Reiki Center of Venice ~ Medical Errors ~ 2 CE's
Medical Errors ~ 2 CE's
Preventing Medical Errors
Reiki Center of Venice
2 CE Hours
Preventing Medical Errors by Francine Milford, LMT
The estimated time to complete this course is 2 hours.
To Complete this Course
- Read this study guide and complete the open-book test that was included in this course.
- Mail in your answers to Francine Milford, 3230 Prairie Dunes Circle W, Lakeland, Fl. 33810 or email to FrancineMilford@cs.com.
- Mail, or email, your course evaluation to address listed above.
- Please keep a copy of your answer sheet for your own records.
Neither the author of this study guide, nor the Reiki Center of Venice, assumes any liability for the learner’s application of the information contained herein. This course is NOT intended for use in prescribing treatments, therapies or recommendations of any kind.
Francine Milford, BS, LMT, is a massage therapist, personal trainer and owner/instructor at the Reiki Center of Venice. She is the author of more than 50 manuals and a dozen home study courses. She resides in Lakeland, Florida where she continues to teach onsite classes at the Center.
Preventing Medical Errors
Copyright©2020 Reiki Center of Venice, LLC.
FL Massage Provider# 50-9690
NCBTMB Provider# 310466-00
Through this course you will discover why medical errors contribute to skyrocketing health-care costs and injury. Learn why it is important for you, as a health care practitioner, to develop a clear and concise plan to guarantee the safety of your clients and customers. This course meets the Florida Medical Errors requirement.
- You will be able to identify ways to avoid making costly medical errors
- You will be able to create work processes that will greatly limit medical errors
- You will be able to identify key safety recommendations
- You will be able to set performance standards and expectations
- You will be able to implement client safety systems
- Federation of State Massage Therapy Boards (FSMTB) during COVID-19
Key Vocabulary Words
Medical Errors defined
Cost of Medical Errors
Causes of Medical Errors
Examples of Medical Errors
Setting Performance Standards and Expectations
Implementing Safety Systems
Legal Ramifications of Medical Errors
Recommendations for Massage Therapists and Bodyworkers
Open-book Test and Course Evaluation
What is a Medical Error?
According to Reference.MD, medical errors are mistakes committed by health professionals that result in harming the patient. Medical mistakes include errors in diagnosis, drug administration, surgical performance, equipment malfunction or misuse, negligence, ignorance, accident or even by criminal intent.
These errors can occur when a health care professional either chooses an inappropriate method of care-or executes the right care but does it incorrectly. Medical errors is one of the leading causes of death and injury in the United States surpassing people who die from motor accidents, breast cancer and AIDS.
According to the article written by Beth Howard titled, “Lessons from America’s Safest Hospitals,” Howard states that Mary McClinton, a 69 year–old social worker, was admitted into Virginia Mason Medical Center in Seattle to under a routine procedure to treat a brain aneurysm. The error occurred when doctors injected her with an antiseptic, instead of a contrast dye. The antiseptic, a topical cleaning agent, was stored in an unmarked container on the same tray as the dye. McClinton died 19 days later as each of her organs began to fail.
Errors such as the one mentioned above are called “never events” and affects at least 6,000 patients every year. Never events are errors that could have been prevented. These events include operating on the wrong limb or leaving instruments inside of a patient during surgery.
The tragedy happened in 2004. Virginia Mason Medical Center decided to do something about that and started a complete turnaround. The hospital decided to make safety their top priority. After issuing a public and private apology to McClinton’s family, the hospital began a program to revamp their safety procedures. Part of their program included implementing new safety protocols, gave nurses more time to spend with patients, instituted checklists before surgeries and established patient safety alerts. The hospital also encouraged their employees to speak up and file reports when they felt that a patient’s health or life was at risk.
While never events may account for harming 6,000 patients a year, medication errors cause approximately 400,000 drug-related injuries a year. On way to help curb this problem was with the implementation of a computerized provider order entry (CPOE) system. The system forces doctors to enter prescriptions into the computer electronically which eliminate transcription errors. The system also has a built-in safety alert which helps keep doctors from prescribing more medicine than is generally accepted. Another part of the system is the bar coding of patient’s bracelets which helps to make sure that the right patient is receiving the right medication and the right medication dosage. In one year, this system has saved thousands of lives. With computerized systems, doctors can track patients outside of the hospital environment to see if they are getting their prescriptions filled which can affect patient compliance. This can also alert doctors to additional issues that the patient may not be reporting to the doctors at the hospital. This knowledge will also help in preventing drug interactions since the doctors will now have a better understanding of the medications that the patient is taking (and maybe not reporting).
Some 100,000 people die each year from preventable infections that they contracted in the hospital. Out of that number, 20,000 patients die from central line infections. It was discovered that the simple act of washing your hands and cleaning the patient’s skin before inserting a line reduced central line infections by as much as 66%. To help lower incidences of preventable infections, hospitals have incorporated checklists and door signs for affected patients.
In an article titled, “The third-leading cause of death in US most doctors don’t want you to know about,” written by Ray Sipherd, special to CNBC.com, and published on Feb. 22, 2018, for Modern Medicine, three key points about medical errors were looked at.
One key point looked at a recent John Hopkins study which claimed that more than 250,000 people in the U.S. die every year from medical errors while other studies claimed that the number was closer to 440,000. The second key point stated that medical errors were the third leading cause of death following heart disease and cancer and the third key points was that advocates were fighting back by requiring greater legislature for patient safety.
