Reiki Center of Venice ~ Medical Errors ~ 2 CE's

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Medical Errors ~ 2 CE's

Preventing Medical Errors



Reiki Center of Venice

2 CE Hours




Preventing Medical Errors by Francine Milford, LMT



The estimated time to complete this course is 2 hours.


To Complete this Course

  1. Read this study guide and complete the open-book test that was included in this course.
  2. Mail in your answers to Reiki Center of Venice, P.O. Box 554, Venice, FL, 34285.
  3. Mail, or email, your course evaluation to address listed above.
  4. Please keep a copy of your answer sheet for your own records.


Neither the author of this study guide, nor the Reiki Center of Venice, School of Massage Therapy and Bodywork, assumes any liability for the learner’s application of the information contained herein. This course is NOT intended for use in prescribing treatments, therapies or recommendations of any kind.


Course Instructor:

Francine Milford, LMT, NCTMB is a massage therapist, personal trainer and owner/instructor at the Reiki Center of Venice, School of Massage Therapy and Bodywork. She is the author of 45 manuals and more than a dozen home study courses. She resides in Venice, Florida where she continues to teach onsite classes at the Center.


Preventing Medical Errors

© Reiki Center of Venice, LLC. 2013

     Massage Provider# 50-9690

     NCBTMB Provider# 310466-00


Through this course you will discover why medical errors contribute to skyrocketing health-care costs and injury. Learn why it is important for you, as a health care practitioner, to develop a clear and concise plan to guarantee the safety of your clients and customers. This course meets the Florida Medical Errors requirement.


Learning Outcomes

  • You will be able to identify ways to avoid making costly medical errors
  • You will be able to create work processes that will greatly limit medical errors
  • You will be able to identify key safety recommendations from the Institute of Medicine
  • You will be able to apply the Code of Ethics to sample cases
  • You will be able to apply the Scope of Practice to sample cases
  • You will be able to set performance standards and expectations
  • You will be able to implement safety systems


Course Outline

Key Vocabulary Words

Medical Errors defined

Cost of Medical Errors

Causes of Medical Errors

Examples of Medical Errors

Setting Performance Standards and Expectations

Implementing Safety Systems

Legal Ramifications of Medical Errors

Recommendations for Massage Therapists and Bodyworkers



Open-book Test and Course Evaluation




Key Vocabulary Words

            Accident: An unplanned event that results in damage.

            Active error: An error whose effects are felt almost immediately.

            Adverse event: An injury directly caused by medical intervention.

            Bad outcome: Failure to receive expected outcome.

            Error: Use of a wrong plan of action to achieve desired goal-or-failure of a plan of action(s) to be completed as directed.

            Failure Mode:  Errors in the system, or process

            Heath-care organization: Legal entities that provide health and medical services.

            Human factors: Study of humans in the environment and the tools that they use.

            Latent error: An error whose effects are generally not felt for a long period of time. These errors may include problems in the design, organization, training or  maintenance of the system, or patient.

            Medical technology: Includes all drugs, equipments and procedures followed by a health care professional in providing medical care to a patient.

            Micro-system: A core team of health care professionals that offer repeatable services to a specific population (such as geriatrics). This group also provides information  and a support system for said population.

            Patient Safety: Development of systems/precautions that minimize errors.

            Quality of Care: The overall success rate of a service to provide desired outcome.

            Scope of Practice: Working within the confines of your license/training.

            Standard: Minimum acceptable results or performance.

            System: Set of elements that interact to achieve a common goal or function.




What is a Medical Error?

             According to Reference.MD, medical errors are mistakes committed by health professionals that result in harming the patient. Medical mistakes include errors in diagnosis, drug administration, surgical performance, equipment malfunction or misuse, negligence, ignorance, accident or even by criminal intent.

            These errors can occur when a health care professional either chooses an inappropriate method of care-or executes the right care but does it incorrectly. Medical errors is one of the leading causes of death and injury in the United States surpassing people who die from motor accidents, breast cancer and AIDS.

