Transcript About Medical Errors - Broward County Dietitian

Preventing
Medical Errors:
Specifically for the
Registered
Dietitian in all
Health Care
Settings
Barbara Truitt, RD, LD/N
Welcome
This is a two hour requirement for our
Registered Dietitian Licensure “in some
states”. This webinar will pose challenging
questions to you and at some points we will
have interactions with each other. We will
review basics of medical errors with
examples and how we can avoid making
medical errors ourselves. We will discuss
most healthcare disciplines, including
dietitians!
Objectives





Define Institute of Medicine (IOM) definition
for “Error”
Describe the interplay between medical
systems and individuals that can lead to
medical errors
Distinguish a bad outcome from a medical
error
Describe looks alike, sound alike medications
Describe The Joint Commission (TJC) “do not
use list of abbreviations”
Who can make a medical
error?
According to IOM: Hospital errors
rank between the fifth and eighth
leading cause of death (44,000 to
100,000), killing more Americans
than breast cancer (42,297), traffic
accidents (43,458) or AIDS (16,516)
Who pays the price?
me, you
my family,
friends, your
family and friends
Institute of Medicine (IOM)Definition
Error: “ The failure to complete a planned action
as intended or the use of a wrong plan to achieve
an aim”
IOMs list of “General Categories
for Medical Errors”
 Diagnostic
errors
 Treatment errors
 Prevention
 Other
Diagnostic errors
 Error
or delay in diagnosis
 Failure to employ indicated tests
 Use of outmoded tests or therapy
 Failure to act on results of monitoring or
testing
https://www.premierinc.com/quality-safety/toolsservices/safety/topics/patient_safety/index_1.jsp#IOM-1 definitions of key terms
Treatment
 Error
in the performance of an operation,
procedure, or test
 Error in administering the treatment
 Error in the dose or method of using a
drug
 Avoidable delay in treatment or in
responding to an abnormal test
 Inappropriate (not indicated)
https://www.premierinc.com/quality-safety/tools-services/safety/topics/patient_safety/index_1.jsp#IOM-1 definitions
of key terms
Prevention
 Failure
to provide prophylactic treatment
 Inadequate monitoring or follow-up of
treatment
https://www.premierinc.com/quality-safety/toolsservices/safety/topics/patient_safety/index_1.jsp#IOM-1 definitions of key terms
Other
 Failure
of communication
 Equipment failure
 Other system failure
https://www.premierinc.com/quality-safety/toolsservices/safety/topics/patient_safety/index_1.jsp#IOM-1 definitions of key terms
How many medical error-related
deaths do you think occur each
year?
 50,000?
 75,000?
 Over
90,000?
Medical errors account
for ∼98,000 deaths per
year in the United
States
Medical errors can lead to deathnot everyone walks away
Medication mistakes are a leading
cause of death after traffic accidents
and the largest percentage of
medical errors
(CDC, LA times)
5 deadly medication errors
http://wellness1.knoji.com/five-deadlymedication-errors/
1. Avoid removing medication labels from Rx and OTC bottles AND
do not mix medications in the same bottle
2. Follow directions on the bottle EXACTLY how prescribed
3. Take medications either with or without food and water
4. Do not mix Rx medications with herbal supplements
5. Read labels when taking an OTC medication with an Rx
Easy to make? You decide!
IOM-1 Medication errors:
A large percentage of medical errors are associated with
medications. The National Coordinating Council for Medication Error
and Prevention (NCCMERP) has approved the following working
definitions specifically for medication errors:


Medication error: Any preventable event that may cause or lead to
inappropriate medication use or patient harm while the
medication is in the control of the healthcare professional, patient,
or consumer. Such events may be related to professional practice,
healthcare products, procedures, or systems including prescribing;
order communication; product labeling, packaging and
nomenclature; compounding; dispensing; distribution;
administration; education; monitoring; and use.
Adverse drug event: An adverse drug event is any injury resulting
from a medical intervention related to a drug. Examples of such
injuries include heart rhythm disturbances, diarrhea, fever, nausea
and vomiting, renal failure, mental confusion, rash, low blood
pressure, and bleeding.
https://www.premierinc.com/quality-safety/tools-services/safety/topics/patient_safety/index_1.jsp#IOM-1
definitions of key terms
Medication errors can occur at any stage of
medication administration. These include:
 Ordering: wrong dose, wrong choice of drug,
 Transcribing: wrong frequency of drug
administration, missed dose because medication is
not transcribed
 Dispensing: drug not sent in time to be
administered at the time ordered, wrong drug,
wrong dose
 Administering: wrong dose of drug administered,
wrong technique used to administer the drug, and
 Monitoring: not noting the effects of the given
medication
https://www.premierinc.com/quality-safety/toolsservices/safety/topics/patient_safety/index_1.jsp#IOM-1 definitions of key terms
medical and medication
errors can happen anywhere
 In
the care of healthcare professionals
 Pharmacy
 Family
 Friends
 Neighbors
 Babysitters
Can you tell the difference?
Which one is red hots and which one is
Sudafed?
Answer
The first one is Sudafed
Look how closely they resemble each other,
could they be mistaken in YOUR house?
More ….
Which one are mints and which are medications?
Answer
The first one are the mints
Once again, look how closely they
resemble each other
See how easily an error can occur in your
home?
Do you know about ….?
Sound-alike
Look-alike
Sound alike, look alike
Patient brochure/website page:
“Ways You Can Help Your Family Prevent
Medical Errors!”
Other ways we and other health care
professionals can advise patients we come
into contact with, suggest they:
1. Voice concerns and all questions to the
appropriate professional if it is out of your
scope
2. Question side effects of medications,
especially new ones
3. Prepare a list of all medicines they currently
take and keep it on them and/or bring it to all
doctors and ER visits
4. Request copies of labs and all test results
Question
Have you PERSONALLY encountered any
medical errors while a patient in a hospital
or doctors office?
____ I have
____ I have not
Dietitians !
Here’s what the lawyers are
saying ….
Doctor or Hospital Liability for Negligence
“When a patient is under the care of a physician while in a hospital or other
facility, there is a duty owed to the patient by the physician and the
institution for reasonable medical care. If a patient must follow a specific
diet plan, failure to adhere to the diet can result in medical
malpractice. Frequently, this type of malpractice occurs when there is an
error on the part of the facility. For instance, if a person must receive a
diabetic, diet plan the wrong meal may be provided to the patient,
resulting in serious injury. Additionally, providing food and drink to a patient
where there is an order not to do so prior to surgery can result in
malpractice if the patient aspirates during the surgery. Other ways that
liability may result from failure of a physician or health facility to provide a
specific diet, is by the physician or health care provider to properly obtain
a full medical history. If there is no note made to a patient’s chart about
the restricted diet, a typical meal [REGULAR DIET]may be served to the
patient, causing injury. Finally, simple neglect of the patient’s dietary
requirements and restrictions may result in medical malpractice.”
Patient Safety:
Preventing Medical Errors – course for
nurses
“Transcription errors which can cause a
patient to receive an incorrect or
unordered treatment such as an erroneous
procedure, medication, activity, or diet”
http://www.orlandohealth.com/pdf%20folder/patient%20s
afety.pdf
Medical error “potentials” for
the nutrition department:
1. Diet orders
2. Food/drug interactions
3. Fluid restrictions
4. Food allergies
5. Religious dietary restrictions
6. Patient preferences
7. Change in location/facility
1. Diet order scenario
Order received for Puree, thickened liquids.
The kitchen gets the order, does not clarify
which level of thickened is correct and
gives the least restrictive: Nectar. The actual
diet order was for Honey and the patient
aspirates, who is responsible?
Error!
All parties hold some level of responsibility,
however, the kitchen will take the most
punishment since they directly provided the
inappropriate order and did not clarify.
Train all staff to double check incomplete
orders.
Risks for incorrect diet orders
There are different risks for diet error, depending
upon the nature of the patient’s diet plan. For
a diabetic, failure to adhere to a medically
required diet plan can result in the following:
●
hyperglycemia
●
kidney problems
●
ketoacidosis
●
death
Risks for diet errors (continued)
For a person on a low sodium or sodium
free diet, failure to follow the plan can result
in the following:
•hypertension
•stroke
•heart attack
•death
Risks for diet errors (continued)
For individuals taking blood thinning
medications, failure to adhere to a specific
diet plan can cause:
•uncontrolled bleeding
•stroke
•death
Registered dietitians cut hospital
nutrition order errors
“Registered dietitians (RDs) are faster and more accurate than other
hospital staff when entering physician-approved nutrition-related orders,
show study findings.
"The difference in error rates supports that RDs are qualified and
knowledgeable at accurately entering diet orders for the patients they
have assessed," say Mary Keith (St Michael's Hospital, Toronto, Ontario,
Canada) and colleagues. Following implementation of the new policy,
each order entered by an RD contained significantly fewer diet order errors
compared with those entered by registered nurses (RNs)and clerical
assistants. Writing in the Journal of the Academy of Nutrition and Dietetics,
the team concludes: "It is imperative that RD access to electronic diet
order entry systems be promoted and supported in hospitals where these
systems exist or are contemplated, as RDs are critical players in the
advancement of patient care."
http://www.news-medical.net/news/20120719/Registered-dietitians-cut-hospitalnutrition-order-errors.aspx
2. Drug-food interactions



