Errors and Mistakes: How to Prevent Them

Objectives

At the end of the class, you will be able to:

1. Details some of the common medical errors and why they occur.
   
2. List some kinds of patients that are at risk for medical errors.
   
3. Describe ways that you can prevent mistakes and errors.
   
4. Discuss root cause analysis and error prevention.
   
   

Introduction

It is a known fact that we make a lot of errors and mistakes every day as we take care of patients and residents. The number of health care errors is very high. No health care worker wants to make a mistake, but they still do happen a lot. No one is happy when they do something wrong or when they forget to do something that they should have done. Bosses and supervisors are also not happy when things are not done when and how they should. The worst part of errors, however, is not how they make us or other people feel. The patients, the people that we take care of can be very seriously hurt and harmed with an error. Our errors can even cause a person to die. They are very serious.

Some of our mistakes are made because we do not do the right thing. These mistakes are called omissions. An example is when a nursing assistant forgets to measure urine for a patient’s I & O at the end of their work day. Other mistakes are made because someone does the wrong thing. These mistakes are called errors of commission. An example of this is when the nursing assistant takes the wrong patient to the operating room for surgery.

In 1999, healthcare givers found out that medical errors kill 98,000 people a year in hospitals. It is likely that the number of deaths is even higher in American nursing homes. Healthcare is at risk for errors. Fortunately, there are many things that all of us can do to stop them and to prevent them from happening. This class will help you to avoid them and it will also help you to work with your hospital or nursing home to find ways that you can keep your patients and residents safe and free from harm.

Things That Are Now Being Done to Prevent Medical Errors

Our government, many states, hospitals and nursing homes are now working very hard to protect our patients. The President of the United States and our national lawmakers have made medical errors a matter of very high priority. They have asked us to immediately lower the number of mistakes so that the health, safety and life of the public can be protected. States like New Jersey, Missouri, Mississippi, Oregon, and Kentucky have put together work groups to solve this big problem. Some states, like Florida, have put together groups such as their Council on Patient Safety to collect and spread medical error information so that the patients in Florida can be safe and without harm. A strict method of reporting errors has also been started in some states, like New York, Florida, Connecticut, Massachusetts, Maryland, and Maine.

Staffing levels and working overtime are also been looked into by some states because it is felt that not enough staff and too much overtime for healthcare workers make our hospitals and nursing homes unsafe. California, North Carolina, and Ohio are three states that are now working in this area. Computers are also being used to prevent errors. They are being used to help nurses give the right medicines and to help identify the right patient. Other states, like the State of Florida, are now making all healthcare workers take a class on medical errors prevention in order to keep their license or certification.

One of the leaders in this area is the Department of Veterans’ Affairs (VA). The VA now has a National Center for Patient Safety that is working very hard to reduce errors in all of their hospitals and nursing homes. The VA looks at mistakes as an chance for us to fix systems and processes in their hospitals. They do NOT blame people for mistakes. They also do NOT punish people for making a mistake.

Some of the things that the VA has done are:

• making a ‘no blame’ place to work. People are not blamed and punished when they make a mistake. They do NOT ask, "Who did it?". They ask, "What happened?" and “What can we do so that it can never happen again?”
  
  
• starting a new system to report errors
  
  
• looking into all errors in a new way that is called root cause analysis. Root cause analysis digs all the way down to the root of the problem, not the person. The root of the problem is most often found to be a policy or procedure that does NOT work well. The best routines in healthcare are the ones that will NOT let a person make a mistake. They try to find ways that mistakes can NEVER be made again.
  
  
• having all of their employees take 20 hours of classes a year about patient safety.
  
  
• writing a newspaper called "Topics In Patient Safety" (TIPS) so that all the healthcare workers in the VA can learn how to keep their patients safe.
  
  
• using bar codes, like a supermarket does, to make sure that patients are identified correctly.
  

Some other healthcare places that have done a lot of good things to make patients safe include:

• Luther/Midelfort Health Care System in Eau Claire, Wisconsin,
  
• Baylor Health Care System,
  
• Aetna U.S. Healthcare,
  
• University Community Hospital (UCH) of Tampa, Florida, and
  
• Valley Hospital of Ridgewood, New Jersey
  

Things That You Can Do To Help Your Patients and Residents

Many mistakes can happen when you are:

• tired,
  
• distracted and interrupted,
  
• under a lot of stress, or
• in a hurry.
  

