A patient’s blood specimen was sent for T & C; he was discharged and later readmitted. His transfusion was sent to the unit with no new T & C specimen sent.

Following a suicide attempt, a teenager was transferred from the ER to a crisis response center.

A preschool child was being evaluated for an unsteady gait. ER nurses told her parents not to let the child walk. They allowed her to walk and she fell.

I incorrectly calculated the dose. I administered milliliters instead of milligrams. I gave an infant five times the dose he should have received. I did this on three occasions.

These healthcare safety events are just examples of the many safety threats that alarm the nation. Nurses and other healthcare professionals are continually seeking solutions, just as error reports are increasing and being addressed so that future occurrences are prevented.

The healthcare industry aims to improve therapeutic outcomes and quality of life, while effectively reducing the risk of harm to patients.¹ Medical errors thwart these goals. Despite the efforts of nurses and other healthcare providers, medical error rates in communities, hospitals, and homes remain high. Patients and families pay for errors through disability and death. Higher premiums for health insurance, higher costs for businesses, lower wages and benefits for employees, and social service programs provided by state and local governments also result.² Some estimate the annual cost of injuries related to medical errors at billions of dollars.

The 2008 National Patient Safety Goals of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) are to:

1. Improve the accuracy of patient identification by using at least two patient identifiers when providing care, treatment, or services;
2. Improve the effectiveness of communication among caregivers, for verbal or telephone orders or for telephonic reporting of critical test results, verifying the complete order or test result by having the person receiving the information record and "read-back" the complete order or test result; standardizing a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization; measuring and assessing, and if appropriate, taking action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values; and implementing a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions;
3. Improve the safety of using medications by identifying and, at a minimum, annually reviewing a list of look-alike/sound-alike drugs used by the organization, and taking action to prevent errors involving the interchange of these drugs; labeling all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field; and reducing the likelihood of patient harm associated with the use of anticoagulation therapy;
4. Reduce the risk of healthcare-associated infections by complying with current World Health Organization (WHO) hand hygiene guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines and managing as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a healthcare-associated infection;
5. Accurately and completely reconcile medications across the continuum of care by implementing a process for comparing the patient’s current medications with those ordered for the patient while under the care of the organization and communicating a complete list of the patient’s medications to the next provider of service when a patient is referred or transferred to another setting, service, practitioner, or level of care within or outside the organization (the complete list of medications is also provided to the patient on discharge from the facility);
6. Reduce the risk of patient harm resulting from falls by implementing a fall reduction program, including an evaluation of the effectiveness of the program;
7. Encourage patients’ active involvement in their own care as a patient safety strategy by defining and communicating the means for patients and their families to report concerns about safety and encouraging them to do so;
8. Have the organization identify safety risks inherent in its patient population and identifies patients at risk for suicide;
9. Improve recognition and response to changes in a patient’s condition by selecting a suitable method that enables healthcare staff members to directly request additional assistance from a specially trained individual(s) when the patient’s condition appears to be worsening.³

Coupled with The Joint Commission annual safety goals are the extensive efforts of the Agency for Healthcare Research and Quality’s researchers whose work on outcomes helps clinicians with decision-making. For example, such outcomes as mortality statistics, physiologic measures, symptoms, functional measures, and patients’ experiences with care provide information about benefits, risks, and results of healthcare practices and treatments. Studies that compare interventions supply evidence for nurses and other healthcare providers to improve care.⁴

Risky responsibility

Healthcare providers confront two types of errors: errors of omission that result from actions not taken, such as a patient fall or even suicide because of a lapse in observation or supervision, and errors of commission that stem from wrong actions taken, such as giving a patient an incompatible type of blood, administering a medication in the wrong eye, or failing to label a spinal fluid specimen correctly.

