UNDERSTANDING CLINICAL RISK MANAGEMENT AND PATIENT

SAFETY

Why Clinical Risk is relevant to patient safety:

Risk management is routine in most industries and has traditionally been associated
with limiting litigation costs. Many corporations try to avoid financial loss, fraud or a
failure to meet production expectations by implementing strategies to avoid such events.
Hospitals and health organizations use a variety of methods for managing risks. The
success of a risk management programme, however, depends on the creating and
maintaining safe systems of care, designed to reduce adverse events and improve
human performance.

Everyone who works in a hospital or clinic has a responsibility to take the correct action
when they see an unsafe situation or environment. Taking steps to ensure a slippery
floor is dry and preventing a patient rom falling over is as important as ensuring that
the medication a patient is taking is the correct one. In the event of a patient falling on a
slippery floor or receiving the wrong medication, it is equally important for a student to
report these events so that steps can be taken to avoid future incidents. Effective risk
management involves every level of the health service, so it is essential that all
healthcare workers understand the objectives and relevance of the risk management
strategies and their relevance to their own workplace. Unfortunately, even though a
hospital may have a policy of reporting incidents such as medication errors, the actual
reporting of them is often sporadic. Healthcare practitioners can begin to practise
reporting by talking with the health-care team about medication errors and the
strategies in place to manage and avoid them. Research shows that nurses are more
likely to report an incident than other health professionals, certainly more so than
doctors. This may be because the blame culture in medicine is a strong deterrent to
reporting. Today, most risk management programmes aim to improve safety and quality
in addition to minimizing the risk of litigation and other losses (staff morale, loss of
staff, diminished reputation), but the degree of their success depends on many factors.
Clinical risk management specifically is concerned with improving the quality and safety
of healthcare services by identifying the circumstances and opportunities that put
patients at risk of harm and then acting to prevent or control those risks. The following
simple four-step process is commonly used to manage clinical risks:

1. identify the risk;

2. assess the frequency and severity of the risk;
3. reduce or eliminate the risk;
4. assess the costs saved by reducing the risk or the costs if the risk
eventuates.

Clinical risk management allows identification potential errors. Health care

itself is inherently risky and although it would be impossible to eradicate all
harm, there are many activities and actions that can be introduced that will
minimize opportunities for errors. Clinical risk is relevant to medical and
healthcare practitioners because it recognizes that clinical care and
treatment are risky and incidents may to occur during clinical care and
treatment.

COMMON ACTIVITIES USED TO MANAGE CLINICAL RISK

INCIDENT REPORTING
Incident reporting has existed for decades. Many countries now have national databases
of adverse
events pertaining to different specialties such as surgery, anaesthesia, maternal and
child health.
WHO defines an incident as an event or circumstance that could have or did
lead to unintended and/or unnecessary harm to a person and/or a
complaint, loss or damage. The main benefit of incident reporting lies in the
information about prevention rather than the frequency of the incident;
other quantitative methods are required for that.

Facilitated incident monitoring refers to the mechanisms for identifying,

processing, analysing and reporting incidents with a view to preventing
their recurrence. The key to an effective reporting system is to have staff routinely
reporting incidents or near misses. However, unless staff trusts that the organization
will use the information for improvement and not to blame individuals, they will
not report. Trust includes the belief that the organization will also act upon
the information. If a medical student reported an incident to a senior nurse or doctor
who dismissed their effort and told them not to bother, then the student is less likely to
make a report again. Even when this happens, students should be encouraged by faculty
staff to continue to report. One day the student will be a senior doctor and their actions
will be highly influential on younger doctors and students. Facilitated monitoring is
designed to identify a greater proportion of incidents and to produce
reports that are aimed at improving care.

Facilitated monitoring is a continuous activity of the clinical team involving the

following actions:

• discussion about incidents is a standing item in the weekly clinical meetings;

• there is a weekly review of areas where errors are known to occur;
• a detailed discussion about the facts of an incident and follow-up action
required is done with the team;
• the discussion is always educational rather then attributing blame;
• identifies the system issues so they can be addressed and other staff made aware
of the potential difficulties.

As well as reporting actual incidents, some organizations encourage the reporting of

“near misses” because of the value they bring about new problems and the factors that
contribute to them, and how they may be prevented, before serious harm is done to a
patient. A near miss is an incident that did not cause harm. Some people call
“near misses” “near hits” because the actions may have caused an adverse
event, but corrective action was taken just in time or the patient had no
adverse reaction to the incorrect treatment. Talking about “near misses” may be
easier in some environments where there is a strong blame culture because no one will
be able to be blamed because there was no adverse outcome to the patient.

