Common medical error in nicu

Dr.Osama Arafa Abd EL Hameed

Consultantof

Pediatrics & Neonatology

Head of Pediatrics Department Port-Fouad Hospital

Common Medical Errors in

NICUBy

To Err Is Human

Kohn LT, Corrigan JM, Donaldson MS, Eds. To Err Is Human. Washington National Press, Wash, DC. 2000.

خطاء ادم بن كلEveryone makes mistakes

Introduction

The incidence and consequences of medication errors in the neonatal intensive care unit (NICU) demonstrate the importance of established safety procedures and guidelines for the prescribing, dispensing, and administration of medications.

As the professional voice of neonatal nurses, the National Association of Neonatal Nurses (NANN) recommends that appropriate measures and education be made available to everyone who prescribes or administers medications in the NICU and that members be proactive in participating in the development and implementation of safe medication practices in the NICU.

Introduction cont.

Three important variables make the medication administration process in the NICU uniquely and inherently risky: the vulnerable nature of NICU patients, the complexity of the medications used, and the challenges of the NICU environment

• Patients in the NICU are undergoing maturational changes in drugsensitive areas such as renal, gastrointestinal, and hepatic systems, resulting in variable responses to drugs and the disease process.• Medications are universally weight based, requiring calculations for each dose. But some of the drugs used also are based on gestational age, making it even more complex.

.

Introduction cont.

• NICU patients often have long hospital stays, which increases exposure to medications and medication errors. In premature infants, the immaturity of developing body systems affects the absorption, distribution, metabolism, and excretion of drugs, and therefore, the risk for medication errors is present.

•NICU patients are nonverbal and unable to actively participate in the patient identification process, which increases the likelihood of wrong-patient errors

•The increased incidence of multiple gestation births has also contributed to the misidentification of NICU patients

"A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.

Defining medication errors

Adverse event: unintended patient harm caused by medical

management rather than by a disease process, which results in a

prolonged hospital stay, morbidity, or mortality

Near miss: an error or mishap that had the potential to cause

patient harm, but did not, either by chance or thanks to timely

intervention

(Cuong Pham,J., Aswani,M.S., Rosen,M., Lee,H.W., Huddle, M.,Weeks, K., & Pronovost, P.J.,

2011, p.2)

Cont.

Effects of medical errors

Increase length of stay

Increased cost

Patient disability

Death

Nurse’s personal and professional status,

confidence, and practice

If you saw this, would you fly ?

Extra ExtraAirlines expect 1-2jets to crash daily

Over 1000 deaths expected weekly

But what about being a patient in the health care system

Extra ExtraAirlines expect 1-2 jets to

crash daily

Over 1000 deaths expected weekly

=44,000 – 98,000deaths annually

due tomedical errors

Accidents123,706

MedicalErrors

~100,000

Alzheimer's74,632

Diabetes71,382

How medical errors rank as cause of mortality

Heart616,067

Cancer562,875

Stroke135,952

Lung127,924

14

Near Misses in the NICU per 100 orders

2.8

1.3

0.77

0.35

0

0.5

1

1.5

2

2.5

3

NICU PICU Med/Surg Adult

**

* P<0.001JAMA 2014;285;2114-20

*

Wrong medication, dose, schedule, or infusion rate (including nutritional agents and blood products (47%)

Error in administration or method of using a treatment (14%)

Patient misidentification (12%)

Other system failure (11%)

Error or delay in diagnosis (8%); and error in the performance of an operation, procedure, or test (4%).

Errors in patient misidentification, for example, were a common cause of feeding a mother's expressed breast milk to the wrong baby.

The most frequent errors in NICU

Identification is important to the administration of medications and blood products, drawing laboratory specimens, performing diagnostic procedures, and administering treatments including surgery.

Patients cannot participate in the identification process, and the methods often used to differentiate individuals (age, size, sex, and hair color) are not as readily apparent in the neonatal population.

Caregivers must use the often difficult-to-read or access patient limb bands to check patient identifiers. Similar-sounding names, identical names, and similar medical record numbers are so frequent in the NICU that on some days, more than 70% of patients can be at risk for misidentification

Misidentification

Weight based dosing

Stock medicine dilution

Ten fold errors

Decreased communication abilities

Inability to self-administer medications

Increased vulnerability of young, critically ill children

Immature renal and hepatic systems

Why medication errors occur in children

18

Administering

Ordering

Dispensing

Transmitting

Administering

Ordering

Dispensing

Transmitting

Preventable ADEs Near Misses

Stages of medication errors

A circumstances exist for potential errors to occurB an error occurred but did not reach the patientC error reached the patient but did not cause harmD patient monitoring required to determine lack of harmE error caused temporary harm and some intervention

F temporary harm with initial or prolonged hospitalizationG error resulted in permanent patient harmH error required intervention to sustain the patient’s lifeI error contributed to the patient’s death

• The ability to care for patient – positive or negative emotion

• Harder to adjust diagnoses to correct ones• Negative Emotion

– Less time– Quicker diagnoses– Sicker patients may be less liked

• Positive Emotion– Under investigate– Delay in diagnosis– Tries to avoid uncomfortable procedures

Emotion and Medical Errors

• Physician writes an order

• Nursing, pharmacist, and clerical staff mechanisms are in place to carry out orders

• What occurs in reality?

