DUE DILIGENCE: Preventing Common Clinical Medical Errors
By CareerSmart® Learning Contributor, June 16, 2017, as published by Healthcare Hot Spot
A recent study examined the rate of fatal hospital errors in the United States and concluded that errors are the cause of nearly a quarter of a million deaths every year. Approximately one percent of hospital patients die every year in the U.S. (Sternberg, 2016). That percentage of fatalities would potentially make medical errors the third leading cause of death in the U.S. While not all medical errors are fatal or directly related to the action of a medical professional, there are three common errors that can easily be prevented, leading to better health outcomes for all patients:
- Medication errors. One study of nurses found that approximately 65 percent of participants reported making at least one medication error during their career. This study stated that the most common types of medication errors were incorrect drug, dosage, and infusion rate (Cheragi, Manoocheri, Mohammadnejad, Ehsani, 2013). Another study found that a leading cause of medication errors is disruptions in nurses’ concentration. Nurses, in particular, deal with non-stop distractions throughout their day. These distractions take their focus off of the current task, which can have disastrous consequences when administering medications (Beyea, 2014). Some hospitals are initiating protocols so that colleagues know not to interrupt nurses who are preparing medications. These protocols can be as simple as nurses in a medication room cannot be disturbed. More importantly, the person who is handling the medication, be it the nurse, pharmacist, or medication technician, must be vigilant in policing their own safety practice at all times.
- Hand hygiene. This might not be the most interesting way to prevent hospital-acquired infections (HAIs), but it is definitely the simplest. Reports consistently show that hand hygiene compliance among healthcare workers is terribly low, close to 40 percent (Pfoh, Dy, Engineer, 2013). A hand hygiene compliance rate of anything less than 100 percent can lead to possible HAIs, in other words, medical errors. Health and illness lie in the nurse’s hands, quite literally. Healthcare professionals often overestimate their hand hygiene compliance, as well as underestimate its importance (Pfoh et al., 2013). While hand hygiene seems simple, it can sometimes seem daunting – when to use hand sanitizer versus soap, whether hand sanitizer is as effective as soap, how long to scrub hands with soap. These are common questions that healthcare workers have, but often feel embarrassed to ask. As a brief overview, so long as hands are not visibly dirty or greasy, hand sanitizers work as well as soap against nearly all germs. If working with a patient with C. diff, hand sanitizer will not be sufficient. To properly use soap, hands must be vigorously scrubbed together for at least 20 seconds. The friction from scrubbing hands together physically removes germs from hands (CDC, 2015). A quick conscious check before a task or caring for your patient is to simply stop and ask yourself; are my hands clean? When in doubt, wash them.
- Personal protective equipment (PPE). Like hand hygiene, PPE is often misunderstood, yet hospitals still provide little training in donning and doffing PPE because seems to be an unsaid expectation that healthcare workers already know all PPE protocols. In one study, nearly 90 percent of respondents reported having seen colleagues in healthcare not wear the appropriate PPE. About one third of those respondents reported having seen PPE non-compliance on several occasions (Pyrek, 2011). Working with an Infection Preventionist to do “re-fresher” trainings on PPE, as well as hand hygiene, is invaluable to protecting staff and patients alike.
We tend to do too much and rush too much in our current hustle and bustle clinical environment and dismiss the importance of these simple practices. It only takes a nano second to cause an error. These three common errors can be prevented with diligence. It takes diligence to tell colleagues not to interrupt during medication preparation. It takes diligence to practice consistent hand hygiene. It takes diligence to take a moment to wear the appropriate PPE for the patient and activity. Be mindful of your actions and be diligent.
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Sternberg, S. (2016). Medical errors are third leading cause of death in the U.S. US News. Retrieved from http://www.usnews.com/news/articles/2016-05-03/medical-errors-are-third-leading-cause-of-death-in-the-us
Cheragi, M.A., Manoocheri, H., Mohammadnejad, E., Ehsani, S.R. (2013). Types and causes of medication errors from nurses’s viewpoint. Iranian Journal of Nursing and Midwifery Research: 18(3): 228-231. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3748543/
Beyea, S. (2014). Interruptions and distraction in health care: Improved safety with mindfulness. Patient Safety Network. Retrieved from https://psnet.ahrq.gov/perspectives/perspective/152/interruptions-and-distractions-in-health-care-improved-safety-with-mindfulness
Pfoh, E., Dy, S., Engineer, C. (2013). Intervention to improved hand hygiene compliance: Brief update review. Making Health Care Safer II: n Updated Critican Analysis of the Evidence for Patient Safety Practices. https://www.ncbi.nlm.nih.gov/books/NBK133371/
Centers for Disease Control and Prevention. (2015). When & How to Wash Your Hands. Retrieved from http://www.cdc.gov/handwashing/when-how-handwashing.html
Pyrek, K.M. (2011). Addressing the challenges of PPR non-compliance. Infection Control Today. Retrieved from http://www.infectioncontroltoday.com/articles/2011/10/addressing-the-challenges-of-ppe-non-compliance.aspx