Preventing Adverse Events- What nurses need to know?

“Too err is Human: Building a Safer Health System”

The title that shocked the healthcare when Institute of Medicine reported that adverse events were the leading cause of death. It is difficult to think that seeking help caused more damage than good. The change began and continue to evolve to make healthcare a safer place with emphasis on errors which occur due to negligence and can be prevented.

Not so long away, a wrong patient was operated on the leg when he was admitted for head injury. Result, patient underwent an unnecessary procedure, has difficulty walking and still left untreated. In this case, the doctor was blamed for the mishap and was barred from operating without supervision. But the question is, was there no one else who had seen the patient before? The nurse who sent the patient for surgery, assistant who transferred the patient or the operating team (junior doctors, nurses)? The answer is complex but since it was a serious adverse event which caused grave damage to the patient, it was highlighted and the one who had the responsibility (surgeon) faced litigation.

Every day such events happen labelled as ‘Adverse events’ but often go unreported with a fear of consequences one might have to face.

‘Adverse’ a word which is frightening when attached to any situation especially in healthcare where the possibilities are enormous and tosses the mind in all sort of directions when we talk about the word ‘Adverse events’. Nurses are involved in most of the patient care delivery services whether in-patient, outpatient, community health care, name it and nurses are there managing patient independently or assisting doctors to do so.

10 facts on patient safety- An eye opener on adverse events (WHO)

  • Patient harm is the 14th leading cause of global burden of diseases
  • While in hospital, 1 in every 10 patients is harmed
  • Unsafe use of medication harms millions and costs billions of dollars annually
  • 15% of hospital spending is wasted dealing with adverse events
  • Investments in reducing patient safety incidents lead to financial savings
  • Hospital infections affected 14 out of every 100 patient admitted
  • More than one million patient die annually from surgical complications
  • Inaccurate or delayed diagnosis affects all settings of care and harm an unacceptable number of patients
  • Overall medical radiation exposure increase is public health and safety concern
  • Administrative errors account for up to half of all medical errors in primary care

What are the types of adverse events in healthcare?

 

Types of adverse event

  • Adverse event- It is an injury that happens to the patient in healthcare and is related medical management that results in measurable disability, prolonged hospitalization or both. The cause of such adverse events however may not always occur as a result of error on the part of healthcare provider. A common example is adverse drug reaction which is unexpected reaction to a drug administered for therapeutic purpose. Adverse event caused by errors may include:
  1. Commission errors- These include errors which occur as a result of doing something wrong. A common nursing commission error would include administering wrong medication dose to a patient.
  2. Omission errors- These errors include the either delay, partially completed or incomplete care that a patient should have received. For example the most common missed nursing care aspects are ambulating a patient, giving mouth care or turning a patient which could lead more grave consequences such as development of pressure ulcer or pneumonia in ventilated patient. Read more here: https://psnet.ahrq.gov/primers/primer/29/Missed-Nursing-Care
  • Error- It is the failure of a planned action to be completed as intended called the error of execution or the use of a wrong plan to achieve an aim called the error of planning. Number of error happening in healthcare may be large so these errors are classified as the one which are potentially harmful (such as near misses).
  • Near miss- It is a serious error that could have caused an adverse event, but did not occur as it was detected or was interrupted. It is encouraged that a near miss event be reported as no harm was done to patient and the healthcare provider will not face in litigation.
  • Hazards and unsafe conditions- These refer to reporting of hazards that may happen for example look alike and sound alike medicines.

 

Medicine

Types of Adverse events in direct nursing care

As per the literature, the following are the most common types of adverse events reported in direct nursing.

1. Adverse events related to medication administration- One of the commonest type of adverse event. The possibilities of adverse events related to medication administration include:

  • Omission of medicine
  • Miscalculation of dosage
  • Errors during medicine administration
  • Inadequate dosage of medicine
  • Technical administration errors

Learn more about medication safety here:

2. Adverse events related to the monitoring of patient- These events happen as a result of lack of adequate monitoring of a patient which demands nursing attention. These include:

  • Patient fall
  • Displacement of catheters, tubes or drains

3. Adverse events related to the maintenance of skin integrity- Pressure ulcers and disrupted skin integrity of a patient is always directly associated with faulty nursing care. These events include:

  • Pressure ulcers as a result of lack of position change and inappropriate position in bed.