Errors affect nurses, physicians, pharmacists, administrators, laboratory technicians, administrators, drug and medical device manufacturers, and patients and family members. All are caught up in the suffering associated with these mistakes. When errors happen, providers react in similar ways, experiencing guilt, worry, and loss of clinical confidence.^5,6

Nurses, in particular, may equate errors with failure, with a breach of trust between themselves, patients, and physicians, and with harming patients, despite the desire and ethical mandate to “do no harm.”⁷ The associated horror and fear of punishment make nurses reluctant to report errors. While they fear for patients’ safety, they also dread disciplinary action from supervisors and employers.^5,6,8 Mistrust of supervisors and others in their employing agencies and fear of losing their jobs and the resulting economic consequences can result in not reporting every incident. However, underreporting and failure to report near-misses, where patients narrowly avoid adverse events, continue the likelihood of serious patient harm.

Nurses are often involved in errors simply because they participate in so many care activities or are the last people in a series of events in which mistakes were made. In spite of fears about malpractice lawsuits, many nurses recognize the benefits of reporting these mistakes. Along with other healthcare providers they share the responsibility to report errors and near-misses. Patient safety is their ultimate concern; being accountable for errors is in the interest of safety.⁹

Acknowledgment and accountability

Covering up errors is never harmless. Nurses who decide not to report them become their own judges,¹⁰ thus eliminating the possibility of investigation that might prevent similar errors. Failure to report errors is also a violation of the standard professional care owed to patients and may subject nurses to increased legal liability.¹¹ But it is no wonder that underreporting has been the norm¹² and prevails among nurses and other clinicians. They recall how professional staff treated them previously. One nurse shares her experience: “I reported [my error] to the head nurse, who humiliated me in front of my peers. I was a new grad.”

Another questions whether disclosure was the best option: “I never understood why it had to be reviewed on so many levels and why I had to go through anguish each time. It made me question if it is worth it to report a medication error. In later life, it helped me counsel young nurses in a more constructive manner to make it a learning experience. In policy, I advocate that one review is sufficient unless there are multiple offenses.”

Nurses are not only afraid of making errors, but also fearful of being known for committing these mistakes. They may have witnessed the expulsion of an error-prone nursing student, a once-common practice that persists in a few schools today. Nurses may have also noted the punishment of a peer in the work setting. They know that mistakes are often permanently recorded in personnel files, along with written warnings and notation of suspensions.

The reality is that punishment reduces reported errors,¹³ while the discipline and humiliation that administrators and regulatory boards visit upon nurses associated with errors may place more patients at risk.¹⁴ Rather than blaming nurses, administrators and review boards should take errors out of the blame-discipline structure and move them to a culture that is oriented in the accountability of a just culture.^9,15 Human error, negligent conduct, reckless conduct, and intentional rule violations describe elements of the just culture in which individual accountability is emphasized and discipline is reinstated. In this model, responses to errors are framed by the nature of the event and the responsibility of providers in the occurrence.

Nurses, perhaps along with everyone else, need to accept the fact that good nurses do make mistakes.¹⁶ It is possible that improved communication between physicians and nurses may foster autonomy and ultimately improve patient safety as nurses make patient care decisions.¹⁷ All providers must accept the contributions of their status and role issues to error-prone environments.

Reporting all errors may better serve patients and all healthcare providers. Because serious errors can be life threatening or cause permanent harm, they often warrant immediate nursing and medical intervention. A patient may need more frequent monitoring, further diagnostic studies, or more intensive nursing in a critical care unit. And documenting each intervention may protect nurses in the event of malpractice litigation.¹⁸

Types of errors and sentinel dvents

One of the leaders in patient safety for healthcare agencies is The Joint Commission. For years, The Joint Commission has required healthcare agencies to report sentinel events. As defined by The Joint Commission, a sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. They signal the need for immediate investigation and response. Not all sentinel events occur because of an error, and not all errors result in sentinel events. Intense analysis is required for confirmed transfusion reactions, significant adverse drug reactions, and significant medication errors. The Joint Commission must review events that have resulted in an unanticipated death or major permanent loss of function, not related to the natural course of the patient’s illness or underlying condition or if the event is one of the following:

• Suicide of any patient receiving care, treatment, and services in a staffed, around-the-clock care setting or within 72 hours of discharge
• Unanticipated death of a full-term infant
• Abduction of any patient receiving care, treatment, and services
• Discharge of an infant to the wrong family      
• Rape    
• Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities
• Surgery on the wrong patient or wrong body part           
• Unintended retention of a foreign object in a patient after surgery or other procedure 
• Severe neonatal hyperbilirubinemia (bilirubin >30 milligrams/deciliter)   
• Prolonged flouroscopy with a cumulative dose >1500 rads to a single field or any delivery of radiotherapy to the wrong body region or >25% above the planned radiotherapy dose.¹⁹

Sentinel event reports have increased dramatically between 1995 and 2007. The Joint Commission has released an analysis of 4,234 sentinel events reviewed since 1995. Sixty-eight percent of these events occurred in general hospitals, while 10.7% were reported in psychiatric facilities. The report with percentages of occurrence defines error-prone situations that deserve special attention by healthcare providers:¹⁹

• Wrong-site surgery (13%)       
• Suicide (12.6%)           
• Operative/postoperative complications (11.9%)           
• Medication error (9.3%)           
• Delay in treatment (7.5%)           
• Patient fall (5.6%)           
• Patient death/injury in restraints (3.7%)           
• Assault/rape/homicide (3.7%)           
• Perinatal death/loss of function (3.7%)          
• Transfusion error (2.4%).²⁰

Other medical errors reported include infection-related event, unintended retention of foreign body, anesthesia-related event, patient elopement, medical equipment-related fire, maternal death, ventilator death/injury, abduction, utility systems-related event, and infant discharge to wrong family.²⁰

Threats to patient safety exist in common causes of patient injuries. Examples of such error-prone situations are patients who have impaired strength and flexibility or impaired cognition; blood product transfusion; and medication ordering and delivery processes, especially for such high-alert medications (amiodarone IV; colchicine injection; heparin, low-molecular weight, injection; heparin, unfractionated, IV; lidocaine, IV; magnesium sulfate injection; methotrexate, oral, nononcologic use; nesiritide; nitroprusside sodium for injection; sodium chloride injection, hypertonic [more than 0.9 concentration]; and warfarin).²¹ Such circumstances should demand direct and immediate attention to prevent patient harm.

Hospitals and their error-reduction strategies for medication-use systems have successfully reduced drug errors. For example, addressing the challenge to patient safety when dealing with medications with high-allergenic potential, one hospital created a system to offer safer alternatives when those drugs were ordered.^22,23

Tubing misconnections, including feeding tubes, peritoneal dialysis catheters, intravenous catheters, epidural lines, distal ports of pulmonary artery catheters, tracheostomy tube, and automatic blood pressure cuff inflation lines, result in serious injury or death.²⁴ Nurses are attentive to the fact that as tubing increases, the potential for misconnection increases.²⁵ Luer-lock (connection made by rotating connector by a half or three-quarter turn) and Luer-slip (connection made by inserting the tapered male end into the female receptor) connections vary, thus promoting error-prone situations. In addition to tracing lines back to their origins before connecting or disconnecting devices or infusions, adequate lighting, patient and family education, and labeling high-risk catheters are some strategies that may help nurses avoid misconnections.²⁵

Factors that impact the occurrence of medical errors

Errors do not arise spontaneously; rather, they emerge from a complex interaction of factors, some situation-specific. The good intentions of healthcare providers are not enough to halt errors. They need to be well-informed about when and where errors can occur. For example, risk factors for wrong-site surgery (referring to surgical procedures performed on the wrong patient, body part, side of the body, or level of anatomical site) have been attributed to multiple procedures/multiple surgeons, communication breakdowns, time pressures, incomplete preoperative assessments, and organizational cultural factors not conducive to promoting teamwork, such as an attitude that surgeons’ decisions, should never be questioned.²⁶

