Download 1 CDC. Diagnoses of HIV Infection and AIDS in the United States

Chapter One
HIV/AIDS
Terms Used in this Section:
AIDS: Acquired immunodeficiency syndrome. AIDS is the most advanced stage of HIV
infection. AIDS is diagnosed when a person infected with HIV has a CD4 count of less than
200 cells/mm3 or has an AIDS-defining condition.
AIDS-defining condition: Any one of several illnesses that can lead to a diagnosis of AIDS
in a person infected with HIV. AIDS is the most advanced stage of HIV infection.
Antiretroviral therapy (ART): The recommended treatment for HIV. ART involves taking a
combination of three or more anti-HIV medications from at least two different drug
classes every day to control the virus.
CD4 cells: Also called T cells or CD4+ T cells. Infection-fighting white blood cells of the
immune system. HIV destroys CD4 cells, making it harder for the body to fight infections.
CD4 count: The number of CD4 cells in a sample of blood. A CD4 count measures how well
the immune system is working.
HIV: Human immunodeficiency virus. HIV is a virus that attacks the immune system,
putting people infected with HIV at risk for life-threatening infections and cancer. AIDS is
the most advanced stage of HIV infection.
Opportunistic infection: An infection that occurs more frequently or is more severe in
people with weakened immune systems (such as people with HIV or people receiving
chemotherapy) than in people with healthy immune systems.
Regimen: A combination of three or more anti-HIV medications from at least two different
drug classes.
Transmission of HIV: The spread of HIV from a person infected with HIV to another person
through the infected person’s blood, semen, genital fluids, or breast milk.
Unprotected Sex: Sex without using a condom
THE BASICS:
What is HIV/AIDS?
The human immunodeficiency virus, or HIV, is the virus that causes HIV infection. During HIV infection, the virus attacks and destroys
the infection-fighting CD4 cells of the body’s immune system. Loss of CD4 cells makes it difficult for the immune system to fight
infections.
Acquired immunodeficiency syndrome, or AIDS, is the most advanced stage of HIV infection.
How is HIV transmitted?
HIV is transmitted (spread) through the blood, semen, genital fluids, or breast milk of a person infected with HIV. Having unprotected
sex or sharing drug injection equipment (such as needles and syringes) with a person infected with HIV are the most common ways HIV
is transmitted.
You can’t get HIV by shaking hands, hugging, or closed-mouth kissing with a person who is infected with HIV. And you can’t get HIV from
contact with objects such as toilet seats, doorknobs, dishes, or drinking glasses used by a person infected with HIV.
Even though it takes many years for symptoms of HIV to develop, a person infected with HIV can spread the virus at any stage of HIV
infection. Detecting HIV early after infection and starting treatment with anti-HIV medications before symptoms of HIV develop can
help people with HIV live longer, healthier lives. Treatment can also reduce the risk of transmission of HIV.
What is the treatment for HIV?
Antiretroviral therapy (ART) is the recommended treatment for HIV infection. ART involves taking a combination (regimen) of three or
more anti-HIV medications daily. ART prevents HIV from multiplying and destroying infection-fighting CD4 cells. This helps the body fight
off life-threatening infections and cancer.
ART can’t cure HIV, but anti-HIV medications help people infected with HIV live longer, healthier lives.
Antiretroviral therapy (ART) is the recommended treatment for HIV infection. ART involves taking a combination (regimen) of three or
more anti-HIV medications daily. ART prevents HIV from multiplying and destroying infection-fighting CD4 cells. This helps the body fight
off life-threatening infections and cancer.
ART can’t cure HIV, but anti-HIV medications help people infected with HIV live longer, healthier lives.
Can treatment prevent HIV from advancing to AIDS?
Yes. Treatment with anti-HIV medications prevents HIV from multiplying and destroying the immune system. This helps the body
fight off life-threatening infections and cancers and prevents HIV from advancing to AIDS.
It takes many years, but without treatment, HIV infection can advance to AIDS. A diagnosis of AIDS requires that a person infected
with HIV have either:
3
3
•A CD4 count of less than 200 cells/mm . (The CD4 count of a healthy person ranges from 500 to 1,200 cells/mm .)
OR

An AIDS-defining condition. (AIDS-defining conditions include opportunistic infections and cancers that are life-threatening in
person with HIV. Having an AIDS-defining condition signals that a person’s HIV infection has advanced to AIDS.
What illnesses are considered AIDS-defining conditions?
The Centers for Disease Control and Prevention (CDC) considers several illnesses AIDS-defining conditions.
Pneumocystis jiroveci pneumonia, tuberculosis, and toxoplasmosis are examples of AIDS-defining conditions.
This information is based on the U.S. Department of Health and Human Services’ Guidelines for the Use of Reviewed
Antiretroviral Agents in HIV-1-Infected Adults and Adolescents (available at http://aidsinfo.nih.gov/guidelines).
.
.
Terms Used in This Section:
HIV antibody test: An HIV test that checks for HIV antibodies in a person’s blood,
urine, or fluids from the mouth. HIV antibodies are a type of protein the body
produces in response to HIV infection.
Mother-to-child transmission of HIV: The passing of HIV from a woman infected with
HIV to her baby during pregnancy, during labor and delivery, or by breastfeeding.
Plasma HIV RNA test (viral load test): A test that measures the amount of HIV in the
blood. This test is used to detect recent HIV infection or to measure viral load at any
stage of HIV infection.
Rapid HIV antibody test: An HIV antibody test that can detect HIV antibodies in blood
or oral fluids in less than 30 minutes.
Transmission of HIV: The spread of HIV from a person infected with HIV to another
person through the infected person’s blood, semen, genital fluids, or breast milk.
Unprotected sex: Sex without using a condom.
Viral load: The amount of HIV in the blood. One of the goals of antiretroviral therapy is
to reduce viral load.
Western blot: A type of antibody test used to confirm a positive HIV antibody or
plasma HIV RNA test.
Window period: The time period between a person's infection with HIV and the
appearance of detectable HIV antibodies.
This information is based on the U.S. Department of Health and Human Services’ Guidelines
for the Use of Reviewed Antiretroviral Agents in HIV-1-Infected Adults and Adolescents
(available at http://aidsinfo.nih.gov/guidelines).
What is the most common HIV test?
The most common HIV test is the HIV antibody test. HIV antibodies are a type of protein the body produces in
response to HIV infection. The HIV antibody test checks for HIV antibodies in a person’s blood, urine, or fluids
from the mouth.
Generally it takes the body about 3 months from the time of infection to produce enough antibodies to be
detected by an HIV antibody test. (For some people, it can take up to 6 months.) The time period between
infection and the appearance of detectable HIV antibodies is called the window period. Because HIV
antibodies are not detectable yet, the HIV antibody test isn’t useful during the window period.
What HIV test is used during the window period?
The plasma HIV RNA test (also called a viral load test) can detect HIV in a person’s blood within 9 days of
infection, before the body develops detectable HIV antibodies. The plasma HIV RNA test is recommended
when recent infection is very likely—for example, soon after a person has had unprotected sex with a partner
infected with HIV.
Detecting HIV at the earliest stage of infection lets people take steps right away to prevent transmission of
HIV. (See the Preventing Transmission of HIV fact sheet.) This is important because immediately after infection
the amount of HIV in the body is very high, increasing the risk of transmission of HIV. Starting treatment at this
earliest stage of infection also can be considered.
What does it mean to test HIV positive?
A diagnosis of HIV is made on the basis of positive results from two HIV tests. The first test can be either an
HIV antibody test (using blood, urine, or fluids from the mouth) or a plasma HIV RNA test (using blood). The
second test (always using blood) is a different type of antibody test called a Western blot test. A positive
Western blot test confirms that a person has HIV.
How long does it take to get HIV test results?
Results of the first antibody test are generally available within a few days. (Rapid HIV antibody tests can
produce results within an hour.) Results of the plasma HIV RNA test and Western blot are available in a few
days to a few weeks.
If I test HIV positive now, will I always test HIV positive?
Yes. There’s no cure for HIV at this time. Because you will always be infected with the virus, you will always test
HIV positive. But treatment with anti-HIV medications can help you live a longer, healthier life.
If a pregnant woman tests positive for HIV, will her baby be born with HIV?
In the United States and Europe, fewer than 2 babies in 100 born to mothers infected with HIV are infected
with the virus. This is because anti-HIV medications given to women infected with HIV during pregnancy and
delivery and to their babies after birth help prevent mother-to-child transmission of HIV. Another reason is
that, in the United States and Europe, mothers infected with HIV do not breastfeed their babies. (For more
information, see the HIV and Pregnancy fact sheet series.)
Where can I find information on HIV testing in my state?
Many hospitals, medical clinics, and community organizations offer HIV testing. To find an HIV testing site near
you, contact AIDSinfo for the number of your state AIDS hotline or visit http://www.hivtest.org/. You can also
find information on testing locations on your state health department website.
This information is based on the U.S. Department of Health and Human Services’ Guidelines for
the Use of Reviewed Antiretroviral Agents in HIV-1-Infected Adults and Adolescents (available
at http://aidsinfo.nih.gov/guidelines). August 2012
HIV in the United States: An Overview
The number of people living with HIV infection in the United States (HIV prevalence) is higher than ever
before. CDC has estimated that approximately 1.2 million (1,178,350) adults and adolescents were living with
HIV infection in the United States at the end of 2008, the most recent year for which national prevalence
estimates are available. This represents an increase of approximately 7% from the previous estimate in 2006 [1].
The increase is due to a higher number of people becoming infected with HIV than the number of people who
die each year with HIV or AIDS.
Despite increases in the total number of people living with HIV infection, the annual number of new HIV
infections (HIV incidence) has remained relatively stable in recent years. According to the most recent
incidence estimates, approximately 48,100 persons were infected with HIV in 2009 [2]. The estimated HIV
incidence has been relatively stable since the late 1990s despite more people living with HIV infection every
year and, thus, increased opportunities for transmission to occur.
The great majority of persons with HIV infection do not transmit HIV to others. CDC estimates that there were
5 transmissions per 100 persons living with HIV infection in the United States in 2006 [3]. This means that at
least 95% of those living with HIV infection did not transmit the virus to others that year–an 89% decline in the
estimated rate of HIV transmission since the peak level of new infections in the mid-1980s. The decline in
transmission is likely due to effective prevention efforts and the availability of improved testing and treatments
for HIV. The lower transmission rate is what has enabled HIV incidence to remain stable despite increasing
prevalence [1].
Estimates of New HIV Infections in the United States, 2009,
for the Most-Affected Subpopulations[2]
Subpopulations representing 2% or less of the overall US epidemic are not reflected in this chart.
More people in the United States with HIV know of their HIV infection. The estimated proportion of persons
in the United States with HIV who know they are infected increased from 75% in 2003 to 80% in 2008 [1]. This is
a sign of progress for HIV prevention because research shows that most individuals reduce behaviors that
could transmit HIV when they know they are infected [4].
Diagnoses of HIV infection reported to CDC have remained stable in recent years. In 2010, an estimated 47,129
persons were diagnosed with HIV infection [a] in the 46 states with long term, confidential, name-based HIV
infection reporting [5]. Diagnoses of HIV infection remained stable in the 46 states from 2007–2010.
The HIV diagnosis rate has also remained stable in recent years. From 2007–2010, the annual estimated rate of
diagnoses of HIV infection (the number of HIV diagnoses per 100,000 persons) remained relatively stable in the
46 states with long term, confidential, name-based HIV reporting. In 2010 the estimated rate of HIV diagnoses
was 16.1 per 100,000 persons [5]. Estimated numbers and rates of diagnoses of HIV infection increased in some
subgroups and decreased in others. Variations in trends between groups may be due to differences in testing
behaviors, targeted HIV testing initiatives, more streamlined surveillance practices in some jurisdictions, and
possibly changes in the numbers of new HIV infections (HIV incidence) in some subgroups.
HIV disproportionately affects certain populations. Men who have sex with men (MSM), blacks/African
Americans, and Hispanic/Latinos are the groups most affected by HIV infection.
Estimated New HIV Infections, 2009,
by Transmission Category [2]
MSM represent approximately 2% of the U.S. population, but accounted for more than 50% of all new HIV
infections annually during 2006–2009 [6,b,2]. In 2010 MSM accounted for 61% of HIV diagnoses [5].

From 2006–2009, over 25,000 MSM were newly infected with HIV annually [2]. Among MSM aged 1329, HIV incidence among black/African American MSM increased significantly (48%) from 2006 through
2009 with a statistically significant 12.2% estimated annual percentage increase [2].

From 2007–2010, the estimated number of HIV diagnoses among MSM increased by approximately 9%
[5]. This increase may be due differences in testing behaviors, targeted HIV testing initiatives, more
streamlined surveillance practices in some jurisdictions, and possibly changes in the numbers of new
HIV infections (HIV incidence) in some subgroups [7,c]. These increases may also be affected by the
degree of uncertainty inherent in statistical estimates.
Blacks/African Americans are the racial/ethnic group most affected by HIV. Blacks/African Americans
represented approximately 14% of the U.S. population, but accounted for an estimated 44% of new HIV
infections in 2009 [2].

At some point in their life, 1 in 16 black/African American men will receive a diagnosis of HIV, as will one
in 32 black women [8].

In 2009 the estimated rate of new HIV infection for black/African American men was more than six
times as high as that of white men, nearly two and a half times that of Hispanic/Latino men, and more
than twice that of black/African American women [2].

In 2009 the estimated rate of new HIV infection for black/African American women was 15 times the
rate for white women, and over three times that of Hispanic women [2]. From 2007–2010, the
estimated number and rate of HIV diagnoses among blacks/African Americans remained stable. In
2010, blacks/African Americans had an HIV diagnosis rate of 62.0 per 100,000 persons [5].
Hispanics/Latinos represented 16% of the population, but accounted for an estimated 20% of new infections in
2009 [2].

In 2009 the estimated rate of new HIV infection among Hispanic/Latino men was two and a half times
that of white men [2].

In 2009 the estimated rate of new HIV infection among Hispanic/Latino women was four and a half
times that of white women [2].

From 2007–2010, the estimated number of HIV diagnoses remained stable among Hispanics/Latinos
[5].

The rate of HIV diagnoses among Hispanic/Latinos decreased by 7%, from 22.0 to 20.4 per 100,000
population, possibly reflecting the growing population of Hispanics/Latinos in the United States [5].
Despite many prevention and treatment successes, people are still dying from HIV disease. HIV remains a
significant cause of death for some populations. For example, in 2007, HIV was the third leading cause of death
for black males and black females aged 35-44 and the fourth leading cause of death for Hispanic/Latino females
in the same age range [9,d]. Further, MSM are strongly affected by HIV and represent the majority of persons
with an HIV diagnosis who have died in the United States.
Overall, nearly 619,400 persons with an AIDS diagnosis in the United States have died since the beginning of
the epidemic through 2009 (the most recent year that death data are available) [5]. From 2007 through 2009,
the annual estimated rate (per 100,000) of deaths of persons with an AIDS diagnosis remained stable.
Interpreting data regarding deaths of persons with a diagnosis of HIV or AIDS can be difficult because many
factors can affect the data. For example:

changes may be influenced by significant efforts that have been made to improve death reporting by
state and local HIV surveillance programs in recent years;

the changes may be related to the availability of more effective treatments for persons with HIV
infection or AIDS;

the group of persons living with HIV infection is aging, which may result in an increased number of
deaths from any cause, including those unrelated to HIV infection;

there are uncertainties inherent in statistical estimates.
Estimated Rate of New HIV Infections, 2009,
by Gender and Race/Ethnicity [2]
Too many people are diagnosed with HIV late in the course of infection. Despite an increase in persons
getting diagnosed with HIV earlier in the course of their infection [7], far too many continue to be diagnosed
late. Among persons initially diagnosed with HIV infection during 2009, one-third (32%) received an AIDS
diagnosis within 12 months [5]. These late diagnoses represent missed opportunities for treatment and
prevention.
AIDS disproportionately affects different parts of the country. HIV and AIDS have had a severe impact on all
regions of the country. It remains mostly an urban disease, with the majority of individuals diagnosed with
AIDS in 2009 residing in areas with 500,000 or more people. Areas hardest hit (by ranking of AIDS cases per
100,000 people) include Baton Rouge and New Orleans, Louisiana; Miami, Florida; Jackson, Mississippi; and
Baltimore, Maryland [5].
Key References that Explain the HIV Epidemic in the United States
Following are some of the key indicators of HIV disease in the United States and the references that best explain them.