Sipherd goes on to give an example of two year old Emily Jerry who lost her life after a pharmacy technician filled her intravenous bag with more than 20 times the recommended dose of sodium chloride. She was put on life support and declared brain dead and died three days later. While Emily’s case is one of the 250,000 medical error cases that are reported in the U.S. each year, the authors of a Johns Hopkins study, led by Dr. Martin Makary, have found that the number of deaths from medical errors in actuality may be as high as 440,000. The difference in these numbers may be due the fact that physicians, coroners, medical examiners and funeral directors my not report the cause of death on death certificates as due to medical errors.
Dr. Makary believes the system itself is to blame. From having inadequately skilled staff to computer breakdowns and dose mix-ups, are all causes of preventable adverse effects. I have personally returned from the pharmacy with what I thought was my medication only to discover that it belonged to someone else. Being honest and aware, I was quick to return the medication to the pharmacy but what if I wasn’t aware of the pills and started taking them? How often do these mix-ups occur? At another time I had a pharmacy question me on a specific medication that was ordered for me because they noted on my file that I had allergies to a specific ingredient in the prescribed medication. Had the pharmacist not notice this potential issue, I could have easily taken medication unaware of the potential problems. If this can happen to me, it can happen to anyone.
But who is to blame? We are only human and we all mistakes, this much is true but when you add to that hospitals and pharmacies that short staffed, backlog of orders, patients needing more attention, and computer breakdowns or lack of correct data entries, then it becomes more than an isolated incident. In the case of Emily, it was discovered that pharmacy technicians were compounding nearly all of the IV medications for patients and many states have no requirements or proof of competency for these workers.
But it is not always the workers that are to blame. Dr. Makary discovered that some 20% of all medical procedures may be unnecessary and that doctors, often encouraged by drug companies to ‘promote’ their products, may result in complications from unneeded medical care and prescription of medication from surgery.
Dr. Makary offers some advice and insight from your health-care provider. When faced with surgery, ask for the benefits, side effects and disadvantages of any recommended medication or procedure. Ask for a second opinion if the situation warrants or if you are still unsure of your diagnosis. Be sure to bring an advocate with you who can understand the information and ask questions. Do your homework and research your conditions and potential treatment plans and lastly, ask for an itemized bill.
Some 12,000,000 Americans are misdiagnosed each year costing roughly $210,000,000,000 annually in medical bills. In any given year, there will be approximately 4,000 surgical errors and 7,000 to 9,000 patients will die from medication errors. As much as 80% of medicals bills will contain at least one error.
Not all medical errors will have a negative effect on you. I myself have missed three B12 shots due to medical errors while I was undergoing chemotherapy one year. The first error was that the nurse didn’t realize that the medication was listed it on the chart for me, a second error was when the pharmacy forgot to fill the order for the medication so I went without it, and the third error was that the pharmacy didn’t deliver the medication to me until after I had left from my appointment. But I consider myself lucky as these errors didn’t end up killing me. Others are not so lucky.
In an article by Linda Carroll titled, “Medical mistakes harm more than 1 in 10 patients. Many are preventable. At least 12 percent of preventable errors caused permanent disability or death, according,” Carroll states that more than 1 in 10 patients are harmed in the course of their medical care with half of those injuries being preventable. Among those preventable errors, 12% of them resulted in a patient’s permanent disability or death. (BMJ 2019).
In the study of 300,000 patients, lead author and senior lecturer at the University of Manchester, Maria Panagioti, discovered that most harm related to medication, an area that preventative strategies could focus on. The study found that 49% of the harms reported were ‘mild’ while 36% were said to be ‘moderate’ and 12% were described as ‘severe.’ (Carroll 2019).
What will the safe hospital room of the future have in it? It will have double-sided linen closets, bar codes on patient bracelets, a hand washing station in every room, hand bars, bed alarms, disinfecting units that use ultraviolet light to kill germs, checklists for health care providers, vents that will filter the air out of the room of sick patients and release it from the building, fall prevention kits, germ-resistant copper alloys on door knobs, faucets and railings, language translators and vital sign monitors.
Causes of Medical Errors
According to the U.S. Department of Health and Human Services, 1 in 7 patients on Medicare in a hospital setting is the victim of a medical error. Medical errors can be caused by any number of reasons including, but not limited to, the following:
- Inexperienced physician and nurses
- Implementation of new procedures for which inadequate training has been provided
- Complexity of care
- Emergency care
- Extreme age
- Improper documentation
- Poor communication
- Illegible handwriting
- Inadequate nurse-to-patient ratios
- Patient non compliance
- Faulty health care system
- Poorly designed process
- Human misjudgment
- Similarly named (or looking) medication
- Lack of coordination within a hospital or clinic
- Disconnected reporting systems (one nurse handing off patient to another nurse without proper documentation)
- Lack of quality skilled technicians
- Cost-cutting measures
- Reliance on automated systems
- The idea that someone else is handling the situation
- The arrival of new residents
- Variations in healthcare provider training and experience
Human Factors to Medical Errors
There are a number of human factors that contribute to causing medical errors. These errors include, but are not limited to, the following:
- Sleep deprivation
- Time restraints
- Similar drug names-or-drugs that look similar
- Increase in Nurse-to-patient ratio (Nursing staff has too many patients to be responsible for)
- Diverse patients (and needs)
- Unfamiliar settings (starting a new job as a health care professional and can’t remember where the supplies, equipments, etc. are).
