Transcript Diabetes Today: An Epidemic

Managing Hospital Safety:
Common Safety Concerns
Part 1 of 4
Objectives
• Focus on the impact of medication errors, “never”
events and hospital-acquired conditions on
patient safety
• Highlight the significance of needlestick injuries and
practices to help prevent their occurrence
• Review the role of the health care team in
maintaining hospital safety
• Discuss best hospital practices when handling
high-alert medications
• Identify strategies and solutions to improve safety
with insulin therapy
Patient Health and Safety Is the
Primary Goal of Hospitals
“First, do no harm”
— Galen
Common Safety Concerns
Within the Hospital Setting
• Medication errors
• Needlestick injuries
• “Never” events
• Hospital-acquired conditions
Medication Errors
• A medication error is defined as "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"1
• May lead to adverse outcomes and potential fatalities2
• Health care staff often worried about inflicting harm on
patients and associated consequences2
1. Phillips J et al. Am J Health-Syst Pharm. 2001;58(19):1835-1841.
2. Pelegrin GM. Medication errors in hospitals: an analysis. Pharmacy Times. October 2004.
http://www.pharmacytimes.com/issues/articles/2004-10_1564.asp. Accessed January 29, 2009.
Medication Errors Within the Hospital
Setting Are a Significant Burden
• ~1.3 million Americans are injured yearly as a result
of medication errors that occur in both the inpatient
and outpatient setting1
• At least 1 death per day is due to a medication error1
• Typically, medication errors occur in nearly 1 out of
every 5 doses given to patients within the hospital2
• Preventable inpatient adverse drug events, including
medication errors, may cost ~$2 billion per year3
1. US Food and Drug Administration. Medication errors. http://www.fda.gov/cder/handbook/mederror.htm.
Accessed January 29, 2009.
2. Barker KN et al. Arch Intern Med. 2002;162(16):1897-1903.
3. Kohn LT et al. To err is human: building a safer health system. 2000. http://www.nap.edu/openbook.php?isbn=0309068371.
Accessed January 29, 2009.
Types of Medication Errors
•
•
•
•
Prescription and Transcription Errors
Illegible orders
Missing or misplaced zeroes and decimal points
Use of abbreviations
Unintended drug ordered based on variety of drug formulations
Dispensing Errors
• Look-alike, sound-alike medications
• Incorrect preparation
Administration Errors
• Incorrect dosage, drug, or infusion rate
• Medication given to wrong patient
• Lack of drug monitoring or double-checking
Jackson MA, Reines WG. US Pharmacist. 2003;28(6):69-79.
Errors Associated With Adverse Drug Events
in the Inpatient Setting*
15
Serious
Patient cases
reported (n)
13
Moderate
11
Significant
10
5
0
4
Selection
Dosage
Surveillance
Type of Error
* Patients studied were in Swiss hospitals. No patients studied were located in the United States.
Of 6383 Swiss patients, error-associated adverse drug events were identified in 28 patients. Hardmeier B et al. Swiss Med
Wkly. 2004;134(45-46):664-670.
Needlestick Injuries
• Injuries due to needlesticks can be caused by
hypodermic needles, blood collection needles,
intravenous (IV) stylets and needles used to connect
parts of IV delivery systems1
• Health care workers are concerned about increased risk
of exposure to bloodborne pathogens and infection1
• Incidence of these injuries is often underreported2
1. National Institute for Occupational Safety and Health. Preventing needlestick injuries in health care settings. November 1999.
http://www.cdc.gov/NIOSH/pdfs/2000-108.pdf. Accessed January 29, 2009.
2. American Nurses Association. 2008 study of nurses’ views on workplace safety and needlestick injuries.
http://www.nursingworld.org/MainMenuCategories/OccupationalandEnvironmental/occupationalhealth/SafeNeedles/2008Invir
oStudy.aspx. Accessed January 29, 2009.
Identify Source of Potential Injury
Handling or
transferring
specimens
Cleanup
Recapping
5
11
10
Handling or
passing
device
during or
after use
Improperly
disposed
sharp
5
12
10
8
8
IV linerelated
causes
4
27
Disposalrelated
causes
Collision
with health
care worker
or sharp
Other
Manipulating
needle in
patient
National Institute for Occupational Safety and Health. Preventing needlestick injuries in health care settings. November 1999.
http://www.cdc.gov/NIOSH/pdfs/2000-108.pdf. Accessed January 29, 2009.