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Prevention of
Medical Errors
DANA BARTLETT, RN, BSN, MSN, MA
Dana Bartlett is a professional nurse and author. His clinical experience includes 16
years of ICU and ER experience and over 20 years of as a poison control center
information specialist. Dana has published numerous CE and journal articles, written
NCLEX material, written textbook chapters, and done editing and reviewing for
publishers such as Elsevire, Lippincott, and Thieme. He has written widely on the
subject of toxicology and was recently named a contributing editor, toxicology
section, for Critical Care Nurse journal. He is currently employed at the Connecticut
Poison Control Center and is actively involved in lecturing and mentoring nurses,
emergency medical residents and pharmacy students.
ABSTRACT
The identification and prevention of medical errors requires the
participation of all members of the health team, including patients. The
traditional way of coping with medical errors was to assume errors
were the result of individual mistakes such as carelessness and
inattention, creating a culture of blame. However, it has become clear
this approach is not optimal. It does not address the root causes of
medical errors, system problems, it discourages disclosure of errors,
and without disclosure errors cannot be prevented. Enhancing health
team knowledge levels and the environment of care helps to reduce
the risk of a medical error.
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Continuing Nursing Education Course Planners
William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,
Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner
Policy Statement
This activity has been planned and implemented in accordance with
the policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's
Commission on Accreditation for registered nurses. It is the policy of
NurseCe4Less.com to ensure objectivity, transparency, and best
practice in clinical education for all continuing nursing education (CNE)
activities.
Continuing Education Credit Designation
This educational activity is credited for 2 hours. Nurses may only claim
credit commensurate with the credit awarded for completion of this
course activity.
Statement of Learning Need
The rates of medical errors remain a public health and safety risk. Safe
patient care requires all members of the health team and the public to
be educated on how to recognize and prevent a medical error, and to
advocate for needed changes to improve the delivery of healthcare.
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Course Purpose
To provide an overview of medical errors in today’s health care system
and to identify the incidence and causes of medical errors and the risk
factors disposing to medical errors, and to provide strategies to
prevent medical errors in the healthcare setting, including by patients.
Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses
and Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Dana Bartlett, RN, BSN, MSN, MA, William S. Cook, PhD,
Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC -all have
no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Activity Review Information
Reviewed by Susan DePasquale, MSN, FPMHNP-BC.
Release Date: 1/1/2016
Termination Date: 7/6/2017
Please take time to complete a self-assessment of knowledge,
on page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge
learned will be provided at the end of the course.
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1.
True or false: A medical error and an adverse event are
identical
a. True
b. False
2.
Diagnostic errors occur when:
a. an incorrect diagnosis is made
b. the diagnosis is changed from the original diagnosis
c. given the available data the correct diagnosis should have been
made
d. the diagnosis was made more than 72 hours after examination
3.
A medication error is defined in part by the words:
a. preventable and patient harm
b. under-dosing and over-dosing
c. adverse effect and therapeutic intervention
d. avoidable and lack of vigilance
4.
A common cause of medication error is:
a. look-alike and sound-alike drug names
b. adult drugs being used for pediatric patients
c. patient refusal to accept the drug therapy
d. undisclosed use of herbal supplements
5.
True or false: medical errors should be disclosed to the
patient.
a. True
b. False
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6.
Diagnostic errors are more likely EXCEPT when
a. the patient has a complex medical history.
b. when there are too many diagnostic resources
c. patient follow-up is sub-optimal
d. time available for diagnosis is limited or perceived to be
limited.
7.
True or False. The healthcare setting is an influencing
factor for diagnostic errors, such as one that is fast-paced
and stressful.
a. True.
b. False.
8.
A 2014 study showed a __________ error rate in medical
dictation/transcription, and poor communication in the
form of using non-standard abbreviations and the common
use of sound-alike medications has long been known as a
cause of medical errors.
a. 15 %
b. 25 %
c. 30 %
d. 44 %
9.
Nurses providing teaching about medication to patients
should include key points of points, such as
a. the purpose for taking a medication
b. common side effects interactions
c. risk factors of taking the medication
d. All of the above.
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10. Starmer, et al. (2013) wrote that communication errors
are a leading cause of
a. sentinel events
b. poor team dynamics
c. medication errors
d. documentation errors
11. True or False. It has been reported that and that
improving handoff communication (i.e., transferring
information about and responsibility for a patient) reduced
medical errors from 38.3 per 100 admissions to 28.
a. True.
b. False.
12. Patient discharge is
a. when medical errors can occur
b. less of a risk factor than admission for a medical error
c. less of a risk factor for a medical error than patient follow-up
d. Both b and c above.
13. True or False. Equipment failures during anesthesia are
relatively uncommon.
a. True.
b. False.
