Errors & Near Misses

                              

A medical error is a preventable adverse effect of care, whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailment.

This is Wiki's definition of a medical error.

Can I just say that I NEVER want to be responsible for a medical error that causes someone harm or worse yet, death!

We researched and reviewed errors this week for our Safety class. We read the story of a young mother who died as a result of care she received at a hospital. There are actually many stories like this and I think it is important that these stories get heard.

                                
Every time I read a story about an error in patient care that resulted in injury or death I am reminded of how important what I do and don't do are. As much as it is hard to read these stories it is so essential that they are in the forefront of my mind because I need to be ever vigilant in all my actions and procedures so I do not cause harm. I didn't get into nursing to hurt, I became a nurse so I could help. 
                               

Many errors that have occurred have resulted in a change in policy or procedure for patient care. These areas include trauma care, anesthesia monitoring, fetal heart monitoring, wrong site amputation or surgery, sponge counts, fatal allergies, potassium mishaps, decubitus ulcers, and lifting techniques. It is unfortunate that some patients and families suffered, but at least their suffering led to saving the lives of others. 

As nurses and professionals we have policies and procedures in place to protect our patients and ourselves from the adverse reactions of errors.... Follow them!!! Use the six rights of medication administration (right patient, right med, right time, right route, right dose, right documentation). There are things we can do to make sure we don't cause harm.

Even though I am new at nursing, here are some of my suggestions:

Slow down

Don't take any procedure or process for granted

If it doesn't seem right, feel right, look right.....ask for help!

When in doubt, look it up or ask your charge nurse

Listen to the patient and their family

Always assess

Take a step back and review

Always double check when it is required (and sometimes if it isn't)

There are many ways we can support our industry and provide patient-centered safe care. They are all available to us, but it is up to us to utilize what we know and reach out when help is needed. Safety saves lives and those lives are in our hands!

                              

The Golden Rule

                                       

Another week of learning about quality and safety. This is an area that should never get old. We can always strive to get better. This week's readings are entitled, "Assessing Risk and Harm in the Clinical Microsystem". This chapter reviewed the key components to reaching a goal in this area by:

1. Identifying Risk

2. Analyzing Risk

3. Controlling Risk

However, what I actually came away with this week was the importance of communication with and focus on our patients, their feelings and what they are experiencing both physically and emotionally. This became evident after reading our case study this week involving a medical error that cost a 15-year-old his life. Also, it was stressed in the article I read in the AHRQ's newsletter involving family and patient centered care.

My mother taught me a very valuable lesson when I was young and it has remained with me all these many, many, (many), years! Do unto others as you would have them do unto you!

                               

If we reversed our roles with our patients and put ourselves in their shoes, would we slow down? Would we take the necessary precautions? Would we listen more closely? Would we assess and intervene with more sincerity? We should!

Sometimes I find myself busy charting on the computer in the patient's room while they are talking to me. I know I'm busy, but I have been trying to make a conscientious effort to stop and look at them and listen with really intent. I want them to know that I am there for them.

                                       
I think if we can improve our communication skills and really apply our focus to our patients, following procedures would come more naturally. I don't know, maybe that's too simplistic or idealistic but shouldn't it be that way? Shouldn't we consider every patient, regardless of background, differences or worldly opinions, as though they were us or our close family so that we could treat them appropriately?

There are so many reasons for medical errors and sometimes it becomes a domino of small mistakes that lead to one great big one that causes harm. Quality and safety is about knowing your role, following guidelines and procedures put in place to steer clear of error, communicating with patients and other healthcare team members in assessing and intervening, listening and understanding patient needs and following through with appropriate care all the while remembering that the patient is our focal point.
                                       

I think this class is so important because in healthcare we must continually be reminded of the important responsibility we have to give patients the best care possible, the same care we would want if we were the patient. If we can keep that in mind, we will know what to do, when to do it, and what will be best practice.