SENTINEL EVENT

A sentinel event is an unexpected occurrence involving death or serious

physical or psychological injury to a patient and includes any process
variation for which a recurrence would carry a significant chance of serious
adverse outcome. The current trend in many countries in analysing adverse events is
to rank the seriousness of the event. A sentinel event is reserved for the most
 serious ones. Many hospitals and clinics have mandated the reporting of
these types of events or events because of the risk of a repeat. These are
often called “never events” that should never be allowed to happen because
of the potential for death or significant harm. Catastrophic event is another term
used and these make up half of all the sentinel events reported in the United States and
over two thirds of those reported in Australia.

TYPES OF ISSUES IDENTIFIED BY INCIDENT REPORTING

Type of Incident % of Report

Falls 29
Injuries other than falls (e.g. burns, pressure injuries, physical assault, self-
13
harm)
Medication errors (e.g. omission, overdose, underdose, wrong route, wrong
12
medication)
Clinical process problems (e.g. wrong diagnosis, inappropriate treatment, poor
10
care)
Equipment problems (e.g. unavailable, inappropriate, poor design, misuse,
8
failure, malfunction)
Documentation problems (e.g. inadequate, incorrect, not completed, out of date,
8
unclear)
Hazardous environment (e.g. contamination, inadequate cleaning or
7
sterilization)
Inadequate resources (e.g. staff absent, unavailable, inexperienced, poor
5
orientation)
Logistic problems (e.g. problems with admission, treatment, transport, response
4
to emergency)
Administrative problems (e.g. inadequate supervision, lack of resource, poor
2
management decisions)
Infusion problems (e.g. omission, wrong rate) 1
Infrastructure problems (e.g. power failure, insufficient beds) 1
Nutrition problems (e.g. fed when fasting, wrong food, food contaminated,
1
problems when ordering)
Colloid or blood product problems (e.g. omission, underdose, overdose, storage
1
problems)
Oxygen problems (e.g. omission, overdose, underdose, premature cessation,
1
failure of supply)

WAYS TO REDUCE RISK:

FALLING:
Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled
body movement, or who get out of bed and walk unsafely without assistance, must be
carefully assessed for the best ways to keep them from harm, such as falling. Assessment
by the patient’s health care team will help to determine how best to keep the patient
safe. Historically, physical restraints (such as vests, ankle or wrist restraints) were used
to try to keep patients safe in health care facilities. In recent years, the health care
community has recognized that physically restraining patients can be dangerous.
Although not indicated for this use, bed rails are sometimes used as restraints.
Regulatory agencies, health care organizations, product manufacturers and advocacy
groups encourage hospitals, nursing homes and home care providers to assess patients’
needs and to provide safe care without restraints.

The Benefits and Risks of Bed Rails

Potential benefits of bed rails include:

 Providing a feeling of comfort and
 Aiding in turning and repositioning security.
within the bed.
 Reducing the risk of patients falling
 Providing a hand-hold for getting into out of bed when being transported.
or out of bed.
 Providing easy access to bed controls
and personal care items.

Potential risks of bed rails may include:

 Strangling, suffocating, bodily injury
or death when patients or part of
their body are caught between rails or
between the bed rails and mattress.
 More serious injuries from falls when
patients climb over rails.
 Skin bruising, cuts, and scrapes.
Meeting Patients' Needs for Safety
Most patients can be in bed safely without bed rails. Consider the following:
 Use beds that can be raised and
lowered close to the floor to
accommodate both patient and health
care worker needs.
 Keep the bed in the lowest position
with wheels locked.
 When the patient is at risk of falling
out of bed, place mats next to the bed,
as long as this does not create a
greater risk of accident.
 Inducing agitated behavior when bed
rails are used as a restraint.
 Feeling isolated or unnecessarily
restricted.
 Preventing patients, who are able to
get out of bed, from performing
routine activities such as going to the
bathroom or retrieving something
from a closet.
 Use transfer or mobility aids.
 Monitor patients frequently.
 Anticipate the reasons patients get
out of bed such as hunger, thirst,
going to the bathroom, restlessness
and pain; meet these needs by
offering food and fluids, scheduling
ample toileting, and providing
calming interventions and pain relief.

When bed rails are used, perform an on-going assessment of the patient’s physical and
mental status; closely monitor high-risk patients. Consider the following:
 Lower one or more sections of the prevent patients from being trapped
bed rail, such as the foot rail. between the mattress and rail.
 Use a proper size mattress or  Reduce the gaps between the
mattress with raised foam edges to mattress and side rails.

