Medical Errors & QSEN Safety Competencies

Medical Errors & Safety

• Medical errors annually result in between 210,000 - 440,000 patient deaths and are the third leading cause of death in the USA.
• Cost of $20 Billion dollars/year in the US.
• Healthcare failures contributing to safety lapses include failure to recognize, failure to rescue, and failure to plan.

QSEN Competencies

• The QSEN competencies include:
  • Patient-Centered Care
  • Teamwork & Collaboration
  • Evidence Based Practice
  • Quality Improvement
  • Safety
  • Informatics

QSEN defines Safety as:

• Minimizing risk of harm to patients and providers through both system effectiveness and individual performance.

TJC 2024 National Patient Safety Goals for Hospitals

• Identify patients correctly
• Improve staff communications
• Use medications safely
  • Label Medications
  • Medication Reconciliation
• Use alarms safely
• Prevent Infection
  • Hand hygiene
• Identify Patient Safety Risks
• Prevent Mistakes in Surgery

Fire Safety - RACE

• Rescue anyone in immediate danger.
• Activate the fire code and notify appropriate person.
• Confine the fire by closing doors and windows.
• Evacuate patients and other people to a safe area.

The BIG 3 in Safety Errors: Medication Errors

• Medication errors are the most common safety errors.
• Medication errors occur at any point in the medication use process.
• 1.2 million patients are harmed each year by medical errors made in US hospitals.
• Over $40 Billion annually goes toward treating the consequences of medication errors.
• Computerized medication ordering systems can prevent 84% of dose, frequency, and route errors.

Types of Medication Errors

• Omission: Drug not prescribed, dispensed, or administered.
• Commission:
  • Wrong drug, dose, or route
  • Wrong patient
  • Frequency, timing, or duration of the drug is incorrect
  • Allergic reaction
  • Drug interaction

Nursing Student Medication Errors

• A systematic review of 1904 nursing student medication errors found:
  • Majority of errors were wrong dose (17%).
  • Other common errors: Omission (16%), Wrong time (13%).

Student Barriers to Building a Safer Culture

• Lack of acceptance of corrective feedback.
• Near misses (no harm to patient) often lack learning opportunities.

The BIG 3 in Safety Errors: Falls

• Falls are considered a "never event" in healthcare.

Fall Demographics

• Females are more likely to fall than males.
• Fall risk increases with age, especially over age 65.
• Over 2.8 million older people are treated in the ED for fall injuries each year.
• 800,000 patients a year are hospitalized after falls.
• Falls result in 27,000 deaths annually.
• Those over 75 years of age who fall are 4-5 times more likely to be admitted to an ECF.
• 50% of people over 75 years old who fall will die within 1 year.
• Cost of falls: $31 Billion Annually.

Falls Risk Factors

• 65 years old or older
• History of falls
• Cognitive impairment
• Altered gait
• Medications
• Incontinence
• Unsafe environment
• Sensory deficits
• Orthostatic hypotension
• Depression
• Assistive devices
• Confusion or disorientation
• New environment

Fall Prevention Interventions

• Complete fall assessments
• Frequent rounding
• Place on fall precautions
• Offer assistance to the toilet Q2
• Treaded socks
• Bed in low position and bed alarms ON
• Personal items within reach
• Call light within reach/Answer call lights promptly

Evaluation of a Patient-Centered Fall-Prevention Tool Kit

• A nonrandomized controlled trial of a patient-specific fall-prevention tool kit was associated with:
  • 15% reduction in overall inpatient falls.
  • 34% reduction in fall injuries.