HIV incidence in the United States (including subpopulation estimates): Prejean J, Song R, Hernandez A, Ziebell R, Green T, et a
(2011) Estimated HIV Incidence in the United States, 2006-2009. PLoS ONE 6(8): e17502. doi:10.1371/journal.pone.0017502.

HIV incidence estimation method: Karon JM, Song R, Brookmeyer R, et al. Estimating HIV incidence in the United States from
HIV/AIDS surveillance data and biomarker HIV test results. Statistics in Medicine. 2008;27(23): 4617–4633.

HIV prevalence in the United States: CDC. HIV surveillance— United States, 1981-2008. MMWR. 2011;60:689-693.

Estimate of undiagnosed persons with HIV in the United States: CDC. HIV surveillance—United States, 1981–2008. MMWR.
2011;60:689-693.

HIV transmission rates: Holtgrave DR, Hall HI, Rhodes PH, et al. Updated annual HIV transmission rates in the United States, 197
2006. J Acquir Immune Defic Syndr 2009;50(2):236-238.

Lifetime risk of HIV infection: CDC. Estimated lifetime risk for diagnosis of HIV infection among Hispanics/Latinos—37 states an
Puerto Rico, 2007. MMWR. 2010;59(40):1297-1301.

Deaths from HIV: CDC. WISQARS Leading Causes of Death Reports, 1999–2007. NCHS. Deaths: Final data for 2006. Statistics Rep
2009;57(14).

Estimate of number of MSM in the United States and MSM’s rates of HIV and syphilis: Purcell DW, Johnson C, Lansky A, et al.
Calculating HIV and syphilis rates for risk groups: Estimating the national population size of men who have sex with men. Prese
at 2010 National STD Prevention Conference; Atlanta, GA. abstract #22896.
The following indicators can be found in the CDC’s HIV Surveillance Report (CDC. HIV Surveillance Report, 2010;
vol 22.)

Diagnoses of HIV infection in the United States (46 states and 5 U.S. dependent areas)

Persons living with a diagnosis of HIV infection (46 states and 5 U.S. dependent areas)

AIDS diagnoses in the United States and 6 U.S. dependent areas

Persons living with an AIDS diagnosis in the United States and 6 U.S. dependent areas

Deaths of persons with a diagnosis of HIV infection or AIDS

Time to AIDS diagnosis after a diagnosis of HIV infection (late HIV diagnoses)

Survival time after diagnosis of HIV infection or AIDS

Geographic (United States) distribution of diagnoses of HIV infection or AIDS
References
1.
CDC. HIV surveillance—United States, 1981-2008. MMWR. 2011;60: 689-693.
2.
Prejean J, Song R, Hernandez A, Ziebell R, Green T, et al. (2011) Estimated HIV Incidence in the United
States, 2006-2009. PLoS ONE 6(8): e17502. doi:10.1371/journal.pone.0017502.
3.
Holtgrave DR, Hall HI, Rhodes PH, et al. Updated annual HIV transmission rates in the United States,
1977-2006. J Acquir Immune Defic Syndr 2009;50(2):236-238.
4.
Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk sexual behavior in persons
aware and unaware they are infected with HIV in the United States: implications for HIV prevention
programs. J Acquir Immune Defic Syndr 2005;39:446-453.
a.
New diagnoses are not the same as new infections (incidence). A person can be infected with HIV for
years before being diagnosed.
5.
CDC. HIV Surveillance Report, 2010, Vol 22. Available at:
cdc.gov/hiv/surveillance/resources/reports/2010report. Accessed March 13, 2012.
6.
Purcell DW, Johnson C, Lansky A, et al. Calculating HIV and syphilis rates for risk groups: Estimating the
national population size of men who have sex with men. Presented at 2010 National STD Prevention
Conference; Atlanta, GA. abstract #22896. Available at
cdc.gov/hiv/topics/msm/resources/research/msm.htm. Accessed March 9, 2012.
b.
The MSM rates were calculated using the methodology described in reference #6, which is different
than the methodology used to calculate the other rates in this fact sheet, which are based on
population estimates from the US Census Bureau.
7.
CDC. Late HIV testing—34 states, 1996–2005. MMWR. 2009;58:661-665.
c.
MSM accounts for a higher proportion of testing for acute (newly acquired) infection relative to other
risk groups.
8.
CDC. Estimated lifetime risk for diagnosis of HIV infection among Hispanics/Latinos —37 states and
Puerto Rico, 2007. MMWR. 2010;59(40):1297-1301.
9.
WISQARS Leading Causes of Death Report, 1999-2007. Available at:
http://webappa.cdc.gov/sasweb/ncipc/leadcaus10.html. Accessed March 7, 2012.
d.
Deaths of persons with a diagnosis of HIV or AIDS may be due to any cause, not necessarily HIV
disease.
Occupational HIV Transmission and Prevention among Health Care Workers
Through December 2001, there were 57 documented cases of occupational HIV transmission to health care
workers in the United States, and no confirmed cases have been reported since 1999. Occupational
transmission of HIV is reported in the Centers for Disease Control and Prevention (CDC) HIV Surveillance Report1 in
the transmission category that includes hemophilia, blood transfusion, perinatal exposure, and risk factor not
reported or not identified.
To prevent transmission of HIV to health care workers in the workplace, CDC offers the following
recommendations.
Prevention Strategies
Health care workers should assume that the blood and other body fluids from all patients are potentially
infectious. They should therefore follow infection control precautions at all times.
These precautions include

routinely using barriers (such as gloves and/ or goggles) when anticipating contact with blood or body
fluids,

immediately washing hands and other skin surfaces after contact with blood or body fluids, and

carefully handling and disposing of sharp instruments during and after use.
Safety devices have been developed to help prevent needle-stick injuries. If used properly, these types of
devices may reduce the risk of exposure to HIV. Many percutaneous injuries, such as needle-sticks and cuts, are
related to sharps disposal. Strategies for safer disposal, including safer design of disposal containers and
placement of containers, are being developed.
Although the most important strategy for reducing the risk of occupational HIV transmission is to prevent
occupational exposures, plans for post exposure management of health care personnel should be in place. CDC
has issued guidelines for the management of health care worker exposures to HIV and recommendations for
post exposure prophylaxis (PEP): Updated U.S. Public Health Service Guidelines for the Management of
Occupational Exposures to HIV and Recommendations for Post exposure Prophylaxis2 (September 30, 2005).
These guidelines outline a number of considerations in determining whether health care workers should
receive PEP and in choosing the type of PEP regimen. For most HIV exposures that warrant PEP, a basic 4week, two-drug (there are several options) regimen is recommended. For HIV exposures that pose an
increased risk of transmission (based on the infection status of the source and the type of exposure), a threedrug regimen may be recommended. Special circumstances, such as a delayed exposure report, unknown
source person, pregnancy in the exposed person, resistance of the source virus to antiviral agents, and toxicity
of PEP regimens, are also discussed in the guidelines. Occupational exposures should be considered urgent
medical concerns.
Building Better Prevention Programs for Health Care Workers
Continued diligence in the following areas is needed to help reduce the risk of occupational HIV transmission to
health care workers.
Administrative efforts. All health care organizations should train health care workers in infection control
procedures and on the importance of reporting occupational exposures. They should develop a system to
monitor reporting and management of occupational exposures.
Development and promotion of safety devices. Effective and competitively priced devices engineered to
prevent sharps injuries should continue to be developed for health care workers who frequently come into
contact with potentially HIV-infected blood and other body fluids. Proper and consistent use of such safety
devices should be continuously evaluated.
Monitoring the effects of PEP. Data on the safety and acceptability of different regimens of PEP, particularly
those regimens that include new antiretroviral agents, should be continuously monitored and evaluated.
Furthermore, improved communication about possible side effects before starting treatment and close followup of health care workers receiving treatment are needed to increase compliance with the PEP.
1
CDC. Diagnoses of HIV Infection and AIDS in the United States and Dependent Areas, 2009. Published
February 2011. Accessed August 22, 2011.
2
CDC. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV
and Recommendations for Postexposure Prophylaxis. MMWR 2005;54(RR09):1-17.
Chapter two
DOMESTIC VIOLENCE
Domestic violence is the act of physical, verbal, emotional or sexual abuse to show power or to control
another. Approximately 95% of domestic violence victims are women. Because the term domestic violence
sometimes overlooks male victims and same sex violence, the Centers for Disease Control and Prevention
(CDC) prefers to use the term ‘intimate partner violence (IPV). Domestic violence or intimate partner violence
is a serious, widespread public health problem in America and around the world. In the United States, a
woman is more likely to be assaulted, raped, or killed by an intimate partner than suffer rape or assault by a
total stranger or acquaintance.
Victims of intimate partner violence are typically women and children. In all Cultures, batterers are more
commonly men, though not always. Domestic violence can affect all ages, religious, ethnic, socio-economic,
and educational backgrounds. The impacts of intimate partner violence can range from emotional problems
that may lead to suicide, suicidal tendencies and depression, with drug and alcohol abuse used as a coping
method. In some cases the violence can be fatal. In the United States, around 11% of all homicides between
1976 and 2002 were committed by an intimate partner. Children who witness such abuse are far more likely to
develop violent and delinquent behaviors during childhood and are at a greater risk of heavy drinking patterns
and alcohol abuse later in life. This consequently increases their risk of becoming perpetrators of violence
themselves.
There are four identified types of intimate partner violence:
PHYSICAL VIOLENCE
SEXUAL VIOLENCE
THREATS OF SEXUAL OR PHYSICAL VIOLENCE
PHYSICAL/EMOTIONAL VIOLENCE
Physical violence is the use of physical force against another in a manor that ends up0 injuring the person or
puts that person at risk of being injured.
Physical violence can include, but is not limited to punching, bashing, choking, slapping, pinching biting, kicking
, pushing, slapping, using a knife, gun or belt to threaten.
Sexual violence includes sexual assault, sexual harassment, and sexual exploitation. Sexual assault is the use of
force to get one to participate in unwanted, unsafe, or degrading sexual activity. Sexual harassment is the use
of ridicule to try to limit one’s sexuality or reproductive choices. Finally, sexual exploitation is forcing someone
to engage in unwanted sexual pornography by watching or actually participating in the sex act.
Threats of sexual or physical violence would include words, gestures or weapons to threaten to kill, injure or
cause physical harm to another human being.
Emotional violence includes mental, emotional and psychological abuse either in a verbal or nonverbal manor.
This type of abuse exhibits by far more subtle actions or behaviors than physical abuse but the emotional scars
are deep. Studies have shown that the emotional abuse can actually be more damaging than physical abuse.
In Florida and other states, stalking is considered a form of intimate partner violence. Stalking is the
harassment of or threatening of another, either physically or emotionally, in a devious or haunting manor. It
can take place either during the relationship by monitoring one’s activities or after when the spouse is trying to
get the partner to come back, can be used as punishment for leaving the relationship. Some tactics that
stalkers may use include but are not limited to, repeated phone call, following, watching with hidden cameras,
and damaging the victim’s personal property. This type of violence should be considered dangerous and
should be taken very seriously. In 1994, Congress passed the Violence Against Women Act (VAWA) in order to
raise awareness of domestic violence and to increase the resources and the number of shelter for battered
women. On January 5, 2006, President Bush signed the VAWA 2005 Reauthorization into law. (Public Law No:
109-162) With the VAWA 2005 in place, it is greatly strengthening the fact that early intervention is a necessity
for our children who have witnessed domestic violence, supporting families who may be at risk for violence,
and changing social norms that target intervention with children and adolescents.
Domestic violence, sexual assault, dating violence and stalking are crimes which directly affect one in four
women and touch the lives of everyone in the community. On average, four women are murdered by their
boyfriends or husbands. Every nine seconds in the United States, a woman is assaulted and beaten. Research
indicates that 4,000,000 women a year are assaulted by their partners.
In November of 2000, Professor Concetta Benn conducted a project that was intended to provide an avenue
through which the older women could tell of their experiences and how such physical and/or emotional abuse
has impacted their lives. The Women’s Safety Survey revealed that for older women who had experienced
sexual or physical assault in the past 12 months that:
5.5 % of women over 45 years of age had experienced some type of sexual or physical violence within the last
year
86% of women over the age of 55 had not told the police about the assault by a man
89.9% of women who experienced the physical assault did not use any services after the assault took place
100% of women did not use any service after a sexual assault.
In general, there is little research on violence against older women. In fact, “elder abuse” has been the focus
of much of the research that has been undertaken. The main focus has been on “abuse” as a way of describing
a broad range of harmful and violent behaviors. Either way the gender factor has become invisible.
DOMESTIC VIOLENCE IN FLORIDA
According to the Florida Department of Law Enforcement, from 1996-2005, domestic violence is down 9.3% in
number and down 27% in rate. In September 2003, the Department of Children and Families received a
$900,000.oo federal grant for domestic violence services in rural communities. The two year project was
intended to increase awareness of the affects of domestic violence on children and child mistreatment. In fact,
the Florida Department of Children and Families is a great resource for those who are or may have been in a
domestic violence situation. Their program mission is to work towards ensuring the safety of victims of
domestic violence by developing partnerships with local organizations to create a smooth system that helps to
address the diverse needs of domestic violence victims and families that are in crisis. Florida now has a system
in place that will enable victims to relocate and maintain address confidentiality through a “mail drop box”
which is administered by the Attorney General’s office. The most recent statistics are in from 2005 and
according to Uniform Crime Reports Annual report, Crime in Florida, a total of 120,386 domestic violence
incidents were reported. Domestic violence accounted for 39% of all reports on violent offenses and simple
assault. Of Florida’s 881 murders, domestic violence accounted for 176 (20%) if them. The live-in partner or
spouse was the victim in 54% of these offenses, while children accounted for 7% of the victims. Florida
participates in the FAMILY VIOLENCE PREVENTION FUND which primarily concentrates on the prevention of
violence in the home and community and to help those whose lives have been devastated by domestic
violence. They are working very diligently on policy changes regarding reporting domestic violence, training
reforms and public education. Florida requires:
Persons in the healthcare industry, health practitioners, to participate in a one hour domestic violence course
as required in the biannual re-licensure. This takes into account physicians, nurses, dentists, mental health
providers, dental hygienists licensed clinical social workers.
Healthcare providers and law enforcement are to report any gunshot or life threatening injuries .
Judges must inform the victims of their rights. This includes the right to appear, be notified, seek restitution,
and make a victim impact statement.
Clerks of the courts must provide victims with information regarding collection of restitution through the
enforcement of liens.
Any person found guilty of domestic violence and who has caused intentional bodily harm to another person
must serve a minimum term of imprisonment (5 days in the county jail). The court may sentence the
perpetrator to a non-suspended period of incarceration in a state correctional facility.
According to the Florida Department of Law Enforcement, 75% of domestic violence perpetrators are male, so
their efforts are being concentrated on setting standards for programs designed for men who commit these
acts.
How Domestic Violence Impacts the Healthcare System
The healthcare system is greatly affected by domestic violence. Homicide, injury, mental illness, substance
abuse and repeated violence across generations, show the range of healthcare problems that relate to
domestic violence. Women tend to be the most frequent consumers of healthcare systems and are the most
common victims of domestic violence. The healthcare providers are in a great position to help their victims put
an end to the abuse that they are experiencing. The healthcare setting can provide the single most important
and most accessed institution in the lives of women and can provide a unique opportunity to intervene, making
it one of the newest and most important areas of the domestic violence movement today.
Risk Factors for Domestic Violence
A number of studies have looked into the women who may be the most at risk for domestic violence and have
found that an imbalance of power and control may be the link. The following are a list of situations that are
common in women who experience domestic violence.