Get Enough Rest and Manage Your Time

You can protect your patients by getting enough rest. Try to get at least 8 hours of sleep a night. This is sometimes a hard thing to do, especially when you have many things to do at work and at home. Try to manage your time in a better way so that you can get enough rest and sleep.

Use time management skills. Set goals and deadlines that you can meet. Do not set ones that you can not meet. Decide on what is really important and then focus on these. Budget your time.

Work In A Safe Place: Stay Away From Distractions & Noise

It is important to pay attention to what you are doing and nothing else when you are providing care to your patients. Try to see and hear nothing other than your patient. Noise, interruptions, distractions, and poor lighting can make people make mistakes. Some mistakes happen because we:

• are sometimes used to doing the same things for all of our patients all of the time without thinking carefully. For example, a nursing assistant who works on a maternity unit usually gives cake or cookies to the patients for their evening snack. When the nursing assistant gives cookies to a diabetic patient on the unit because they were not paying attention to the diabetic patient and the fact that they can not have regular cookies or cake, a mistake has been made. This kind of mistake would probably not occur as often on a unit with older patients where many of them have diabetes. Another example is when a nursing assistant gives a person their usual breakfast without checking to see that they are NPO that morning for lab work.
  
  
• forget to do something new for our patient. For example, a nursing assistant who gives an enema to the wrong person and not the right person has forgotten to do the right thing because it was a new order. The person needed the enema the night before surgery. It was a new order and something that is done only once.
  
  
• are interrupted. Try to pay attention to what you are doing at all times.
  
  
• are overly sure and confident of what we do and are doing. Never be too sure. Always double check yourself.
  

Learn How to Deal With Stress

Nursing assistants, nurses and most other people have a lot of stress in their life. Today, we live in a very fast paced and complicated world. We also have to do many things at one time, every day. We get stress from our home life, our work life and our private life.

We have to work, be a mother or father, be the child of a parent that may need our help, be a wife or husband, be an active member of our community within our schools, church or another group. We wear many hats. We have many roles that we have to do. We juggle all of these roles every day but we only have a certain amount of limited time to do it. Life is not easy.

Nursing assistants are NOT the only ones with all of this stress. Many other jobs have the same amount of stress. The secret to success in managing stress is to MANAGE IT BEFORE IT TAKES CONTROL OF YOU.

Stress will never go away. We have to get rid of it completely or change how we react to it. The first steps in managing stress are:

1. Find out the source of the stress. Where is the stress coming from?
   
   
2. Decide if you can get rid of the source of stress. For example, if you are stressed because you are cooking all the meals for the family in addition to working a full time job, you should decide if you can get rid of the cooking and/or get rid of the job.
   
   
3. Get rid of all the stress you can. Get other members of the family to help cook meals. Cut up the food and get it ready before you go to work so that another member of your family can simply cook it for you.
   
   
4. Do NOT take on more stress by saying yes. Learn how to say no. Do NOT take on more than you can handle. Say no whenever you can. Say no when someone asks you to do something you do not want to do. Say no to things you cannot do because you have too much to do already. Free yourself from stress by saying no.
   
   
5. Change how you think about something that stresses you. Which stress is worse, not having hot water to get a bath or hearing that you have a fatal disease? Yes, the terminal disease is far worse than not having enough hot water. Why then do we react to the lack of hot water as a big thing? We react because we allow our mind to make small things into big things. We must step back and look at things in a realistic way. Not having hot water is a little thing that will last only for a short time. Do NOT make an ant hill into a mountain with your mind.
   
   
6. Be good to yourself. Use stress management skills every day to deal with the stress that you cannot get rid of. Use stress management skills when your mind is not able to make the stress small! Some great stress management skills are discussed in our class called Stress Management. You may want to take this class to learn more about stress and how to deal with it.
   

Take Your Time: Do Not Skip Important Rules Like Patient Identification

There are many things that nursing assistants and other people who work in hospitals and nursing homes can do to make sure that their patients are safe and not the victim of a medical mistake. One of the most important things that you can do is to be accurate in identifying the people that you take care of. When you do not properly identify a patient, you may see your name in one of these news headlines:

• Wrong patient diagnosed with cancer. Laboratory specimen not labeled correctly!
  
