcare Professionals (Mandatory) 2 CE Hours
By: Elizabeth D. DeIuliis, OTD, MOT, OTR/L, CLA, FNA Learning objectives After completing this course, the learner will be able to: Define common terminology inclusive in medical errors. Recognize factors that impact the occurrence of medical errors. Course overview 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
Identify error-prone scenarios in healthcare settings. Recall processes to analyze, prevent, and/or reduce medical errors. Recognize safety needs of special patient populations. 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.
INTRODUCTION
progressive change. Consequently, healthcare professionals must be equipped with knowledge that is data-driven, consistent, measurable, and timely. 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. This course provides information to all members of the interprofessional team that can be readily applied to their practice, no matter what the setting, with the ultimate goal of providing safer care to all patients. Healthcare providers will demonstrate knowledge of medical errors and populations at risk, the impact on patient care outcomes, and the resources and initiatives available to promote a culture of safety as an integral part of healthcare delivery. This course meets the state of Florida licensure renewal requirements for the identification and prevention of medical errors and the promotion of patient safety.
Numerous governmental agencies, healthcare improvement groups, noted thought leaders, and scholars have identified that healthcare is in the midst of a patient safety emergency. Despite an impassioned call over a decade ago through the seminal report To Err Is Human: Building a Safer Health System (Kohn et al., 2000); a decade of innovative, targeted protocols; and initiatives such as performance reimbursement metrics, the number of medical errors ranks as the third leading cause of preventable deaths in the United States per a study conducted by John Hopkins (Makary & Daniel, 2016). All healthcare professionals play an important role in managing, coordinating, and delivering direct care to patients. Therefore, it is important for healthcare professionals to obtain and maintain knowledge about safe patient care practices that are based on evidence. Although identification of safety issues is not a new concept, the measurement of outcomes and the multifactorial approaches used to address interventions moving from a culture of “blame” to one supporting care providers and identifying systems issues continue to evolve. Healthcare professionals are often called to serve as advocates in making substantive changes that directly impact patient outcomes. They navigate a complicated medical culture, imbedded bias, and practice patterns of diverse healthcare providers, patients, and institutions in order to promote
BACKGROUND AND SCOPE
equated the number of hospitalized patient deaths to the downing of approximately 10 jumbo airliners weekly, with the loss of all passengers on board the planes. The Agency for Healthcare Research and Quality (AHRQ, 2014) identified that 1 of every 10 patients developed a hospital-acquired infection (HAI) or had a fall, a pressure ulcer, or a medication error during their hospital stay. Nanji et al. (2016) found that 1 out of every 2 surgeries, or 50% of surgical patients, had an adverse drug event and/or a medication error. According to Singh et al. (2014), more than 12 million outpatients are recipients of a diagnostic error, and more than half of those diagnostic errors to patients were possibly harmful. Among Medicare recipients, approximately one third of patients
The landmark report of 2000, To Err Is Human: Building a Safer Health System , from the Institute of Medicine (IOM), now known as the Health and Medicine Division of the National Academies of Sciences, Engineering and Medicine, highlighted the broad reach of medical errors in the United States. That report identified that medical errors result in harm to 1 in every 25 hospitalized patients. In 2000, Kohn et al. reported an estimated 44,000 to 98,000 preventable deaths are attributable to medical errors. Since that landmark report, the number of Americans whose deaths are attributable to preventable harm has also been estimated between 210,000 and 440,000 deaths per year, or one sixth of all deaths (James, 2013). Watson (2016)
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Book Code: MFL1225B
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