PREVENTION OF MEDICAL ERRORS 2 HOUR UPDATE 2.0 CE Hr.
Successful completion of this packet meets requirements for Healthcare Providers.

PURPOSE

Medical Error reports are more frequently appearing in newspaper articles and in television news stories.  It is estimated that medical mistakes are responsible for 44,000 to 98,000 deaths each year.  In general, health care is extremely safe, but is also not risk free.  Health care can often times be very complex, and even by competent medical professionals can sometimes make mistakes.  But, by continually learning from such mistakes and educating ourselves, we can reduce the frequency of medical errors occurring.

OBJECTIVES

Upon finishing this self study packet, participants will be able to:

                1.)  State 4 factors that contribute to medical errors
                2.)  Be able to identify potential error situations
                3.)  Discuss strategies to decrease errors and improve patient outcomes
                4.)  Understand the roles and responsibilities of error reporting
                5.)  Describe safety necessities for special populations
                6.)  Understand professional and public education and awareness

OUTLINE

I.          Prevention of Medical Errors
                 A.  Statistics
                 B.  Legislative/Government Initiatives

II.         How Medical Errors Occur
                 A.  Various Kinds of Errors

III.        Situations in Which Errors Are More Likely to Occur

IV.        Methods to Reduce and Avoid Medical Errors

V.         Roles and Responsibilities for Reporting

VI.        Special Populations

VII.      Education

VIII.     Posttest and Evaluation 

Note:  Much of the information in this packet has been adapted from Institute of Medicine and Institute for Safe Medicine Practice guidelines.

Instructions:
Read the material, complete the test and course evaluation.  You may mail this to the above address.  You may fax the completed answer sheet, personal info, and evaluation (1 page) to (954) 322-8817 if you have a 24 hour dedicated fax line for us to fax your certificate to.  All passing tests received by fax will be returned via fax by 6pm the following business day.

PREVENTION OF MEDICAL ERRORS

People come to health care facilities with both an expectation of quality medical care and fear of the unknown. They have most likely learned something about the latest in medical technology. They also know the treatments they will receive may have inherent complications. Medical errors are not a secret — the more sensational ones are reported in the media. Less sensational errors are discussed and passed along within friends and families. The best hospitals can and do have adverse events. The difference between an excellent hospital and a less-than-excellent hospital is that the excellent hospital is committed to continuously improving quality, examining systems and process for potential error risks, revising, and monitoring procedures.
    
Medical errors happen when something that was planned as a part of health care doesn't work out, or when the wrong plan was used in the first place. Medical errors can occur anywhere in the health care system: hospitals, clinics, outpatient surgery centers, doctors' offices, nursing homes, pharmacies and even patients' homes. Errors can involve medicines, surgery, diagnoses, equipment and lab/diagnostic reports. Health care professionals characteristically do their best in providing care. Mistakes happen and can be made by even the most conscientious professionals. Medical errors affect us all whether we are involved or not: loss of confidence in the quality of health care in the US, negative patient outcomes, increased mortality and morbidity, increased costs, increased stress and tension for professionals and between patients and professionals.
    
Common medical errors include medication errors (wrong dose, wrong time, wrong medication, wrong patient), wrong site surgery, punctured organs, mislabeled specimen or results placed on the wrong chart, sponges and other surgical tools left inside patients, misread lab or radiology tests, transfusion errors, incorrect diagnosis, delays in getting an accurate diagnosis that slows down or stops recovery, blood transfusion with the wrong blood type.
    
The number of deaths in US hospitals due to medical errors is disturbingly high. The subject of medical error is not new or recent - it has been researched and studied for the past 30 years. Historically, medical errors were rarely discussed, much less reported. Errors made while providing care to patients were considered endemic to the heath care professions - virtually a cost of doing business. The strategy for dealing with/reducing errors focused on the individual involved and disciplining that individual. The number and types of errors increased, but reporting did not, nor did any system or process changes occur. As these errors were discovered, more attention was directed at them. As a result of this spotlight, the health care industry is slowly realizing that the potential for errors extends far beyond individual practice to the design and organization of systems and policies. Many errors do not cause harm, but in many ways, these are as important as errors that do. They indicate a breakdown in the system or a erroneous decision. If we are to learn from mistakes then we need to know about as many as possible so that we can make suitable changes.
    
Another result of this spotlight is that medical error has come to the forefront of presidential attention, legislative oversight, regulatory and accrediting agency scrutiny, and participation by health insurances and scrutiny of professional organizations (physicians, nurses and pharmacists etc).  Why all this attention at so many levels — because of the high rate of errors in a health care system based on the premise to first "do no harm".
    
The error rate in health care is well known and researched. Now what do we do what that information?  Let's start with another term for commonly used to describe an error and the process of analyzing and developing corrective actions: sentinel event. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) defines a "sentinel event" as an unexpected occurrence involving death, serious physical or psychological injury or the risk thereof. This event is called 'sentinel' because it sends a signal or warning that requires immediate attention and involves an unexpected variation in a process or outcome.  Sentinel events can results from errors of commission (such as forgetting to give a medication) or omission (such as when a required action is delayed or not carried out). Both sentinel events and errors are unexpected and unintended outcomes.  In the non-punitive, system-based approach, sentinel events offer one more strategy for ongoing scrutiny of potential error sources and quality improvement opportunities.
    
The second step in the sentinel event process is looking for the common cause variation. A common cause variation is a variation that occurs because of the way a process is designed.
    
The third step is a root cause analysis. This is an investigative process that examines an error or sentinel event from every angle to identify the cause and from there develop strategies to avoid or reduce errors.
     
This 3-step process speaks directly to IOM's position that errors or sentinel events extend far beyond individual practice to the design and organization of systems and policies, and that this very design and organization must be continuously evaluated to identify potential risk areas to avoid and reduce error recurrence.

PROFESSIONAL GOVERNMENTAL and LEGISLATIVE INITIATIVES

On November 29, 1999 the Institute of Medicine (IOM) released "To Error Is Human: Building a Safer Health System,” reporting for the first time the results of an in-depth study that names medical errors as the nation's leading cause of death, permanent disability and injury. The report is the first in a series released by the IOM as an initiative to develop a strategy for improving the quality of health care in America. The Institute of
Medicine (IOM) is an affiliate of the National Academy of Sciences, which is chartered by Congress but operates as a private, non-profit institution. The IOM provides health policy advice to the federal government usually by producing extensive, peer-reviewed reports such as the November 29,1999 report described below.  The Institute of Medicine has been the frontrunner in the research of medical errors and the proactive systems approach to error reduction. IOM research and recommendations have revealed startling data on medical error and offers strategies to recognize potential error situations and systems approaches to reduce these errors. As such you will see many of their recommendations throughout this module. 
    
