Online Healthcare Continuing Education

Prevention of Medical Errors for Florida Healthcare Professionals




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Wild Iris Medical Education is approved as a provider of nursing continuing education by the Florida Department of Health, Division of Quality Assurance, Board of Nursing. Florida Board of Nursing Accreditation #NCE3403.

Course Availability: Expires February 1, 2018. You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity. Wild Iris Medical Education, Inc. provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional health care.  Medical Disclaimer   Legal Disclaimer   Disclosures

NoteThis course fulfills the Florida requirement for 2 hours of continuing education in prevention of medical errors, both for initial licensure and biennial renewal.

Prevention of Medical Errors for Florida Healthcare Professionals

COURSE OBJECTIVE:  The purpose of this course is to prepare Florida nurses and other healthcare professionals to prevent medical errors in the practice setting using current, evidence-based information.


Upon completion of this course, you will be able to:

  • Define medical error, adverse event, near miss, never event, and sentinel event.
  • List causes and types of medical errors.
  • Discuss the scope and significance of medical errors in the current U.S. healthcare environment.
  • Identify populations of special vulnerability to medical errors.
  • Describe strategies and interventions to prevent medical errors.
  • Describe elements of a root cause analysis.
  • Discuss Florida’s medical error reporting requirements.

Medical errors are a serious public health problem that threatens patient safety. In the 1950s medical errors were considered to be the price paid for modern diagnosis and therapy. But over the ensuing decades, medical errors have increased to epidemic proportions and currently are the third leading cause of death in the United States. Those in leadership roles claim that error reduction is extremely difficult due to the complex nature of healthcare facilities and the fact that patients are very sick. Our expanding awareness of this issue demands improvement in our understanding of the problem and in finding effective solutions and prevention strategies to make our healthcare system safer.

Acknowledging that errors happen, learning from them, and working to prevent future errors represents a major change in the culture of healthcare—a shift from blame and punishment to analysis of the root causes of errors and the creation of strategies to improve. In other words, healthcare organizations need to create a culture of safety that views medical errors as opportunities to improve the system. Every person on the healthcare team has a role in making healthcare safer for patients and workers.


The Institute of Medicine (1999) defines an error as “the failure of a planned action to be completed as intended (i.e., error of execution) or the use of a wrong plan to achieve an aim (i.e., error of planning).” To ensure consideration of all relevant issues related to medical errors, the Quality Interagency Coordination Task Force (a federal entity overseen by the Agency for Healthcare Research and Quality), has expanded the definition as follows:

An error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems.

Adverse Events, Sentinel Events, and Near Misses

An adverse event is an injury caused by medical management rather than the underlying condition of the patient. An adverse event attributable to an error is a preventable adverse event.

The Joint Commission defines a sentinel event as “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. The phrase ‘or the risk thereof’ includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.” Sentinel events are so named because they signal the need for immediate investigation and response (JC, 2013a).

Near misses are potential adverse events, errors that could have caused harm but did not, either by chance or because something or someone in the system intervened. Near misses provide opportunities for developing preventive strategies and actions and should receive the same level of scrutiny as adverse events.

Never Events

Never events are errors that should never happen. The National Quality Forum identifies these as Serious Reportable Events (SREs) and groups them into the categories of:

  • Surgical
  • Product/device
  • Patient protective
  • Care management
  • Environmental
  • Radiological
  • Criminal

Classification of Errors

Research on why humans make errors (Reason, 1990) has identified two types of errors: active and latent. Active errors (human errors) are those that involve individuals who are actually doing a task, and their effects are felt almost immediately. Latent errors are errors in system or process design, faulty installation or maintenance of equipment, or ineffective organizational structure.

Latent errors are present but hidden and may go unnoticed for a long time with no ill effect. However, when a latent error combines with an active human error, an event occurs. The active human error triggers the hidden latent error causing an adverse event.

Root Causes of Medical Errors

A root cause is an action, deficiency, or decision that if corrected, eliminated, or avoided will eliminate the undesirable consequence. The most common root cause of medical errors is communication problems, which can include unclear lines of authority, inadequate error sharing, or disconnected reporting systems. Other root causes involve:

  • Human factors, which are aberrations in mental functioning that include unconscious glitches in automatic activity, misapplied expertise, lack of knowledge, or misinterpretation of a problem
  • Patient-related issues, including improper patient identification, incomplete assessment of the patient, failure to obtain consent, inadequate patient education, and the complexity of care in areas such as ICU
  • Organizational transfer of knowledge, including deficiencies in orientation or training, lack of education, or inconsistent education and training for healthcare providers
  • Staffing patterns and work flow, including inadequate staffing or supervision
  • Technical failures involving devices/equipment and complications or failure of implants or grafts
  • Inadequate policies and procedures that show a commitment to patient safety
    (Leape, 2014)


A decade and a half has passed since the IOM published To Err Is Human: Building a Safer Health System. This landmark report revealed an epidemic of medical errors in the United States, with an estimate of up to 98,000 people dying each year due to mistakes made in hospitals (IOM, 1999). In 2010, the Office of Inspector General for the Department of Health and Human Services reported that more than 180,000 patients enrolled in Medicare alone die in a given year because of poor hospital care (U.S. DHHS, 2010).

In 2013, the Journal of Patient Safety reported that between 210,000 and 440,000 patients each year who enter a hospital experience some type of preventable harm that contributes eventually to their death, making medical errors the third-leading cause of death in America behind heart disease (the first) and cancer (the second). The study also reported that tens of thousands also die from preventable mistakes made outside hospitals in outpatient settings and the community, including deaths from missed diagnoses or injuries from medication (James, 2013).

A recent study of medical malpractice claims showed that slightly more than half (52.5%) of the paid claims related to outpatient care. Most malpractice claims for hospital care are related to surgical errors, whereas most claims for outpatient care are related to missed or late diagnosis. Medication errors are also common in outpatient malpractice claims, particularly those related to transition from hospital to community-based care (Bishop et al., 2011).

The High Price of Medical Errors

Medical errors add substantially to the direct costs of healthcare and to the loss of income. “More than 400,000 Medicare ‘never events’ occurred in the United States in 2008, with an estimated total cost of $3.7 billion. The cost of these events constitutes 22% of the total cost for medical errors” (van den Bos et al., 2011).

It is not uncommon for healthcare facilities to take cost-containment measures that reduce staffing, particularly RN staffing. When this occurs there is an increase in medical errors and poor outcomes. An analysis of data from nearly 200,000 hospital admissions and 176,000 nursing shifts of eight hours each showed that staffing of RNs below target levels was associated with increased mortality (Needleman et al., 2011).

Most Commonly Occurring Medical Errors

Errors can be placed into five general categories: surgical, diagnostic, medication, devices and equipment, and systems failures (including healthcare-associated infections, falls, and healthcare technology).


