Patient Safety

Evelyn M. Hickson, RN, MSN, CNS, WCC

Objectives

By the end of the presentation, the participant will beable to:

1. Describe the most common causes of medication errors and the actions needed to ensure safe medication administration

2. Be able to state 4 current national patient safety goals

3. Describe the principle of professional, accountable communication

4. Identify perinatal risk management strategies

Patient Safety

1. Are we as nurses responsible for ensuring patient safety?

2. Do nurses have a medical-legal responsibility to provide safe patient care?

3. What methods do nurses have to use to facilitate the provision of safe patient care?

Definition

Patient safety is a discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. Patient safety is also an attribute of health care systems; it minimizes the incidence and impact of, and maximizes recovery from, adverse events.

What Exactly Is Patient Safety? Linda Emanuel, MD, PhD, Don Berwick, MD, MPP, James Conway, MS, John Combes, MD, Martin Hatlie, JD, Lucian

Leape, MD, James Reason, PhD, Paul Schyve, MD, Charles Vincent, MPhil, PhD, and Merrilyn Walton, PhD.*, Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 1: Assessment). Rockville (MD): Agency for Healthcare Research and Quality; 2008 Aug.

2013 Hospital National Patient Safety Goals

Joint Commission of Accredited Health Care Organizations (JCAHO or “Joint”) Changes have been made and since the

mandated implementation of NPSG from the Joint in 2004

Not all of the current safety goals apply to the in-patient acute care setting

Hospital has 15 for 2013 – No new ones were added for this year

www.jointcommision.org

1. NPSG.01.01.01 - Use at least two (2) patient identifiers whenever: Giving medicationsProviding CareGiving any TreatmentsProviding Services

2. NPSG.01.03.01 –Make sure that the correct patient gets the correct blood when they get a blood transfusion

Identify Patients Correctly

Improve the effectiveness of communication among caregivers

3. NPSG.02.03.01 Standardize a list of abbreviations, acronyms,

symbols, and dose designations that are not be used throughout the organization

hs = hour of sleep bid = twice per day

MgSO4 = magnesium sulfate

Improve the effectiveness of communication among caregivers

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

Improve the effectiveness of communication among caregivers

Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.

Improve the effectiveness of communication among caregivers

Implement a standardized approach to “hand- off” communications, including an opportunity to ask and respond to questions.

Clear, concise, factual, appropriate report when patient is transferring within facility, to different level of care or to another facility

Team approach to conflict

Professional Communication

Multiple studies and publications by JCAHO found that health care worker’s inability to communicate effectively contribute to errors and problems within health care that are typically avoidable.

Medication errors

Patient safety

Quality of care

Nursing staffing and turnover

Joint Commission Publications

http://www.jointcommission.org/Advancing_Effective_Communication/

SBAR

Situation-what is going on with the patient at this time

Background-significant medical and obstetrical history

Assessment-vital signs, labs, fetal monitoring assessment

Recommendation-what you want from the MD/provider – order(s), actions,etc.

SBAR

Documentation Patient Hand-off – Report Conversations with MD/Providers

Perinatal SBAR 30-60 Second Report

Before Calling the Provider: 1. Assess the patient 2. Read the most current notes, lab data, orders, etc 3. Have the chart in hand

SBAR Report Obstetric Patient Situation Identify yourself and where you are calling from

Give patient name and reason for call: “Pt was admitted for___________ and/or has recently had a _____________” “I am concerned about____________” FHR pattern Labor Progress Contract Pattern (hyperstim or lack of) BP/Vital signs Vag Bleeding, etc

Background G___ P___ @ _______wks gest OB Attending ______________ Significant med history _____________ Significant OB history __________ Problems with current pregnancy _______ Patient complaints are____________ Patient pain level _____________

Assessment Maternal vital signs Cervical exam Labor progress FHR – Variab, Baseline, Accel, Decels, UC pattern, reassure Vs non-reassuring Lab values that are abnormal or changed Interventions you have had to implement and the patient’s response Your conclusions about the present situation