• Infant gets a circumcision without consent of the parents.
  
• Deaf, elderly patient gets a treatment that was not ordered for her!
  
• Patient brought to the wrong nursing home. The wrong Mr. Smith went.
  
• Patient dies from too much insulin because a nursing assistant charted the wrong blood sugar.
  

Patient identification errors most often happen when a patient:

• has the same name as another patient in the hospital or nursing home,
  
• has a mental problem like confusion,
  
• is NOT awake or conscious,
  
• has a mental illness,
  
• can NOT see,
  
• can NOT hear,
  
• is taking some medicines, like a sleeping pill,
  
• is an infant or young child, or
  
• is taking some medications, like a sleeping pill.
  
  

All of these things and other things can lead to the incorrect identification a patient unless we take the time to pay close attention to doing it correctly. People that are confused, sleepy, in a coma or have a mental illness may not be able to tell you their name when you ask them to state their name. Also, when you have 2 or more patients with the same last name, be careful. Make sure that the right Mr. Jones is going to the operating room before you bring them there.

Here are some ways that you can properly identify your patients:

• Patients must always have a secure identification (ID) band on. Do NOT provide any care to any person unless their ID band is on.
  
  
• Refer to this patient identification band before you do anything for the patient. Check and double check the first and last names.
  
  
• Ask the patient to state their name before you do anything. This double check will work for most patients. It will not, however, help identification if the person is confused or sleepy. It will also not help with young children, infants and those with a severe psychiatric illness.
  
  
• Asking a patient, "Is your name Mr. Smith?" can sometimes help with those unable to speak. However, those poor hearing may very well shake their head “yes” without ever having heard what you have asked.
  
  
• Check all treatment records against the patient's identification band.
  
  
• Educate the patient. Tell them what you are doing before you do it. If the patient questions what you are doing, STOP! Re-check the orders so that you are certain that you have identified the correct patient.
  
  
• Know your patients and their needs. If a treatment or other intervention does not make sense or does not seem to be the right thing for the patient, double-check the order and the identity of the patient.
  
  
• Do not call patients by room number or diagnosis. Do NOT refer to patients as the “CVA in room 234”. Refer to patients using their name. Asking a nurse to "bring the infant in 16 to get a circumcision," can be heard by the nurse as "15" thus possibly leading to a surgery on the wrong baby. The parent or legal guardian has not agreed to this.
  
  
• Do not rely on room or bed numbers. For any number of reasons, including confusion and dementia, a patient can go from one room to another or from one bed to another. Do NOT use room numbers or bed numbers to identify your patients.
  
  
• Carefully check the patient's first and last names against the order. Be very careful when two or more patients have the same or like last or first names. For example, when Alex Smith and Alan Smith are in the same unit of the hospital, the wrong Mr. Smith may go to the operating room!
  
  
• Label all specimens and patient care equipment or supplies, such as bedpans and urinals, with the patient name while referring to the patient’s ID band.
  
  
• Avoid distractions and interruptions during the course of patient care.
  
  
• Be a part of the solution. If you think that there are problems in your hospital or nursing home regarding poor procedures, tell the nurse. The proper identification of the patient is a legal and ethical responsibility that should never be skipped. The lives of your customers are at stake.
  

High Risk Areas for Mistakes

Below are some of the high risk areas for mistakes:

Broken and Faulty Medical Equipment

Do NOT use any patient care equipment that is broken or not working correctly. Report all broken and faulty equipment to the supervisor. Get taught how to use a piece of equipment before you use it. If you are not sure how to use a piece of equipment, tell the nurse in charge. Do NOT use something unless you are sure you know how to use it correctly.

Falls

Falls kill and injure many patients and residents every year. Frequently observe and monitor your patients who are at high risk for falls. Report and communicate unsafe behaviors to your supervisor. To learn more about falls and preventing falls, take the NursingAssistantEducation.com class called “Preventing Falls”.

Restraints

You must constantly observe patients who are restrained to protect their own safety and the safety of others. Be sure that you are competent and able to apply restraints if you are asked to do so. Do not do anything for your patients if you are not sure of how to do it correctly. If you need help or more training, report this need to the nurse.