A Personal Example of a Hospital Error:
I took my husband to a hospital where the attending physician was a practical nurse who was visiting from Ohio and her attendee was a nurse who was just visiting from Indiana. Neither of these health care practitioners was able to locate the specific tools that they needed to do the stitches that my husband needed. They asked another hospital worker who shrugged and said that this was only their second day on the job and that they didn’t know if the hospital had of those requested supplies. But he ended up asking around for the instruments that the doctor needed.
Examples of Medical Errors
There are a variety of ways in which medical errors can, and do, occur. Among these include, but are not limited to, the following:
- Failure to diagnose the condition
- Misdiagnosis of the condition
- Delay in diagnosing the condition
- Prescribing the wrong drug (or doses, application, times, etc.)
- Giving patient two or more drugs that don’t interact well together (or are poisonous)
- Wrong-site surgery (amputating the wrong arm)
- Leaving tools (or sponges) behind in the patient after surgery
- Using race as a diagnosis (and not as a factor)
- Transplanting organs using the wrong blood type (or using inferior or infected organs)
- Incorrect record-keeping and/or documentation
- Inability of doctors to deal with patients with special needs (such as mental illness, bipolar disorders, mental disorders, dissociative identity disorders, schizophrenia, etc.)
The Five most Common Misdiagnoses
- Myocardial infarction
- Pulmonary emboli
- Cardiovascular disease
In many hospitals today, it is a current standard of practice for patients to disclose medical errors. In the American Medical Association's Council on Ethical and Judicial Affairs, it states in its ethics code the following:
"Situations occasionally occur in which a patient suffers significant medical complications that may have resulted from the physician's mistake or judgment. In these situations, the physician is ethically required to inform the patient of all facts necessary to ensure understanding of what has occurred. Concern regarding legal liability which might result following truthful disclosure should not affect the physician's honesty with a patient."
And in the American College of Physicians Ethics Manual:
“In addition, physicians should disclose to patients information about procedural or judgment errors made in the course of care if such information is material to the patient's well-being. Errors do not necessarily constitute improper, negligent, or unethical behavior, but failure to disclose them may.”
But because of malpractice litigation, many physicians and staff are unwilling to disclose errors. To combat this refusal to have communication between patient’s family members and hospital employees, the United States enacted laws where anything that the physician or surgeon may say to console grieving family members such as, “I am so sorry,” cannot be used in a court of law as an admission of that physicians’ or surgeon’s proof of liability. And in fact, there is even some evidence that full disclosure may actually reduce malpractice payments as family members are only looking for closure in the death of a loved one.
Ways to Reduce Medical Errors
There exists within every system a number of ways that medical errors can be reduced or eradicated all together. These include, but are not limited to, the following:
- Sufficient training
- Sufficient time to perform the task (check workload)
- Offer additional or specialized training
- Updated technology awareness and training
- Using updated research
- National and International color coding standards
- Standardize medication (doses, etc.)
- Encourage patients to get a second opinion if they have doubts
- Have clients fill out in-depth client forms (and then read them)
- Ask clients to clarify any questions you may have about the information in the client in-take form, or the lack thereof.
- Putting together a system of checks and balances. One such system is the Formulary System. In the world of pharmaceuticals, professionals work with a process called the Formulary System with a list of drugs known as the Formulary. This helped in the implementation of unit dose packaging and distribution systems to centralize admixture services. This system reduces the risk of wrong drug doses, decreases the risks of contaminated and infected intravenous medications, improves the safe and effective use of medications and provides a computerized check of patient’s medical history to avoid drug interactions.
When speaking of procedures and the risk of medical errors, there are some common and inherit problems. The most avoidable adverse events often occur in high risk, or emergency procedures. Because of the circumstances surrounding the patient at this time, the adverse outcomes are usually not due to error but to the severity of the condition at time of treatment. Medications given at this time are three times more likely to cause harm to the patient than at any other time of admittance.
And it should be noted that most medical care comes with some level of risk. This risk could be in the form of complications, unforeseen circumstances, an underlying condition, or a side effect (such as an allergy to the medication). If a patient experiences any of these adverse events during the treatment process, an error has occurred.
The article titled ‘JCAHO Revises Standards to Help Reduce Medical Errors,’ written by Robert C. Morell, MD., talks about how an improvement in patient safety can directly minimize medical errors. The author of the article, Dr. Morell, is the Director of the Preoperative Assessment Clinic and Associate Professor, Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC.
JCAHO stands for the Joint Commission on Accreditation of Health Care Organizations. It is an independent, not-for-profit organization that accredits and certifies more than 19,000 health care organizations and programs in the United States. This commission has since been renamed, The Joint Commission.’ The job of the commission it to recognize those organizations that improve patient safety, reduce risks, and to minimize medical errors. You can download the commission’s findings and read the full article at their homepage at: http://www.jointcommission.org
On July 1, 2001, the Joint Commission published new language. On this list was the addition of the definition of the following words:
- Error: "An unintended act, either of omission or commission, or an act that does not achieve its intended outcome."