Recommendation What I would like from you is _________________ (I need you to come now to assess the patient, etc…)

Be specific about the time frame Be specific about interventions (FSE, IUPC, Pit, Terb) Clarify orders, vital signs, labor plans, when to call back, lab work, etc…

Other Methods

Key phrases that stop every member of the team: Huddle “Can I have a moment” “Team Up” Rounds

Seven Areas Where Communication Breaks Down

Broken rules – not following policy/protocols Mistakes Lack of support – from team, peers, administration Incompetence Poor teamwork Disrespect Micromanagement

Actions

What actions can

we as nurses take in order to attend to these 7

essential areas?

Broken Rules

Shortcuts can be dangerous when it comes to patient care

Policies and procedures are considered institutional standards / guidelines

Mistakes

Important to follow directions Ability to make sound clinical judgments that are

appropriate and individualized for the patient Critical Thinking Skills Assessment skills Triaging and diagnosing Requesting treatment and assistance

Lack of Support

Willingness to help, mentor, precept, answer questions, be a resource

Be an active team player – help out Give emotional support Pats on the back for a job well-done

Incompetence

Precept Mentor Educate Report – at times first line of action, other

times last. Patient safety comes first.

Poor Teamwork

Don’t participate in gossip Participate and lead team building activities Celebrate the things to be grateful for – the

positives Promotion of a culture that is focused on the

patient – improved safety and quality of care

Disrespect

Do not promote or participate in: Insulting others Being condescending Rude behavior Insolent behavior Insubordination to supervisors Portraying yourself and your profession negatively

to the public, students, patients, families and peers

Micromanagement

Do not participate in or allow others to:Abuse authorityPull rankBullyThreaten Force a point of view just to be right

Perspective

“No one can make you feel inferior without your consent”

Eleanor Roosevelt

Improve the safety of using medications

4. NPSG.03.04.01 - Label all medications, medication containers (syringes, medicine cups, basins), or other solutions on and off the sterile field and in the areas where supplies are set up.

Improve the safety of using medications

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

Standardize and limit the number of drug concentrations used by the organization

Improve the safety of using medications

5. NPSG.03.05.01 – Take extra care with patients taking medications to thin their blood

Accurately and completely reconcile medications across the

continuum of care

6. NPSG.03.06.01 Record and pass along correct information

about the patient’s medications Compare any new medications ordered/started

during hospital stay with previously used medications

Make sure the patient knows how to take them – including food and drug interactions

Improve the Safety of High-Alert Medications

Complete lists available on www.ismp.org Anti-arrhythmics Anti-coagulants Chemotherapy Vasopressors Insulin Sedation and Opiates PCA/Epidural Medications Concentrated electrolytes

Other Medication Safety Recommendations

Pumps with alarm systems Distribution Units (i.e. Pyxis) Bar Code Scanning Computerized Physician Order Entry Fostering an environment of safety –

improvement without blame

The American Hospital Association lists the following as some common types of medication errors:

Incomplete patient information (not knowing about patients' allergies, other medicines they are taking, previous diagnoses, and lab results, for example)

Unavailable drug information (such as lack of up-to-date warnings); Miscommunication of drug orders- poor handwriting, confusion

between drugs with similar names, misuse of zeroes and decimal points, confusion of metric and other dosing units, and inappropriate abbreviations

Lack of appropriate labeling as a drug is prepared and repackaged into smaller units

Environmental factors, such as lighting, heat, noise, and interruptions, that can distract health professionals from their medical tasks.