The IOM report indicates that medical errors kill between 44,000 and 98,000 people in the U.S. hospitals each year. Deaths from medical errors are higher than from highway accidents, breast cancer or AIDS - combined.  These statistics do not include deaths from errors in day surgery and outpatient clinics, retail pharmacies, nursing homes and home care. This IOM report also revealed total national costs (lost income, lost household production, disability, and health care costs) of preventable medical errors resulting in injury are estimated to be between $1-7 and $29 billion! 
    
Other statistics indicate that medical errors may be the fifth leading cause of death. Although these numbers represent a tiny number of patient care encounters, they reflect a large number of preventable injuries and as such pose significant concern and challenges for nurses, physicians, administrators and payers.  The IOM report revealed that although many errors could be avoided, the climate to change practices and systems that would minimize these errors does not yet exist. The IOM set a goal of a 50% reduction in medical errors by the year 2004. In their report, IOM stated: "It may be part of human nature to err, but it is also part of human nature to create solutions, find better alternatives and meet challenges ahead".
    
IOM research discovered that the majority of medical errors do not result from individual recklessness or carelessness, but from basic flaws in the way the health care system is organized. For example, according to the study, the current health care structure creates an environment for error such as drugs kept on units that are lethal unless diluted, illegible medical records, fast-paced disruptive environment, lack of knowledge, unfamiliar drug, constantly changing drugs and technology that doesn't keep pace with communication of such changes, new procedures or equipment to name only a few. In the past, when an error occurred, all accountability fell on the individual. Silence surrounded the issues in this system. The November 1999 IOM report calls this "finger pointing" and faultfinding system a pointless exercise. This report also strongly supports a non-punitive system-based approach that evaluates all points in a system that have a role in patient care and a role in a potential error situation. The IOM believes such a non-punitive system-based multidisciplinary collaborative approach is the most effective strategy of continuously monitoring quality and effectiveness of procedures.  The American Nurses Association (ANA) has also been active in the movement away from blame and actively supports the role of nurses in multidisciplinary collaboration to identify and reduce errors. The ANA report "Shared Accountability in Today's Work Environment" advocates efforts that focus on correcting systems errors with particular note of inadequate nurse staffing as a source of error.
    
Changing the mindset to non-punitive, system-based thinking and accountability is a major change.  A non-punitive, system-based approach to error reduction does not diminish accountability; it redefines it and directs it in a much more productive, problem-solving manner. In a non-punitive, systems approach, analyzing errors is the first step in determining how errors occur-and how to prevent them.
    
Accountability - not for zero errors but for making patient safety "job one" - should be equally shared among all health care providers. Webster's defines accountability as an "obligation to provide a satisfactory explanation, or to be the cause, driving force, or source.”  These definitions offer insight into at a more effective safety accountability model. In a model based on this definition, accountability lies not in performing perfectly, but in proactively identifying safety problems, implementing system-based solutions, and embracing a culture of safety. The 1999 IOM report describes the health care industry in the US as being at least a decade behind other high-risk industries, such as the airlines and manufacturing, in addressing safety concerns. Systems-based approaches to reducing error emphasize focus on systems rather than individual(s) as illustrated by progress in the airline industry, where the Aviation Safety Report Service (ASRS) has led to the identification and correction of unsafe conditions in several areas.
    
Another key participant in the field of medical error prevention is the Institute for Safe Medication Practice (ISMP). The ISMP strongly supports the IOM report and recommendations. The Institute for Safe Medication Practices is a nonprofit organization that works closely with health care practitioners and institutions, regulatory agencies, professional organizations and the pharmaceutical industry to provide education about adverse drug events and their prevention. The Institute provides an independent review of medication errors that have been voluntarily submitted by practitioners to a national Medication Errors Reporting Program (MERP) operated by the United States Pharmacopeia (USP) in the USA. Information from the reports may be used by USP to impact drug standards. All information derived from the MERP is shared with the U.S. Food and Drug Administration.  (FDA) and pharmaceutical companies whose products are mentioned in reports. The Institute is an FDA MEDWATCH partner and regularly communicates with the FDA to help to prevent medication errors. The Institute encourages the appropriate reporting of medication errors to the MEDWATCH Program.
    
In February 2000, President Clinton called for all medical errors in hospitals that result in death or serious injury to be publicly reported as part of a mandatory national error prevention system. The plan calls a new federal office to research and promote "patient safety," for new standards to reduce medical errors caused by similar-sounding prescription drug names, and for legislation that would allow hospitals and doctors to investigate their errors without fearing that the information would used in future malpractice suits against them.

In March 2001, the Institute of Medicine released a second report on its research into the safety of health care in the US: "Crossing the Quality Chasm: A New health System for the 21st Century.”   This report focuses on thirteen specific recommendations designed to provide a guide for organizations to use in their efforts to improve patient safety. These recommendations are vision, redesign of the delivery system, building organizational support for change and environmental change. These recommendations offer strategies for examining medical errors, identifying and recognizing potential sources and high-risk areas, using multidisciplinary systems-thinking to research an error and adopt strategies to avoid further errors, reporting to the health care system as a whole and the public (within parameters that protect confidentiality) and education for professionals, patients, families and the public.

Below is a summary of legislative actions from 1997 to 2001. These are included to emphasize the spotlight and attention medical errors are receiving.

•    June 1997 - AMA launched the National Patient Safety Foundation (NSPF)

•    October 1997 -  US Dept. of Veterans Affairs launched National Patient Safety Partnership.

•    January 1998 - NPSF's first "Request for Proposals" to support patient safety research.

•    March 1998 - "Quality First: Better Health Care for All Americans", the final report of the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, recommended that "reducing health care errors" be included as 1 of 6 national aims for improvement of health care quality.

•    June 1998. US Department of Health and Human Services released a report, "The Challenge and Potential for Assuring Quality Health Care for the 21str Century", that emphasized the need for health care organizations to launch new initiatives to improve health care quality and patient safety.

•    November 1999. The first IOM report, "To Error Is Human: Building a Safer Health System"

•    February 2000. President Clinton's proposal for a national reporting system.

•    March 2001. The second IOM report, "Crossing the Quality Chasm: A New health System/or the 21st Century" with its 13 specific recommendations.