Wrong-site surgery represents an important opportunity for patients and family members to correct a significant mistake. Engaging all stakeholders in knowing and minimizing the risks might prevent wrong body part surgery, surgery on the wrong patient, or a wrong surgical procedure. Increasing communication among patients, family members, and healthcare providers about the possibility of such mistakes alerts all to checks. Staffing issues, distraction factors, availability of pertinent information, such as X-rays and other imaging studies in the operating room, and cultural issues in an organization contribute to errors. Time outs, the immediate preoperative pauses involving the entire surgical team, occur on location where procedures are to be performed, such as when the patient is on the operating room table, are essential. The universal protocol is mandatory.^27,28

To prevent more serious patient outcomes, ORs, ambulatory surgery settings, labor and delivery rooms, radiology departments, endoscopy suites, physician offices, and other settings should label solutions and medications stored and delivered in bulb syringes, medication cups, basins, and other containers.^29,30,31,32

It is important to create courteous and respectful workplaces and to collaborate on action plans that eliminate interdisciplinary intimidation.³³ Pharmacy and therapeutics committees, patient safety committees, and multidisciplinary task forces are good places to work collaboratively on risk assessment and risk reduction. Another initiative is joint education programs in which providers learn roles and develop relationships with the agenda of improving patient safety.³⁴

Other causes of errors are more general. In addition to a breakdown in communication among healthcare providers, errors may stem from inadequate documentation, not following established policies and protocols or not having them at all, staffing patterns, and human error. Appropriate nurse staffing and shift work are linked with adverse events.^{35,36,37,38,39} In the case of operative and postoperative complications, The Joint Commission found six specific causes related to two general problems of communication and protocols —

• Necessary personnel not available when needed
• Incomplete preoperative assessment
• Deficient credentialing and privileges
• Inadequately supervised house staff
• Inconsistent postoperative monitoring procedures
• Failure to question inappropriate orders.⁴⁰

Ineffective communication compromises patient safety and is a leading cause of errors. Important risk factors include language barriers associated with culture and ethnicity; socioeconomic variables, such as education, literacy, and income; gender differences among providers and patients; and personality differences.

Communication failure results from perceptions of physicians as autonomous agents, lack of team training, hierarchy/power issues, and trust issues. Environmental issues that jeopardize safety include interruptions, noise, time constraints, heavy workload, multiple conversations, and absent face-to-face conversations. Daily changes in patients’ conditions constantly imperil safety efforts; such changes are counterbalanced by providers’ continuous and skillful responses to them with safety an ever-present agenda.^41,42

The Agency for Healthcare Research and Quality offers 10 Patient Safety Tips, distilled from research, to increase patient safety:

1. Survey staff in individual units and throughout the hospital on the need to assess and improve the culture of patient safety;
2. Limit shifts of more than 24 hours for medical residents and make sure they do not drive home after working extended shifts;
3. Eliminate the tradition of shifts of more than 30 consecutive hours by interns working in hospital ICUs;
4. Adopt interventions to reduce the incidence of ventilator-associated pneumonia in critically ill patients;
5. Count surgical instruments and sponges before and after procedures, and X-ray patients after surgery to reduce the likelihood of objects being left inside patients;
6. Use senior nurses and maintain appropriate round-the-clock staffing levels in ICUs to prevent airway tube complications;
7. Ensure that personal digital assistant-based drug information is readily available at the point of care;
8. Download a free software tool to identify ways to improve medication safety in the ambulatory care setting;
9. Use computer-based order entry to reduce catheter-related urinary tract infections;⁸
10. Minimize interruptions and other distractions faced by the nursing staff in their day-to-day routines.⁴³

Error prevention

A variety of strategies must be used to form a safety net. For example, a safety net against error can be created by combining interventions, such as placing hazard warnings where they will be seen, using computer technology for order entry, following written protocols and procedures, promoting the value of documentation, and providing education.

For many years, healthcare agencies have monitored their medical error rates, and nurses have been very involved in the documentation of errors. Error data collection and analysis have occurred for the most part on an institutional basis.⁴⁴ Incident reports are often the most common vehicle for reporting error in the workplace.