What is a drug-food interaction?
A drug-food interaction happens when the
food you eat affects the ingredients in a
medicine you are taking so the medicine
cannot work the way it should.
Drug-food interactions can happen with both
prescription and over-the-counter medicines,
including antacids, vitamins and iron pills.
http://familydoctor.org/familydoctor/en/drugs-procedures-devices/prescriptionmedicines/drug-food-interactions.printerview.all.html
Food/Drug Interaction Scenario
Green leafy vegetables were served to a
patient who is on a blood thinner because
the diet clerk failed to enter the restriction
of high Vitamin K foods.
Error! Staff needs education
3. Fluid restriction scenario #1
The kitchen only counted “beverages”
given to a patient with a fluid restriction of
1000 ml daily for his diagnosis of Congestive
Heart Failure. He received jello and soup on
his lunch tray and a popsicle on his dinner
tray.
Error!
Fluid restriction scenario #2
An order for John Doe reads 1000ml fluid
restriction.
1. What if the kitchen gives all 1000ml?
2. What if the kitchen followed facility
protocol and gave half, but then nursing
didn’t follow protocol and gave 1000ml?
3. What if both gave 1000ml?
4. What if the nurses aide provides a water
pitcher to the patient?
Error!
How can we prevent this error
from occurring again?
Education to all staff who handle fluids and
interact with patients
Enforcing protocols to all participating
departments
Education to the patient, family and
caregivers
4. Food allergy scenario
Food allergies
A patient’s diet order comes down as Regular diet, allergy to soy. This patient
received many items with soy on her trays, because staff didn’t learn how to
properly read food labels. The two ways allergens are to be listed on a label
are shown below:

In parentheses after the name of the ingredient:
Example: lecithin (soy), flour (wheat), whey (milk)
OR