Which Ways of Reducing Risks are Best?

A process that requires ongoing patient evaluation and monitoring will result in
optimizing bed safety. Many patients go through a period of adjustment to become
comfortable with new options. Patients and their families should talk to their health care
planning team to find out which options are best for them.

Patient or Family Concerns About Bed Rail Use

If patients or family ask about using bed rails, health care providers should:
 Encourage patients or family to talk
 Reassure patients and their families
to their health care planning team to that in many cases the patient can
determine whether or not bed rails sleep safely without bed rails.
are indicated.
 Reassess the need for using bed rails
on a frequent, regular basis.
IN AN EVENT OF PATIENT FALLING:

Step one: assessment. When a patient falls, don't assume that no injury has
occurred-this can be a devastating mistake. Before moving the patient, ask him what he
thinks caused the fall and assess any associated symptoms. Then conduct a
comprehensive assessment, including the following:
* Assess the current level of
* Check the vital signs and the apical consciousness and determine whether
and radial pulses. the patient has had a loss of
* Check the cranial nerve. consciousness.
* Check the skin for pallor, trauma, * Look for subtle cognitive changes.
circulation, abrasion, bruising, and * Check the pupils and orientation.
sensation. * Observe the leg rotation, and look for
* Check the central nervous system for hip pain, shortening of the extremity,
sensation and movement in the lower and pelvic or spinal pain.
extremities. * Note any pain and points of
tenderness.
Be aware of the following warning signs: numbness or tingling in the extremities, back
pain, rib pain, or an externally rotated or shortened leg. These symptoms suggest spinal
cord injury, leg or pelvic fracture, or head injury.

Step two: notification and communication. Notify the physician and a family
member, if required by your facility's policy. Also, most facilities require the risk
manager or patient safety officer to be notified. Be certain to inform all staff in the
patient's area or unit. Such communication is essential to preventing a second fall.

Step three: monitoring and reassessment. After the patient returns to bed,
perform frequent neurologic and vital sign checks, including orthostatic vital signs. Fall
victims who appear fine have been found dead in their beds a few hours after a fall.

Step four: documentation. Follow your facility's policies and procedures for
documenting a fall. Thorough documentation helps ensure that appropriate nursing
care and medical attention are given. Whether it's written on the patient's chart or
entered in the hospital's electronic medical record, documentation for a fall should
include

* all observations. * notifications.

* patient statements. * interventions.
* assessments. * evaluation.
 Be sure to note the patient's thoughts about the cause of the fall and associated
symptoms, and whether the patient lost consciousness.

Classification. To measure the outcome of a fall, many facilities classify falls using a
standardized system. Follow your facility's policy.

Reporting. Most facilities also require that an incident report be completed for quality
improvement, risk management, and peer review. This report should include

* patient history. * intervention.

* how the fall occurred. * outcome.
* assessment.
* diagnoses.

Analysis. Identify the underlying causes and risk factors of the fall. What was done to
prevent it? Is the fall considered accidental (extrinsic), anticipated physiologic
(intrinsic), or unanticipated physiologic (unpredictable)? Immediate follow-up will help
identify the cause and enable staff to initiate preventative measures.

PREVENT MEDICATION ERROR

As nurses, we are often the last “gatekeeper” in the administration process to prevent
medication errors. It is important to take the time needed to ensure patient safety, and
to minimize distractions throughout the process. Strategies to reduce medication errors
include:

• The rights of medication administration. Initially, there were five rights for
administration including the right patient, drug, time, dose and route. A sixth right is
the right reason. Some literature describes up to 12 rights, including education,
documentation, right to refusal and expiration date.

• Independent double checks. The Institute for Safe Medication Practices (ISMP)
(2014) recommends the use of redundancies, such as independent double checks of high
alert medications due to the increased risk for patient harm. This includes independent
calculations for dose and rates of medication.

• Medication review. Practices include comparing the medication administration

record and patient record at the beginning of a nurse’s shift; determining the rationale
for each ordered medication, and requesting that physicians rewrite orders when
improper abbreviations are used, are important strategies.

• Knowledge. A nurse should never administer a medication which he/she is

unfamiliar.

• Patient education. Ensuring that patients and families are knowledgeable regarding
the medication regimen so that they can question unexplained variances are also
associated with lower rates of medication errors.