Surgical errors (or surgical adverse events) account for a high percentage of all adverse events. According to a study by the Johns Hopkins University School of Medicine reported in 2012, at least 4,000 surgical errors occur in the United States each year. National data was analyzed and it was estimated that 80,000 “never events” occurred in U.S. hospitals between 1990 and 2010 and that the figure may be on the low side (Johns Hopkins Medicine, 2012).

The Joint Commission found that robotic surgery, a relatively new technological procedure, resulted in an increase in surgery-related sentinel events from 2006 to 2013. Complications were usually due to hemorrhage caused by lacerations and injury to surrounding tissues (JC, 2014a).


The Joint Commission estimates the death toll from diagnostic errors at 40,000 to 80,000 per year, with 40,500 preventable deaths arising in the ICU alone. One patient in every six has personally been affected or has had a family member or friend affected. Almost half of pediatricians come upon one or more diagnostic errors every month, and 1 in every 1,000 primary care encounters will cause preventable harm from diagnostic error (JC, 2014b).

Although delayed or inaccurate diagnoses are often attributed to physician error, members of the healthcare team can and do contribute to delayed or inaccurate diagnoses due to information gaps and communication problems.

Most diagnostic errors occur in primary care settings and most frequently in the testing phase (failure to order, faulty interpretation of results, missed follow-up and tracking) (Joszt, 2013).

Other errors were attributed to failure to make referrals and patient-related issues such as inaccurate medical histories (Wood, 2014).

Misdiagnosis occurs in diagnostic radiology when the radiologist or interpreting physician fails to see an abnormality that is present on the image due to what has been called an unexplainable “psycho-visual phenomenon.” Many other radiologic errors are cognitive: the abnormality is plainly visible but is not appreciated because of lack of understanding or poor judgment (Berlin, 2011).

The most common cognitive error that clinicians make is the premature closure of the diagnostic process, where common benign diagnoses are made for patients with uncommon serious disease, signaling a need to broaden differential diagnosis. It is to be noted that a lot of symptoms patients present with are vague, such as fatigue, resulting in a vague differential diagnosis.

Sentinel event statistics compiled by the Joint Commission from 2004 to 2013 show that one of the most frequently reported events is delay in treatment. In 2013 delay in treatment was the third most documented reviewable sentinel event. This includes delays in medication, lab testing, physical therapy, or any other kind of treatment (Wyatt, 2014).

Diagnostic errors increase costs due to the need for hospital readmission that could have been avoided if the correct diagnosis had been made. Another source of unnecessary costs is unwarranted treatments given due to a wrong diagnosis (Wood, 2014).


The National Coordinating Council for Medication Error Reporting and Prevention (2014) defines a medication error 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 healthcare professional, patient, or consumer. Such events may be related to professional practice, healthcare products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.

In a study conducted by the Economic Cycle Research Institute (ECRI) patient safety organization, it was found that the phase of the medication process in which the highest number of medication errors occurred was during the administration phase, and more than a third involved intravenous errors (Oh, 2012a).


According to the Joint Commission (2014c), tubing and catheter misconnections are “a persistent and potentially deadly occurrence.” Although misconnections are often caught and corrected before the patient is injured, these adverse events can have life-threatening consequences. This is a complex issue involving medication errors and equipment design problems. Medications are being delivered via the wrong route, and equipment design leads to making such misconnections.

Luer connectors were implicated in many of the misconnections. These universal connectors have a “female” and a “male” component designed to lock together. Unfortunately, this universal design allows tubes or catheters with dissimilar function to be connected, with potentially disastrous results. Other factors contributing to misconnections include the routine use of tubes or catheters for unintended purposes, such as using IV extension tubing for epidurals, irrigation, drains, and central lines.

In addition, movement of a patient from one setting to another and staff fatigue related to working consecutive shifts contribute to these adverse events (JC, 2014c).


Patient’s feeding tube was inadvertently connected to the instillation port on the ventilator in-line suction catheter, delivering tube feeding into the patient’s lungs, causing death. (Source: FDA, 2013.)


Design flaws, misuse, and malfunction of medical devices and equipment are all common causes of medical errors. Subtle differences in a familiar pattern using a device can affect the speed and accuracy of data entry, and the lack of standardization invites user mistakes. Poor medical device design and lack of usability testing have also been repeatedly discussed as being key factors in many device-related incidents.

An increasing number of medical devices are also implanted in patients. These include cardiac pacemakers, defibrillators, and deep brain stimulation neurotransmitters to control tremors in people with Parkinson’s disease. Any malfunction of such devices can be serious and even life threatening.


HAIs are considered a systems failure. According to the CDC, 1 of every 20 hospitalized patients will experience a healthcare-acquired infection. These infections lengthen hospital stays, cost U.S. hospitals an estimated $33 billion annually, increase patients’ pain and suffering, and can prove fatal.

Failure of physicians, nurses, and other caregivers to practice basic hand hygiene helps spread bacteria, some of which are antibiotic-resistant and can prove life-threatening. Studies have shown that hospital workers wash their hands as little as 30% of the time that they interact with patients and that physicians tend to be the most resistant to hand hygiene (Hartocollis, 2013).


Falls are also considered a systems failure. Falls are a commonly reported sentinel event in 24-hour care facilities and can be fatal. Each year, one third of people over 65 suffer a fall, and one third of these falls cause both fatal and nonfatal injuries. In 2013 the Joint Commission reviewed 82 fall-related events resulting in death or permanent loss of function (JC, 2013b).

Older patients are not the only population at risk. Any patient who has had excessive blood loss may experience postural hypotension, increasing the risk of falling. Maternity patients or other patients who have epidural anesthesia are at risk for falls due to decreased lower-body sensation.

Risk factors associated with falling are clinically identified as either intrinsic or extrinsic. Intrinsic factors include the characteristics or conditions of a person, which can include vision, gait, and health history. Intrinsic factors may or may not be modifiable. Extrinsic factors involve conditions outside the person, such as environmental hazards and medications. Extrinsic factors are modifiable.


The Institute of Medicine (IOM) has evaluated safety concerns and identified actions that can be taken to lessen safety risks linked with health IT. The literature about health IT and patient safety is inconclusive, yet it shows substantial potential hazards for patient safety (IOM, 2012).

Electronic Health Records (EHRs)

While adoption of EHR systems offers to provide substantial benefits, there are serious unintended consequences that have emerged from their implementation. Currently, there is no regulatory framework to monitor EHR system safety and no agreed-upon design standards.

Many providers find that EHRs decrease efficiency and add hours to their workday due to non-user-friendly interfaces and difficult navigation. They report many EHR systems are awkward and time consuming. In addition, they report the computer comes between the patient and provider and fosters distractions.

