Reducing Medical Errors:
State of Florida Mandatory Training

Interventions

Introduction

Scope of the Problem

Defining Medical Errors

Patient Safety Organizations

Interventions

Conclusion

Resources

References

Test

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Many of the Patient Safety Organizations above have released goals for patient safety and have promoted particular interventions for the improvement of patient safety. This course provides an overview of some of the recommendations of a sampling of safety organizations. In particular interventions from the Agency for Healthcare Research and Quality (AHRQ) and a compilation of safety interventions focusing on the development of a healthcare partnership between provider and patient as a means of promoting patient safety and reducing medical errors.

Interventions from The Agency for Healthcare Research and Quality (AHRQ)

Medical errors may occur in different health care settings, and those that happen in hospitals can have serious consequences. AHRQ, which has sponsored hundreds of patient safety research and implementation projects, offers these 10 Evidence-Based Tips to Prevent Adverse Events (AHRQ, 2009a) from occurring in the hospital setting. These healthcare "tips" are a result of safety research.

1. Prevent central line associated blood stream infections.

   Central venous catheters or central line catheters, are placed into large veins in a patient's neck, chest, or groin to administer medication or fluids or to collect blood samples. Their placement disrupts skin integrity, allowing for potential infections. An infection can then cause bacteremia and hemodynamic changes and organ dysfunction can occur (IHI, 2008).

   Each year, an estimated 250,000 cases of central line-associated blood stream infection (CLABSI) occur in U.S. hospitals, and an estimated 30,000 to 62,000 patients who get the infections die as a result, according to CDC (AHRQ, 2009). Among patients in an intensive care unit (ICU), 48% have central venous catheters (IHI, 2008). The case fatality rate for catheter related blood stream infections is almost 20% (IHI, 2008).

   The site with the highest occurrence of infection is the femoral artery, especially in obese patients (IHI, 2008). The subclavian site has a lower risk of infection than the internal jugular vein (IHI, 2007). Risks and benefits for site selection must be weighed for each patient.

   In addition to the high human cost of central venous catheter infections, the financial burden is high as well. According to the Institute for Healthcare Improvement (2008), the attributable cost per bloodstream infection is up to $29,000 per case. The total financial burden attributable to HAIs is estimated to be between $28 billion to $33 billion each year (AHRQ, 2009).

   Being vigilant in preventing central line associated blood stream infections involves taking five steps every time a central venous catheter is inserted. These steps are often called "the central line bundle":

   1. Wash your hands;
   2. Use full-barrier precautions;
   3. Clean the skin with chlorhexidine;
   4. Avoid femoral lines; and
   5. Remove unnecessary lines.

   
   Taking these steps consistently reduced this type of deadly health care-associated infection to zero in a study at more than 100 large and small hospitals (AHRQ, 2009). The benefits of reducing such infections include (IHI, 2008):

   • Better outcomes for patients;
   • Reduced mortality;
   • Improved satisfaction among nurses, physicians, patients and families;
   • Financial benefits.

   
   For more information about the prevention of infection related to central venous line catheters and how to implement this program, go to http://www.ihi.org/IHI/Programs/Campaign/CentralLineInfection.htm and download the Updated How-To Guide.

2. Re-engineer hospital discharges.

   In the years since hospital stays have been drastically reduced, discharge planning has often taken a back seat to the acute needs of the hospitalization. The transfer of patient care from the hospital to primary care or other providers in the community, at the time of discharge, is a high-risk process that is often characterized by fragmented, non-standardized, and haphazard care leading to errors and adverse events (Anthony, et al., 2005).

   These "principles of the newly re-engineered hospital discharge", developed as a result of research, include the following (Anthony, et al., 2005):

   • There must be explicit delineation of roles and responsibilities.
   • Patient education must occur throughout the hospitalization, not only at the time of discharge.
   • Information must flow easily from the primary care provider (PCP) to the hospital team, among the hospital team, and back to the PCP.
   • Information should be captured throughout the hospital stay, not only at the time of (or after) discharge.
   • Every discharge must have a written discharge plan that is comprehensive in scope and that addresses medications, therapies, dietary and other lifestyle modifications, follow-up care, patient education, and instructions about what to do if the condition worsens.
   • This comprehensive discharge plan should be completed before the patient leaves the hospital.
   • Patients at high risk of re-hospitalization should have the discharge plan reinforced by contact from the hospital team after discharge.
   • All information about the admission must be organized and delivered to the PCP within 24 hours.
   • Waiting until the discharge order is written before beginning the discharge process is likely to increase the risk of errors.
   • Efficient and safe hospital discharge is significantly more difficult to achieve if the case management staff works only the 7 a.m.-3 p.m. shift (i.e., the "first" shift).
   • All patients should have access to their discharge information in their language and at their educational level.

   
   Reduce potentially preventable readmissions by implementing interventions founded on 11 discrete, mutually reinforcing components and has been proven to reduce re-hospitalizations and yields high rates of patient satisfaction. Examples include assigning a staff member to work closely with patients and other staff to reconcile medications and schedule necessary follow-up medical appointments, creating a simple, easy-to-understand discharge plan for each patient that contains a medication schedule, a record of all upcoming medical appointments, and names and phone numbers of whom to call if a problem arises.

   AHRQ-funded research conducted by the Boston University Medical Center's Re-Engineered hospital Discharge (Project RED) shows that taking these steps can help reduce potentially preventable readmissions by 30 percent. An online toolkit is available at http://www.bu.edu/fammed/projectred/.

