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.

Nursing Sensitive Indicators and its impact on Accreditation

Accreditation in Healthcare- Role of Nursing Sensitive Quality Indicators

The current trend in healthcare is encouraging organizations to acquire ‘accreditation’ with national (NABH) and international organizations (JCI). The process not only helps the institution to demonstrate quality patient care, understand lacunae, scope of improvement but also enhancing their reputation as healthcare providers.

Accreditation in Healthcare– What does it mean?

Accreditation is granting recognition or certification to an institution that maintain defined benchmark standards. Accreditation in healthcare happens through a review process where the healthcare organization is allowed to demonstrate their ability to meet regulatory standards.

Who defines the standards?

Usually the healthcare organization have to meet the standards that are defined by a recognized accreditation organization for example:

Joint Commission International (JCI)- Joint commission international is one of the relied upon international accreditation body known for its standards and stringent quality evaluation process. Learn more about JCI here:

https://www.youtube.com/watch?time_continue=82&v=19ffgRFCt8Y

National Accreditation Board for Hospitals & Healthcare Providers (NABH)-  It is the Indian accreditation body established to operate the accreditation program of health care organizations. Learn more about NABH here:

 

 

How does accreditation help?

In Healthcare, accreditation has multiple benefits. It influences organization, patient and the professionals like nurses as well.

1. Benefits to the Patient- Patient gets quality care from credentialed professionals where patient satisfaction is given preference and their rights are respected.

2. Benefit to Healthcare Organization- Healthcare organization gets to keep abreast with the benchmark standards, ensuring quality care with increased confidence of the society in the services provided by the organization.

Click to know more:

3. Benefits to Healthcare professionals- Healthcare professionals’ credentials are part of the assessment process during the accreditation process. It ensures that the professionals are updated and also checks that there competency is assessed periodically. For example nurses need to be trained in performing CPR and must be given a chance to update through in-service education.

To learn more you may enroll for the CPR course here: https://bodhihealthedu.org/product/cardio-pulmonary-resuscitation-cpr-adult/

Role of Nursing Sensitive Indicators during Accreditation

Quality indicators as such are important to achieve the target of getting an organization accreditation. Though the review of literature presents a complex picture, quality indicators are very important to enhance the quality of healthcare services undergoing accreditation process. Nursing sensitive indicators generally refers to various aspects of nursing care including the following:

Nursing sensitive indicators

1. Structure Indicators- These include nursing manpower, competency or skill level of nursing staff and education as well as certification levels of nursing staff.

2. Process Indicators- Includes patient assessment methods and nursing interventions.

3. Outcome Indicators- These refer to outcome of patients depending upon the quality of nursing care provided such as patient fall, pressure ulcers, infections and patient satisfaction with nursing care.

During the accreditation assessment process all these aspects are assessed for nursing professionals.

Improving the Nursing Sensitive Indicators- Getting ready for the Accreditation!

As a nurse leader, one often faces challenge to allocate and manage resources ensuring the quality of care a patient receives. Let us learn about what you can do as nursing professionals to focus on structure, process and outcome standards which you may be asked about during the accreditation process and how to prepare yourself for that in advance.

Structure Indicators

  • Nursing Manpower- Nursing manpower is crucial and a difficult area to conquer. It is forte of the HR and chief of nursing together. To ease the efforts and to follow the league as nurse leaders try the advance tools available. One such system is acuity based staffing. Such systems are based on patient requirement. For example a nurse can be allocated to one, two or multiple patients based on needs with patient categorized as dependent, semi-dependent and independent. Learn more about staffing here:

  • Skill assessment– Nursing skill assessment is done in many organization periodically by education department. However, in India, competency based assessment is very limited. Do note that accreditation agency look out for these parameters.

  • Certification and Continuing education- The education team has to often present the record of nursing staff during the accreditation. The staff nurses might be picked up randomly and the records may have to display in front of the auditor. Nurse educators often struggle to reach every nurse for updating them. Switch to online education for easy access and record maintenance. This can help you as educator to track the progress of individual nurses and also provide flexibility to the nurses to learn at their own pace and anywhere they want. Follow the link to know more: https://bodhihealthedu.org/product-category/nursingcourses/

Process Indicators

  • Patient assessment methods and nursing interventions- Patient assessment methods should be relevant but should not overburden the nurses. The purpose of assessment methods is to ensure minimize the loop holes in care provided to the patients. A measure to ensure quality care by the nurses. Nurses must be involved in the care assessment pathways developed for the patient care. Latest addition to the care pathways is to develop decision support systems which not only guides the nurses what to assess but what action they must take next. Follow the link to know more:

 

Outcome Indicators

These indicators are the most crucial Nursing Sensitive Indicators as these are directly related to patient outcome.

