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Perspective Learner Course Guide Slide 49 LEGIBILITY ‒ EHRs have made illegible handwriting an anomaly rather than a norm. ‒ Remember, technology may be interrupted by Mother Nature, requiring the use of paper records. ‒ Make sure the opportunity for misinterpreting your documentation is minimal. The use of electronic health records (EHRs) has offered reduction in medication errors. Illegible handwriting is rarely an issue and most systems are designed to incorporate information about the patient’s allergies, past dose-responses, and other significant information. The caveat to the usefulness of the EHR is that the information is only as accurate as the data which the user places in the system. Hurriedly placing a medication list into an electronic record but neglecting to list allergies may prove to be a work-around which results in medical error and patient harm. Slide 50 Treatment Errors Unclear communication regarding: ‒ Treatment rationale ‒ Drug name ‒ Drug appearance ‒ Dosage & length of therapy ‒ Common side effects Unclear communication contributes to treatment errors. The following information should always be clearly relayed: Drug name, Drug appearance, Why the drug has been prescribed, How much and how often to take it, when to take it, How long to take it, What common side effects may occur, What the new drug replaced or supplements (Academy of Managed Care Pharmacy, 2010). The prudent nurse who is unfamiliar with a medication to be administered will stop and familiarize her/himself with the medication and potential side effects prior to administering the medication. He/she will also ensure the patient has a firm understanding of a newly prescribed medication. 35 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 51 Treatment Errors Lapse in basic infection control practices Recent study has revealed an alarming lapse in basic infection control practices associated with the use of syringes, needles, multi-dose vials, single-use vials and flush solutions. Slide 52 CASE STUDY In 2009, more than 2000 insulin-dependent diabetic patients from a U.S. Army hospital were placed at risk for acquiring blood-borne diseases when staff reused insulin pens between patients after only changing the needle. Consider this case study. Practitioners often do not recognize or understand that single-dose vials do not contain any type of preservative. Once opened and accessed for use with a single patient, these vials should be disposed of immediately, regardless of the amount of product remaining in them. Although today’s healthcare climate emphasizes cost containment, once opened and accessed for use with a single patient, these vials should be disposed of immediately, regardless of the amount of product remaining in them. Although disposing of multi-dose vials after one use might be difficult for some frugal users, keep in mind that the cost of a new vial per patient (unless it is a medication that is very difficult to obtain or expensive) is certainly less when compared with an outbreak in your facility (Paparella, 2011). 36 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 53 CASE STUDY ‒ As a young child, Josie had been given penicillin, turned blue, and was rushed to the hospital. ‒ She was 15 when she got strep throat, was given penicillin, and died. ‒ No one had asked her about medication allergies. In 2008, the Pennsylvania Patient Safety Advisory cited more than 3800 cases in which patients received medications to which they had documented allergies. Breakdowns in communication of allergy information include "documentation of patient’s allergies on paper but not entered into the organization's computerized orderentry systems, and allergies arising during episodes of care but not documented in the medical record or communicated to appropriate staff." Slide 54 VACCINE ADMINISTRATION Vaccine administration errors ‒ patient harm ‒ inconvenience ‒ wasted vaccine ‒ wasted time Historically, one of the cornerstones of public health medicine has been the administration of vaccines. Errors in the administration of vaccinations may result in: • Patient harm • Inconvenience to the parties • Wasted vaccine • Wasted time 37 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 55 6 “Rights” of Vaccine Administration Right ‒ Vaccine ‒ Patient ‒ Documentation ‒ Dosage ‒ Time ‒ manner To ensure the accurate administration of vaccinations, consistently utilize the 6 “Rights” of Vaccine Administration. • Right vaccine - Triple check the label to ensure you are administering the right medication. Always use the right diluent for the right vaccine. • Right patient - Verify the patient’s information. Always ask for the patient’s name and date of birth prior to vaccination. • Right documentation - Document the vaccine information statement date, vaccine manufacturer and lot number, clinic name and the person administering the vaccine. • Right dosage - Split or partial vaccine doses are NOT recommended. • Right time – Follow recommended intervals and age recommendations; administer vaccine before the expiration date. • Right route of administration - Review the package insert to determine the correct route of administration. Slide 56 Vaccine Administration Safety Habits ‒ Two identifiers ‒ Vaccine information sheets ‒ Proper storage and management – medicine and vaccine – sample medications Continued… There are several habits of safety which are conducive to prevention of medication errors: • Utilize two identifiers on all patient information. • Provide vaccine information sheets. • Perform proper medicine and vaccine storage and management. • Properly manage and store sample medications. 38 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 57 Vaccine Administration Safety Habits ‒ Appropriate refrigerator labeling ‒ Documentation: – Full vaccine administration – Non-prescription – Prescription (Continued) • Make sure that refrigerated medications are appropriately labeled. • Fully document vaccine administration without leaving blank spaces. • Reconcile and accurately document the patient’s use of non-prescription and prescription medications in the patient’s medical chart. Slide 58 PREVENTIVE ERRORS When it is clearly indicated that preventive actions should be taken, failure to do so is a medical error. The failure to prevent a condition is a type of medical failing and may include: • Inadequate monitoring or follow-up treatment, • Failure to implement action which would prevent known complications of a diagnosed disease, • Failure to treat family members or others exposed to infectious disease, • Failure to address clear risk factors for various conditions. Slide 59 CASE STUDY ‒ An 8 year old child presents to the local county health department following a non-life threatening stray dog bite. ‒ The child is examined and no serious injury is detected. Continued… Take a moment to review the offered case study. Does this case represent the occurrence of a medical error? YES The State of Florida requires surveillance and investigation of dog bite incidents which may pose risk of rabies. Staff must have knowledge and judgment of rabies prevention and control procedures. They must also possess the skills necessary to follow and apply guidelines. Data about the animal bit exposure should have been collected upon receipt of the initial 39 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide report/patient visit and efforts should have been implemented to locate the stray animal in order to determine risk for rabies exposure. If risk of rabies exposure was determined, animal isolation/ quarantine and rabies testing should have been conducted with recommendation for human post exposure prophylaxis treatment as appropriate. Mandatory state reporting should have followed