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Keep situational awareness’ during care episode
By Patrice Spath, ART
Brown-Spath & Associates
Forest Grove, OR
Patient safety and error reduction have become national priorities. No physician wants to give the wrong medication to a patient; no unit clerk means to transcribe penicillin as penicillamine. In a perfect world, there would be no errors, patient care activities would be under complete control at all times, and there would be no unplanned, undesirable events or accidents. Unfortunately, mistakes do happen in all health care organizations. The tools used for care coordination are important weapons in the war against medical accidents. Clinical paths, standing order sets, clinical algorithms, and other point-of-care reminders can lessen the risk of human errors. Case managers also can play an important role in patient safety by staying informed about the patient’s plan of care and monitoring treatment regimens.
The Institute for Safe Medication Practices (ISMP) evaluates medication error data to determine the factors that contributed to the mistakes. The common causes of hospital medication errors were reported in the June 3, 1998, issue of ISMP’s Medication Safety Alert. These problems, along with ways that point-of-care reminder tools can help reduce or eliminate these problems, are listed below.
• Critical patient information (diagnoses, lab values, allergies, etc.) is often unavailable to pharmacy and nursing staff prior to dispensing or administering drugs for new admissions.
Hospitals must identify more effective ways to obtain and communicate pertinent clinical information and never rely on admissions office staff or unit clerks to supply these data. Stan dard ized patient assessment/intake forms can ensure that all relevant patient information is gathered by clinical staff at the time of the patient’s admission.
• Medication errors occur most often during the prescribing and administration stages.
Accessible drug information always must be readily available and close at hand for all staff who prescribe and administer drugs. To improve dissemination of pertinent medication usage information, be sure to incorporate details about drug usage into clinical paths, protocols, standing orders, and other point-of-care reminder tools. Consider developing clinical algorithms if clinicians need help in making treatment decisions.
• Policies for handling medication use conflicts between practitioners are often ineffective or absent.
ISMP receives many reports of lethal errors in which orders were questioned but not changed. Establish maximum doses for high-risk drugs, and incorporate these criteria into pathways or standing orders. If a prescribed dose exceeds the recommended level, practitioners should be empowered to take steps to resolve drug therapy conflicts. The improved teamwork that results from pathway development makes collaboration easier and can eliminate flawed communication among disciplines.
• A frequent cause of serious errors during drug administration is the misuse of infusion pumps and other parenteral device systems.
The settings on PCA pumps often default to a standard concentration, requiring the operator to change the setting if a nonstandard concentration is used.
PCA pump settings should be set by one individual and independently checked by another before administration. Incorporate double-check procedures into pathways and protocols. Require sign-off that procedures are followed.
• Simple mistakes due to distractions are responsible for almost three-quarters of all errors that occur during medication order transcription.
While minimizing distractions can help reduce order transcription errors, preprinted orders are a good way to eliminate the chance of errors. With preprinted order sets and protocols, staff can focus their attention on relevant patient care issues rather than spending time rewriting orders. Good examples of the value of these point-of-care reminders are protocols that caregivers use for chemotherapy, heparin, and Coumadin. These drugs are particularly high-risk for medication errors because of dosing complexity and variation of regimens, according to the patient’s clinical presentation.
• Inadequate communication causes many medication errors.
Standardizing communication through the use of preprinted orders can reduce errors. However, preprinted orders must be carefully designed and checked. ISMP was notified of a case where a preprinted order listed the dose of magnesium sulfate as 16g (130 mEq) instead of 16 mEq (2g). The pharmacist assumed it was correct because it was listed on the preprinted orders, and he dispensed the dose. The patient became hypotensive but recovered. Case managers should encourage their institutions to develop adequate control mechanisms for evaluating and using order forms to prevent similar types of errors from occurring.
Medication errors are not the only type of mistake that can be prevented by point-of-care reminder tools. The incidence of patient falls and suicides can be reduced through the use of risk assessment tools and prevention protocols. Preoperative checklists can lessen the chance of wrong-site surgery and unexpected complications. While many of these tools were originally developed to reduce costs and unnecessary variation among caregivers, improvement of patient safety is an important by-product.
During the course of patient care, clinicians are likely to make errors. These slips, mistakes, or unsafe practices are often in response to immediate circumstances involving patient care. Physicians must make decisions about phenomenally complex problems, at times under very difficult circumstances. Often, they are in the impossible position of not knowing the outcomes of different actions, but having to act anyway.
Case managers often are assigned to oversee care for injured, frail, or feeble patients. These patients, particularly those with multiple morbidities, have little capacity to respond to treatment errors. The adverse effect of error on one part of the patient’s physiologic state may quickly exacerbate failure of other bodily states. Thus, responses of a frail patient to seemingly harmless slips, mistakes, or unsafe acts may be catastrophic. As an integral member of the health care team, case managers play a vital part in error reduction. They also serve an important safeguard role, helping caregivers catch mistakes and correct them before the patient is harmed.
Case managers can help the other members of the health care team maintain situational awareness, which is a term used to describe caregivers’ level of awareness of important patient-related information (e.g., clinical status, care plan, etc.). Patients move very quickly through the episode of care and may experience a rapidly changing course of events. Without an accurate awareness of the current state of affairs, clinicians can make mistakes. The case manager should be on the alert for a loss of situational awareness, which creates a climate for errors. For example, a patient may be having trouble swallowing, but no one has brought this problem to the attention of the physician. Or the resident may have ordered a potentially toxic medication, but nursing staff have yet to discontinue the intravenous drip. Quick intervention by the case manager will help alleviate the risk of patient harm.
Case managers should be involved in the investigation of adverse patient care events, as they are very knowledgeable about hospital operations. As a member of a sentinel event investigation team, the case manager can help the team learn how the mistake was caused. The case manager also can make an important contribution by recommending modifications to systems and processes to prevent another similar mistake from occurring. Case managers also should be involved in proactive accident prevention. It is important to identify and report potential hazards to the quality or risk management department. By documenting unsafe situations, case managers can help set in motion the improvement activities necessary to prevent potential accidents and minimize patient injuries.
Health care professionals too frequently have relied solely on the quality of individual performance to prevent patient accidents. Too often, we have warned someone who made a mistake to "be more careful next time." Despite our best efforts to the contrary, things still go wrong. Health care organizations now are beginning to build error-proof processes and correct the real underlying causes of problems. Point-of-care reminder tools like clinical paths, guidelines, protocols, standing orders, and the like can help eliminate some of the process inadequacies that allow or cause mistakes to happen in the first place. In addition, case managers serve as safeguards to protect against a negative patient outcome even if an error occurs.
By sounding an alarm, case managers can help ensure errors are corrected without an adverse result for the patient.