• Practice environment. A supportive practice environment, including teamwork

between physicians and nurses; opportunities for nurses to participate in hospital- and
unit-level decisions; continuity of patient care assignments; continuing education
opportunities; and the retention of nurse administrators who are visible and accessible,
who listen to nurses’ concerns, and who have high expectations of their nurses are
associated with a higher quality of nursing care. (James, 2013; RWJF, 2012; Simonsen
et al., 2011)

Avoiding medication errors

How can you safeguard your practice from medication errors? For starters, be
conscientious about performing the “five rights” of medication administration every
time—right patient (using two identifiers), right drug, right dosage, right time, and right
route. Some experts have expanded this list to include:
 right reason for the drug  right to refuse medication
 right documentation  right evaluation and monitoring
Be sure to use the safety resources available at your facility. Don’t use workarounds to
bypass safety systems. In a 2008 study, one-third of nurses reported they sometimes
bypass safety systems. Nurses working in critical care and pediatrics were more likely to
do this; yet medication errors in these settings can be particularly devastating. Where
nurses routinely bypass safety systems and create workarounds, the employer must
conduct a root-cause analysis to identify the reason for the workaround, and take action
to correct the situation and prevent recurrences.
Additional steps you can take to promote safe medication use include:
 reading back and verifying abbreviations. In 2004, the JC
medication orders given verbally published a list of abbreviations
or over the phone. asking a that shouldn’t be used because
colleague to double-check your they can contribute to medication
medications when giving high- errors. For instance, in one
alert drugs documented case, a “naked”
 using an oral syringe to decimal point (one without a
administer oral or NG leading zero) led to a fatal tenfold
medications overdose of morphine in a 9-
 assessing patients for drug month-old infant. The dosage was
allergies before giving new written as “.5 mg” and
medications interpreted as “5 mg.”
 becoming familiar with your
facility’s “do not use” list of
Eliminating medication errors
Avoiding medication errors requires vigilance and the use of appropriate technology to
help ensure proper procedures are followed. Computerized physician order entry
reduces errors by identifying and alerting physicians to patient allergies or drug
interactions, eliminating poorly handwritten prescriptions, and giving decision support
regarding standardized dosing regimens.
The Leapfrog Group (whose mission is to trigger giant leaps forward in healthcare
safety, quality, and affordability) supports computerized physician order entry as a way
to reduce medication errors. Use of computerized physician order entry and barcodes
may reduce errors by up to 50%.
Yet computerization can’t prevent or catch all errors. In one near-miss incident, an I.V.
bag of a standardized diltiazem (Cardizem) solution (125 mg in 125 mL normal saline
solution) was inadvertently labeled as an insulin drip, even though it had scanned
correctly (the barcode had been applied by the pharmacy). Fortunately, an alert ICU
nurse realized the bag she had in her hand was a premixed solution and not a pharmacy
admixture. When she turned it over, she could see the manufacturer’s label.
Be sure to use the safety practices already in place in your facility. Eliminate distractions
while preparing and administering medications.

PREVENT DIAGNOSTIC ERROR

Diagnostic errors mean a diagnosis that was either “wrong, missed, or unintentionally
delayed.” No-fault errors may happen when there are masked or unusual symptoms of a
disease, or when a patient has not fully cooperated in care. Diagnostic errors may also
result from system-related problems, such as equipment failure or flaws in
communication. A wrong diagnosis may also occur when the clinician relies too much
on common symptoms, and choosing an obvious answer, without looking further into
what may be causing them.

What Nurses Need to Know About Diagnosis Errors:

1. Misdiagnoses are the most common and deadly of medical errors.
2. The first recommendation of National Academy of Medicine’s report “Improving
Diagnosis in Health Care” is to “Facilitate more effective teamwork in the
diagnostic process among health care professionals, patients, and their families.”
The report specifically recommends interprofessional teamwork, including
nursing engagement, in the diagnostic process.
3. Historically, there has been an explicit distinction between nursing and medical
diagnoses that makes it abundantly clear to providers that the medical diagnostic
process is not a nursing role function, limiting opportunities to actively engage
nurses in improving diagnostic safety and quality.
4. Nurses have always played important, tacit roles in medical diagnosis. When
triage nurses identify chief complaints and assess illness severity, they are playing
a critical role in accurate and timely emergency department diagnosis. Likewise,
when hospital nurses on a surgical floor decide whether to call for a physician to
assess a patient with pain (rather than treating the patient symptomatically with
pain medications), they are playing a critical role in accurate and timely post-
operative diagnosis.
5. There are heavily ingrained barriers to full nurse participation in the diagnostic
process that must be overcome through innovative changes to nursing education,
culture, operations, and logistics.
6. Despite the sociocultural barriers, nurses are ready and able to effectively use
diagnostic reasoning skills as full members of the diagnostic team.
7. If nurses are encouraged to practice to the full extent of their training, education,
and experience and key barriers are removed, they will be perceived (and will
perceive themselves) as integral diagnostic team members.
8. Nurses have been a driving force behind major quality improvement and patient
safety efforts, and must take part in helping lead efforts to reduce diagnostic error.
PREVENT RISK DUE TO EQUIPMENT PROBLEMS