In a separate list after or next to the ingredients list.
Example: Contains soy, wheat, and milk.
8 common allergens:
Milk, Eggs, Fish (such as flounder, bass, or cod),Crustacean shellfish (such as
crab, lobster, or shrimp), Tree nuts (such as almonds, walnuts, or pecans),
Peanuts, Wheat, Soybeans
5. Religious diet restriction scenario
Kosher: means more than just “do not serve
meat and dairy at the same meal”
A patient receives an item on his or her tray
that does not meet their request.
Error!
6. Patient preference scenario
A patient tells the diet clerk she is a vegetarian,
the diet clerk “not realizing the different types of
vegetarianism” assumes no meat and hence
sends milk and eggs on her breakfast tray
because she felt the patient didn’t order
enough food. The diet clerk is confused and
can’t understand why the patient is upset. The
kitchen staff needs occasional in-services on
diets including all the different types of
vegetarianism.
Error!
7. Change in location scenario
Monday 7am Mr. Jones was discharged from room
300A, he was on a Regular diet.
8:30am Mr. Smith was transferred into room 300-A, he is
NPO for surgery at 2pm.
9:00am Mr. Jones breakfast tray was delivered to room
300A, the tray passer did not check name band or
verify patients name.
Mr. Smith did not know what NPO meant, so he ate the
Regular breakfast tray. When his nurse realized what
happened, Mr. Smith’s surgery was postponed and his
hospitalization was extended by one day.
Error!
Charting ….
Question
Do you abbreviate words or phrases in your
patient notes?
__ Yes
__ No
__ Sometimes
Find out what your facility has
approved before abbreviating
STANDARD PRACTICE
Page 1 of 55
Date:
February 1978
Date Reviewed:
February 1980; January 1982; January 1985; May 1988; July 1992; July
1993; November 1995; February 1996; May 1998; July 1999; September
2000; October 2001, September 2002, October 2003, November 2004,
January 2005, July 2007, August 2007, September 2007, September 2010;
August 2011: July 2013
Date Revised:
November 2008; November 2009; June 2011; August 2011; July 2013
Title:
COMMON ABBREVIATIONS USED AT
Policy:
Abbreviations used at
' shall be reviewed annually by the
Clinical Forms Committee. Approval by the Administrative Staff, the Medical
Staff, and the Executive Committee will be requested when revision to the abbreviation
list is recommended.
Abbreviations include:
A. Common General Hospital Abbreviations
B. Common Symbols
C. Metric System
Pages 2 - 53
Page 54
Page 55
STANDARD PRACTICE
Date:
Page 1 of
May 2004
Date Reviewed:
September 2005; April 2007; January 2008
Date Revised:
May 2004, September 2005; April 2007; January 2008
Title:
DO NOT USE ABBREVIATIONS
Purpose:
has developed an evidenced based list of dangerous abbreviations
based on the Joint Commission and the Dangerous Abbreviation list distributed by
the Institute for Safe Medicine Practices (ISMP). The following abbreviations should not be utilized in
any orders or handwritten medication related documentation.
1.
2.
U
IU
3.
QD
4.
5.
6.
7.
8.
QOD
MS
MS04
MgSO4
Trailing zeros (except that Trailing zeroes may be used where required to demonstrate the level
of precision of the value being reported, such as laboratory results, imaging studies that report
the size of lesions, or catheter/tube sizes)
Lack of leading zeros
9.
When the meaning or intent of an order is unclear for any reason, there must be written evidence of
confirmation of the intended meaning before the order is carried out.
See also:
Standard Practice titled: Standards for Documentation
Standard Practice titled: Common Abbreviation List
Notes and Abbreviations
Writing “cals” for “calories” or “BW” for “body
weight” may seem like harmless abbreviations,
but until you are sure it is a standardized
abbreviation by your organization, it is best to
play it safe and s-p-e-l-l i-t o-u-t
Misinterpretation
Think of the types of abbreviations that dietitians
use most often…
PRO
CHO
IBW
ABW (actual or adjusted body weight ?)
…and many more
Spell it out
It may seem obvious between dietitians, but
other healthcare professionals working in
the same environment may use similar
abbreviations, and it can cause confusion.
For example: ADA means:
American Disabilities Act
American Diabetes Association
American Dental Association and used to stand
for American Dietetic Association
Abbreviations – what does this
note say?
31 yo female adm with cc: CHF, ARF, HA, PE
following tx for OB, ? CP, may need to be
transferred to CCU.
Let’s think about it
Remember,
For every medical abbreviation you find, there can be up to ten
or more terms
Let’s take a glance at just a few ……
ARF means ….
 Acute
Renal Failure
 Acute Respiratory Failure
 Acute Rheumatic Fever
BA means ….
 Barium
 Baker
Act
 Backache
 Benzyl Alcohol
 Bronchial Asthma
 Brachial Artery
BP means ….
 Blood
pressure
 Bathroom privileges
 Bedpan
BS means ….
 Bowel
Sounds
 Bedside
 Breath Sounds
Capital C means ….
 Calorie
 Carbon
 Celsius
 Centigrade
 Clearance
(rate, renal)
 Compliance
 Concentration
 Cornea
CC means ….
 Cubic
Centimeter
 Chief Complaint
 Cardiac Catheterization
 Complications and Comorbidities
 With Meals (Latin)
 Caucasian Child
CCU means ….
 Coronary
Care Unit
 Critical Care Unit
CP means ….
 Cerebral
Palsy
 Chest Pain
DC means ….
 Discharge
 Discontinue
FX means ….
 Fracture
 Function
HA means ….
 Headache
 Heart
Attack
 Hahnium
 Hyaluronic Acid
 Hemagglutinin
 Hearing Aide
MR means ….
 Magnetic
resonance
 Medical records
 Mental retardation
OB means ….
 Obstetrics
 Occult
Blood
 Overactive Bladder
PE means ….
 Pleural
Effusion
 Pulmonary Edema
 Pulmonary Embolism
 Physical Exam
 Pelvic Exam
 Phenylephrine
PT means ….
 Patient
 Physical
Therapy
 Posterior Tibial artery pulse
SX means ….
 Signs
 Symptoms
 Surgery
 Suction
TX means ….
 Therapy
 Treatment
 Traction
How confusing is this?
 Gluc.
 GT
 GTT
 gtt.
 gtts.
Glucose
gait training
glucose tolerance test
Drop
Drops
Or this ?








