Preventing Medical Errors in the School Setting - PowerPoint PPT Presentation

Loading...

PPT – Preventing Medical Errors in the School Setting PowerPoint presentation | free to download - id: 3ffe8f-NGNhN



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Preventing Medical Errors in the School Setting

Description:

Medical/medication errors carries a potentially high liability for school districts and county health departments. Errors can be attributed to poor training, ... – PowerPoint PPT presentation

Number of Views:115
Avg rating:3.0/5.0
Slides: 61
Provided by: Barbara392
Learn more at: http://www.doh.state.fl.us
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Preventing Medical Errors in the School Setting


1
Preventing Medical Errors in the School Setting
2
About This Presentation
  • Originally developed for Excellence in
  • School Nursing (2000)
  • Content and design updates for
  • conferences (2003 and 2004)
  • Revision for presentation to Manatee
  • County school nurses (2007)
  • Template for use across
  • the state (2008)

3
CE Requirements
  • Florida statute 456.013(7) requires health care
    professionals to have two hours of training in
    prevention of medical errors

4
Mission of School Health
  • To appraise, protect,
  • and promote
  • the health of students

5
Quality of Care
  • The degree to which health services for
    individuals and populations increases, and the
    likelihood of desired health outcomes are
    consistent with current professional knowledge.

Institute of Medicine (2000)
http//www.health-central.org/images/SchoolNurseCa
rtoon01.gif
6
Quote
  • Mistakes are a fact of life. Its the response
    to the error that counts.

-Nikki Giovanni (American poet, 1943- )
7
Objectives
  • Examine sources and types of medical errors
  • Identify error prone situations
  • Discuss safety needs of special populations
  • Apply quality improvement strategies, including
    root cause analysis, to reduce the occurrence of
    errors and improve student outcomes

8
Objectives (cont.)
  • List individual responsibilities for reporting
    medical errors
  • List strategies for improving student outcomes
    and preventing errors
  • Discuss the importance of public education in
    reducing errors

9
Definition of Medical Errors
  • The failure of a planned action to be completed
    as intended, or the use of a wrong plan to
    achieve an aim (IOM, 2000)

10
Medical Errors
  • Everyones problem
  • Adverse events that are preventable with our
    current state of medical knowledge

11
Scope of the Problem
  • 8th leading cause of death
  • A leading source of cost
  • A high risk for children
  • Low estimates due to under reporting
  • Huge non-economic impact
  • Trust of public
  • Stress on providers

12
Two Types of Errors
  • Omission
  • Result from actions not taken
  • Medication not administered
  • Positive screening results not reported to family
  • Suicide because threats not reported
  • Commission
  • Wrong actions taken
  • Wrong medication administered
  • Procedure performed on the wrong
    student

13
Sentinel a Watch or Guard
  • Healthcare facilities are required to report
    sentinel event to the state and to JCAHO
  • An unexpected occurrence or variation that
    involves death or serious physical or
    psychological injury or the risk thereof to a
    patient

//www.jcaho.org/aboutus/newsletters/sentineleve
ntalert/sea_16.htm
14
http//www.jcaho.org/aboutus/newsletters/jcahonl
ine/index.htm
  • Joint Commission on Accreditation
  • of Healthcare Organizations JCAHO sets the
    standards by which health
  • care quality is measured in America
  • and around the world
  • Sentinel Event Statistics Update
  • Updated as of June 30, 2007
  • 4,473 patients were affected by these sentinel
    events
  • 3,257, or 71 percent, of those resulting in
    patient death

15
Top 10 Most Frequently Reported Sentinel Events
  • 1. Patient suicide - 555 (12.4)
  • 2. Operative/post-operative complication 534
    (11.9)
  • 3. Wrong-site surgery 592 (13.2)
  • 4. Medication error 416 (9.3)
  • 5. Delay in treatment 336 (7.5)
  • 6. Patient death or injury in restraints
  • 7. Patient fall
  • 8. Assault, rape or homicide
  • 9. Transfusion error
  • 10. Perinatal death/loss of function

16
Root Cause Analysis
  • What is the real problem?

17
Problem Solving Process
  • Assess
  • Diagnose
  • Outcome
  • Plan
  • Implement
  • Evaluate

18
Root Cause Analysis
  • A problem-solving tool for identifying
    prevention strategies

19
Root Cause Analysis
  • Questions to answer
  • What happened?
  • Why did it happen?
  • What can be done to
  • prevent it from happening
  • again?