In the cases analyzed, 3 predominant equipment-related issues were identified:

 equipment malfunctions and failures

 wrong application, improper use, or unapproved use of equipment during a
procedure or during medication delivery by physicians and other healthcare
professionals
 new equipment issues, including training and supervision deficiencies
Issues identified
Many equipment issues that had an impact on patient care were beyond the control of
the physician, whereas others were due to operator performance. At times, these issues
coexisted within the same case. Mechanical issues and faulty equipment were often
determined to be the responsibility of the healthcare facility or manufacturer. In
contrast, physicians and other healthcare professionals were often held accountable for
the wrong application or improper use of equipment.

Regardless of the causes, patient injury resulting from equipment-related

misadventures was a recurrent theme. Burns, lacerations, and perforations were the
most prevalent injuries.

A sampling of the diverse equipment issues identified in the cases reviewed, as well as
illustrative cases, are presented here.

Sample of equipment issues related to organizational factors

The responsibility for equipment care and maintenance varies according to the location
of care. For example, in a trial case involving a hospital's failure to calibrate equipment
on a regular basis, the judge concluded equipment maintenance was the hospital's
responsibility. A peer expert in this case further maintained that the physician's role
would centre on the functioning of the equipment during the procedure. However, in
clinics or private office settings, the onus for equipment maintenance might shift to the
clinic owner or the physician.

Equipment deficiencies during a procedure or during medication delivery

 breakage of surgical instruments (e.g. needles, scalpel blades)
 malfunctioning equipment or equipment failure (e.g. misfiring of a stapler;
malfunction of a patient controlled analgesia [PCA] pump)
 detachment of equipment (e.g. ureteric stone basket)
 defective equipment (e.g. rupture of a catheter balloon)
 lack of optimal equipment (e.g. lack of appropriate syringes)
System factors
 improper set-up or monitoring of equipment by others (e.g. incorrect settings on
phototherapy, laser and lithotripsy machines)
 failure of the healthcare facility to follow the equipment manufacturer's
recommendations for maintenance, cleaning, calibration, and replacement
 not reporting equipment malfunction to the appropriate personnel for follow-up and
testing
 incorrect training information
 inadequate communication of manufacturer equipment recalls
 pager system failure

Sample of issues related to equipment operator performance

Inappropriate use of equipment

 use of equipment for non-indicated purposes (e.g. inappropriate laser for tattoo
removal; use of latex gloves for a patient with a known latex allergy)
 incorrect use of equipment (e.g. misapplication of forceps during delivery)
 incorrect equipment assembly
 failure to check or readjust machine settings prior to a procedure (e.g. laser machine
settings)
 failure to use equipment safeguards (e.g. failing to activate properly functioning
alarms on an anaesthesia monitor)
 failure to maintain sterile precautions
 continuing a procedure once an equipment problem was evident (technical
difficulties with the camera lighting supply during a laparoscopic procedure)
 failure to check equipment for completeness at the end of a procedure (e.g.
detachment of a ureteric stone basket)

New equipment issues

 lack of familiarity with new equipment or equipment an individual has not used
before
 failure to adjust the treatment parameters for new equipment (e.g. former cautery
settings inappropriate for new cautery equipment)
 inadequate supervision of inexperienced physicians and other healthcare
professionals
Other equipment issues
 lack of documentation of the level of supervision or direction provided by a physician
to clinic or office employees using equipment for technical procedures

Managing medico-legal risks

The following risk management considerations are based on the expert opinions in the
analyzed cases:

Organizational factors
Responsibility and accountability for equipment set up, care, and maintenance varies
according to the location of care. For example, in the hospital setting, the organization
and healthcare professionals other than the physician are usually responsible for these
tasks. However, in clinics or private office settings, the clinic owner or physicians may
have responsibility for equipment. Organizations should consider:

 Is there a verification process that the required equipment is available, appropriately

sterilized, and functioning, and that the settings are appropriate for the particular
case?
 Are the manufacturer's recommendations for equipment maintenance, cleaning,
calibration, and replacement followed? Do clear policies and procedures exist for
handling equipment concerns and recalls?
 If new equipment is introduced, do healthcare professionals receive appropriate
training prior to using it?
Equipment operator factors
Users of equipment should consider:

 Are you familiar with the equipment you are using, and is it appropriate for the
procedure?
 If the desired equipment is not available, have you appropriately considered and
documented your options and discussed these with the patient?
 If equipment malfunctions or fails during a procedure, do you take and document
appropriate measures, including advising the required personnel for maintenance?
 Is all equipment inspected for completeness at the end of the procedure, particularly
if the instrument breaks, is disassembled during the procedure, or has the potential
to detach?
 When supervising or delegating a procedure involving equipment to a trainee or
another healthcare professional, do you consider if the individual has the required
knowledge, skills, qualifications, and experience to perform the procedure and to
operate the necessary equipment? If necessary, is appropriate supervision available?

DOCUMENTATION ERRORS

Nurses have a lot to contend with today-from electronic health records (EHRs) with
page after page of forms and boxes to tick and fill in, to overcrowded conditions at
healthcare facilities, to long and exhausting shifts. Environmental conditions,
distractions, lack of training, infrastructural problems, and lack of communication
can all lead to documentation errors. Nurses learn proper documentation
procedures during their initial training, but nurse CE courses can provide important
refreshers and updated information pertaining to documentation.

Ahead we'll define what proper documentation is and why it's so

important, explore common documentation errors, and look at some
dos and don'ts of proper documentation.

DEFINING PROPER DOCUMENTATION AND ITS IMPORTANCE

Nurses are on the front lines of patient care. Their written accounts are critical for
planning and evaluation of medical interventions and ongoing patient care. Nursing
documentation must provide an accurate, complete, and honest account of the
events that occurred and when. Good documentation is:

 Accurate  Timely (current)

 Factual  Organized

 Complete  Compliant with healthcare laws

and facility standards
This applies to nursing documentation across every type of practice setting-from
clinics, to hospitals, to nursing homes, to hospices.

Proper documentation serves many purposes for patients, physicians, nurses and
other care providers, and families.

Thorough, accurate documentation is important for communication and

continuity of care-everyone involved in the delivery of care requires information
about the patient.

Documentation is important for quality assurance-the information contained in

patient charts is often used to evaluate the quality of service and the
appropriateness of care delivered by nurses.

Proper documentation also establishes professional accountability,

demonstrating a nurse's knowledge and judgment skills, and it can help
facilities assess funding and resource management.

Documentation is also very important for legal reasons-patient records are

frequently used as evidence in court.

10 COMMON DOCUMENTATION ERRORS

#1: Not dating, timing, and signing entries
Every single entry should have the date, time, and the name of the person who
entered it. Unless you're working with an EHR/PMS that enters this information
automatically, you must enter it every time. On paper charts, indicate the date and
time, along with your first initial, full last name, and your title (RN, LPN, etc.).
When your documentation continues from one page to the next, write your name on
each page, along with the date and time, and indicate "continued from previous
page" on all subsequent pages.

#2: Writing sloppily or illegibly

This requires little explanation. Sloppy writing can result in confusion and
communication problems that, at best, can lead to inefficiencies and, at worst, could
cost patients their lives. Sloppy writing can also interfere with a nurse's defense in a
malpractice suit.

#3: Not documenting omitted medications or treatments

Medication and treatment omissions happen, especially when your facility is short
staffed or when you're pressed for time because you're working a double shift.
Regardless of the circumstances, you are still accountable for these oversights.
Always document omitted medications or treatments along with the reason for the
omission and your signature.

#4: Leaving blanks on forms

This leaves the reader wondering if care was delivered and not recorded, or not
delivered at all, as in the legal case we looked at earlier. Nurses need to draw a line
through blanks that are not applicable on documentation forms, and initial them.

#5: Adding late entries

Anyone who has ever tried to briefly memorize a phone number before dialing it
knows that the information can slip away within seconds. Failing to record actions
taken and other information immediately or very soon after the event can lead to
lost detail-especially when it comes to numbers-and ultimately errors down the line
that could negatively impact the patient. Clearly state the date and time of the late
entry, indicate the actual time the care or observation occurred, and mark it as "late
entry."

#6: Documenting subjective data

Using terms like "demanding," "grumpy," and "irritating" to describe a patient

reveals more about the nurse's attitude than the patient. In cases where the patient
has a bad outcome, terms like these on a chart will call into question the kind of care
the nurse provided.

#7: Using inappropriate abbreviations

Avoid using abbreviations that can be misinterpreted, and result in confusion and
errors. For example, using "D/C" for discharge can be confused with discontinuing
medications. Always write "discharge." Avoid abbreviations that are non-medical,
which can result in interpretation errors.