Computerized Prescriber Order Entry (CPOE)

CPOE can help hospitals reduce ADEs, but only about one third of hospitals have a CPOE system and less than half use barcode medicine administration (BCMA) (Halvorson, 2011). Research shows that BCMA can reduce the rate of potential adverse drug events (ADEs) as much as 50%, but errors can still occur (Poon et al., 2010).

Only 8% of U.S. hospitals have fully implemented CPOE systems. One obstacle is the upfront cost, which is approximately $1.9 million, with $500,000 per year for maintenance. Another obstacle is resistance by physicians to utilize such tools, instead preferring to rely on practice experience (Leapfrog, 2014).


Older Adults

People age 65 years and older consume more prescription and over-the-counter (OTC) medications than any other age group. Although medications may improve the quality of life and health, they also hold the potential for misuse, overuse, and life-threatening complications.

The older adult population (ages 65 and older) receives more than 50% of all prescription medication, and most who engage in the healthcare system take 6 to 8 medications (polypharmacy). The prevalence of older adults taking five or more medications is close to 7%. In addition to prescription medications, older adults purchase 40% of over-the-counter medications, use OTCs three times more, and use herbals twice as much as the younger population.

The risk for an adverse drug event is 15% with two medications, 58% with five, and 82% with seven or more medications. Nearly 17% of hospital admissions are due to an adverse drug event, and the rate increases to 33% in patients 75 years of age and older. Additionally, while in hospital, 17% of older adults experience an adverse drug event (Bland, 2013).

Visual, hearing, or cognitive problems may lead to misunderstanding of instructions or failure to question an incorrect or unfamiliar drug.

Older adult patients are also at high risk of falling, and medications increase that risk. Researchers in Sweden found that two thirds of patients with hip fracture were prescribed fall risk–increasing drugs before fracture, and the number increased after fracture (Kragh et al., 2011).

Prescribing physicians need to consider the slowed metabolism and excretion of drugs in older adult patients—not only the choice of drugs but also the dosage and timing of administration. Because older adults experience a decrease in total body water and a relative increase in body fat, water-soluble drugs become more concentrated and fat-soluble drugs have a longer half-life.

Infants and Children

The potential for ADEs is higher in the pediatric population than that found in hospitalized adult patients. The factors that place them at higher risk include:

  • Changing pharmacokinetic parameters between patients at various ages and stages in development
  • Need for calculation of individualized doses based on the patient’s age, weight, body surface area, and clinical condition
  • Need for precise dosage measurement and appropriate delivery systems
  • Lack of communication abilities

Medication dosing errors occur in up to 17.8% of hospitalized children (Wesley & Washick, 2013).

Intensive Care Patients

Intensive care units (ICUs) host the sickest patients whose conditions require extraordinarily complex care. Errors associated with drugs can be particularly common in the ICU. Critically ill patients receive nearly twice as many medications as patients in general care units, and most medications involve calculations for bolus administration or continuous infusion. The most common medication error types in ICU are administering the wrong dose, omission of a dose, wrong administration rate, and wrong administration time (Blumenthal, 2014).

The complexity of care in the ICU can lead to life-threatening, sometimes fatal, tubing misconnections, infections, and other complications. These patients often have feeding tubes, chest drainage tubes, and central venous catheters, and the most common types of adverse events in the ICU involve these lines, tubes, and drains.

Patients with Limited English and/or Health Literacy

The National Institutes of Health (2014) reports that less than 60% of the U.S. population has English as a first language, and 10 million Americans speak no English at all. Health literacy is defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Low health literacy is linked to a higher risk of death and more emergency room visits and hospitalizations.


Oversight of healthcare quality in the United States is accomplished through both professionally based accrediting bodies in the private sector and through federal and state regulatory agencies.

The Joint Commission

The Joint Commission is an independent not-for-profit agency whose mission is to continuously improve the safety and quality of care provided to the public.


The Joint Commission encourages, but does not require, reporting of any sentinel event. However, in the interest of continuous improvement in safety and quality of care, the Joint Commission requires that healthcare organizations:

  • Have a process in place to recognize sentinel events
  • Conduct thorough and credible root cause analyses that focus on process and system factors, not on individual blame
  • Document a risk-reduction strategy and internal corrective action plan within 45 days of the organization becoming aware of the sentinel event

The sentinel event policy (JC, 2013c) has four goals:

  1. To have a positive impact in improving patient care, treatment, and services and preventing sentinel events
  2. To focus the attention of an organization that has experienced a sentinel event on understanding the factors that contributed to the event (such as underlying causes, latent conditions and active failures in defense systems, or organizational culture) and on changing the organization’s culture, systems, and processes to reduce the probability of such an event in the future
  3. To increase the general knowledge about sentinel events, their contributing factors, and strategies for prevention
  4. To maintain the confidence of the public and accredited organizations in the accreditation process

Although accredited facilities are expected to identify and respond appropriately to all sentinel events, but not to report them, if the Joint Commission becomes aware of an event, facilities are required to submit the findings of their root cause analyses and corrective action plans. This information can be included in the Joint Commission’s review of sentinel events, helping track national trends and develop strategies for improving patient safety.


The Joint Commission has issued mandatory goals and recommendations to improve patient safety. Hospitals and other organizations will be evaluated by accreditation representatives to see whether these recommendations or acceptable alternative measures are being implemented. Failure to implement the recommendations could result in loss of accreditation and federal funding.


  • Identify patients/residents correctly
  • Improve staff communication
  • Use medicines safely
  • Prevent infection
  • Organizational identification of risk inherent to the patient population
  • Universal protocol

Long-Term Care

  • Identify patients/residents correctly
  • Use medicines safely
  • Prevent infection
  • Reduce risk of falls
  • Prevent pressure ulcers

Home Care

  • Identify patients/residents correctly
  • Use medicines safely
  • Prevent infection
  • Reduce risk of falls


  • Identify patients/residents correctly
  • Use medicines safely
  • Prevent infection
  • Reduce risk of falls
  • Organizational identification of risk inherent to the patient population
  • Universal protocol
    (Joint Commission, 2014d)

Misreading medical abbreviations can also be a cause of serious medication errors, and the Joint Commission has created a “do not use” list of abbreviations that endanger patients’ safety and that it requires its members to follow.


The Joint Commission requires that a thorough, credible root cause analysis and corrective action plan be performed for each reported sentinel event within 45 days of the event’s occurrence or of the organization’s becoming aware of the event (JC, 2013d). (See also “Root Causes of Medical Errors” earlier in this course.)

