Blog » To Err Is Human

To Err Is Human

Created Dec 06 2017, 03:15 PM by Lippincott Solutions
  • CDC
  • Center for Disease Control
  • medication errors
  • US News & World Report
  • nursing documentation
  • Patient Safety
  • Falls
  • medical errors
  • hospital-acquired infections


That’s the number of avoidable deaths that occur each year, due to inadvertent medical errors.  If you break that down, it’s equivalent to about 10 jumbo jets crashing, every single day.  Not surprisingly, a recent U.S. News & World Report study concluded that medical errors are the 3rd leading cause of death in the United States, after heart disease and cancer. 

With these staggering numbers, it’s clear that every hospital should and does have the goal of reducing errors and improving patient outcomes. Medical errors can occur anywhere in the health care system: hospitals, clinics, surgery centers, doctors' offices, nursing homes, pharmacies, and patients' homes. Errors can involve medicines, surgery, diagnosis, equipment, or lab reports and often occur during transitions in care.

Nursing errors commonly revolve around patient falls, infections, medication errors, documenting errors, and equipment injuries. Here are some tips you can use to promote safer care at your organization. 

Staffing Matters

Nursing administrators play an important role in preventing nursing errors. They're able to create changes to the practice environment that support safety for both patients and clinicians.  Staffing shortages can also lead to errors, so they must be addressed. Ideally, experienced nurses should outnumber novice nurses on each shift to provide a supportive environment.

Errors can result from failures to:

  • collaborate with other healthcare team members
  • clarify interdisciplinary orders
  • ask for and offer assistance
  • utilize evidence-based performance guidelines or bundles
  • communicate information to patients and families
  • limit overtime
  • adequately staff patient care units with enough nurses to allow them to safely provide care.

Preventing Falls

The Center for Disease Control (CDC) estimates that one out of three adults (33%) age 65 and older experiences a fall each year.  Physiologic effects can contribute to falls, such as vertigo, influenza, multiple sclerosis, and anesthetic medications commonly used during inpatient and outpatient procedures.

Nurses can take simple preventive measures to protect patients from falls. Assess each patient's gait. Encourage patients to ask for help when they get out of bed, and make sure there are no obstacles to the restroom or around the bed.

Verify activity orders. These can vary during the hospital stay and after changes in condition or medical-surgical interventions. Continuously assess and compare the patient's ability with the written activity orders.

Be aware of any medications that may cause drowsiness, dizziness, or impaired judgment.

Use protective measures, such as nonslip socks and bed alarms, to decrease the risk of falls.

Keeping Infections at Bay

Basic hand hygiene can go a long way to prevent infections. Other measures that are effective in the prevention of infection include using chlorhexidine for skin preparation, practicing sterile technique, and following guidelines for central line use and removal to prevent bloodstream infections.

Appropriately cleaning urinary catheters, removing them in a timely manner, and avoiding long-term use unless medically necessary can prevent catheter-related infections.

Managing Medications

When administering medications, nurses should avoid all distractions. In the United States, medication errors kill one person every day, according to the National Medication Errors Reporting Program.

Utilize a bar coding medication scanning system allows nurses to verify the six medication rights (correct medication, patient, route, dose, time, and documentation). Take an active role in consulting with the interdisciplinary team, including the pharmacy, to ensure all look-alike or sound-alike medications aren't stored near each other.

Double check all high-alert medications with another nurse. Understand and know the medications that are being administered, along with adverse reactions. Tell each patient what he or she is receiving and the reason for each medication.

Accurate Documentation

You should accurately document all major events and changes in patient condition in a timely manner. Monitor patients regularly and document interventions performed. Report adverse events immediately to the nurse manager or supervisor.

Check the healthcare provider's orders for monitoring and notification intervals, such as BP parameters, fever, heart rate, and abnormal heart rhythms.

Document as patient’s condition warrants. For example, if the patient is declining, document every intervention and notification you perform. Address all signs and symptoms of distress. Document the time and content of all healthcare provider notifications. Ensure all documentation is on the correct patient. Document patient education and patient and caregiver comprehension of the information.

Using Equipment Safely

Equipment continually changes in the patient care environment. Nurses have a responsibility to stay abreast of these changes and be competent in the use of necessary equipment. Nurse educators play an important role in ensuring all nursing personnel are trained and competency is documented.

To prevent equipment-related injuries:

  • Request training on equipment you aren't sure how to use.
  • Examine all equipment and remove if damaged.
  • Report any incidents or defects to the risk management department, patient safety department, or your supervisor.
  • Thoroughly document any injury related to the equipment.
  • Use the equipment only as recommended.
  • Routinely validate your clinical competence to operate your facility's equipment to reduce the likelihood of injury to patients, staff, and yourself.

So what should you do if you make a mistake? Many professional medical associations advocate disclosing the error. The Patient Safety and Quality Improvement Act of 2005 encourages voluntary and confidential reporting of any event that may adversely affect patients.

Speak to your facility's risk management department. They specialize in the process, and can assist you with the most appropriate way to handle the situation. To prevent errors to begin with, stay up to date on training and have thorough knowledge of your facility's policies.

The Right Answers, Right Now

For further support on reducing care-related errors, Lippincott Advisor can help.  Our industry-leading clinical decision support software for institutions contains over 17,000 evidence-based content entries and patient teaching handouts. 

With instant 24/7 access to numerous robust content sets on diseases and conditions, drug guides, signs & symptoms, Advisor also includes Quality and Safety initiatives on core measures, hospital-acquired conditions, sentinel events and more.  Click HERE to learn more and request a free demo for your organization.