•   April 23, 2001. On, HHS (Health and Human Services) formally established a new patient safety task force, HHS Patient Safety Task Force, led by the Agency for Healthcare Research and Quality (AHRQ), CDC, FDA and CMS. (CMS is "Centers for Medicare and Medicaid Services", formerly HCFA [Health Care Financing Administration].) The purpose of the task force is to identify and helps to monitor health care safety, compliance with existing regulations on blood products, devices, drugs, and the safety of patients in Medicare-funded institutions. The task force will be studying ways to implement a user-friendly internet-based patient safety reporting format. This will enable faster cross-matching and electronic analysis of data, and more rapid responses to patient safety problems.

•    October 2001.  HHS focuses on patient safety research and announced the release of $50 million fund 94 new research grants, contracts and other projects to reduce medical errors and improve safety. The-initiative, funded by HHS AHRQ, represents the federal government's largest single investment to address patient deaths related to medical errors. The 94 projects now being fund  (be carried out at state agencies, major universities, hospitals, outpatient clinics, nursing homes, physicians' offices, professional societies and other organizations across the country.

Disciplinary, legal, or regulatory sanctions and education as individual strategies have proven ineffective identifying and developing strategies to reduce medical error. With this new emphasis on recognizing, reducing and reporting error, even stronger emphasis is now placed on multidisciplinary systems thinking, root cause analysis and non-punitive correction of system failures that contributed to the error. 

HOW MEDICAL ERRORS HAPPEN

The delivery of health care is complex and involves multiple providers with various degrees of specializations all of whom have a high degree of interdependency on each other. Many factors contribute to medical error.

Organizational factors include the institution's culture, workflow design, staffing levels, reliance on mandatory overtime and overall resource allocation for patient care delivery.

Ergonomic factors such as lighting, noise, design of equipment and furniture, legibility of labels, positioning of controls, and confusingly similar designs contribute to errors.
Human vulnerabilities such as poor planning ability, poor short-term memory, poor problem-solving ability and limited attention span are also complicating factors.
Situational factors are everywhere in health care and include fatigue, stress, illness and sensory overload.
Cognitive lapses contribute to errors in the form of overconfidence, overgeneralization, reversion to the familiar when under stress and confirmation bias (looking for something that confirms what one believes regardless of accuracy).

External factors such as regulations, litigation, payers and consumers may also contribute to errors. As far as examples of errors, medication errors comprise the largest majority of medical errors because these include mistakes within all the layers of medication administration. Errors can occur in any of me 5 R's, illegible handwriting, incorrect abbreviations, misread abbreviations (was it 10 milligrams or 10 micrograms), interruptions in preparing medications, faulty labeling, faulty organization of patient care, lack of education, antagonistic environmental conditions (crowding, excessive clutter, excessive interruptions, poor lighting). Too many drug names sound confusingly alike. Consider the painkiller Celebrex and the anti-seizure drug Cerebyx; or Narcan, which treats morphine overdoses, and Norcuron, which can paralyze breathing muscles.  Another source of error is omission and commission caused by inadequate information, unsuitable  mental processing of information, inappropriate actions stemming from adequate information.

Although medication errors represent a large majority of errors, there is a wide range of other medical errors. Examples are illegible handwriting, unclear or un-clarified verbal orders, inappropriate abbreviations, mistakes in diagnosis, delays in getting an accurate diagnosis that slows down or stops recovery, mislabeled specimens or lab results on the wrong chart, misread laboratory tests, administration of incorrect blood type or mislabeling of a blood product, wrong-site surgery, wrong patient surgery, punctured organs, sponges and other surgical gear left inside patients, hospital-acquired infections, dietary errors (giving a patient on a salt-free diet, a meal high in salt), connecting TPN to an IV line, improper use of restraints or injury resulting from the use of restraints, mistakes related to use or application of medical devices or the inadequacy or ambiguity in the design of a medical device. Here are several, actual incidents to illustrate this. 

1. A patient comes in for an MRI of the chest and forgets to remove the chain around his neck or staff overlooks it. What occurred was accidental introduction of a metal object into a MRI exam room. 

1. Potassium chloride concentrate for injection is another example.  In this case, JCAHO issued a "sentinel event alert" that recounted the misadministration of concentrated potassium chloride. This alert recommended removing this drug from nursing units because of packaging similarities. Since then, the pharmaceutical industry developed premixed solutions, physicians standardized potassium replacement therapy, and vials of potassium chloride were removed from patient care units.

           Rhode Island hospital performed a tonsillectomy
      on the wrong patient because staff confused her and
      another girl with similar last names.
          Neurosurgical instruments used by Tulane
      University on a patient was later found to be
      infected with Creutzfeld-Jakob disease may be the
      cause of transmitting that illness to eight other
      patients.
     Health care has come late to the study of errors on an industry-wide level. JCAHO has established requirements for sentinel event reporting and investigation just a few years ago to encourage hospitals to investigate errors and to begin a central system for collecting and analyzing information. Setting a goal of "zero errors" in health care is unrealistic. Errors will always occur. The same systems that produce success also produce failure. We can reduce their frequency and severity by understanding the causes and building proactive strategies preventive into our procedures.

RECOGNIZE POTENTIAL ERROR SITUATIONS: WATCH FOR THE SIGNALS

Research is showing that most of the problems are not due to individual performance, but due to system failures. Nurses, physicians and administrators must focus on how to make the systems work better! One way to begin efforts to improve patient safety is to think about the patient care and risk issues that keep you up at night, advises Sandra Berkowitz, RN, JD. There are red flags in the office and hospital setting you can look for that can signal that your systems need improvement. These include:

1. patients who see multiple providers in different settings and none of whom have access to complete information
2. crowded, busy spaces, subject to disruptions, where orders are taken, transposed or medications prepared
3. lab or test results without definitive patient identification
4. patients with ambiguous symptoms (shortness of breath, abdominal pain, and dizziness) whose heart attack is not diagnosed by emergency room staff.
5. patients who call more than three times or frequent (re)admissions for the same issue;
   recovery taking longer than expected
6. noncompliance related to a prescription not filled because it is 'not covered by my plan' or 'too expensive'
7. providers who are over-tired (providers working a regular workday and then take call after hours)
8. more verbal than written orders

STRATEGIES FOR REDUCING AND AVOIDING ERRORS

Across the healthcare professions, who has greater knowledge and understanding of health care processes than we do? The keys to identifying sources of error and strategies to avoid them are communication and teamwork.  This means crossing "turf lines,” abolishing "tribal mentalities" and keeping our collective focus on the common goal: safe, excellent patient care. We provide quality patient care every day through conscious or unconscious collaboration with many different health care professionals. Who better to collaborate on improving our delivery of safe, quality health care but us?