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14. One example of the second strategy to eliminate cognitive
errors involves a common error in the diagnostic process
known as
a. Time out
b. It-Takes-Two
c. Anchoring
d. Pause
15. Approximately 25% of medication errors that occur in the
United States involve
a. verbal orders
b. name confusion
c. hand-written notes
d. an inexperienced nurse
Introduction
Medical errors are a significant problem in the healthcare system. The
seminal 1999 monograph by The Institute of Medicine (IOM) reported
that between 44,000 and 98,000 patients die each year in the United
States as a result of a medical error, and that 7% of all hospital
admissions experience a serious medication error,1 and this disturbing
situation has not changed since then. This study module is an excerpt
from a larger course on medical errors that provides nurses with a
review of six types of medical errors: 1) Diagnostic errors; 2) Falls; 3)
Laboratory errors; 4) Medication errors; 5) Surgical errors, and; 6)
Treatment errors. The incidence, etiology, and risk factors of each will
be examined, and strategies for their prevention will be discussed.
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Definitions Associated With Medical Errors
The terminology associated with medical errors can be confusing:
adverse events, adverse effects, errors of commission, errors of
omission, medical errors, near misses, preventable adverse effects,
and side effects are all frequently mentioned in discussions of medical
errors. All of these have some relevance to the discussion of medical
errors, but the terms that are important for this module are medical
error and adverse event. This module will define a medical error as:1
Failure of a planned action to be completed as intended, or,
the use of a wrong plan to achieve a goal.
Medical error
A medical error may result in injury or it may not, but the potential for
injury is present. Medical errors can be errors of execution or planning.
An execution error is one in which a plan of action such as a specific
therapy is considered appropriate and correct but it was not properly
carried out. Execution errors can be errors of commission or errors of
omission. In the former, an incorrect action was done unintentionally
and, in the latter, the correct action was unintentionally not done. A
planning error is one in which the plan of action is not considered
appropriate or correct for the patient.2
Adverse event
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An adverse event is defined as a preventable medical error that causes
harm to the patient. Not all medical errors are adverse events and
medical errors and not all medical errors become adverse events. The
differences between a side effect and an adverse event are
predictability, severity, and consequences.
At times the distinction between a side effect and an adverse event
can be blurred. A side effect is typically considered to be predictable,
minor in severity and often temporary in duration, and it will not cause
harm or require treatment. An adverse event is typically considered to
be (somewhat) unpredictable, moderate to severe, possibly
permanent, and it may cause harm and/or require treatment and
stopping the use of a medication suspected to be causing the adverse
event.
Diagnostic Errors
Diagnostic errors are relatively common, but when compared to other
medical errors such as falls and medication errors they have received
much less attention and research.3 Despite the obvious and immediate
effects of a medical error, such as a fall, diagnostic errors can be a
significant cause of morbidity and mortality and at times more so than
other types of medical errors.4 There is no universally accepted
definition of a diagnostic error. This module will define a diagnostic
error as follows:5
A diagnostic error has occurred if the wrong diagnosis was made; and,
1) there was adequate data to suggest the correct diagnosis, or, 2) the
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clinical findings should have prompted the medical provider to do
further evaluation in order to make the proper diagnosis.
In essence, a diagnostic medical error has happened when it could be
reasonably expected that a competent and experienced medical
provider should have been able to make the correct diagnosis; or, that
further evaluation and testing should have been ordered in order to
make a correct diagnosis given the clinical findings.
The true incidence of diagnostic errors is not known, but it is generally
assumed to be approximately 10%-15%.6 However, the reported
incidence has varied from 1% to 55%,7 and a recent (2014) survey
estimated the incidence of diagnostic errors in the outpatient setting to
be 5.08% or 12 million adults every year in the United States.8 This
wide range can be explained by many factors, and some key factors
are outlined in the sections to follow.3,6
Patient population
Consideration of the patient population involves taking into account
the demographics of the persons receiving care and the location where
health care is delivered. Diagnostic errors will clearly be more likely if
the patient has a complex medical history and multiple medical
problems. Additionally, diagnostic errors will be more likely if
diagnostic resources are limited, patient follow-up is sub-optimal and
the time available for diagnosis is limited or perceived to be limited.
The setting in which health care is delivered is another influencing
factor, such as, a setting that is particularly fast-paced and stressful
can be predisposed to diagnostic errors. Skill and experience level of
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the diagnostician is another obvious factor in the accuracy of the
diagnostic process.
Data sources
Autopsy reports, chart reviews, clinical laboratory records and reviews,
medical malpractice claims, patient and provider surveys, peer
reviews, simulations and standardized patients, and voluntary
reporting have all been used to determine the incidence of diagnostic
errors. For this purpose, all of these have strengths and weaknesses,
and they can all either under-report or over-report the incidence of
diagnostic errors. Still, these all reveal an incidence of diagnostic
errors that is disturbing.
Autopsy studies show an incidence of diagnostic errors of 10%-20%.
The use, interpretation, or follow-up of laboratory data accounted for
44% of all diagnostic errors. There have been study reports that
revealed: pediatricians had a diagnostic error of over 50% within one
month of being surveyed; the ability of radiologists to detect breast
cancers varied by up to 11%; and, simulations and standardized
patients have demonstrated a rate of diagnostic accuracy of 25% 57%.6,9-12
Some types of diagnoses are much more difficult to make than others.
Patients in their early stages of an illness, such as an infection with
HIV or tuberculosis, can be very difficult to correctly diagnose. The
incidence of these medical errors clearly depends in part on how they
are defined.