                            

                                

The chapter we read this week is entitled, "The Role of Health Information Technology in Quality Improvement: From Data to Decision"

I have to hand it to those who are able to collect data from the hospital setting and display it in charts and graphs so that the information can be analyzed and areas of concern can be addressed. That is a hefty task. I expected to learn how this was done before beginning this unit and I feel that I have received a fairly sufficient overview. 

                                 

I learned that this system of data collection and decision making has it share of faults. It is dependent upon the human element for data collection. Some areas of concern are timeliness of reporting, bias interference, accessibility to data, differences in terminology or classification, finding relevant data and agreed upon interpret ability. There are also many forms of statistical analysis such as sampling or analytical approaches including classical statistics, event analysis, and data mining. Then there are different ways the information is shared and applied. 

                                                              

As I read through the chapter I thought about my anatomy class. They stressed and over stressed the importance of using the proper nomenclature in anatomy ensure that everyone, nation and worldwide, is using the same terminology. Then, you get out into the field and start applying all you learn and people use whatever terminology they want to use. So, it would be great if all companies would use the same system and report their data the same way, but in the 'real world' of things, that is not happening. That seems to be the biggest problem with streamlining data collection and analyzing that information for application in quality and safety.

                             

We are changing our computer system at work at the end of next month and I am hoping this will bring our hospital one step closer to a streamlined system of reporting. The system we use now is years and years old. For my nursing practice, I will do my best to utilize our computer charting system with the most accurate data I can give it. That is probably the best I can do to apply what I have learned this week to my career.

                   

Case Study Week #10 Telehealth Work Center

Telehealth

                                                             

A newly hired registered Nurse (RN) is assigned to work at the telehealth work center.  The RN is monitoring the in coming data from home-bound (based) patients from around the county, checking to see if there are any situations which require nursing interventions and taking the appropriate actions. One (1) patient is a type II diabetic. He reports his fasting blood sugar level of 54. Another patient who has congestive heart failure (CHF) and regularly reports in on daily basis does not send in any information (data).

• What is the best course of action for the RN to take regarding the diabetic patient?

• Assessing for symptoms
• Was any insulin administered prior to this result
• Have patient eat 15-20 grams of glucose or simple carbs to increase blood glucose
• Have him then recheck the blood sugar and provide updated information
• Advise small snack if he isn't going to eat within the next couple of hours.  
• What are normal parameters for this patient
• Diet history
• Follow up with diabetic education and nutrition information

• How should the RN proceed regarding the lack of information from the CHF patient ?  

                                             

• Contact the CHF patient
• If can't reach patient, contact emergency contact person
• Determine if this is an emergency situation or just a mistake in reporting from the patient
• Follow protocol for facility if this is an emergency

Telehealth: The Future of Medicine

Hmmmmmmmm.......................

                            

One of our responsibilities on the floor is to reconcile the patient's Medication Record in the chart with the Electronic Medical Record of medications in the computer. It is the nurses responsibility to ensure that what the patient and doctor have concluded as being the patient's actual medication, route of delivery, dose, and reasoning for taking is accurate. So, questions.......

                                   

1. Does the use of the Electronic Medical Record guarantee error-free patient care?

I say there is really never 'guarantee' when the human element is added to anything. However, by using this double check, there is the opportunity to catch any human errors that may have occurred. I have personally caught errors when reviewing this document. It is usually an error of entry into the computer by the pharmacy or a deciphering error of the written record. There is clearly an improved opportunity to provide the best quality care for patient's medication records by using an electronic system that is double checked by the nurse. Just take into consideration that where there is the human element, there is always a possibility for error.

                                      

2. What types of nursing behavior regarding the use of Electronic Medical Record's might contribute to jeopardizing patient safety?