Reduce Errors by Educating Patients: Customer Service and Communication

Teaching patients how to be a responsible partner in their care goes a long way toward reducing medical errors. One approach is to develop a brochure that introduces patients to their illness or injury care and explains how they can work to ensure an optimal outcome. Offer written materials in conjunction with face-to-face or telephone communications. Encourage your patients to be totally honest with the doctor, the nurse practitioner or nurse and not hide or emphasize symptoms. It's difficult to assess and provide care when you don't know what the problem is. Encourage patients and families to keep journals and write down questions and symptoms. Keep compliance in the forefront. Be alert to any problems a patient may have with compliance and address these issues upfront. Find out if the patient might have problems taking medication or can't afford it, and deal with it promptly. If you think a patient needs a drug that can't be taken with alcohol and the patient loves fine wines, you need to know it and make sure the patient is comfortable with taking the drug. If you believe a patient needs a certain antibiotic but her plan won't cover it, be honest with that patient. Tell her how much it is likely to cost out of pocket and ask if she still wants that prescription. If she doesn't, suggest alternatives and be honest about the pros and cons of any alternatives. Physicians, nurses and pharmacists aren't intruding into the patients' finances, but are offering informed choices and education. For both health plans and practitioners, it is a matter of supporting patients to be empowered to make decisions. Patients have choices to make and we have to be ready, not with answers, but with choices and education.

What makes the patient satisfied is to feel better, to have a chronic illness managed properly, to have someone they can talk to and answer their questions. If patients are unhappy, they feel dissatisfied and have negative outcomes, then you have all the right ingredients for a lawsuit.

Safe Practice Recommendation: Take that Extra Step to Verify and Clarify

We hear of medication errors that were prevented by health care professionals who are persistent enough to fully investigate situations that "just don't seem right," even after there's been an initial confirmation by an authoritative source. Use the most-current reference(s) you can. Use the internet carefully! Not all info on the net is legitimate. Check with the library or pharmacy to see if they have sites they use regularly. Taking this "extra step" can often avoid patient harm.

Here's one example. A patient with several health conditions, including glaucoma and diabetes, was admitted to a hospital with medication orders that included "glucose control solution one-drop to left eye twice a day." Since this substance is actually used to verify proper functioning of a glucose monitor, the pharmacist questioned the nurse and prescriber, both of whom stated "that's what the patient uses at home."  The pharmacist then took the time to question the patient directly. Indeed, the patient said that he'd been instilling glucose control solution into his left eye at home and thought this was the correct, based upon instructions from his local physician. The pharmacist, still not satisfied, telephoned the original prescriber who indicated that, actually, timolol ophthalmic solution was to be used for the patient's glaucoma. The pharmacist later discovered that the diabetic patient, with very poor eyesight, had interchanged the glucose control solution with the timolol (both products are available in small dropper containers with yellow caps and black lettering.  
And One Step Further
Consider publicizing some of the phrases used to justify a questionable order before an error becomes apparent.  Add additional reasons as appropriate. Mandate that these statements - shortcuts really - won't be used or at least won't be allowed to dissuade anyone from performing additional follow up:

"That is what the doctor ordered"
"The attending told me to order it that way"
"The patient says that's how they take it at home"
"It was published in recent literature"
"This is a special case"

"The patient's been titrated up to that dose"

"The patient is on a protocol"
"The dose is from the patient's old chart"
"It's on the list of meds the patient gave me"
"We always give it that way"

When medication orders do not seem quite right, pharmacists, nurses, and physicians must take that "extra step" to verify an order before a medication is prescribed, dispensed, or administered. Just following orders is not an excuse, legally or ethically. In the example cited above, the pharmacist did not just take the word of the physician, nurse, or patient, all of whom said that the prescription was accurate. During orientation of new staff, and continuing education of current staff, we must emphasize the thought that the "reasons" cited above are unacceptable responses if an order is questioned. Practitioners, coworkers and management must work collaboratively to pursue questionable medication orders until there is absolute satisfaction that the order is appropriate.

Develop Systems-Thinking: More Heads are Better Than One

The most effective solutions are achieved with systems thinking. Systems-thinking uses multidisciplinary teams that openly discuss errors and refuse to settle for old familiar ways of solving problems. If education is identified as an error reduction strategy, we can't stop there. Instead of just building processes to detect errors before they reach patients, we need to find ways to actually prevent them. We must always ask, "why did this  happen,” "what would make it possible for an error to occur here,” "are there ways to make it impossible, not just unlikely, for people to make such a mistake?" These are the contributions root cause analyses offers in systems-thinking. Systems-thinking is the key to bridging the gap between understanding the causes of errors and choosing error-reduction strategies that have the greatest likelihood of success. With practice and a little creativity, we can become more innovative in identifying system-wide strategies that work continuously and automatically to prevent errors and injuries.

Encourage Broad-Based Thinking: Pass the Word

Every hospital has a "wrong-site" surgery procedure/process.  Know what it says. Actor Dana Carvey was hospitalized for angioplasty. Unfortunately, the surgeons operated on the wrong coronary artery and the surgery had to be repeated. In other case, the wrong limb was amputated. These procedures list explicit steps for everyone involved to follow. Physicians, surgeons, anesthesia, OR-nurses, floor nurses all have a role. These steps serve as checks and balances. The key here is communication, pass the word to everyone caring for that patient.

What if the problem involves a medical device?  Most hospitals include several different steps in the procedure.  Some of these steps include:  Materials Management works with the "end-user" (i.e. Nursing) and Risk Management. If a device is faulty, the end-user reports it and removes the device from service. If a device is recalled, Materials Management notifies the end-user and the device is removed from service. Materials Management is developing a process for device alerts in which the company notifies them and they communicate with whoever the end-user is. Materials Management communicates with a variety of patient care areas.

Then, there's those safety inspections. Equipment in the right place (out of the hall), lighting, accurate and legible labeling, infection control, electrical safety, clean and dry floors to name only a few points. Each time we enter a patient's room, to provide care, are we taking the opportunity to survey that environment for potential trip/fall or injury hazards? We're familiar with the hospital or office environment but our patients and families are not. It is these very safety inspections that keep us focused on identifying and avoiding potential accidents for patients, visitors and ourselves. When and if you had a hazard, pass it on to Housekeeping, Facilities Engineering, Risk Management — the appropriate department to work with you to resolve it.

Resource allocation means you know where to go to find information, ask questions and maximize resources effectively.  Be sure you know where the drug reference is, how to reach the pharmacist, how to manage a spill, the location of the MSDS.

Ask for help when you need it. Consistently review your priorities for the day and ask yourself what's the best way to accomplish this and is there another best way. These are the hallmarks of performance improvement.  The people performing the service best accomplish performance improvement — they are the 'service experts'.