LLB
LLE
LLL
LLQ
LML
LUL
LUE
LUQ
long leg brace
left lower extremity
left lower lung, lobe
left lower quadrant-abdomen
left middle lung, lobe
left upper lung, lobe
left upper extremity
left upper quadrant
Let’s rewrite it !
31 yo female admitted with chief complaint
(cc): Congetive Heart Failure (CHF), Acute
Renal Failure, Headache, Pulmonary
Edema following treatment (tx) for Obstetric
care, ? Chest Pain, may need to be
transferred to Coronary Care Unit.
Is that what you guessed?
Communication
In all work environments, communication is
crucial for preventing medical errors.
Whether you are in a hospital or have a
private practice, communicating with other
staff is important for the well-being of your
patients or clients.
Miscommunication
When miscommunication happens, it opens
the door for medical errors
DOCUMENT
DOCUMENT
DOCUMENT
When documenting:
1. Follow policies – use facility approved
sources [diet manual, guidelines,
abbreviations]
2. Use NCP, ADI
3. Be clear, consistent, precise
4. Use evidenced based calculations and
recommendations, up-to-date references
5. Never cut and paste
6. Be sure you are in the correct chart
Open references
Have references ready so your calculations
will be consistent every time
Am I in the right chart?
Before you
continue with
correct
documentation,
you may want
to check… are
you in the
correct
patient’s chart?
Wrong chart scenario
The RD goes to pick up a chart for Patient A,
and at the same time a nurse has a question
about Patient B, so the RD picks up that chart
too. Then the RD gets a phone call, and asked
another question by another nurse. Finally
they get back to charting on Patient A… in
Patient B’s chart.
Simple, honest mistake, cross thru with a single
line, write “error” and initial, now the same
situation can happen with Electronic
Charting…..
The same mistake can happen with Electronic
Medical Records too. Clicked on Patient A to
begin charting, but Patient B’s doctor calls and
wants a supplement added. Resume charting
on Patient A… in Patient B’s record.
Hints
Organize your patient information by using
checklists, to do lists or create your own
forms …..
RD form/template
To be certain you include everything you need
to in your notes, it’s a good idea to make a
cheat sheet, template form. On my cheat
sheet, the following items are listed so I am
consistent with my charting:
1. Height, Weight, BMI
2. Diet order & intake OR Enteral feeding
order and tolerance, residuals
3. Diagnosis, History, Labs, Skin condition
4. Edema, Braden Score
5. Important MD, RN or other discipline
comments about patient’s condition
Academy of Nutrition and Dietetics
charting recommendations
as listed in their toolkits :
Always do the following when
documenting on a patient …
At all times remember to:
• Check that you have the correct chart before you write.
• Chart a patient's refusal to allow treatment. Be sure to report this
to the patient's physician.
• Write "late entry" and the date and time if you forgot to
document something.
• Write often enough to tell the whole story.
• Chart preventive measures.
• Chart contemporaneously (contemporaneous notes are
credible). [happening at the same time]
At all times remember to:
• Write legibly, offering concise, clear notes reflecting facts.
• Chart what you report to other healthcare providers.
• Chart solutions as well as problems.
• Document your observations. Write only what you see, hear, feel,
or smell.
• Encourage others to document relevant information that they
share with you.
• Document circumstances and handling of errors.
• Chart your efforts to answer your patients' questions.
• Chart patient/family teaching and response.
• Chart all referrals/support efforts.
Academy of Nutrition and Dietetics
charting recommendations
as listed in their toolkits :
Never do the following when documenting
on a patient …
Do not:
• Chart a verbal order unless you have received one.
• Chart a symptom (for instance: c/o excessive thirst),
without also charting what you did about it.
• Wait until the end of the day and rely on memory.
• Ever alter a record. If you make an error, do mark
through it with one line, indicate you are making a
correction, and initial (or sign) and date.
Do not:
• Document what someone else said they heard, saw, or
felt (unless the information is critical -- then quote and
attribute).
• Write trivia: "a good day." (What does that mean?)
• Be imprecise. Avoid terms like "large amounts" and
"appears."