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Causes of diagnostic errors
Research into the root causes of diagnostic errors has suggested that
these errors occur from either a failure of the physicians’ intuitive
reasoning process (i.e., pattern recognition and memory retrieval) or a
failure of their consciousness reasoning process.13 Viewed this way, it
is possible to understand in a generalized way how diagnostic errors
occur. However, it is helpful to look at the specific situational causes of
diagnostic errors.
Singh, et al. (2013) examined diagnostic errors that were made in
primary care settings and five distinct factors were identified as
primary causes of diagnostic errors:5
1. Patient related
Singh reported that in 16.3% of all cases patient related factors
were the primary causes of diagnostic error. These factors
included failure of the patient to provide an accurate medical
history, failure of the patient to seek help in a timely manner, a
communication barrier between the patient and the practitioner.
2. Patient-practitioner
An issue between the patient and the practitioner during the
clinical encounter was identified in 78.9% of all cases of
diagnostic errors. Specific problems were: errors made by the
clinician during the physical examination; failure to review
medical records; failure to ask questions needed to make the
diagnosis (i.e., data gathering); failure to order the appropriate
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diagnostic and laboratory tests; and, failure to take a
comprehensive medical history.
3. Diagnostic tests
Incorrect use, incorrect interpretation, and incorrect follow-up of
diagnostic tests were identified in 13.7% of all cases of
diagnostic errors.
4. Follow-up and tracking
Inadequate follow-up and tracking errors, such as, failure to
have a follow-up system in place or failure to follow-up
diagnostic tests were identified in 14.5% of all cases of
diagnostic errors.
5. Referrals
In 19.5% of all cases, diagnostic error mistakes in the referral
process were identified. These included failure to contact the
appropriate expert, failure to identify when a referral was
needed, lack of knowledge that would have helped the
practitioner identify the need for a referral, failure to consider
the patient’s condition serious enough to require a referral, or an
error when taking a medical history.
In 43.7% of all cases in which the correct diagnosis was not made,
more than one of the five factors identified above was operative. The
researchers noted that in 37.9% of all cases the failure to correctly
diagnose the patient’s problem could have resulted in considerable
harm, and in 14.2% of the cases the patient could have suffered
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immediate or inevitable death.5 The clinical problems were not highly
complex or unusual; pneumonia, congestive heart failure, acute renal
failure, and urinary tract infections were among the diagnoses that
were commonly missed.5
The research indicates that practitioner errors involving mistakes in
information gathering and synthesis and reasoning are the most
common cause of diagnostic errors,5,14-17 and this fact could be
dismissed by some as, in part, inevitable; people make mistakes.
However, the wide variation in the incidence of diagnostic errors clearly
shows that they are not inevitable and that some practitioners are not
making cognitive errors during the diagnostic process. The hope is that
the habits and techniques of a successful diagnostic process can be
identified and taught, and that the incidence of diagnostic errors could
be reduced. Several strategies for doing this have been researched
and will be discussed later in this study module.
Patient Falls
Patient falls are very common medical errors, and they are one of the
most common adverse events that happen to hospital in-patients.18 It
has been estimated that up to 20% of
all in-patients suffer a fall at least
once during a hospital
stay,19
and the
rate of falls in acute care hospitals
has been reported to be between 1.3
to 8.9 per 1000 hospital days.20
Joint Commission definition of
a sentinel event:
an unexpected occurrence
involving death or serious
injury or psychological injury,
or the risk thereof. The term
sentinel is applied to these
events because they indicate
the need for immediate
investigation and response,
and, the possibility of serious
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systemic
errors in the
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healthcare facility and/or the
delivery of healthcare.
Falls can be very serious. Between 30%-50% of all patient falls result
in an injury, and patients who suffer a fall have longer hospital stays
and higher health care costs.20,21 The Joint Commission considers a fall
that results in death or major permanent loss of function, as a result of
injuries sustained in the fall, to be a reviewable sentinel event; and,
fall prevention is one of the Joint Commission’s National Patient Safety
Goals.22,23 Additionally, the World Health Organization (WHO) defines
fall as an event that results in a person coming to rest inadvertently on
the ground or some lower level.24
Several risk factors identified with falling exist, such as being elderly or
having urinary frequency.25 Healthcare teams frequently use
assessment tools to identify patients that are at risk for falling and
there are many screening tools and fall risk algorithms available
through the Center of Disease Control (CDC) website, a helpful
resource with multiple fall prevention patient handouts at:
http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html.
Laboratory Errors
Laboratory medical errors can be divided into three categories: pretest, testing, and post-test. The incidence of testing performance
errors, which are errors that occur with the technical processing of
specimens, is comparatively low as standardization of analytical
methods and materials and improved instrumentation have greatly
decreased the incidence of in-laboratory analytical error.28,29
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Most in-laboratory errors involve specimen mis-labeling,30,31 and the
incidence of inaccurate test performance is very low, estimated at
0.002%.32 However, pre-test and post-test medical errors involving the
clinical laboratory are quite common.28,29 A ten-year study of
laboratory errors showed that 69.1% of all laboratory errors occurred
in the pre-test phase, 15.0% in the testing phase, and 23.1% occurred
in the post-test phase.33 Pre-test and post-test errors are outlined
below:
Pre-test errors:
1. Inappropriate ordering of tests, i.e., ordering a test
that has no relevance to the clinical situation;
2. Test performance and specimen collection errors such as
improper site preparation, specimen contamination, improper
performance of the test, not using the correct specimen
containers or tubes, mislabeling of specimens, and performing
a test on the wrong patient.