#8: Accepting incomprehensible orders

Never accept questionable or incomprehensible orders. If you don't understand the

orders, or feel they are not in the best interest of the patient, question them every
time. Remember that you are also liable for patient outcomes, even when following
someone else's orders.

#9: Failing to document new symptoms or conditions

 You should document any new condition where appropriate, including the time of
occurrence, the action you took, and the patient's response. This includes new
abrasions, cuts, and pressure marks, falls, bumps, elevated temperatures, seizures,
pressure ulcers, unusual behaviors, diarrhea, changes in bowel habits, changes in
vital signs, etc.

#10: Entering information into the wrong chart

This error can happen easily, especially with electronic records. Ultimately the
problem occurs when a nurse isn't paying attention to the patient's identity. Always
address your patient by name and ensure you have right electronic record or chart
in front of you before entering information.

DOCUMENTATION DOS AND DON'TS

 Don't take shortcuts in electronic records systems, including copying and
pasting medical records, which can lead to the carryover of inaccurate or
outdated information. It takes more time, but it's important to type out your
notes every time.

 Do make sure you're charting on the correct record. With so many patients
moving through a typical facility, it's easy to start documenting on the screen in
front of you, only to realize you're in the wrong patient's chart.

 Don't delay documentation. It's too easy to forget details if there is a delay
between the time you took an action and recorded it. This can lead to a host of
problems.

 Don't document medications or treatments before they are administered or

completed.

 Do use the patient's own words, gestures, and non-verbal cues as much as
possible, which helps paint a picture of what you encountered.

 Don't use vague terms, such as "fair" and "normal." Be clear, concise, and
specific in your documentation.

 Do correct errors. Draw a straight line through incorrect entries, and write
"error" above them. Initial and date the correction. With electronic records, this
may be trickier-that's why it's important for facilities to have procedures in
place for correcting entries. In general, you should make a new entry along with
the date and time. Indicate that you are correcting an error in a previous entry,
and point clearly to that entry. The bottom line: It should be very obvious to
readers which entry you are correcting.

PREVENT HEALTH CARE ASSOCIATED INFECTION

Nurses have a responsibility to ensure an optimal health-care environment, to enable

patient recovery, respite or relief. The level of noise, the temperature and the amount of
light are all important, but the cleanliness of the environment is crucial, conferring a
sense of safety and comfort and promoting an atmosphere of competent caring.

The role of the nurse in cleaning

Part of the role of the nurse is to facilitate cleaning, to determine cleaning requirements,
to monitor the quality of cleaning and, where necessary, to supplement cleaning, for
example by dealing with body substance spillages or cleaning a washbowl after use.
Some routine cleaning is part of the work of a nurse, for example cleaning a dressing
trolley before use or cleaning the commode between patients. Sometimes nurses will
have to do other general cleaning in an emergency but should recognise that health-care
cleaning is a skill and requires knowledge and training.

Cleaning skills and methods

Expectations that cleaners will be able to do everything are unrealistic, so it is important
that all health-care staff participate in keeping the environment clean and tidy. While
routine general cleaning should be undertaken by trained cleaning staff, nurses and
other health-care workers should familiarise themselves with the whereabouts of
equipment should they need to use it. It is also important that staff are trained how to
clean and how to use cleaning equipment. A recent online publication by NHS Estates
gives very helpful information about cleaning methods and equipment This also
includes the national colour-coding system of the British Institute of Cleaning Science
(see Figure 1). This colour codes areas to be cleaned to prevent cross contamination. The
colour-coding system also relates to all cleaning equipment, cloths and gloves.

Cleaning equipment for nurses

It is important that nurses adopt and have access to the same systems as the trust
cleaners. It is not acceptable to have a mop and bucket ‘for the nurses’ which is left
festering in a dirty utility room. Such items are frequently a potential source of
contamination.
In addition to standard cleaning equipment, disposable wipes are a useful resource.
Disposable detergent wipes remove debris and are useful for commodes, bedpan holders
and drip stands. Alcohol-based wipes are useful as secondary cleaning after debris has
been removed such as on dressing trolleys.

Other sprays and substances may also be appropriate, particularly when used with
disposable cloths. Made-up solutions will have a limited life, so use them and then
dispose of them. They should be kept in originally labelled containers that include the
batch number and expiry dates. Disinfectants should be used in accordance with the
institution policy.