Root cause analysis is a tool for identifying prevention strategies. It is a process that is part of the effort to build a culture of safety and move beyond the culture of blame. In RCA, basic and/or contributing causes are discovered in a focused review process similar to diagnosis of disease—with the goal always in mind of preventing recurrence. The goal of a root cause analysis is to find out:

  • Who was involved
  • When it happened
  • What happened
  • Why it happened
  • What to do to prevent it from happening again

Root cause analysis is:

  • Interdisciplinary, involving experts from the frontline services
  • Involving those who are the most familiar with the situation
  • Continually digging deeper by asking “why, why, why” at each level of cause and effect
  • A process that identifies changes that need to be made to systems
  • A process that is as impartial as possible

To be credible, a RCA must:

  • Include participation by the leadership of the organization and those most closely involved in the processes and systems
  • Be internally consistent
  • Include consideration of relevant literature

Accreditation Association for Ambulatory Health Care (AAAHC)

The Accreditation Association for Ambulatory Health Care was founded in 1999 by the AAAHC Institute for Quality Improvement, which offers ambulatory healthcare organizations opportunities to learn about and become involved in performance measurement, benchmarking, and quality improvement. The studies conducted by the institute are designed specifically for ambulatory care environments (AAAHC, 2014).

Ambulatory care organizations are offered accreditation by AAAHC to demonstrate that the organization takes part in ongoing self-evaluation, peer review, and education to continuously improve its care and services. The organization performs on-site surveys by healthcare professionals at least every three years.

Federal Government Efforts

In 2006, Congress passed the Deficit Reduction Act of 2005, authorizing Medicare and Medicaid to tie healthcare facilities’ Medicare eligibility to the occurrence of preventable “never events,” and in 2007 the Center for Medicare and Medicaid Services issued a new rule denying reimbursement for treatment to hospitals for treatment of preventable errors, injuries, and infections.


The following preventable complications are no longer reimbursed by Medicare and Medicaid if acquired during an inpatient stay:

  • Foreign object retained after surgery
  • Air embolism
  • Blood incompatibility
  • Stage III and IV pressure ulcers
  • Falls and trauma
  • Fractures and dislocation
  • Intracranial injuries
  • Crushing injuries
  • Burns
  • Electric shock
  • Catheter-associated urinary tract infection
  • Vascular catheter–associated infection
  • Manifestations of poor glycemic control:
    • Diabetic ketoacidosis
    • Nonketoacidosis
    • Hyperosmolar coma
    • Hypoglycemic coma
    • Secondary diabetes with ketoacidosis
    • Secondary diabetes with hyperosmolarity
  • Surgical site infection following:
    • Coronary artery bypass graft (CABG); mediastinitis
    • Bariatric surgery
    • Laparoscopic gastric bypass
    • Gastroenterostomy
    • Laparoscopic gastric restrictive surgery
  • Surgical site infection following certain orthopedic procedures:
    • Spine
    • Neck
    • Shoulder
    • Elbow
  • Deep vein thrombosis (DVT)/pulmonary embolism (PE) following total knee or hip replacement, with pediatric and obstetric exceptions
  • Surgery on the wrong patient, wrong surgery on a patient, and wrong-site surgery

Source: CMS, 2014.

Florida Sentinel Event Law

Reporting sentinel events to the Joint Commission is voluntary. However, Florida law makes such reporting mandatory. Florida’s Comprehensive Medical Malpractice Reform Act of 1985 (F.S.395.0197) mandates that each licensed hospital and ambulatory surgery center implement a risk-management program with state oversight and an internal incident-reporting system. State oversight is provided by the Florida Agency for Health Care Administration (AHCA). Each licensed facility is required to hire a risk manager, licensed under F.S. 395–10974, who is responsible for implementation and oversight of the risk management program.


The 2014 Florida Statute 395.0197 mandated internal reporting of any adverse incident (event) over which healthcare personnel could exercise control, that is associated in whole or in part with medical intervention rather than the condition for which such intervention occurred, and that:

  1. Results in one of the following injuries:
    • Death
    • Brain or spinal damage
    • Permanent disfigurement
    • Fracture or dislocation of bones or joints
    • A resulting limitation of neurologic, physical, or sensory function which continues after discharge from the facility
    • Any condition that required specialized medical attention or surgical intervention resulting from non-emergency medical intervention, other than an emergency medical condition, to which the patient has not given his or her informed consent
    • Any condition that required the transfer of the patient, within or outside the facility, to a unit providing a more acute level of care due to the adverse incident rather than the patient’s condition prior to the adverse incident
  2. Was the performance of a surgical procedure on the wrong patient, a wrong surgical procedure, a wrong-site surgical procedure, or a surgical procedure otherwise unrelated to the patient’s diagnosis or medical condition
  3. Required the surgical repair of damage resulting to a patient from a planned surgical procedure, where the damage was not a recognized specific risk, as disclosed to the patient and documented through the informed-consent process
  4. Was a procedure to remove unplanned foreign objects remaining from a surgical procedure

Every licensed facility must establish an internal risk management program that must:

  • Investigate and analyze the frequency and causes of adverse incidents to patients
  • Educate all non-physician personnel in risk management and risk prevention as part of their initial orientation
  • Provide at least 1 hour of such education and training annually for all personnel of the facility working in clinical areas and providing patient care, except for licensed healthcare practitioners who are required to complete continuing education coursework pursuant to chapter 456 or their respective practice act
  • Analyze patient grievances related to patient care
  • Have a system for informing a patient or designee pursuant to state law that the patient was the subject of an adverse event.
  • Have an incident reporting system to report adverse incidents to the risk manager or designee within 3 business days after their occurrence.

Licensed facilities in Florida are required to submit two types of reports to AHCA: Code 15 reports and annual reports.

Code 15 reports must be submitted to the agency within 15 calendar days after its occurrence for any of the following adverse incidents, whether occurring in the licensed facility or arising from healthcare prior to admission to the licensed facility:

  • Death of a patient
  • Brain or spinal damage
  • Surgical procedure on the wrong patient
  • Wrong-site surgical procedure
  • Surgical procedure that is medically unnecessary or unrelated to patient diagnosis or medical condition
  • Surgical report of damage from a planned surgical procedure, where damage is not a recognized specific risk
  • Procedures performed to remove unplanned foreign objects remaining postoperatively

The annual report summarizes the incident reports that have been filed in the facility for that year, and includes:

  • The total number of adverse incidents
  • Types of adverse events listed by category and number of incidents occurring within each category
  • Code numbers of each professional and individual directly involved and number of incidents each has been directly involved in
  • Description of all malpractice claims filed against the facility, including number of pending and closed claims, the status and disposition of each claim


Changes in organizational culture, involvement of leadership, education of providers, development of patient safety committees, adoption of safe protocols and procedures, and use of technology are all essential strategies healthcare facilities must consider in their efforts to reduce medical errors.

Creating a Culture of Safety

The mistaken attitude in healthcare that errors are solely the fault of individual practitioners has proven a major barrier to reporting. When the reporting of medical errors focuses on the identification and punishment of individual health professionals, there is a huge disincentive for reporting errors, and this punitive attitude severely limits the reporting of errors. In fact, research shows that when the fear of punishment is removed, reporting of errors actually increases.