            According to the article written by Beth Howard titled, “Lessons from America’s Safest Hospitals,” Howard states that more than 180,000 people die every year from hospital errors. The story follows the death of 69 year-old social worker, Mary McClinton. McClinton was admitted into Virginia Mason Medical Center in Seattle to under a routine procedure to treat a brain aneurysm. The error occurred when doctors injected her with an antiseptic, instead of a contrast dye. The antiseptic, a topical cleaning agent, was stored in an unmarked container on the same tray as the dye. McClinton died 19 days later as each of her organs began to fail.

            Errors such as the one mentioned above are called “never events” and affects at least 6,000 patients every year. Never events are errors that could have been prevented. These events include operating on the wrong limb or leaving instruments inside of a patient during surgery.

            The tragedy happened in 2004. Virginia Mason Medical Center decided to do something about that and started a complete turnaround. The hospital decided to make safety their top priority. After issuing a public and private apology to McClinton’s family, the hospital began a program to revamp their safety procedures. Part of their program included implementing new safety protocols, gave nurses more time to spend with patients, instituted checklists before surgeries and established patient safety alerts. The hospital also encouraged their employees to speak up and file reports when they felt that a patient’s health or life was at risk.

            While never events may account for harming 6,000 patients a year, medication errors cause approximately 400,000 drug-related injuries a year. On way to help curb this problem was with the implementation of a computerized provider order entry (CPOE) system. The system forces doctors to enter prescriptions into the computer electronically which eliminate transcription errors. The system also has a built-in safety alert which helps keep doctors from prescribing more medicine than is generally accepted. Another part of the system is the bar coding of patient’s bracelets which helps to make sure that the right patient is receiving the right medication and the right medication dosage. In one year, this system has saved thousands of lives. With computerized systems, doctors can track patients outside of the hospital environment to see if they are getting their prescriptions filled which can affect patient compliance. This can also alert doctors to additional issues that the patient may not be reporting to the doctors at the hospital. This knowledge will also help in preventing drug interactions since the doctors will now have a better understanding of the medications that the patient is taking (and maybe not reporting).

            Some 100,000 people die each year from preventable infections that they contracted in the hospital. Out of that number, 20,000 patients die from central line infections. It was discovered that the simple act of washing your hands and cleaning the patient’s skin before inserting a line reduced central line infections by as much as 66%. To help lower incidences of preventable infections, hospitals have incorporated checklists and door signs for affected patients.

            What will the safe hospital room of the future have in it? It will have double-sided linen closets, bar codes on patient bracelets, a hand washing station in every room, hand bars, bed alarms, disinfecting units that use ultraviolet light to kill germs, checklists for health care providers, vents that will filter the air out of the room of sick patients and release it from the building, fall prevention kits, germ-resistant copper alloys on door knobs, faucets and railings, language translators and vital sign monitors.

            In the United States alone, medical errors account for more than one million injuries and up to 200,000 preventable deaths each year. And there is a financial cost to these errors. According to the Institute of Medicine, preventable medicine errors were the most common medical mistakes harmed more than 1.5 million people every year. This finding included 400,000 preventable drug-related injuries in hospitals, 800,000 in long-term care and 530,000 among Medicare recipients in outpatient clinics. These findings also came with a hefty price tag costing more than $2 billion each year. Where errors have resulted in death, the Agency for Heathcare Research and Quality have estimated that while 6,000 deaths each year have resulted in work-related injuries, 7,000 deaths each year are caused from medication errors.