Protective equipment and safety

Standard disposable gloves are not designed for prolonged cleaning tasks and may
deteriorate rapidly, offering little protection. Use household-grade gloves for cleaning
tasks where possible and wash hands on the removal of gloves.
Wearing a disposable plastic apron during cleaning prevents contamination of clothes.
Splashing or aerosolisation may occur. Select appropriate equipment to protect the eyes,
nose and mouth if such a risk is identified.

Always ensure that electrical equipment is both switched off and unplugged or that it is
safe to wipe over while plugged in.

Frequency of cleaning
Until recently there was little guidance on how frequently the environment and
equipment should be cleaned. The Revised Guidance on Contracting for Cleaning (NHS
Estates and DH, 2004), details cleaning frequencies of common items and includes
comprehensive advice on quality monitoring. The document focuses on hospitals and
determines cleaning frequencies according to the risk of them not being adequately
cleaned. Very high-risk areas include operating theatres, accident and emergency
departments and intensive therapy units. High-risk areas include general wards, sterile
supplies stores and public toilets. Significant risk areas include laboratories, outpatient
departments and mortuaries. Low-risk areas include administrative and record storage
areas. Each area is divided into elements that include the floor, fixtures and equipment.
Each element is allocated a frequency. Some examples of the guidance are set out in
Table 1 and may form the basis for dialogue about cleaning schedules.

Maintenance

It is difficult for cleaning staff to clean a poorly maintained environment and they may
not have the authority or ability to request repairs. Staff should regularly check their
areas for faults and repairs that are required and ensure that these are followed up and
resolved. The general decor, flooring and furniture should be reviewed critically and
regularly.

Public perception

The public perception is that nurses have a responsibility for the cleanliness of health-
care facilities. Nurses do have a role in ensuring cleaning is done and is of a good
standard. However, cleaning is a time-consuming skill that requires training, equipment
and resources. One of the hardest problems is to determine who cleans what, when and
how, particularly when equipment is involved. The recent guidance from NHS Estates
offers comprehensive information on what is required. Nurses should be aware of this
and understand how they can contribute positively to a clean health-care environment.

The role of complaints in improving care

• A complaint is defined as an expression of dissatisfaction by a patient, family member

or carer with the care provided. It helps to identify areas that can be improved.
• Complaints highlight problems that need addressing, such as poor communication or
suboptimal decision-making. Communication problems are common causes of
complaints, as are problems with treatment and diagnosis.
• Complaints also:
o help maintain trust in the profession;
o help maintain high standards; o encourage self-assessment;
o reduce the frequency of litigation; o protect the public.

• Most health-care providers will receive complaints during their careers and this is not
an indication of incompetence. Even the most conscientious and skilful health-care
providers
make mistakes. Health-care error is a subset of human error; all humans make
mistakes.
Personal accountability for managing risk

o The role of fatigue and fitness to practise

There is strong scientific evidence linking sleep deprivation and fatigue to poor clinical
performance. Studies have shown that sleep deprivation can have symptoms similar to
those of alcohol intoxication. Fatigue will lead to being less alert and unable to perform
as normal in a variety of psychomotor tasks. Fatigue has been linked to increased risk of
errors.

o Stress and mental health problems

Performance is affected by stress. There is strong evidence that inadequate sleep
contributes to stress and depression, rather than the number of hours worked. Other
stressors identified include financial status, educational debt, term allocation, emotional
pressures caused by demands from patients, time pressures and interference with one’s
social life.

o Work environment and organization

Certain factors and time periods, such as shift work, overtime, shift changes, nights and
weekends, are associated with increased numbers of errors. The factors underpinning
these errors can range from lack of oversight and instruction or supervision to tiredness.
Health-care providers should be extra vigilant during these times.

o Instruction and supervision

The failure of health professionals to provide adequate instruction or supervision to
junior staff makes them more vulnerable to making mistakes either by omission (failing
to do something) or commission (doing the wrong thing).

o Communication issues
Multiple health professionals-nurses, midwives, doctors, dentists, pharmacists,
radiologists, and others-must record their communications in health-care records. The
role of good communication in the provision of quality health care, and the role poor
communication plays in substandard care are both well documented. For example,
treatment errors caused by miscommunication and absent or inadequate
communication occurs daily in all health-care settings. Checklists, protocols and care
plans are ways of better communicating patient-care orders.

How to understand and manage clinical risks

• Know how to report known risks or hazards in the workplace
• Keep accurate and complete health-care records
• Know when and how to ask for help from a supervisor or senior health-care
professional
• Participate in meetings that discuss risk management and patient safety
• Respond appropriately to patients and families after an adverse event
• Respond appropriately to complaints.