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Patient safety: To do no harm
editorial opinion Patient Safety: To Do No Harm JAN ODOM, “As to diseases, make a habit of two things—to help, or at least, to do no harm.” Hippocrates
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O THOSE OF US IN health care who believe we practice as Hippocrates advocated, it is shocking that we are, in fact, harming patients. The Institute of Medicine estimates that 44,000 to 98,000 Americans die each year from preventable medical errors.1 In response, the Business Roundtable (BRT) initiated a new program, The Leapfrog Group, to encourage employers to reward hospitals that implement major safety improvements. The Leapfrog Group is a consortium of approximately 60 members who provide health benefits to over 20 million Americans and spend over $40 billion on health care each year. These employers have agreed to base their purchases of health care on rigorous patient safety measures. They have identified those safety measures as (1) computerized physician order entry, (2) evidence-based hospital referral, and (3) intensive care staffing by physicians trained in critical care medicine.2 It has been estimated that at least half of adverse reactions to medicines are the result of medical errors, and some statistics suggest that medical errors are the eighth leading cause of death among Americans.1 This is staggering news. It has also been sensational news. The Chicago Tribune ran a 3-part series on the problem of medical errors, and if you believed the titles, attributed much of the problem to nurses. The titles were “Problem Nurses Escape Punishment,”3 “Nursing Accidents Unleash Silent Killer,”4 and “Nursing Mistakes Kill, Injure Thousands.”5 The articles discussed what the author perceived as lax discipline by some boards of nursing, information on the misuse of infusion pumps that did not have safeguards built in place to stop the free flow of intravenous fluids, and errors that had occurred when nurses were inadequately educated or overwhelmed be-
MS, RN, CPAN, FAAN
cause of staffing shortages. There were kernels of truth in the series of articles. No one would disagree that there is a problem—with some medical devices and the conditions under which some nurses across the country function each day. However, patient safety is a much broader issue than just nursing. It involves physicians, pharmacists, nurses, medical devices, and most of all, the systems under which all these persons must perform. As has been recognized, one of the most common errors involves medication errors. One of the most common causes of medication errors has been identified as errors in prescribing or filling prescriptions.6 This is the reason that the Leapfrog Group has identified computerized physician order entry as one of the 3 criteria to use to determine health care services for their employees. One hospital reported decreasing the serious medical error rate by 55% with only minimal technical support and 80% with an advanced technology.6 Other causes of medication errors include incomplete patient information, confusion of drugs with similar names, lack of appropriate labeling, and environmental factors that distract health professionals.1 Admitting overflow patients to a unit that is not routinely assigned to that type of patient has also been mentioned as a problem because of the
The ideas and opinions expressed in this editorial are those solely of the author and do not necessarily reflect the opinions of ASPAN, the Journal, or the publisher. Jan Odom, MS, RN, CPAN, FAAN, is a Clinical Nurse Specialist, Surgical Services, at Forrest General Hospital, Hattiesburg, MS. Address correspondence to Jan Odom, MS, RN, CPAN, FAAN, 3007 Raphael Dr, Hattiesburg, MS 39402; e-mail address: [email protected]. © 2001 by American Society of PeriAnesthesia Nurses. 1089-9472/01/1604-0001$35.00/0 doi:10.1053/jpan.2001.26698
Journal of PeriAnesthesia Nursing, Vol 16, No 4 (August), 2001: pp 243-245
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JAN ODOM
244
unfamiliar drugs and routines for those particular patients. Using evidence-based hospital referral for patients with complex medical needs can reduce a patient’s risk of dying by more than 30% according to research.6 This involves referring to hospitals based on scientifically valid criteria, such as the number of times the hospital performs these procedures each year; and, interestingly enough, staffing ICUs with physicians who have credentials in critical care medicine has reduced the risk of patients dying in the ICU by more than 10%.6 What does this mean to those of us in perianesthesia nursing? First, I believe that being informed about what is happening in health care and nursing as a whole is invaluable. We know there are problems with patient safety. What can we do?