- Sentinel Event: "An unexpected occurrence involving death or serious physical or psychological injury or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase "or risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome."
- Near Miss: "Used to describe any process variation which did not affect the outcome but for which a recurrence carries a significant chance of a serious outcome. Such a near miss falls within the scope of the definition of a sentinel event, but outside the scope of those sentinel events that are subject to review by the Joint Commission under its Sentinel Event Policy."
- Hazardous Condition: "Any set of circumstances (exclusive of the disease or condition for which the patient is being treated) which significantly increases the likelihood of a serious adverse outcome."
The Commission created a set of Standard Policies that they felt would ensure patient safety and minimize medical errors. Among these findings were:
- Leaders ensuring implementation of an integrated patient safety program throughout the [healthcare] organization.
- Designation of one or more qualified individuals or an interdisciplinary group to manage the organization-wide patient safety program. Typically these individuals may include directors of performance improvement, safety officers, risk managers and clinical leaders.
- Procedures for immediate response to medical/health errors, including care of the affected patient(s), containment of risk to others, and preservation of factual information for subsequent analysis.
- Clear systems for internal and external reporting of information relating to medical/health care errors.
- Defined mechanisms for responding to the various types of occurrences, e.g., root cause analysis in response to a sentinel event, or for conducting proactive risk reduction activities.
- Defined mechanisms for support of staff that have been involved in a sentinel event.
- Definition of the scope of the program activities, which is the types of occurrences to be addressed, ranging from “no harm” frequently occurring “slips” to sentinel events with serious adverse outcomes.
- At least annually, a report to the governing body on the occurrence of medical/health care errors and actions taken to improve patient safety, both in response to actual occurrences and proactively.
In addition to recognizing the important of data collection and analysis, JCAHO also suggested proactive programs for identifying risks and reducing medical errors BEFORE they happened rather than programs that dealt with how to handle errors after they happened.
The identification of errors in the system, or process, called "failure modes" is vital to ensure patient safety. The commission encourages redesigning faulty programs or processes and implementing better safeguards.
According to the article, “JCAHO also recognizes that barriers to effective communication among caregivers must be minimized. Specific attention is focused on "ensuring accurate, timely, and complete verbal and written communication among caregivers." Standard RI.1.2.2 also states that, "Patients and, when appropriate, their families are informed about the outcomes of care, including unanticipated outcomes." The intent of this regulation is to have the responsible practitioner (or designee) clearly explain the outcome of any treatments or procedures to the patient (and/or family) whenever the outcome differs significantly from the anticipated outcome. “
Legal Ramifications of Medical Errors
There are many legal, professional and ethical ramifications for committing medical errors. There are several standards and regulations for medical malpractice and these vary by country and jurisdiction within countries. A professional found guilty of medical error can be fined, face imprisonment, be personally sued, and lose their license. In the United States, medical professionals, health care professionals, and massage therapists and Bodyworkers may obtain professional liability insurance to help them offset the risks and costs of any lawsuit.
If you own your own business, or office, then looking for a good insurance policy is extremely important. Find a policy that covers slip and fall, product liability and medical errors.
Be Sure to Report an Error
When hospitals do not make safety a top priority in their facilities, then accidents and errors can and do happen. A five-year study published in 2010 in the New England Journal of Medicine showed that 25 percent of all people admitted to hospitals in North Carolina were harmed by the medical care that they received. These percentages are too high for preventable events.
But, in order to fix problems that exist, you have to know about them. That is why reporting errors are so important. When a hospital receives a report, it triggers a review which can then lead to changes that are needed to prevent the recurrence of the error. Preventing recurring errors can cause changes in protocols, procedures, checklists, oversight, or the installation and use of new technology or technological systems.
Some of the items that are track-able are what is referred to as a preventable-harm index. Included in this index would be cardiac arrests, adverse drug events, surgical complications, falls, hospital acquired infections and pressure ulcers, among others.
In Washington, the Centers for Medicare and Medicaid Services have given a $5 million grant to a consortium of Ohio children's hospitals. The grant is to be used to help eliminate preventable errors. For adults, an initiative by the Department of Health and Human Services called, "Partnership for Patients: Better Care, Lower Costs," intends to reduce preventable injuries in U.S. hospitals by 40 percent by 2014. This would result in saving 60,000 lives.
Peter Pronovost, a Johns Hopkins anesthesiologist and critical care specialist launched the Keystone Project, a project that reduced the rate of bloodstream infections by 60% among patients in intensive care units who were receiving central lines or catheters. That 60% mark represented 1,500 lives and approximately $100 million each year. At the core of the Keystone Project was a checklist for the medical team to follow. Simple items on the list include hand-washing and mask wearing. Pronovost received government funding to extend the program to more than 1,400 ICUs in 48 states.
What can you do to Prevent Errors (as a consumer)
There are many ways in which you can take on an active role in your own health care. Patients who get involved in their own care tend to get better results. According to the article, “20 Tips to Help Prevent Medical Errors.” Patient Fact Sheet. AHRQ Publication No. 00-PO38, February 2000. Agency for Healthcare Research and Quality, Rockville, MD. Here are some those tips:
- Become an active participant in your health. Do research, ask questions, etc.
- Inform your doctor of all your current medications including herbal remedies, vitamin supplements, and over-the-counter medicines. The best way to do this is to bring ALL of your medications and supplements with you to your doctor’s visit and show them to the nurse and/or doctor.
