Over the past several decades, and even more so over the past several years, there has been a strong focus in the medical community and health care industry to reduce medical errors. Medical errors not only increase health care costs, they often also result in costly litigation.
Health care centers, providers, and hospitals are heavily regulated. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is an independent organization accredits and certifies nearly 21,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.
Quality control (often called QC) is a procedure/set of procedures followed to ensure that a product or service adheres to a defined set of quality criteria and/or meets the quality requirements of a client or health center.
A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called "sentinel" because they signal the need for immediate investigation and response.
Root Cause Analysis (RCA)
RCA is a structured method used to analyze serious adverse events. Initially developed to analyze industrial accidents, RCA is now widely deployed as an error analysis tool in health care. A central tenet of RCA is identifying underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals. Accordingly, some find the term to be misleading and have suggested replacing the term “root cause analysis” with “systems analysis.” The goal of RCA is thus to identify both active errors and latent errors (the hidden problems within health care systems that contribute to adverse events). RCAs should generally follow a pre-specified protocol that begins with data collection and reconstruction of the event in question through record review and participant interviews. A multidisciplinary team should then analyze the sequence of events leading to the error, with the goals of identifying how the event occurred (through identification of active errors) and why the event occurred (through systematic identification and analysis of latent errors). The ultimate goal of RCA, of course, is to prevent future harm by eliminating the latent errors that so often underlie adverse events.
The primary aim of RCA is to identify the factors that resulted in the negative outcomes of one or more past events to identify what needs to be changed to prevent future events. RCA is performed by a team systematically as part of an investigation, with conclusions and root cause(s) supported by documented evidence. There may be more than one root cause for an event or a problem. All possible solutions to a problem are identified to prevent future events at the lowest possible cost and in the simplest possible way. The RCA should determine a sequence of events or a timeline to understand the relationships between the root cause(s) and the event to prevent it from happening in the future. Root cause analysis reduces the frequency of events that occur over time within the environment where the RCA process is used. RCA uses the 5 “whys” to get to the bottom of the situation (asking why 5 times to get to the real root of a problem).
The Joint Commission has mandated use of root cause analysis (RCA) to analyze sentinel events (such as wrong-site surgery) since 1997. As of April 2007, 26 states have mandated reporting of serious adverse events, and many states also require that RCA be performed and reported after any serious event. Although no data are yet available on this subject, root cause analysis use has likely increased with the growth in mandatory reporting systems.
Fishbone Diagrams (Ishikawa diagrams) can be used to determine the cause of error.
Communication is a complex process of sending,
receiving, and comprehending messages
between two or more people. It is a dynamic and
ongoing process that creates a unique experience
for the participants. When communication breaks
down, the result can be workplace errors and the
loss of professional credibility.
Communicating effectively is a skill that nurses
must develop. Nurses use communication when
providing care to demonstrate caring, establish
therapeutic relationships, obtain and deliver
information, and assist with changing behavior.
Therapeutic communication is foundational to the
nurse‑client relationship. Effective communication
is key to ensuring clients’ safety.
A Nurse's Role in Preventing Medical Errors Can Include:
Use risk assessment tools to evaluate clients and their
environment for safety.
Encourage clients to speak up and take an active role in
their health care and in preventing errors.
Create a culture of checks and balances to avoid errors
when working in stressful circumstances.
Communicate risk factors and plans of care to clients,
family, and other staff.
Use protocols for responding to dangerous situations.
Adopt quality care priorities from the National Quality
Forum, including “Never Events.”
Use current evidence to promote a culture of safety,
while using the National Patient Safety Goals as a guide.
Know the facility’s disaster plan, understand the chain
of command and roles, and use common terminology
when communicating with the team.
Identify and document incidents and responses
according to the facility’s policy. These reports help
identify trends, patterns, and the root cause of
Know the location of safety data sheets and hazardous
chemicals in the environment.
Use equipment only after adequate instruction and
Having knowledge of federal, state (nurse practice
acts), and local laws, and facilities’ policies that govern
the prescribing, dispensing, and administration
Preparing, administering, and evaluating clients’
responses to medications
Developing and maintaining an up‑to‑date knowledge
base of medications they administer, including uses,
mechanisms of action, routes of administration, safe
dosage range, adverse and side effects, precautions,
contraindications, and interactions
Maintaining knowledge of acceptable practice and
Determining the accuracy of medication prescriptions
Reporting all medication errors
Safeguarding and storing medications
To ensure safe medication administration
and prevent errors, nurses must know the
therapeutic effect, potential adverse effects,
interactions, contraindications, and precautions
for each medication they administer.
Every medication has the potential to
cause adverse effects. These are undesired,
inadvertent, and harmful effects of the
medication. Adverse effects can range from
mild to severe, and some can be life‑threatening.
Medications are chemicals that affect the body.
With concurrent use of medications, there is a
potential for an interaction. Medications can also
interact with foods and dietary supplements.
Contraindications and precautions for specific
medications are conditions (diseases, age,
pregnancy, lactation) that make it risky or
completely unsafe for clients to take them.
Anticipation of adverse effects, interactions,
contraindications, and precautions is an
important component of client education. Both
the nurse and the client should know the major
adverse effects a medication can cause. Early
identification of adverse effects allows for timely
intervention to minimize harm.