One of the main goals of organizations working to improve patient safety should be to encourage the creation of a “culture of safety” in which medical errors are discussed openly and addressed thoroughly. A culture of safety includes:

  • Acknowledgment of the high-risk, error-prone nature of an organization’s activities and the determination to achieve consistently safe operations
  • A blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment
  • Encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems
  • Organizational commitment of resources to address safety concerns
    (AHRQ, 2014)

A challenge exists in distinguishing between a system that might cause errors, human error that might result in a bad outcome, and reckless behavior that intentionally puts lives or organizations at risk. One popular approach is the Just Culture model developed by David Marx and colleagues (2005), which helps differentiate human error from blameworthy errors. The Just Culture model involves:

  • Creating an environment where staff can raise their hand when they see a risk or have made a mistake
  • Rewarding reporting and placing a high value on open communication and knowledge
  • A well-established system of accountability
  • An organization that understands shared accountability

A just culture acknowledges that competent professionals make mistakes and recognizes that competent professionals may develop unhealthy norms such as shortcuts and routine rule violations, but has zero tolerance for reckless behavior.


The National Quality Forum (2010) lists “Leadership Structures and Systems” as the first of 34 safe practices for better healthcare, stating: “Leadership structures and systems must be established to ensure that there is organization-wide awareness of patient safety performance gaps, direct accountability of leaders for those gaps, and adequate investment in performance improvement abilities, and that actions are taken to ensure safe care of every patient served.” The overarching goal should be to create and sustain a culture of safety rather than a culture of blame.

Health Information Technology (HIT)

HIT has great potential for improvement in the quality and safety of healthcare. Electronic health records (EHRs) should help reduce medication errors, avoid the need to repeat laboratory tests, and improve continuity of care across the healthcare system. Facilities should carefully select the best system available, adopt best practices for EHR implementation and management, monitor how the health IT system is used, and report any adverse events.


Surgical Error Interventions

Surgical errors are not the sole responsibility of the operating surgeon. All operating room personnel have a role in ensuring patient safety by verifying the surgical site and pointing out a possible error. To reduce the risk of wrong-site, wrong-procedure, or wrong-person surgeries, the Joint Commission developed a Universal Protocol (UP) in 2004 requiring compliance by all accredited hospitals, ambulatory care, and office-based surgery facilities (JC, 2014e). The three principal components of the UP include a pre-procedure verification, site marking, and a time out.


A surgical checklist is an algorithmic listing of actions to be taken in any given clinical situation intended to make everyone aware that others expect these things to be done. Checklists have been responsible for some of the greatest successes of the patient safety era, particularly in improving safety for surgical patients.


“SIGN IN” checklist must be completed before induction of anesthesia (with at least a circulating nurse and anesthetist)

  1. Has the patient confirmed his/her identify, site, procedure, and consent?
  2. Is the site marked?
  3. Is the history and physical present?
  4. Is the anesthesia machine and medication check complete?
  5. Are diagnostic and radiologic test results present?
  6. Are blood products available?
  7. Is the pulse oximeter on the patient and functioning?
  8. Are all special equipment, devices, and implants present?
  9. Does the patient have a:
    • Known allergy?
    • Difficult airway or aspiration risk?
    • Risk of >500 ml blood loss (7ml/kg in children)?

“TIME OUT” checklist must be completed before skin incision (with circulating nurse, anesthetist, and surgeon)

  1. Have all team members introduced themselves by name and role?
  2. Has the patient’s name, procedure, and where the incision will be made been confirmed?
  3. Has antibiotic prophylaxis been given within the last 60 minutes?
  4. For the anticipated critical event:
    • Surgeon
      • What are the critical or non-routine steps?
      • How long will the case take?
      • What is the anticipated blood loss?
    • Anesthetist
      • Are there any patient-specific concerns?
    • Nursing team
      • Has sterility (including indicator results) been confirmed?
      • Are there equipment issues or any concerns?
  5. Is essential imaging displayed?

“SIGN OUT” checklist must be completed before the patient leaves the operating room (with circulating nurse, anesthetist, and surgeon)

  1. Have the scrub and circulating personnel verbally confirmed:
    • The name of the procedure?
    • Completion of instrument, sponge, and needle counts?
    • Specimen labeling (read aloud specimen labels, including patient name)?
    • Whether there are any equipment problems to be addressed?
  2. Have the surgeon, anesthetist, and nursing personnel discussed:
    • What are the key concerns for recovery and management of this patient?

Source: WHO, 2014.

Medication Error Interventions

AHRQ (2012b) has identified four pathways between a healthcare provider’s prescribing decision and the patient who will receive the medication:

  • Prescribing
  • Transcribing
  • Dispensing
  • Administering

For each of the pathways, there are strategies recommended to prevent adverse drug reactions.

When prescribing:

  • Order the appropriate medication, dose, and frequency.
  • Avoid unnecessary medications (polypharmacy).
  • Use computerized prescriber order entry (CPOE).
  • Perform medication reconciliation at times of transition of care.

There are many facilities that have instituted the practice of medication reconciliation at all transitions in care to prevent adverse drug events. Medication reconciliation is the process of creating the most accurate list possible of all the medications a patient is taking—including the drug name, dosage, frequency, and route—and comparing that list against the physician’s admission, transfer, and/or discharge order. The goal is to ensure the correct medication is provided to a patient at all points of transition within the facility (IHI, 2014a).

When transcribing:

  • In non-computerized systems, read and interpret the prescription correctly.
  • Implement computerized prescriber order entry to eliminate errors due to handwriting.

When dispensing:

  • Check for drug-to-drug interactions and allergies.
  • Dispense the correct quantity of medication in the correct form.
  • Supervise the process of dispensing medications by assistants.
  • Use different lettering and other strategies in order to reduce confusion between medications that look alike or sound alike. (“Tall man” lettering is the practice of writing part of a drug’s name in upper case, e.g. chlorproMAZINE and chlorproPAMIDE.)

When administering:

  • Adhere to the “eight rights” of medication administration safety:
    • Right patient
    • Right medication
    • Right dose
    • Right route
    • Right time
    • Right documentation
    • Right reason
    • Right response
  • Utilize barcode medication administration to guarantee accuracy.
  • Use smart infusion pumps when administering intravenous fluids/medications to catch errors at the point of care.
  • Provide patients with education to enhance comprehension of instructions for taking medications.