- Be sure that your doctor is aware of any allergic or adverse reaction that you have had to any medication.
- Make sure to read your doctor’s prescription and have him or her, clarify anything that you cannot read or understand.
- Ask your doctor questions about any medications that he prescribes to you. (side effects, how long, how often, take with or without food, what to do in case of reactions, etc.)
- When you pick up your prescriptions from the pharmacy check your bottle against the prescription. Be sure that they are indeed the same name and dose. My husband has already had to return medicine to a pharmacy that was not his.
- The pharmacy is a great resource of information about the medication that you will be taking and usually have more time to explain it to you than your doctor does. Make use of this time if you are unsure about the directions on your medicine label or how to take it. Pharmacies now offer a full booklet with your prescriptions that give you a wealth of knowledge about the medicines that you are taking-be sure to read it.
- If you are facing an amputation of a limb, the American Academy of Orthopedic Surgeons recommend its members to sign their initials directly on the site that they will be operating on to avoid mistakes.
- Have someone with you to act as your advocate, or sounding board, in case you need them. They will also be a better place to hear the information that is given to you.
- If you are having a test taken, call for the results. Not all places will call you giving you the test results.
- Make sure that your doctor/hospital is up-to-date on the latest procedures and technologies regarding your specific condition.
A set of Universal Precautions for Health Care professionals have been created by the Occupational Health and Safety Administration to prevent the spread of disease.
For massage therapists, this list includes such safety precautions as:
- Clean massage tables, chairs and equipment before/after each use. Do not trust other therapists who use the same equipment before you to do the right job.
- Shower at the beginning of the day-and at the end of the day.
- Bring a change of clothes with you to work and change into your street clothes after you work day is over.
- Brush your teeth and keep your gums healthy.
- Wash your hands before and after each session and often throughout the day. Follow the hand washing protocols that you learned in school.
- Keep your nails cut and neat.
- Never wear jewelry such as bracelets and rings while doing massages as germs/skin cells can hide underneath them.
- Massage therapists should be trained in First Aid and CPR. After training, be sure to keep a health kit complete with a mouth guard for giving CPR.
- Create a safe working environment by taping down turned up carpet edges and removing obstacles from the walk area (such as wires and cords).
- Be sure to keep a workable schedule allowing with enough time in between clients to fill out your Client In-take form. Do not overwork yourself or schedule more clients in one day than your body can handle.
- Establish a basic protocol that you can follow to perform daily tasks such as doing the laundry, cleaning supplies and equipment, asking Client questions, etc.
U.S. Hospital Rankings and what it means to you
For 25 years, hospitals have been ranked nationally. On July 15, 2014, the US News & World Report, published the list of the national’s best ranked hospitals for the 2014-2015 year. The list included the nation’s top 50 hospitals in key specialties such as cancer and cardiology. Big winners include the Mayo Clinic and John Hopkins. While only 17 hospitals ranked high enough in six or more specialties to make the list the rest of the hospitals did not. In fact, only 144 of the 4,743 hospitals evaluated did well enough to even be ranked in at least one specialty of the 12 specialties listed. That’s only 3% of our nation’s hospital system (Omstead et al, 2014).
There were several factors that determined the overall hospital score. Some of these factors included structure, process, outcome, reputation among specialists and patient safety. There were new changes that took place in the 2014-2015 judging. The biggest change came in the form of adding more weight (from 5% to 10%) for patient safety. This increase was done in order to recognize those facilities that provided quality and patient safety.
In addition to adding more weight to the overall score, two patient safety indicators were added the score. Now consumers can see the differences in patient safety performance between hospitals.
The top 20 Hospitals in the United States are listed below:
U.S. News 2019-20 Best Hospitals Honor Roll
- 1. Mayo Clinic, Rochester, Minnesota
- 2. Massachusetts General Hospital, Boston
- 3. Johns Hopkins Hospital, Baltimore
- 4. Cleveland Clinic
- 5. New York-Presbyterian Hospital-Columbia and Cornell, New York
- 6. UCLA Medical Center, Los Angeles
- 7. UCSF Medical Center, San Francisco
- 8. Cedars-Sinai Medical Center, Los Angeles
- 9. NYU Langone Hospitals, New York
- 10. Northwestern Memorial Hospital, Chicago
- 11. University of Michigan Hospitals-Michigan Medicine, Ann Arbor
- 12. Stanford Health Care-Stanford Hospital, Stanford, California
- 13. Brigham and Women's Hospital, Boston
- 14. Mount Sinai Hospital, New York
- 15. UPMC Presbyterian Shadyside, Pittsburgh
- 16. Keck Hospital of USC, Los Angeles
- 17. University of Wisconsin Hospitals, Madison
- 18. (tie) Hospitals of the University of Pennsylvania-Penn Presbyterian, Philadelphia
- 18. (tie) Mayo Clinic-Phoenix
- 20. (tie) Houston Methodist Hospital
- 20. (tie) Yale New Haven Hospital, Connecticut
Beginning October, 2014, in an effort to require hospitals to lower their incidences of hospital-acquired conditions (HAC), the Centers for Medicare & Medicaid Services (CMS) began reducing Medicare payments to hospitals with poor outcomes under the Hospital-Acquired Condition (HAC) Reduction Program.
