3 Facts Every Nurse Should Know About Medical Errors
For this year’s National Nurses Week, The American Nurses Association (ANA) has chosen the theme “A Culture of Safety” to remind nurses of the vital role they play in maintaining a high level of safety in their healthcare setting. By focusing on safety, the ANA is also raising awareness for a continued need for improvement in the area of medical error prevention. According to a 2014 study by Healthcare IT News, preventable medical errors are the third most prevalent cause of death in the United States--after heart disease and cancer. These errors account for nearly 400,000 deaths per year, at a cost of $1 trillion dollars.1
Whether you have years of experience in the healthcare industry or are currently working to complete your nursing degree, National Nurse Week is the ideal time to take a moment and recommit yourself to patient safety and medical error prevention. It’s also an opportunity to focus on those common factors that can lead to accidents and injuries at your healthcare workplace. Dr. Tarantine shares some startling facts about medical errors and highlights ways nurses can help mitigate adverse events.
The Most Common Medical Errors are the Most Preventable
According to the U.S. News and World Report, medication errors and hospital acquired infections (HAI’s) are the two leading causes of preventable medical errors.2 Although electronic records and point-of-care technologies have led to improvements, CTU’s Dean of Nursing, Ruth Tarantine, believes that we still have a way to go before becoming fully optimized.
Healthcare is complex and the systems that surround healthcare continue to operate in silos. Tarantine explains, “If you are a current consumer of healthcare, which most of us are, it’s easy to see the fragmentation of care on a daily level. “Despite nationwide awareness and multiple patient safety initiatives, it is not enough,” she says. Medication errors are still common. “We are slowly getting better (at mitigating errors), but we need to move faster. Lives depend on it.”
Hospital acquired infections is also a serious problem. The CDC estimates that 1 in every 25 patients contract an infection while staying in a hospital, which can be caused by infectious agents like bacteria, fungi, and viruses. “We have seen many hospitals combat hospital acquired infections head on and achieve dramatic results in the areas of central line-associated bloodstream infections, surgical site infections, and MRSA bacteremia,3” says Tarantine. “The most encouraging point is that hospitals that have done well are willing to share best practices with other facilities.”
Good Communication Leads to Safe Practices
The root cause of the majority of adverse events, however, continues to be communication, specifically at the point when one provider “hands off” a patient to another in order to transfers them to a new hospital area. In their examination of event causes, The Joint Commission found that, “Ineffective hand-off communication is recognized as a critical patient safety problem in healthcare.” They estimate that nearly 80% of serious medical errors involve miscommunication between caregivers during the transfer of patients.4
“It’s easy to see how miscommunications during hand offs happen once you realize that different specialties or areas of healthcare may concentrate on different aspects of the human condition,” says Tarantine. “What is important to the ICU nurse might not be as important to the radiology nurse.” In response to this problem, many facilities have adopted a checklist format for handing off patients. “Consistency in reporting is one approach that has effectively reduced in “hand off errors”, notes Tarantine.
Nurses Are Vital to Reducing Medical Errors
Because of their involvement and expertise in so many areas of the healthcare system, nurses are well positioned to spot and prevent medical errors, but they have to be empowered to communicate their concerns. As Tarantine explains, “Nurses must speak up with any safety concern. All too often, an error occurs which causes a patient death. Once a root cause analysis (RCA) is done, the facility often finds out that employees were aware of a fragmented or broken system and did daily “work arounds” to do their job. Using work-arounds to deliver patient care is never okay.”
Nurses also serve as an invaluable point of coordination and verification when a patient is moving between different hospital areas. For example, if a healthcare provider writes an order for antibiotics, a nurse should not assume that he or she saw the allergy alerts on the patient’s chart. They have the power to stop and verify. “Even if it is three o’clock in the morning, pick up the phone and verify. You might just save your patient’s life because of making that phone call.”
Ultimately, Tarantine believes that many medical errors can be prevented by nurses and other healthcare professionals simply making the promise to offer the same level of care that they would want for their loved ones. “Looking at healthcare through the lens of a patient or family member can certainly change your perception of the care that is delivered,” says Tarantine.
Tarantine says the biggest opportunities for reducing preventable medical errors lie with communication and care coordination. “Better communication among all providers will only continue to improve quality and mitigate errors,” she says. “And, care coordination isn’t possible unless all providers communicate with one another.”
Click here to learn more about National Nurses Week and watch short video from Nurse Kelley Johnson (Miss Colorado 2015).
1McCann, E. (2014, July 18). Deaths by medical mistakes hit records. Retrieved April 22, 2016, from http://www.healthcareitnews.com/news/deaths-by-medical-mistakes-hit-records
2 Miller, A. M. (2015, March 30). 5 Common Preventable Medical Errors. Retrieved April 22, 2016, from http://health.usnews.com/health-news/patient-advice/slideshows/5-common-preventable-medical-errors/5
3 Healthcare Associated Infections Progress. Retrieved April 28, 2016 from http://www.cdc.gov/media/pdf/releases/2015/p0114-mrsa-hospitals-report.html.pdf
4 Root Causes by Event Type. (n.d.). Retrieved April 21, 2016, from http://www.jointcommission.org/assets/1/18/Root_Causes_by_Event_Type_2004-2015.pdf.