  • Patient Fall- Patient fall is one of the most dreaded incident on the list of a clinical nurse as well the whole caring team. Fall can cause internal injury, laceration, fractures and bleeding. Studies show that about ‘one-third’ of the hospital falls are preventable. Especially in elder population fall can be important cause of mortality and morbidity. Causes are many including previous history of fall, drugs, and other causes such as visual disability or neurological impairment. Assessment tools are available and must be used by nursing professionals to avoid the events.

Patient fall

Centre for Disease Control (CDC) has proposed fall prevention program called STEADI (Stop Elderly Accidents, Deaths and Injuries). Follow the link to know more: STEADI Pocket Guide

STEADI tool kit for Healthcare Providers:

  • Hospital Acquired Pressure ulcers (HAPU)- HAPU indicates the poor quality of care in a healthcare set up. Especially if the pressure ulcer progresses to stage 3 or 4, it can cause infection, mortality and morbidity and also increases the length of stay of a patient.

Florence Nightingale in 1859 wrote:

“If he has a bedsore, it’s generally not the fault of the disease, but of the nursing”

Though it has been supported by many studies that the entire team (doctors, nurses, physiotherapist and dietician) is responsible if a patient develops pressure ulcer but it largely falls on the shoulders of nursing team. Assessment is the key to prevention for most of the outcome based quality indicators. Braden scale is reliable and popular scale used in healthcare setting to assess the risk of pressure ulcer as development of pressure ulcer is affected by many factors. Here are the components of Braden scale.

Learn how to assess stages of pressure ulcers. It is very important that nurses look out for patient vulnerable surfaces every day and pick early signs of pressure ulcer.

Stage I pressure ulcer- It is characterized by intact skin with non-blanching erythema.

NOTE: This is an important time to identify pressure ulcer and many professionals fumble about identifying the stage I pressure ulcers. If the nurses are careful to document there are chances that the pressure ulcer is detected only when it reaches stage II.

Stage-1 pressure ulcer

 

How to test for Non-blanchable erythema- The classic sign of Stage I pressure ulcer?

  • Apply light pressure on the suspected area for few seconds
  • Release and watch for return to usual skin color

Blanchable- Skin color returns immediately to normal. See blanchable skin.

NOTE- it is normal response.

 

Non-blanchable- Persistent redness or rashes in lightly pigmented skin. See how you can identify non-blanchable

erythema to label it as LEVEL I PRESSURE ULCER.

Stage II pressure ulcer- Pressure ulcer turns into an open ulcer involving epidermis, dermis or both.

stage 2 pressure ulcer

 

Stage III pressure ulcer- It involves full-thickness tissue loss with visible subcutaneous fat.

stage 3 pressure ulcer

 

Stage IV pressure ulcer- In stage IV the pressure ulcer has involves underlying muscle and bone.

stage 4 pressure ulcer

See link to know more about staging, back care and management of pressure ulcer here:

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

  • Central line associated blood stream infection- A central line-associated bloodstream infection (CLABSI) is infection that occurs when organisms enter the bloodstream through the central line.

CDC recommends the following precautions for health professionals to prevent CLABSI:

  1. Perform hand hygiene.
  2. Apply skin antiseptic.
  3. Ensure that the skin preparation agent is completely dried before inserting the central line.
  4. Use maximal sterile barrier precautions including sterile gloves sterile gown, cap, mask and sterile drape.
  5. Once the central line is placed follow recommended central line maintenance practices. Wash hands with soap and water or an alcohol-based hand rub before and after touching the line
  6. Remove a central line as soon as it is no longer needed.
  7. Also find the checklist proposed by CDC called the CLABSI bundle.

https://www.cdc.gov/hai/pdfs/bsi/checklist-for-CLABSI.pdf

  • Catheter Associated Urinary Tract Infection- Urinary tract infections account for 40% of all hospital-acquired infections and 80% of such infections are known to be associated with indwelling urethral catheters.