Post-test errors:
1. Errors in receiving, such as test results being incorrectly
transmitted by the sender, test results being incorrectly
recorded by the receiver, and test results not transmitted to
the right person or not transmitted in a timely manner;
2. Errors in interpretation;
3. Errors in follow-up, such as failure to check for test results,
failure to use test results in a timely manner, failure to order
further testing that would be indicate by the previous test
results, failure to appropriately use test results to change
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therapies, and failure to send test results to patients or to
contact them about test results.28,32
Plebani (2010) noted that laboratory errors could result in mistakes in
digoxin or heparin therapies, inappropriate admissions, and other
clinical problems.33 Additionally, 24%-30% of laboratory errors had an
effect on patient care, and the risk for adverse events from laboratory
errors was 2%-12.7%.33 Such studies highlight the serious harm to
patients that can occur as a result of laboratory errors.
Medication Errors
A medication error is defined in this section as follows:
“Any preventable effect that may cause or lead to inappropriate use or
patient harm while the medication is in control of the healthcare
professional, patient, or consumer.”34
Two terms in this definition that should be remembered are
preventable and patient harm; indicating that the medication error was
preventable and may have caused or lead to patient harm. In this
study module, the medication errors presented are divided into four
categories:
1. Prescribing
2. Administration or preparation
3. Dispensing
4. Monitoring
Prescribing errors
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Prescribing errors include but are not limited to:
1. Wrong drug because of drug-drug interactions and/or drug
allergies;
2. Incorrect dose, concentration, route, or frequency;
3. Drug prescribed for the wrong patient;
4. Duplicate drugs prescribed;
5. The appropriate drug not prescribed;
6. The prescription was written illegibly or improper
abbreviations were used.
Transcribing errors involve a mistake that was made when the order
was transcribed, either in the pharmacy or in a clinical setting.
Administration and preparation errors
Administration errors are often the same as prescribing errors and
include:
1. Missed doses or doses given at an incorrect time;
2. Medication given by someone unauthorized to do so;
3. Improper administration technique;
4. Incorrect rate of administration;
5. Administration of an expired drug;
6. Drug prematurely discontinued or administered for too long;
7. Duplicate administration, i.e., a double dose;
8. Incorrect dosage calculations;
9. Failure to document administration of a drug or incorrect
documentation;
10. Failure to use medication administration safeguards, i.e.,
double checking calculations;
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11. Failure to comply with medication administration policies, i.e.,
leaving medications unattended, and not watching a patient
take a medications;
12. Improper or incomplete administration directions given to a
patient.
Preparation errors are typically a drug improperly constituted or
incorrectly concentrated.
Dispensing errors
Dispensing: A drug can be dispensed to the wrong patient, the drug
may not be dispensed in a timely manner, or the wrong drug can be
dispensed.
Monitoring errors
Monitoring is a very important part of medication therapy to ensure
the medication is effective, tolerated, and to make dose adjustments.
Safe use of medications like digoxin, lithium, and warfarin requires
periodic laboratory testing of blood levels, and other drugs require
measurement of blood glucose, electrolytes, or renal function in order
to measure their effectiveness or to detect adverse effects. Monitoring
errors includes:
1. Not ordering the proper laboratory tests;
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2. Not responding appropriately to laboratory tests;
3. Ordering test but the test are not performed;
4. Failure to monitor for drug effectiveness, adverse
effects, and side effects.
Monitoring errors appear to be less common than prescribing,
administering, and dispensing errors, but there is limited data and a
wide variation in monitoring errors has been reported. In a 2012
study, 6048 prescriptions written by general practitioners showed a
0.9% rate of monitoring errors,35 but a 2009 study of nursing homes
showed a 14.7% rate of monitoring errors.36
Clearly, medication errors are not unusual, but for several reasons the
exact incidence of medication errors is not known. Firstly, there is no
universally used system for detecting and reporting medication errors.
Self-reporting, incident reports, chart reviews, direct observation, and
trigger tools can and have been used as tools for detecting medical
errors, but each one yields different results. Self-reporting appears to
greatly underestimate medication errors while direct observation
consistently detects a large number of medication errors.37 Secondly,
the definition of a medication error is a significant influence on the
reported incidence of medication errors.
Keers, et al. (2013) did a systematic review of 91 direct observational
studies of medication errors and found a median error rate of 19.6%,37
but if timing errors (i.e., the medication was not given at the
prescribed time) were excluded, the median error rate was 8.0%.37
The issue is further complicated by different definitions of timing error.
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Some of the studies Keers, et al., reviewed defined a timing error as a
delay of 30 minutes or more while some simply reported timing errors
but did not provide a definition of what a timing error was considered
to be. In addition, 28 of the 91 research papers either did not define a
medication error or used a definition that was exclusive to the study.