Common Medication Errors
Wrong medication or IV fluid
Incorrect dose or IV infusion rate
Wrong client, route, or time
Administration of a medication to which the client
Omission of a dose or extra doses
Incorrect discontinuation of medication or IV fluid
Preventing Medication Errors: The 10 Rights of Safe Medication Administration
Verify clients’ identification before each medication
administration. The Joint Commission requires two client
identifiers. Acceptable identifiers include the client’s name,
an assigned identification number, telephone number,
birth date, or other person‑specific identifier, such as
a photo identification card. Nurses also use bar‑code
scanners to identify clients. Check for allergies by asking
clients, checking for an allergy bracelet or medal, and
checking the MAR.
Correctly interpret medication prescriptions, verifying
completeness and clarity. Read medication labels and
compare them with the MAR three times: before removing
the container, when removing the amount of medication
from the container, and in the presence of the client
before administering the medication. Leave unit‑dose
medication in its package until administration.[IMAGE GOES HERE]
Use a unit‑dose system to decrease errors. If not available,
calculate the correct medication dose; check a drug
reference to make sure the dose is within the usual range.
Ask another nurse to verify the dose if uncertain of the
calculation. Prepare medication dosages using standard
measurement devices, such as graduated cups or syringes.
Some medication dosages require a second verifier or
witness, such as some cytotoxic medications. Automated
medication dispensing systems use a machine to control
the dispensing of medications.
Administer medication on time to maintain a consistent
therapeutic blood level. It is generally acceptable to
administer the medication 30 min before or after the
scheduled time. Refer to the drug reference or the
facility’s policy for exceptions.
The most common routes of administration are
oral, topical, subcutaneous, intramuscular (IM), and
intravenous (IV). Additional administration routes include
sublingual, buccal, intradermal, transdermal, epidural,
inhalation, nasal, ophthalmic, otic, rectal, vaginal,
intraosseous, and via enteral tubes. Select the correct
preparation for the route the provider prescribed (otic vs.
ophthalmic topical ointment or drops).
Immediately record pertinent information, including
the client’s response to the medication. Document the
medication after administration, not before
Right client education
Inform clients about the medication: its purpose,
what to expect, how to take it, and what to report. To
individualize the teaching, determine what the clients
already know about the medication, need to know about
the medication, and want to know about the medication.
Right to refuse
Respect clients’ right to refuse any medication. Explain
the consequences, inform the provider, and document
Collect any essential data before and after administering
any medication. For example, measure apical heart rate
before giving digoxin.
Follow up with clients to verify therapeutic effects as well
as side and adverse effects.
The 5 most mis-diagnosed disease areas:
Untimely diagnosis and response to complications during surgery and after surgery
Failure or delay in diagnosing a cancer can be devastating. Up to 15% of cancer patients are, at some point, misdiagnosed. Because of the anatomic location, some cancers are often more difficult to diagnose as they are not always apparent on physical examination. Lung and breast cancer, can be missed if an x-ray or radiologic imaging is mis-interpreted or there is a lack of follow-up to a suspicious study. There can also be a delay to diagnosis if a diagnostic test is not followed up, such as an elevated PSA in prostate cancer.
Stroke is cited as the most common culprit in this category. Delayed or missed diagnosis of stroke can lead to lifelong morbidity and death. Particularly in younger patients (under 50) stroke is often misdiagnosed. The window for thrombolytic treatment is short and suspected stroke patients should receive immediate attention and care.
An acute coronary event is the most common cause of cardiac morbidity and death when misdiagnosed. The “classic” symptoms (chest pain, left arm pain, chest heaviness) are often not presenting symptoms, particularly in women and elderly patients. They more often present with paresthesias, burning and prickling type pain in atypical areas such as the back, shoulders, and ears. Misinterpretation of an EKG or failure to order cardiac enzyme laboratory tests also lead to misdiagnosis of ACS.
Wrongsite surgeries and retained surgical items are leading causes of surgical error. Following proper timeout procedures and counts have reduced these errors significantly.
Post-operative complications account for a significant number of preventable patient deaths. These include complications such as wound issues, infections, bleeding, thrombosis, post-anesthesia complications, among others. The patient should be carefully monitored before, during, and after surgery to reduce the likelihood of one of these complications going unnoticed before it is too late to treat it as effectively.
Urological issues can often present similarly to many other diagnoses. Failure to obtain a urinalysis and culture can lead to a missed or delayed diagnosis of a UTI. Nephrolithiasis can present similarly to many acute illnesses such as UTI, aortic aneurysm tear, acute gastritis, etc. A missed kidney stone that causes complications can lead to medical complications and liability.
The Joint Commission National Patient Safety Goals Effective January 1, 2014 – Hospital Accreditation Program http://www.jointcommission.org/standards_information/npsgs.aspx
Daraswhe, A. et al. (2007) Misdiagnoses ACS. Israeli Journal of Emergency Medicine. 2007;7(3):3-10
PN Mental Health Nursing REVIEW MODULE EDITION 10.0 2017 Assessment Technologies Institute, LLC.
Fundamentals for NursingREVIEW MODULE EDITION 9.0 2017 Assessment Technologies Institute, LLC.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)