CAUTI Prevention- Nurses must consider the following points when planning to insert a catheter.

  • Insert catheter only when indicated. Consider other options such as condom drainage or intermittent catheterization.
  • Ensure that only trained professionals insert the catheter. You may access the course here:

Urinary Catheterization

  • Follow sterile technique during insertion of catheter.
  • Minimize days of insertion. Remove catheter as soon as possible.
  • Maintain close drainage system.
  • Practice hand hygiene and standard precaution during patient care.

Learn about Nurse driven protocol to reduce CAUTI by Joint Commission International (JCI) for free:

https://www.jointcommissioninternational.org/spotlight-on-success-implementing-nurse-driven-protocols-to-reduce-cautis/

Restraints- Use of restraint in hospitalized patient especially in ICU patients is practiced is listed as a nursing quality indicator by National Database of Nursing Quality Indicators in US. Many times it becomes difficult to avoid the use of restraints but it is always suggested that restraints be used as a last resort when patient poses threat to self or others.

Types of Restraints-

Types of restraints

 

Physical restraints- These restraints restrict or control the movement or behavior. These include hand mittens, belts, bed rails, lap cushions etc.

Chemical restraints- These restraint control the movements or behavior through medications such as tranquilizers and sedatives.

Nursing responsibilities when a patient is prescribed restraints:

  • Observe patient every 15 minutes for the first hour of restraint and subsequently as per the age every 2 hourly or 4 hourly.
  • Assess physical condition of the patient including, vitals, hydration, nutrition, and joints of extremities being restraint, comfort of the patient and hygiene needs.
  • Psychological status and need for further revision of orders.
  • Assess patient for continuous need for restraint and patient behaviors during temporarily removal of restraints.
  • Special care should be given to the area where the restraint is applied example hands must be assessed when using wrist restraint or mittens as restraints for any injury resulting from the restraint.

Outcome indicators must be monitored, documented and reported by each team of a unit in the healthcare setting and measures to improve the outcomes must be discussed and implemented in consensus with quality team and nursing team to achieve the goals as a team to improve patient care using the recent evidence based practices. The whole process is usually a matter of interest for the treating team but also for the accreditation agencies to track the progress an organization makes to ensure quality care to a patient which generally goes by the name of ‘Root cause analysis’ by the quality team.

Conclusion

Nursing sensitive quality indicators are a must to be monitored in any healthcare organization as it is a direct measure of nursing care in an organization, also it pushes the healthcare team to perform better in addition plays a crucial role about reflection of best practices in an organization during the accreditation process. Learn more about NABH accreditation Nursing Excellence Standards here:

https://www.nabh.co/NURSINGEXCELLENCE.aspx

References:

1. Heslop L, Lu S. Nursing-sensitive indicators: a concept analysis. J Adv Nurs. 2014 [cited 2019 Feb 28]: 70(11); 2469–2482. doi: 10.1111/jan.12503.

2. The Sentinel Watch. The three types of nursing indicators. 2011 Nov 2 [cited 2019 Feb 28]. Available from: https://www.americansentinel.edu/blog/2011/11/02/what-are-nursing-sensitive-quality-indicators-anyway/

3. Almoajel AM. Relationship Between Accreditation and Quality Indicators in Hospital Care: A Review of the Literature. World Applied Sciences Journal. 2012 [cited 2019 Feb 28]: 17 (5); 598-606. Available from: https://pdfs.semanticscholar.org/581c/5fbb1fa8e12ecbf6feb8989ba499b02d0162.pdf

4. Nightingale F. Notes on nursing . Philadelphia: Lippincott; p. 1859.

5. Cuddigan J. Stage 1 Pressure Injury: Non-Blanchable Erythema of Intact Skin. National Pressure Ulcer Advisory Panel. 2017 Mar 3 [cited 2019 Mar 3]. Available from: https://www.npuap.org/wp-content/uploads/2017/03/Cuddigan-Janet-Stage-1.pdf

6. Salamon L. Catheter-associated urinary tract infections: a nurse-sensitive indicator in an inpatient rehabilitation program. Rehabil Nurs. 2009 Nov-Dec [ cited 2019 Mar 3] :34(6); 237-41. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19927851

7. Registered nursing.org. Use of Restraints and Safety Devices: NCLEX-RN. Available from: https://www.registerednursing.org/nclex/use-restraints-safety-devices/

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