Published studies of ADEs have consistently identified certain classes of medications as particularly serious threats to patient safety. The Joint Commission and the Institute for Safe Medication Practices (ISMP) have published lists of high-alert medications. These “high-risk” medications include:

  • Concentrated electrolyte solutions such as potassium chloride
  • Intravenous insulin
  • Chemotherapeutic agents
  • Intravenous opiate analgesics
  • Anticoagulants such as heparin and warfarin
Safe System Design

In 2012 the Institute for Healthcare Improvement (IHI) created a how-to guide for the prevention of harm from high-alert medications, recommending three principles of safe system design: 1) design processes to prevent errors and harm, 2) design methods to identify errors and harm when they do occur, and 3) design methods to lessen the harm that may result from the error.

Processes to prevent errors and harm:

  • Standardize the approach to treatment by developing order sets, preprinted orders, clinical pathways or protocols.
  • Standardize concentrations and dose strength to the minimum needed for safe care.
  • Centralize pharmacist- or nurse-run anticoagulation, insulin management, and pain management services.
  • Implement protocols for vulnerable populations (elderly, pediatric, obese patients).
  • Use “tall man” lettering for pharmacy-produced labels for differentiation of drug names that look alike or sound alike.

Methods to identify errors and harm when they do occur:

  • Include in order sets, protocols, and flow sheets reminders and other information about monitoring parameters.
  • Ensure availability of critical lab information.
  • Use independent double check.
  • Educate patients to monitor for symptoms and when to contact their provider.

Methods to lessen the harm that may result from the error:

  • Utilize protocols allowing for administration of reversal agents without having to contact the physician.
  • Ensure rescue protocols are available.
FDA Warnings

High-alert (high-risk/high-hazard) drugs such as neuromuscular blocking agents, chemotherapy agents (some of which are carcinogens), and opioid analgesics require special precautions to prevent catastrophic errors. Although many of these drugs carry a black box warning (BBW), the FDA’s strongest labeling requirement, one study indicated that some physicians and pharmacists might ignore BBWs in prescribing and dispensing drugs.


The Physician-Patient Alliance for Health & Safety (PPAHS) reported that there is cause for concern in patients using patient-controlled analgesia (PCA), and there is a great lack of consistency in safety procedures followed by hospitals across the country. This is believed to account for a large proportion of adverse events and deaths related to its use. There is evidence that hospitals that continuously monitor their patients with pulse oximetry and/or capnography are better able to avert adverse events.


Checklists for safe use of PCA pumps are available. The PPAHS checklist recommends certain steps be taken when initiating, refilling, or reprogramming PCA pumps, and PCA checks to be taken at shift change and hourly.

PCA pump initiation, refilling, or programming a change require:

  • Assessment of the patient for increased risk of respiratory distress:
    • Obesity
    • Low body weight
    • Current medication that can potentiate sedative effects
    • Pre-existing conditions such as asthma, COPD, and sleep apnea
    • Advanced age
  • Pre-procedural cognitive assessment to determine the capability of patient to participate in pain management (may not be suitable for pediatric patients)
  • Provision of information to the patient on proper use of the PCA and purpose of monitoring
  • Two healthcare providers independently double-check:
    • Patient’s identification
    • Allergies
    • Drug selection and concentration confirmed as prescribed
    • Any dose adjustment completed
    • PCA pump settings
    • Line is attached to the patient and tubing is inserted into pump
  • Electronic monitoring:
    • Pulse oximetry
    • Capnography

Change of shift and every hour require:

  • Assess patient for level of pain, alertness, and adequacy of ventilation
  • Verify PCA pump settings
  • Verify electronic monitoring
  • Document patient assessment and condition, PCA dosing, and monitoring

Source: Wong et al., 2013.


Many health professionals work or consult in non-healthcare settings such as adult daycare, summer camps, schools, group homes, board-and-care facilities, and jails. These facilities are usually licensed by the state but often use unlicensed staff members to dispense medications to patients. According to the National Coordinating Council for Medication Error Reporting and Prevention, medication errors are a significant problem in these settings.

The council’s recommendations for the handling of medications (including OTC medications) in these settings include proper storage, written policies and procedures, limitations on the type of medications stored by the organization, training programs, safeguards to prevent theft of controlled medications, and reporting and evaluation of medical errors.

Interventions to Prevent Tubing Misconnections

An analysis of research and recommendations for preventing misconnections suggests that equipment redesign to make enteral and IV systems incompatible is the most effective way to reduce misconnection errors (Simmons et al., 2011). The International Organization for Standardization (ISO) has adopted new standards intended to address connector cross-compatibility issues between products for a variety of medical applications (e.g., enteral, parenteral, IV, epidural, etc.) and identifies specific designs for each application to eliminate the possibility of misconnections (JC, 2014f).

Connectors manufactured according to the new specifications are entering the workplace, and temporary adaptors are being introduced to connect the old tubing with the new tubing. However old connectors will remain in use and the potential for misconnections will still exist until existing supplies are depleted (JC, 2014f).


Until tubing has been redesigned to meet safer standards, the Joint Commission recommends the steps outlined below:

  • Review currently used systems to assess practices with the potential for misconnection, including nonstandard, rigged work-arounds (for example, Luer adapters).
  • Instruct nonclinical staff and visitors not to reconnect lines but to seek clinical assistance instead. Only clinicians or users knowledgeable about the use of the device should make a reconnection.
  • Do not modify or adapt IV or feeding devices. Doing so may compromise the safety features incorporated in the design.
  • When making a reconnection, routinely trace lines back to their origins and ensure that they are secure.
  • On arriving at a new setting or as part of a hand-off process, recheck connections and trace all tubes.
  • Route tubes and catheters with different purposes in unique and standardized directions (e.g., IV lines routed toward the head, enteric lines toward the feet).
  • Package together all parts needed for enteral feeding and reduce availability of additional adapters and connectors to minimize availability of dissimilar tubes or catheters that might be improperly connected.
  • Label or color-code feeding tubes and connectors. Educate staff about the labeling or color-coding process in the institution’s enteral feeding system.
  • Identify and confirm the solution’s label because a three-in-one parenteral nutrition solution can appear similar to an enteral nutrition formulation bag. Label the bags with large, bold statements such as “WARNING! For Enteral Use Only—NOT for IV Use.”
  • Identify and minimize conditions and practices that may contribute to healthcare worker fatigue and take appropriate action.

Source: JC, 2014g.

Medical Device and Equipment Problem Interventions

The FDA regulates devices that support or sustain human life, are of substantial importance in preventing impairment of human health, or present a potential unreasonable risk of illness or injury by using a process of scientific and regulatory review to evaluate safety and effectiveness.

Health professionals should familiarize themselves with their institution’s procedures for reporting adverse events to the FDA (FDA, 2009a & b). Under the Safe Medical Devices Act of 1990, facilities (hospitals, ambulatory surgical centers, nursing homes, or outpatient centers) are required to:

  • Report to the FDA and to the manufacturers any suspected medical device–related deaths
  • Report medical device–related serious injury only to the manufacturer, if known; if the manufacturer is unknown, report serious injury to the FDA
  • Submit an annual report to the Secretary of Health and Human Services summarizing adverse events attributed to medical devices

The medical device and equipment user (physician, nurse, therapist, technologist, patient, and other service personnel) is the human factor that must be taken into consideration when a new device is being designed in order for it to be operated correctly and safely. This means the design must consider the perceptual abilities associated with sight, hearing, and touch.