Causes of Medical Errors


Medical errors can be caused by any number of reasons including, but not limited to, the following:


  • Inexperienced physician and nurses
  • Implementation of new procedures for which inadequate training has been provided
  • Complexity of care
  • Emergency care
  • Extreme age
  • Improper documentation
  • Poor communication
  • Illegible handwriting
  • Inadequate nurse-to-patient ratios
  • Patient non compliance
  • Faulty health care system
  • Poorly designed process
  • Human misjudgment
  • Similarly named (or looking) medication
  • Lack of coordination within a hospital or clinic
  • Disconnected reporting systems (one nurse handing off patient to another nurse without proper documentation)
  • Lack of quality skilled technicians
  • Cost-cutting measures
  • Reliance on automated systems
  • The idea that someone else is handling the situation
  • The arrival of new residents
  • Variations in healthcare provider training and experience



Human Factors to Medical Errors


There are a number of human factors that contribute to causing medical errors. These errors include, but are not limited to, the following:

  • Depression
  • Burnout
  • Fatigue
  • Sleep deprivation
  • Time restraints
  • Similar drug names-or-drugs that look similar
  • Increase in Nurse-to-patient ratio (Nursing staff has too many patients to be responsible for)
  • Diverse patients (and needs)
  • Unfamiliar settings (starting a new job as a health care professional and can’t remember where the supplies, equipments, etc. are).


A Personal Example Of Hospital Error:

I took my husband to a hospital where the attending physician was a practical nurse who was visiting from Ohio and her attendee was a nurse who was just visiting from Indiana. Neither of these health care practitioners was able to locate specific tools that they needed to do the stitches that my husband needed.  They ended up asking around for the instruments that they needed.


Examples of Medical Errors

There are a variety of ways in which medical errors can, and do, occur. Among these include, but are not limited to, the following:


  • Failure to diagnose the condition
  • Misdiagnosis of the condition
  • Delay in diagnosing the condition
  • Prescribing the wrong drug (or doses, application, times, etc.)
  • Giving patient two or more drugs that don’t interact well together (or are poisonous)
  • Wrong-site surgery (amputating the wrong arm)
  • Leaving tools (or sponges) behind in the patient after surgery
  • Using race as a diagnosis (and not as a factor)
  • Transplanting organs using the wrong blood type (or using inferior or infected organs)
  • Incorrect record-keeping and/or documentation
  • Inability of doctors to deal with patients with special needs (such as mental illness, bipolar disorders, mental disorders, dissociative identity disorders, schizophrenia, etc.)



The Five most Common Misdiagnoses

  • Infection
  • Neoplasm
  • Myocardial infarction
  • Pulmonary emboli
  • Cardiovascular disease


        In many hospitals today, it is a current standard of practice for patients to disclose medical errors. In the American Medical Association's Council on Ethical and Judicial Affairs, it states in its ethics code the following:


"Situations occasionally occur in which a patient suffers significant medical complications that may have resulted from the physician's mistake or judgment. In these situations, the physician is ethically required to inform the patient of all facts necessary to ensure understanding of what has occurred. Concern regarding legal liability which might result following truthful disclosure should not affect the physician's honesty with a patient."


And in the American College of Physicians Ethics Manual:


“In addition, physicians should disclose to patients information about procedural or judgment errors made in the course of care if such information is material to the patient's well-being. Errors do not necessarily constitute improper, negligent, or unethical behavior, but failure to disclose them may.”

        But because of malpractice litigation, many physicians and staff are unwilling to disclose errors. To combat this refusal to have communication between patient’s family members and hospital employees, the United States enacted laws where anything that the physician or surgeon may say to console grieving family members such as, “I am so sorry,” can not be used in a court of law as an admission of that physicians’ or surgeon’s proof of liability. And in fact, there is even some evidence that full disclosure may actually reduce malpractice payments as family members are only looking for closure in the death of a loved one.



Ways to Reduce Medical Errors


There exists within every system a number of ways that medical errors can be reduced or eradicated all together. These include, but are not limited to, the following:

·        Sufficient training

·       Sufficient time to perform the task (check workload)

·        Offer additional or specialized training

·        Updated technology awareness and training

·        Using updated research

·        National and International color coding standards

·        Standardize medication (doses, etc.)

·        Encourage patients to get a second opinion if they have doubts

·        Have clients fill out in-depth client forms (and then read them)

·        Ask clients to clarify any questions you may have about the information in the client in-take form, or the lack thereof.

