1. Medical Errors 2013 It’s all about patient safety! Updated 03.13.13JP

2. What do we want to learn?  What do we know?  Pretest – for your eyes only Please take a few minutes to complete on your own

3. What do we want to learn? Student Learning Goals:  Understand the significance of medical errors in professional practice and be able to:  Define factors that increase the incidence of medical errors  Recognize error-prone situations  Discuss processes to improve patient outcomes  Describe your responsibilities as a healthcare professional for reporting medical errors  Identify and discuss the safety needs of special populations in your practice.  Discuss the importance of public education to reduce medical errors

5. Background Information  Concern over incidence of Medical Errors  IOM Landmark Report (1999)  To Err is Human: Building a Safer Healthcare System  Statistics  44,000 – 98,000 Hospital deaths due to medical error 5

6. Definitions  What is a Medical Error? 6

7. Definitions  Medical Error  Preventable adverse events with our current state of medical knowledge  Adverse Event:  Injury caused by medical management rather than underlying disease condition  Not defined as intentional act of wrongdoing 7

8. Definitions  What is a Sentinel Event?  What is the difference between a medical error and a sentinel event?

9. Definitions Sentinel Event  an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.  Such events are called “sentinel” because they signal the need for immediate investigation and response. Sentinel Event and Medical Error – are they the same?

10. Responsibility in Reporting What is your responsibility in reporting medical errors/sentinel events? Let’s see…………………..

11. Reporting Requirements  Florida Law requires all licensed facilities to:  Have Internal Risk Management and incident reporting system  Report Serious Adverse Events to:  AHCA Agency for Health Care Administration  The Joint Commission  Mandatory reporting guidelines 11

12. The Joint Commission aka: TJC formerly: JCAHO  National organization  Mission to improve the quality of care in healthcare institutions  Provides Accredited status to healthcare facilities 12

13. The Joint Commission  Requires:  Process in place to recognize sentinel events  Credible root cause analysis (RCA)  Focus on systems not individuals  Risk reduction strategies  Internal corrective action plan  Measure effectiveness of process  System improvements to reduce risk 13

14. Question? What is a root cause?

16. Root Cause definitions  Fundamental reason(s) for the failure or inefficiency of one or more processes.  Point(s) in the process where an intervention could reasonably be implemented to change performance and prevent an undesirable outcome.  The majority of events have multiple root causes. 16

17. Question?  What is root cause analysis?  This wasn’t on the Pretest but……..

18. Root Cause Analysis  Goal-directed, systematic process  Uncovers basic factors that contribute to medical error  Focuses primarily on systems and processes and not individuals  Product is an action plan to reduce risk of similar future events 18

19. The Joint Commission Website  Amazing Resource  Great Collection of Data  Information for Patient Safety  For Healthcare Personnel  For the Public 19

20. Question?  What is one of the top 3 sentinel events?  Let’s see……………………

21. TJC Sentinel Event Stats  An education  Let’s look together!  Help us to recognize error prone situations  Help us to identify and discuss the safety needs of special populations

23. Sentinel Events Stats by Setting Joint Commission Data 2004 - 2012  Hospital (65%)  Psychiatric Hospital (11.2%)  Emergency Dept. (6.1%)  Psych unit in general hosp. (5.2%)  Ambulatory Care (4.1%)  Behavioral health facility (3.6%)  Home Care (1.8%)  Long Term Care (1.2%) 23

25. Sentinel Events Stats by Type Joint Commission Data 2012 (4 th Quarter)  Top 6  Unintended Retention of Foreign Body  Wrong Pt., Wrong Site, Wrong Procedure  Delay In Treatment  Suicide  Op/Post-Op Complications  Fall What is still missing in the top 6? 25

26. Sentinel Events Stats by Type TJC Data 2004 - 2012  Top 6  Wrong Pt., Wrong Site, Wrong Procedure  Delay In Treatment  Unintended Retention of Foreign Body  Op/Post-Op Complications  Suicide  Fall 26

27. Question?  What is one of the top 3 root causes of sentinel events?  Let’s look at root causes ………

29. Most Frequently Identified Root Causes of Sentinel Events 2012  Human Factors - 614  Leadership - 557  Communication - 532  Assessment - 482  Information Management - 203 29

30. Most Frequently Identified Root Causes of Sentinel Events 2012  Physical Environment - 150  Continuum of Care - 95  Operative Care - 93  Medication Use - 91  Care Planning - 81 30

31. Now What?  We have knowledge of the risks  How do we reduce the risk of errors?  Let’s discuss processes to improve patient outcomes together………………..

32. Question?  What are Sentinel Event Alerts?  Ongoing Education and Awareness  Just looking at the topics creates awareness  Let’s take a look…………….

33. Review of Sentinel Event Alerts The Latest from 2012:  Sentinel Event Alert Issue 49: Aug. 8, 2012  Safe use of opioids in hospitals 33

34. Review of Sentinel Event Alerts  Sentinel Event Alert Issue 48: Dec. 14, 2011  Health care worker fatigue and patient safety  Sentinel Event Alert, Issue 47: Sept 1, 2011  Radiation risks of diagnostic imaging  Link to all SEA’s:  http://www.jointcommission.org/daily_update/join t_commission_daily_update.aspx?k=721&b=&t=4 http://www.jointcommission.org/daily_update/join t_commission_daily_update.aspx?k=721&b=&t=4

