Focus on these four areas of improvement to avoid common safety errors
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January 1, 2019
In the healthcare safety world, much attention is paid to the need for hospitals to ramp up their security and safe practices game, mainly because adherence to strict accreditation standards is closely tied to the Medicare funds those facilities rely on.
However, medical clinics are a different story, especially the smaller, independent ones. These smaller clinics generally don’t face the oversight of organizations such as CMS or The Joint Commission, and even OSHA only keeps close eyes on the clinics that draw their attention through complaints. So, without the discipline that comes with regulatory oversight, who’s to say that clinics are keeping safe practices?
In 2017, the American College of Emergency Physicians said in a report that the focus on patient safety must extend to the outpatient setting, where healthcare interactions far outnumber those in hospital visits and the risk of errors is just as high, if not higher, than in hospitals.
In the Q3 2018 issue of Inside Medical Liability, the magazine of the Medical Professional Liability Association (MPLA), the problem of patient safety in clinics was taken on, and the group conceded that an equivalent level of safety in hospitals and clinics may never truly be achieved.
“Although much research in patient safety has focused on hospitals, physician practices cannot simply apply the patient safety strategies used in hospitals to outpatient care,” the report said. “Not all hospital safety practices transfer to outpatient settings. For example, avoiding patient identification errors has been a focus in hospital safety, and instituting a protocol to use at least two patient identifiers can prevent patient identification mix-ups in all types of clinical settings; however, strategies emphasizing alarm safety are important in hospitals but have less relevance for physician practices. Physician practices must develop patient safety programs tailored to their needs, as well as to the needs of their specific patient population.”
It’s not a complete lost cause, as medical clinics aren’t run in a vacuum and many are helmed by respected healthcare professionals. The magazine identified four patient safety topics that physician practices may overlook and can improve on: vaccination safety; medication sample management; telephone and in-person triage; and competency assessment of unlicensed nonphysician providers, such as medical assistants. The report outlined some of the biggest problems and offered some helpful tips that clinics can use to ramp up their safety game.
1. Vaccination safety
Most people aren’t going to hospitals for a flu shot or a vaccination, so it stands to reason that clinics would be an immediate red flag for safety issues regarding vaccinations and related infrastructure, such as the needles used to administer them. Much has been said over the years about the need for better needlestick prevention and safe sharps practice, but what about the actual medicine that is injected into patients?
“The safe administration of vaccines depends on professional staff who are trained and educated in the proper storage and handling of vaccines, correct techniques for vaccine reconstitution, and appropriate timing of vaccine administration according to evidence-based vaccine schedules issued by the Centers for Disease Control and Prevention,” the MPLA report said.
Given the millions of vaccines that are administered every year at physicians’ offices, it’s surprising that there aren’t more errors reported. Still, mistakes involving vaccine administration do occur, and the report highlighted several of them, including the following:
- Giving the wrong vaccine
- Administering the wrong dose
- Giving an expired vaccine
- Missing or omitting a recommended vaccine
What can physicians’ offices do to reduce the chances of errors when administering vaccinations? Consider the magazine’s suggestions. Strategies that practices might use include the following:
- Ensure that staff have access to current patient information (such as immunization records) and current immunization schedules. This may require a computer update.
- Ensure that providers give a vaccine information statement (VIS) to every patient for each vaccine administered, before administering the vaccine. VIS sheets describe indications, risks, and contraindications. In addition to providing the VIS, providers need to engage patients (and parents of pediatric patients) in discussions about vaccines; patients are the last line of defense in preventing errors.
- Set up task-specific templates (electronic) or order forms (paper) that identify the vaccine’s name (trade and generic), patient age parameters, dosage, and route of administration.
- Require staff to check vaccine expiration dates before reconstitution or administration.
- Instruct staff to follow the “rights” of vaccine administration with every patient (i.e., right patient, vaccine and diluent, time, dosage, route, site, documentation); require and monitor that all staff verify the patient’s identity by checking two patient identifiers (e.g., asking the patient to state his or her name and date of birth) immediately before administering the vaccine.
- Unless the vaccine is prepared in front of the patient, label all syringes with the name of the vaccine to be administered.
2. Medication sample management
Many medical clinics have stopped giving out free samples of medications; they may be wary of conflicts of interest or liability for expired medication, or maybe they just don’t want drug representatives soliciting in their offices. Still, the MPLA says that roughly 30% of physicians have accepted medication samples from pharmaceutical sales reps to distribute to patients. If your clinic is among those, consider the group’s advice:
- Educate pharmaceutical company reps regarding the practice’s policy on sample medications, and have reps sign in and out upon each visit.