·        Putting together a system of checks and balances. One such system is the Formulary System. In the world of pharmaceuticals, professionals work with a process called the Formulary System with a list of drugs known as the Formulary. This helped in the implementation of unit dose packaging and distribution systems to centralize admixture services. This system reduces the risk of wrong drug doses, decreases the risks of contaminated and infected intravenous medications, improves the safe and effective use of medications and provides a computerized check of patient’s medical history to avoid drug interactions.




When speaking of procedures and the risk of medical errors, there are some common and inherit problems. The most avoidable adverse events often occur in high risk, or emergency procedures.  Because of the circumstances surrounding the patient at this time, the adverse outcomes are usually not due to error but to the severity of the condition at time of treatment. replica breitling Medications given at this time are three times more likely to cause harm to the patient than at any other time of admittance.


And it should be noted that most medical care comes with some level of risk. This risk could be in the form of complications, unforeseen circumstances, an underlying condition, or a side effect (such as an allergy to the medication). If a patient experiences any of these adverse events during the treatment process, an error has occurred.     


The article titled ‘JCAHO Revises Standards to Help Reduce Medical Errors,’ written by Robert C. Morell, MD., talks about how an improvement in patient safety can directly minimize medical errors. The author of the article, Dr. Morell, is the Director of the Preoperative Assessment Clinic and Associate Professor, Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC.


JCAHO stands for the Joint Commission on Accreditation of Health Care Organizations. It is an independent, not-for-profit organization that accredits and certifies more than 19,000 health care organizations and programs in the United States. This commission has since been renamed, The Joint Commission.’ The job of the commission it to recognize those organizations that improve patient safety, reduce risks and to minimize medical errors. You can download the commission’s findings and read the full article at their homepage at:


On July 1, 2001, the Joint Commission published new language. On this list was the addition of the definition of the following words:


  1. Error: "An unintended act, either of omission or commission, or an act that does not achieve its intended outcome."


  1. Sentinel Event: "An unexpected occurrence involving death or serious physical or psychological injury or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase "or risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome."


  1. Near Miss: "Used to describe any process variation which did not affect the outcome but for which a recurrence carries a significant chance of a serious outcome. Such a near miss falls within the scope of the definition of a sentinel event, but outside the scope of those sentinel events that are subject to review by the Joint Commission under its Sentinel Event Policy."


  1. Hazardous Condition: "Any set of circumstances (exclusive of the disease or condition for which the patient is being treated) which significantly increases the likelihood of a serious adverse outcome."




The Commission created a set of Standard Policies that they felt would ensure patient safety and minimize medical errors. Among these findings were:


  1. Leaders ensuring implementation of an integrated patient safety program throughout the [healthcare] organization.


  1. Designation of one or more qualified individuals or an interdisciplinary group to manage the organization-wide patient safety program. Typically these individuals may include directors of performance improvement, safety officers, risk managers and clinical leaders.


  1. Procedures for immediate response to medical/health errors, including care of the affected patient(s), containment of risk to others, and preservation of factual information for subsequent analysis.


  1. Clear systems for internal and external reporting of information relating to medical/health care errors.


  1. Defined mechanisms for responding to the various types of occurrences, e.g., root cause analysis in response to a sentinel event, or for conducting proactive risk reduction activities.


  1. Defined mechanisms for support of staff that have been involved in a sentinel event.


  1. Definition of the scope of the program activities, which is the types of occurrences to be addressed, ranging from “no harm” frequently occurring “slips” to sentinel events with serious adverse outcomes.


  1. At least annually, a report to the governing body on the occurrence of medical/health care errors and actions taken to improve patient safety, both in response to actual occurrences and proactively.




In addition to recognizing the important of data collection and analysis, JCAHO also suggested proactive programs for identifying risks and reducing medical errors BEFORE they happened rather than programs that dealt with how to handle errors after they happened.


The identification of errors in the system, or process, called "failure modes" is vital to ensure patient safety. The commission encourages redesigning faulty programs or processes and implementing better safeguards.