The Patient Safety Program, a program called for by the Affordable Care Act (ACA), will begin in 2015. Under this program, hospitals are given a rank according to 11 categories. The lowest performing 25 percent of hospitals with lose (1) percent of each Medicare payment paid under the Inpatient Prospective Payment System (IPPS), for the upcoming (2015) year. This ranking is based on two unique findings: HAC’s reported between Jan. 1, 2012-Dec. 31, 2013 and nine Patient Safety Indicators between July 11-June 2013.
Other provisions under the new rule will include increasing portions of Medicare payments to fund value-based incentive payments to 1.25 percent, add new readmission measures, and establish quality reporting programs to help align quality measure reporting.
The HAC Reduction Program is only one in over 70 programs that rate quality indicators in hospitals. The hope is that programs like these will encourage hospitals to improve their quality of care and implement better patient safety system.
The 11 categories of HACs listed below:
- Foreign Object Retained After Surgery
- Air Embolism
- Blood Incompatibility
- Stage III and IV Pressure Ulcers
- Falls and Trauma
- Intracranial Injuries
- Crushing Injuries Burn
- Other Injuries
- Manifestations of Poor Glycemic Control
- Diabetic Ketoacidosis
o Nonketotic Hyperosmolar Coma
o Hypoglycemic Coma
o Secondary Diabetes with Ketoacidosis
o Secondary Diabetes with Hyperosmolarity
- Catheter-Associated Urinary Tract Infection (UTI)
- Vascular Catheter-Associated Infection
- Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG):
- Surgical Site Infection Following Bariatric Surgery for Obesity
o Laparoscopic Gastric Bypass
o Laparoscopic Gastric Restrictive Surgery
- Surgical Site Infection Following Certain Orthopedic Procedures
- Surgical Site Infection Following Cardiac Implantable Electronic Device (CIED)
- Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Following Certain Orthopedic Procedures:
o Total Knee Replacement
o Hip Replacement
- Iatrogenic Pneumothorax with Venous Catheterization
Key Vocabulary Words
Accident: An unplanned event that results in damage.
Active error: An error whose effects are felt almost immediately.
Adverse event: An injury directly caused by medical intervention.
Bad outcome: Failure to receive expected outcome.
Error: Use of a wrong plan of action to achieve desired goal-or-failure of a plan of action(s) to be completed as directed.
Failure Mode: Errors in the system, or process
Health-care organization: Legal entities that provide health and medical services.
Human factors: Study of humans in the environment and the tools that they use.
Latent error: An error whose effects are generally not felt for a long period of time. These errors may include problems in the design, organization, training or maintenance of the system, or patient.
Medical technology: Includes all drugs, equipments and procedures followed by a health care professional in providing medical care to a patient.
Micro-system: A core team of health care professionals that offer repeatable services to a specific population (such as geriatrics). This group also provides information and a support system for said population.
Patient Safety: Development of systems/precautions that minimize errors.
Quality of Care: The overall success rate of a service to provide desired outcome.
Scope of Practice: Working within the confines of your license/training.
Standard: Minimum acceptable results or performance.
System: Set of elements that interact to achieve a common goal or function.
Federation of State Massage Therapy Boards (FSMTB) during COVID-19
Disclosure: The following information has been taken from the official website for the Federation of State Massage Therapy Boards (FSMTB). For more details, please visit this website at the end of this article.
On May 19, 2020, the Federation of State Massage Therapy Boards (FSMTB) published the massage therapy and bodywork guideline for practice with Covid-19. Below are the recommendations from this organization for everything from cleaning products, to scheduling and wearing face masks.
While some massage therapists and Bodyworkers use homemade cleaning products in their practice, the FSMTB suggests that therapists use products such as soap and water to wash down surfaces to remove visible soil and a glass cleaner on glass surfaces. Surfaces should first be cleaned to remove visible dirt and them followed by disinfection.
Fabrics (curtains, upholstered couches and chairs, etc.) should be disinfected with EPA-registered disinfectants that are specific to use against SARS-COV-2. Check the label to be sure and follow the label directions when using the product.
Some of the best ways to deal with the virus is to look around your office and find ways to reduce the replace items to make it easier to clean and disinfect your space. Some of these ways include removing items such as magazines, brochures, candy bowls, etc. from your waiting area. Any knickknacks should also be removed from your office to cut down on cleaning time. Just pack all of these non-essential items in a box and put away for safe keeping.
You can also look over your reception area and remove extra chairs so that you can maintain the 6’ social distancing recommendation.
Be sure to have hand sanitizer easily accessible to your clients. These hand sanitizers should be 60-95% alcohol.
Encourage clients to wear their own face masks or provide a disposable face mask if you can. You can place signs that are available from the CDC to help educate clients about proper hygiene procedures and cough etiquette.
High touch surfaces such as door handles, counter tops, pens and pencils, water fountain, clipboard, etc., should be wiped down between each client. Floors should be cleaned at the end of the day (carpets vacuumed with HEPA filter and hard floors should be mopped). Clean restroom surfaces between clients and at the end of the day including the door handles, toilet seat, counter tops, light switches, faucets and etc. You should be wearing a face mask when completing these tasks. If possible, try to ventilate the session room in between clients or provide a good HEPA filter.
If you are offering products for sale at your practice, then these items should be disinfected between clients and communal product samples, such as testers, should be removed from the shelves.
