2012 Joint Commission National Patient Safety

GoalsGoal 1: Improve the accuracy of

patient identification

A. Use at least two patient identifiers (neither to be the patients room number) when providing care, treatment or services

Joint Commission Patient Safety 2012

Eliminate Transfusion Errors when administering blood and blood products

Nurses must adhere to a strict patient

identification protocol when administering blood

2012National Patient Safety

Goals

Goal 2- Improve the effectiveness of communication among caregivers

2012 National Patient Safety Goals

For verbal or telephone orders or for telephonic reporting of critical test results, verify “read -back” of the complete order or test result by the person receiving the order or test result

2012 National Patient Safety Goals

Standardize a list of abbreviations, acronyms and symbols that are NOT to be used throughout the organization.

The use of certain abbreviations has

been associated with errors.

Case Study

• An 81 year old female with a history of chronic Atrial Fibrillation who was receiving warfarin (Coumadin) developed asymptomatic runs of ventricular tachycardia

http://www.ahrq.gov

Case Study

Unit RN contacted MD

who was involved in a

sterile procedure and

gave a verbal order to

the procedure nurse

who relayed the

message to the RN

Someone in the verbal

order(by phone) said

“40 of K”. The unit RN

wrote the order as

“Give 40mg of Vit K IV

now”

Case Study

The hospital

pharmacist contacted

The MD concerning

The high dose and the

Route for the

medication order

Clarification of order

Was obtained and

correct order was

“40 mEq of KCL

(Potassium Chloride)

PO( by mouth)”

Simultaneously the unit RN had obtained the Vit K on over rideFrom the Pyxis system( cabinet where medications are kept) and gave the IV dose of Vit K instead of KCL.

Case StudyThe RN attempted to contact the MD but

was told he was busy. The MD was not

notified until the next day. Heparin was

started and warfarin was retitrated. No

long term consequences were suffered.

Abbreviations were used in this case

study which was identified as one of the

root causes for the error. What are other

possible root causes?

Do Not Use Abbreviations

Abbreviation Mistaken for Suggestion

U for unit Zero, four, cc Unit

IU International unit

IV or 10 International unit

Q.D. Q.O.D.

Each other Daily or every other day

Abbreviation Mistaken for Suggestion

Trailing zero (1.0mg) Lack of a leading ero (.1mg)

Decimal point is missed Read as 10 mg Read as 1 mg

Never write a zero after a decimal point and always use a zero before a decimal point

MS MSO4 MgSO4

Confusion Morphine sulfate vs Magnesium sulfate

Write out name of drug

Abbreviation Mistaken for Suggestion

mcg Milligram Write out microgram

TIW Three times a week

HS Multiple meaning

Write out meaning bedtime half strength

How Important is Communication and Patient

Safety? 70-80% of health care errors are caused

by human factors associated with interpersonal interactions (Schaefer,1994)

Behaviors That Impede Patient Safety

• Reluctance or refusal to answer questions- avoidance

• Rude or condescending comments

• Threatening body language

• Verbal abuse

• “I am in charge. Just do it”

• Threats to reputation

Behaviors That Support A Culture of Safety

• Collaboration

• Respect

• Interdisciplinary rounds/conferences

• Open, honest and direct communication

• Supportive non-punitive reporting

• Goal directed interactions

Reporting Incidents: SBAR

• A method of communication used to report a critical situation to a physician or other health care provider is

• S = Situation- What happened• B = Background- Patient information• A = Assessment- What you found• R = Recommendation- What needs to be done

2012 National PatientSafety Goals

Goal 3 Improve the safety of using medications

Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs

Case Study

A woman with chronic renal failure

& diabetes was transferred from a nursing

home to the hospital for treatment of an

infection. Bicitra (citric acid)30ml four times a

day was ordered on admission. The

pharmacist filled the order with Polycitra

instead ( contains citric acid & Potassium

citrate). The patient drank the entire dose.

Case StudyThe nurse on the next shift noted the

empty container. The MD was notified

and a potassium blood level was > 8mEq/L.

(Normal is 3.5-5) and her blood glucose was

600mg/dl( normal < 129) The patient was

Treated with Kayexalate and insulin without

complications. What happened? Reference: http://www.ahrq.gov

Near Miss• The wrong drug was administered to the

patient. This is an example of a sound alike drug error. Nurses are responsible to know what medications they are administering and question all inconsistencies.

2012 National PatientSafety Goals

- Label all medications, medication containers(syringes, medicine cups,etc)

or other solutions on & off the sterile field( Area where instruments and solutions are placed during

procedures)

Case Study

A woman was injected with Chlorhexidine(topical anti microbial solution) instead of theIntended contrast media during a cerebralangiogram procedure. The clear pink tingedChlorhexidine solution was placed in a basinidentical to that used to hold clear coloredcontrast media. Neither basin was labeled soboth solutions looked very similar. ISMP Medication Safety Alert! August 2005 Vol3 Issue 8

Case Study

The patient experienced an acute severechemical injury to the blood vessels in her leg.Within two weeks her leg was amputated. Shethen suffered a stroke and organ failure leadingto her death.

ISMP Medication Safety Alert! August 2005 Vol3 Issue 8

What Happened ?

Is this an example of an active or latent failure?

What Happened ?

It is an example of both.

• The lack of labeling on the basins is an active failure.

• The change in cleaning solutions is a latent failure. Administration neglected to notify staff regarding the change.