The reporting of medical errors and action plans to correct the problems have been on the national agenda. Some organizations have taken healthcare institutions to task as they invited voluntary reporting of healthcare mistakes. Two guiding frameworks for analysis have emerged to strengthen efforts devoted to improving patient safety.

Root cause analysis (RCA) is a process used to identify factors that underlie variations in performance, especially those associated with sentinel events. Incidents that result in serious physical or psychological injury or death are sentinel events. The occurrence of a serious error triggers an investigation aimed at improving systems and processes to reduce the likelihood of such an event in the future.^19,45

The Joint Commission requires healthcare agencies to conduct a RCA following the discovery of a sentinel event.⁴⁶ A root cause is the most fundamental reason for the failure or inefficiency of a process. This process pinpoints causative factors that bring about variations in performance, including the actual occurrence or possible occurrence of a sentinel event. Frequently, RCA is used after the fact to discover why problems occurred. However, some institutions are encouraging the use of RCA to prevent errors. Actions for improvement are specified and composed into action plans.

A sentinel event sets the RCA process in motion. For example, the following medication error was followed by RCA. A physician, who prescribed indomethacin (Indocin) for a patient who was allergic to aspirin, did not know about the crossover sensitivity between the two medications. A nurse, who subsequently administered the drug, also did not connect the aspirin allergy with indomethacin. The patient suffered a respiratory arrest and died. Following protocol, this sentinel event was reported to The Joint Commission within five days of discovery and an RCA was conducted and an action plan developed to prevent a reoccurrence. The Joint Commission received and reviewed the report. The agency maintained the RCA and action plans in confidence.

After data are entered into the The Joint Commission database, documents are destroyed. The Joint Commission aggregates the data, tracks errors, and shares risk reduction strategies with healthcare organizations through their Sentinel Event Alert newsletter. RCA and action plans help to improve compliance and determine risk. RCA is used to identify the most obvious opportunities for improvement that will prevent recurrence. The process may be used proactively to even greater organizational benefit; for example, a team of healthcare providers can study practices to prevent future problems from ever occurring.⁴⁷

The intention of RCA is to discover the hidden causes of error. Healthcare providers look beneath the surface of error events to get at the sources or most important reasons for mistakes. They persistently search for causes, so that they are satisfied that they have explained the event as logically as possible. Causes in clinical and organizational processes are investigated. An investigation that focuses only on the actions or omissions of clinicians is unfinished and flawed. Nurses and others should work as a team to focus primarily on systems and processes, not just on individual performance. Ideally, they avoid punitive approaches with involved individuals. They identify changes in systems and processes through redesign or creation of systems or processes that will improve performance and reduce the risk of a serious, future sentinel event. Healthcare providers often discover that many stakeholders in the healthcare agency share the problem. Ultimately, the implications of an agency’s not performing or not completing the RCA process is being placed on accreditation watch, a publicly disclosable indication that a sentinel event has occurred and an acceptable RCA and action plan have not been completed within a specified time frame. The Joint Commission conducts onsite reviews of sentinel events when patient health and safety are threatened. In more than 40 states, licensure and accreditation are intertwined.⁴⁸

Because patient safety is always the goal of healthcare agencies, reporting should always be encouraged among employees. Information from reports should be shared to prevent future errors.⁴⁸ For example, nurses, physicians, and other involved healthcare providers should be notified of errors made in the organization, situations in which errors could easily occur (near-misses), and strategies to prevent errors. Error trends should also be published across the organization.

RCA leads to action plans that include strategies that enable healthcare agencies to identify and reduce the risk of future, similar events. For example, regarding medication errors, action plans specify strategies for clinical processes and protocols that address high-alert drugs, the responsibility for implementation, time lines, and measurements of the action plan’s outcomes.