According to the article, “JCAHO also recognizes that barriers to effective communication among caregivers must be minimized. Specific attention is focused on "ensuring accurate, timely, and complete verbal and written communication among caregivers." Standard RI.1.2.2 also states that, "Patients and, when appropriate, their families are informed about the outcomes of care, including unanticipated outcomes." The intent of this regulation is to have the responsible practitioner (or designee) clearly explain the outcome of any treatments or procedures to the patient (and/or family) whenever the outcome differs significantly from the anticipated outcome. “




Legal Ramifications of Medical Errors

      There are many legal, professional and ethical ramifications for committing medical errors. There are several standards and regulations for medical malpractice and these vary by country and jurisdiction within countries. A professional found guilty of medical error can be fined, face imprisonment, be personally sued, and lose their license. In the United States, medical professionals, health care professionals, and massage therapists and bodyworkers may obtain professional liability insurance to help them offset the risks and costs of any lawsuit.

      If you own your own business, or office, then looking for a good insurance policy is extremely important. Find a policy that covers slip and fall, product liability and medical errors.



Be Sure to Report an Error

             When hospitals do not make safety a top priority in their facilities, then accidents and errors can and do happen. A five-year study published in 2010 in the New England Journal of Medicine showed that 25 percent of all people admitted to hospitals in North Carolina were harmed by the medical care that they received. These percentages are too high for preventable events. 

            But, in order to fix problems that exist, you have to know about them. That is why reporting errors are so important. When a hospital receives a report, it triggers a review which can then lead to changes that are needed to prevent the recurrence of the error. Preventing recurring errors can cause changes in protocols, procedures, checklists, oversight, or the installation and use of new technology or technological systems.

            Some of the items that are track-able are what is referred to as a preventable-harm index. Included in this index would be cardiac arrests, adverse drug events, surgical complications, falls, hospital acquired infections and pressure ulcers, among others.

            In Washington, the Centers for Medicare and Medicaid Services have given a $5 million grant to a consortium of Ohio children's hospitals. The grant is to be used to help eliminate preventable errors. For adults, an initiative by the Department of Health and Human Services called, "Partnership for Patients: Better Care, Lower Costs," intends to reduce preventable injuries in U.S. hospitals by 40 percent by 2014. This would result in saving 60,000 lives.

            Peter Pronovost, a Johns Hopkins anesthesiologist and critical care specialist launched the Keystone Project, a project that reduced the rate of bloodstream infections by 60% among patients in intensive care units who were receiving central lines or catheters. That 60% mark represented 1,500 lives and approximately $100 million each year. At the core of the Keystone Project was a checklist for the medical team to follow. Simple items on the list include hand-washing and mask wearing. Pronovost received government funding to extend the program to more than 1,400 ICUs in 48 states.



What can you do to Prevent Errors (as a consumer)

There are many ways in which you can take on an active role in your own health care. Patients who get involved in their own care tend to get better results. According to the article, “20 Tips to Help Prevent Medical Errors.” Patient Fact Sheet. AHRQ Publication No. 00-PO38, February 2000. Agency for Healthcare Research and Quality, Rockville, MD. Here are some those tips:

  1. Become an active participant in your health. Do research, ask questions, etc.
  2. Inform your doctor of all your current medications including herbal remedies, vitamin supplements, and over-the-counter medicines. The best way to do this is to bring ALL of your medications and supplements with you to your doctor’s visit and show them to the nurse and/or doctor.
  3. Be sure that your doctor is aware of any allergic or adverse reaction that you have had to any medication.
  4. Make sure to read your doctor’s prescription and have him or her, clarify anything that you cannot read or understand.
  5. Ask your doctor questions about any medications that he prescribes to you. (side effects, how long, how often, take with or without food, what to do in case of reactions, etc.)
  6. When you pick up your prescriptions from the pharmacy check your bottle against the prescription. Be sure that they are indeed the same name and dose. My husband has already had to return medicine to a pharmacy that was not his.
  7. The pharmacy is a great resource of information about the medication that you will be taking and usually have more time to explain it to you than your doctor does. Make use of this time if you are unsure about the directions on your medicine label or how to take it. Pharmacies now offer a full booklet with your prescriptions that give you a wealth of knowledge about the medicines that you are taking-be sure to read it.
  8. If you are facing an amputation of a limb, the American Academy of Orthopedic Surgeons recommend its members to sign their initials directly on the site that they will be operating on to avoid mistakes.
  9. Have someone with you to act as your advocate, or sounding board, in case you need them. They will also be a better place to hear the information that is given to you.
  10. If you are having a test taken, call for the results. Not all places will call you giving you the test results.
  11. Make sure that your doctor/hospital is up-to-date on the latest procedures and technologies regarding your specific condition.