Despite the difficulty in determining the true incidence of medication
errors, the reviews of the literature and the studies of medication
errors are very instructive. Regardless of study design or the definition
of medical error that was used, the research consistently shows that
the incidence of medication errors is disturbingly high and that there
are multiple and easily identifiable causes of medication errors.
Baumgart-Huckels (2014), et al., studied the rate of medication errors,
and the causes and consequences of medication errors in a large
teaching hospital over a four-year period.38 The use of medication was
divided into a process of five steps:
1.
Prescribing
2.
Transcribing
3.
Preparation
4.
Administration
5.
Monitoring
Medication errors in the 2014 study were categorized as the wrong
patient, wrong dose, wrong drug, wrong dose, wrong quantity, or a
medication omitted/not given. Medication errors recorded in the fouryear period amounted to 1591 incidents, and most of the errors
occurred during the medication preparation and administration steps.
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The majority of the medication errors, 74.2%, involved more than
one-step in the medication use process, and only 25.8% were detected
early in the process. The authors report that 84.3% of the errors
reached the patients and 8.8% reached the patient and required
monitoring to confirm no harm or intervention to prevent harm. The
authors also reported that inattention was the most common cause of
the medication errors (60.5%). This was followed by work conditions,
such as poor staffing and heavy workload (31.4%). Ryan, et al. (2014)
also examined the prevalence and causes of prescribing errors made
by trainee physicians.39 A prescribing error was defined as:
“One which occurs when, as a result of a prescribing decision or
prescription writing process, there is an unintentional significant
reduction in the probability of treatment being timely and
effective or an increase in the risk of harm when compared with
generally accepted practice.’’39
A total of 44,276 prescriptions were examined, and the error rate was
7.5%. The most common prescribing order error is omission, such as,
when a medication was not ordered but should have been. Doses that
were too low or too high were also common; however, fortunately,
prescribing medications that would result in a harmful interaction and
prescribing a medication for the wrong patient were uncommon, which
accounted respectively for 1.5% and 0.5% of the errors.
Ryan, et al. (2014) identified that prescribing errors were “of frequent
and of complex causation”. The authors also found that the work
environment and the lack of knowledge of medications by health staff
were the most common causes of the medication prescribing errors. It
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is interesting to note that a potential cause of a prescribing error was
due to the physicians’ perception that if they made a prescribing error
it was likely to be detected by other physicians or hospital staff and
the error corrected before a medication administration error occurred.
Honey, et al. (2014) also studied 2491 prescriptions that were written
by medical residents and found a prescribing error rate of 5.88%.40
Doses that were too high, too low, or of unclear quantity were the
most common prescribing errors, which accounted respectively for
being 17.3%, 13.8%, and 12.7% of the errors made. The study was of
pediatric patients; and, the relatively high rate of dosage errors were
presumed to be because drug dosages for children are more frequently
based on body weight than drug dosaging for adults, thus, more
proneness to human error of drug dosing calculations made by the
prescriber.
Beardsley, et al. (2013) examined the medical records of all patients
who had been discharged from a general medical practice. Patient
records were examined for a period of 60 days prior to discharge and
for a period of 60 days after discharge.41 The authors found
prescribing errors in 34.5% of the pre-discharge records and in 17% of
the post-discharge records. Medication omission and dosage errors
were the most common, and 3% of the errors were considered to be
serious, such as:

the route of administration could have led to severe toxicity;

the dose was 4-10 times the normal and the drug had a low
therapeutic index;
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
the dose was too low and the patient had a serious condition;

the dose was too high and led to a blood level that was
potentially toxic.
The risks of medication errors increase if the patient is very young,
very old, has complex medical problems, or is taking multiple
medications. The risk for medication errors has also been associated
with specific drugs. The United States Pharmacopeia published a list of
medications that were commonly involved in medication errors:42
MEDICATION NAME
% MEDICATION ERROR
Insulin
4%
Morphine
2.3%
Potassium chloride
2.2%
Albuterol
1.8%
Heparin
1.7%
Vancomycin
1.6%
Cefazolin
1.6%
Acetaminophen
1.6%
Warfarin
1.4%
Furosemide
1.4%
The list above was similar to one published by Grissinger in 2007,43
which is outlined in the table below:
MEDICATION NAME
% MEDICATION ERROR
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Insulin
8%
Anticoagulants
6.2%
Amoxicillin
4.3%
Aspirin
2.5%
Trimethoprim-sulfamethoxazole
2.2%
Hydrocodone/acetaminophen
2.2%
Ibuprofen
2.1%
Acetaminophen
1.8%
Cephalexin
1.6%
Penicillin
1.3%
Desai, et al. (2013) in a study of medications errors that occurred in
nursing homes and residential facilities found that anxiolytics/
sedatives/hypnotics, anti-diabetic agents, anticoagulants,
anticonvulsants, and ophthalmic preparations were “frequently and
disproportionately involved in errors in nursing homes . . . “, and “ . . .
certain drug classes are more likely to be involved in medication errors
in nursing home patients regardless of the extent of their use.”44
Other Medical Errors
There are other medical errors noted in the literature, which would be
outside the scope of this study. This includes a wide body of research
and literature on surgical and other treatment errors in healthcare
settings.