The FSMTB also suggests that you cover your massage table with a heavy-duty plastic sheet or plastic table protector to make it easier to clean and disinfect between clients. As part of Linen Management, not only should you be sure to provide clean laundered sheets for each client, including the face cradle cover, eye pillow cases, bathrobes, blankets, pillow cases, bolster covers and towels. All clean and laundered linens should be stored in a closed container, preferably in another room, to insure that they don’t get contaminated by virus droplets.
At the end of each session, soiled linens (any cloth material used during a massage session or touches a client’s skin) should be removed the session room. If there is blood or body fluid present on the linens, wear gloves and place linens in a leak proof bag separate from the other linens. Be sure not to ‘shake’ soiled linens as this may disperse contaminated droplets into the air. Wash linens in hot water with detergent and dry using heat. For soiled sheets, add fabric-safe bleach. Before and after handling linen, therapist should wash or disinfect your hand according to CDC guidelines.
For spa equipment, ultraviolet radiation (UV), is an accepted disinfection method for spa equipment when appropriate and based on manufacturer’s recommendations. Clean and disinfect hydrotherapy tub jets, foot basin and gets, whirlpool jets, wet tables, steam cabinets, showers, etc., using manufacturer approved disinfectants between each client.
When working with co-workers, other ideas may help reduce the chance of catching the Covid-19 virus by staggering break times to reduce the number of people in the break room at any one time, limit number of people in laundry room at any one time,
As far as outcalls are concerned, the FSMTB recommends that while COVID-19 is present in a community that mobile massages are unsafe and are prohibited since the practitioner would be unable to control the cleanliness or disinfection practices at the client’s home.
When working with more than one practitioner at a facility, attempt to stagger session schedules to prevent crowding in reception area and to allow ample time between clients to properly clean and disinfect. Walk-in appointments during this virus are not advised and your current policy should read, “by appointment only.” If possible, you could screen clients by asking COVID-19 specific questions, taking the client’s temperature (should be no higher than 100.4 degrees F) before beginning the session, and having them sign the COVID-19 health intake addendum (discussed later on). If you suspect a client is contraindicated for a massage, then you should postpone their session.
You can also ask clients to wait outside or in their cars until you ‘call’ them in or text them. Greet your clients but refrain from hugging and shaking hands. If the client arrives wearing medical gloves, have them remove the gloves and they could be contaminated with droplets from the virus.
Since respiratory droplets can be dispersed when people talk, the CDC recommends that clients limit their communication to pressure, warmth, and comfort while in the session room.
During this time, the FSMTB is prohibiting intra-oral or nasal massage due to the increase of risk of COVID-19 exposure.
The FSMTB also suggest that practitioners shower and wash their hair on workdays, keep facial hair trimmed and that long hair be pulled back and secure so that it does not touch a client during massage or bodywork session. Therapist fingernails should be kept clean and short with a smooth edge. Therapist should remove all jewelry including watches, fitness trackers, rings, and bracelets.
The FSMTB recommends that therapists use Personal protective equipment (PPE). PPE refers to gloves, face masks, respirators, protective eye wear, and special clothing healthcare professionals use to shield themselves from infectious diseases while working with patients and clients. For massage therapists, FSMTB advised the use of face masks, gloves to handle soiled linens, and protective clothing (scrubs). Therapist should always bring a change of scrubs to work with them and change between clients.
The CDC recommends that if possible, therapists should change out of their work clothes and work shoes at work and then change into street clothes to go home.
Yes, there is such a thing as cough etiquette and now, more than ever, it is extremely important to practice good cough etiquette. First and foremost, cover your mouth and nose with a tissue when coughing or sneezing. If a tissue is not available, then cough or sneeze into an elbow. Be sure to dispose of soiled tissues immediately after use and wash your hands, or use a hand sanitizer.
If a therapist suspects that they have been exposed to the COVID-19 virus, then they should get tested and self-isolate until they receive the results of the test showing that they have cleared of infection. If a client calls to report that they tested positive for COVID-19 virus within two weeks of the massage or bodywork session, then the therapist should self-isolate until they can obtain testing.
Changes to Client Informed Consent
The FSMTB also suggests changes to the Client Informed Consent form. Since therapists may assume that clients are unaware of the risk of infection from COVID-19, then it is up to the therapist to inform the client of the risk of contact of the virus in a massage session. A client signature would indicate that they understand the risk and wish to go ahead and receive massage therapy services anyway. The following simple statement should suffice,
“I understand that close contact with people increases the risk of infection from COVID-19. By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive massage from this practitioner.”
But it doesn’t end there. Therapists must also alert clients of procedures related to possible exposure to COVID-19. The following simple statement should suffice,
“I understand that my name and contact information might be shared with the state health department in the event that a client or practitioner at this facility tests positive for COVID-19. My contact details will only be shared in the event they are relevant based on suspected exposure date, and only for appropriate follow-up by the health department.” (FSMTB, 2020)
20 Tips to Help Prevent Medical Errors: Patient Fact Sheet. September 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/patients-consumers/care-planning/errors/20tips/index.html.
Carroll, Linda. (18 July, 2019). “Medical mistakes harm more than 1 in 10 patients. Many are preventable. At least 12 percent of preventable errors caused permanent disability or death, according.” aNBC News and Reuters Health. Web. Accessed on July 12, 2020 at https://www.nbcnews.com/health/health-news/medical-mistakes-harm-more-1-10-patients-many-are-preventable-n1030996
Howard, Beth. (2013). Lessons from America’s safest hospitals. AARP Magazine. Volume 56, Number 3A. (46-52).
