Ensuring Patient Safety: A Clinical Approach in a Chiropractic Clinic

by Dr Alex Jimenez DC, APRN, FNP-BC, CFMP, IFMCP | Chiropractic, Chiropractic Examination, Chiropractic News, Chronic Pain, Imaging & Diagnostics, Treatments

How do healthcare professionals in a chiropractic clinic provide a clinical approach to preventing medical errors for individuals in pain?

Introduction

Medical errors resulted in 44,000–98,000 hospitalized American deaths annually, and many more caused catastrophic injuries. (Kohn et al., 2000) This was more than the number of people who died annually from AIDS, breast cancer, and auto accidents at the time. According to later research, the actual number of deaths may be closer to 400,000, placing medical errors as the third most common cause of death in the US. Frequently, these mistakes are not the product of medical professionals who are inherently bad; rather, they are the outcome of systemic issues with the health care system, such as inconsistent provider practice patterns, disjointed insurance networks, underutilization or absence of safety protocols, and uncoordinated care. Today’s article looks at the clinical approach to preventing a medical error in a clinical setting. We discuss associated medical providers specializing in various pretreatments to aid individuals suffering from chronic issues. We also guide our patients by allowing them to ask their associated medical providers very important and intricate questions. Dr. Alex Jimenez, DC, only utilizes this information as an educational service. Disclaimer

Defining Medical Errors

Determining what medical error is the most crucial step in any conversation about preventing medical errors. You might assume this is a very easy chore, but that is only until you delve into the vast array of terminology utilized. Many terms are used synonymously (sometimes mistakenly) since some terminology is interchangeable, and occasionally, the meaning of a term depends on the specialty being discussed.

Even though the healthcare sector stated that patient safety and eliminating or reducing medical errors were priorities, Grober and Bohnen noted as recently as 2005 that they had fallen short in one crucial area: determining the definition of “perhaps the most fundamental question… What is a medical error? A medical error is a failure to complete a planned action in a medical setting. (Grober & Bohnen, 2005) However, none of the terms that one would often identify expressly with a medical error—patients, healthcare, or any other element—are mentioned in this description. Despite this, the definition offers a solid framework for further development. As you can see, that specific definition consists of two parts:

• An execution error: A failure to complete a planned action as intended.
• A planning error: is a technique that, even with perfect execution, does not produce the desired results.

The concepts of faults of execution and planning errors are insufficient if we are to define a medical error adequately. These may occur anywhere, not only at a medical establishment. The component of medical management must be added. This brings up the idea of unfavorable occurrences, known as adverse events. The most common definition of an adverse event is unintentional harm to patients brought about by medical therapy rather than their underlying disease. This definition has gained international acceptance in one way or another. For example, in Australia, the term incidents are defined as in which harm resulted in a person receiving health care. These consist of infections, injury-causing falls, and issues with prescription drugs and medical equipment. Certain unfavorable occurrences might be avoidable.

Common Types of Medical Errors

The only issue with this notion is that not all negative things happen accidentally or intentionally. Because the patient may ultimately benefit, an expected but tolerated adverse event may occur. During chemotherapy, nausea and hair loss are two examples. In this instance, refusing the recommended treatment would be the only sensible approach to prevent the unpleasant consequence. We thus arrive at the concept of preventable and non-preventable adverse occurrences as we further refine our definition. It isn’t easy to categorize a choice to tolerate one impact when it is determined that a favorable effect will occur simultaneously. But purpose alone isn’t necessarily an excuse. (Patient Safety Network, 2016, para.3) Another example of a planned mistake would be a right foot amputation due to a tumor on the left hand, which would be accepting a known and predicted unfavorable event in the hopes of a beneficial consequence where none has ever arisen before. There is no evidence to support the anticipation of a positive outcome.