Surgical errors
Major complications occur in 3%-16% of all surgical procedures and
the rate of permanent disability or death from surgery has been
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reported to be 0.4%-8%.45 Each year in the United States there are
over 70 million applications of anesthesia52 and errors are inevitable.
Equipment failures during anesthesia are relatively uncommon. Most
involve a disconnection or misconnection of the breathing circuit and
the rate of these errors has been estimated to range from 0.06% to
0.7%,53 however, these types of errors account for approximately
20% of all critical anesthesia events.54 The incidence of medication
errors in the practice of anesthesia has been reported to be 1 in every
13,000 administrations.55
Antibiotics, inhalation gases, local anesthetics, muscle relaxers,
opiates, and vasoactive drugs are the medications most commonly
involved in anesthesia medication errors.56 Failure to read labels or
misreading labels, distractions, carelessness and inattention, lack of
vigilance, stress and poor communication are the root causes of
anesthesia medication errors; and, they usually result in a missed
dose, an incorrect dose, improper drug substitution, omission, double
dosing, or the use of an incorrect route.57
Treatment errors
Other treatment errors are those errors that occur during the
performance of an operation, test, or procedure.1 The following list
includes examples of treatment errors, and is not all-inclusive.

Administering blood and blood products

Advanced monitoring, i.e., intracranial pressure monitoring

Intravenous insertions

Nasogastric tube insertions

Phlebotomy
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
Urinary catheterization
Surgical errors have been closely studied to help health teams identify
mistakes most likely to happen. The basic types of errors that can be
made when nurses are performing a procedure, such as collecting a
specimen or doing a treatment during post-operative care, are errors
identified during planning performance and follow-up. The root causes
of treatment errors involve human factors and system factors.
Prevention Of Medical Errors
Human factors and system factors are the root causes of medical
errors, but there are certain ways in which people perform and that
healthcare systems are organized which are the specific causes of
medical errors. These human and system factors are discussed below.
Fragmentation
The use of multiple medical specialists or medical systems to care for
one individual is a large contributor to errors. Information does not
always follow patients; there is no one place that knows all about one
patient’s health. Fragmented health services are largely responsible for
health care information not being centralized.
One medical provider caring for all of a patient’s medical needs is not
the norm in today’s health care setting. Fragmentation leads to
duplicate medications and services, which is not only costly but
increases the risk of a medical error. An individual with diabetes, heart
failure, prostate cancer and depression could be seeing six providers
including an endocrinologist, cardiologist, urologist, oncologist,
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psychiatrist, and a primary care provider. The increasing use of
hospitalists is another piece of the health care system that leads to
fragmentation.
The hospitalist is a medical provider specializing in the care of the
patient who is admitted to the hospital. These providers are experts in
caring for hospitalized patients, but they are not primary care
providers and the lack of familiarity with the patient and (perhaps)
incomplete access to a patient’s medical history can be a source of
errors. Fragmentation can also be a result of the use of different
pharmacies and hospitals.
Time constraints
Health care takes place at a rapid pace. Each day, providers are seeing
a large volume of patients, pharmacists are filling a large number of
prescriptions, and nurses are often caring for more patients than they
should. Many health care providers are overworked. They need to work
fast to meet the demands of administrators, patients and the financial
bottom line. When people are working quickly - perhaps too quickly the risk of errors is increased. Nurses often report that they do not
have enough time to properly perform their work.
Poor communication
Poor communication is often identified as a major cause of medical
errors. Communication errors are common and can happen anywhere
within the healthcare system. For example, a 2014 study showed a
30% error rate in medical dictation/transcription,59 and poor
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communication in the form of using non-standard abbreviations and
the common use of sound-alike medications has long been known as a
cause of medical errors.
Starmer, et al. (2013) wrote that communication errors are a leading
cause of sentinel events, and that improving handoff communication
(i.e., transferring information about and responsibility for a patient)
reduced medical errors from 38.3 per 100 admissions to 18.3.60 Poor
communication is also an issue between healthcare providers and
patients. Good listening requires that the health care provider listen
fully and hear their patient. In addition to listening, health care
providers need to communicate information accurately and simply.
Lack of knowledge
Both researchers and healthcare professionals often identify lack of
knowledge as a major cause of medical errors, and lack of knowledge
affects all parts of the healthcare delivery process. They also note that
there is a lack of resources and/or time for increasing knowledge.
Healthcare setting
Emergency rooms, intensive care units, and the operating room are
high-risk areas for medical errors. The health acuity of the patients
(intensive care and emergency room), sudden and unexpected
increases in patient census (emergency room), and the use of
anesthesia and the need for strict adherence to infection control
protocols (operating room) all contribute to an increased incidence of
medical errors in these settings of patient care.
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Admission and discharge to the hospital are common times in which
medical errors occur. A medical provider who is unfamiliar with the
patient’s medical history often admits the patient to the hospital, and
the patient is often in his/her most vulnerable condition at the time of
admission. Discharge requires patient teaching, perhaps many new
medications that the patient must take, and follow-up care; these are
multiple opportunities for mistakes to be made and medical errors to
occur.