● Volunteer to work with any hospital or nursing workgroups that deal with patient safety. We have much to contribute. ● Look carefully at the systems in place in your perianesthesia setting to protect the patient. I think that the PACU is at greater risk for failure of the system than many other areas of the hospital. We are often in emergency situations with verbal orders spouted and medications delivered before accessing the computer—which means that some built-in systems will not be there to protect us. We have to be vigilant. What medications have cross-reactions with the medication we are administering? Have all the patient allergies been documented correctly? Are we administering the right dose? If treating a pediatric patient, was the zero and decimal point in the proper place and was the drug dosage based on weight? ● Know how to operate all equipment efficiently. Do away with any equipment that is a safety hazard for patients such as those infusion pumps that allow free flow if not programmed correctly. Use only the pumps that either provide no flow or the amount of flow programmed. Have the proper equipment in the unit, which has been maintained and is in working order, and know how to use the equipment. ● Maintain competencies. Some of this responsibility is shared by the facility where you
work. They must educate you on new procedures and new equipment. For the most part, however, it is our own responsibility to make sure that our competencies are maintained. Ask for help if you feel there is a procedure or treatment that you need to be more competent. Look up a medication if you are not familiar with the drug. ● Thoroughly educate patients on medications that they take and treatments that are prescribed. Encourage them to ask questions when something doesn’t seem right. ● Be very attentive and cautious when caring for patients who are not routinely assigned to your unit. This issue of Journal of PeriAnesthesia Nursing deals with clinical issues that can make a difference. All 3 of the original articles can have an impact on competencies that are critical. Malignant hyperthermia is a rare but life-threatening occurrence, and we must be competent to respond. Perianesthesia nurses routinely administer opioids in all perianesthesia settings. Knowing detailed information about the opioids can prevent future adverse drug reactions. For those perianesthesia nurses who routinely care for open-heart patients or plan to take the CPAN exam, the article on perianesthesia care of the cardiac patient can add knowledge to your practice. The Clinical Clips column discusses the issue of the overflow ICU patients in the PACU. Resolving and working with this issue in the best manner will decrease the risks associated with caring for patients not routinely cared for in your environment. Let’s resolve to be a part of the solution for the issue of patient safety and continue to “help or do no harm” to the patients in our care.
REFERENCES 1. Nordenberg T: Make no mistake: Medical errors can be deadly serious. Available at http://www.fda.gov/fdac/features/ 2000/500_err.html. Accessed June 2001 2. Business Roundtable: The business roundtable launches effort to help reduce medical errors through purchasing power clout. Available at http://www.brtable.org/press.cfm/464. Accessed May 2001 3. Berens MJ: Problem nurses escape punishment. Chicago Tribune, Chicago, IL. Available at http://www.chicagotribune. com/news/nationworld/article/0,2669,ART-46846,FF.html. Accessed September 2000 4. Berens MJ: Nursing accidents unleash silent killer.
PATIENT SAFETY Chicago Tribune, Chicago, IL. Available at http://www. chicagotribune.com/news/nationworld/article/0,2669,ART46845,FF.html. Accessed September 2000 5. Berens MJ: Nursing mistakes kill, injure thousands. Chicago Tribune, Chicago, IL. Available at http://www.
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chicagotribune.com/news/nationworld/article/0,2669,246844,FF.html. Accessed September 2000 6. Nando Media: Doctors turn to technology for clearer prescriptions. Nando Media. Available from archives at nandomedia.com. Accessed May 2001
T
O THOSE OF US IN health care who believe we practice as Hippocrates advocated, it is shocking that we are, in fact, harming patients. The Institute of Medicine estimates that 44,000 to 98,000 Americans die each year from preventable medical errors.1 In response, the Business Roundtable (BRT) initiated a new program, The Leapfrog Group, to encourage employers to reward hospitals that implement major safety improvements. The Leapfrog Group is a consortium of approximately 60 members who provide health benefits to over 20 million Americans and spend over $40 billion on health care each year. These employers have agreed to base their purchases of health care on rigorous patient safety measures. They have identified those safety measures as (1) computerized physician order entry, (2) evidence-based hospital referral, and (3) intensive care staffing by physicians trained in critical care medicine.2 It has been estimated that at least half of adverse reactions to medicines are the result of medical errors, and some statistics suggest that medical errors are the eighth leading cause of death among Americans.1 This is staggering news. It has also been sensational news. The Chicago Tribune ran a 3-part series on the problem of medical errors, and if you believed the titles, attributed much of the problem to nurses. The titles were “Problem Nurses Escape Punishment,”3 “Nursing Accidents Unleash Silent Killer,”4 and “Nursing Mistakes Kill, Injure Thousands.”5 The articles discussed what the author perceived as lax discipline by some boards of nursing, information on the misuse of infusion pumps that did not have safeguards built in place to stop the free flow of intravenous fluids, and errors that had occurred when nurses were inadequately educated or overwhelmed be-
MS, RN, CPAN, FAAN
cause of staffing shortages. There were kernels of truth in the series of articles. No one would disagree that there is a problem—with some medical devices and the conditions under which some nurses across the country function each day. However, patient safety is a much broader issue than just nursing. It involves physicians, pharmacists, nurses, medical devices, and most of all, the systems under which all these persons must perform. As has been recognized, one of the most common errors involves medication errors. One of the most common causes of medication errors has been identified as errors in prescribing or filling prescriptions.6 This is the reason that the Leapfrog Group has identified computerized physician order entry as one of the 3 criteria to use to determine health care services for their employees. One hospital reported decreasing the serious medical error rate by 55% with only minimal technical support and 80% with an advanced technology.6 Other causes of medication errors include incomplete patient information, confusion of drugs with similar names, lack of appropriate labeling, and environmental factors that distract health professionals.1 Admitting overflow patients to a unit that is not routinely assigned to that type of patient has also been mentioned as a problem because of the
The ideas and opinions expressed in this editorial are those solely of the author and do not necessarily reflect the opinions of ASPAN, the Journal, or the publisher. Jan Odom, MS, RN, CPAN, FAAN, is a Clinical Nurse Specialist, Surgical Services, at Forrest General Hospital, Hattiesburg, MS. Address correspondence to Jan Odom, MS, RN, CPAN, FAAN, 3007 Raphael Dr, Hattiesburg, MS 39402; e-mail address: [email protected]. © 2001 by American Society of PeriAnesthesia Nurses. 1089-9472/01/1604-0001$35.00/0 doi:10.1053/jpan.2001.26698
Journal of PeriAnesthesia Nursing, Vol 16, No 4 (August), 2001: pp 243-245
243
JAN ODOM
244
unfamiliar drugs and routines for those particular patients. Using evidence-based hospital referral for patients with complex medical needs can reduce a patient’s risk of dying by more than 30% according to research.6 This involves referring to hospitals based on scientifically valid criteria, such as the number of times the hospital performs these procedures each year; and, interestingly enough, staffing ICUs with physicians who have credentials in critical care medicine has reduced the risk of patients dying in the ICU by more than 10%.6 What does this mean to those of us in perianesthesia nursing? First, I believe that being informed about what is happening in health care and nursing as a whole is invaluable. We know there are problems with patient safety. What can we do?
