Medical Error Prevention

About this course

The modern healthcare system, despite its remarkable advancements in technology, treatment methodologies, and patient care strategies, continues to contend with the pervasive issue of medical errors – mistakes that can occur at any stage of the patient journey. These errors, which can range from subtle oversights to more glaring failures, pose a significant risk to patient safety and are a principal cause of harm within the healthcare environment. To prevent medical errors, The Joint Commission provides a framework for healthcare facilities to implement robust protocols and promote a culture of continuous improvement. This course discusses the National Patient Safety Goals of The Joint Commission, equipping healthcare professionals with the knowledge and tools necessary to foster safer patient care environments and restore public trust in the healthcare system.

Learning objectives

• Define medical errors.
• Review statistical data regarding the occurrences of medical errors.
• Understand the Role of the Joint Commission.
• Comprehend The Joint Commission’s National Patient Safety Goals.
• Understand the importance of practicing vigilance, collaboration, and effective communication, to reduce the risk of medical errors within the healthcare setting.

Course outline

17 sections · finish in any order across devices

1. 1

   Introduction

   The modern healthcare system, despite its remarkable advancements in technology, treatment methodologies, and patient care strategies, continues to contend with the pervasive issue of medical errors – mistakes that can occur at any stage of the patient journey. These errors, which can range from sub

   4 min

2. 2

   Definition of Medical Errors

   Medical errors are mistakes in healthcare delivery that may harm a patient, either directly or indirectly.2 These mistakes encompass a wide variety of issues in medical practice and are generally classified into several categories: errors of omission, errors of commission, errors of communication, d

   4 min

3. 3

   Medical Error Statistics

   Medical errors are a significant yet vastly underreported issue in US healthcare, as these incidents are rarely documented on death certificates. A Johns Hopkins study estimates over 250,000 Americans die annually from medical errors.4 However, other studies place this figure even higher, suggesting

   4 min

4. 4

   The Role of The Joint Commission

   The Joint Commission is an independent nonprofit association that raises healthcare standards through rigorous accreditation and certification.11 Established in 1951 by the American College of Surgeons, the American Hospital Association, the American Medical Association, and the Canadian Medical Ass

   4 min

5. 5

   The Joint Commission’s National Patient Safety Goals (NPSGs)

   The Joint Commission’s National Patient Safety Goals (NPSGs) were developed to address the most pressing patient safety issues.12 Established in 2002 and first implemented in 2003, these goals aim to standardize best practices, thereby minimizing risks in key areas. The NPSGs are updated annually an

   4 min

6. 6

   1. Identify Patients Correctly

   Mistakes in patient identification can lead to profound consequences, such as administering the wrong treatment, medication errors, or even performing procedures on the wrong patient. The problem often originates during patient registration, with misidentification at this stage being a primary cause

   4 min

7. 7

   2. Improve Staff Communication

   Ineffective communication among healthcare staff is a frequent source of errors, especially in settings where time-sensitive information is critical, such as in critical access hospitals, standard hospitals, and laboratories.13 Miscommunication can cause delays in treatment or misunderstandings abou

   4 min

8. 8

   3. Use Medicines Safely

   Medication errors arise from issues such as improper labeling, dosing mistakes, or the misuse of high-risk drugs. Such errors can result in adverse reactions, prolonged hospital stays, and even death.8 Due to these risks, The Joint Commission introduced several goals to reduce medication errors, nam

   4 min

9. 9

   4. Use Clinical Alarms Safely

   In healthcare settings, there are a wide variety of clinical alarm systems that monitor various aspects of care.17 These include visual or auditory alerts for monitoring devices, infusion pumps, ventilators, patient beds, color codes, and environmental emergencies such as fires or power failures. Wh

   4 min

10. 10

    5. Prevent Infections

    Infection prevention is another component of patient safety, as infections can occur while receiving medical care, especially in environments where invasive procedures or surgeries are performed. These infections can lead to significant morbidity, prolonged hospital stays, and even increased mortali