Learn more about pressure ulcer care here:

https://bodhihealthedu.org/product/care-of-patient-with-pressure-injury-bed-sore/

4. Adverse events related to material resources- These are the events which are preventable to quite an extent with efficient management and ensuring quality resources in patient care. Examples of these events related to material resources include:

  • Adverse event due to lack of equipment
  • Adverse event due to defective equipment

Are sentinel event and adverse event same?

Those of you who have participated in the process of accreditation especially Joint Commission International (JCI) must have heard the term Sentinel event. So, is it the same as adverse events?

Sentinel event- JCI defines sentinel event as an unanticipated death or loss of function unrelated to the natural course of the patient’s illness or underlying condition or wrong-site, wrong-procedure, wrong-patient surgery. It is called sentinel because it signals a need for an immediate investigation and response.

Sentinel Event= Adverse event + Near Miss

Sentinel event combines adverse event and near miss and covers the full range of undesirable events with varying degrees of serious outcomes.

Most commonly reported Sentinel events

Joint Commission on Accreditation of Healthcare Organizations (JCAHO) maintains database for the most commonly reported sentinel event which include the following:

  • Patient suicide
  • Operative/postoperative complication
  • Wrong-site surgery
  • Medication error
  • Delay in treatment
  • Patient fall
  • Patient death or injury in restraints
  • Assault, rape, or homicide
  • Transfusion error
  • Perinatal death/loss of function

Evidence based Patient Safety Intervention

The following are evidence based safety interventions based on extensive review which can prevent sentinel events in patient admitted in hospital.

  • Guidelines- Follow antibiotic guidelines to prevent pneumonia and reduce mortality rates.
  • Protocol for catheter insertion and maintenance- Catheter-associated urinary tract infection is a preventable event in healthcare setting. It can be done by giving catheter reminders and stop orders as soon as the requirement is not there. Nurses should be made in charge of assessment and suggest decisions when a patient does not need a catheter.
  • Use of care bundles- Care bundles to reduce rates of central-line-associated blood stream infections (CLABSI) are encouraged and are known to influence the rate of CLABSI. Similarly care bundles for other hospital acquired infections.
  • Use of Clinical pathways to avoid complications is encouraged. Clinical pathways are evidence based set plan of care involving a team of professionals (doctors, nurses, dietician, and physiotherapist) with defined time frames and expected outcomes for a particular disease condition.
  • Promoting multidisciplinary team collaboration and interventions to reduce mortality rates.
  • Multi-component interventions for reducing events like falls and delirium.
  • Encourage exercises to reduce risk of falling.
  • Regular review by pharmacist in the clinical areas to prevent adverse events related to medication and to control medication errors.
  • Increase number of trained support staff to reduce mortality.
  • Nurse-led early-discharge programmes to reduce mortality rates.
  • Creation of rapid response team with defined roles to manage cardiopulmonary arrest.
  • Surgical safety checklist to reduce the risk for surgical-site infections and reduce mortality rates.

What to do if the adverse event has happened?

Despite all the efforts there are times in clinical setting that adverse events happen and the nurse leaders need to take actions. The following image shows the possible sequence of action that must take place to ensure patient safety and to understand what precautions to take next when managing a similar case next time.

 

Step to manage adverse event

How to encourage adverse event reporting?

1. Positive reporting system- A positive atmosphere can promote increased reporting by the health professionals. It is the responsibility of top leaders to encourage professionals to report events and near misses without being fearful about negative consequences.

2. Educate- Organization must ensure regular sessions are organized as per the scope of errors they might come across during patient care, their responsibilities and clinical protocols that must be followed in adverse events.

3. Anonymous reporting and use of software- Anonymous reporting can be encouraged through placement of boxes or use of software for error reporting that a user can report on without disclosing their identities.

Learn more about encouraging reporting adverse event here:

 

Root cause analysis

As the name indicates, earlier root cause analysis was introduced in healthcare to analyze the serious adverse events. Usually, the purview of quality team in a hospital setting now involves the team altogether to understand the sequence of events that lead to a particular event.

Root cause analysis

An example from a real scenario:

A 50 year old patient collapsed in an OPD setting and suffered a cardiac arrest. The only nurse posted in the area approached the patient and started CPR. Code blue was activated eventually and crash cart was brought located on another floor of OPD. Patient could be revived but suffered complications due to delay in first aid.