Why Do Errors Occur?

A true comedy (tragedy) of errors

• Attending MD tells the resident to give the patient “free water” (meaning let her drink water”)

• Resident assumes he meant an IV and writes for water to be given IV

• New RN can’t find IV water and calls pharmacy asking where they get IVs; pharmacy asks no questions and tells the RN they get them from C.S.

• RN obtains IV from C.S. never questioning RN why she by-passed pharmacy; water bag says “water for irrigation”

A true comedy of errors

(continued)

• RN attaches the bag to regular IV tubing; RN infuses 600 mL of “free water”

• At change of shift, more experienced RN notes patient is lethargic, sees bag of water, removes it, and calls MD

A true comedy of errors

Free water has no electrolytes and would likely have caused burst red blood cells and

death if the second RN hadn’t interceded

• MD #1: used an unfamiliar term “free water” when he meant let the patient drink water

• MD #2: Intimidated to clarify so he wrote what he assumed was supposed to be an IV

• RN: well-meaning, wanted to help her patient; she called pharmacy and talked to whoever answered the phone; went to obtain the IV directly from Central Stores Dept

What did staff do wrong ?Should someone be fired ?

(continued)

• Pharmacy tech: didn’t identify herself as a tech; didn’t ask why the RN had this unusual request; didn’t consider having pharmacist consult with RN

• C.S. staff: never questioned RN why pharmacy was not involved; provided drug directly to RN without normal pharmacy process

What did staff do wrong ?Should someone be fired ?

An example of a latent condition is a laboratory report sheet that does not have alternating gray (shaded) and white rows.

A physician scanning the sheet reads the wrong value for platelets, and the infant receives an unnecessary platelet transfusion.

Alternating shaded and white rows are easier to read and would have likely prevented this error.

Examples from NICU Examples from NICU

The tubing misconnection errors reported recently in which a piece of tubing used for enteral feedings can be fitted to an intravenous line, eventually it will be, with disastrous consequences.

When this error occurs, the problem will not be prevented from occurring again by blaming the individual who made the error.

What we must do is make it impossible for such errors to occur by only using special enteral tubing for feedings that cannot be attached to an intravascular line.

Examples from NICU Cont,. Examples from NICU Cont,.

Many NICUs use some form of a "double-check" or "2-nurse check" system in an attempt to prevent errors, particularly medication and intravenous pump errors.

The very idea of having to confirm the calculation of a medication or how much is drawn into the syringe is insulting to many individuals because it suggests questioning of competence.

The double-check system can suffer from what is known as the halo effect -- professionals inherently shy away from questioning the integrity of other professionals. If someone has the reputation of being a good nurse, other nurses are unlikely to look closely at or question their medication calculations or how they have set their intravenous pumps.


• If Nurse A says to Nurse B, "I'm giving Baby Ahmed 1 mg of furosemide and it's 10 to 1, so I'm giving point 1 cc," and Nurse B says, "OK," a true double check has not been conducted. Nurse A has biased Nurse B's response by telling her that what she has drawn up is furosemide, what the concentration is, and how much is in the syringe. The only effective way to use the double-check system is to perform an independent double check. In this system, Nurse A would show Nurse B the order, vial, and syringe, and Nurse B would independently check to see whether the correct medication, correct concentration, and correct volume were drawn up for the correct baby. Obviously, independent double checks are more time-consuming and must be supported by providing adequate nurse-to-patient ratios.


OK – so what can we do ?

Communication and Teamwork

Many principles have been adopted from crew resource management, a system of training first used in the aerospace industry. A few good practices:

•Always identify yourself. Another person might be reluctant to speak up about a patient safety issue if he or she doesn't know your name. Identification of each team member also helps to establish role clarity.

•Use 3-way communication to request something you need during a critical situation. Using the person's name, make a request. •They should repeat the request, and you confirm it. This is known as request-response-confirmation (or challenge-response-response). It is much more effective than just yelling "somebody do this" and "somebody do that."

Communication and Teamwork Cont.

Learn to use SBAR, the structured language that can concisely communicate key information to others (Situation, what is going on; Background, how the situation developed, the objective data; Assessment, what you think the problem is; and Recommendation, what you think needs to be done).In a critical situation, if you are uncomfortable pointing out a safety concern, learn and use specific words or phrases that assertively express your concern.

One example used in crew resource management is, "I need clarity." Upon hearing this phrase, the team leader should understand that the team member is trying to raise a concern, and the team should stop what they are doing until the concern has been addressed.