Blunt End Sharp End

Additional Medication Safety Issues

The National Coordinating Council for Medication Error Reporting & Prevention defines a medication error as follows: “A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer. Such events may be related to professional practice, health care products, procedures and systems, including prescribing; order communication; product labeling, packing, and nomenclature; compounding; dispensing; distribution, administration; education;monitoring;and use.”

TYPES OF ERRORS

• Unauthorized drug• Improper dose• Omission• Prescribing• Wrong time• Wrong Patient• Extra dose

• Wrong administration technique

• Wrong method of preparation

• Wrong dosage form• Wrong route• Failure to monitor

How Often Do Medication Errors Really Occur ?

• According to the IOM study more than 7000 deaths occur each year related to medication errors.

• Another study found that as many as 1 in every 5 medications reach the patient in error.

Medication Errors

• Keep in mind that the reporting of medication errors is thought to be grossly under reported !

• Reporting agencies include the FDA, US Pharmacopeia via Medmarx , ISMP and Joint Commission.

Where in the Process do Medication Errors Occur?

Reference: http://www.ahrq.gov

Where in the Process do Medication Errors Occur?

• Most errors occur during the prescribing /ordering process.

• About 50% of those prescribing errors are caught prior to reaching the patient.

• Greater than one third of errors occur during administration but only 2% of these errors are caught prior to reaching the patient.

ISMP Medication Safety Alert, November 2005

Patient is the Last Line of Defense

• Errors made during the administration process are much more likely to reach the patient and are associated with those errors that cause harm.

• Encourage patient and families to ask questions.

ISMP Medication Safety Alert, November 2005

Do All Medication Errors Result in Harm to Patient?

• According to MEDMARX 2002 Data report (USP) out of 192,477 reported med errors-82 % were classified as non-harmful.

• However, a reported 3,193 were classified as harmful and 20 as fatal errors.

Key Points• Written orders must be clear and legible !

• Clarify any order that is questionable including sound alike/ look alike drugs.

• Patients age, sex,current medications, diagnosis, co morbidities, concurrent conditions, laboratory values, allergies and past sensitivities must be available to prescriber

Case StudyA patient was admitted to a teaching hospital withsuspected vasculitis. During rounds the senior residentinstructed the intern to “give the patient one gram ofsteroids.” Following rounds the interns ordered”Prednisone 20mg tabs 50 pills PO x 1 now”. Thepharmacist contacted the intern to clarify the order. Shesuggested to the intern that the order should probablybe given in an IV form. The intern refused to change theOrder despite the pharmacists suggestion to contact thesenior resident for clarification. The intern added to giveMaalox with the steroids. The patient reluctantly took the fifty20 mg pills and developed mild nausea and heartburn. Thefollowing day the senior resident found the error andchanged the order to the IV form. Reference: http://www.ahrq.gov

What Happened?• The intern did not seek clarification as suggested by

the pharmacist, who is an expert in pharmacology. Lack of interdisciplinary approach to patient care. The intern may have been fearful of the senior residences reaction to seeking clarification.

• The pharmacist did not follow the chain of command by calling the senior resident when the discrepancy was not addressed by the intern.

• Asking a person to take 50 pills is NOT appropriate.QUESTION INCONSISTENCIES-YOUR PATIENT’S

SAFETY IS IN YOUR HANDS

Medication Errors :Prevention Strategies

Adhere to standards of medication administration -“8 Rights”

Communicate with the patient /family Identify medications with high risk for

error and institute specific protocols

Medication Errors :Prevention Strategies

• Training & competency assessment

Decrease distractions

Computerized order entry

Automated dispensing devices

Medication Errors :Prevention Strategies

• Proper storage & labeling

• Bar coding-decreases errors in administration

Increased clinical Pharmacists

2012 Patient Safety Goals

Reduce the likelihood of patient harm

associated with the use of

anticoagulation therapy.

Case Study

Three neonates died at a hospital as aresult of accidental heparin overdoses.A pharmacy technician inadvertently filledthe automated dispensing cabinet with1ml vials of heparin containing10,000 units/ml instead of the1ml vials ofheparin10 units/ml. The nurses did not noticethe discrepancy and the heparin wasadministered to the neonates. ISMP Medication Safety Alert Oct 2006 4/10

RecommendationsIn order to prevent this tragedy from happening againthe following recommendations have been made:

1. Eliminate 10, 000 units/ml concentration vials stocked in the hospital. If this concentration remains in the pharmacy, keep the vials separate from other concentrations.

2. Require an independent double check of drug.3. Reduce look alike/ sound alike drug packaging The vials of heparin had similarities that may have

contributed to the error.

For all recommendations see reference

Unintended Medication Discrepancies at the Time of

Hospital Admission

6% Severe harm potential

61%

No harm potential

33%

Moderate harm potential

More than half of patient have 1 unintended medication discrepancy at hospital admission

Reference: http://www.ahrq.gov

Unintended Medication Discrepancies at the Time of

Hospital Admission

Cornish,Knowles & Marchensano(2005)found greater than 50% of patients had at least 1 medication discrepancy upon hospital admission. The most common error was omission of a regularly used medication. Obtaining an accurate medication history at the time of admission is critical to prevent such errors.

Reference: http://www.ahrq.gov

2012 National PatientSafety Goals

Goal 8- Accurately and completely Reconcile Medications across the continuum of care