Medical Errors And Reduction Strategies
Reducing the number of medical errors is an important part of
improving the American health care system. There is a three-tier
approach to reducing the number of errors. The first is an overall
improvement in the health care system. Currently, there is a national
focus with health care leaders working to collect data, enhance
knowledge to reduce the number of medical errors. The second is an
effort on each individual health care provider to provide safe and
effective care. Lastly, each patient needs to be an active consumer of
health care. Some specific interventions that can be used to reduce
types of medical errors will be presented first in this section, followed
by a short discussion on helping patients prevent medical errors.
Diagnostic errors
Thammasitboon and Cutrer (2013) categorized diagnostic errors and
found cognitive mistakes that were common to many diagnostic
errors.63 Their strategies to eliminate cognitive error and improve
diagnostic accuracy focused on three areas. The first strategy was
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expanding clinical expertise, which is simply involves identifying the
gaps in the knowledge base and to try to eliminate them. The second
strategy is to avoid cognitive processing errors, and this is subtler; the
authors described eight cognitive errors that can cause a diagnostic
error and strategies for correcting them.
One example of the second strategy to eliminate cognitive errors
involves a common error in the diagnostic process known as
anchoring, which involves the clinician staying with the original
diagnosis despite evidence to the contrary. In order to correct or
reduce anchoring, clinicians can be trained to consciously use debiasing techniques, to periodically re-evaluate evidence, and to pause
during the diagnostic process and to re-examine their assumptions. In
the final strategy to eliminate cognitive errors, wrong diagnoses can be
avoided by reducing the cognitive burden. This can be achieved
through appropriate requests for consultations (i.e., another medical
specialist or ancillary health service), the use of checklists, or by team
consensus or decision-making.
Medication error prevention
The causes of medication errors are complex, and there are many
possible approaches to the problem. A simple and effective way to
avoid medication errors is through the use of the eight rights of
medication administration. These eight rights of medication
administration include:
1. Right patient
All healthcare facilities have a procedure for identifying patients.
The minimum number of identifiers is two, and the patient must
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be correctly identified in person and on all medication orders.
Making sure the nurse is giving a medication to the right patient
is largely a matter of communication.
2. Right drug
The medication and the order must be checked against one
another to make sure that the right drug will be given. Also,
before giving a drug that is new for a patient, the nurse should
re-check drug allergies, re-check possible drug-druginteractions, and make sure that at some time the patient has
been asked about her/his use of herbal supplements.
3. Right dose
The right dose should be checked using current references, with
the pharmacy or an appropriate staff member as secondary
resources. Nurses should be aware of common dosing errors
such as a 10-fold increase in dose, and calculations should be
double-checked.
4. Right route
These are important questions a prudent nurse would want to
consider related to patient status and the right route. The nurse
should always check to see that the route is correct.
5. Right time
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The nurse should always check to see when the last medication
dose was given to make sure that it is not being administered
too early or too late.
6. Right documentation
Proper documentation should include the time and route of
administration, and, if needed, the patient’s vital signs before
and after medication administration.
7. Right reason
A medication should be appropriate for the patient and for the
clinical condition it is supposed to treat, and nurses have a
responsibility to check this information before giving a drug.
8. Right response
The definition of a drug is a substance that is given to prevent or
treat an illness, and which has a measurable effect. In order to
avoid medication errors nurses should have a basic
understanding of how a drug works, and how its effectiveness
can be measured or monitored.
Two other preventive strategies for avoiding medication errors are: 1)
awareness of look-alike and sound-alike drugs; and, 2) using
abbreviations properly. Approximately 25% of medication errors that
occur in the United States involve name confusion,67 and these errors
have the potential to cause great harm. Several websites include The
United States Pharmcopeia and The Institute for Safe Medication
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Practices, which can be accessed by nurses. Regarding proper use of
abbreviations, each healthcare facility should have a list of acceptable
abbreviations and nurses should know where the list is and what it
contains.
Commonly used abbreviations related to medication administration
that can be used mistakenly or misidentified are ones, such as: U (or
u) intended to mean unit but easily mistaken for a 0 or 4; SC intended
to mean subcutaneous but easily mistaken for SL (sublingual); and,
QOD intended to mean every other day but easily mistaken as QD
(every day) if it is written sloppily. The Institute for Safe Medication
practices has a list of dangerous abbreviations and dose designations
on its website at:
http://www.ismp.org/newsletters/acutecare/articles/dangerousabbrev.
asp.
Avoiding surgical errors
There are many approaches to avoiding medical errors involving
surgery, but one of the simplest and most commonly used is the World
Health Organization (WHO) Surgical Safety Checklist. This can be
viewed on the WHO website at
http://www.who.int/patientsafety/safesurgery/ss_checklist/en/.
The Surgical Safety Checklist has three components: the sign in, the
time out, and, the sign out. These three components correspond to
before anesthesia, before skin incision, and the post-operative period.
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Prevention of treatment errors
Methods for preventing treatment errors are essentially the same as
those used for preventing the other medical errors that been discussed
previously. These methods include health team members having a
good knowledge base, good communication, and team adherence to
the healthcare facility’s protocols.
