Errors and Mistakes: How to Prevent Them
At the end of the class, you will be able to:
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:
Some other healthcare places that have done a lot of good things to make patients safe include:
Things That You Can Do To Help Your Patients and Residents
Many mistakes can happen when you are:
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:
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:
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:
Patient identification errors most often happen when a patient:
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:
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 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”.
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.
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
Communicate with your supervisor and other members of the healthcare team.
Report, report and report.
Respond to your patients and residents.
Identify your patients and residents.
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
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:
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.
Hockenberry, Marilyn J. and David Wilson. (2010).Wong's Essentials of Pediatric Nursing. 8th Edition. Elsevier Mosby.
Kee, Joyce LeFever and Evelyn Hayes. (2009). Pharmacology: A Nursing Process Approach 6th Edition. Saunders Elsevier.
Monahan, Frances Donovan and Wilma J. Phipps (2007). Phipps’ Medical-Surgical Nursing: Health and Illness Perspectives. 8th Edition. Elsevier Mosby.
Nettina, Sandra M. (2009). The Lippincott Manual of Nursing Practice. 7th Ed. Lippincott, Williams and Wilkins.
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.
State of Florida Agency for Healthcare Administration (AHCA). (2001). “Report to the Governor and the Legislature”. [online]. http://www.doh.state.fl.us/mqa/FCHCE/FCHCEfinalrpt02-01-01.pdf
United States Department of Veterans Affairs. (2010)"National Center for Patient Safety". [online]. http://www.patientsafety.gov/vision.html
VHA. (2003). "VHA Honors Eight Health Care Organizations with Leadership Awards" .[online]. http://www.vha.com/news/releases/2001/04_23_01.shtml
Copyright © 2010 Alene Burke
TAKE THE TEST