VA National Center for Patient Safety
www.patientsafety.gov/tools.html
20
Root Cause Analysis
  • Exhibits collaboration between leadership and
    individuals
  • Is internally consistent
  • Includes consideration of relevant literature

21
2007 JCAHO National Patient Safety Goals
  • Improve the accuracy of patient information
  • Improve the effectiveness of communication among
    caregivers
  • Improve the safety of high-alert medications
  • Eliminate wrong-site, wrong-patient,
    wrong-procedure surgery

22
JCAHO Patient Safety Goals (cont)
  • 5. Improve the safety of infusion pumps
  • 6. Improve the effectiveness of clinical alarm
    systems
  • Reduce the risk of health care-acquired
    infections
  • Accurately and completely reconcile medications
    across the continuum of care

23
A Problem for the Individual or the System?
  • The key to reducing medical errors is to focus on
    improving systems of delivering care and not to
    blame individuals (IOM, 2000)
  • A shift from blaming individuals to sharing
    accountability for problem solving is required

24
Factors Contributing to Medical Errors
  • Individuals
  • Systems

25
High Risk Areas for Nursing Medical Errors
  • Medication delivery
  • Blood transfusions
  • Using restraints
  • Preparation and monitoring for procedures and
    surgery
  • Falls
  • Using equipment
  • Treatments
  • Delegation

26
Think-Pair-Share
  • What are some of the barriers and challenges of
    collecting data on medical errors?
  • What are the benefits of reporting medical
    errors?

27
Barriers to Reporting
  • Lack of time
  • Fear of punishment
  • Unclear reporting protocols
  • Poor record of improvement
  • Forgetting to complete form(s)

28
Adverse Event Reporting
  • Follow procedure and report immediately
  • Notify parents
  • Notify supervisor / principal
  • Document incident factually
  • Do not blame or make excuses!
  • Expect investigation to begin to identify
    contributing factors

29
Basis for Planning Follow-up
  • Conduct a thorough analysis
  • Inherent principle Dont blame the person
    rather, fix the system
  • Develop a timely corrective action plan (within
    45 days)

30
Populations at Risk
  • Rehabilitation patients
  • Persons with diminished capacity
  • Children

31
Age Specific Considerations
  • Emotional development of children
    their ability to cooperate with care
  • Patients who need supervision due to inability to
    care for self
  • Reduced medication dosing for neonates, infants,
    children elderly
  • Ability of different age groups to
    follow directions related to safety and
    asking for help

32
Special Populations
  • Patients with
  • Chronic illness
  • Renal or liver impairment
  • Immune system impairment

33
Brainstorm Activity
  • What types of medical errors can occur in the
    school setting?

34
Adverse Events in the School Setting
  • Screening
  • Skilled nursing care
  • Emergency care
  • Child neglect and abuse reporting

35
Adverse Events in the School Setting (cont.)
  • Unlicensed Assistive Personnel
  • Delegation transfer of responsibility for the
    performance of an activity from one individual to
    another with the former retaining accountability
    for the outcome
  • Medication Administration

36
Medication Safety
Phase 1 Ordering / Prescribing Phase 2
Dispensing Phase 3 Administration
37
Error Stage for Adverse Drug Events
  • Prescribing
  • Administration

68
25
Supply
7
38
Medication Errors in the School Setting
  • Type of Error Percent
  • Missed Dose 79.7
  • Not Documented 29.8
  • Over/double dose 22.9
  • No Authorization 20.6
  • Wrong Medication 20.0

Source McCarthy, Kelly and Reed - 2000
39
Medication SafetyPhase 1 Ordering / Prescribing
  • Essential Information
  • Diagnosis
  • Allergies
  • Age
  • Weight
  • Lab values
  • Essential Reference Material
  • PDR
  • Drug Handbook
  • MicroMedix

40
Medication SafetyPhase 1 Ordering / Prescribing
  • Development of protocols for high risk
    medications
  • Standardize where possible
  • Prohibit potentially confusing orders
  • Decrease the possibility of illegible or
    confusing orders.