Healthcare-Associated Infection (HAI) Interventions

The CDC (2012) provides recommendations for prevention of these infections. A summary of the top recommendations for preventing each type of infection follows.

  • Insert catheters only for appropriate indications.
  • Leave catheters in place only as long as needed.
  • Ensure that only properly trained persons insert and maintain catheters.
  • Insert catheters using aseptic technique and sterile equipment (acute care setting).
  • Follow aseptic insertion; maintain a closed drainage system.
  • Maintain unobstructed urine flow.
  • Comply with CDC hand hygiene recommendations and Standard Precautions.

Also consider:

  • Alternatives to indwelling urinary catheterization
  • Use of portable ultrasound devices for assessing urine volume to reduce unnecessary catheterizations
  • Use of antimicrobial/antiseptic-impregnated catheters

Before surgery:

  • Administer antimicrobial prophylaxis in accordance with evidence-based standards and guidelines.
  • Treat remote infections whenever possible before elective operations.
  • Avoid hair removal at the operative site unless it will interfere with the operation; do not use razors.
  • Use appropriate antiseptic agent and technique for skin preparation in the period prior to surgery and immediately before the placement of surgical drapes.

Also consider:

  • Nasal screening and decolonization for Staphylococcus aureus carriers for select procedures (i.e., cardiac, orthopedic, neurosurgery procedures with implants)
  • Screening preoperative blood glucose levels and maintaining tight glucose control

During surgery:

  • Keep OR doors closed during surgery except as needed for passage of equipment, personnel, and the patient.
  • Re-dose antibiotic at the 3-hour interval in procedures with a duration greater than 3 hours.
  • Adjust antimicrobial prophylaxis dose for obese patients (body mass index >30).
  • Use at least a 50% fraction of inspired oxygen intraoperatively and immediately postoperatively in select procedure(s).

After surgery:

  • Maintain immediate postoperative normothermia.
  • Protect primary closure incisions with sterile dressing.
  • Control blood glucose level during the immediate post-operative period (cardiac).
  • Discontinue antibiotics according to evidence-based standards and guidelines.

CLABSIs typically cause a prolonged hospital stay with increased cost and mortality risk. Preventing these dangerous oversights may have a low-cost, high-yield solution, such as a simple checklist of evidence-based practices in infection control, like handwashing and other fundamental procedures. CDC guidelines include a checklist that covers the following:

For clinicians:

  • Promptly remove unnecessary central lines.
    • Perform daily audits to assess if each central line is still needed.
  • Follow proper insertion practices.
    • Perform hand hygiene before insertion.
    • Adhere to aseptic technique.
    • Use maximal sterile barrier precautions (mask, cap, gown, sterile gloves, and sterile full body drape).
    • Perform skin antisepsis with >0.5% chlorhexidine with alcohol.
    • Choose the best site to minimize infections and mechanical complications.
    • Avoid femoral site in adult patients.
    • Cover the site with sterile gauze or sterile, transparent, semipermeable dressings.
  • Handle and maintain central lines appropriately.
    • Comply with hand hygiene requirements.
    • Scrub the access port or hub immediately prior to each use with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol).
    • Access catheters only with sterile devices.
    • Replace dressings that are wet, soiled, or dislodged.
    • Perform dressing changes under aseptic technique using clean or sterile gloves.

For facilities:

  • Empower staff to stop non-emergent insertion if proper procedures are not followed.
  • “Bundle” supplies (e.g., in a kit) to ensure items are readily available for use.
  • Provide the checklist above to clinicians to ensure all insertion practices are followed.
  • Ensure efficient access to hand hygiene.
  • Monitor and provide prompt feedback for adherence to hand hygiene.
  • Provide recurring education sessions on central line insertion, handling, and maintenance.

Supplemental Strategies

  • Use 2% chlorhexidine for bathing.
  • Use antimicrobial/antiseptic-impregnated catheters.
  • Use chlorhexidine-impregnated dressings.
  • For peripheral catheters, an upper extremity site is preferred in adults. In pediatric patients, the upper or lower extremities or the scalp (in neonates or young infants) can be used.
  • Avoid steel needles when administering fluids and medications that might cause tissue necrosis if extravasation occurs.
  • If the duration of intravascular therapy is likely to be more than six days, a midline catheter or PICC is preferred to a short peripheral catheter.
  • Evaluate the catheter insertion site daily and remove peripheral venous catheters if signs of phlebitis develop.
  • For patients with chronic renal failure, a fistula or graft instead of a CVC for permanent access for dialysis should be used.
  • Any intravascular catheter that is no longer essential should be promptly removed.
  • When adherence to aseptic technique cannot be ensured, such as during a medical emergency, the catheter should be replaced as soon as possible (within 48 hours).
  • Systemic antimicrobial prophylaxis before insertion or during use of an intravascular catheter is not routinely recommended to prevent catheter colonization or CRBSI.
  • Use Contact Precautions for duration of diarrhea.
  • Comply with CDC hand hygiene recommendations.
  • Adequately clean and disinfect equipment and environment.
  • Implement a laboratory-based alert system for immediate notification of positive test results.
  • Educate about CDI: healthcare personnel, housekeeping, administration, patients, and families.

Also consider:

  • Extending use of Contact Precautions beyond duration of diarrhea (e.g., 48 hours)
  • Presumptive isolation for symptomatic patients pending confirmation of CDI
  • Evaluating and optimizing testing for CDI
  • Using soap and water for hand hygiene before exiting room of a patient with CDI
  • Implementing universal glove use on units with high CDI rates
  • Using EPA-registered disinfectants with sporicidal claim (e.g., bleach) or sterilants for environmental disinfection
  • Implementing an antimicrobial stewardship program
  • Comply with hand hygiene as recommended by the CDC.
  • Implement Contact Precautions when working with patients with MDRO infection.
  • Use antibiotics only when needed and for the shortest time possible.
  • Place patients with a MDRO infection in a private room or share a room with others who have the same infection.
  • Clean and disinfect all patient care items, equipment, and room surfaces every day; utilize a checklist to ensure compliance.
  • Recommend vaccination against Streptococcus pneumonia.
  • Monitor the spread of MDROs and educate caregivers.

Many hospitals are reporting significant reductions in ventilator-acquired pneumonia (VAP) in critical care units. Some have reached zero cases by taking an approach that involves a checklist that includes a “bundle” of evidence-based care processes that reduces the incidence of pneumonias in ventilator patients by one fourth and reduces length of stay in ICU by one half. The bundle includes four processes: peptic ulcer disease prophylaxis, deep vein thrombosis prophylaxis, elevation of the head of the bed, and a “sedation vacation.”