Effective Root Cause Analysis

Leadership sets the tone and culture for patient safety. A team of people, leaders, peers and front-line staff related to the incident accomplishes Root cause analysis. These individuals review a patient safety incident or a near miss and recommend solutions and improvements. There are 5 principles to effective root cause analysis.

1.Clearly show the cause and effect relationship.  If an incident occurred, there has to be a reason why it happened.

2. Do not use negative language.  This fires up the culture of blame. Instead, focus on something that happened that he/she couldn't do what they were supposed to.

3. Each human error must have a preceding cause.  Most errors and adverse events involve a set of events and errors.
 
4. Procedure deviations are not root causes and must have a preceding   cause. Again, what caused an event to occur that shouldn't have?

5. Failure to act is only causal when there is a pre-existing duty toact.
Root cause analysis keeps asking “why” until the lowest common denominator is reached. Only then can solutions and strategies be developed.

Institute of Medicine's 4 Themes
The 4 themes from it's report "Crossing the Quality Chasm: A New Health System/or the 21st Century” are vision, redesign of the delivery system, building organizational support for change, and environmental change.  From these 4 themes, the March 2001 IOM report stated that health care should be:
•    Safe - avoiding injuries to patients from care intended to help them
•    Effective — providing services based on scientific knowledge to all who can benefit and refraining from providing service to those not likely to benefit
•    Patient-centered — providing care respectful of and responsive to individual patient preference, needs and values and ensuring that patient values guide all clinical decisions
•    Timely — reducing Wait times and sometimes harmful delays for those who receive and those who give care
•    Efficient -- avoiding waste, including waste of equipment, supplies, ideas and energy
•    Equitable — providing care that does not vary in quality because of personal characteristics such as sex, ethnicity, geographical location or socioeconomic status.

Develop a Non-Punitive Culture for Reporting and Problem-Solving

Despite a growing awareness of the system-based causes of errors, many in health care are still struggling to come to terms with the role of individual accountability in a non-punitive culture. Administrators, physicians, nurses, pharmacists - all interested parties — must confront many barriers in their attempts to study medical error. Identifying and addressing these barriers begins the process. The first step is admitting that errors occur. The second step is recognizing resistance to change. Other barriers include fear of discipline, fear of licensure sanction, hindsight bias, need to blame, need to rationalize a negative event, legal system that focuses on faultfinding, and liability exposure.

A non-punitive, system-based approach to error reduction does not diminish accountability; rather it redefines and directs accountability in a more productive manner. A non-punitive approach focuses on the system's contributions so that the workforce and leaders are equally accountable for evaluating and protecting patient safety, not striving for zero errors. There is no evidence to support the premise that a non-punitive culture will increase carelessness. In fact, experience has shown that a non-punitive culture increases staff awareness of safety and promotes innovations for changing error-prone systems within their own system! As the IOM reports states: "It may be part of human nature to err, but it is also part of human nature to create solutions, find better alternatives and meet the challenges ahead".

Insights into People

The health care industry has recognized that system failures cause errors and that well-designed systems and technology offer the best chance of preventing errors. This begs the next question: in our growing focus on systems and technology, have we overlooked human function? While we are focusing attention on more effective and efficient healthcare systems, have we devoted equal attention to understanding how the human mind operates and the situations that adversely affect its function - specifically identifying stress-producing aspects of complex systems and steps to help people cope with them? Are we considering how personal beliefs, values, and attitudes influence performance?

In a recent article, Tony Grasha, Ph.D., Professor of Psychology at the University of Cincinnati, studied cognitive functions and psychosocial factors that impact the accuracy of outpatient pharmacists. His research suggests tools that can enhance memory and sensory input while taking into account environmental factors and organizational dynamics such as supervisory practices, as well as personal qualities such as demeanor, patience, ability to manage stress, and interpersonal relationships. These tools offer multidisciplinary impacts. If one group of professionals is affected by stress within complex systems, other groups of professionals are also affected.  Identifying and avoiding medication errors is a good example of a complex multidisciplinary effort and is a good example. Here's a sampling of what he found with specific interventions.  Even though his research focused on pharmacists, do you see anything that applies to nursing practice of safe medication preparation and administration?

Periodic self-monitoring and verification: Errors were reduced by 21% when pharmacists periodically monitored themselves to detect errors. Each subsequent check identified 95% of errors that were missed during a prior check. However, mistakes were detected less frequently as the amount of continuous time spent on the specific activity increased. Thus, taking a short break or changing to a different task before self-monitoring increases effectiveness.

Light and magnification: Errors were reduced by 16% when   pharmacists were given a high intensity task light and magnification lens to read prescriptions.

Copyholders: Errors were reduced by 24% after installing a device to hold prescriptions on the computer monitor, closer to eye level, to improve the visual angle during order entry.

Alerts: Posting alerts in strategic locations with 30 error-prone products reduced errors with these products by 71% and potentially significant occurrences by 45%. Errors with non-targeted drugs also were reduced by 56% simply through heightened error awareness.
 
Exaggerated product labels: Errors were reduced by 35% after affixing product sleeves with exaggerated, non-conventional type fonts to better read sections of drug names/doses.

Cognitive style and coping skills: Pharmacists who could attend to details and focus their attention made fewer errors. About 12% of pharmacists had difficulty with details and focus, and they accounted for 33% of the all the mistakes observed. High intensity lights, copyholders, and exaggerated product labels were especially helpful for such people. Pharmacists with adequate coping skills and stress management training also made fewer errors 

RESPONSIBILITIES AND ROLES IN REPORTING MEDICAL ERRORS

Many health care leaders and professionals are uncomfortable with the increased scrutiny of their practice and organization by non-medical professionals. If we can redesign the current 'culture of blame' to anon-punitive systems-thinking culture, we can start sharing ideas and working together to reduce the frequency and severity of medical errors.

Historically, mandatory reporting has not been very successful either in gathering data or developing strategies for improvement. The IOM report, "To Err is Human: Building a Safer Health System," has been the driving force in medical error research and reporting for the goal of improved patient safety. As such, we included the iom's review of the existing mandatory and voluntary, reporting systems with goals that offer insight of the benefits of reporting medical errors. The IOM in conjunction with other federal and regulatory agencies (i.e. HHS, CMS and JCAHO) will continue to be the forerunners in this process. All health care providers must actively stay informed of their progress and recommendations, as these will be impacting our practices. The IOM report has two main goals. The first is to make errors costly by placing external pressure on providers so they are compelled to take action to improve safety. The second is to enhance knowledge about the causes of errors and their prevention. The report suggests that these two purposes may be difficult to achieve simultaneously with a single type of reporting system. Therefore, the IOM recommends:
           •  The establishment of state-administered mandatory reporting systems that would  receive reports of very serious adverse events and thereby hold providers accountable, deliver the necessary incentives for organizations to make patient safety a priority, and regain public trust in health care;
   
    •   The increased usage of current voluntary reporting systems which receive reports of  non-serious adverse events and errors and thereby learn about the caused errors and improve patient care and safety.
    •    A requirement for public and legal disclosure of very serious adverse events caused                                                                                                                                 errors and reported to mandatory reporting systems; and
    •    The enactment of federal legislation that would extend peer review protections for non-serious adverse events caused by errors and reported to voluntary reporting systems.
(This document, which has been prepared by the nonprofit Institute/or Safe Medication Practices (ISMP), mil address IOM recommendations related to reporting systems and provide a conceptual framework for a model reporting system.)