Root cause analysis was done and it was found that due to delay in receiving the team support and arrival of crash cart, patient suffered complications. What we learnt from this?

  • More crash carts were installed.
  • Support staff were trained in CPR in all areas and trained how to assist in using a crash cart in both inpatient and OPD setting.
  • A team of professionals from the OPD to respond to Code blue was chosen as OPD and inpatient buildings were separate buildings.

Scenario two, same institute:

Another patient suffered an arrest in basement of inpatient building, where patient was undergoing a diagnostic tests. Technician and nurse manage patient. Patient is revived without any complications.

Take away:

One adverse event helped improve overall revival rate in the hospital and enhanced patient safety through the process of root cause analysis and implementation of solutions proposed.

Conclusion:

Adverse events are unfortunate but can be avoided with mutual team cooperation without blaming anyone. Hold your team together, you don’t know who will save you next. Remember before ‘REACTING’ to what your nursing team did wrong, understand how terrible must a person have felt after committing that error and he/she as healer caused more harm to the patient. See the link ‘When nurse becomes victim’-

 

References:

1. Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academy Press; 1999.

2. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370-6

3. World Health Organization. 10 facts on patient safety. Available from: https://www.who.int/features/factfiles/patient_safety/en/

4. Directorate General of Health Services Ministry of Health and Family Welfare Government of India. National Consultation Workshop on Patient Safety. 2010 May 10-20. Available from: https://www.nabh.co/Images/PDF/patientsafety.pdf

5. Duarte Sda C, Stipp MA, Da Silva MM, De Oliveira FT. Adverse events and safety in nursing care. Rev Bras Enferm. 2015 Jan-Feb;68(1):136-46, 144-54. doi: 10.1590/0034-7167.2015680120p.

6. Ostenberg PR, Reis P. Understanding and Preventing Sentinel and Adverse Events. ICU Management and Practise. 2008; 8 (2).

7. Nursing2019. 10 most common sentinel events. 2004 Nov; 34 (11): 35.

8. Zegers M, Hesselink G, Geense W, Vincent C, Wollersheim H. Evidence-based interventions to reduce adverse events in hospitals: a systematic review of systematic reviews. BMJ Open. 2016; 6(9): e012555. doi:10.1136/bmjopen-2016-012555

9. Kang JH, Kim CW, Lee SY. Nurse-perceived patient adverse events and nursing practice environment. J Prev Med Public Health. 2014; 47(5): 273-80.

Impact of Nurses on Patient Mortality and Morbidity

Doctors are often cited as ‘God’ in healthcare setting. Ever wondered what happens when doctor leaves a patient, who is the constant source of energy, support and care. Answer isn’t a tricky one, it is the nurses who stand by the patients when in an ICU a patient is not happy with his meals and wants to have his juice exchanged as he doesn’t like the flavor or a patient who is disoriented and wouldn’t let anyone touch him is taken care by the nursing team.

“Number of Nurses had greater impact on patient at higher risk whereas the effect of medical staff remain unchanged”

West E, 2014

Surprising, isn’t it. But research says so. There are nurses who would go beyond their call of duty and cross a river full of crocodile to reach the people for treatment literally! Read story of Sunita Thakur, an ordinary nurse who changed the world around.

nurse crossing river on duty call

I am sure if you are in healthcare, you must have come across few of these heroes who either taught you how to give injection, stood there with you when you were delivering a baby for the first time or encouraged you as you performed an independent surgery all by yourself.

However derogatory the remarks would have been against nurses, we have all met and worked with some, who continue to work, thrive and make us proud of who we are- Nursing Professionals.

Patient outcome and journey in a health care set up is enormously impacted by the nursing care he/she receives. Whether it is an operation theatre where a nurse tells the surgeon to count the sponges and instrument so that there are no accidents or it is the post-operative nurse who quickly assesses, identifies a life threatening arrhythmia and informs the doctor on duty, it all matter. It will decide whether the patient will be re-admitted for an avoidable mistake or if the patient will suffer a complication and stay longer than expected in the critical care unit.

Difference between Morbidity and Mortality

Morbidity- Morbidity in literal sense means being sick, ill or unhealthy. When we describe it in terms of ‘increased morbidity’ it means the reference is deterioration or impairment of health which happens over time.

Mortality- Mortality is related to one’s risk of death. Usually mortality is described in number of deaths in a setting over time (say month/yearly).

Do nurses impact morbidity and mortality in healthcare?