Huffington Post. 2014. 2014 State rankings released for support for emergency care. Accessed on November 11, 2014 from http://www.huffingtonpost.com/2014/01/16/emergency-care-rankings-state-support-_n_4597481.html
Omstead, M., Geisen, E., Murphy, J., Bell, D., Morley, M., Stanley, M. (14 July, 2014). Methodology:U.S. News & World ReportBest Hospitals 2014-15. Accessed on November 11, 2014 from http://www.usnews.com/pubfiles/BH_2014_Methodology_Report_Final_Jul14.pdf
Ray Sipherd, (22 Feb 2018). “The third-leading cause of death in US most doctors don’t want you to know about,”CNBC.com. web. Accessed on July 3, 2020 at https://www.cnbc.com/2018/02/22/medical-errors-third-leading-cause-of-death-in-america.html
Sternberg, Steve (2012, August 29). Medical errors harm huge numbers of patients. Web. Retrieved from http://www.huffingtonpost.com/2012/08/29/medical-errors-hospitals-harm-patients_n_1839814.html.
- The Federation of State Massage Therapy Boards (FSMTB). (19 May, 2020). Massage and Bodywork Guidelines for Practice with Covid-19. Web. Accessed on June 24, 2020 at fsmtb.org.
- Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 12 May 2020. “Information for Healthcare Professionals about Coronavirus (COVID-19).” Web. Access on June 24, 2020 at cdc.gov/coronavirus/2019-ncov/hcp/index.html.
- Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 26 Jan. 2016, “Standard Precautions for All Patient Care.” Web. Access on June 24, 2020 at cdc.gov/infectioncontrol/basics/standard-precautions.html.
- Centers for Disease Control and Prevention, Disease Control and Prevention, 24 Apr. 2020, “Infection Control Centers for Guidance for Healthcare Professionals about Coronavirus (COVID-19).” Web. Access on June 24, 2020 at www.cdc.gov/coronavirus/2019-ncov/hcp/ infection-control.html?CDC_AA_refVal=https%3A%2F%2F www.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection- control%2Findex.html.
- Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, Apr. 2020. “Coronavirus Disease 2019 (COVID-19).” Web. Access on June 24, 2020 at cdc.gov/coronavirus/2019-ncov/index.html.
A Federal report on medical errors (Publication No. OM 00-0004) is available from the AHRQ Publications Clearinghouse: phone, 1-800-358-9295 or E-mail: AHRQPubs@ahrq.hhs.gov.
Preventing Medical Errors Final Test
Other License Number ___________________________
Email Address ________________________________________________________________
Contact Number _______________________________________________________________
After reading this course, choose the ONE best answer for each question and circle it. Remit test for grading to FrancineMilford@cs.com or mail to: Francine Milford, 3230 Prairie Dunes Circle W, Lakeland, FL. 33810.
- According to Reference. MD., the words, ‘medical errors,’ is defined as:
- Mistakes committed by Health Professionals that result in harming the patient.
- Mistakes committed by patients who should know better.
- Mistakes that anyone could make in the medical industry.
- Mistakes in general
- ‘Never Events’ affect at least how many patients a year?
- One million
- In the United States alone, medication errors account for approximately how many injuries each year?
- What percentage of preventable errors results in a patient’s permanent disability or death?
- Human factors contributing to causing medical errors include:
- Similar looking drugs
- All of the above
- Medical errors cost more than ___________ each year.
- $2 billion
- $10 billion
- $100 billion
- $210 billion
- An unintended act, either of omission or commission, or an act that does not achieve its intended outcome is called a(n):
- Near Miss
- Unplanned Outcome
- One common cause for medical errors is:
- Improper or Incomplete documentation
- Eating too much sugar
- Drinking too much coffee
- Not wearing a good pair of shoes
- A system of checks and balances that contain a database of drugs and their normal doses is called:
- The Formulary System
- Pharmacy Balancing
- The Formulation System
- None of the above
- Massage therapists can reduce the potential of spreading disease by:
- Cleaning massage tables, chairs and equipment before and after each use
- Putting your hair up in a ponytail
- Playing the right kind of music
- Hanging pictures on the wall
- Massage therapists can avoid making medical errors in their practice by:
- Taping down the edges of carpets
- Removing obstacles
- Practice good communication skills with your clients
- All of the above
- One of the Universal Precautions for Health Care professionals created by the Occupational Health and Safety Administration to prevent the spread of disease is:
- Change your scrubs before going home
- Brush your teeth and keep your gums healthy
- Keep your nails cut and clean
- All of the above
- To help reduce error, you as a consumer should do the following:
- Become an active participant in your health
- Inform your doctor of all your current medications
- Tell your doctor of any allergic or adverse reaction that you have had
- All of the above
- Any set of circumstances which significantly increases the likelihood of a serious adverse outcome is called a(n):
- A Hazardous Condition
- Near Miss
- A core team of health care professionals that offer repeatable services to a specific population (such as geriatrics) and also provides information and a support system for said population is called a(n):
- Support Team
- None of the above
Cost of Course
Cost: $10 for Medical Errors-2 ce's.