• In general:– a safety culture is pivotal to improving

medication safety (encourage voluntary reporting)

– senior management must devote adequate attention to safety

– provide sufficient resources to quality improvement and safety teams

– authorize resources to invest in technologies, such as computerized provider order entry (CPOE) and electronic health records

Reducing medication errors in long-term care facilities

• Prescribers:– use sound med reconciliation techniques– avoid verbal orders except in emergencies– avoid abbreviations (U for units seen as a 0)– inform patients of reasons for all medications– work as a team with consultant pharmacists

and nurses– use special caution with high-risk medications– report errors and ADEs


• Pharmacists:– monitor the medication safety literature– in conjunction with doctors and nurses,

develop, implement, and follow a medication error avoidance plan

– verify the accurate entry of data on new prescriptions (avoid abbreviations; use TALLman lettering)e.g. Morphine HYDROmorphone

– report errors and near misses to internal and external medication error reporting programs


• Nurses:– foster a commitment to patients’ rights

(YOU are the patient’s advocate)– be prepared and confident in questioning

medication orders– participate in, or lead, evaluations of the

efficacy of new safety systems and technology

– support a culture that values accurate reporting of medication errors


JUST CULTUREManaging Errors

The term just culture describes a learning culture that provides a safe haven in which errors may be reported without the fear of disciplinary action in events in which there was no intent to harm.

It is a culture that rewards reporting and places a high value on communication.

Because it is a culture that thrives on knowledge, the reporting of near-miss and no-harm errors is just as important as the errors that result in harm to patients.

Of the 2 chief approaches to error:,

is the Person approach and the other is the systems approach.

The traditional person approach, also known as the "naming, shaming, and blaming" approach, will not help to prevent future errors.

If you focus only on the individual and not on the system, the error will occur again.

Errors Waiting to Happen

The systems approach recognizes that every system is perfectly designed to get the results that it gets, so if you want different results, you need to change the system.

The focus is on latent errors -- factors in the work environment that predispose to errors.

Latent conditions are like resident pathogens lurking in the system, waiting for the right opportunity to become errors.

Errors Waiting to Happen Cont.,

Conclusion

Medical errors are common in neonatal intensive care, and frequently result in harm to patients.

Reporting and analysis of all errors, and not just those that result in harm, are essential in learning how to prevent medical error.

Develop a working culture in which communication flows freely regardless of the authority gradient.

Finally, prevention requires an approach that doesn't blame individuals for errors, but focuses on a systems approach that seeks to root out, find, and correct the true causes of errors.

REFERENCES• 1 Ross LM, Wallace J, Paton JY. Medication errors in a paediatric teaching hospital in the UK: five years

operational experience. Arch Dis Child 2000;83:492–7. 2 Dean B, Schachter M, Vincent C, et al. Causes of prescribing errors in hospital inpatients: a prospective study. Lancet 2002;359:1373–8. 3 Expert Group on Learning from Adverse Events in the NHS. An organisation with a memory. London: Department of Health, 2000. 4 Folli HL, Poole RL, Benitz WE, et al. Medication error prevention by clinical pharmacists in two children’s hospitals. Pediatrics 1987;79:718–22. 5 Koren G, Reich A, Hales B. The role of clinical pharmacists in preventing potentially fatal ten-fold medication errors in children. J Pharm Technol 1991;7:219–21. 6 Leape LL, Cullen DJ, Clapp MD, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999;282:267–70. 7 Frey B, Buettiker V, Hug MI, et al. Does critical incident reporting contribute to medication error prevention? Eur J Pediatr 2002;161:594–9. 8 Kaushal R, Shonjania KG, Bates DW. Effects of computerized physician order entry and clinician decision support systems on medication safety: a systematic review. Arch Intern Med 2003;163:1409–16. 9 King JW, Paice N, Rangrej J, et al. The effect of computerized physician order entry on medication errors and adverse drug events in pediatric inpatients. Pediatrics 2003;112:506–9. 10 Kaushal R, Barker KN, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001;285:2114–20. 11 Deshpande SA. How common are violations of good prescribing practice in the neonatal unit? Arch Dis Child 2003;88(suppl 1):A20. 12 Koren G, Barzilay Z, Greenwald M. Tenfold errors in administration of drug doses: a neglected iatrogenic disease in pediatrics. Pediatrics 1986;77:848–9. 13 Choonara I. How to harm children in hospital: a guide for junior doctors. Paediatric and Perinatal Drug Therapy 1999;3:34–5. 14 Wilson DG, McArtney RG, Newcombe RG, et al. Medication errors in paediatric practice: insights from a continuous quality improvement approach. Eur J Pediatr 1998;157:769–74. 15 Fortescue EB, Kaushal R, Landrigan CP, et al. Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics 2003;111:722–9.

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Common medical error in nicu

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