    4 min

11. 11

    6. Identify Patient Suicide Risks

    Suicidal thoughts and behaviors in patients, particularly those in mental health units, can arise from a variety of factors, including underlying mental health disorders, trauma, social isolation, and feelings of hopelessness.10 These patients often face unique vulnerabilities, making it crucial for

    4 min

12. 12

    7. Prevent Mistakes in Surgery

    A surgical error is any preventable event that may cause or lead to patient harm. These errors can occur before, during, or after a surgical procedure and appear for several reasons, including communication failures, misjudgment, or technical mistakes. Surgical errors can be categorized broadly into

    4 min

13. 13

    8. Prevent Pressure Ulcers

    Pressure ulcers, (decubitus ulcers or bedsores) are localized injuries to the skin and underlying tissue.21 They can range in severity from mild redness to deep wounds exposing muscles and bones. These ulcers occur when pressure prevents sufficient blood from the skin and are most seen in patients c

    4 min

14. 14

    9. Prevent Falls

    Falls are a major concern in healthcare environments, particularly for elderly patients. Older adults are more inclined to fall due to age-related declines in strength, balance, vision, and cognitive function.6 However, fall risk is not limited to the elderly. Those on multiple medications may exper

    4 min

15. 15

    10. Prevent Healthcare-Associated Infections (HAIs)

    Healthcare-associated infections (HAIs) are infections patients acquire while being treated for other conditions within a healthcare setting.9 These infections can lead to serious health complications, prolonged hospital stays, and additional healthcare costs. The most common HAIs are catheter-assoc

    4 min

16. 16

    Nursing Considerations

    The impact of nursing practices on medical error rates, communication, and patient outcomes cannot be overstated.27 Their proximity to patients and involvement in daily care routines position nurses as frontline defenders against medical errors. In addition, nurses are often the primary communicator

    4 min

17. 17

    Conclusion

    Medical errors represent a critical challenge within the healthcare system, impacting patient safety and care quality across various settings. These errors can lead to severe complications, increased healthcare costs, and even loss of life. There is an urgent need for practical strategies to mitigat

    4 min

This course satisfies

Requirement summaries come from our state requirement records. Always confirm details with your board before you renew.