• Write your opinions.
• Blanket chart or pre-chart. It is considered fraud to chart
that you've done something you didn't do.
Charting Scenario
An RD visits their last patient of the day, but
forgets to write the chart note until the
following morning. Overnight, the MD
ordered a consult of the same patient for the
RD to complete the next day.
What should they do?
Document both interactions with the
patient, addressing discrepancy in date on
the first note.
NEVER BACKDATE!
Since the last RD note:
Patient had surgery on his ankle
He had a HgbA1C drawn, result: 13
BUT, because the RD copied and pasted, the follow up
note did not reflect any of these events
We actually ended the
webinar here !
Let’s look at some Dietitian
scenarios
Order recommendation
scenario
What if an RD meant to recommend an
order for 250ml enteral formula every six
hours (sometimes written QID) but instead
was written as QD (which is not suppose to
be used).
What would happen?
Weight loss
Dehydration
Abnormal labs
Low Pulse, Low Blood Pressure
Low Heart Rate
Confusion, Dementia
Constipation
Error!
Lets reverse it
An RD meant to recommend an order for 250ml
enteral formula once a day(sometimes written
QD, again not suppose to be used) but instead
was written as QID (four times a day) for a new
admission, 16 year old female, who has
Anorexia Nervosa and weighs only 55 pounds.
What would happen?
Pay attention to the “key facts” in this example
Refeeding
Edema
Abnormal labs
Error!
Education documentation
scenario
A patient is newly diagnosed with type 2
diabetes. Upon visiting the patient, the RD
provides verbal information as well as
educational handouts regarding blood sugar
monitoring, confirming the patient’s
understanding. Months later, the patient
returns with complications of diabetes, stating
they never received any type of education
on diabetes management.
In this case, what happens?
The dietitian’s notes are pulled to confirm
that it was discussed.
Or …… a note was not written
If the RD did not document education at
all, he or she has no defense that it was
provided.
If it’s not in the notes, it never happened
Document, document, document!
The best defense against medical errors is
proper documentation. If you say or do
anything related to a patient, put it into your
notes for accountability.
Learning new things….
 Changing
to NCP?
 Changing to computerized charting?
Using NCP – start slowly
 Pick
a few simple ones to start with and
slowly learn some of the others
 Focus on nutrition problems, not medical
Signing and Dating
Electronic medical records make changes to
the way we chart, making sure that all notes
are properly signed with the correct date of
documentation is still an important step. Be
certain to your computer displays the correct
date and time each day.
Nutrition Support
Both parenteral and enteral nutrition
support are high-risk for medical errors. But
would it be the dietitian that’s liable for
these errors?
What could go wrong…
Improper placement
Tube blockage
Infection
Blood sugar fluctuations
Aspiration
GI distress
Malnutrition
Electrolyte imbalance
Infusion discrepancies (bolus vs. continuous)
Under typical circumstances, any issues
relating to the type, amount, or rate of
formula/solution could leave the dietitian
responsible for errors. Procedural errors will
depend on the facility.
How to avoid complications:
 Monitor
labs (especially electrolytes)
 Address high levels of residuals
 Assess for protein-energy-malnutrition
 Ensure understanding between staff
members regarding instruction
 Check orders
Enteral feeding scenario
The dietitian writes the order for an enteral
feeding through an Nasogastric-tube as
“250ml”, not indicating whether it was bolus or
continuous.
A nurse reads the order and assumes 250ml/hr
rate.
What do you think the dietitian meant to order?
What could happen?
Of course the dietitian meant to write this order for a
BOLUS feeding, however, if the person who entered
or transcribed the order was in a hurry or had
people talking to them or they just didn’t verify
orders, mistakes like this can occur.
If not caught:
• The patient could aspirate
• Begin to vomit
• Have excessive diarrhea
• Hyponatremia
• Stress the kidneys, etc …..
Error!
Be clear and concise
Especially with nutrition support orders, it is
important to write them in a way that others
can understand.
Never assume that someone knows what
you mean… be very clear!
Always state full name of product, route,