Medical errors that cause harm to the patient are typically the focus of our research. Nonetheless, medical mistakes can and do occur when a patient is not harmed. The occurrence of near misses could provide invaluable data when planning how to reduce medical errors in a healthcare facility. Still, the frequency of these events compared to the frequency clinicians report them needs to be investigated. Near misses are medical errors that could have caused harm but did not to the patient, even if the patient is doing well. (Martinez et al., 2017) Why would you acknowledge something that could potentially result in legal action? Consider the scenario where a nurse, for whatever reason, had just been looking at photographs of different medications and was about to provide a medication. Maybe something lingers in her memory, and she decides that’s not how a specific medication looks. Upon checking, she found that the incorrect medicines had been administered. After checking all the paperwork, she fixes the mistake and gives the patient the right prescription. Would it be possible to avoid an error in the future if the administration record included photographs of the proper medication? It is easy to forget that there was a mistake and a chance for harm. That fact remains true regardless of whether we were fortunate enough to find it in time or suffer any negative consequences.

Errors of Outcomes & Process

We need complete data to develop solutions that improve patient safety and decrease medical errors. At the very least, when the patient is in a medical facility, everything that can be done to prevent harm and put them in danger should be reported. Many doctors have determined that using the phrases errors and adverse events was more comprehensive and suitable after reviewing mistakes and adverse events in health care and discussing their strengths and weaknesses in 2003. This combined definition would increase data gathering, including mistakes, close calls, near misses, and active and latent errors. Additionally, the term adverse events includes terms that usually imply patient harm, such as medical injury and iatrogenic injury. The only thing that remains is determining whether a review board is a suitable body to handle the separation of preventable and non-preventable adverse events.

A sentinel event is an occurrence where reporting to the Joint Commission is required. The Joint Commission states that a sentinel event is an unexpected occurrence involving a serious physical or psychological injury. (“Sentinel Events,” 2004, p.35) There isn’t a choice, as it needs to be documented. Most healthcare facilities, however, do keep their records outlining sentinel incidents and what to do in the event of one to guarantee that the Joint Commission standards are met. This is one of those situations when it’s better to be safe than sorry. Since “serious” is a relative concept, there may be some wriggle room when defending a coworker or an employer. On the other hand, reporting a sentinel event incorrectly is better than failing to report a sentinel event. Failing to disclose can have serious consequences, including career termination.

When considering medical errors, people frequently make the mistake of focusing just on prescription errors. Medication errors are undoubtedly frequent and involve many of the same procedural flaws as other medical errors. Breakdowns in communication, mistakes made during prescription or dispensing, and many other things are possible. But we would be gravely misjudging the issue if we assumed that drug errors are the only cause of harm to a patient. One major challenge in classifying the different medical errors is determining whether to classify the error based on the procedure involved or the consequence. It is acceptable to examine those classifications here, given numerous attempts have been made to develop working definitions that incorporate both the process and the outcome, many of which are based on Lucian Leape’s work from the 1990s. 

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Analyzing & Preventing Medical Errors

Operative and nonoperative were the two main categories of adverse events that Leape and his colleagues distinguished in this study. (Leape et al., 1991) Operative problems included wound infections, surgical failures, non-technical issues, late complications, and technical difficulties. Nonoperative: headings such as medication-related, misdiagnosed, mistreated, procedure-related, fall, fracture, postpartum, anesthesia-related, neonatal, and a catch-all heading of the system were included under this category of adverse occurrences. Leape also classified errors by pointing out the point of process breakdown. He also categorized these into five headings, which include: 

• System
• Performance
• Drug Treatment
• Diagnostic
• Preventative

Many process faults fall under more than one topic, yet they all help to pinpoint the exact cause of the issue. If more than one physician was engaged in determining the precise areas that need improvement, then additional questioning might be required.