A set of Universal Precautions for Health Care professionals have been created by the Occupational Health and Safety Administration to prevent the spread of disease.


For massage therapists, this list includes such safety precautions as:

  • Clean massage tables, chairs and equipment before/after each use. Do not trust other therapists who use the same equipment before you to do the right job.
  • Shower at the beginning of the day-and at the end of the day.
  • Bring a change of clothes with you to work and change into your street clothes after you work day is over.
  • Brush your teeth and keep your gums healthy.
  • Wash your hands before and after each session and often throughout the day. Follow the hand washing protocols that you learned in school.
  • Keep your nails cut and neat.
  • Never wear jewelry such as bracelets and rings while doing massages as germs/skin cells can hide underneath them.
  • Massage therapists should be trained in First Aid and CPR. After training, be sure to keep a health kit complete with a mouth guard for giving CPR.
  • Create a safe working environment by tacking down turned up carpet edges and removing obstacles from the walk area (such as wires and cords).
  • Be sure to keep a workable schedule allowing with enough time in between clients to fill out your Client In-take form. Do not overwork yourself or schedule more clients in one day than your body can handle.
  • Establish a basic protocol that you can follow to perform daily tasks such as doing the laundry, cleaning supplies and equipment, asking Client questions, etc.



U.S. Hospital Rankings and what it means to you

            For 25 years, hospitals have been ranked nationally. On July 15, 2014, the US News & World Report, published the list of the national’s best ranked hospitals for the 2014-2015 year. The list included the nation’s top 50 hospitals in key specialties such as cancer and cardiology. Big winners include the Mayo Clinic and John Hopkins. While only 17 hospitals ranked high enough in six or more specialties to make the list the rest of the hospitals did not. In fact, only 144 of the 4,743 hospitals evaluated did well enough to even be ranked in at least one specialty of the 12 specialties listed. That’s only 3% of our nation’s hospital system (Omstead et al, 2014).

            There were several factors that determined the overall hospital score. Some of these factors included structure, process, outcome, reputation among specialists and patient safety. There were new changes that took place in the 2014-2015 judging. The biggest change came in the form of adding more weight (from 5% to 10%) for patient safety. This increase was done in order to recognize those facilities that provided quality and patient safety.

            In addition to adding more weight to the overall score, two patient safety indicators were added the score. Now consumers can see the differences in patient safety performance between hospitals.


2014-15 Best Hospitals Honor Roll - Rank Hospital Points Specialties


  1. Mayo Clinic, Rochester, Minn.


  1. Massachusetts General Hospital, Boston


  1. Johns Hopkins Hospital, Baltimore


  1. Cleveland Clinic


  1. UCLA Medical Center, Los Angeles


  1. New York]Presbyterian University Hospital of Columbia and Cornell, N.Y.


  1. Hospitals of the University of Pennsylvania]Penn Presbyterian, Philadelphia


  1. UCSF Medical Center, San Francisco


  1. Brigham and Women's Hospital, Boston


  1. Northwestern Memorial Hospital, Chicago


  1. University of Washington Medical Center, Seattle


  1. Cedars]Sinai Medical Center, Los Angeles


  1. UPMC]University of Pittsburgh Medical Center


  1. Duke University Hospital, Durham, N.C.


  1. NYU Langone Medical Center, New York


  1. Mount Sinai Hospital, New York




Emergency Room Problems

          According to a report from the American College of Emergency Physicians, government support for emergency care in the United States is worse now than in previous years. Before, the grade given for government policy support for emergency care was a C-, now that grade dropped to a D+. The report looked at state and government support of emergency care which included access to emergency care, disaster preparedness, quality and patient safety, public health, medical liability and injury prevent (Huffington Post, 2014).