References and resources

• Kalra, J. (2004). Medical errors: An introduction to concepts. Clinical Biochemistry, 37(12), 1043-1051. https://doi.org/10.1016/j.clinbiochem.2004.08.007
• James, J. (2013). September 2013 - Volume 9 - Issue 3: Journal of Patient Safety. Lww.com. https://journals.lww.com/journalpatientsafety/Fulltext/2013/09000/A_New
• Liukka, M., Steven, A., Vizcaya Moreno, M. F., Sara-aho, A. M., Khakurel, J., Pearson, P., Turunen, H., & Tella, S. (2020). Action after Adverse Events in Healthcare: An Integrative Literature Review. International Journal of Environmental Research and Public Health, 17(13), 4717. https://doi.org/10.3390/ijerph17134717
• Anderson, J., & Abrahamson, K. (2018). Your health care may kill you: Medical errors. Studies in Health Technology and Informatics. https://pubmed.ncbi.nlm.nih.gov/28186008/
• Centers for Disease Control and Prevention. (2024, May 2). Leading causes of death. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
• LeLaurin, J. H., & Shorr, R. I. (2019). Preventing falls in hospitalized patients. Clinics in Geriatric Medicine, 35(2), 273–283. https://doi.org/10.1016/j.cger.2019.01.007
• Maul, J., & Straub, J. (2022). Assessment of the Use of Patient Vital Sign Data for Preventing Misidentification and Medical Errors. Healthcare, 10(12), 2440. https://doi.org/10.3390/healthcare10122440
• Academy of Managed Care Pharmacy. (2019, July 18). Medication Errors | AMCP.org. Www.amcp.org. https://www.amcp.org/concepts-managed-care-pharmacy/medication-errors
• Centers for Disease Control and Prevention. (2024, May 17). HAIs: Reports and Data. Healthcare-Associated Infections (HAIs). https://www.cdc.gov/healthcare-associated-infections/php/data/index.html
• Incidence and method of suicide in hospitals in the United States – Suicide Prevention Resource Center. (2018). Sprc.org. https://sprc.org/online-library/incidence-and-method-of-suicide-in-hospitals-in-the-united-states
• The Joint Commission. (2023). Facts About The Joint Commission | The Joint Commission. Www.jointcommission.org. https://www.jointcommission.org/who-we-are/facts-about-the-joint-commission/
• The Joint Commission. (2024). National Patient Safety Goals. The Joint Commission. https://www.jointcommission.org/standards/national-patient-safety-goals/
• Howick, J., Bennett-Weston, A., Solomon, J., Nockels, K., Bostock, J., & Keshtkar, L. (2024). How does communication affect patient safety? Protocol for a systematic review and logic model. BMJ Open, 14(5). https://doi.org/10.1136/bmjopen-2024-085312
• AHRQ. (2019). Tool: SBAR | Agency for Healthcare Research and Quality. Www.ahrq.gov. https://www.ahrq.gov/teamstepps-program/curriculum/communication/tools/sbar.html
• The Joint Commission. (2023). Do Not Use List | The Joint Commission. Www.jointcommission.org. https://www.jointcommission.org/resources/news-and-multimedia/fact-sheets/facts-about-do-not-use-list/
• Karet, G. B. (2023). Linguistic Analysis of Generic-Generic Drug Name Pairs Prone to Wrong-Drug Errors for which Tall-Man Lettering is Recommended. Therapeutic Innovation & Regulatory Science, 1–8. https://doi.org/10.1007/s43441-023-00526-0
• Woo, M., & Bacon, O. (2020). Alarm Fatigue. In www.ncbi.nlm.nih.gov. Agency for Healthcare Research and Quality (US). https://www.ncbi.nlm.nih.gov/books/NBK555522/
• Targeted Solutions Tool. (2024). Jcrinc.com. https://www.jcrinc.com/what-we-offer/high-reliability/targeted-solutions-tool/?_ga=2.178669604.1644591706.1730703749-398748467.1730703749
• CDC. (2024, February 27). About Hand Hygiene for Patients in Healthcare Settings. Clean Hands. https://www.cdc.gov/Clean-Hands/About/Hand-Hygiene-for-Healthcare.html
• The Joint Commission. (2020). Universal Protocol. Jointcommission.org. https://www.jointcommission.org/standards/universal-protocol/
• Mervis, J. S., & Phillips, T. J. (2019). Pressure ulcers: Prevention and management. Journal of the American Academy of Dermatology, 81(4), 893–902. https://doi.org/10.1016/j.jaad.2018.12.068
• CDC. (2024, May 10). Catheter-Associated Urinary Tract Infections (CAUTI) Prevention Guideline. Infection Control. https://www.cdc.gov/infection-control/hcp/cauti/index.html
• The Joint Commission. (2020). Central Line-Associated Bloodstream Infections Toolkit and Monograph. Jointcommission.org. https://www.jointcommission.org/resources/patient-safety-topics/infection-prevention-and-control/central-line-associated-bloodstream-infections-toolkit-and-monograph/
• Viasus, D., Gaia, V., Manzur-Barbur, C., & Carratalà, J. (2022). Legionnaires’ Disease: Update on Diagnosis and Treatment. Infectious Diseases and Therapy, 11(3). https://doi.org/10.1007/s40121-022-00635-7
• CDC. (2023, August 30). Information for Health Professionals. Centers for Disease Control and Prevention. https://www.cdc.gov/flu/professionals/
• CDC. (2024, April 12). MDRO Prevention and Control. Infection Control. https://www.cdc.gov/infection-control/hcp/mdro-management/prevention-control.html
• Salar, A., Kiani, F., & Rezaee, N. (2020). Preventing the medication errors in hospitals: A qualitative study. International Journal of Africa Nursing Sciences, 13(1), 1–5. https://doi.org/10.1016/j.ijans.2020.100235

Update history