Yes, the nurses have very critical role to play in patient outcome in terms of morbidity and mortality. Nurses provide patient care round the clock as a result they are in the best position to identify the early signs of any deterioration in patient condition and take action.

A large study done by Needleman et al found the link of increased patient mortality with low staffing.

Read more here: https://www.nejm.org/doi/full/10.1056/nejmsa1001025

Case Study: Readmission of Patient with Planned Appendectomy

Day 1: A patient 45 years old gets admitted for appendectomy. He is a smoker (1 pack/day) and has no other history of medical condition and is not taking any medications.

Day 2: Patient is received post procedure in the post-surgical unit after successful surgery with no complications. Vitals are stable. Patient is conscious and reports pain at the surgery site. Urine output at the end of the day is 1000 ml/ day.

Day 4: Patient is discharged from the hospital with precautions explained to him and follow up.

Day 5: Patient returns to the hospital complaining of breathlessness. Nurse starts oxygen at 5 l/min as oxygen saturation is 90% and informs doctor about the patient. Patient is monitored and assessed for any complication and surgery site. Saturation of the patient is maintained 98% to 100% and patient feels better. The patient reveals that he did not quit smoking just a day before the surgery as well and also suffered nasal congestion as he had infection.

The information in this case was missed by the health professionals as patient continued to smoke. Patient also failed to mention about the infection he suffered just before the surgery. In this condition, the surgery of the patient could have been postponed as this was not an emergency procedure. But, what happened?

Patient got readmitted and could have possible suffered a complication. This case study demonstrates the possible patient morbidity due to improper assessment and missed information. Not blaming anyone, it was the responsibility of both the doctor and the nurse. But as we know, nursing assessment is an important first step and many fragmented pieces of information which can be missed by doctors can be easily recovered if the nurse assesses a patient well. Knowledge and skill of the nurse does matter.

Morbidity and Mortality in healthcare and Role of Nurse

In healthcare setting there are certain group of complications whose outcome is impacted by nursing care the patient receives. These include the following:

Conditions that increase the morbidity rate at healthcare setting impacted by nurses

  • Urinary tract infection
  • Pressure ulcers
  • Hospital acquired pneumonia
  • Deep vein thrombosis
  • Pulmonary embolism
  • Procedure related upper GI bleeding
  • Sepsis
  • Shock
  • Cardiac arrest
  • Surgical wound infection
  • Pulmonary failure
  • Metabolic imbalances such as hypo/hypernatremia, hypo/hyperkalemia

Note that mortality rate in a hospital is increased as a result of failure to rescue due to above conditions which are the reason for higher morbidity.

Does increased staffing help prevent mortality and morbidity?

The answer is yes. Employing qualified nursing professionals as per the need of the unit is found to be related to patient outcomes and development of morbid complications that directly impacts the patient outcome.

There are many studies that support it. Nursing hours per patient day influenced patient outcomes tremendously. As per the literature the complications that were found to be directly impacted by staffing were:

  • Urinary tract infection
  • Pneumonia after surgery
  • Thrombosis
  • Pulmonary complications in surgery patients
  • Medication errors
  • Pressure ulcers
  • Patient complaints
  • Hospital acquired infections rate
  • Mortality in healthcare setting

All these studies which found a direct relation between staffing and patient outcome also indicated that increased staffing was inversely related mortality rates, decrease mean length of stay and lower complications.

Does qualification of nurse impact morbidity and mortality?

Role of qualified nurses has long been recognized globally. A skilled nurse can judge and prevent adverse events in a unit. That’s why in many settings like post-surgical units, I have witnessed that the treating team relied more upon the nurses for patient progress in crucial hours. This is only possible if a nurse is qualified.

How do we define a qualified nurse? Does the degree matters?

Yes it does. A study indicated that 10% more B.Sc. nurses, decreased deaths and failures in among 665 hospital, regardless of their work environment, by roughly 4%.

Read more about the study here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3217062/

Similarly, an extensive review of 27 studies done in 2018 says that higher levels of nurses’ education were associated with lower risks of failure to rescue and mortality in 75% and 61.1% of the reviewed studies pertaining to these adverse events. How qualified a nurse was also found to be associated with lowers hospital admissions and shorter length of stay.

