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Orange Park: Patient Safety

Medical Errors

Medical errors rank behind heart disease and cancer as the third leading cause of death in the U.S., Johns Hopkins researchers say. ... Based on an analysis of prior research, the Johns Hopkins study estimates that more than 250,000 Americans die each year frommedical errors.May 3, 2016

10 percent of U.S. deaths are due to preventable medical mistakes.

PATIENT HARMS

SURGICAL ERRORS        

Wrong-Site, Wrong-Procedure, and Wrong-Patient Surgery
Common Surgical Errors: They can Change Your Life
Patient Safety in the Surgical Environment - ACOG Committee Opinion 464
HOW TO AVOID SURGICAL ERRORS - OR /Today 2016
Speak Up: Preventing Surgical Errors - Joint Commission
Clinician Information - SAFR Guidelines

MEDICATION ERRORS     

Specifically, 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.

Medication Errors Related to Drugs - Food and Drug Administration

About Medication Errors | NCC MERP

Medication errors: Best Practices - American Nurse Today

MedlinePlus - National Institutes of Health

Institute for Safe Medication Practices

MEDICATION ERRORS IN NURSING: COMMON TYPES, CAUSES, AND PREVENTION - mEDCOM

 

DIAGNOSTIC ERRORS         
Diagnostic Errors - AHRQ
​Diagnostic Errors - World Health Organization 2016
Reducing Diagnostic Errors - Health Leaders October 2016

Improving Diagnostic Safety - AHRQ

The Path to Improve Diagnosis and Reduce Diagnostic Error - in Improving Diagnosis in Health Care - National Academies Press

National Guideline Clearinghouse

 

 

HOSPITAL ACQUIRED INFECTION      


Hospital-acquired infections are caused by viral, bacterial, and fungal pathogens; the most common types are bloodstream infection (BSI), pneumonia (eg, ventilator-associated pneumonia [VAP]), urinary tract infection (UTI), and surgical site infection (SSI).

HAI Data and Statistics - CDC summary of select HAIs across four healthcare settings; acute care hospitals (ACHs), inpatient rehabilitation facilities (IRFs),long-term acute care hospitals (LTACHs) and critical access hospitals (CAHs).

Top 10 Most Common Diseases Found in Hospitals

Hospital-Acquired Infections - Medscape

Clinical Advisor - Hospital Associated Infections

Clinical Advisor - Nosocomial Infections

Hospital-Acquired Infection: Definition and Patient Education - Healthline

Healthcare-associated Infections - CDC

Healthcare-associated Infections (HAI) Progress Report

Committee to Reduce Infection Deaths

Hospital-Acquired Condition Reduction Program - Medicare

Dangerous superbug appears to be spreading stealthily in US hospitals - Jan. 2017

How Your Hospital Can Make You Sick - Consumer Reports 2015

Guidelines Issued on Contact Precautions for MRSA - The Society for Healthcare Epidemiology of America has issued guidelines on how long contact precautions in acute-care hospitals should persist for numerous drug-resistant infections and Clostridium difficile.

HANDWASHING

The CDC has identified handwashing as the single most important means of preventing the spread of infection.5 

Clean your hands:

  • Before eating
  • Before and after having direct contact with a patient’s intact skin (taking a pulse or blood pressure, performing physical examinations, lifting the patient in bed)
  • After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings
  • After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient
  • If hands will be moving from a contaminated-body site to a clean-body site during patient care
  • After glove removal
  • After using a restroom

 

 

 

 
 

 

 

HANDOFFS - HANDOVERS - SHIFT REPORT

 

The process of transferring responsibility for care is referred to as the "handoff," with the term "signout" used to refer to the act of transmitting information about the patient. 

Ineffective hand-off communication is recognized as a critical patient safety problem in health care; in fact, an estimated 80% of serious medical errors involve miscommunication between caregivers during the transfer of patients.

Communication failures linked to 1,744 deaths in five years, US malpractice study finds - STAT February 2016

Handoff Communications - Joint Commission Center for Transforming Healthcare
      The Joint Commission requires that the “process for hand-off communication provides for the opportunity for discussion between the giver and the receiver of patient information” 

Handoffs and Signouts - AHRQ Patient Safety Network

I - Pass. Better Handoffs. Safer Care - Boston Children's Hospital

Communications Strategies for Patient Handoffs - ACOG Committee Opinion 517

Warm Handoff : transfer of care between two members of the health care team, where the handoff occurs in front of the patient and family. - AHRQ

10 Patient Handoff Communications Tools - Beckers 2014

Bedside Reporting at Shift Change - Press Ganey

SHAPED Patient-Centered Approach to Nurse Shift Change Bedside Report - Institute for Healthcare Improvement

Standardization of Inpatient Handoff Communication - Pediatrics Nov. 2016


Patient Engagement versus Patient Experience - NEJM

 

HOSPITAL ACQUIRED INJURIES

Hospital-acquired injuries are falls and other traumatic injuries (broken or dislocated bones, crushing injuries, or burns) that occur while a patient is in the hospital.

Medicare Penalizes Group of 751 Hospitals for Patient Injuries

FALLS

Researchers estimate that more than 500,000 falls happen each year in U.S. hospitals, resulting in 150,000 injuries.

Preventing falls and fall-related injuries in health care facilities - The Joint Commission, 2015

Preventing injuries from patient falls - American Nurse Today, July 2015

 

PRESSURE INJURIES (formerly PRESSURE ULCERS)

Pressure injuries (previously referred to as pressure ulcers) can occur for a variety of reasons, and can lead to pain, decreased quality of life, ​psychological stress, loss of work, and even death

Preventing Hospital Acquired Pressure Ulcers/Injuries - Health Research & Educational Trust (2017, April)

Ready, Set Go - Know Your Risks : Pressure Injuries - ECRI Institute

Impairment of a healthcare professional is the inability or impending inability to practice according to accepted standards as a result of substance use, abuse, or dependency (addiction). 

Drug Addiction in Health Care Professionals - Drug Enforcement Administration

New Law Requires Reporting of Healthcare Workers Who Fail or Refuse Drug Tests - Tennessee

Recognizing Impairment in the Workplace for Florida Nurses - Wild Iris Online Continuing Education Course

Nurses and Addiction

Diversion: A Quiet Threat in the Healthcare Setting - American College of Emergency Physicians

Workplace Impairment of the Health Care Professional - AMA policies and JCAHO standards

ASHP Guidelines on Preventing Diversion of Controlled Substances

Drug diversion and impaired healthcare workers - Joint Commission April 2019

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