35. Other Joint Commission Tools  Do Not Use List  NPSG’s – National Patient Safety Goals  Speak Up

36. Joint Commission Do Not Use List  U for Unit – write unit  IU for International Unit – write international unit  QD, QOD – Write daily or every other day  Trailing zero (X.0 mg.) – write (X mg.)  Lack of leading zero (.X mg) - write (0.X mg)  MS, MSO4, MgSO4 - write morphine sulfate, magnesium sulfate 36

37. Questions?  What are two national patient safety goals (NPSG’s) for your area of practice? Let’s see………………………..

38. National Patient Safety Goals 2013 – same as 2012  Let’s look at Home Care  Identify Patients Correctly  Use Medicines Safely  Prevent Infection  Prevent Patients from Falling  Identify Patient Safety Risks  Focus on Home Oxygen 38

39. NPSG’s  On Joint Commission Website  http://www.jointcommission.org/standards_infor mation/npsgs.aspx http://www.jointcommission.org/standards_infor mation/npsgs.aspx

40. Question?  What is the Speak Up Initiative all about?  Great for healthcare consumers – public education!  Let’s see………………………

41. SPEAK UP Initiative  Speak up if you have questions or concerns. If you still don’t understand, ask again. It’s your body and you have a right to know.  Pay attention to the care you get. Always make sure you’re getting the right treatments and medicines by the right health care professionals. Don’t assume anything.  Educate yourself about your illness. Learn about the medical tests you get, and your treatment plan.  Ask a trusted family member or friend to be your advocate (advisor or supporter).  Know what medicines you take and why you take them. Medicine errors are the most common health care mistakes.  Use a hospital, clinic, surgery center, or other type of health care organization that has been carefully checked out. For example, The Joint Commission visits hospitals to see if they are meeting The Joint Commission’s quality standards.  Participate in all decisions about your treatment. You are the center of the health care team.

42. Speak Up Materials  Speak Up materials are available for free download on The Joint Commission website.  Includes brochures, posters and videos.

43. Speak Up Initiatives  What applies to your practice setting?  Speak Up – Home Care  Speak Up - Help Prevent Errors in Your Care  Speak Up - 5 Things You Can Do To Prevent Infection  Speak Up - Reduce Your Risk of Falling  Speak Up - Understanding Your Doctors and Other Caregivers  Speak Up - Help Avoid Mistakes With Your Medicines 43

44. TJC New Pain Video  Developed for National Patient safety Awareness week (March 3 – 9, 2013)  http://www.jointcommission.org/multimedia/ speak_up_about_your_pain_english/www.jointcommission.org/multimedia/ speak_up_about_your_pain_english

45. Now What?  Learn from Knowledge of:  Sentinel Event Statistics, Alerts and Root Causes  Make Prevention a Priority  Implement Joint Commission Patient Safety Initiatives/Recommendations  Use Speak Up  Update on NPSG’s  Read Sentinel Event ALERT 45

46. Question?  What are 3 good resources for information on patient safety/medical errors?  Let’s see………………………..

47. Valuable Resources  TJC - The Joint Commission  FDA - Food and Drug Administration  US Food and Drug Administration  AHRQ – Agency for Healthcare Research and Quality  US Department of Health and Human Resources  ISMP – Institute of Safe Medication Practices  Medline Plus  A service of the US National Library of Medicine and National Institutes of Health  Healthfinder.gov  A Federal Government Web site managed by the U.S. Department of Health and Human ServicesU.S. Department of Health and Human Services

48. ISMP Institute of Safe Medication Practices  http://www.ismp.org/ http://www.ismp.org/  is the nation’s only 501c (3) nonprofit organization devoted entirely to medication error prevention and safe medication use.  certified as a Patient Safety Organization (PSO) by the Agency for Healthcare Quality and Research 48

49. ISMP Provides us with valuable information:  Medication Alert Newsletters and News Releases  Educational Programs  Consumer Information  Medication Safety Tools and Resources 49

50. ISMP Medication Safety Tools and Resources  High Alert Drugs  Potentially Dangerous Abbreviations  Confused Drug Name List  Tall Man Letters  Improving Medication Safety with Anticoagulant Therapy  "Do Not Crush" List 50

51. ISMP: Tall Man Letters  Table 1. FDA Approved List of Established Drug Names with Tall Man Letters  acetoHEXAMIDE ­acetaZOLAMIDE  hydrALAZINE – hydrOXYzine  buPROPion ­busPIRone  medroxyPROGESTERone methylPREDNISolone methylTESTOSTERone  chlorproMAZINE – chlorproPAMIDE  clomiPHENE – clomiPRAMINE  cycloSPORINE – cycloSERINE  niCARdipine – NIFEdipine  DAUNOrubicin – DOXOrubicin  predniSONE – prednisoLONE  dimenhyDRINATE – diphenhydrAMINE  sulfADIAZINE – sulfiSOXAZOLE  DOBUTamine – DOPamine  TOLAZamide – TOLBUTamide  glipiZIDE – glyBURIDE  vinBLAStine – vinCRIStine 51

52. ISMP  Links to FDA Safety Alerts and Medication Safety Videos  http://www.ismp.org http://www.ismp.org  www.fda.gov/psn www.fda.gov/psn And Much, Much More – A Great Resource! 52

53. What about Special Populations?  What are the special populations in your practice  What can you do to decrease risk? 53

54. Post Test  Look at your Pretest  It is now your Post Test  How did you do?

55. What did we learn? Back to the Student Learning Goals:  Understand the significance of medical errors in professional practice and be able to:  Define factors that increase the incidence of medical errors  Recognize error-prone situations  Discuss processes to improve patient outcomes  Describe your responsibilities as a healthcare professional for reporting medical errors  Identify and discuss the safety needs of special populations in your practice.  Discuss the importance of public education to reduce medical errors