1. Current Mandatory Reporting Systems
     Mandatory reporting systems have traditionally been less than successful in holding providers accountable for improving safety and providing information that leads to improvement, for the following reasons:
•   They have had punishment at their core, which has suppressed reporting and inhibited open discussion about errors;
•   Reports have not come from front-line practitioners who could best describe the event and the circumstances leading to errors; and
•   Report recipients have had insufficient expertise to analyze the data and thus have had very limited success in recommending broad system improvements to enhance safety.
2. Current Voluntary Reporting Systems

     Voluntary reporting systems have experienced great success with providing information that leads to improvement, primarily for the following reasons:
       •   A non-punitive environment has been encouraged, so trust and respect has developed between those who report errors and experts who have received and analyzed the reports;
       •   Voluntary systems have received a representative and sufficient sample of reports from front-line practitioners who have provided necessary and insightful information about an incident and its causes;

• Reported information has been swiftly analyzed and used confidentially and proactively to establish and publish safe practice recommendations; and
•  Expert analysis has been focused on learning from the event and preventing future errors through system-based solutions that can be extrapolated widely to all healthcare settings.

However, the missing link in obtaining full success with voluntary reporting systems has been the lack of universal accountability for adoption of proven error reduction strategies by providers and others in the health care field.
3. Conclusions

     The fundamental goal of any reporting system is to gain knowledge about adverse events, gain new knowledge about the causes of errors, and share that knowledge with the healthcare community.
-  While voluntary reporting systems have clearly demonstrated their ability to provide information that leads to patient safety, most mandatory-reporting systems have been less successful than originally envisioned.
 
-  Experience has shown that mandatory reporting systems, as they currently exist, will not increase provider accountability for patient safety or increase the public's trust in the health care system, since fear of reprisal will drive errors further underground.                                              

-  If provider accountability must be addressed through a reporting system, success will be much more likely if organizations are expected to report serious adverse events to a public agency, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), rather than state regulatory agencies. While the Joint Commission encourages voluntary reporting of sentinel events, the organization also provides the level of expertise needed to validate, during on-site review, that system-based changes were made to prevent reoccurrence.

- Peer review protection must be extended for reports of all adverse events (including those that result in serious harm), "near misses," and other errors submitted to reporting programs to provide the necessary incentives for practitioners to disclose and report errors.
 
    
     The Institute for Safe Medication Practice (ISMP) strongly supports these IOM recommendations. ISMP also supports the conceptual framework of focused reporting systems referred to as "mini-systems" in the IOM report that are targeted toward selected areas in healthcare, such as surgical events, anesthesia events, and medication events. Such focused reporting systems should:

-  Be national in scope.

-  Be voluntary in nature.
Experience has shown that the volume of reports is far less significant than the quality of information contained in a smaller number of reports that represent a sampling of medical errors across the nation.
-  Encourage unrestricted practitioner reporting.
The system should receive reports of serious/fatal events caused by errors, "near misses," and hazardous situations from front-line practitioners who can best describe the event and causes.

-  Be non-punitive -with respect to those who report errors.
Reporters should have no fear of retaliation.

-  Function independently of regulatory or accrediting bodies.
The cause of errors and their solution must be determined objectively, absent any conflict of interest.
-  Analyze and use the information effectively and credibly.
Multidisciplinary experts in the field must analyze reports and aggregate data.
-  Provide timely and widespread communications about errors and prevention.
Name-blinded error descriptions and prevention strategies must be communicated rapidly through a formally sanctioned process.
- Encourage universal acknowledgment, adoption, and implementation of proven safety practices.
Reporting systems would not have the power to mandate implementation of recommendations that stem from error analysis. Findings must be shared with regulatory agencies, accrediting bodies, federal agencies, and healthcare purchasing groups to assist them in establishing and enforcing appropriate safety recommendations as standards. Regulatory and accrediting agencies should hold providers and other healthcare participants accountable for the successful implementation of selected safety strategies. Regulatory or accrediting bodies should be able to disclose information publicly if providers do not comply with adopted safety standards.
-  Be confidential.
Provider and reporter identity could be removed following expert analysis.
The system should encourage providers to disclose medical errors honestly and promptly to patients and/or families.

-  Offer a level of evidentiary protection.
Federal legislation should extend state peer review protections to all information submitted to the reporting system.

SAFETY CONSIDERATIONS FOR SPECIAL POPULATIONS

Special populations include the older and elderly patients, pediatric patients, patients with cognitive and/or physical disabilities. These populations require extra vigilance because they are at higher risk of injury and error. Age possess challenges of physiologic differences. Children's renal and liver functions are still immature.  Older adults suffer from diminished renal and liver function increasing the chance of drug toxicities due to decreased metabolism and excretion. Older adults have diminished capacities such as vision. Consider the child who cannot articulate questions about medications or procedures and the elderly adult who has aphasia. Neither group has the capacity to tell you "that's not the same pill I take" or "no, it's my other arm".

There is a myriad of strategies for these special populations. Pay extra attention to the 5 Rights of medication administration. Resist the urge to combine or modify these steps on a busy day because these are one of the best defenses against errors. Never leave medications at the bedside.

Take an accurate and careful drug and allergy history and be aware of side effects and interactions with foods and other drugs and communicate these to other professionals involved in the care of that patient.  Take mat extra step " double check critical drugs with another nurse or pharmacist such as digoxin, insulin and heparin. Work with the pharmacy to review and revise labeling as necessary to avoid errors.  Begin patient and family teaching as early as possible not only because LOS are shorter but to allow time for you to reinforce the information, identify areas of potential problems, people to absorb information and ask questions.