Technically, a medical error can be made by any staff member at a hospital. It is not limited to medical professionals like physicians and nurses. An administrator may unlatch a door, or a cleaning crew member could leave a chemical within a child’s grasp. What matters more than the identity of the perpetrator of the mistake is the reason behind it. What before it? And how can we make sure that doesn’t occur again? After gathering all the above data and much more, it’s time to figure out how to prevent similar errors. As for sentinel events, the Joint Commission has mandated since 1997 that all of these incidents undergo a procedure called Root Cause Analysis (RCA). However, using this procedure for incidents that need to be reported to outside parties would need to be corrected.

What Is A Root Cause Analysis?

RCAs “captured the details as well as the big picture perspective.” They make evaluating systems easier, analyzing whether remedial action is necessary, and tracking trends. (Williams, 2001) What precisely is an RCA, though? By examining the events that led to the error, an RCA can focus on events and processes rather than reviewing or placing blame on specific people. (AHRQ,2017) This is why it is so crucial. An RCA frequently makes use of a tool called the Five Whys. This is the process of continuously asking yourself “why” after you believe you have determined the cause of an issue.

The reason it’s called the “five whys” is because, while five is an excellent starting point, you should always question why until you identify the underlying cause of the problem. Asking why repeatedly could reveal many process faults at different stages, but you should keep asking why about every aspect of the issue until you run out of other things that could be adjusted to provide a desirable result. However, different tools besides this one can be utilized in a root cause investigation. Numerous others exist. RCAs must be multidisciplinary and consistent and involve all parties involved in the error to avoid misunderstandings or inaccurate reporting of occurrences.

Conclusion

Medical errors in healthcare institutions are frequent and mostly unreported events that seriously threaten patients’ health. Up to a quarter of a million individuals are thought to pass away each year as a result of medical blunders. These statistics are unacceptable in a time when patient safety is supposedly the top priority, but not much is being done to alter practices. If medical errors are accurately defined and the root cause of the problem is found without assigning blame to specific staff members, this is unnecessary. Essential changes can be made when fundamental causes of system or process faults are correctly identified. A consistent, multidisciplinary approach to root cause analysis that uses frameworks like the five whys to delve down until all issues and defects are revealed is a helpful tool. Although it is now necessary for the wake of sentinel events, the Root Cause Analysis may and should be applied to all mistake causes, including near misses.

References

Agency for Healthcare Research and Quality. (2016). Root Cause Analysis. Retrieved March 20, 2017, from https://psnet.ahrq.gov/primer/root-cause-analysis

Grober, E. D., & Bohnen, J. M. (2005). Defining medical error. Can J Surg, 48(1), 39-44. https://www.ncbi.nlm.nih.gov/pubmed/15757035

Kohn, L. T., Corrigan, J., Donaldson, M. S., & Institute of Medicine (U.S.). Committee on Quality of Health Care in America. (2000). To err is human : building a safer health system. National Academy Press. http://books.nap.edu/books/0309068371/html/index.html

Leape, L. L., Brennan, T. A., Laird, N., Lawthers, A. G., Localio, A. R., Barnes, B. A., Hebert, L., Newhouse, J. P., Weiler, P. C., & Hiatt, H. (1991). The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med, 324(6), 377-384. https://doi.org/10.1056/NEJM199102073240605

Lippincott ® NursingCenter ®. NursingCenter. (2004). https://www.nursingcenter.com/pdfjournal?AID=531210&an=00152193-200411000-00038&Journal_ID=54016&Issue_ID=531132

Martinez, W., Lehmann, L. S., Hu, Y. Y., Desai, S. P., & Shapiro, J. (2017). Processes for Identifying and Reviewing Adverse Events and Near Misses at an Academic Medical Center. Jt Comm J Qual Patient Saf, 43(1), 5-15. https://doi.org/10.1016/j.jcjq.2016.11.001

Patient Safety Network. (2016). Adverse events, near misses, and errors. Retrieved March 20, 2017, from https://psnet.ahrq.gov/primer/adverse-events-near-misses-and-errors

Williams, P. M. (2001). Techniques for root cause analysis. Proc (Bayl Univ Med Cent), 14(2), 154-157. https://doi.org/10.1080/08998280.2001.11927753

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