Failure mode effect analysis (FMEA) is a theory of error prevention that fosters safety in systems and the prevention of accidents. FMEA assumes that errors are not only possible, but also even likely, despite knowledgeable and careful healthcare professionals. This theory takes the onus for preventing errors off individuals by using an interdisciplinary group to engage in a never-ending process of quality improvement to assess and correct areas where errors are likely.⁴⁹ The Joint Commission has included a criticality assessment in the FMEA process. Failure mode, effects, and criticality analysis (FMECA) is a proactive risk reduction approach. The FMECA approach is similar to RCA, but differs in a more proactive rather than reactive orientation. Its aim is to determine failure modes in a system and to identify catastrophic and critical failure probabilities to minimize them as early as possible.^50,51,52,53 A failure mode includes systems and processes that could lead to a drug error. For example, a new drug to be evaluated for purchase by a hospital could be evaluated from acquisition through administration. If the name of the drug could lead to error, healthcare providers could create steps to prevent nurses, pharmacists, and physicians from confusing the new medication with another agent that had a look-alike name.

At checkpoints in each step of the process, FMECA strategies build redundancies that serve as safety nets or error traps. For example, when administering medications nurses may be required to read containers three times or have a second nurse check their work. Other checkpoints along the medication administration process where safety net strategies may be applied could be when —

• A provider writes a prescription, a unit clerk reads and transcribes the order, and a nurse checks the clerk’s work.
• A pharmacy technician reads, transcribes, and enters an order into the computer; a technician prepares doses for dispensing; and a pharmacist checks the technician’s work.
• A pharmacist dispenses medications and a nurse checks the pharmacy’s dispensing accuracy and medication doses before they are administered, or when the patient checks doses before they are administered.
• A pharmacist investigates why doses are returned or not administered.⁵⁴

Additional safety net strategies might include eliminating dangerous items from floor stock, limiting use or access to stored drugs in the pharmacy, building in safeguards to avoid confusing sound-alike or look-alike drugs, adopting a lock-and-key design for IV equipment, or using tactile cues and special packaging for medications.⁵⁵ Healthcare providers share the same concerns regarding medication prescribing, administration, and monitoring. Interdisciplinary collaboration is essential to accomplish safe medication use systems.⁵⁶ Courteous and respectful workplaces and collaboration on action plans will eliminate the safety threats of interdisciplinary intimiditation.³³ Pharmacy and therapeutics, quality improvement, and patient safety committees are good places to start to work collaboratively on risk assessment and risk reduction. Another example of FMECA applied to prevent pump programming errors tested a dose-error reduction system with a predefined drug library with dose limits for each drug.⁵⁷ Selected recommended actions were keypad backlighting and alerts for when rate or dose is out of range; nurse training to use a calculator on the pump; set pump question to clarify patient new to pump versus hospital; develop profile for code situations; enforce double check, preprinted drug levels to identify tubing above and below the IV pump, use tubing separators; and place concentrations on one screen.

Preventing errors and improving patient outcomes

Safety net strategies are as numerous as the causes of medication errors. To start, nurses should structure their work environment to reduce the probability of error. Some hospitals have created medication administration areas called quiet zones and encouraged nurses to discourage conversation. Also, separate supplies of look-alike medications and store them away from toxic chemicals. Hospitals are expected to take action to reduce look-alike/sound-alike misunderstandings, such as grouping drugs by category instead of alphabetical order, placing reminders in computerized systems and on labels of medication containers, and checking the medication label against the patient’s chart before giving the dose to the patient. Remove dangerous drugs, such as neuromuscular blocking agents and concentrated potassium chloride, from floor stock, and discard out-of-date drugs. Encourage pharmacists to purchase oral liquids in unit dose packages only.