Be attuned to the total patient - mental disorders such as delirium or dementia may be caused by neurochemical changes, brain infection or trauma, systemic infections, medications, withdrawal from drugs, endocrine dysfunction, electrolyte imbalance, multisystem disorders and nutritional deficiencies. (NOTE:  Delirium is an acute, treatable and reversible disorder; dementia is a chronic, progressive and brain damage is irreversible due to gradual deterioration of neurons.) For these patients, a safe, structured environment is a priority. Provide routine schedules, permit extra time, offer reorientation cues as appropriate, and a balance in sensory stimulation. Encourage memory function but do not challenge or confront a forgetful or confused patient. Be very conscious of the environment and actively seek out possible hazards for falls and other injuries. Communicate these to coworkers and other departments who can work with you to ensure safety and reduce hazards.

PUBLIC EDUCATION

When people enter me health care system, they enter a strange world with language, procedures and routines all its own! Part of our role as an advocate is to teach patients and their families how to carefully navigate their way around our world. The single most important way people can help to prevent errors is to be an active member of their health care team. They are responsible for their care and we are responsible to supporting them. If hospitalized, patients must be sure to identify and inquire about what care they are receiving.

At The Doctor's Office (and before)

Teach them about and stress that they must learn about their illness and treatment options. Informed patients are better able to participate in their care, increasing probability of detecting any mistakes.  Teach them to seek respected sources for information; misinformation abounds/Possible resources: books, Web sites (WebMD is a great one), medical organizations (e.g., American Cancer Society), others who have had the same condition, and, of course, their doctor.

A critical aspect is communication with their physician and other medical providers. As part of then-personal health record, they must write down their questions - much like they write a shopping list to go grocery shopping! This list of questions should cover all their health concerns. They should expect their doctor to spend 15-20 minutes with them. During that time, encourage them to discuss any headaches, dizziness, chest pain, shortness of breath or chronic cough, any change in nutrition and bowel/urinary habits (anorexia, dark/blood-tinged stools, difficulty urinating or incontinence), questions about how their medications work and any side effects, what tests have been ordered including the purpose and results. Teach them to know their lab-test results, X-ray outcomes, etc., and what they mean. They must request explanations - even insist - for terms and results they do not understand.

Encourage them to ask when and how they will get the results of tests or procedures. If they do not get them when expected - in person, on the phone or in me mail, do not assume the results are fine. Call the doctor and ask for the results and an explanation for what the results mean for their care. Discuss any feelings or fears they may have about "back-seat-driving". Some providers may resent this but most welcome an involved and interested partner in the care of the patient.

Be flexible and prepared to ask questions. Keep asking - courteously and agreeably - until they feel informed. After all, it is their body. If the doctor seems impatient, they must ask themselves whether this is the right doctor for them. Have an advocate - a trusted relative or friend who will be with them at important physician appointments and the hospital. The advocate can help ask questions, remember answers and raise concerns they might not think of while under stress.

Persuade them to take a note pad to doctor appointments. Encourage patients and families to "do their homework": write down everything important that's said, such as information about test results, medications, etc. even if they think have a good memory. Write down any health problems such as heart disease, high blood pressure, diabetes, poor-vision or hearing, epilepsy because these can influence treatment choices for a new condition. They should include immunization status, dates of last Pap and mammogram, prostate exam and eye exam, any previous surgeries including where and when performed. They must be specific about family history (such as heart disease, cancer or diabetes) and describe previous health status, age and cause of death of deceased family members. A social history such as smoking, alcohol intake, marital status, children and employment is important. A complete list of medications -- and allergies to medications, food and environment is essential. This list must include prescription drugs, over-the-counter drugs, birth control methods, vitamin and herbal supplements and their dose and frequency. Bring pill bottles with that list of all medications they take. This will avoid the risk that an incorrect or out-of-date medication list will be used at the hospital or office. Even if you've written these down on a form, remind your doctor, especially at the time he or she prescribes new medications. Adverse drug interactions can be serious, even fatal.

They must tell the doctor if they use any medicinal herbs or illegal drugs (the information is protected), since these also can interact with conventional medicines.  Teach patients that is their physician prescribes medication, learn its purpose, name, it appearance, the dose he or she is to take, and any side effects.  If you can’t read your doctor’s prescription, ask him or her to write it again. It should be legible to anyone. Tell them to keep a personal record of each doctor visit: date, reason for visit, what was done, test readings (blood pressure, etc.), advice given, prescriptions, etc. They should do the same with other health-care providers. Keeping a record helps the patient track their own health care and be more active in their health care decisions. When presented with medical forms, don't sign them without reading them first. It is their body! Be sure the patient comprehends what he or she is signing and doesn't sign it until they do. They should get another opinion on any diagnosis or proposed treatment of major consequence.

At The Hospital

Patients should have a trusted advocate, or advocates, with them to make sure they get needed attention from nurses and doctors, check that they are getting the right food, medications or painkillers and convey by their presence that you are important and deserve the best care.  A private room is a good idea if they can afford it. They'll likely get better rest, lower their risk of receiving a roommate's medicine by mistake, and be surrounded by fewer germs.                                                                                                                                                    
They can write their name on a piece of paper or small poster board and keep it handy. This helps prevent busy nurses from giving them a medicine or procedure intended for someone else. They should also include their room number, serious allergies and chronic medical conditions.  When a nurse brings a medication, the patient should remind her of his or her name and make sure she checks their hospital ID bracelet and medical chart.

Patients must be assertive yet nonabrasive. They must ask questions, raise concerns, make special requests (if important), tell nurses and doctors if they think something is wrong about their care or condition. They must complain or make special requests only when necessary. It helps if they do so gently and try to keep a sense of humor, so hospital staffers will enjoy giving the most quality care possible. A patient doesn't want to be avoided as a constant complainer.

Patients must know the names, purposes, what they look like (pink pill, etc.) and the dose of their regular medications.  It helps to bring a list. Then if a nurse hands him or her a yellow pill, they must say, "I don't take a yellow pill."  They must learn that same information about any new medication prescribed in the hospital and then ask the
nurse who brings it to double-check that it's correct. This applies to IV- medications as well as pills or injections. Patients must know what time of day they are supposed to receive various medications so they can tell someone if they don't get them. Also, they must make sure different caregivers do not mistakenly repeat a medication after they've already had a dose for the day. The chart should show what they've received; make sure the nurse checks what was given earlier and writes down what she gives. Patients must tell a nurse immediately if they notice an unexpected reaction to a medication or IV. Possible signs include pain or burning sensation, shortness of breath or trouble breathing, dizziness, confusion, chest tightness, numbness or itching.

Patients must monitor hand washing. They must ask all caregivers to wash their hands before touching them. The spread of germs is a major hazard in hospitals and is believed to cause thousands of infections nationwide every year. A number of studies have shown it is common to see doctors checking one patient after another without washing their hands between patients. Latex gloves are not a guarantee of cleanliness. Patients must know they can ask for a different room if their roommate is coughing or sneezing. Airborne germs could infect them.