Read more here: https://www.sciencedirect.com/science/article/pii/S002074891830018X

Other nursing factors impacting morbidity and mortality

Nursing skill mix- Nursing skill mix means nurses are replaced with other staff like nurses’ aides and other assistant personnel and usually a cost control method employed by the hospitals. Arguments have also been there for more than a decade now where the nurses also support the employment of such personnel for certain tasks referred to as ‘Non-nursing tasks’. Twigg DE found that there was significant increases in three adverse events including failure to rescue, urinary tract infection and falls with injury where the assistant in nursing wards were placed with one significant decrease that is mortality.

Nursing skill mix has also been found to be associated with:

  • Mortality
  • Patient rating of hospital
  • Nurse reported adverse events

It has been indicated that employment of temporary nurses are associated with increased mortality. The possible reason could be lack of orientation to the unit, understanding of protocols and accountability. Therefore, it is often been debated even in India with this trend that has recently come in to mix permanent with temporary nurses in certain setting including government set ups. Nurses have been protesting against it and demanding to absorb such nurses on permanent basis. The administration must understand that skill mix in this regard dilutes the quality of care a patient receives in any healthcare set up.

However, adding assistants to nurses who perform non-nursing tasks is appreciated as it prevents nurses’ burnout and let them concentrate on other tasks that are need more of their attention. The only way to ensure that the patient receives quality care even by these assistants is by educating them, training them and putting a set protocol which are monitored by quality nurses periodically.

Nurse- Physician Relationship- Believe it or not practical environment where a nurse works is found to impact how well care a patient receives. It also impacts nurses retention in a hospital. A good example that I quote from my own experience is in a tertiary care hospital, where neonatal ICU is managed by a great team of doctors and nurses. It is constantly been in top neonatal units in Asia. What is different? When I was gaining experience as a student in the unit, I saw a difference. The daily rounds of the consultant would include report of individual neonate from their respective assigned nurses. And as a student we were told by our peers to be extra prepared to answer questions that would be asked by doctors and nurses unequivocally. It was an experience I still cherish. Neonatal mortality has been magically controlled in this unit. Kudos to such team.

A study Siedlecki S, 2015 quoted that 55% of nurses said that physician’s behavior impact nursing decisions especially young nurses were affected more than older nurses. Similarly, Aiken LH also reported that hospital with better physician-nurse had lower 30-day mortality.

Happy Nurses Happy Patients

Nursing professionals to perform their best must be supported well. How can we do that?

  • Know the nurses well who enter your organization. Use smart applications to assess them and understand their capabilities and place them accordingly. See link to know more: SMARTHIRE- https://play.google.com/store/apps/details?id=org.bodhihealthedu.smarthire
  • Use acuity systems and distribute your nurses wisely.
  • Promote individual endeavors. Support nurses to perform better by encouraging them to keep themselves updated and keep learning. You can enroll here: https://bodhihealthedu.org/product-category/nursingcourses/
  • Promote professional interactions and follow evidence based practices.
  • Teach and reinforce quality patient care with accountability. Educate nurses about the need, indicators and their role in preventing such events. Encourage them to monitor patient progress and publish their achievements.
  • Teach assertiveness and encourage professional communication by setting an example by yourself. Learn more about here: https://bodhihealthedu.org/product/soft-skills-personality-types/

References:

1. West E. Barron DN, Harrison D, Rafferty AM, Rowan K, Sanderson C. Nurse staffing, medical staffing and mortality in Intensive Care: An observational study. International Jounral of Nursing Studies [Internet]. 2014 May [cited 2019 Mar 10]: 51 (5); 781-94.

Available from: https://www.sciencedirect.com/science/article/pii/S0020748914000340

2. Twigg DE, Myers H, Duffield C. Impact of skill mix variations on patient outcomes following implementation of nursing hours per patient day staffing: a retrospective study. Journal of Advance Nursing [Internet]. 2014 Feb 4 [cited 2019 Mar 10]: 2710-18.

Available from: https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2648.2012.05971.x

3. Aiken LH, Sloan D, Griffiths P. Nursing skill mix in European hospitals: association with mortality, patient ratings, and quality of care. BMJ Qual Saf 2016;[Internet]. doi: doi:10.1136/bmjqs-2016-005567

4. Siedlecki S, Hixson E. Relationships between Nurses and Physicians Matter” OJIN [Internet]: 2015 Aug 31 [cited 2019 Mar 10]; 20 (3). DOI: 10.3912/OJIN.Vol20No03PPT03

Top