3. Prevent venous thromboembolism.

   Pulmonary embolism resulting from deep vein thrombosis (DVT)-collectively referred to as venous thromboembolism (VTE)-is the most common preventable cause of hospital death. Despite the inclusion of prevention interventions in various consensus guidelines, efforts at prevention of VTE are underused in the healthcare setting (Kucher, et al., 2005).

   In the absence of prophylaxis, the risk of VTE across almost all populations of hospitalized patients is significant, as shown in Table 1. (AHRQ, 2008).

Fortunately, pharmacologic methods to prevent VTE are safe, effective, cost-effective, and advocated by authoritative guidelines. Yet, despite the reality that hospitalized medical and surgical patients routinely have multiple risk factors for VTE, making the risk for VTE nearly universal among inpatients, large prospective studies continue to demonstrate that these preventive methods are significantly underutilized. The American Public Health Association has stated that the "disconnect between evidence and execution as it relates to DVT prevention amounts to a public health crisis." (AHRQ, 2008).

Individual health centers have published results of successful local initiatives for improving prevalence of VTE prophylaxis, however, no single strategy has proven yet to be effective, sustainable, and widely applicable to other centers. Experiences with VTE management are rapidly evolving, validating the risk assessment techniques and implementation techniques. To implement effective protocols that minimize the incidence of hospital-acquired VTE, while at the same time minimizing adverse outcomes, redesign is needed in both care delivery and performance tracking (AHRQ, 2008).

Using an evidence-based guide to create a VTE protocol can eliminate hospital-VTE. One such evidence-based guide is available from AHRQ, without charge. This guide explains how to take essential first steps, lay out the evidence and identify best practices, analyze care delivery, track performance with metrics, layer interventions, and continue to improve. Ordering information for Preventing Hospital-Acquired Venous Thromboembolism: A Guide for Effective Quality Improvement (AHRQ Publication No. 08-0075) is available at http://www.ahrq.gov/qual/vtguide/.

4. Educate patients about using blood thinners safely.

   Surgical patients often leave the hospital with a new prescription for an anticoagulant, such as warfarin (brand name: Coumadin®), to prevent the development of VTE. However, if used incorrectly, such blood thinners can cause uncontrollable bleeding and are among the top causes of adverse drug events.

   In addition the patient, education needs to be directed to, families, caregivers, staff and clinicians. Standardized order sets can be part of this educational process for staff and clinicians. Anticoagulant use in the prevention of VTE challenges the in-patient care system to monitor it's own effectiveness in obtaining required laboratory studies, following compliance issues, ensuring dietary restrictions, tracking adverse drug events and preventing drug interactions when treating patients with anticoagulants. Another important area is transition of care from the in-patient to the out-patient setting. The need to monitor this process to ensure a seamless transition is stressed. Clearly this intervention dove-tails with the need to re-engineer hospital discharges.

   The management of "high alert" drugs such as heparin and warfarin are significant challenges for all institutions. Multiple healthcare safety organization have the goal to promote best practices on the safe use of anticoagulant drugs. This goal would standardize care and implement best practices to reduce the number of medication errors that could lead to patient harm (HCIF, 2010):

• Demonstrating standardization through limiting the number of concentrations of heparin, including therapeutic heparin and heparin flush solutions;
• Developing or refining existing standard protocols and nomograms for prescribing, dispensing, administrating and monitoring of anticoagulant therapy;
• Implementing practices or procedures to avoid unsafe concomitant administration of multiple anticoagulants.

A free 10-minute patient education video and companion 24-page booklet, both in English and Spanish, help patients understand what to expect when taking these medicines. Ordering information for Staying Active and Healthy with Blood Thinners (AHRQ Publication No. 09-0086-DVD) and Blood Thinner Pills: Your Guide to Using Them Safely (AHRQ Publication No. 09-0086-C) is available at http://www.ahrq.gov/consumer/btpills.htm. A downloadable version of the booklet appears in the "Resources" section of this course.

5. Limit shift durations for medical residents and hospital staff whenever possible.

   According to the American Nurses Association (ANA) (2009), "Concern for the long term effects of overtime leading to fatigue include potential for diminished quality of care, errors or near misses, as well as the negative impact on the care-givers health. Research indicates that risks of making an error are significantly increased when work shifts are longer than 12 hours, when nurses worked overtime, or when they worked more than 40 hours per week." The ANA , in it's Nationwide State Legislative Agenda, supports state laws and regulations prohibiting the use of mandatory overtime as well as pursuing federal legislation with similar goals.

   As of 2009, fifteen states have restrictions on the use of mandatory overtime for nurses. In thirteen states, these restrictions appear in state law: CT, IL, MD, MN, NJ, NH, NY, OR, PA, RI, TX, WA, and WV. In two states, these mandatory overtime limit provisions appear in state regulations: CA and MO (ANA, 2009).

Evidence shows that acute and chronically fatigued medical residents are more likely to make mistakes. Ensure that residents get ample sleep and adhere to 80-hour workweek limits. Residents who work 30-hour shifts should only treat patients for up to 16 hours and should have a 5-hour protected sleep period between 10 p.m. and 8 a.m. Resident Duty Hours: Enhancing Sleep,Supervision, and Safety is available at http://books.nap.edu/openbook.php?record_id=12508&page=R1.

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