Medication Error Stats

2.5 million deaths occur annually in the USA 42% of people believed they had personally

experienced a medical mistake (NPSF survey) 44,000 to 98,000 deaths annually from medical

errors (Institute of Medicine) 225,000 deaths annually from medical errors

including 106,000 deaths due to "non-error adverse events of medications" (Starfield)

Medication Errors

Annual cost of drug-related morbidity and mortality is nearly $177 billion in the United States

180,000 deaths annually from medication errors and adverse reactions (Holland)

2.9 to 3.7 percent of hospitalizations leading to adverse medication reactions

Medication Error Stats

• 7,391 deaths resulted from medication errors (Institute of Medicine)

• 2.4 to 3.6 percent of hospital admissions were due to (prescription) medication events (Australian study)

Medication Error in Perinatal Area

According to the U.S. Pharmacopeia, Center for the Advancement of Patient Safety between 1998-2002 the of the 3,775 medication errors reported in three areas of OB: Labor and Delivery = 49% OB Recovery = 10% Maternity Unit = 41%

Medication Errors

76.7 % of those total errors reached the patient but did not do harm

70% of errors occurred during administration of the medication

3.2 % reached the patient and did significant harm

0.03% caused a death

Medication Errors

Most common errors in Obstetrics Omission of the medication or missed doses Improper dose / quantity Unauthorized (unordered) Wrong drug Knowing absolute contraindications – i.e., an epidural on a

anti-coagulated patient Wrong Timing Extra doses Wrong administration technique

Top 10 Causes of Medication Errors in the Obstetrical Area

Performance Deficit Not following protocol or policy Communication Knowledge deficit Documentation Transcription error / omission Dispensing device System safeguards broke down Improper use of pumps Drug distribution systems

Drugs that are commonly involved

Over 300 total in all three areas Most common: Insulin Antibiotics – Ampicillin, Cefazolin, Gentamycin Magnesium Sulfate Oxytocin – most frequently cited medication with adverse obstetrical events that

lead to professional liability claims Prostaglandins – cervical ripening Narcotics Anticoagulants Asthma Medications

Common Areas of Error

Infusion pumps that are not programmed correctly Misconnected or disconnected IV tubing Administering medications or mainline fluids

through epidural catheter Omission of an antibiotic per protocol or order Lack of allergy information documented and patient

banded at the time of medication administration Incomplete communication and documentation

Prevention

5 Rights – take the time to make sure you do them EVERY time

RIGHT MEDICATION/CONCENTRATION RIGHT DOSE RIGHT PATIENT RIGHT TIME AND FREQUENCY (Even if double sign off) RIGHT ROUTE Evelyn’s 6th Right*** RIGHT INDICATION

Documentation of Medication Errors

Adverse Reaction to Medication Form PRN Quality Improvement/Assurance Forms Chart – just the facts

What you did Who you notified How the patient responded

Prevention of Infections

Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection.

Reduce the risk of health care-associated infection

7. NPSG.07.01.01 -Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.Hospitals in WA now implementing programs were the patients are asking the medical staff if they have washed their hands prior to touching them or giving care and medications.

Reduce the Risk of Health Care-Acquired Infections

8. NPSG.07.03.01 – Use guidelines to prevent infections that are difficult to treat

9. NPSG.07.04.01 – Use guidelines to prevent infection of the blood from central lines

10. NPSG.07.05.01 – Use proven guidelines to prevent infection after surgery

11. NPSG.07.06.01- Use proven guidelines to prevent infections of the urinary tract that are caused by catheters

Reduce the Risk of Health Care-Acquired Infections

According to a report published in 2007 by the CDC, “in American hospitals alone, hospital acquired infections account for an estimated 1.7 million infections and 99,000 associated deaths each year”

Hospital-acquired infections are the sixth leading cause of death nationally, costing the health care industry $6 billion annually

MDRO

Study reported in Consumer Affairs in 2005: Chicago's Northwestern Memorial Hospital swabbed computer keyboards t identify if any dangerous germs were present and for how long they lived.

Contaminated keyboards with three types of bacteria that can cause life-threatening infections in severely ill hospital patients. They found that the bacteria known as VRE (enterococcus) and MRSA survived for at least 24 hours, while PSAE (pseudomonas) bacteria survived for an hour.

When volunteers tapped a key contaminated with MRSA, the bacteria spread to their hands 92 percent of the time. Contamination rates for lower for the other two bacteria -- 50 percent for VRE and 18 percent for PSAE.

