CE1005 | Contact Hours: 2
Medical Error Reduction and Prevention
The purpose of this course is to educate health care professionals on root cause analysis, medical error reduction and prevention and patient safety. Upon completion of this activity, the health care provider will be able to:
1. Define medical error and understand how these errors negatively impact patient care.
2. Understand root cause analysis for sentinel events.
3. Describe the most frequent types of sentinel events identified by the Joint Commission.
4. Identify what types of adverse incidents must be reported to the Florida Agency for Health Care Administration.
5. Understand the five most common medical misdiagnoses as recognized by the Florida Board of Medicine.
*There’s some material in this course that’s specific to Florida but there’s a lot of good information and this course is ANCC approved so any RN or LPN/LVN can complete this course and receive credit for it.
Sara Hilgenberg, LPN
CRITERIA FOR SUCCESSFUL COMPLETION
All learners must complete the entire activity and complete the evaluation to receive contact hours.
APPROVAL STATEMENT (ACCREDITATION INFORMATION)
This nursing continuing professional development activity was approved by the Ohio Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. (OBN-001-91).
In addition to states that accept American Nurses Credentialing Center (ANCC) courses, CE Leaders is an approved provider by the Florida Board of Nursing, and a registered provider with the Arkansas State Board of Nursing, District of Columbia Board of Nursing, Georgia Board of Nursing, Kentucky Board of Nursing, New Mexico Board of Nursing, South Carolina Board of Nursing and West Virginia Board of Registered Nurses (Provider # 50-33450).
RELEVANT FINANCIAL RELATIONSHIP
No one with the ability to control content of this activity has a relevant financial relationship with an ineligible company.
The United States spends more on healthcare but has worse outcomes than other high income countries around the globe. In 2019, the Commonwealth Fund surveyed healthcare system performance in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States across five domains. These domains were: access to care, care process, administrative efficacy, equity, and healthcare outcomes. The United States placed last overall and in every domain except care process, which it ranked second (1). The US has the highest infant mortality rate (5.7 deaths per 1,000 live births) and the lowest life expectancy rate of these nations (1). The US rate of preventable mortality of 177 deaths per 100,000 people is more than double that of the best performing country of Switzerland at 83 deaths per 100,000 (1). Medical error deaths are listed as the third highest cause of death here in the US, only behind heart disease and cancer and are responsible for an estimated 250,000 deaths per year (2). US surveyed participants have reported at least one of four types of errors personally experienced: a medical mistake in treatment or care, were given the wrong medication or dose, given incorrect results for a test, or experienced delays in being notified about abnormal test results (3). It is essential for the US to commit to a better overall healthcare system. Health care professionals need to pay greater attention to their patients, collaborate more effectively among their peers, evaluate new approaches to prevent medical errors, and close gaps in care to address the magnitude of medical errors observed.
1. The Joint Commission: jointcommission.org.
2. Florida Statutes: http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0300-0399/0395/Sections/0395.0197.html.
3. The Agency for Healthcare Research and Quality (AHRQ): (301) 427-1364 or www.ahrq.gov/tools/index.html for practical, research-based tools and resources to help a variety of healthcare organizations, providers, and others to make care safer in all healthcare settings.
4. The Institute for Safe Medication Practices publishes a list of error-prone abbreviations, symbols, and dose designations online at: https://www.ismp.org/Tools/errorproneabbreviations.pdf.
1. Mirror, Mirror 2021: Reflecting Poorly: Health Care in the U.S. Compared to Other High-Income Countries. Website. https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly?gclid=EAIaIQobChMIguiZy8uY9gIVkRh9Ch0gFwziEAAYAiAAEgJC_PD_BwE. Published August 4, 2021. Accessed February 25, 2022.
2. Johns Hopkins Study Suggests Medical Errors are Third Leading Cause of Death in U.S. Website https://hub.jhu.edu/2016/05/03/medical-errors-third-leading-cause-of-death/. Published May 3, 2016. Accessed February 25, 2022.
3. Doty M., Zapert K., Osborn R., et al. Taking the Pulse of Health Care Systems: Experiences of Patients with Health Problems in Six Countries. Website. https://www.commonwealthfund.org/publications/journal-article/2005/nov/taking-pulse-health-care-systems-experiences-patients-health?redirect_source=/publications/in-the-literature/2005/nov/taking-the-pulse-of-health-care-systems--experiences-of-patients-with-health-problems-in-six-countri. Published November 1, 2005. Accessed February 25, 2022.
4. AMA Code of Medical Ethics’ Opinions on Patient Safety. doi:10.1001/virtualmentor.2011.13.9.coet1-1109. Published September 1, 2011. Accessed February 25, 2022.
5. The 8 Most Common Root Causes of Medical Errors. Website. https://alwaysculture.com/hcahps/communication-medications/8-most-common-causes-of-medical-errors/#:~:text=A%20few%20of%20the%20most,on%20test%20results%2C%20failure%20to. Updated March 16, 2021. Accessed February 25, 2022.