Fall Prevention


Preventing falls begins with assessment of the patient using one of the several tools available, such as the Morse Fall Scale. It is recommended that assessment for fall risk should be done by nursing for every patient on admission. Reassessment should be done upon transfer of a patient from one unit to another, with any status change, following a fall, at regular intervals, and with changes in caregivers. Post-fall assessment should include a history of the fall from the patient and/or witnesses; the circumstances (e.g., time, location, activity); review of underlying illness, medications, and environmental conditions; and functional, sensory, and psychological status.


The MFS is used widely by nurses in both hospital and long-term care inpatient settings. The MFS requires systematic, reliable assessment of a patient’s fall risk factors upon admission, after a fall, upon change in status, and at discharge or transfer to a new setting. MFS subscales include assessment of:

Risk Factor Score
1. History of falling; immediate or within 3 months No = 0
Yes = 25
2. Secondary diagnosis No = 0
Yes = 15
3. Ambulatory aid None, bed rest, wheelchair, nurse = 0
Crutches, cane, walker = 15
Furniture = 30
4. IV/heparin lock No = 0
Yes = 20
5. Gait/transferring Normal, bed rest, immobile = 0
Weak = 10
Impaired = 20
6. Mental status Oriented to own ability = 0
Forgets limitations = 15
Risk Level MFS Score Action
No Risk 0–24 None
Low Risk 25–50 Standard fall prevention interventions
High Risk 51+ High-risk fall prevention interventions

Source: Oh, 2012b.


Fall prevention interventions include both standard and high-risk categories.

Standard fall prevention strategies:

  • Orient the patient to the environment.
  • Place the call light (bell) within reach and have the patient demonstrate its use.
  • Ensure that necessary items are within the patient’s reach.
  • Keep the hospital bed in low position and the brakes locked.
  • Make certain the patient is wearing non-slip, well-fitting footwear.
  • Provide a nightlight or other lighting.
  • Keep floors clean and dry.
  • Clean up spills immediately.
  • Provide grab bars in patient bathrooms and rooms.
  • Install handrails in hallways.
  • Keep patient care areas free of clutter.

High-risk prevention strategies:

  • Provide visual cues to communicate risk of falls.
    • Post a sign outside the patient’s door and in the room.
    • Apply a coded wristband.
    • Use designated color socks or blankets.
    • Post an alert in the medical record.
  • Cue the patient for toileting at least every two hours while awake.
  • Do not leave the patient unattended when assisted to the bathroom or commode.
  • Use safe transfer and handling techniques, utilizing gait belt or assistive devices if needed.
  • Use low beds and floor mats, if appropriate.
  • Apply bed and chair alarms.
  • Observe frequently or continuously, if necessary.
    (Gardner & Feil, 2013)


Many errors have been demonstrated to arise from the lack of adequate or accurate communication. Meticulous medical documentation helps to prevent practice errors and provides a shield against errors arising from miscommunication.

Good Documentation

Documentation must be credible and timely and must accurately reflect the patient’s condition as well as the care given. Illegible writing, overuse of abbreviations, and poor transfer of information (both within a department and when a patient transfers to another department) can cause medical errors. Healthcare professionals must learn and follow their facility’s policies and procedures about charting.

  • Document in the correct chart.
  • Document any prevention measures, including patient education.
  • Write legibly, using agency-approved abbreviations.
  • Be objective, state the facts, and avoid personal opinions.
  • If a problem is identified, document the actions taken to address the problem.
  • Document all communication with colleagues.
  • Document errors and how they were dealt with.
  • Document referrals to other health practitioners or services.
  • Follow agency procedures for correcting a charting error.
  • Document in a timely manner throughout the shift.
  • Never document what someone else saw or heard unless the information is critical.

It is necessary to consider the possibility of malpractice lawsuits and how best to avoid potential legal liability. Documentation must be complete, correct, and timely. To avoid liability, it is important to be able to explain and justify (based on EBP) the care given by each person if one is subpoenaed.

  • Do not chart a symptom without also charting what action was taken in response.
  • Do not alter a patient’s record (a criminal offense).
  • Do not use abbreviations that are not facility approved and widely accepted.
  • Do not write inexact descriptions such as “a large amount.”
  • Do not chart excuses for omissions such as “dressing not changed because supply not available.”
  • Do not document what someone else said, heard, felt, or smelled unless it is pertinent, and if so, place it in quotation marks.
  • Do not chart ahead of time. Charting care a clinician hasn’t done is considered fraud.
    (NSO, 2013)

Communication Tools

Research indicates that poor communication is a root cause in more than half of all sentinel events. Whether it is nurse-to-nurse, nurse-to-physician, or physician-to-physician communication, having a standard framework and proven tools for reporting and sharing information can enable more effective communication.


One increasingly popular communication tool is the SBAR format: Situation (S), Background (B), Assessment (A), and Recommendation (R). It was originally developed by the U.S. Navy and since the 1990s has been used in healthcare settings. This tool can be used for hand-offs between shifts and between caregivers, as well as for debriefings on internal issues, information on new procedures, and email communication.

  • Situation: What’s happening right now?
  • Background: What are the circumstances that led up to this situation?
  • Assessment: What do I think the problem is with this patient?
  • Recommendation: What should be done to correct the situation?

Source: IHI, 2014c.


For over a decade, patient safety has become a topic of national concern. Everyone has a stake in the safety of the healthcare system—healthcare workers as well as the general public. In the past, patient safety and quality have not been a traditional part of the education of most healthcare workers, but today this is no longer an acceptable reason for not taking an active role in the prevention of negative outcomes for those we care for. It is essential that we all understand the journey every patient makes through the system, recognizing how the system can fail and what can be done to prevent those failures.

To counter errors and safeguard patients, changes must continue to be made in how the workforce is deployed, how work processes are designed, and to leadership, management, and the culture of healthcare organizations. Physicians, nurses, therapists, and other healthcare personnel are members of a team, and it is crucial that these team members work together and communicate effectively. Collaborative teamwork is essential for optimizing quality and safety in healthcare.


AHRQ Patient Safety Network

Florida Agency for Health Care Administration, Division of Health Quality Assurance

Health Care at the Crossroads: Strategies for Improving the Medical Liability System and Preventing Client Injury (Joint Commission) (PDF)

Hospital Safety Score

Institute for Healthcare Improvement

List of High-Alert Medications (Institute for Safe Medication Practices) (PDF)

NCCMERP (National Coordinating Council for Medication Error Reporting and Prevention)

National Patient Safety Foundation

National Quality Forum

VA National Center for Patient Safety

Your Medicine: Be Smart, Be Safe (AHRQ) (PDF)


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