Remove concentrated electrolytes from patient care units.⁵⁸ Create computer-based forms for parenteral nutrition orders to assist clinicians with the ordering process.⁵⁹

Nurses themselves should find places where distractions can be minimized when checking transcribed or computerized orders or preparing medications before administration. They also need to focus on the tasks at hand and avoid being rushed, no matter how challenging the situation. Nurses can help each other by offering support to colleagues when they are involved in similar activities. The Joint Commission requires nurses to use at least two patient identifiers when labeling, delivering, and maintaining specimen integrity, for example, the patient’s name spelled correctly and the correct date of birth. Since this is a National Patient Safety Goal, The Joint Commission surveyors will be closely observing the nursing staffs’ compliance with this requirement as they prepare blood products for transfusion, transfer patients unit to unit, and give patients their medications.

Activities that evaluate and strengthen the knowledge and performance of nurses and other healthcare providers can reduce errors. Nurses should attend periodic reviews, inservices, and sessions that focus on error-prone situations and test their ability to deal with them.

Other interventions involve the prescribers. Healthcare organizations can set policies that require them to print or type prescriptions and that allow telephone or verbal orders only when it is impossible for prescribers to write them. In the latter case the nurse must read back orders and receive confirmation from the prescribers. One of The Joint Commission’s National Patient Safety Goals specifies that for verbal or telephone orders and reporting critical test results, a “read-back” is required by the person receiving and recording the order or result, who must then read back the order verbatim to the initiating practitioner.

The practitioner should in return verbally acknowledge the accuracy of the order. When writing orders or prescriptions, providers should use only standard abbreviations, write a zero before a decimal point dose (e.g., 0.5 mL, not .5 mL), and avoid a “trailing zero” (e.g., 0.5 mcg, not 0.50 mcg). Likewise, look-alike abbreviations of QD, QOD, U, IU, or HS should be eliminated and included on a “do not use” list.⁴⁴ The Joint Commission has developed its own list of unauthorized abbreviations in association with their National Patient Safety Goals. In addition to leading and trailing zeros, QD, QOD, IU and U, mentioned above, the following unauthorized abbreviations will be checked for by surveyors when they read physicians’ orders and medication administration records, for example, MS and MS04 should be written out as morphine sulfate, and MgSO4 should be written out as magnesium sulfate.⁶⁰ Physicians and nurse practitioners should double-sign and double-check high-alert medications, especially those with narrow ranges of values for a therapeutic effect.

Communication breakdowns among healthcare providers can result in errors. SBAR (Situation-Background-Assessment-Recommendation) technique helps clinical teams connect when communicating about patients’ conditions and helps to frame conversations that call for immediate response.⁶¹ SBAR is used when the listener repeats the message back. Additional research needs to evaluate the effect of SBAR training.⁶² Moreover, teamwork training and education may improve the safety of healthcare agencies. Accepting the role and contributions of team members, reducing barriers that status imposes, and behaving at work with respect for all team members will affect patient safety.⁶³

Clinical decision-making is supported by computerized physician/ provider order entry (CPOE) systems. CPOE systems intercept errors when they most commonly occur at the time medications are ordered; prompt warnings against the possibility of drug interaction, allergy, or overdose; give accurate, up-to-date information on new drugs; provide drug-specific information, eliminating confusion from drug names that sound-alike; improve communication between physicians, nurse practitioners, and pharmacies; and increase efficiencies.^23,64 Clinical decision-making is also assisted by computerized alerting systems (wireless alerting systems). Both technologies might decrease errors, improve therapy, and improve outcomes.

Bar code medication administration (BCMA) and wireless handheld personal digital assistants (PDAs) are used to increase medication administration safety by providing real-time patient information, medication profiles, normal laboratory values, and drug information for accurate medication administration and documentation.⁶⁵ Electronic medication administration records help to identify incorrect and omitted medications, and cancelled or changed medication orders. Circumventing or working around barcode procedures threaten safety at point of care.

Automatic dispensing systems (ADS) free some of pharmacists’ time from dispensing medications by making drugs available to nurses at the point of care.⁶⁶ Root causes of medication errors related to automated medication dispensing machines include: machines filled with wrong product; different products mixed in same drawer; inadequate or lack of double checks when restocking; unused medication returned to wrong place; inattention to product label; errors in data entry to gain access; ability to override medication-use process safeguards; lack of pharmacist review of order; and deterioration of medication (i.e., past expiration, incorrect storage temperature).⁶⁷ The benefits and the threats of technology must be consistently evaluated.