Previous abusive relationships

Poverty or poor living conditions

Physical or mental disabilities

Unemployment

Isolated socially from family and friends

Pregnancy (especially if unplanned)

Stalked by a partner
The abuser also has risk factors that may lead them to choose violence as a way to get what they want in a
relationship. The following are factors may indicate an increased likelihood that a partner may choose
violence:

Abuses alcohol or drugs

Witnessed abuse as a child

Abused former partners

Unemployed

Abusive to pets or animals
Poverty is very damaging to health and wellbeing in so many immeasurable ways, exposure to domestic
violence is just one.
Studies consistently show that at least 50-60% of women living off of welfare have experienced some type of
intimate partner violence at some point in their adult life, in comparison to 22& of the general population.
Some studies show an overwhelming 82% in some cases. In addition to domestic violence, some women
receiving welfare have other barriers to overcome when it comes to employment including lack of child care,
disabilities, either mental or physical, substance abuse, housing instability, or lack of transportation.
Pregnancy is one of the most common reasons a woman may experience intimate partner violence because
the father or male partner feels threatened or stressed by the impending birth of the baby. The stress
manifests itself into frustration which in turn is taken out on the mother. Studies have shown that teens
between the ages of 13-17 have a greater chance of experiencing some type of abuse whether verbal or
physical. Due to the elevated risk of teenage abuse during pregnancy, the US is trying to get the subject into
the regular sex education curriculum. (‘Nearly 10% of Teenage Mothers Experience Violence while Pregnant”
Family Planning Perspectives 31:1999).
Women are more likely to suffer increased abuse due to an unwanted or unplanned pregnancy. In these
attacks, the abuser usually directs the attacks at the breasts, abdomen or genitals. This puts not just one but
two lives at risk. The long term psychological consequences of domestic violence during pregnancy are
severely detrimental to the child’s psychological development. Thus, the child, more than likely, will witness
domestic violence after he/she is born. Even more alarming, the man who abuses his partner will likely abuse
his children.
Screening and assessment in healthcare facilities is an effective way to help potential domestic violence
victims. The screening is very short and researchers have found a two minute assessment that can screen for
early detection of abuse to women, children, and the elderly.
TABLE 1
SCREENING TOOL FOR ABUSE OF WOMEN
Question
Circle best answer
In general, how would you describe your relationships?
A lot of
some
no tension
Do you and your partner work out arguments withgreat difficulty
some difficulty
no difficulty
Do arguments ever result in you feeling put down or bad about yourself?
Often
sometimes never
Do arguments ever result in hitting, kicking or pushing?
Often sometimes
never
Do you ever feel frightened by what your partner says or does?
Often sometimes
never
Has your partner ever abused you physically?
Often sometimes
never
Has your partner every abused you emotionally?
Often sometimes
never
Has your partner ever abused you sexually?
Often sometimes
never
Source: Center for Studies in Family Medicine, n.d. Used with permission.
Signs and symptoms related to IPV should be noted by healthcare providers. These symptoms may include
missed appointments, a delay in seeking healthcare, inconsistent explanations to injuries, depression and social
isolation. Some victims may also turn to substance abuse and /or the use of drugs or alcohol. During an
appointment with a healthcare provider, the victim may not make eye contact and /or the partner may be very
reluctant in leaving the victim alone with anybody. During the physical examination, the healthcare provider
would note any injuries to the most common areas on the body. These would include the face, throat, chest,
abdomen, and genitals. Bruises, burns, or wounds shaped like an object or puncture wound should be noted
as well.
Healthcare providers play such an important role in a victim of domestic violence’s life. They can have such an
impact on whether or not the victim wins the case if there is legal action taken. Careful documentation of any
and all injuries is crucial. Healthcare providers know that they must contact the authorities if they suspect
someone to be a victim of domestic abuse. The documentation can be used as third-party evidence and can be
used for obtaining a restraining order, public housing, welfare, health and life insurance and immigration relief.
In order for medical documentation to be admissible in court, it must include the following (Isaac & Enos,
2001):

Photographs taken of injuries during initial examination

Quotation marks must be used to express the patient’s own words when explaining how certain
injuries occurred

A description of the patient’s demeanor

A notation of time between event and statements made

Excited utterances or spontaneous exclamations made by the patient should be well documented

Body maps should be used to document extent and location of injuries

Write legibly otherwise the evidence will not be allowed in court
STAGES OF THE BATTERED WOMAN SYNDROME
There are four psychological stages of the battered woman syndrome. They consist of (1) denial (2) guilt (3)
enlightenment (4) responsibility. The first stage, denial, occurs because the woman refuses to admit to herself
and anyone else that she has been abused either physically and/or verbally. She will often make up excuses for
the violence and truly believes it will never happen again. The second stage, guilt, usually means that she has
finally acknowledged the problem but feels that she “deserves” the abuse because she is not perfect and is
not measuring up to her partner’s expectations. Enlightenment is the third stage and happens when the
woman realizes that no one deserves to be abused or beaten. She no longer feels responsible for her partner’s
actions. She usually stays committed to her relationship, stays with her partner, and hopes that it will never
happen again. On average, the abused woman will leave her partner 6 to 8 times. Situational factors are
usually the reason for staying or returning to their current living conditions. These would include economic
dependence, fear, lack of job skills, or social isolation. The final stage of responsibility is acceptance of the fact
that her partner will not and cannot change his violent and emotional abuse and she finally decides she will no
longer expose herself and possible her children to such behavior and moves on to start a new life.
COST OF DOMESTIC VIOLENCE
Domestic violence is impossible to measure. In the Unites States alone 12.6 billion dollars a year are on partner
violence including health care and judicial systems, refuge, and lost earnings. In fact, domestic violence3 is the
number one cause of women visiting the hospital emergency room. Victims of domestic violence spend more
on operative surgery, doctor visits, hospital stays, visits to the pharmacy, and mental health counselors than a
non-victimized woman. The average cost for a woman to receive medical help after being a victim of domestic
violence is $483, compared to $83 for a man.
Domestic violence professionals feel that the risks of such statutes far outweigh the benefits which were
anticipated: greater awareness and prompt response to victims.
There is evidence to support that retaliation by the batterer is a risk which results in even greater danger to the
victim and her children. It is also felt that such statutes will keep victims away from the health care system.
Many batterers now forbid their victims to seek medical attention for injuries even where there is no risk of
being "turned in".
Trust and security in the patient-provider relationship, with its veil of confidentiality, is severely hampered
under these statutes to the frustration of the caring medical professional who may have spent considerable
time building a relationship with the victim patient where she felt safe and comfortable disclosing her
experience.
Most health care professionals and domestic violence service providers feel that improved training, particularly
in assessment and screening techniques is by far the safer and more effective way to serve victims of domestic
violence. Many medical professionals are extremely uncomfortable being placed in the role of law
enforcement on this issue.
Finally, unlike the vulnerable populations of children and elderly abuse victims, battered women are often
extremely resourceful and reach out several times for assistance before finally leaving the batterer. The
philosophy supporting their successful resumption of control over their lives and their futures rests in self-help,
empowerment and advocacy as the most effective support in returning families to peace and stability.
Advocates provide options, as do medical professionals, but do not make choices or take action for the victim.
Each victim is encouraged to build on her own inner strength and design her own future action plan. In short
she is encouraged to take control of her own actions and decisions and most victims are able to do so when
they are safely away from the batterer.
RESOURCES:
Florida Coalition Against Domestic Violence
1-800-500-1119 Ext. 3
Florida Abuse Hotline
1-800-932-2873 (1-800-96ABUSE)
National Domestic Violence Hotline
1-800-799-7233 (1-800-799-SAFE)
The Rape, Abuse, Incest National Network
1-800-656-4673 (1-800-656-HOPE)
REFERENCES:
http://www.endabuse.org/resources/facts
http://www.ncadv.org/learn/learn/TheProblem_100.html
http://www.vawa2005.org/search
http://www.rwh.org/wkgwitholderwomen_report
http://www.fdle.state.fl.us/fsac/crime
http://www.dcf.state.fl.us/domesticviolence/grant
http://www.cdc.gov
http://www.aardvarc.org
http://www.fcadv.org
http://www.endabuse.org/programs/displat.php
http://www.emedicinehealth.com/domestic_violence
http://www.endabuse.org/resources/facts/welfare
http://www.paho.org/English/AD/GE/VAW_Pregnancy
http://www.letswrap.com/dvinfo/stats.htm
http://www.letswrap.com/dvinfo/warning.htm
http://www.letswrap.com/dvinfo/psych.htm
http://www.letswrap.com/dvinfo/whystay.htm
http://www.vantageproed.com/viol/viol.htm
Chapter three
Medical Record Documentation and Legal Aspects Appropriate to
Nursing Assistance
Introduction
Certified Nursing Assistance (CNAs) perform basic nursing functions related to patient or resident comfort,
safety, care, hygiene, ADLs, and protection of patients right. CNAs work in nursing home facilities, hospitals
and private homes and have a great responsibility to the facility where they work and to the patients or
residents they assist. The objective of this course is to ensure a better understanding of the importance of
proper and timely documentation as well as the professional and legal responsibility that CNAs have in their
role as a daily care giver to the patient or resident.
What is a Medical Record?
The medical record includes a variety of types of "notes" entered over time by health care professionals,
recording observations and administration of drugs and therapies, orders for the administration of drugs and
therapies, x-rays, test results, treatment plans and objectives, reports, etc. The maintenance of complete and
accurate medical records is a requirement of health care providers and is generally enforced as a licensing or
certification prerequisite. The information in a medical record is considered sensitive personal information
covered by expectations of privacy. Ethical and legal issues are implicated in the maintenance, storage and
disposal of all medical records.
The medical record is compiled over a lifetime and is updated every time a patient receives medical care. The
medical record is used by doctors, nurses, therapist and other medical staff to ensure the patient receives
quality healthcare. It allows for:




Communication between doctors and other healthcare providers of the patients plan of care
and treatment
Serves as a legal document describing the care given to and received by the patient
Serves as a verification for insurance company and patients for services rendered and billed
for were actually provided
Provides a history of all healthcare providers who have treated the patient
The medical record should be all encompassing, containing past and present medical history as well as
treatments. One should be able to read the patient medical record and without even seeing the patient, be
able to gain a comprehensive understanding of the patient’s medical care.
Most hospitals and nursing home facilities have their own specific rules about documentation and forms that
must be filled out. It is very important that you learn your facilities rules, including common abbreviations
used, and any other specific documentation procedures required.
What is Medical Documentation?
Documentation is the formal written communication about an individual patient, resident or client which is
entered into a medical record. It can serve as daily assessment of how the individual is doing and responding
to care. These documents can be reviewed by state agencies, and determines whether or not the facility will
be reimbursed for medical expenses associated with the recipients of Medicaid or Medicare.
“If it’s not documented, it has not been done” Is a common phrase used when discussing proper
documentation. It is critical part of caring for patients or residents. Documentation in the medical record
must be:




Done on time
Done objectively
Done completely
Done accurately
Be Timely: Documentation must be done on time and on a regular basis. It should be done in a timely manner.
You should document your patient care and interaction as it occurs if possible. You should not wait until the
end of your shift and rely on memory to chart your daily activities and interaction with your patient. Waiting to
document or chart your interactions could lead to omitting vital information. Never pre-chart or chart in
advance, it is considered fraud to chart that you have done something you did not do.
Be Objective: You should avoid documenting your opinion about what happened, what you observed and
what you might have done. Everything you write in the patients chart or medical record should be factual.
Your documentation should be able to be observed and repeated by other health care professionals,
document what can be measured or seen. Being objective protects you as well as the patient. Do not use
words that express your opinion or are demeaning such as whimpering or whining.
Be complete: You must document everything you do and everything you observe. All treatments, activities,
and care must be recorded. You should include your observation of the patient, noting any behavior that may
be out of the ordinary. You should date, put the time and initial or sign all your documentations in accordance
with your facilities procedures. Entries should be consistent over time, using same language and format.
Entries should be concise without omitting anything important or useful to other care givers. It is also
necessary to document refusal of service or other non-compliance with the care plan. Any patient that refuse
to take needed medications or any other activities or behaviors that pose risk to the patient or any other
patient or person should be documented and reported to the nurse or supervisor immediately. The nurse is
then responsible for charting a narrative note as to why the care was not done.
Be Accurate: You should always make sure you have the right patient, the right chart, the right information. In
order to document accurately you must record only factual information, observations, and actions. Once again
do not record opinions, or ideas about the patient or their condition. Only document verifiable details and
avoid unclear or unnecessary information. Whether recording on a daily flow sheet or in a patient’s chart it is
important to be accurate, these documents are legal representation of how the person is doing that day and
over time.
What Should CNAs Document?
In the course of the day a CNAs interactions and observations with the patient or resident must be
documented. Daily communication with other nursing staff and health care providers, both verbal and written
must be a routine part of your practice. Not only should you keep the nursing staff verbally informed of any
abnormal behaviors or complaints of pain, these findings must also be documented in your facilities daily chart
or medical records. CNAs should document things such as:
Daily Living Task:












Bathing (showers, tub baths, bed baths)
Feeding (if patient requires assistance or is able to feed themselves)
Dressing (according to patient’s needs and assistance)
Toileting (bed pan, assistance to bath room, etc.)
Vital signs (blood pressure, pulse)
Bed turning and positioning
Ambulation assistance
Fluid intake
Catheter care (emptying, Intake and output sheets)
Range of Motion Exercise
Report all changes physical and mental
Anything else that you may do
Observations:











Orientation to person, place, and time
Levels of consciousness
Height, weight
Temperature
Pulse
Respiratory rate
Appetite
Glucose reading
Things patients say (“use quotation marks”)
Attitude, behavior (anger, pain)
Anything abnormal
Use correct spelling and abbreviations approved by your facility. Avoid slang, jargon or complicated medical
terms. Do not use abbreviations not approved by your facility, or try abbreviating phrases that are not
generally known. Most facilities have their own approved abbreviations; Here are some commonly used
abbreviations in health care:
 Activities of Daily Living: ADL
 Blood Pressure: BP
 Bowel Movement: BM
 NO known drug allergies: NKDA
 Not applicable: N/A
 Pain: Pn or Px
 Range of Motion: ROM
 Respiratory: Resp
 Short of Breath: SOB
Only use abbreviations that are approved by your facility and that support your treatment and care of your
patient. Make sure to write them clearly so that they do no become misinterpreted. Some abbreviations lend
themselves to medical errors because the caregivers’ writing is not clear. For example, “Q.D.” an abbreviation
used for “every day” is no longer common practice because the period after the “Q” has sometimes been
mistaken for an “I”, and the medication has been given “QID” which is “four times a Day” rather than daily.
Remember that as a legal document you are responsible for all your documentation and a clear, concise,
correct note protects you, the facility and the patient. At times payers review medical documents to ensure
services are furnished and have been accurately documented.
Hospitals, nursing homes, home health agencies, medical centers, clinics, cancer centers and other facilities
may use medical flow sheets. Medical flow sheets are most commonly used for tracking things such as vitals,
pain assessment, insulin dosages, blood pressure, lab results, exercise routine, medication dosages and
frequency just to name a few. The flow sheet serves as a reminder of care and a record of whether
expectations have been met. For example, the patients orders calls for specific range of motion exercises
times a day, once in the morning and again afternoon. The flow sheet will tell us if the care plan was carried
out at the right time and in the right manner. It is important to follow the procedure which your facility has
established regarding charting in the medical flow sheet. You should not wait until the end of the day to
record or document what you have done with the patient.
CNAs play a big role in the care and assistance of activities of daily living (ADLs). The majority of ADLs and
personal care to the assigned resident or patient will be performed by a CNA. CNAs play a critical part of the
health care team and will need to participate in the documenting of their interaction with the patient or
resident. ADLs are routine activities that people need to do every day. There are six basic categories of ADLs:






Bathing
Continence
Dressing
Eating
Toileting
Transferring
A patients ability do perform ADLs will determine what type of long-term care (nursing- home care or home
care) and coverage the patient needs (Medicare, Medicaid, or long-term care insurance). Not only is it
important to document objective measurements of the patient’s ability to perform the task, but also any
complaints of pain or discomfort before, during or after the task.
What are the Do’s and Don’ts of Legal Documentation?
Medical records are legal documents. They must be used and kept according to the law and policies of your
facility. When you are documenting your patient care, keep these dos and don’ts of documentation in mind.
Do's of documentation:









always write with blue or black ink (unless your facility has a specific color)
write clearly, concise notes reflecting facts
check that you have correct chart prior to writing
time and date your notes
sign your full name and title (follow your facilities guidelines, initial as needed)
use only accepted abbreviations
document your observations, write what you see, feel, hear or smell
document circumstances and handling of errors
document timely, objectively, completely and accurately
Don'ts of documentation:








Don’t write in penciled or erasable ink
Don’t scribble out errors, if you make an error strike one line through the error, sign and date the
correction
Don’t write things you have not done or write things you intend to do later (pre chart)
Don’t write for other people or shifts
Don’t write your opinions such as the patient is lazy
Don’t use abbreviations unless they are accepted by your facility
Don’t wait until end of shift to do all you’re charting and rely on memory
Don’t allow anyone to look at a patients or residents chart unless they are a healthcare provider caring
for the patient
Be professional in your documentation. Handwriting should be neat. Your notes should be concise. Spelling
should be correct. If you are not sure of the spelling look it up. Do not make up abbreviations for words if you
are not sure of the spelling. Be professional and careful with what you write. The chart is not the place to
express your own feelings about the patient or their care. For example, avoid writing statements such as, “the
nurse has not come in all afternoon” or “the patient was very whinny today and lazy”. These statements are
not objective and are very unprofessional. Also it is important that your documentation match the information
on your assignment sheets, orders, care plan or instructions by the nurse. To any one reviewing the chart, the
patient’s condition and the needs that require your special services should be clear. The information as always
should be factual and objective; this is a legal paper trail of the care provided and the patient’s response to that
care.
Why Documentation is Important:





It supports payment for insurance coverage
It is the only written source for communication between you and other members of the health care team
It’s a legal record of care
It is a source of review and evaluation of the care provided
Required for certification or accreditation
The ability to write a concise and complete note in the patients chart requires practice, experience and a clear
understanding of your facilities protocol for documenting. Your facility should have a list of approved
abbreviations and may have examples of notes, medical flow sheets or charts for you to review. It would be to
your advantage to ask if any of these are available, especially if you do not have much experience in the setting
which you will be working in. With a little practice, good documentation becomes easy and is not extremely
time-consuming.
As for the legal aspect of documentation, remember the simple adage “if it isn’t documented, it hasn’t been
done. If you ever find yourself in court involving a patient’s care, the courts are more inclined to believe a
written record than what you remember. If there is no documentation that something was done or has
happened, the courts would be very likely to conclude that there is no proof and that you had not done what
you said you had done.
Examples of Poor Documentation: What to avoid
Why it’s important to document in a timely manner and avoid duplicate treatments.
You are caring for a post-operative hip surgery patient; your instructions are to ambulate with the patient 100’
down the hall and back. As you approach the turning point of your walk the patients becomes very weak and
tired, despite your efforts the patient falls to the floor, landing on the new hip and opening the incision site.
You are informed later that another CNA, in their efforts to be helpful, had gotten the patient up 45 minutes
earlier and walked down the hall and back, but did not document the fact.
In this case study notice that the patient did not mention the fact that just 45 minutes earlier someone had
gotten them out of bed and taken them for a walk. Patients expect that their care givers are well informed and
are doing their jobs correctly. This would have been avoided if the treatment would have been documented in
a timely manner.
Pre-charting is fraudulent and should never be done: What to avoid
Your orders are to irrigate a patient’s PEG tube (used to deliver food and medications to patients that can’t
swallow). PEG tubes are irrigated periodically with water or saline so that they do not become clogged. As you
check the chart you see that the CNA working the shift before you decided to document that he had irrigated
the patient’s PEG tube before he actually performed the task, before he performed the task he was called
away and never returned to actually irrigate the PEG tube. Eight hours later the PEG tube becomes clogged
and it subsequently has to be removed and replaced. The patient missed receiving her medications and
feedings.
It is very serious to chart something that has not been done. Your intentions may be good and you may feel
like per-charting is more efficient since you may be documenting other things you have completed at the time,
but it is never correct or a good idea. You never know if you may be asked to perform another duty or
something may change with the patient in a moment’s notice.
Example Incomplete and Unprofessional Documentation: What not to do
12/6 morning: Pt. not happy today seems lazy. Complaining again about hip;
I’m not sure why. Walked a little bit and then pt. wanted to quit. Left pt. in a chair.
12/7 9:30: Helped with shower. Ate breakfast. Have not seen a nurse or doctor visit patient today. Noticed
blood stain on bandage on knee. Patient does not want to walk today, told him that’s ok he look shaky
anyways. patient should be sent to a nursing home. Dave Smith, HHA
Example of Complete and Concise Documentation: What to do
BP 120/80 recorded at 11:00 AM. Took meds in morning slot. Red area on left hip reported to nurse Bill Bell.
Jane Doe, CNA
12/7/11 10:00 AM: Assisted patient out of bed. Patient complained that he did not want to ambulate as he is
afraid to get 12/6/11 11:18 AM: Morning care performed including lunch preparation. Ambulated down hall way
with walker. out of bed so soon after her surgery. I informed the patient that T.I.D. ambulation was ordered
by the physician. Helped patient walk from room to end of hall and back, total time 7 minutes. During walk
patient complained of feeling tired and pain in her right knee. Returned patient back to bed at 10:07. Informed
Sally Jones RN, of patients’ fear of ambulation and pain in right knee. Jon Stone, HHA
It should be clear how important your role is as a health care provider and how vital it is for everyone
involved in patient care to document completely, timely, concisely, and accurately.
Chapter four
Residents' Rights Overview
The federal 1987 Nursing Home Reform Law guarentees residents’ rights. This law requires
nursing homes to “promote and protect the rights of each resident” and places a strong
emphasis on individual dignity and self-determination. If a nursing home accepts Medicare or
Medicaid, it must meet federal residents' rights requirements. Some states have residents'
rights in state law or regulation for nursing homes, licensed assisted living, adult care homes, and
other board and care facilities. A person living in a long-term care facility maintains the same
rights as an individual in the larger community.
What this law means is that a resident should not decline in health or well-being as a result of the way a nursing
facility provides care.
The 1987 Nursing Home Reform Law protects the following rights of nursing home residents:
The Right to Be Fully Informed of

Available services and the charges for each service

Facility rules and regulations, including a written copy of resident rights

Address and telephone number of the State Ombudsman and state survey agency

State survey reports and the nursing home’s plan of correction

Advance plans of a change in rooms or roommates

Assistance if a sensory impairment exists

Residents have a right to receive information in a language they understand (Spanish,
Braille, etc.)
Right to Complain

Present grievances to staff or any other person, without fear of reprisal and with prompt
efforts by the facility to resolve those grievances

To complain to the ombudsman program

To file a complaint with the state survey and certification agency
Right to Participate in One's Own Care

Receive adequate and appropriate care

Be informed of all changes in medical condition

Participate in their own assessment, care-planning, treatment, and discharge

Refuse medication and treatment

Refuse chemical and physical restraints

Review one's medical record

Be free from charge for services covered by Medicaid or Medicare
Right to Privacy and Confidentiality

Private and unrestricted communication with any person of their choice

During treatment and care of one's personal needs

Regarding medical, personal, or financial affairs
Rights During Transfers and Discharges

Remain in the nursing facility unless a transfer or discharge:

(a) is necessary to meet the resident’s welfare;

(b) is appropriate because the residents’ health has improved and s/he no longer
requires nursing home care;

(c) is needed to protect the health and safety of other residents or staff;

(d) is required because the resident has failed, after reasonable notice, to pay the facility
charge for an item or service provided at the residents’ request

Receive thirty-day notice of transfer or discharge which includes the reason, effective
date, location to which the resident is transferred or discharged, the right to appeal, and
the name, address, and telephone number of the state long-term care ombudsman

Safe transfer or discharge through sufficient preparation by the nursing home
Right to Dignity, Respect, and Freedom

To be treated with consideration, respect, and dignity

To be free from mental and physical abuse, corporal punishment, involuntary seclusion,
and physical and chemical restraints

To self-determination

Security of possessions
Right to Visits

By a resident’s personal physician and representatives from the state survey agency and
ombudsman programs

By relatives, friends, and others of the residents' choosing

By organizations or individuals providing health, social, legal, or other services

Residents have the right to refuse visitors
Right to Make Independent Choices

Make personal decisions, such as what to wear and how to spend free time

Reasonable accommodation of one's needs and preferences

Choose a physician

Participate in community activities, both inside and outside the nursing home

Organize and participate in a Resident Council

Manage one's own financial affairs
Advocates for Residents Rights
Where do you go for help if you're concerned a facility is not guaranteeing the rights of residents?
Contact your local or state long-term care ombudsman or, if one exists, your state's citizen advocacy group.
The Long-Term Care Ombudsman Program is required by federal law to promote and protect the rights of
residents in licensed long-term care facilities. The Consumer Voice can help you locate advocates and
ombudsmen in your area. Visit our website: www.theconsumervoice.org to view a map listing ombudsmen and
citizen advocacy groups nationwide.
References
http://www.theconsumervoice.org/resident/nursinghome/residents-rights
http://www.theconsumervoice.org/sites/default/files/resident/nursing-home/ResidentRights-an-Overview.pdf
Chapter five
Prevention of Medical Errors
In the United States there is a hidden epidemic of medical errors. This epidemic has a result of injury in every 25
hospital clients and tens of thousands of death each year. (IOM, 1999). Medical errors are more deadly than
breast cancer, motor vehicle accidents, or AIDS. The Institute of Medicine's To Err Is Human: Building a Safer
Health System reports that medical errors cost the economy as much as $29 billion each year (IOM, 1999).
To Err Is Human made headlines across the country, with anticipated consequences on the national agenda.
From local hospitals and clinics to state and federal agencies, medical errors became a priority. Five examples
follow:
1.
2.
3.
4.
5.
The Florida state legislature mandated that all licensees must complete a two-hour course on
prevention of medical errors, which meets the criteria of Florida Statute 456.013 for initial licensure
and biennial renewal.
Twenty-three states, including Florida, have mandatory or voluntary systems for reporting medical
errors in hospitals and other healthcare organizations (Gebhardt, 2005).
The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) requires that
healthcare institutions analyze serious medical errors to determine the root cause and develop an
action plan to prevent those errors in the future.
In December 2000 Congress approved a $50 million annual appropriation for research on client safety,
primarily by the Agency for Healthcare Research and Quality (AHRQ).
In July 2005 President Bush signed into law S.544, the Client Safety and Quality Improvement Act,
which established a voluntary confidential reporting system to create a national database of medical
errors for analysis and development of evidence-based client safety measures.
Florida has taken other important steps to prevent medical errors and improve client safety.
In 2004, the Florida Client Safety Corporation was implemented. It is a voluntary statewide reporting program
to track and analyze near misses in healthcare. The same legislation demands that the state make public
important performance outcome indicators for healthcare facilities (ie, volume of cases, average length of
stay, complication rates, mortality rates, infection rates for various medical conditions). You can view this
public information online at http://www.floridacomparecare.gov.
In November 2004 voters sanctioned two controversial amendments to the Florida constitution that could
upset many of the client safety initiatives in the 2004 legislation. The Clients' Right-to-know About Adverse
Medical Incidents Act grants people who have been harmed access to all records of their care, including
documents of provider deliberation.
The Florida Board of Medicine has been asked to enforce the Three Strikes and You Are Out Act. This act would
revoke medical licenses from providers who have had three adjudicated malpractice incidents. Due to these
amendments, there has been a chilling effect on reporting and discussion of adverse events, which imperils the
research that needs to happen (Barach, 2005). It is possible that the passage of the federal Client Safety
Improvement Act of 2005, which protects the reporting of adverse events, may preempt Florida's Three
Strikes, but it is too early to tell.
Evidence has shown that rarely a medical error is the result of the carelessness or misconduct of a single
individual. The AHRQ has shown that medical errors result most frequently from systems errors—the
organization of healthcare delivery and the ways resources are provided in the delivery system.
Experts feel that client safety is slowly improving. However, the public and healthcare providers remain
concerned and are apprehensive with the pace of improvement. According to a recent survey performed by
the Kaiser Family Foundation in 2004, 40% of the people questioned said the quality of care has gotten worse in
the past five years. Only 17% said the quality of care had improved
In 2002, an analysis of hospitals in Missouri and Utah revealed that, although three-quarters of hospitals
reported implementing a written client safety plan, about one-tenth reported having no written plan at all.
Only a third of the hospitals had fully enforced computerized physician order entry (CPOE) for prescription
drugs by 2004, and only 3% of the hospitals enforced CPOE requiring physicians to use them. “Quality systems
are improving, but such change takes time, progress is slow, and the gap between the best possible care and
actual care remains large.”, say researchers (Longo et al., 2005)
Errors can present at any point in the healthcare delivery system. Accepting that errors happen, learning from
them, and working to prevent future errors represents a major change in the culture of healthcare— shift from
blame and punishment to analysis of the root causes of errors and design strategies to improve. Every person
on the healthcare team has an active duty to make healthcare safer for clients and workers
TYPES OF MEDICAL ERRORS
The IOM report interprets an error as “the failure of a planned action to be completed as intended (ie, error of
execution) or the use of a wrong plan to achieve an aim (ie, error of planning).”
An injury caused by medical management rather than the underlying condition of the client is known as an
adverse event. A preventable adverse event, also called a sentinel event, is attributable to error because it
signals the need to ask why the error occurred and make changes in the system.
Researchers have identified two types of errors humans make (Reason, 1990): active and latent. Active errors
usually arise at the level of the individual, and their effects are most likely felt instantly. Latent errors are more
likely to be beyond the control of the individual. Most likely they are errors in system design, faulty installation
or maintenance of equipment, or ineffective organizational structure. The effects of latent errors may not
materialize for months or even years but they can eventually lead to a cascade of active errors, resulting in
fatality.
“Close calls” are potential adverse events, errors that could have caused harm but did not, either by chance or
because something or someone in the system interfered. For example, a physician writes a prescription for a
patient that could potentially cause a drug overdose. The nurse recalls this potential hazard and does not
administer the drug but instead calls the error to the physician's attention. The nurse has now prevented an
adverse drug event (ADE). Close calls provide opportunities for developing preventive strategies and actions,
and should receive the same analysis as adverse events.
The Florida Client Safety Corporation (FPSC) was founded as a learning organization to create a Near Miss
Reporting System (NMRS). As a result, in 2006, the website was created to help healthcare providers improve
the quality and safety of care and reduce harm to clients. According to the NMRS:





Reporting will be voluntary, anonymous and independent of mandatory reporting systems used for
regulatory purposes.
Reports of near-miss data will be published regularly.
Special alerts will be published regarding newly identified, significant risks.
Aggregated data will be made publicly available.
Performance and results of the near-miss project will appear in its annual report.
Surgical Errors
Surgical errors may account for a high percentage of all adverse events. A study of hospitals in Colorado and
Utah found that surgical adverse events accounted for two-thirds of all adverse events and 1 of 8 hospital
deaths (Gawande et al., 1999).
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) found that wrong-site surgery
was most common in orthopedic procedures. A review of the contributing factors resulting in error included:
more than one surgeon involved in the case, multiple procedures performed during a single operating room
visit, and unusual time pressures—particularly pressure to speed up preoperative procedures.
Due to the number of surgical errors, such as wrong site, wrong-procedure, or wrong-person surgery, JCAHO
established a Universal Protocol, which all accredited healthcare organizations were required to implement by
July 2004 (JCAHO, 2004) hoping to reduce the risk of wrong-site, wrong-procedure, or wrong-person
surgeries. These types of surgical errors are not the sole liability of the operating surgeon but also the
operating room personnel. Everyone must ensure client safety by verifying the surgical site and pointing out a
possible error.
Competent nursing care following surgical procedures is crucial. In a study of Pennsylvania hospitals, it showed
the risk of client death following common surgical procedures was 30% higher in hospitals where nurses' mean
workloads were eight clients or more each shift than in hospitals where nurses' cared for four or fewer clients
(Aiken et al., 2002). A later study in Pennsylvania found that hospitals with higher proportions of nurses
educated at the baccalaureate level or higher had lower rates of postoperative mortality and failure-to-rescue
(deaths of clients with serious complications) (Aiken et al., 2003).
Diagnostic Inaccuracies
A proper diagnosis is imperative for correct and effective treatment. An inaccurate diagnosis may delay
treatment or result in incorrect, ineffective treatment which can lead to costly, invasive, and unnecessary tests.
Inexperience with a difficult diagnostic procedure can affect the accuracy of the results.
According to JCAHO (2002) misdiagnosis is a major factor contributing to delays in treatment. Hospital
emergency departments were responsible for just over one-half of all sentinel-event cases of patient death or
permanent injury due to delays in treatment. Please note that these serious events can take place in other
healthcare settings, including intensive-care units, medical-surgical units, inpatient psychiatric hospitals, the
operating room, and the home care setting. In this report, 52 out of the 55 reported cases of delays in
treatment resulted in client death.
Medication Errors
Medication errors are one of the most common types of error, and are of the utmost concern to the nurses
who administer them, the practitioners who prescribe them, and to the pharmacists who dispense them.
Medication errors are called preventable ADEs. In 2005, according to U.S. Pharmacopeia (USP), MEDMARX, the
largest nongovernmental database of medication errors, has received more than 1 million medication error
records since the program’s introduction in 1998. About half of the reported errors reached the client;
however, 98% resulted in no harm (USP, 2005).
Researchers from AHRQ and the National Center for Health Statistics, ADEs accounted for an estimated 4.3
million physician visits in the United States during 2001, up from 2.7 million such visits in 1995. Women 65 to 74
years of age had the highest incidence of ADEs (Zhan et al., 2005).
On July 1, 2003 Florida passed law 456.42, F.S, which requires physicians in Florida to either print legibly or type
prescriptions and to include the name and strength of the drug prescribed, the quantity of the drug prescribed
in both textual and numerical formats, and the directions for taking the drug.
The state also:




Requires physicians to read each prescription to the client so they know what it says in case the
pharmacist asks.
Requires the physician to check if the client has allergies and document on the prescription.
Requires physicians, who write illegible prescriptions, be reported to their licensing board.
Requires physicians in Florida to either print legibly or type prescriptions.
These requirements help to improve client safety and reduce the risk for medical errors.
The U.S. Pharmacopeia (USP, 2000) reported three most frequently reported types of medication errors were:
1.
2.
Omission errors (failure to administer an ordered medication dose)
Improper dose/quantity errors (any medication dose, strength, or quantity that differs from that
prescribed)
3.
Unauthorized drug errors (the medication dispensed and/or administered was not authorized by the
prescriber); this category includes dispensing or administering the wrong drug
According to USP's frequently asked questions (2005):


The primary contributing factors to medication errors were distractions, workload increases, and
staffing issues such as inexperienced or temporary staff and insufficient staffing. Many of these
factors may have resulted from efforts at cost containment.
Insulin, heparin, warfarin, and albuterol were the medications most often associated with errors.
Computerized prescriber order entry (CPOE) is aiding many hospitals to reduce ADEs but it has not eliminated
medication errors. The USP reported that nearly 20% of hospital and health system medication errors reported
to MEDMARX in 2003 involved computerization or automation (such as automated dispensing devices used in
client care areas of more than half of U.S. hospitals). Nearly half of all CPOE errors were dosing errors (extra
dose, wrong dose, or omission). Because of computerization, however, only 1.3% of those errors resulted in
client harm (USP, 2004).
Client-controlled analgesia (PCA) pumps can also result in medication errors, more than tripling the risk of
client harm. According to the USP, the most common types of error involving PCA pumps were improper
dose/quantity, unauthorized/wrong drug, and dose omission. Despite the built-in safety features of PCA
pumps—including a lockout interval that sets a minimum time between each dose and a maximum allowable
dose during a specified time period—medication errors involving these pumps continue (USP-CAPS, 2004).
USP recommendations for preventing errors with PCA pumps are included on the following page:
PREVENTING ERRORS IN CLIENT-CONTROLLED ANALGESIA
1. Include bar codes on all PCA medications in facilities where point-of-care bar code systems or other
item identification technology (e.g., radio frequency identification) are implemented.
2. Conduct a failure modes and effects analysis (FMEA) for existing pumps, as well as for new pumps
that are brought into the facility. Consider what default settings are preprogrammed. Consider if the
pumps can be programmed by drug (eg, morphine PCA vs. hydromorphone PCA). Consider if the
pump resets to a default (other than “000,” which would require active entry) after it turns off.
3. Perform double-checks for initial setup and maintenance, and dose changes/change orders. Doublecheck clamp (to open position) before closing the pump. Check that the pump is turned on. Check
whether connections are to IV or epidural lines to prevent wrong-route errors. Check for kinked tubing
in the pump door.
4. Educate staff about sound-alike and look-alike drugs, especially when bar code technology is not part
of the existing system. Many drug errors with PCA pumps are due to name confusion (eg, morphine,
hydromorphone, meperidine).
5. If using preprinted order forms, prohibit writing over information on the form.
6. Educate clients, family members, and staff (including physical therapists, x-ray technicians) about the
use of the pumps. Written instructions should be provided to clients. Instruct family members NOT to
administer PCA doses—PCA by definition should be administered at the client's perception of need.
Document education of client and family members.
Please visit http://www.usp.org/clientSafety/briefArticlesReports/
qualityReview/qr812004-09-01.html for additional recommendations.
Source: USP-CAPS, 2004.
High-risk drugs such as neuromuscular blocking agents, chemotherapy agents (some of which are
carcinogens), and opioid analgesics must have special precautions to prevent fatal errors. Although many of
these drugs carry a black box warning (BBW), the FDA's strongest labeling requirement, one recent study
points out that some physicians and pharmacists may ignore BBWs in prescribing and dispensing drugs
(Wagner et al., 2005).
Listed below are the recommendations from The Institute for Safe Medical Practices to prevent catastrophic
errors with neuromuscular blocking agents:



Limit access. When possible, dispense neuromuscular blocking agents from the pharmacy as
prescribed for clients. Allow floor stock of these agents only in the OR, ED, and critical care units
where clients can be properly ventilated and monitored.
Segregate storage. When these agents must be available as floor stock, have the pharmacy assemble
the vials in a sealed box with warnings affixed as noted below. Sequester the boxes in both
refrigerated and nonrefrigerated locations.
Warning labels. Affix fluorescent red labels that note: “Warning: Paralyzing Agent–Causes Respiratory
Arrest” on each vial, syringe, bag, and storage box of neuromuscular blocking agents. Commercially
available labels can be purchased from United Ad Label Co. Call 1-800-992-5755 and order item
#AM282. (ISMP, 2005)
Even though nurses do not write the prescription or dispense the drug from the pharmacy, they play a huge
role in recognizing possible errors when certain drugs are prescribed and dispensed. Nurses who administer
medication should always remember these following six “rights”.






Right Client
Right drug
Right Dose
Right Dosage Form
Right Route
Right Time
In 1999, The National Client Safety Partnership, a coalition of healthcare organizations, released a list of best
practices in medication safety. If hospitals implemented all of these practices, it could markedly reduce
medication errors.
BEST PRACTICES FOR MEDICATION SAFETY
To reduce the occurrence of adverse drug events (ADEs—events that can
cause, or lead to, inappropriate medication use and client harm):
Clients can help by:





Telling physicians about all medications they are taking and
responses/reactions to them.
Telling physicians about any change in their health since the
previous visit.
Asking for information in terms they understand before accepting
medications.
Insisting that the physician include the purpose of the medication
on the prescription.
Checking to be sure a refill is what it's supposed to be.
Providing organizations and practitioners can help by:










Educating clients.
Putting allergies and medications on client records.
Stressing dose adjustment in children and older persons.
Limiting access to high-hazard drugs.
Using protocols for high-hazard drugs.
Computerizing drug order entry.
Using pharmacy-based IV and drug mixing programs.
Avoiding abbreviations.
Standardizing drug packaging, labeling, & storage.
Using "unit dose" drug systems (packaged and labeled in standard
client doses).
Purchasers can help by:




Requiring machine-readable labeling (barcoding).
Buying drugs with prominent display of name, strength, warnings.
Buying "unit of use" packaging ("unit dose").
Buying IV solutions with two-sided labeling.
Clients should always ask the following questions before accepting
prescription drugs in order to prevent a potential hazard by taking a
medication that was not prescribed for them or cannot be safely taken by
them





Is this the drug my doctor (or other healthcare provider) ordered?
What is the trade and generic name of the medication?
What is the drug for? What is it supposed to do?
How and when am I supposed to take it and for how long?
What are the likely side effects? What do I do if they occur?
Is this medication safe to take with other over-the-counter or
prescription medications, or dietary supplements, that I am already
taking? What food, drink, activities, dietary supplements or other
medication should be avoided while taking this medication?
Retrieved from: National Client Safety Partnership, News Release, May 12,
1999.
System Failures
Analysis of medical errors continues to show that human fallibility is only part of the picture. System failures
are also guilty. In a major study, Leape and colleagues (1995) showed that failures at the system level—in
publicizing pharmaceutical information, in checking drug dosages and client identities, and in making client
information available—were the real culprits in more than 75% of adverse drug events.
Cost containment is a system-level factor that can affect medical errors. Researchers at AHRQ believe financial
pressure at hospitals is associated with increases in the rate of adverse events. The Healthcare Cost and
Utilization Project (HCUP) State Inpatient Data for Florida found that clients have significantly higher odds of
experiencing AEs when hospital profit margins decline over time. These include nursing-related AEs, surgeryrelated AEs, and all likely preventable AEs (Encinosa-Bernard, 2005).
Research on system failures, (Peterson, 1996) which have caused major industrial disasters found that the
systems had nine characteristics in common:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Diffuse responsibilities
Underestimation of the severity of risks
Belief that compliance with the rules was sufficient to achieve safety
Lack of acceptability for team members to speak up
Failure to share and implement lessons learned in other facilities
Subordination of safety to other performance goals
Persistence of flawed design features
Failure to use risk management techniques
Poorly defined responsibility for safety within the organization
Healthcare systems with these characteristics constitute an unsafe environment for both clients and staff.
FACTORS THAT INCREASE THE RISK OF ERRORS
“To err is human” according to the IOM but there are certain factors that can definitely increase the error rate
(Reason, 1990)


Fatigue. Working a double shift, for example, can increase the likelihood of errors. Medical residents
on call for 24 hours or more are also at high risk for errors. Research shows how such system-based
changes as reducing the work hours of medical personnel can reduce the error rate in hospitals
(Landrigan et al., 2004).
Alcohol and/or other drugs. Use of alcohol and/or drugs is incompatible with competent, professional,
safe client care. Unfortunately, the combination of high stress and easy access to medications has led
to substance abuse by physicians, nurses, and other healthcare professionals.









Illness. Coming to work when you aren't well jeopardizes your health and the health and safety of
clients.
Inattention/distraction. A noisy, busy emergency department can make it difficult to concentrate on
one client's care, especially if you know that other clients are waiting to see you.
Emotional states. Anger, anxiety, fear, and boredom can all impair job performance and lead to errors.
A heavy workload, conflict with other staff or with clients, and other sources of stress increase the
likelihood of errors.
Unfamiliar situations or problems. Nurses who "float" from one hospital department to another may
not have the expertise needed for all situations.
Equipment design flaws. Training and experience with equipment are essential to avoiding errors.
Inadequate labeling or instructions on medication or equipment. Look-alike or sound-alike drugs can
lead to errors. Incomplete or confusing instructions on equipment can result in inappropriate use.
Communication problems. Lack of clear communication among staff or between providers and clients
is one of the most common reasons for error.
Hard-to-read handwriting. Physicians' handwriting has long been criticized for its illegibility,
particularly on prescriptions. Fortunately, computerized medication ordering has eliminated this
problem in many healthcare organizations.
Unsafe working conditions. Poor lighting and/or slippery floors can lead to errors, especially falls—a
costly hazard in every hospital.
POPULATIONS OF SPECIAL VULNERABILITY
The safety of all clients is of huge concern for all care providers. However, some clients are more susceptible to
the effects of medical errors, often due to their inability to participate actively as a member of the healthcare
team, most commonly related to communication issues. Nurses and other health care providers need to
recognize the special needs of these clients and handle each case accordingly.
Older Clients
The normal aging process commonly includes some degree of impairment in vision and hearing. Older people
may also suffer varying degrees of cognitive impairment. Alone or in combination, these problems contribute
to difficulties in communication between clients and care providers. Serious illness, accidents, or trauma such
as surgery that require hospitalization add anxiety and possible confusion that can further interfere with
communication between clients and care providers, potentially leading to errors.
Older clients are at special risk from medication errors, which can have life-threatening or even fatal effects
due to the declining ability of the aging body to metabolize drugs. Visual, hearing, or cognitive problems may
lead to misunderstanding of instructions or failure to question an incorrect or unfamiliar drug. When caring for
older clients, communication with a responsible family member or other client advocate is essential.
Older clients are also at high risk of falling. Reasons include medication effects, existing health problems such
as arthritis, confusion or other cognitive deficit, or postural hypotension.
Infants and Children
The younger the client, the greater the risk of serious medication errors with devastating effects. Weight-based
dosing is required for almost all pediatric drugs, and errors often occur when physicians or pharmacists convert
dosage from pounds (for adults) to kilograms (for children). The USP advises that parents should know their
child's weight in kilograms and reconfirm with the doctor that the dosage is correct for that weight.
Infants and young children do not have the communication skills needed to alert clinicians about adverse
effects that they experience. Infants, particularly newborns, are physiologically ill-equipped to deal with drug
errors. Parents of infants and children need to be fully informed and involved in their child's care during
hospitalization and must be educated to question caregivers about medications and procedures.
Intensive Care Units
Intensive care units (ICUs) host the sickest clients, which makes them more vulnerable to medical errors and
more prone to injury. The AHRQ researchers reported that more than 20% of clients admitted to two ICUs at a
teaching hospital experienced an AE, almost half of which were preventable. A significant number of the AEs
involved medication errors, most commonly a wrong-dose error. Most of the AEs occurred during routine care,
not at admission or during an emergency (AHRQ, 2005b).
Language Skills or Literacy
In Florida, there is a diverse population, both culturally and ethnically. Meeting the healthcare needs of these
people can be quite challenging. They may require bilingual care providers, translators or interpreters, or other
communication experts. Without these experts available, communication of vital information between client
and provider can lead to misunderstanding and errors. Fortunately, many hospitals have translators or
interpreters available for clients who do not speak English.
General guidelines to assist nurses caring for clients from thirty-five different cultural groups can be found in
Culture and Nursing Care: A Pocket Guide (Lipson, Dibble & Minarik, 2005). Each chapter outlines issues related
to health and illness, symptom expression, self-care, birth, death, religion, family participation in care, and
other topics.
When caring for clients whose verbal abilities are limited either by education, development, or a neurologic
impairment, assistive devices such as an alphabet board, a picture board, or a magic slate may prove helpful.
Clients who are unable to speak because of a tracheostomy or other surgical procedure should also have these
devices available, along with pencil and paper (Adkins, 1991).
Fall Risk
Falls are a commonly reported sentinel event, and often times can be fatal. They not only affect older patients
but also a patient who has had excessive blood loss and/or maternity patients who may have had an epidural
and experience decreased lower body sensation Factors that increase the risk of falls are summarized on the
following below:
RISK FACTORS FOR FALLS
Special risk factors for falls include:










Age 65 or over
History of falling
Impaired mobility or difficulty walking
Need for assistance in getting out of bed or transferring to/from chair
History of dizziness or seizures
Impaired vision, hearing, or speech
Need for mobility-assistive devices (cane, walker, wheelchair, crutches or braces)
Weakness or fatigue
Confusion, disorientation, impaired cognitive function
Use of medications such as diuretics, laxatives, or consciousness-altering drugs including sedatives,
analgesics, hypnotics, antidepressants, tranquilizers.
Source: Harkreader, 2005.
REPORTING ERRORS
In order to improve client safety, it begins with prompt reporting of errors, followed by analysis of the root
causes and contributing factors and the development and execution of a plan of action to prevent similar
errors in the future. This is the only way for healthcare organizations to gauge the safety of care delivered and
determine whether safety is improving.
The attitude in the healthcare industry that errors are solely the responsibility of individual practitioners has
proved a major barrier to reporting. Instead of analyzing the multiple factors that contribute to errors, efforts
have focused almost entirely on making providers more careful, reinforced by fear of punishment when they
fail. Until the mid-1990s, this punitive attitude severely limited the reporting of errors. In fact, research shows
that when the fear of punishment is removed, reporting of errors increases by as much as ten- to twenty-fold
(Leape, 2000).
Joint Commission on Accreditation of Healthcare Organizations
All accredited healthcare organizations are required to have two systems for reporting errors: an internal
system and an external system. JCAHO, whose mission is "to continuously improve the safety and quality of
care provided to the public," requires that healthcare organizations:



Have a process in place to recognize sentinel events
Conduct thorough and credible root cause analyses that focus on process and system factors, not on
individual blame
Document a risk-reduction strategy and internal corrective action plan within 45 days of the
organization becoming aware of the sentinel event
A sentinel event, according to JCAHO is any unexpected occurrence involving death or serious physical or
psychological injury, or the risk thereof. Including the words “or the risk thereof” broadens the definition to
include potential sentinel events (close calls/near misses). The following page expalins examples of reportable
JCAHO sentinel events.
JCAHO REPORTABLE SENTINEL EVENTS
The Joint Commission encourages, but does not require, reporting of any sentinel event meeting the criteria
below.
Unanticipated death or major permanent loss of function, unrelated to the natural course of the client's illness
or underlying condition, or one of the following (even if the outcome was not death or major permanent loss
of function unrelated to the natural course of the client's illness or underlying condition):










Suicide of any individual receiving care, treatment, or services in a staffed around-the-clock care
setting or within 72 hours of discharge
Unanticipated death of a full-term infant
Abduction of any individual receiving care, treatment, or services
Discharge of an infant to the wrong family
Rape
Hemolytic transfusion reaction involving administration of blood or blood products having major
blood group incompatibilities
Surgery on the wrong individual or wrong body part
Unintended retention of a foreign object in an individual after surgery or other procedure
Severe neonatal hyperbilirubinemia (bilirubin >30 milligrams/deciliter)
Prolonged fluoroscopy with cumulative dose >1500 rads to a single field, or any delivery of
radiotherapy to the wrong body region or >25% above the planned radiotherapy dose
Source: JCAHO, 2005.
All accredited facilities are required to report not only actual but also potential sentinel events, the close calls
and near misses that afford valuable learning opportunities for prevention of future errors. Once sentinel
events are reported, the JCAHO requires facilities to submit the findings of their root cause analysis and
corrective action plans. This information can be included in JCAHO's review of sentinel events, helping track
national trends and develop strategies for improving client safety. JCAHO states:
“If the submitted root cause analysis or action plan is not acceptable or none is submitted within 45 days, the
organization is at risk for being placed on Accreditation Watch by the Accreditation Committee of the Joint
Commissioners. Accreditation Watch is a publicly disclosable attribute of an organization’s existing
accreditation status and signifies that the organization is under close monitoring by the Joint Commission. The
Accreditation Watch status is removed once the organization completes and submits an acceptable root cause
analysis.
Failure to perform an acceptable root cause analysis and implement appropriate actions can result in a change
in accreditation status, including loss of accreditation.” (JCAHO, 2005)
Since 1995 JCAHO has reviewed 3,197 sentinel events. The most common sentinel events are client suicide,
operative/postoperative complications, wrong-site surgery, and medication errors. Accredited organizations
are expected to:





Review and consider relevant information, if appropriate to the organization's services, from each
Sentinel Event Alert.
Consider information in an alert when designing or redesigning relevant processes.
Evaluate systems in light of information in an alert.
Consider standard-specific concerns.
Implement relevant suggestions or reasonable alternatives or provide a reasonable explanation for
not implementing relevant changes.
FLORIDA LAW
In most states reporting sentinel events to JCAHO is voluntary. Florida law makes such reporting mandatory.
Florida's Comprehensive Medical Malpractice Reform Act of 1985 (F.S.395.0197) mandates that each licensed
hospital and ambulatory surgery center implement a risk-management program with state oversight and an
internal incident-reporting system. State oversight is provided by the Florida Agency for Healthcare
Administration (AHCA). Each licensed facility is required to hire a risk manager, licensed under F.S. 395–10974,
who is responsible for implementation and oversight of the risk management program.
Statute 395.0197 mandates internal reporting of any adverse incident (event) "over which healthcare
personnel could exercise control, and which is associated in whole or in part with medical intervention, rather
than the condition for which such intervention occurred, and which:
1.
Results in one of the following injuries:
* Death
* Brain or spinal damage
* Permanent disfigurement
* Fracture or dislocation of bones or joints
* A resulting limitation of neurologic, physical, or sensory function which continues after discharge from the
facility
* Any condition that required specialized medical attention or surgical intervention resulting from nonemergency medical intervention, other than an emergency medical condition, to which the client has not given
his or her informed consent, or
* Any condition that required the transfer of the client, within or outside the facility, to a unit providing a more
acute level of care due to the adverse incident, rather than the client's condition prior to the adverse incident;
2.
3.
4.
Was the performance of a surgical procedure on the wrong client, a wrong surgical procedure, a
wrong-side surgical procedure, or a surgical procedure otherwise unrelated to the client's diagnosis or
medical condition
Required the surgical repair of damage resulting to a client from a planned surgical procedure, where
the damage was not a recognized specific risk, as disclosed to the client and documented through the
informed-consent process, or
Was a procedure to remove unplanned foreign objects remaining from a surgical procedure.
(F.S.395.0197)
The risk-management reporting system must:



Investigate and analyze the frequency and causes of adverse incidents to clients
Educate facility staff and agents
Analyze client grievances related to client care
All incident reports must be filed with the risk manager of the healthcare organization or his or her designee
within three days after the event occurred. Following receipt of the report, the risk manager in turn must
report the event to the Florida Agency for Healthcare Administration.
In addition to their internal reporting system, Florida hospitals and ambulatory surgical centers also must
submit two types of reports to the Florida AHCA:
1.
2.
A Code 15 reports which reports in detail on each serious client injury, the facility's investigation of the
injury, and whether the factors causing or resulting in the adverse incident represent a potential risk to
other clients. The findings of that investigation must be reported to AHCA within 15 days of an adverse
incident. Failure to comply with this mandate may result in fines of as much as $25,000.
The annual report, which includes all adverse incidents that occur in the facility and malpractice
actions (new, pending, and closed) in the course of a calendar year. Facilities are also required to
report any injuries of which they are aware that occur through any healthcare service, including
nursing homes, home health organizations, doctors' offices, dentists' offices, or any other purveyor of
healthcare service. Florida Statute 641.55 requires similar reporting of client injury incidents by HMOs.
These reports are due after the first of each year for the previous year.
IMPROVING CLIENT OUTCOMES
Root Cause Analysis (RCA)
Root cause analysis is a tool for identifying prevention strategies. It is a process that is part of the effort to
build a culture of safety and move beyond the culture of blame.
A root cause analysis (RCA) and corrective action plan are required by JCAHO for each reported sentinel event
within 45 days of the event's occurrence or of the organization's becoming aware of the event. JCAHO
research shows the leading root causes of sentinel events between 1996 and 2004 were communication,
orientation/training, client assessment, and staffing. The U.S. Department of Veterans Affairs, National Center
for Client Safety, offers the following guidance.
The goal of a root cause analysis (RCA) is to find out:



What happened
Why it happened
What to do to prevent it from happening again
Root cause analysis is:





Interdisciplinary, involving experts from the frontline services
Involving of those who are the most familiar with the situation
Continually digging deeper by asking why, why, why at each level of cause and effect
A process that identifies changes that need to be made to systems
A process that is as impartial as possible
To be thorough, an RCA must include:





Determination of human and other factors
Determination of related processes and systems
Analysis of underlying cause and effect systems through a series of why questions
Identification of risks and their potential contributions
Determination of potential improvement in processes or systems
To be credible, an RCA must:



Include participation by the leadership of the organization and those most closely involved in the
processes and systems.
Be internally consistent.
Include consideration of relevant literature. (U.S. Dept. Veterans Affairs, 2005)
Electronic medical records (EMRs) and other technological information can improve communication and client
safety if fully implemented in hospitals and other healthcare facilities. For example, EMRs can help reduce
medication errors, avoid the need to repeat laboratory tests, and improve continuity of care across the
healthcare system. All healthcare providers within a system have access to accurate and complete information
when they need it.
Many healthcare organizations find the cost of EMRs a deterrent. According to the Leapfrog Group, a national
coalition of large healthcare providers, a purchase and implementation of EMRs in a 200-bed hospital can cost
from $1 to $7 million. However, the return on investment in terms of increased efficiency and improved client
safety can be substantial (Joint Commission, 2005).
The JCAHO issued new mandatory goals and recommendations to improve client safety which took effect in
January 2006. Hospitals and other organizations will be evaluated by accreditation representatives to see
whether these recommendations or acceptable alternative measures are being implemented. Failure to
implement the recommendations could result in loss of accreditation and federal funding. The 2006 National
Client Safety Goals and Recommendations are summarized below. New goals are in boldface type.
2006 JCAHO NATIONAL SAFETY GOALS
Goal 1. Improve the accuracy of client identification.
Recommendations:

Use at least two client identifiers (neither of which is the client's room number) whenever
administering medications or blood products. Taking blood samples or other specimens for clinical
testing, or providing any other treatments or procedures.
Goal 2. Improve the effectiveness of communication among caregivers.
Recommendations:




For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete
order or test result by having the person receiving the order or test result "read-back" the complete
order or test result.
Standardize a list of abbreviations, acronyms and symbols that are not to be used throughout the
organization. (See Table 1 below for official JCAHO “Do Not Use” List.)
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.
Implement a standardized approach to “hand off” communications, including an opportunity to ask
and respond to questions.
Goal 3. Improve the safety of using medications.



Standardize and limit the number of drug concentrations available in the organization.
Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the
organization, and take action to prevent errors involving the interchange of these drugs.
Label all medications, medication containers (eg, syringes, medicine cups, basins), or other solutions
on and off the sterile field in perioperative and other procedural settings.
Goal 4. Not applicable
Goal 5. Retired in 2006
Goal 6. Not applicable
Goal 7. Reduce the risk of healthcare-associated infections.


Comply with current CDC hand hygiene guidelines.
Manage as sentinel events all identified cases of unanticipated death or major permanent loss of
function associated with a healthcare-associated infection.
Goal 8. Accurately and completely reconcile medications across the continuum of care.


Implement a process for obtaining and documenting a complete list of the client's current medications
upon the client's admission to the organization and with the involvement of the client. This process
includes a comparison of the medications the organization provides to those on the list.
A complete list of the client's medications is communicated to the next provider of service when a
client is referred to or transferred to another setting, service, practitioner or level of care within or
outside the organization.
Goal 9. Reduce the risk of client harm resulting from falls.

Implement a fall reduction program and evaluate the effectiveness of the program.
Goal 10. Not applicable
Goal 11. Not applicable
Source: JCAHO, 2005. Modifications of these goals for ambulatory care, assisted living, long term care, diseasespecific care and laboratory can be found at http://www.jcaho.org.
TABLE 1
JCAHO DO-NOT-USE LIST*
Do not use
Potential problem
Use instead
Mistaken for “0” (zero), the number “4,” (four) or
U (unit)
Write "unit"
“cc”
Mistaken for IV (intravenous), or the number 10
IU (International Unit)
Write "International Unit"
(ten)
Q.D., QD, q.d., qd (daily)
Mistaken for each other
Write "daily"
Q.O.D., QOD, q.o.d, qod
Period after the Q mistaken for "I" and the "O"
Write "every other day"
(every other day)
mistaken for "I"
Trailing zero (X.0 mg)*
Decimal point is missed
Write X mg
Lack of leading zero (.X mg) Decimal point is missed
Write 0.X mg
MS
Can mean morphine sulfate or magnesium sulfate Write "morphine sulfate"
MSO4 and MgSO4
Confused for one another
Write "magnesium sulfate"
*Applies to all orders and all medication-related documentation that is handwritten (including free-text
computer entry) or on pre-printed forms. Exception: A “trailing zero” may be used only where required to
demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies
that report size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medicationrelated documentation.
Source: JCAHO, 2005.
In July 2001 the Agency for Healthcare Research and Quality released a report outlining evidenced-based
clinical recommendations for improving client safety. Titled Making Healthcare Safer: A Critical Analysis of
Client Safety Practices, the report reviews 79 practices to prevent adverse events and improve client safety,
based on current research. The eleven most highly rated practices are bulleted below. The authors of this
report emphasized that this list should not be considered complete, and that it was weighted toward care of
the very ill, rather than the mildly or chronically ill (Shojania et al., 2001). For a summary of the AHRQ report, go
to http://www.ahrq.gov/clinic/ptsafety/summary.htm.
CLINICAL OPPORTUNITIES FOR SAFETY IMPROVEMENT