● Volunteer to work with any hospital or nursing workgroups that deal with patient safety. We have much to contribute. ● Look carefully at the systems in place in your perianesthesia setting to protect the patient. I think that the PACU is at greater risk for failure of the system than many other areas of the hospital. We are often in emergency situations with verbal orders spouted and medications delivered before accessing the computer—which means that some built-in systems will not be there to protect us. We have to be vigilant. What medications have cross-reactions with the medication we are administering? Have all the patient allergies been documented correctly? Are we administering the right dose? If treating a pediatric patient, was the zero and decimal point in the proper place and was the drug dosage based on weight? ● Know how to operate all equipment efficiently. Do away with any equipment that is a safety hazard for patients such as those infusion pumps that allow free flow if not programmed correctly. Use only the pumps that either provide no flow or the amount of flow programmed. Have the proper equipment in the unit, which has been maintained and is in working order, and know how to use the equipment. ● Maintain competencies. Some of this responsibility is shared by the facility where you
work. They must educate you on new procedures and new equipment. For the most part, however, it is our own responsibility to make sure that our competencies are maintained. Ask for help if you feel there is a procedure or treatment that you need to be more competent. Look up a medication if you are not familiar with the drug. ● Thoroughly educate patients on medications that they take and treatments that are prescribed. Encourage them to ask questions when something doesn’t seem right. ● Be very attentive and cautious when caring for patients who are not routinely assigned to your unit. This issue of Journal of PeriAnesthesia Nursing deals with clinical issues that can make a difference. All 3 of the original articles can have an impact on competencies that are critical. Malignant hyperthermia is a rare but life-threatening occurrence, and we must be competent to respond. Perianesthesia nurses routinely administer opioids in all perianesthesia settings. Knowing detailed information about the opioids can prevent future adverse drug reactions. For those perianesthesia nurses who routinely care for open-heart patients or plan to take the CPAN exam, the article on perianesthesia care of the cardiac patient can add knowledge to your practice. The Clinical Clips column discusses the issue of the overflow ICU patients in the PACU. Resolving and working with this issue in the best manner will decrease the risks associated with caring for patients not routinely cared for in your environment. Let’s resolve to be a part of the solution for the issue of patient safety and continue to “help or do no harm” to the patients in our care.
REFERENCES 1. Nordenberg T: Make no mistake: Medical errors can be deadly serious. Available at http://www.fda.gov/fdac/features/ 2000/500_err.html. Accessed June 2001 2. Business Roundtable: The business roundtable launches effort to help reduce medical errors through purchasing power clout. Available at http://www.brtable.org/press.cfm/464. Accessed May 2001 3. Berens MJ: Problem nurses escape punishment. Chicago Tribune, Chicago, IL. Available at http://www.chicagotribune. com/news/nationworld/article/0,2669,ART-46846,FF.html. Accessed September 2000 4. Berens MJ: Nursing accidents unleash silent killer.
PATIENT SAFETY Chicago Tribune, Chicago, IL. Available at http://www. chicagotribune.com/news/nationworld/article/0,2669,ART46845,FF.html. Accessed September 2000 5. Berens MJ: Nursing mistakes kill, injure thousands. Chicago Tribune, Chicago, IL. Available at http://www.
245
chicagotribune.com/news/nationworld/article/0,2669,246844,FF.html. Accessed September 2000 6. Nando Media: Doctors turn to technology for clearer prescriptions. Nando Media. Available from archives at nandomedia.com. Accessed May 2001