Wandering and Elopement

Some patients and residents are at risk for harm and injury because they are confused. They may wander off to unsafe places and even leave the hospital or nursing home (elopement). Respond immediately to calls for help, bed alarms and exit door alarms.

Suicide

Many patients commit suicide in our hospitals and nursing homes. If you are asked to monitor a patient at risk for suicide, do NOT take your eyes off them. Follow the instructions of the nurse and never leave the person unattended.

Basic Rules to Prevent Mistakes

Be competent.

• Do NOT do anything when you are not sure how to do it. Get the training you need to do things right. Tell the nurse if you do not know how to do something that you have been asked to do.
  

Communicate with your supervisor and other members of the healthcare team.

• Communication, including documentation, helps to prevent mistakes.
  

Report, report and report.

• Report everything that seems unusual. Report all changes in the patient or resident. Report things that do not seem right. Report all dangers. Report all safety problems. Report all mistakes and near misses.
  

Respond to your patients and residents.

• Listen and respond to your patients and residents. If they question a treatment, stop and check the order. Immediately respond to all alarms and calls for help.
  
  

Identify your patients and residents.

• Accurate identification is critical to patient safety. Do NOT skip this important part of patient care.
  
  

Pay attention to what you are doing.

• Do NOT get distracted. Pay attention to what you are doing.
  
  

Reporting Errors: The Road to Preventing Other Mistakes

One of the best ways to protect our patients and maintain their safety is to report all errors that are made. You can prevent future errors when you immediately report errors. Reporting gives us a chance to look at things that led to the mistake. It also gives us a chance to fix the things that are not good. You should report actual errors and also when you almost made an error. Reporting should never be used to blame the person or to punish the person for making a mistake. Reporting errors and near misses helps us to make things better. The goal of reporting is to help us all find ways to prevent future mistakes.

Root Cause Analysis

Root cause analysis is a process that is used to dig down to the deepest, real reasons why mistakes are made. These reasons are usually procedures and processes and NOT people.

Teams of people, including those who usually do the process being looked at, are put on the root cause team. For example, nursing assistants who bring patients to the operating room will be on a root cause team that is looking into the problem of the wrong surgery on the wrong patient.

Root cause analysis team members use a number of tools and techniques to help them look at errors and their causes. Some of these tools and techniques are:

• discussion about the error or incident report;
  
• collection of extra information that is, or could be, useful;
  
• brainstorming;
  
• flow charting; and
  
• care thought.
  

This process can take several hours and even days. It is done when the team is able to identify all those deep down (root) contributory factors that led to the error or near miss. Once these contributory factors are identified, a corrective action plan is then written and followed.

It is up to the entire team to make a safe and error free place to care for our patient and residents.

References

Florida State Council on Patient Safety
http://www.doh.state.fl.us/mqa/FCHCE/FCHCEfinalrpt02-01-01.pdf

Hinkley, Gerald M and Rachel Glitz. “To Err Is Human - The States Respond”. http://www.dwt.com/practc/healthcr/to_err_is_human.htm

Kentucky's Medical Errors Initiatives
http://www.lrc.state.ky.us/2001rsrecord/hc24.htm

Massachusetts Coalition for the Prevention of Medical Errors
http://www.mhalink.org/mcpme/mcpme_welcome.htm

Missouri State Legislative Initiatives to Reduce Medical Errors
http://www.house.state.mo.us/bills01/biltxt01/ intro01/HB0620I.htm

Nevada's Legislative Initiatives to Reduce Medical Errors
http://www.leg.state.nv.us/71st/bills/acr/acr7.html

New Jersey Medical Error Reduction Study
http://www.njleg.state.nj.us/2000/Bills/a3000/2776_s1.htm

Oregon's Legislative Initiatives to Reduce Medical Errors
http://www.leg.state.or.us/01reg/measures/hb3500.dir/ hb3512.intro.html

Shapiro, Joseph P. (December 13, 1999). "Doctoring a sickly system. Deadly medical mistakes are rampant. One expert thinks they can be avoided" U.S. News.

United States Department of Veterans Affairs. "National Center for Patient Safety" http://www.patientsafety.gov/vision.html

VHA. "VHA Honors Eight Health Care Organizations with Leadership Awards" http://www.vha.com/news/releases/2001/04_23_01.shtml

Copyright © 2003 Alene Burke