Patients should ask to be moved to a different floor if another patient on that floor has the same or a similar name as theirs. Moving could prevent medical mix-ups.

Patients should avoid consumption of undercooked eggs in the hospital; they could contain harmful bacteria, to which patients may be more vulnerable than usual because of their weakened condition.

Patients must not assume all hospital personnel are aware of what the doctor has ordered for them. If an order about medications, food, etc., does not reach everybody involved in their care, someone might try to give them food before surgery or a medicine they're no longer supposed to take. It is another reason to pay attention.

Patients must be pleasant to nurses, aides and other personnel. They're vital to both their comfort and health. Because they see patients more often than doctors do, nurses, PCTs and other personnel can spot changes in patients' condition that might need attention. It helps when patients and families express gratitude, when appropriate, for good care and solicitous attention.

Before Surgery

Teach them and their advocate to learn as much as possible about the operation.  Teach patients to learn about alternatives to surgery and get a second opinion. Teach patients to ask what is being done, why is it being done, what are the consequences of delaying or not having the surgery. Depending on the answer, the patient may decide the better choice is not having it. When a patient is presented with medical forms, they shouldn't sign them without reading them first. This is their body! Be sure they understand what they are signing and don't sign it until they do.

They must ask who is actually doing it - the main doctor, a resident, an intern or a tech. Check that the surgeon has performed the procedure numerous times. Ask about his or her success rate. If the patient is not satisfied, they should consider getting another surgeon.
Teach patients to make sure before a surgery on an arm or leg that the correct arm or leg is marked clearly. They should look for "wrong leg" or "wrong arm" to be written across the limb that is not to operated on.  Wrong-limb surgeries and amputations have occurred often enough to make this precaution important. (An "X" or the words "Right leg" on a limb could be ambiguous.) Some hospitals will even have the patient mark it him or herself.

Some references suggest not scheduling surgery for a Friday, if possible, because hospitals often have reduced staff on duty over the weekend.  Patients must be aware of whether they can eat or drink anything before surgery (probably not). Violating this order can be dangerous. They must not let an uninformed staff person try to feed them.

Patients should have an advocate with them before and after surgery. The advocate can observe whether his or her pain or other problems are being controlled and make sure they get needed attention. In the pre-surgery interview with an anesthesia professional, patients must mention all health conditions they have, medications they take, the amount of alcohol they drink, any illegal drugs they use, including marijuana, and allergic reactions or other problems they or a blood relative have had with an anesthetic. Any of these could critically affect their reaction to an anesthetic.  Patients should ask whether the anesthesia professional who conducts their pre-surgery interview is the same one who will perform anesthesia duties in the operating room.  If not, they should ask how the medical staff will make sure that person receives the above information.

After surgery, patients should ask whether they had any unusual reactions to the anesthetic and write down the information. This could be important if they have any future surgery.   Patients should ask what to expect in the recovery room; how they will feel and how pain will be controlled.

Emergency Room

Patients must wear a medical bracelet or carry a wallet card listing any health conditions, medications, allergies, doctor's name, a relative's phone number, etc. - vital information in case of an accident or medical emergency and are unconscious. Even if they are able to speak, they might forget important facts. Keep the information updated. Have someone contact their doctor, the professional who knows most about their health.  Patients should have an advocate with them if possible.

At The Pharmacy

Patients should use the same pharmacy regularly; the computer record of their medications can help the pharmacist spot possible prescription errors or potentially harmful drug interactions.  Patients should plan ahead and not wait until the last minute to get a refill.  A good suggestion is to always call ahead, 24 hours in advance when possible.   Patients should ask their pharmacist about any new prescription ordered for them: when and how to take it, potential side effects, potential interactions with other medications.  The pharmacist will verify the doctor’s prescription and make sure it is legible.  The patient can do this also.  When getting a refill, patients should make sure the pills are the same size and color they usually get.  If not, they should ask the pharmacist to examine them.

The important thing to remember is that the patient is responsible for his or her medical care.  It is easy for patients and families to think of the health care provider or pharmacist as infallible, but they are just as human as patients and families and thus just as prone to making mistakes.

CONCLUSION

The best hospitals can and do have adverse events.  The difference between an excellent hospital and one that is less than excellent is that the excellent hospital is committed to continuously improving quality, examining systems and process for potential error risks, revising, and monitoring procedures.

Medical errors can take place anywhere in the health care system: hospitals, clinics, outpatient surgery centers, doctor’s offices, nursing homes, pharmacies and even patients’ homes.  Mistakes can involve medicines, surgery, diagnosis, equipment, and lab and diagnostic reports.  Health care professionals do their best in providing care, but mistakes can occur and be made by even the most conscientious medical professionals.  Medical errors affect us all, even if we are not immediately involved.  The health care industry is slowly realizing that the potential for mistakes extends further than individual practice to the organization and design of health care systems and policies.  We must begin to utilize a systems-based way of conceptualizing the causes behind medical errors that focuses on increasing staff awareness of safety and promotes innovations for changing error-prone systems within their own system.  Who better to collaborate on improving our delivery of safe, quality health care but us?  As professionals, we must stay current on research and innovations related to medical error to ensure our own growth and success at reducing errors.

Selected References

JCAHO. (2007). Joint Commission on Accreditation of Healthcare Organizations. Retrieved 1/25/07 from http://www.jointcommission.org.

JCAHO. (2009) Accreditation Program: Hospital, Chapter: National Patient Safety Goals. Retrieved December 26, 2008 from http://www.jointcommission.org/NR/rdonlyres/31666E86-E7F4-423E-9BE8-F05BD1CB0AA8/0/HAP_NPSG.pdf.

JCAHO. (2007). Sentinel Event Policy and Procedures. Updated July 2007, Retrieved 1/25/09 from http://www.jointcommission.org/SentinelEvents/PolicyandProcedures/

JCAHO (April, 2008). Preventing Pediatric Medication Errors. Sentinel Event Alert. Issue 39, April 11, 2008. Retrieved 1/25/09 from http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_39.htm.

JCAHO, (September, 2008). Preventing Errors Relating to Commonly used Anticoagulants. Sentinel Event Alert. Issue 41, September 27, 2008. Retrieved 1/2/09 from thttp://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_41.htm.


JCAHO. (January, 2006). Using Medication Reconciliation to Prevent Errors. Sentinel Event Alert. Issue 35, January 25, 2006. Retrieved 1/8/09 from http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_35.htm.



Society of Academic Emergency Medicine Patient Safety Task Force (2005) Applying Human Factors to Patient Safety: Core Curriculum for Patient Safety.

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