Preventing Medical Errors: Helping The Patient
Medical errors by patients, especially medication errors, are very
common and may cause serious harm. Acetaminophen is very popular
and very safe when taken in therapeutic amounts. However, in recent
years acetaminophen overdose has been the leading cause of acute
liver injury in the United States,68 and many of these cases are not
deliberate overdoses done with the intent to cause self-harm but
therapeutic mistakes made by the lay public.69
Teaching patients about medication safety is an important of
preventing medication errors. Prescribers, nurses and pharmacists
should spend time teaching patients about their medications.
Nurses providing teaching about medication to patients should
encourage them to write this information down. Key points of patient
teaching and medication administration and safety should include such
concerns as the purpose for taking a medication and common side
effects, interactions and risks that require ongoing monitoring.
Disclosure Of Medical Errors
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Medical errors should be disclosed to the patient and, if appropriate, to
family members. Disclosure of an error is difficult, but it is vital for the
patient’s physical and emotional wellbeing. Disclosure of an error is
also vital for the well being of the healthcare system as acknowledging
errors is the first step in correcting them.
In many jurisdictions the disclosure of medical errors is mandatory and
most health care facilities have, or should have, a policy that outlines
how and by who a medical error should be disclosed. This policy
should be reviewed before a medical error is disclosed.
Summary
The prevention of medical errors is not easy. Hospitals and other
healthcare facilities are complex organizations and the work
environment is fast-paced. There is significant external and internal
pressure on staff to perform the work correctly, which requires
experience and specialized knowledge. The traditional culture of blame
has made it hard to disclose errors and learn from them. However,
other organizations that share many of these stresses, such as the
airlines, are remarkably error free. They have done this by a
commitment to preventing errors and not reacting to errors. If safe
patient care is the goal, perhaps modeling other public service
industries that have successfully reduced errors is the way for the
healthcare industry moving forward.
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Please take time to help NurseCe4Less.com course planners
evaluate the nursing knowledge needs met by completing the
self-assessment of Knowledge Questions after reading the
article, and providing feedback in the online course evaluation.
Completing the study questions is optional and is NOT a course
requirement.
1.
True or false: A medical error and an adverse event are
identical
a. True
b. False
2.
Diagnostic errors occur when:
a. an incorrect diagnosis is made
b. the diagnosis is changed from the original diagnosis
c. given the available data the correct diagnosis should have been
made
d. the diagnosis was made more than 72 hours after examination
3.
A medication error is defined in part by the words:
a. preventable and patient harm
b. under-dosing and over-dosing
c. adverse effect and therapeutic intervention
d. avoidable and lack of vigilance
4.
A common cause of medication error is:
a. look-alike and sound-alike drug names
b. adult drugs being used for pediatric patients
c. patient refusal to accept the drug therapy
d. undisclosed use of herbal supplements
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5.
True or false: medical errors should be disclosed to the
patient.
a. True
b. False
6.
Diagnostic errors are more likely EXCEPT when
a. the patient has a complex medical history.
b. when there are too many diagnostic resources
c. patient follow-up is sub-optimal
d. time available for diagnosis is limited or perceived to be
limited.
7.
True or False. The healthcare setting is an influencing
factor for diagnostic errors, such as one that is fast-paced
and stressful.
c. True.
d. False.
8.
A 2014 study showed a __________ error rate in medical
dictation/transcription, and poor communication in the
form of using non-standard abbreviations and the common
use of sound-alike medications has long been known as a
cause of medical errors.
a. 15 %
b. 25 %
c. 30 %
d. 44 %
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9.
Nurses providing teaching about medication to patients
should include key points of points, such as
a. the purpose for taking a medication
b. common side effects interactions
c. risk factors of taking the medication
d. All of the above.
10. Starmer, et al. (2013) wrote that communication errors
are a leading cause of
a. sentinel events
b. poor team dynamics
c. medication errors
d. documentation errors
11. True or False. It has been reported that and that
improving handoff communication (i.e., transferring
information about and responsibility for a patient) reduced
medical errors from 38.3 per 100 admissions to 28.
a. True.
b. False.
12. Patient discharge is
a. when medical errors can occur
b. less of a risk factor than admission for a medical error
c. less of a risk factor for a medical error than patient follow-up
d. Both b and c above.
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13. True or False. Equipment failures during anesthesia are
relatively uncommon.
a. True.
b. False.
14. One example of the second strategy to eliminate cognitive
errors involves a common error in the diagnostic process
known as
a. Time out
b. It-Takes-Two
c. Anchoring
d. Pause
15. Approximately 25% of medication errors that occur in the
United States involve
a. verbal orders
b. name confusion
c. hand-written notes
d. an inexperienced nurse
Correct Answers:
1.
b
6.
b
11.
b
2.
c
7.
a
12.
a
3.
a
8.
c
13.
a
4.
a
9.
d
14.
c
5.
a
10.
a
15.
b
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References Section
The reference section of in-text citations include published works
intended as helpful material for further reading. Unpublished works
and personal communications are not included in this section, although
may appear within the study text.
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