MDRO

**A CDC study published in the current issue of the Journal of the American Medical Association : MRSA - is much more prevalent than previously thought. The study found MRSA cases tripled in the United States between 2000 and 2005, and estimated 94,360 people are infected and 18,650 die annually, killing more people annually than HIV.

***A 2003 Centers for Disease Control and Prevention study: 52 percent of doctors did not clean their hands between patients.Doctor's lab coat picked up MRSA bacteria 65 percent of the time when leaning over an infected patient (1997) 77 percent of blood pressure cuffs on rolling carts were contaminated with MRSA. (2007 study)

MDRO

According to the Centers for Disease Control, recent studies place hand hygiene adherence in hospitals at between 29 percent and 48 percent.

Methicillin-resistant Staphylococcus aureus (MRSA), can cost hospitals roughly $30,000 per case.

Brad Sokol, CEO of Fast Track Technologies, a health care consulting firm, has estimated that our  nation suffers 13,000 to 26,000 thousand deaths annually from infection caused by contaminated medical devices and instruments.

Reduce Risk of Patient Harm Resulting from Falls

NPSG 09.02.01 – Reduce the risk of falls Implement a fall reduction program including an

evaluation of the effectiveness of the program

Identify Patient Safety Risks

12. NPSG.15.01.01 – Find out which patients are likely to try to commit suicidePost partum depression = Post partum ComplicationsWithout treatment, depression can last for many months and may have long-term consequences. Research suggests that postpartum depression can interfere with bonding between mother and child, which can lead to behavior problems and developmental delays when the child gets older.

Identify When there is a change in the Patient’s Condition

Develops criteria for calling additional assistance to respond to a change in the patient’s condition or a perception of change by the staff, the patient and/or family Rapid Response Codes

Staff seek additional assistance when they have concerns about a patient’s condition

Formal education is done for urgent response policies and practices Mock Codes

Prevent Mistakes in Surgery

13. UP.01.01.01- Make sure that the correct surgery is done on the correct patient at the correct place on their body

14. UP.01.02.01 – Mark the correct place on the patient’s body where the surgery is done

15. UP.01.03.01 – Pause before the surgery to make sure that a mistake is not being made

The organization Meets the Expectation of the Universal

Protocol Verification of the correct person, site and procedure occurs

at the following times: When the procedure is scheduled Preadmission testing and assessment Admission or entry for procedure whether it is scheduled or

emergent Before leaves the pre-procedural area or enters the

procedure room Anytime responsibility for the care of the patient is

transferred to another member of the procedural care team at the time of, and during, the procedure

With the patient involved, awake and aware if possible

Pre-procedural Checklist

Relevant documentation H&P Nursing assessment Pre-anesthesia assessment

Accurately completed and signed consent form Correct diagnostic and radiology test results Any blood products, implants, devices and or

special equipment for the procedure

Pre-Procedural Time Out

Conducted prior to starting the procedure and ideally, prior to induction of anesthesia, unless contraindicated

Standardized Initiated by a designated member of the team Involves the immediate members of the procedure team Involves interactive verbal communication between all

team members

Pre-Procedural Time Out

Includes a defined process for reconciling differences in responses

During time out all other activities are suspended (as long as it does not compromise patient safety)

If two or more procedures are being performed on the same patient, a time out is performed to confirm each subsequent procedure before it is initiated

Pre-Procedural Time Out

Addresses the following: Correct patient Confirmation that side and site are marked Accurate procedure consent Agreement of procedure to be performed Correct patient position Relevant images, diagnostic tests and results are properly

labeled and displayed The need to administer antibiotics or fluids Special equipment or supplies Safety precautions based on the patients current

medications or history

Marking the Procedure Site

Performed by a Licensed Independent Provider credentialed to perform procedure

Marked while patient is awake if possible Marked prior to going into procedural room

Marking of the Side and Site for OB

OB is excepted on most side and site marking: C-sections D & C and D & E Vaginal Delivery Cerclage Hysterectomy Bilateral Tubal Ligation Circumcisions