6. Health Care Associated Infections. Website. https://www.floridahealth.gov/diseases-and-conditions/health-care-associated-infections/index.html. Updated February 28, 2022. Accessed March 1, 2022.
7. How to perform a root cause analysis for workup and future prevention of medical errors: a review. Patient Safe Surg. 2016;10:20. doi: 10.1186/s13037-016-0107-8. Published September 21, 2016. Accessed February 25, 2022.
8. Sentinel Event Policy and Procedures. Website. https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-policy-and-procedures/. Accessed February 25, 2022.
9. The 2021 Florida Statues. 395.0197 Internal Risk Management Program. Website. http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0300-0399/0395/Sections/0395.0197.html. Accessed February 25, 2022.
10. LeLaurin JH, Shorr RI. Preventing Falls in Hospitalized Patients: State of the Science. Clin Geriatr Med. 2019;35(2):273-283. doi:10.1016/j.cger.2019.01.007. Published March 1, 2019. Accessed March 1, 2022.
11. Florida: Special Emphasis Report: Fall Injuries Among Older Adults 2005-2014. Website. https://www.floridahealth.gov/statistics-and-data/florida-injury-surveillance-system/_documents/older-adult-falls-emphasis-report-2014.pdf. Published October, 2016. Accessed March 1, 2022.
12. STEADI- Older Adult Fall Prevention. Website. https://www.cdc.gov/steadi/. Updated July 26, 2021. Accessed March 1, 2022.
13. Florida Administrative Code. 64B8-13.005. Continuing Education for Biennial Renewal. Website. https://www.flrules.org/gateway/RuleNo.asp?ID=64B8-13.005. Accessed February 25, 2022.
14. Cancer Facts and Statistics. Website. https://www.cancer.org/research/cancer-facts-statistics.html. Accessed February 28, 2022.
15. Serious Misdiagnosis-Related Harms in Malpractice Claims: The “Big Three” – Vascular Events, Infections, and Cancers.doi.org/10.1515/dx-2019-0019. Published July 11, 2019. Accessed February 28, 2022.
16. Commonly Misdiagnosed Gastrointestinal (GI) Conditions. Website. https://www.healthline.com/health/epi/commonly-misdiagnosed. Updated March 6, 2019. Accessed February 28, 2022.
17. Gastrointestinal Diseases. Website. https://my.clevelandclinic.org/health/articles/7040-gastrointestinal-diseases. Updated January 14, 2021. Accessed February 28, 2022.
18. Wong CW, Tafuro J, Azam Z, et al. Misdiagnosis of Heart Failure: A Systematic Review of the Literature. J Card Fail. 2021;27(9):925-933. doi:10.1016/j.cardfail.2021.05.014. Published May 25, 2021. Accessed February 28, 2022.
19. Kwok, Chun Shing MBBS, PhD, Bennett, Sadie MS, Azam, Ziyad MBChB, et al. Misdiagnosis of Acute Myocardial Infarction: A Systematic Review of the Literature, Critical Pathways in Cardiology: Volume 20 - Issue 3 - p 155-162 doi: 10.1097/HPC.0000000000000256. Published September, 2021. Accessed February 28, 2022.
20. Kreiner, M. DDS PhD; Okeson, J. DMD; Tanco, V. DDS, et al. Orofacial Pain and Toothache as the Sole Symptom of an Acute Myocardial Infarction Entails a Major Risk of Misdiagnosis and Death. Website. http://www.quintpub.com/userhome/ofph/ofph_34_1_Kreiner_p53.pdf. Published November 1, 2020. Accessed February 28, 2022.
21. Silent Heart Attack. Website. https://my.clevelandclinic.org/health/diseases/21630-silent-heart-attack. Updated July 28, 2021. Accessed March 1, 2022.
22. Virani, S; Alonso, A; Aparicio, H; et al. Heart Disease and Stroke Statistics—2021 Update: A Report from the American Heart Association. 143:e254–e743. https://doi.org/10.1161/CIR.0000000000000950. Published January 2021. Accessed March 1, 2022.
23. Diagnostic Error is Patients with Neurologic Symptoms. Website. https://www.medscape.com/features/slideshow/diagnostic-errors/neurologic. Published October 31, 2016. Accessed March 1, 2022.
24. Gaitán, M; Correale, J. Multiple Sclerosis Misdiagnosis: A Persistent Problem to Solve. Frontal Neurol. 2019;10: 466. doi: 10.3389/fneur.2019.00466. Published May 7, 2019. Accessed March 1, 2022.
25. Spinal Cord Compression. Website. https://www.hopkinsmedicine.org/health/conditions-and-diseases/spinal-cord-compression. Accessed March 1, 2022.
26. Arce, Daisy MD; Sass, Pamela MD; Abul-Khoudoud, Hassan MD. Recognizing Spinal Cord Injuries. 64(4):631-639. https://www.aafp.org/afp/2001/0815/p631.html. Published August 15, 2001. Accessed March 1, 2022.