rate, how often and if it does or does not
include flushes.
Example:
Nutrition Supplement Glucose 1.5, via
Nasogastric Tube, 40 ml hour x 24 hours. This
does not include flushes, refer to MD for
flush orders.
NDT, NGT, NJT
Why did I spell out Nasogatric Tube?
There is a big difference between
Nasogastric Tube and Nasoduodenal and
Nasojejunal tube.
Sometimes patients have more than one
tube i.e. trauma
PEG, PEJ
Do you know the differences in feeding
which need to be addressed with
Percutaneous Endoscopic Gastrostomy
(PEG) and Percutaneous Endoscopic
Jejunostomy (PEJ)?
What is it?
PEG tubes can allow for bolus feedings
because formulas and flushes are going
directly into the stomach.
PEJ tubes cannot allow for bolus feedings
because formulas and flushes are going
directly into the jejunum.
Medications and Enteral Formula
Enteral feeding may interfere with certain
medications. Though physicians and nursing staff
are also aware of these interactions, it is still
important to make note of the drugs.
Typically, for drugs to be given on an empty
stomach, the feed should be stopped 30 minutes
before and after administration. Nurses are usually
told “not to add medications while the feed is still
running. Stop the feed, flush the tube with water
and flush after each drug before starting the feed
again.”
It is always a good idea for the dietitian to remind nurses of this when this
type of medicine is noticed.
THIS IS WHERE THE ME PPT
ENDED IN AUG 2013
Prevention – the best
medicine
Most medical errors are preventable.
The more you are aware of possible errors,
the more likely you are to catch them.
In all of the scenarios that we looked at, did
you pick up on any ideas for preventing
medical errors?
1.
Document, document,
document!
2.
Communicate with staff
3.
Listen to your patients
and/or clients
Medical Errors in Health Care:
Josie's Story
http://www.nursetogether.com/medicalerrors-in-health-care-josies-story
This is a story of a woman who had her daughter in
a burn hospital and at some point during her care,
she noticed weight loss, thirst and a change in her
eyes. She knew her daughter was not right, the
hospital wanted to discharge her and the mothers
concerns were not taken seriously. Her daughter,
Josie, at age 18 months old, died from
complications of dehydration.
4.
Individualize care
5.
Promote safety in the
workplace
6.
Create routine to prevent
gaps in work
7.
Acknowledge areas of
improvement
8.
Report new issues
(or new ideas)
Medical errors may be simple and harmless,
or major and life-threatening. Doing what
you can to prevent all errors can save a life!
Scope of Practice
In hospitals, the role of the dietitian is fairly
cut-and-dry, but in smaller facilities, it’s easy
for the dietitian to become mixed up in
other roles.
Keeping boundaries
For example, in a behavioral health facility,
dietitians may play more of a therapeutic
role in treatment. But where do you draw
the line and refer to the therapist?
In a nursing home, is it the dietitian’s
responsibility to turn the patients to prevent
decubitus wounds? Wound care is
important, but remember your role as the
dietitian.
The best thing to remember is that if it feels
out of your realm of expertise, it probably is.
To ensure safety of your patient or client,
always reach out or refer.
Summary

Anyone dealing with a patient can cause a medical error

7 areas for the nutrition department where medical errors are
most likely going to occur:


Diet orders

Food-Drug interactions

Fluid restriction

Food allergies

Religious diet restrictions

Patient preferences

Change in location
Never backdate, it’s OK to write a note the following day as
long as you mention your interaction with the patient was prior
Summary - continued

Always document, EVERY encounter with patients

Double check you are in the correct chart/record

Organize your information and thoughts on a charting
template

Create your own worksheet, develop a routine so you don’t
miss anything

Don’t make up your own abbreviations

Spell out as much as possible

Only use facility approved resources
Summary - continued

Refer to ANDs charting recommendations of Do’s and Don’ts

Use evidence-based, up-to-date references

Be clear, specific with recommendations, especially enteral

Remember PEG, PEJ differences, educate staff and
medications which require TF to be turned off

Remember your scope of practice

In-service staff often

Notify management of mistakes, learn from them

Communicate
Thank-you !!!!