*** Exception – UNILATERAL tubal or ovary surgery

Sentinel Events

Organization is placed on an “Accreditation Watch” when a sentinel event has occurred and has come to the Joint’s attention

Adverse Drug Event Adverse Event

Death of a patient (unexpected) Retained foreign object Patient Falls Perforation, hemorrhage, bacteremia, complications to anesthesia or

sedation Any complication that leads to undesirable outcomes Any adverse/undesirable outcomes that result from providers or health care

staff that result in an illness or injury Errors of commission or omission that result in patient severe or

permanent injury

Bariatric Patients

Special Population that has additional safety risks for Obstetrics

Body Mass Index (BMI)

Correlates but does not directly measure body fat

Calculated from weight and height Correlates with body fat that is measured by

underwater and x-ray absorptiometry methods

Cheaper, more efficient and more readily available method of measurement to the medical practitioner

BMI

BMIBMI Weight CategoryWeight Category

<18.5 Underweight

18.5-24.9 Normal

25.0-29.9 Overweight

30-39.9 Obese

> 40 Extremely (Morbidly) Obese

Statistics

More than one-third of U.S. adults (35.7%) are obese.

Non-Hispanic blacks have the highest age-adjusted rates of obesity (49.5%) compared with Mexican Americans (40.4%), all Hispanics (39.1%) and non-Hispanic whites (34.3%) JAMA. 2012;307(5):491-497. doi:10.1001/jama.2012.39.

US Statistics

In 2008, medical costs associated with obesity were estimated at $147 billion

Medical costs for people who are obese were $1,429 higher than those of normal weight

1998

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1998, 2006

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

2006

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

United States 2011 Obesity Rates

Adult Women Affected by Obesity

49% of Non-Hispanic African American Women 38% of Hispanic Women 31% Non-Hispanic Caucasian Women

National Health and Nutrition Examination Survey (NHANES) 2002

Medical Conditions and Obesity

Sleep Apnea Hypertension Malnutrition Type II Diabetes Coronary Heart Disease Strokes Gallbladder Disease Osteoarthritis Cancer

Endometrial Breast Colon

Obstetrical Risk Factors and Obesity

Diabetes Type II Gestational

Spontaneous AbortionPreclampsiaGestational HypertensionFetal Macrosomia

Obstetrical Risk Factors and Obesity

Cesarean Birth (related to failure to progress) 20.7% if BMI <30 33.8% if BMI 30-34.9 47.4% if BMI 35-39.9

Shoulder dystocia

Prenatal Assessment

Early Diabetes Screening On first or second OB visit Again at 24-28 weeks Use 50 Gram glucose tolerance test (GTT)

Nutrition consult Assessment for vitamins, nutrients Weight management during pregnancy

Normal weight gain 25-35 lbs for the “normal” weight patient Overweight patient gain 15-25 lbs 15 lbs for the obese patient

Intrapartum Issues

May be difficult to:

Obtain accurate estimated fetal weight

Perform Leopold's maneuver

Monitor fetal well being and uterine activity

Find the right equipment – size, fit, weight restrictions

Hill-Rom Affinity bed = 500 lbs

Foot of the bed = 400 lbs

Find medical staff members with knowledge of how to care for patient with her particular needs

Nursing Care Issues

Sue Yager 1600 lbs

Nursing Care Issues

Prejudice Require EARLY anesthesia consult regarding pain management and

surgical planning Medication Management

May require more antibiotics per kilogram weight – need to check with pharmacy

Require antibiotics 30 minutes PRIOR to surgery Requires longer needles for IM injections – 2 inch to 2 ½

inch May react to pain medications differently – take longer to

clear (due to increased fat storage)

Surgical Management Considerations

Airway management Preoperative showering for c-section with chlorhexidine (48

hour kill rate) Potential for excessive blood loss Anesthesia challenges for induction Increased operative time