I would say that error in relation to the human element includes occurrences involving interpretation of hand written orders by secretaries and nurses, not to mention the doctor who wrote the order. The alertness of the nurse. Shortages of nurses and/or under staffing can emerge in nurses who are tired. Also, nurses can become overwhelmed with duties and may tend to rush through tasks. There is always a good chance of error when rushing on the job. Lastly, if there is a way to short cut the procedure, some nurses may take advantage of that and skip steps or even just note the medication record assuming it is correct without really reviewing it. These are all ways that may contribute to patient safety with regard to medications.

                                             

3. What are the dangers of excessive system alerts in computer charting systems?

I think the number one danger of excessive system alerts is they become so common place that they are skipped over or not taken seriously. It's a matter of, "oh there is that message again, just hit escape and move on". Nurses are moving fast from the moment they come on shift. They hit the floor running and don't stop for at least 12 hours. Excessive system alerts can get in the way and nurses can become really skilled at finding ways around them.

                                    

4. How can the nurse guard against the potential effect?

The best way to ensure you're doing a good job as a nurse and providing excellent patient care and safety is to slow down, pay attention and do your best. I have found this to be true as a new nurse. I have felt on several occasions that going to work on my own without a clinical coach is like drinking all day out of a fire hydrant. But, I have been conscientiously working on slowing down every time I stop at the acudose to get a medication, take a breath and really focus on the medication, dose, and accuracy of what I am putting in my patient's hands. I speed up where I can but I do take time to stop and take a breath.... it really can make a difference. I would rather be late in charting something or even late in giving a medication as long as I know I took the time to do the job right and not rush pass safety nets that have been placed before me to help me do my job safely.  

                                        

                                          

The Patient and Continuous Quality Improvement

This weeks chapter covered "The Role of the Patient in Continuous Quality Improvement". So, I was expecting to learn more about continuous quality improvement. The first thing I really learned though was during this week's discussion. It covered a management process to bring about improvement. I was unsure about this to begin with so I did some research online about the subject regarding indicators and benchmarks. This is what I learned, especially from our team discussion this week:

Example: Patient post operative infections are increasing

                                      

INDICATOR: An indication or signal that a process needs evaluation and adjustment. A tool of measure used to judge whether the care delivered was appropriate or satisfactory. Indicators assess a clinical process or outcome to determine whether they are meeting the standard. From what I understand, in this case, it is a collection of data that can be examined to see how that process is functioning; is it meeting the standard the company wants or is it falling short? 

Example: patients are showing signs and symptoms of infection along with an increase in admittance of post operative patients for infections. 

PROCESS OF CARE INDICATOR: This is the process developed and put in place to correct or adjust the procedure that is not working or performing as the company would like. 

Example: Preventative measures are created such as antibiotic prophylactic treatment, patients bathing before surgery, and surgical site is shaven just prior to surgery.

                                      

OUTCOME INDICATOR:  I understand outcome indicators as another measure to determine the effectiveness of the steps shown above. In other words, it is a check-point along the way to see if the process of care indicator is working. It is like an ongoing assessment of the process.

Example: The in house documentation or checklists for surgery both pre and post are being evaluated and reviewed to make sure that the Process of Care Indicators are being done.

                                             

BENCHMARK: The benchmark is your goal, has it been met? In our example, have infection rates decreased due to the above process. Are we meeting the mark?

I am hoping that I understood this process because I really wanted to understand what we talked about this week in discussion. I have to admit when I read posts from the others in my team I feel that either I didn't get it or they didn't. So, I would like to know if I'm getting the right idea about these terms.

I do like to find better ways of doing things and I believe this is another example of how we can look for things that are not going as they should and look for better, more effective ways.

I also think the patient should be involved in their care. Sometimes I think they are so tunnel visioned on their pain or condition that they can't see outside the box. This is totally understandable. That's where we can step in and help them see beyond the pain and focus more on moving forward in the healing process. 

These are the different things that I learned this week and I will continue to work toward incorporating them into my nursing care.

                                

Okay, I just put this one in because I work nights and it made me laugh!