Rapid response teams (RRTs) aim to prevent cardiac or respiratory arrest, failure to rescue, complications, and unexpected deaths.⁶⁸ RRTs (also called medical emergency teams or critical response teams) bring critical care expertise to the bedside or wherever it is needed.⁶⁹ RRT members in hospitals respond to urgent requests for improved quality and outcomes by The Joint Commission, the Center for Medicare Services, and the Institute of Health Care Improvement,⁷⁰ and healthcare providers’ professional organizations.

RRTs assist nurses in clinical decision-making and thus improve patient safety. RRTs bring structure to clinical crises. Team members act as consultants and assist staff in assessing and managing patients.⁶⁸ Many times nurse-to-nurse consultation results in the call for the RRT. Besides nurses, nursing assistants, physicians, and respiratory therapists, and anyone in hospitals initiate RRTs.

Effective handwashing has been linked to improved morbidity and mortality rates.³⁵ Central venous catheter bloodstream infection, catheter-associated urinary tract infection, and surgical site infection counts are being monitored by unit in hospitals along with staff compliance with effective hand washing. Sink availability and convenient paper towels in sink areas prevent nosocomial infections. The Centers for Disease Control and Prevention provided revised hand hygiene guidelines to reduce organism transmission, thus protecting patients. These guidelines include using alcohol-based handrubs, washing hands with traditional soap and water, avoiding artificial nails, keeping natural nails less than one quarter of an inch long, and changing gloves between patients.⁷¹ Role modeling by higher-ranking providers has been linked with compliance.³⁵ Patient crowding and staffing shortages have also been implicated increased infection rates.^65,72

Falls continue to threaten patients in hospitals. Elders fall walking and from beds, chairs, litters, and commodes. They are at risk for falls because of altered mental status, recent environmental change, need to urinate, strength, and balance. When risk of falling is assessed and patients are toileted, patient falls decrease.^35,73,74,75

All providers should follow well-communicated common protocols that guide care. And patients should be incorporated into their own care. Providers should listen to patients’ questions about how their care is delivered. Patients’ concerns must be respected and accepted as correct until confirmed. Nurses should provide patients with the information they need about their care. Well-informed patients can help providers avoid serious errors. The Joint Commission has supported this approach for a number of years with their “Speak Up” initiative that encourages hospitals to inform patients early in their hospitalization about the importance of their contributions to the safety of the care they receive. Encouraging patients to “speak up” when they are asked to take unfamiliar medications, verify the correct surgical site, experience inadequate pain management, act to prevent infection, or are about to be taken for diagnostic tests that they had no knowledge of makes them an active participant in preventing medical errors.⁷⁶

Patient safety will continue to increase as mortality and morbidity rates decrease when interdisciplinary efforts result in implementation of action plans aimed at reducing medical errors. Patient deaths resulting from healthcare-associated infections will decline when protocols, such as hospital-acquired, ventilator associated pneumonia protocols, are sustained. Blood transfusion errors will be prevented when healthcare providers join efforts to standardize procedures across all hospitals, orient staff to transfusion procedures, and patient/blood verification procedures.⁷⁷ Care quality will be manifested by decreased nosocomial infections, better managed pain, maintained skin integrity, reduced falls, improved functional status, enhanced quality of life, and enhanced social interaction and patient satisfaction with care.

Accountability for reporting and investigating

Medical errors and near-misses must be reported as soon as they are discovered. Nurses or other providers involved in errors may be the first who report them, when noticing a change in patients’ conditions that indicates an accident happened. The dissemination of emination of the just culture approach in which personal accountability results in increased reporting will decrease errors. Additional nursing research will contribute to patient safety outcomes. Because of their proximity to patients and families, nurses are in a unique position identify and carry out patient safety research.⁷⁸ Many are conducting research on nurse-sensitive outcomes addressing patient safety.