41
Medication SafetyPhase 1 Ordering / Prescribing
  • Avoid
  • Abbreviations
  • Acronyms
  • Trailing Zeros

2.0mg
  • Use
  • Leading 0 with
  • Decimals 0.25 mg
  • Total Dose
  • Acceptable Order Format

42
Medication SafetyPhase 2 Dispensing
  • Use of technologies
  • Prefilled syringes
  • Premixed IV solutions
  • Acudose, other security
  • devices
  • Education about product changes
  • Neonatal pediatric medication calculations
    checked by pharmacist

43
Medication SafetyPhase 3 Administration
  • The RIGHT way to Give Medications RIGHT patient
  • RIGHT medication
  • RIGHT dose
  • RIGHT dosage form
  • RIGHT route
  • RIGHT time
  • RIGHT documentation
  • RIGHT to refuse

44
Medication SafetyPhase 3 Administration
  • Professional nurse must be knowledgeable about
  • Drug indications
  • Precautions
  • Contraindications
  • Potential adverse reactions
  • Interactions
  • Proper methods of administration

45
Documentation of Medication
  • Communication between provider, parent and school
  • Provides legal documentation of service

46
Types of Medication Information
  • Prescription
  • Physician orders medication
  • Authorization Form
  • Provides direction and parent permission or
    medication administration
  • Administration Record
  • Individual Medication Log
  • Medication Count Sheet

47
Medication Administration Review
  • Medication Policy available
  • Monitoring of UAPs
  • Annual training of UAPs (recommend)
  • Parental permission on file
  • Documentation of counting medications
  • Medications stored in original containers
  • Meds stored in locked cabinets or refrigerator
  • OTC drugs labeled with student name
  • Individual med logs
  • Tracking system for no shows

48
Activity Case Studies
  • Designate
  • Reader
  • Facilitator
  • Reporter
  • Read the case
  • Answer the questions
  • Report to the group

49
Reporting Errors in the School Setting
  • Initiate report at the time of the event
  • Follow district procedures for submitting the
    documentation to supervisors
  • DO NOT CITE THE REPORT IN THE STUDENT RECORD

50
Accidental Disclosure
  • Inappropriate or unintentional sharing of
    protected information with people without the
    need or right to know
  • Improper storageunrestricted access
  • Loud talking-overheard by uninvolved persons
  • Inappropriate discussions
  • Faxes and e-mails may be intercepted

51
Forms for Reporting Errors
  • Complete Forms
  • School District
  • Student Accident Report
  • Medication Incident Form
  • Medication Incident Correction Form
  • County Health Department
  • Incident Report

52
Processes to Improve Patient/ Student Outcomes
  • Simplify task
  • Standardize
  • Stratify - not one size fits all
  • Improve communication
  • Support team communication
  • Make the right procedure the simplest
  • Automate cautiously
  • Use good physical flow mechanisms
  • Respect human limits
  • Encourage reporting of errors and error
  • prone situations

53
Strategies for Prevention of Medical Errors in
the School Setting
  • Collaborate with partners
  • (CHD school district)
  • Establish clear communication
  • Meet with principal at the beginning of the
    school year
  • Clarify RN , LPN, Health Assistants, Health Aide
    roles and responsibilities
  • Review critical policies
  • Emergencies
  • Confidentiality

54
Establish Procedures, Training and Supervision
  • Establish and utilize procedures
  • Implement performance-based training and
    supervision
  • Observation and supervision checklists

55
Structure Work Environment to Reduce Probability
of Error
  • Separate supplies of look-alike medications
  • Discard d/c and out of date drugs
  • Encourage use of unit dose packages and separate
    containers for school and home
  • Minimize distractions when checking orders and
    preparing medications before administration

56
Educate Students and Families
  • Listen to student/family questions and concerns
  • Educate on treatment, medications, equipment,
    procedures, policies
  • Demonstration and return demonstration (practice)
  • NOTE Well informed students/families can help
    avoid serious errors

57
Looking to the Future
  • The safety of medication use in the pediatric
    population represents an important area of
    research need. This knowledge could minimize the
    risk and maximize the quality of care that
    children receive.

(AAPNational Summit on Medical Errors and
Patient Safety Research 2000)
58
Summary
  • Children are at risk for medical error
  • Errors should be tracked and analyzed
  • Root cause analysis helps identify contributing
    factors
  • Nurses have responsibility for reporting problems
    and potential concerns
  • Developing strategies for prevention can minimize
    unnecessary errors

59
  • Incompetent people are, at most 1 of the
    people. The other 99 are good people trying to
    do a good job who make very simple mistakes, and
    it is the processes that set them up to make
    these mistakes.
  • Dr. Lucien Leape,
  • Harvard School of Public Health

60
Contact Information
About PowerShow.com