         Nationwide, emergency care scored a D-, a C for public health and injury prevention, and a C- for disaster preparedness. That is pretty dismal to say the least. Issues involved in earning this poor score include a shortage of qualified health care professionals, shortage of on-call specialists, limited hospital capacity and long emergency department wait times.


Below is a list of the top 10 states, and lowest ranking states, for emergency care based on the same criteria:


Top states for emergency care 1. District of Columbia 2. Massachusetts 3. Maine 4. Nebraska 5. Colorado 6. Pennsylvania 7. Ohio 8. North Dakota 9. Utah 10. Maryland


Worst states for emergency care 51. Wyoming 50. Arkansas 49. New Mexico 48. Montana 47. Kentucky 46. Michigan 45. Illinois 44. Alabama 42. Louisiana 42. Alaska




Hospital-Acquired Conditions

       Beginning October, 2014, in an effort to require hospitals to lower their incidences of hospital-acquired conditions (HAC), the Centers for Medicare & Medicaid Services (CMS) began reducing Medicare payments to hospitals with poor outcomes under the Hospital-Acquired Condition (HAC) Reduction Program.

       The Patient Safety Program, a program called for by the Affordable Care Act (ACA), will begin in 2015. Under this program, hospitals are given a rank according to 11 categories. replica rolex watches The lowest performing 25 percent of hospitals with lose (1) percent of each Medicare payment paid under the Inpatient Prospective Payment System (IPPS), for the upcoming (2015) year. This ranking is based on two unique findings: HAC’s reported between Jan. 1, 2012-Dec. 31, 2013 and nine Patient Safety Indicators between July 11-June 2013.

      Other provisions under the new rule will include increasing portions of Medicare payments to fund value-based incentive payments to 1.25 percent, add new readmission measures, and establish quality reporting programs to help align quality measure reporting.


The HAC Reduction Program is only one in over 70 programs that rate quality indicators in hospitals. The hope is that programs like these will encourage hospitals to improve their quality of care and implement better patient safety system.


The 11 categories of HACs listed below:


  • Foreign Object Retained After Surgery


  • Air Embolism


  • Blood Incompatibility


  • Stage III and IV Pressure Ulcers


  • Falls and Trauma


o    Fractures


o    Dislocations


o    Intracranial Injuries


o    Crushing Injuries


o    Burn


o    Other Injuries


  • Manifestations of Poor Glycemic Control


o    Diabetic Ketoacidosis


o    Nonketotic Hyperosmolar Coma


o    Hypoglycemic Coma


o    Secondary Diabetes with Ketoacidosis

o    Secondary Diabetes with Hyperosmolarity

  • Catheter-Associated Urinary Tract Infection (UTI)
  • Vascular Catheter-Associated Infection
  • Surgical Site Infection, Mediastinitis, Following Coronary Artery Bypass Graft (CABG):
  • Surgical Site Infection Following Bariatric Surgery for Obesity

o    Laparoscopic Gastric Bypass

o    Gastroenterostomy

o    Laparoscopic Gastric Restrictive Surgery

  • Surgical Site Infection Following Certain Orthopedic Procedures

o    Spine

o    Neck

o    Shoulder

o    Elbow

  • Surgical Site Infection Following Cardiac Implantable Electronic Device (CIED)
  • Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) Following Certain Orthopedic Procedures:

o    Total Knee Replacement

o    Hip Replacement


  • Iatrogenic Pneumothorax with Venous Catheterization







20 Tips to Help Prevent Medical Errors: Patient Fact Sheet. September 2011. Agency for Healthcare Research and Quality, Rockville, MD.


Elsevier, Ltd. (26 July, 2014). The real meaning of US hospital rankingsOriginal Text. The Lancet Volume 384, Issue 9940, Page 282. doi:10.1016/S0140-6736(14)61245-9


Howard, Beth. (2013). Lessons from America’s safest hospitals. AARP Magazine. Volume 56, Number 3A. (46-52).


