Medical Errors

Course Outline

Chapter 1. Medical Errors: The Scope of the Problem

  • An Epidemic of Errors
    • Where Errors Occur
    • Costs
    • Not a New Issue
    • Public Fears
    • It’s a Systems Problem
    • Types of Errors
    • Preventing Errors
  • Five Steps to Safer Health Care

Chapter 2. 20 Tips to Help Prevent Medical Errors

  • What Are Medical Errors
  • What Can You Do? Be Involved in Your Health Care
    • Medicines
    • Hospital Stays
    • Surgery
    • Other Steps You Can Take
  • Ways You Can Help Your Family Prevent Medical Errors!
    • What Are Medical Errors?
    • What Can You Do?

Chapter 3. Helpful Hints for Preventing Medical Errors

  • The Problem
  • Prevention Tips
    • Ways to Minimize Errors
  • Thorough and Credible Root Cause Analysis
  • Common Error Types and “High-Alert” Medications
    • Target Drugs
    • Target Procedures
    • Points in the Process Where Errors Can Occur
  • Resources at Glance

Chapter 4. Improving Medication Safety

  • Background
  • Common Sources of Error
  • Steps for Improving Medication Safety
  • Our Sources
  • Books
  • Patient Information Brochures
  • Information on Safe Medication Practices
  • Successful Practices for Improving Medication Safety
    • Easily Implemented Changes (Process Design)
    • Longer-Term Changes (Systems Redesign)

Chapter 5. Reducing Errors in Health Care

  • Patients at Risk
  • How Errors Occur
    • Medication Errors
    • Surgical Errors
    • Diagnostic Inaccuracies
    • System Failures
  • Improving Patient Safety
    • Computerized ADE Monitoring
    • Computer-Generated Reminders for Followup Testing
    • Standardized Protocols
  • Promoting Safety
  • References
  • Recommendations for Identifying and Learning From Errors in Pediatrics

Chapter 6. Root Cause Analysis

  • Background
  • Practice Description
    • Prevalence and Severity of the Target Safety Problem
    • Opportunities for Impact
    • Study Designs
    • Study Outcomes
    • Evidence for Effectiveness of the Practice
    • Potential for Harm
    • Costs and Implementation
    • Comment
    • Authors

Chapter 7. Fatigue, Sleepiness, and Medical Errors

  • Introduction
  • Background
    • Sleep Deprivation
    • Night Shifts and Shift Rotation
  • Prevalence and Severity
  • Practice Descriptions
    • Hours of Service
    • Direction and Speed of Rotation of Shift Work
    • Improving Sleep: Education About Sleep Hygiene
    • Lighting at Work
    • Napping
    • Medical Therapies
  • Comment
  • References

Chapter 8. Mental Health Professionals

  • The Duty to Protect
  • Child Abuse and Neglect

Evaluation of Individual Objectives

To assess the effectiveness of the course material, we ask that you evaluate your achievement of each learning objective on a scale of A to D (A=excellent, B=good, C=fair, D=unsatisfactory). Please indicate your responses next to each learning objective and return it to us with your completed exam.

Learning Objectives

  1. Identify following sources of error and describe the steps you would take to avoid them:
    • Abbreviation
    • Administration complication
    • Administration route mix-up
    • Allergic reaction
    • Documentation problem
    • Dosage error
    • Drug name confusion
    • Drug preparation problem
    • Equipment misuse
    • Infusion misuse
    • Insulin error
    • I.V. therapy mistake
    • Label confusion
    • MAR misuse
    • Order misunderstanding
    • Patient name mix-up
    • Patient-teaching failure
    • Protocol violation
    • Storage problem
    • Symbol misinterpretation
    • Syringe and Tubex problem
    • Telephone miscommunication
    • Transcription error
    • Unfamiliarity and carelessness
    • Verification failure
  2. Name “5 rights” of drug administration.
  3. List two cardinal rules for administering insulin.
  4. Explain the importance of not leaving substances at a patient’s bedside without clear instructions.
  5. Take appropriate action with the drug manufacturer when you see a misleading package label.
  6. Differentiate between the workings of volumetric and nonvolumetric infusion controllers.
  7. Take proper steps to avoid errors in the administration of cancer drugs.
  8. List the three different times when the drug label should be checked.
  9. Describe what a nurse should do when seeing an unclear order.
  10. Explain why metric is a better system to use.
  11. Explain the pitfalls of relying on only one health professional to interpret a drug order.
  12. Explain how one can avoid an error that can occur by injecting medication into the wrong catheter tube.
  13. Follow the proper procedure to avoid complications arising from administering inappropriate dosage of analgesics to patients recovering from anesthetics.
  14. Stress the importance of checking the MAR before giving a drug.
  15. Explain how an order that calls for two tablets should be transcribed in three separate lines.


“Great course!” – J.B., LMHC, FL