Large panis Increased time to close

Operative Beds Regular beds – 400 lbs “Hercules” table – 800-1000 lbs (better hydraulics)

Surgical Management Considerations

5-15% Complication Wound dehiscence Wound infection Poor wound healing Endometritis Deep Vein Thrombosis (DVT) Pulmonary Edema Pulmonary Emboli Pneumonia Sleep apnea – respiratory depression

Surgical Wound

Surgical Wound

Post Operative Issues

Wounds may be left openVertical exterior wounds JP drainsConsideration of whether need PACU

recovery and ICU stay

Moving Bariatric Patients

Good body mechanics

No holding legs for 2nd stage!!!! Team approach – 3-4 Lift team Right Equipment

Hover mats Lifts – KCI 1000 lbs Stretchers

Stryker 1710 = 500 lbs

Wyeast = 600 lbs

Stryker Bariatric = 660 lbs

Other Equipment

Hill-Rom VersaCare Bed – Up to 600 Lbs and can convert to a chair (costs about $7,500)

Other Equipment

Wall mounted toilets only hold 250-300 lbs Commodes – regular commode holds 250 lbs

Bariatric commode 750-800 lbs and need to provide privacy measures (costs about $300)

Bariatric Weight Loss Procedures

Bariatric Weight Loss Procedures

Multiple Bariatric Weight Loss Procedures are surgically available now.

Some will impact pregnancy more than others

Adjustable Gastric Banding

Roux-en-Y Stomach Bypass

Biliopancreatic Diversion (BPD)

Biliopancreatic Diversion with Duodenal Switch

Dumping Syndrome

Post Bariatric Surgery and Pregnancy

Nutrition Absorption Fetal growth and development Recommendation is to wait 12-24 months after surgery Pregnancy less likely to be complicated by:

Gestational or Type II Diabetes Hypertension Fetal Macrosomia Cesarean birth

Patient Satisfaction Surveys

Working toward the JCAHO Safety Goals The Ideal Patient Experience:Positive AttitudeSense of Ownership & AccountabilityCollaboration & Participation-Pt centered

care

Organizational/Nursing Actions That Lead to Improved Patient

Outcomes Positive Attitude Sense of Ownership and Accountability Collaboration & Participation in Patient &

Family Centered Care Information sharing – keeping the patient informed

in a language that they understand Follow up and see if they have any other questions

or needs

Opportunities for Improvement in Patient Care

Increase trust Increase confidence Continuity of care Explaining procedures Emotional support Treating patients with respect and dignity

Ideal Patient Experience

Hospitals are now looking at patient satisfaction surveys as part of their Continuous Quality Improvement (CQI) process

Looking for ways to improve the patient care experience

Organizational/Nursing Actions That Lead to Improved Patient

Outcomes

Practice good telephone etiquette Have professional and appropriate appearance Perform random acts of kindness Provide smooth transitions – patient handoffs Provide safe, age appropriate, and comfortable care Appreciate and celebrate staff for jobs well done

References

BRFSS, Behavioral Risk Factor Surveillance System http: //www.cdc.gov/brfss/

Mokdad AH, et al. The spread of the obesity epidemic in the United States, 1991—1998 JAMA 1999; 282:16:1519–1522.

Mokdad AH, et al. The continuing epidemics of obesity and diabetes in the United States. JAMA. 2001; 286:10:1519–22.

Mokdad AH, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA 2003: 289:1: 76–79

CDC. State-Specific Prevalence of Obesity Among Adults — United States, 2005; MMWR 2006; 55(36);985–988

References

JCAHO 2013 National Patient Safety Goals JCAHO News release 1/27/2005, “Speak Up: New National

Campaign Offers America To Prevent Medication Mistakes”

Maxfield, D., Grenny, J., McMillan, R., Patterson, K., & Switzer, A. Vitalsmarts Industry Watch, Executive Summary (2005). Silence Kills: The Seven Crucial Conversations in Healthcare.

U.S. Pharmacopeia, edited version of AWHONN Lifelines (April/May 2004) Errors in Obstetrics.