Huffington Post. 2014. 2014 State rankings released for support for emergency care. Accessed on November 11, 2014 from


Omstead, M., Geisen, E., Murphy, J., Bell, D., Morley, M., Stanley, M. (14 July, 2014). Methodology:U.S. News & World ReportBest Hospitals 2014-15. Accessed on November 11, 2014 from


Sternberg, Steve (2012, August 29). Medical errors harm huge numbers of patients. Web. Retrieved from





More Information

A Federal report on medical errors (Publication No. OM 00-0004) is available from the AHRQ Publications Clearinghouse: phone, 1-800-358-9295 or E-mail:




Open Book Test for Preventing Medical Errors



Name_ _________________________________________________  Date ________________


Address__ ____________________________________________________________________


MA #_________________________ Other License Number ___________________________


Email Address ________________________________________________________________


Contact Number _______________________________________________________________


After reading this course, choose the ONE best answer for each question and circle it. Remit test for grading to Francine Milford, P.O. Box 554, Venice, FL. 34285.



1. In the United States alone, medical errors account for more than one million injuries and up to ____________ preventable deaths each year. a. 2000 b. 2,000 c. 20,000 d. 200,000

2. According to the Institute of Medicine, preventable medicine errors were the most common medical mistakes harmed more than _________ people every year. a. 1 million b. 1.5 million c. 2 million d. 3 million

3. According to the Institute of Medicine, __________ preventable drug-related injuries occur in hospitals each year. a. 400,000 b. 300,000 c. 200,000 d. 100,000

4. Medical errors cost more than ___________ each year. a. $2 billion b. $1 billion c. $10 million d. $100 million

5. An unintended act, either of omission or commission, or an act that does not achieve its intended outcome is called an: a. Near Miss b. Accident c. Error d. Unplanned Outcome

6. One common cause for medical errors is: a. Improper or incomplete documentation b. Too much sugar c. Drinking too much coffee d. Not wearing a good pair of shoes

7. The identification of errors in the system, or process, to ensure patient safety is called a. System b. Failure modes c. Safety d. Hazardous conditions

8. In this course, patient safety is defined as: a. Development of systems/precautions that minimize errors. b. Freedom of speech and movement c. Freedom from intentional injury d. No worries

9. Massage therapists can reduce the potential of unintended accidents by: a. Cleaning massage tables, chairs and equipment before/after each use. b. Hanging pictures on the wall. c. Putting their hair up in a ponytail d. Playing the right kind of music

10. Massage therapists can avoid making medical errors in their practice by: a. Using their memory more b. Working at least 40 hours a week c. Do plenty of hard treatments d. Practice good communication skills with their clientele

11. Pharmaceutical companies have a check and balance system in place to reduce the risk of wrong drug doses and medication interactions. This system is called: a. Check and Balance b. Pharmacy Balancing c. Pharmacy List d. Formulary System

12. One of the Universal Precautions for Health Care professionals created by the Occupational Health and Safety Administration to prevent the spread of disease is: a. Take a bath instead of a shower whenever possible b. Brush your teeth and keep your gums healthy c. Wear gloves when you work on your clients d. Changes you scrubs with every client that you work on

13. You should establish a basic protocol that you can follow to perform daily tasks to reduce errors. One basic protocol that you can establish: a. Taking your walk at the same time each day b. Walking to your mail box at the same time each day c. Washing your laundry with special soaps d. Get in the habit of washing your hands before and after each client

14. To help reduce error, you as a consumer should do the following: a. Become an active participant in your health. b. Inform your doctor of all your current medications c. Tell your doctor of any allergic or adverse reaction that you have had. d. All of the above

15. Any set of circumstances which significantly increases the likelihood of a serious adverse outcome is called a(n): a. Hazardous Condition b. Accident c. Event d. Near Miss

Cost of Course

Cost: $10 for Medical Errors-2 ce's.