Appropriate use of prophylaxis to prevent venous thromboembolism in clients at risk
Use of perioperative beta-blockers in appropriate clients to prevent perioperative morbidity and
mortality
Use of maximum sterile barriers while placing central intravenous catheters to prevent infections
Appropriate use of antibiotic prophylaxis in surgical clients to prevent perioperative infections
Asking that clients recall and restate what they have been told during the informed consent process
Continuous aspiration of subglottic secretions (CASS) to prevent ventilator-associated pneumonia
Use of pressure-relieving bedding materials to prevent pressure ulcers
Use of real-time ultrasound guidance during central-line insertion to prevent complications
Client self-management for warfarin (Coumadin) to achieve appropriate outpatient anticoagulation
and prevent complications
Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill
and surgical clients
Use of antibiotic-impregnated central-venous catheters to prevent catheter-related infections
To speed the most urgent improvements in client safety, the Institute for Healthcare Improvement (IHI), a
nonprofit organization headquartered in Cambridge, Massachusetts, launched the 100,000 Lives campaign in
December 2004. The American Medical Association, the American Nurses Association, and JCAHO signed on as
collaborators together with four government agencies: the Centers for Disease Control and Prevention, the
Centers for Medicare and Medicaid Services, the Veterans Health Administration, and AHRQ.
This campaign focuses on six basic measures that could save as many as 100,000 lives each year if even 2,000
hospitals adopted them. The good news is that nearly 3,000 hospitals have enrolled in this campaign in its first
year (IHI, 2005).
The six measures of the campaign are based on the best practices from AHRQ's Making Healthcare Safer report
and include:
1.
2.
3.
4.
5.
6.
Prevention of ventilator-associated pneumonia
Prevention of central-line infections
Prevention of surgical-site infections
Deployment of rapid-response teams*
Assurance of optimal care for clients with acute myocardial infarction
Prevention of adverse drug events
*Rapid-Response Teams ensure that critical early warnings of a client’s deteriorating condition and potential
cardiac arrest are taken seriously. Their role is to assess, stabilize, assist with communication, educate and
support, and assist with transfer, if necessary. Research in Australia has shown that rapid-response teams may
be able to cut hospital death rates by 20% or more (Berwick, 2005).
In 2005, JCAHO released Healthcare at the Crossroads: Strategies for Improving the Medical Liability System and
Preventing Client Injury. This report outlines a public policy action plan based on three broad recommendations:
1.
2.
3.
Pursue client safety initiatives that prevent medical injury.
Promote open communication between clients and practitioners.
Create an injury compensation that is client-centered and serves the common good. (JCAHO, 2005)
Public Education Measures Related to Client Safety
Making the client and the family part of the healthcare team is an important strategy in improving client safety
and reducing medical errors. There are organizations that provide material to educate clients about their role
on the healthcare team. The AHRQ has developed a simple message for clients called Five Steps to Safer
Healthcare, as well a comprehensive patient fact sheet that hospitals are encouraged to make available to
clients.
The single most important way clients can help to prevent errors is to be an active members of the healthcare
team. That means taking part in every decision about their healthcare. Research shows that clients who are
personally involved with their care tend to get better results. Some specific tips, based on the latest scientific
evidence about what works best, can be found on the following page.
Medicines
1.
2.
3.
4.
5.
6.
7.
8.
9.
Make sure that all of your doctors know about everything you are taking. This includes prescription
and over-the-counter medicines, and dietary supplements such as vitamins and herbs.
At least once a year, bring all of your medicines and supplements with you to your doctor. "Brown
bagging" your medicines can help you and your doctor talk about them and find out if there are any
problems. It can also help your doctor keep your records up to date, which can help you get better
quality care.
Make sure your doctor knows about any allergies and adverse reactions you have had to medicines.
This can help you avoid getting a medicine that can harm you.
When your doctor writes you a prescription, make sure you can read it. If you can't read your doctor's
handwriting, your pharmacist might not be able to either.
Ask for information about your medicines in terms you can understand—both when your medicines
are prescribed and when you receive them. What is the medicine for? How am I supposed to take it,
and for how long? What side effects are likely? What do I do if they occur? Is this medicine safe to take
with other medicines or dietary supplements I am taking? What food, drink, or activities should I avoid
while taking this medicine?
When you pick up your medicine from the pharmacy, ask: Is this the medicine that my doctor
prescribed? A study by the Massachusetts College of Pharmacy and Allied Health Sciences found that
88% of medicine errors involved the wrong drug or the wrong dose.
If you have any questions about the directions on your medicine labels, ask. Medicine labels can be
hard to understand. For example, ask if "four doses daily" means taking a dose every 6 hours around
the clock or just during regular waking hours.
Ask your pharmacist for the best device to measure your liquid medicine. Also, ask questions if you're
not sure how to use it. Research shows that many people do not understand the right way to measure
liquid medicines. For example, many use household teaspoons, which often do not hold a true
teaspoon of liquid. Special devices, like marked syringes, help people to measure the right dose. Being
told how to use the devices helps even more.
Ask for written information about the side effects your medicine could cause. If you know what might
happen, you will be better prepared if it does—or, if something unexpected happens instead. That
way, you can report the problem right away and get help before it gets worse. A study found that
written information about medicines can help clients recognize problem side effects and then give
that information to their doctor or pharmacist.
Hospital Stays
1.
2.
3.
If you have a choice, choose a hospital at which many clients have the procedure or surgery you need.
Research shows that clients tend to have better results when they are treated in hospitals that have a
great deal of experience with their condition.
If you are in a hospital, consider asking all healthcare workers who have direct contact with you
whether they have washed their hands. Handwashing is an important way to prevent the spread of
infections in hospitals. Yet, it is not done regularly or thoroughly enough. A recent study found that
when clients checked whether healthcare workers washed their hands, the workers washed their
hands more often and used more soap.
When you are being discharged from the hospital, ask your doctor to explain the treatment plan you
will use at home. This includes learning about your medicines and finding out when you can get back
to your regular activities. Research shows that at discharge time doctors think their clients understand
more than they really do about what they should or should not do when they return home.
Surgery
1.
If you are having surgery, make sure that you, your doctor, and your surgeon all agree and are clear on
exactly what will be done. Doing surgery at the wrong site (for example, operating on the left knee
instead of the right) is rare. But even once is too often. The good news is that wrong-site surgery is
100% preventable. The American Academy of Orthopedic Surgeons urges its members to sign their
initials directly on the site to be operated on before the surgery.
Other Steps You Can Take
1.
2.
3.
4.
5.
6.
7.
Speak up if you have questions or concerns. You have a right to question anyone who is involved with
your care.
Make sure that someone, such as your personal doctor, is in charge of your care. This is especially
important if you have many health problems or are in a hospital.
Make sure that all health professionals involved in your care have important health information about
you. Do not assume that everyone knows everything they need to.
Ask a family member or friend to be there with you and to be your advocate (someone who can help
get things done and speak up for you if you can't). Even if you think you don't need help now, you
might need it later.
Know that "more" is not always better. It is a good idea to find out why a test or treatment is needed
and how it can help you. You could be better off without it.
If you have a test, don't assume that no news is good news. Ask about the results.
Learn about your condition and treatments by asking your doctor and nurse and by using other
reliable sources.
Source: AHRQ, 2005b.
TIPS FOR PARENTS: PREVENTING MEDICATION ERRORS
 On admittance to the hospital, provide the healthcare practitioner (HCP) with an up-to-date list of all
medicines (prescription and over-the-counter) and dietary supplements that your child is taking. This
will help minimize medication errors and prevent drug interactions during your child's hospital stay.
 Make sure your child's HCP is aware of any allergies your child may have. For life-threatening allergies,
be sure that your child wears a Medic Alert bracelet at all times.
 Medications administered to children are based on the child's weight in kilograms. For purposes of
preparing appropriate dosages of medicines, your child's weight in pounds must be divided by 2.2 to
convert it into kilograms. Be aware of this calculation and/or your child's weight in kilograms, and
reconfirm the correct dosage with your child's HCP if you have concerns.
 Be sure that you are provided with verbal and written information about your child's medications, the
common side effects, and the adverse events that should be reported to your child's HCP.
 Pay close attention to how your child is feeling while in the hospital. Notify the HCP immediately if you
notice any negative side effects from the administered medications, such as sudden difficulty in


swallowing or breathing.
If your child is given a liquid medication to take after release from the hospital, be sure you are
provided with an appropriate measuring device and instructions to ensure proper medication doses.
In case of an emergency, be sure that your child's school has a list of any medical conditions or
allergies your child may have.
Infants and children have the greatest risk of harm from medical errors, so it is essential that parents be well
informed about how to reduce the risk of medical errors in their children's healthcare. Below are
recommendations for parents to ensure the safety of their child and quality of care.
A truly national response to the IOM's call to reduce preventable client injuries by 90% requires that every
healthcare board, executive, physician, and nurse make improving safety an absolutely top strategic priority—
fully equal to the corporate priority of financial health. At a national level, such a commitment has yet to
emerge; indeed, it is not in sight.
Leape & Berwick, 2005
RESOURCES
100,000 Lives Campaign
Videos, how-to-guides, and other resource materials
http://www.ihi.org/ihi/programs/campaign
Agency for Healthcare Administration
http://www.ahca.myflorida.com
Agency for Healthcare Research and Quality (AHRQ)
http://www.ahrq.gov
Client Safety Network
http://psnet.ahrq.gov
Web Morbidity and Mortality Rounds
http://www.webmm.ahrq.gov
Association of Operating Room Nurses
http://www.aorn.org
Florida Compare Care
http://www.floridacomparecare.gov
Florida Health Statistics
http://www.FloridaHealthStat.com
Florida State Board of Nursing
Department of Health
Board of Nursing
P.O. Box 6330
Tallahassee FL 32314-6330
http://http://www.doh.state.fl.us/mqa/nursing
e-mail: [email protected]
850 488 0595
Food and Drug Administration
http://www.fda.gov
Healthcare at the Crossroads
Strategies for improving the medical liability system and preventing client injury
http://www.jcaho.org
Institute for Healthcare Improvement (IHI)
http://www.ihi.org
Institute for Safe Medication Practices
http://www.ismp.org
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
http://www.jcaho.org
The Leapfrog Group
http://www.leapfroggroup.org
National Center for Client Safety
http://www.clientsafety.gov
National Client Safety Foundation
http://www.npsf.org
National Quality Forum
http://www.qualityforum.org
Society of Pediatric Nurses
7794 Grow Drive
Pensacola FL 32514-7072
850 494 9467
Toll free 800 723 2902
http://www.pedsnurses.org
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Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (2005b). Healthcare at the Crossroads:
Strategies for Improving the Medical http://www.iom.org.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (2005c). JCAHO Do-Not-Use List
http://www.jcaho.org/accredited+organizations/laboratory+services/
npsg/06_dnu_list.pdf.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (2004). Universal Protocol.
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universal+protocol/universal_protocol.pdf.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (2002). Delays in Treatment. Sentinel
Event Alert 26. June 17, 2002.
Joint Commission Perspectives on Client Safety (2005). Using electronic medical records to improve care.
Volume 5, Issue 7. http://www.jcrinc.com/printview.asp?durki=10721.
Kaiser Family Foundation (2004, November 17). Five years after IOM report on medical errors, nearly half of all
consumers worry about the safety of their healthcare. Press release.
http://www.kff.org/kaiserpolls/pomr111704pkg.cfm.
Landrigan, CP, Rothschild JM, Cronin JW, et al. (2004). Effect of reducing interns' work hours on serious
medical errors in intensive care units. New England Journal of Medicine 351:1838–48.
http://content.nejm.org/cgi/reprint/351/18/1838.pdf.
Leape LL, Bates DW, Cullen DJ, et al. (1995). Systems analysis of adverse drug events. JAMA 274:35–43.
Leape LL, Woods DD, Hatlie MJ, et al. (1998). Promoting client safety by preventing medical error [editorial].
JAMA 280:1444–47.
Leape LL. (2000). Accelerating Change Today (A.C.T.) for America 's health. Washington DC: The National
Coalition on Healthcare. Retrieved from http://www.aha.org/medicationsafety/medsafety.asp.
Lipson J, Dibble S, Minarik P. (2005). Culture and Nursing Care: A Pocket Guide. San Francisco: University of
California Nursing Press.
Longo DR, Hewett JE, Bin G, et al. (2005). The long road to client safety: A status report on client safety
systems. JAMA 294:2858–06. Retrieved December 17, 2005 from http://www.jama.com.
National Client Safety Partnership. (1999, May 12). Healthcare leaders urge adoption of methods to reduce
adverse drug events. Press Release: May 12, 1999. Washington DC: VA Public Affairs office.
Peterson D. (1996). Human Error Reduction and Safety Management. New York: Van Nostrand Reinhold.
Reason JT. (1990). Human Error. Cambridge: Cambridge University Press.
Shojania K, Duncan B, McDonald K, Wachter RM (eds.). (2001). Making healthcare safer: A critical analysis of
client safety practices. Rockville MD: Agency for Healthcare Research and Quality. Evidence Report/Technology
Assessment No. 43; AHRQ publication 01-E058 http://www.ahrq.gov/clinic/ptsafety/chap57.htm.
United States Pharmacopeia (USP). (2005). Medication errors frequently asked questions. Retrieved from
http://www.usp.org/clientSafety/mer/faq.html#Q3.
United States Pharmacopeia (USP). (2005, September 27). USP's national adverse drug event database hits one
million records milestone. Press release. http://www.usp.org.
United States Pharmacopeia (USP). (2004, December 20). Computer entry a leading cause of medication
errors. Press release http://www.usp.org.
United States Pharmacopeia (USP). (2000). Summary of 1999 information submitted to MEDMARX : A national
database for hospital medical error reporting. Rockville, MD : author.
U.S. Department of Veterans Affairs, National Center for Client Safety. (2005). Root Cause Analysis.
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USP Center for the Advancement of Client Safety (CAPS). (2004). Quality Review 81. http://www.usp.org.
Wagner AK, Chan KA, Dashevsky I, et al. (2005, November 18). FDA prescribing warnings: Is the black box half
empty or half full? Pharmacoepidemiology and drug safety. [E-pub ahead of print DOI 10.1002/pds.1193.]
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Weeks WB, Bagian JP. (2000). Developing a culture of safety in the Veterans Health Administration. Effective
Clinical Practice, November-December. http://www.acponline.org/journals/ecp/novdec00/weeks.htm.
Zhan C, Arispe I, Kelley E, et al. (2005). Ambulatory care visits for treating adverse drug effects in the United
States, 1995–2001. Joint Commission Journal on Quality and Client Safety 31:372–78
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00000031/0000007/art00002.
Chapter six
Cardiopulmonary Resuscitation For Certified Nursing Assistants
It is important that CNAs who are responsible for providing care for patients on a
daily basis be trained in CPR. It is important for CNAs to recognize the signs of a patient
having a heart attack or distress so they may be able to react appropriately and potentially save a patient’s life.
CNAs must renew their CPR training according to the standards established in their states and by the
organizations for which they work. This section should serve only as a refresher, and is not intended for CPR
certification or recertification.
What is Cardiopulmonary Resuscitation or CPR?
Cardiopulmonary resuscitation (CPR) is an emergency procedure, performed in an effort to manually preserve
intact brain function until further measures are taken to restore spontaneous blood circulation and breathing
in a person in cardiac arrest. It is indicated in those who are unresponsive with no breathing or abnormal
breathing, for example, agonal respirations.
CPR involves chest compressions at least 5 cm deep and at a rate of at least 100 per minute in an effort to
create artificial circulation by manually pumping blood through the heart. In addition, the rescuer may provide
breaths by either exhaling into the subject's mouth or nose or utilizing a device that pushes air into the
subject's lungs. This process of externally providing ventilation is termed artificial respiration. Current
recommendations place emphasis on high-quality chest compressions over artificial respiration; a simplified
CPR method involving chest compressions only is recommended for untrained rescuers.
CPR alone is unlikely to restart the heart; The main purpose is to restore partial flow of oxygenated blood to
the brain and heart. The objective is to delay tissue death and to extend the brief window of opportunity for a
successful resuscitation without permanent brain damage. Administration of an electric shock to the subject's
heart, termed defibrillation, is usually needed in order to restore a viable or "perfusing" heart rhythm.
Defibrillation is only effective for certain heart rhythms, namely ventricular fibrillation or pulseless ventricular
tachycardia, rather than asystole or pulseless electrical activity. CPR may succeed in inducing a heart rhythm
which may be shockable. CPR is generally continued until the subject regains spontaneous circulation (ROSC)
or is declared dead
When is CPR necessary?
CPR is used on people in cardiac arrest in order to oxygenate the blood and maintain a cardiac output to keep
vital organs alive. Blood circulation and oxygenation are required to transport oxygen to the tissues. The brain
may sustain damage after blood flow has been stopped for about four minutes and irreversible damage after
about seven minutes. Typically if blood flow ceases for one to two hours, the cells of the body die. Because of
that CPR is generally only effective if performed within seven minutes of the stoppage of blood flow. The heart
also rapidly loses the ability to maintain a normal rhythm. Low body temperatures, as sometimes seen in neardrownings, prolong the time the brain survives. Following cardiac arrest, effective CPR enables enough oxygen
to reach the brain to delay brain death, and allows the heart to remain responsive to defibrillation attempts.
What is cardiac arrest?
Cardiac arrest is the cessation of normal circulation of the blood due to failure of the heart to contract
effectively. Medical personnel may refer to an unexpected cardiac arrest as a sudden cardiac arrest or SCA.
A cardiac arrest is different from (but may be caused by) a heart attack, where blood flow to the muscle of the
heart is impaired.[2]
Arrested blood circulation prevents delivery of oxygen to the body. Lack of oxygen to the brain causes loss of
consciousness, which then results in abnormal or absent breathing. For the best chance of survival and
neurological recovery, immediate and decisive treatment is imperative.
Cardiac arrest is a medical emergency that, in certain situations, is potentially reversible if treated early.
Unexpected cardiac arrest sometimes leads to death almost immediately; this is called sudden cardiac death
(SCD). The treatment for cardiac arrest is cardiopulmonary resuscitation (CPR) to provide circulatory support,
followed by defibrillation if a shockable rhythm is present.
• Every year in the US, EMS treats almost 383,000 out-of-hospital sudden cardiac arrests – that’s more
than 1,000 a day.
• Almost 80 percent of sudden cardiac arrests happen at home and are witnessed by a loved one. Put
very simply: The life you save with CPR is mostly likely to be the life of someone you love.
• Currently, less than 12 percent of victims survive sudden cardiac arrest. Effective bystander CPR
provided immediately after sudden cardiac arrest can double or triple a victim’s chance of survival, but
only 41 percent of cardiac arrest victims get CPR from a bystander.
Sudden Cardiac Arrest (SCA) & CPR Fast Facts
• Sudden cardiac arrest can happen to anyone at any time. Many victims appear healthy with no known
heart disease or other risk factors.
• Sudden cardiac arrest is not the same as a heart attack. Sudden cardiac arrest occurs when electrical
impulses in the heart become rapid or chaotic, which causes the heart to suddenly stop beating. A heart
attack occurs when the blood supply to part of the heart muscle is blocked. A heart attack may cause
cardiac arrest.
• African-Americans are almost twice as likely to experience cardiac arrest at home, work or in another
public location than Caucasians, and their survival rates are twice as poor as for Caucasians.
• The most effective rate for chest compressions is greater than 100 compressions per minute – the same
rhythm as the beat of the BeeGee’s song, “Stayin’ Alive.”
What are signs and symptoms of cardiac arrest?
Cardiac arrest is an abrupt cessation of pump function in the heart, due to inadequate cerebral perfusion, the
patient will be unconscious and will have stopped breathing. The main diagnostic criterion to diagnose a
cardiac arrest is lack of circulation.
Sudden cardiac arrest symptoms are immediate and drastic:

Sudden collapse

No pulse

No breathing

Loss of consciousness
Sometimes other signs and symptoms precede sudden cardiac arrest. These may include fatigue, fainting,
blackouts, dizziness, chest pain, shortness of breath, weakness, palpitations or vomiting. But sudden cardiac
arrest often occurs with no warning.
What causes cardiac arrest?
Coronary heart disease is the leading cause of sudden cardiac arrest.
Coronary Heart Disease and Heart Attacks:
Heart attacks most often occur as a result of coronary heart disease (CHD), also called coronary artery disease.
CHD is a condition in which a waxy substance called plaque builds up inside the coronary arteries. These
arteries supply oxygen-rich blood to your heart.
When plaque builds up in the arteries, the condition is called atherosclerosis. The buildup of plaque occurs over
many years.
Eventually, an area of plaque can rupture (break open) inside of an artery. This causes a blood clot to form on
the plaque's surface. If the clot becomes large enough, it can mostly or completely block blood flow through a
coronary artery.
If the blockage isn't treated quickly, the portion of heart muscle fed by the artery begins to die. Healthy heart
tissue is replaced with scar tissue. This heart damage may not be obvious, or it may cause severe or long-lasting
problems.
Heart With Muscle Damage and a Blocked Artery
Figure A shows a heart with dead heart muscle caused by a heart attack. Figure B is a cross-section of a
coronary artery with plaque buildup and a blood clot.
A less common cause of heart attack is a severe spasm (tightening) of a coronary artery. The spasm cuts off
blood flow through the artery. Spasms can occur in coronary arteries that aren't affected by atherosclerosis.
Heart attacks can be associated with or lead to severe health problems, such as heart failure and lifethreatening arrhythmias .
Heart failure is a condition in which the heart can't pump enough blood to meet the body's needs. Arrhythmias
are irregular heartbeats. Ventricular fibrillation is a life-threatening arrhythmia that can cause death if not
treated right away.
Approximately 60–70% of SCD is related to coronary heart disease. Among adults, ischemic heart disease is the
predominant cause of arrest with 30% of people at autopsy showing signs of recent myocardial infarction.
Heart attack symptoms include:

Chest pain or discomfort. This involves uncomfortable pressure, squeezing, fullness, or pain in the
center or left side of the chest that can be mild or strong. This discomfort or pain often lasts more
than a few minutes or goes away and comes back.

Upper body discomfort in one or both arms, the back, neck, jaw, or upper part of the stomach.

Shortness of breath, which may occur with or before chest discomfort.

Nausea (feeling sick to your stomach), vomiting, light-headedness or sudden dizziness, or breaking out
in a cold sweat.
It is important to recognize symptoms that a patient may exhibit before or during a heart
attack to ensure that CPR is delivered promptly. Many times, the CNA may be the first health care professional
who recognizes the patient’s distress. It is important to note that women and elderly patients may not present
the “typical” symptoms of a heart attack described above. They may not even have chest pain. This can make it
harder to recognize if these patients are having a heart attack. They may exhibit symptoms such as the
following: Pain between the shoulder blades, pain in the arm (especially the left arm), back, neck and
abdomen, jaw or throat pain, nausea and vomiting, unusual or overwhelming fatigue. If you suspect that a
patient is having a heart attack, get help immediately. If you’re are a CNA working in the hospital or an area
where nurses and doctors are present and help is available, press the call light and call for help immediately. If
you are in the patient’s home, call 911 for immediate help. If the patient is conscious, while you are waiting for
assistance take the vital signs and encourage the patient to rest quietly. If the patient is truly having a heart
attack, physical activity should be avoided and the patient should rest. During a heart attack, the patient’s
heart is lacking adequate blood flow and oxygenation. If the patient stays active during a potential heart
attack, the heart rate and blood pressure will increase.
Updated CPR Guidelines:
In 2010, the American Heart Association and International Liaison Committee on Resuscitation updated their
CPR guidelines. The importance of high quality CPR (sufficient rate and depth without excessively ventilating)
was emphasized. The order of interventions was changed for all age groups except newborns ABC ( airway,
breathing, chest compressions ) has been replaced with CAB (chest compressions, airway, breathing ). An
exception to this recommendation is for those who are believed to be in a respiratory arrest (drowning, etc.).
Adult CPR:
In adults, major reasons that heartbeat and breathing stop include:





Drug overdose
Excessive bleeding
Heart disease (heart attack or abnormal heart rhythm)
Infection in the bloodstream (sepsis)
Injuries and accidents
For an adult that does not demonstrate signs of life, begin CPR using the following steps:





Open airway and give 2 rescue breaths
Compress chest 30 times
Give 2 rescue breaths
Compress chest 30 times
Continue cycles of 2 breaths and 30 compressions
Compressions:
If the victim is not breathing, place the heel of your hand in the middle of his chest. Put your other hand on top
of the first with your fingers interlaced. Compress the chest at least 2 inches (4-5 cm). Allow the chest to
completely recoil before the next compression. Compress the chest at a rate of at least 100 pushes per minute.
Perform 30 compressions at this rate (should take you about 18 seconds).
1.
If you have been trained in CPR, after 30 compressions, open the victim's airway using the head-tilt, chinlift method. Pinch the victim's nose and make a seal over the victim's mouth with yours. Use a CPR mask if
available. Give the victim a breath big enough to make the chest rise. Let the chest fall, then repeat the
rescue breath once more. If the chest doesn't rise on the first breath, reposition the head and try again.
Whether it works on the second try or not, go to step 4.
If you don't feel comfortable with this step, just continue to do chest compressions at a rate of at least
100/minute.
2.
Repeat chest compressions. Do 30 more chest compressions just like you did the first time.
3.
Repeat rescue breaths. Give 2 more breaths just like you did in step 3 (unless you're skipping the rescue
breaths).
4.
Keep going. Repeat steps 4 and 5 for about two minutes (about 5 cycles of 30 compressions and 2 rescue
breaths).
If you have access to an automated external defibrillator (AED), continue to do CPR until you can attach it
to the victim and turn it on. If you saw the victim collapse, put the AED on right away. If not, attach it after
approximately one minute of CPR (chest compressions and rescue breaths).
5.
After 2 minutes of chest compressions and rescue breaths, stop compressions and recheck victim for
breathing. If the victim is still not breathing, continue CPR starting with chest compressions.
6.
Repeat the process, checking for breathing every 2 minutes (5 cycles or so), until help arrives. If the victim
wakes up, you can stop CPR.
Time is very important when an unconscious person is not breathing. Permanent brain damage begins after
only 4 minutes without oxygen, and death can occur as soon as 4 - 6 minutes later.


If the person has normal breathing, coughing, or movement, do NOT begin chest compressions. Doing
so may cause the heart to stop beating.
Unless you are a health professional, do NOT check for a pulse. Only a health care professional is
properly trained to check for a pulse.
CPR for Infants (Up to One Year Old)
Airway
With infants, be careful not to tilt the head back too far. An infant’s neck is so pliable that forceful backward
tilting might block breathing passages instead of opening them.
Breathing
Do not pinch the nose of an infant who is not breathing. Cover both the mouth and the nose with your mouth
and breathe slowly (one to one and a half seconds per breath), using enough volume and pressure to make the
chest rise.
With a small child, pinch the nose closed, cover the mouth with your mouth and breathe at the same rate as for
an infant. Rescue breathing should be done in conjunction with chest compressions. (See next section.)
Chest Compressions on Infants
If alone with an unresponsive infant, give five cycles of CPR (compressions and ventilations) for about two
minutes before calling 911 or your local emergency number.
Use only the tips of the middle and ring fingers of one hand to compress the chest at the sternum
(breastbone), just below the nipple line, as described in the table below. The other hand may be slipped under
the back to provide a firm support. (However, if you can encircle your hands around the chest of the infant,
using the thumbs to compress the chest, this is better than using the two-finger method.)
Depress the sternum between a third to a half the depth of the chest at a rate of at least 100 times a minute.
Two breaths should be given during a pause after every 30 chest compressions (a 30:2 compression-toventilation ratio or two breaths about every two minutes) on all infants (excluding newborns).
Continue CPR until emergency medical help arrives.
Small Children (ages one to eight)
Give five cycles of CPR (compressions and ventilations) for about two minutes before calling 911.
Use the heel of one or two hands, as needed, and compress on the breastbone at about the nipple line.
Depress the sternum about a third to a half the depth of the chest, depending on the size of the child. The rate
should be 100 times per minute.
Give two breaths for every 30 chest compressions (30:2 ratio) or two breaths about every two minutes.
Continue CPR until emergency medical help arrives.
Choking
Choking is third leading cause of home and community death in the United States. Foods are responsible for
most choking incidents. But for children, objects such as small toys, coins, nuts or marbles can get caught in
their throats. Choking can cause a simple coughing fit or something more serious like a complete block in the
airway, which can lead to death.
Signs of a choking infant

Difficulty breathing

Weak cry, weak cough or both

Unable to cry or make a sound

Bluish skin color

Loss of consciousness

Soft or high-pitched sounds while inhaling

Difficulty breathing – ribs and chest pulled inward
Signs of a choking adult

Coughing or gagging

Clutching throat or pointing to throat

Suddenly unable to talk

Wheezing

Passing out; loss of consciousness

Skin, lips or nail turning blue
Chapter Seven
Communication with Cognitively Impaired Residents/Patients
Cognitive impairment is a broad term to describe a wide variety of impaired brain function relating to the ability
of a person to think, concentrate, react to emotions, formulate ideas, problem solve, reason and remember. As
a CNA, you will likely care for a patient or resident with cognitive impairment. These individuals with moderate
to severe cognitive impairment often require specific considerations and accommodations. Depending on the
type of impairment experienced and the level of severity, the individual may require around- the-clock
supervision, specialized communication techniques, and techniques to manage behavior difficulties. They
require assistance with ADLs such as, feeding, transfers, toileting, bathing and personal care.
Cognitively impaired patients may have difficulty with memory, perception, concentration or reasoning skills.
Cognitive impairment can be associated with many disabilities and disorders that can be present at birth or
acquired later in life. Cognitive impairments are commonly caused by disease or head injury that affects the
brain such as Alzheimer’s disease, Parkinson’s disease, dementia, stroke, brain tumor or brain injury. Although
each condition may have its own unique symptoms, healthcare providers share similar problems, strategies
and situations in working with these patients.
Cognitive impairment can be associated with many disabilities and disorders that can be present at birth or
acquired later in life. Some examples are below:








Acquired brain injury
Autism spectrum disorder
Intellectual disabilities
Organic dementia
Other neurological conditions
Other psychiatric and mental health
Specific learning disabilities
Substance dependencies
Dementia
Dementia describes a group of symptoms affecting intellectual and social abilities severely enough to interfere
with daily activities. Memory loss generally occurs in dementia and can make one confused and unable to
remember people and names. You also may experience changes in personality and social behavior. However,
some causes of dementia are treatable and even reversible. The reversible symptoms can be caused by high
fever, dehydration, vitamin deficiency, and poor nutrition, a bad reaction to a certain medication, thyroid gland
problems, or a minor head injury. Is such cases, they should be treated as soon as possible. Now the types of
dementia that are not curable are known as Alzheimer’s disease and vascular dementia.
Multi-infarct (vascular) dementia
Vascular dementia is a general term used to describe problems with reasoning, planning, judgment, memory
and other thought processes caused by brain damage from impaired blood flow to the brain. Following a
stroke one can develop vascular dementia due to the change in the brain’s blood supply therefor causing the
brain tissue to die.
Factors that increase your risk of heart disease and stroke include but are not limited to high blood pressure,
high cholesterol and smoking. All of which raise your vascular dementia risk. Controlling these factors can help
lower your chances of developing vascular dementia.
Mild Cognitive Impairment (MCI)
The stage between normal forgetfulness due to the aging process and the development of dementia is called
mild cognitive impairment. People with MCI have mild problems with thinking and memory that do not
interfere with everyday activities. Most people with MCI aware of the forgetfulness and not everyone with MCI
develops dementia.
Symptoms of MCI include:




Difficulty performing more than one task at a time
Difficulty solving problems or making decisions
Forgetting recent events or conversations
Taking longer to perform more difficult mental activities
Alzheimer’s Disease (AD)
The most common form of dementia is known as Alzheimer’s disease. It is an irreversible degeneration of the
brain that causes disruptions in memory, cognition, personality, and other functions that eventually lead to
death from complete brain failure. Alzheimer's disease is the sixth-leading cause of death across all ages in the
United States. For those 65 and older, it is the fifth-leading cause of death.
Risk Factors
Age and genetics are the two main risk factors for developing Alzheimer’s disease. But also believed to
contribute to the possible development are environmental factors, lifestyle and overall general health. For
those 65 and older, the chance of developing Alzheimer’s rises but it is not a normal part of the aging process.
Genetics
In some families, there is a very clear inheritance of the disease from one generation to the next. This is often
in families where the disease appears relatively early in life. If a parent or other relative has Alzheimer's, your
own chances of developing the disease are only a little higher than if there were no cases of Alzheimer's in the
immediate family.
Research has also shown that people who smoke, and those who have high blood pressure, high cholesterol
levels or diabetes, are at increased risk of developing Alzheimer's. You can help reduce your risk by not
smoking, eating a healthy balanced diet and having regular checks for blood pressure and cholesterol from
middle age. Maintaining a healthy weight and leading an active lifestyle combining physical, social and mental
activity will also help.
Communication Tips:







Set yourself up for success. Approaching your patient from the front will eliminate the possibility of
startling her and getting off to a rocky start.
Be aware of tone and body language. Speaking clearly in a relaxed tone of voice will put your patient at
ease. Friendly gestures will also foster positive interactions.
Keep it simple. Difficult words or long sentences may overwhelm someone with Alzheimer's.
Wait for a response. It might take longer for your patient to respond, so be patient and give him time.
Be clear. Avoid phrases that can be interpreted literally, such as “break a leg” or “chew the fat,” which
might be confusing.
Focus on the key word or idea. Emphasize the most important word in your message either verbally or
nonverbally (pointing).
Account for hearing or vision problems. Make sure that your patient is wearing a working hearing aid
and/or clean glasses, if prescribed.
REFERENCES:
http://www.alz.org/alzheimers_disease_what_is_alzheimers.asp
http://www.mayoclinic.com/health/vascular-dementia/DS00934
http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=100
http://alzheimers.about.com/od/caregiving/a/communication.htm
http://www.alz.org/alzheimers_disease_causes_risk_factors.asp