Best practices and unique approaches to reducing the occurrence of the nine most common medical errors
After Partnership for Patients released a report earlier this year detailing the nine most common medical errors in the United States, Sen. Barbara Boxer (D-Calif.) sent a letter to 283 acute-care hospitals in California asking them to detail the actions they are taking to reduce medical errors.
So far, 87 percent of hospitals have responded to Sen. Boxer's letter. She and her staff recently released a report that includes best practices gathered from hospitals' responses on how they are working to reduce the occurrence of the nine most common medical errors in their facilities.
The following is a breakdown of four best practices and unique approaches to reducing each medical error, gathered from Sen. Boxer's report. View the full report here.
Adverse drug events
- Use barcode technologies and electronic health records with computerized prescriber order entry
- Involve pharmacists throughout a patient's hospitalization
- Require nurses who are administering medicine to wear a colored sash or vest to prevent interruptions
- Have two clinicians independently verify doses prior to administering medication
Catheter-Associated Urinary Tract Infections
- Assess catheter necessity daily
- Maintain proper hand hygiene compliance
- Allow nurses to remove catheters without a physician order to remove unnecessary catheters in a more timely manner
- Set a standard time frame to remove catheters after operations (like two days after surgery) unless directed otherwise by a surgeon
Central-Line Associated Blood Stream Infections
- Use disinfection caps or antimicrobial port covers
- Use chlorhexidine baths and cloths
- Use maximal sterile barriers, like caps, masks, gowns, gloves and drapes
- Train staff in a simulation center on how to insert central lines
Injuries from falls and immobility
- Educate patients and their families and incorporate fall-prevention education in employee orientation
- Use a scoring system to assign risk to patients
- Place high-risk patients in rooms closer to nursing stations
- Use bed, chair and portable alarms for high-risk patients
Obstetrical adverse events
- Establish a "hard-stop" policy, like 39 weeks, to reduce rate of early elective deliveries
- Conduct emergency drills for certain situations, like postpartum hemorrhage
- Hold a multidisciplinary debriefing after emergency situations
- Reduce C-section deliveries for first-time mothers
Pressure ulcers
- Assess all patients for pressure ulcers before and during admission
- Have nurses discuss pressure ulcers during shift reports
- Employ a wound care team
- Use turn logs and clocks to remind nurses to reposition patients
Surgical site infections
- Use chlorhexidine baths or showers
- Use proper hair removal techniques to limit skin trauma
- Don't allow staff with open wounds, bandages or casts to scrub into surgical cases
- Conduct random black light inspections on ORs after cleaning
Venous thromboembolism
- Assess patients for their risk before surgery
- Use EHR prompts to have clinicians either order deep-vein thrombosis prevention or document why it was not ordered
- Reduce unnecessary central venous catheter days and limit the size of the catheters
- Employ wound care specialists
Ventilator-Associated Pneumonia
- Elevate patients' heads 30 to 45 degrees
- Maintain oral hygiene
- Wean ICU patients off the ventilator more quickly with the use of a percussion vest
- Assess patient readiness to extubate daily
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