- Remove samples from examination rooms and store them in a secure location, in sight of office staff and locked during nonpatient hours, to avoid stolen samples of controlled substances.
- Keep a log of medication samples that lists the drug name, lot number, quantity, and expiration date. Providers and office staff who distribute samples should sign the medications out using this log.
- Provide written information about the medication to the patient (e.g., reason for the medication, dose, special precautions, and side effects, including allergic reactions).
- Track sample medications to their final disposition and be alert to recalls. In the event of a recall of medications dispensed from the office, the practice must notify the patients to whom the medications were dispensed.
- Separate and clearly identify medications of different strengths. For high-alert medications with the potential to cause serious harm if administered incorrectly, limit the number of doses and forms available.
- Store medications according to class or in some other easily understood order that prevents mix-ups of similarly packaged products. Do not store medications in alphabetical order.
- Stock medications with look-alike or sound-alike product names in separate areas. Attach brightly colored warning labels to packages of drugs that might be easily confused.
- Routinely inspect medication samples, promptly removing recalled or expired drugs from the inventory. Discard expired medication samples in accordance with federal, state, and local laws.
- Limit samples to medications most often prescribed by the practice’s providers.
3. Telephone and in-person triage
This is a big one. For a long time, clinic safety officials have been warning about the need for front-end staff to improve patient intake procedures. Triage is a necessary evil for many reasons, from maintaining tighter security by monitoring who is in the waiting room to keeping infectious diseases away from the general population of the clinic.
Use these recommendations to review the way your staff triages incoming patients:
- Identify the “red flag” complaints that should prompt an urgent response. These cases probably shouldn’t even see your front door but warrant a trip to the hospital instead.
- Get enough information to give informed advice. Give advice based on the worst-case scenario.
- Follow standard written protocols for triage of patient symptoms. Protocols are used to explore patients’ symptoms with a preestablished set of questions and then recommend a course of action. The CDC encouraged this approach for suspected Ebola patients after the 2014 scare.
- Resist being dismissive of a caller’s concerns or overinvesting in the patient’s self-assessment of his or her condition without asking more questions.
- If the call is about a previous or unresolved problem, revisit that problem until it is resolved.
- Document the history taken and advice given by telephone.
Keep in mind that triage tends to be limited by the training or knowledge of the individual staff member conducting it. Frontline staff don’t know all the answers, so medical staff need to be available to back them up if they have concerns or questions. To identify gaps, the office should periodically assess its triage practices. Sample questions might include the following:
- Is a system in place to monitor triage staff compliance with triage protocols?
- Do nurses and other licensed professionals who give telephone advice have speci?c training, experience, and documented competence in telephone assessment techniques?
- Are the standard triage protocols reviewed and updated at least every two years to ensure consistency with current standards of care?
- Are triage staff instructed to consult a physician whenever they have doubts about proper instructions or advice?
- Are physicians assigned to back up triage staff to answer questions? Are physicians receptive to questions from triage staff regarding patient calls?
4. Competency assessment of nonphysician providers
We’re sure that you take great care in hiring the best staff for your clinic, and it’s a good practice to make sure you have your protocols outlined in case an OSHA inspector stops by. There are always improvements that can be made to your hiring process. Consider the following:
- Examine the hiring process to make sure that it includes verifying the applicant’s training, education, certifications, and experience, as well as checking his or her references.
- Review all job descriptions at least every two years or more often, if position responsibilities or advances in technology necessitate an update. Check the state’s scope-of-practice laws before updating any job description.
- Review the staff orientation process to ensure that it includes a general office orientation as well as orientation to responsibilities outlined in the individual’s job description. Use a checklist to be sure that all items are covered.
- Review the available training for clinical staff, recognizing the limitations and roles of the position. Use different types of learning methods—such as written information, video, demonstration, and simulation—to ensure that the individual has a comprehensive understanding of the topic.
- Identify staff who can take on training responsibilities and ensure that they understand their role in training new staff using current policies and best practices. Do not permit training based on the shadowing of staff; this can lead to the adoption of ingrained bad habits, such as workarounds and omission of necessary steps in a process.
- Assess staff competencies in all areas, but especially in high-risk or high-volume areas, such as medication administration, weights and measures, and specimen collection.
- If a staff member’s skills fall short in a particular area, institute a process to retrain and retest the individual, and document the outcome.
- Develop a performance appraisal form that is consistent with the staff person’s job description. This will provide guidance on an annual basis to help the individual perform within his or her scope of practice and effectively demonstrate competency.
- Establish an internal committee (or use an existing one) to periodically review the forms used for orientation, competence, and performance evaluations to be sure that they are up to date and accurate.