NSG 1000: Patient Safety and Medical Errors (Week 11)

According statistics posted by the Center for Disease Control and prevention (CDC), medical errors is the

3rd leading cause of death behind heart disease and cancer

Patient safety

defined by the IOM as "the prevention of harm to patients"

1999, the Institute of Medicine (IOM) release a report entitled

"To Err is Human: Building A Safer Health System"

Medical errors cost the nation an estimated

$1 trillion each year

In an integrated patient safety system, staff and leaders work together to

-Eliminate complacency -Promote collective mindfulness -Treat each other with respect & compassion -Learn from their patient safety events, including close calls and other system failures that have not yet led to patient harm

NPSGs Program Areas

- Ambulatory Health Care - Behavioral Health Care - Critical Access Hospital - Home Care - Hospital - Laboratory Services - Nursing Care Center - Office-based Surgery

2017 NPSGs

- Identify patients correctly -- use at least two ways to identify patients. - Improve staff communication -- get important test results to the right staff person on time. - Use medicines safely -- before a procedure, label medicines that are not labeled. Record and pass along correct information about a patient's medicines. - Use alarms safely -- make improvements to ensure that alarms on medical equipment are heard and responded to on time. - Prevent infection -- Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization. Use proven guidelines to prevent infections that are difficult to treat, infection of the blood from central lines, infection after surgery and infections of the urinary tract that are caused by catheters. - Identify patient safety risks -- find out which patients are most likely to try to commit suicide. - Prevent mistakes in surgery -- make sure that the correct surgery is done on the correct patient and at the correct place on the patient's body.

Key features of the Culture of Safety

- acknowledgment of the high-risk nature of an organization's activities and the determination to achieve consistently safe operations - a blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment - encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems - organizational commitment of resources to address safety concerns

Common medical errors

- improper transfusions - too much oxygen for premature babies - health-care associated infections - central-line infections - falls - surgical errors - pharmacy errors - lab errors - treatment errors - birth injuries - restraint-related injuries or death - burns - pressure ulcers - mistaken patient identities

Nurses play a vital role in ensuring patient safety by

- monitoring patients for clinical deterioration - detecting errors and near misses - understanding care processes and weaknesses inherent in some systems - coordinating high-quality care through collaboration with physicians, pharmacists, families, and all other members of the health care team

The goals of a response to a medical error is to

- protect the patient - improve systems - prevent further harm

An integrated safety system includes

-Culture of Safety -Validated methods to improve processes and systems -Standardized ways for interdisciplinary teams to communicate and collaborate -Safely integrated technologies

Emphasis is placed on the system of care delivery that

1. prevents errors 2. learns from the errors that do occur 3. built on a culture of safety that involves health care professionals, organizations, and patients

Resulting from medical errors, each day cases of serious complications of approximately

10,000

As of result of medical errors more than...

1000 people die each day

Most recent studies estimate that because of the result of medical errors

210,000-440,00 patients per year who seek care at a hospital die

The first set of NPSGs was effective

January 1, 2003

In 2002, The Joint Commission established its

National Patient Safety Goals (NPSGs) program

Sentinel event

a patient safety event (not primarily related to the natural course of the patient's illness or underlying condition), that reaches a patient and results in any of the following: - death - permanent harm (serious physical or psychological injury) - severe temporary harm and intervention required to sustain life

The NPSGs were established to help

accredited organizations address specific areas of concern in regard to patient safety

In response to a medical error

accredited organizations are expected to use a "thorough and credible Root Cause Analysis (RCA) and action plan" and should disclose the error and apologize to the patient, report the event, and waive all costs associated with the event

Promoting safe patient care is important in

all areas of nursing practice (clinical, management , education, research, etc.)

Serious adverse events of a medical error require

an immediate investigation and response

The Joint Commission

an independent, not-for-profit organization; it accredits and certifies nearly 21,000 health care organizations and programs in the U.S.

Being the patient's advocate is

an integral part of nursing practice

The "To Err is Human: Building A Safer Health System" report put the spotlight on

how tens of thousands of Americans die each year from medical errors and effectively put the issue of patient safety and quality on the radar screen of public and private policymakers It estimated that up to 98,000 people a year die because of hospital mistakes.

most common medical error

medication errors

The statistics do not account for deaths that occur in

outpatient clinics, nursing homes and other non-hospital settings where health care workers care for fragile patients who need complex care

Errors can include problems in

practice, products, procedures, and systems

Patient safety is an essential and fundamental component of

quality nursing care

Joint Commission accreditation and certification is recognized nationwide as a symbol of

quality that reflects an organization's commitment to meeting certain performance standards

Medical error

the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim

The World Health Organization (WHO) defines patient safety as

the prevention of errors and adverse effects to patients that are associated with health care

The purpose of the NPSGs is

to improve patient safety; they focus on problems in health care safety and how to solve them