The Patient’s Hospital Safety Guide

By Marlene McAllister MSN, RN, NEA, BC, CNO (Ret.) and Ronald Liss.

The following is an abridged online version of the Patient’s Hospital Safety Guide app. The app is more comprehensive, much easier to use and navigate, can be used in a hospital and it’s immediately available whenever needed. Download the app from the App Store (for iPhone) and Google Play Store (for Android).

DISCLAIMER: The following content and any and all associated information is not offered as, nor intended to be, a substitute for professional medical advice, diagnosis or treatment. Always seek the advice of a licensed healthcare practitioner for any health-related matter.

TERMS AND CONDITIONS: Upon any use of this guide the user agrees to the Terms and Conditions. If you do not agree with all of the Terms and Conditions do not use this guide! 

IMPORTANT NOTICE   

      If you are experiencing unusual pain or another problem as a result of your hospital medical treatment see 10 Warning Signs of a Patient in Trouble.

      If you think that you have been harmed by your hospital medical treatment see What to Do If You Have Been Harmed or Think An Error Has Occurred. See also Table of Medical Errors if you think an error has occurred.

Table of Contents

Introduction 

What to Do When Being Admitted to a Hospital

What Are Your Rights as a Hospital Patient

Hospital Personnel – Who is Who and How to Identify Them

Care Coordination

Harm, Medical Errors, and Adverse Events

How to Protect Yourself While in a Hospital

10 Warning Signs of a Patient in Trouble

Types of Medical Errors, Their Causes, How to Recognize and Avoid Them

Table of Medical Errors

Never Events

What to Do If You Have Been Harmed or Think An Error Has Occurred

Is It an Emergency or Do You Think It May Be Life-Threatening

How to Report a Medical Error, Patient Harm, or Dangerous Conditions 

Submit a Review About Your Hospital Experience

About the Authors and APRA

Donate

 

INTRODUCTION

This guide contains much life-saving information that hospitals do not provide to patients. It includes links to valuable online supplemental information that is available for free upon registration.

WHAT TO DO WHEN BEING ADMITTED TO A HOSPITAL 

  1. Choose someone to be your legal health care agent. They will make medical decisions for you in case you become unable to, for any reason; 
  2. Choose someone to be your patient advocate. They will help guide your care while you are in the hospital. They can’t make medical decisions for you unless you also name them as your health care agent. If your advocate and agent are different people each should be informed of the other;
  3. Prepare your advance care planning documents (aka advance directives). These are legal documents related to your medical care and naming the people (or person) you chose to be your health care agent and your patient advocate. The documents you need will depend upon which state you are in. If you are a student you will need forms for both your home and school state. Learn more about medical-legal documents.
  4. Provide a copy (not the original) of your advance care planning documents to the admissions person at the hospital. They should be made a part of your hospital record. If you don’t have them with you, tell the admissions person where they can be found and have your family bring a copy. If you have not yet prepared them, consider doing so while hospitalized. You can ask your care team for help;

     At the time of admission:

  1. Provide an up-to-date medications list to the admitting nurse and keep another copy with you for your doctor or nurse to review. 
  2. Provide a copy of your medical history and condition to the admitting nurse and attending physician;
  3. Ask what the hospital policy is in case of an error and what to do;
  4. Ensure your ID band has your correct name, birthdate, and allergies;
  5. Read your admission history and physical exam for accuracy of your medical problem(s), medical diagnosis, and all data. If the hospital won’t allow you to access your medical records see Where to Go For Further Help. If your hospital allows you to access or create an online account do so to check your information; 
  6. Discuss your medications list and your hospital medication plan with your doctor/nurse. If you bring any medications from home, give them to your nurse. He/she must administer them. Do not take them without the nurse’s supervision. Doing so may interfere with another drug you are receiving. All medications must be dispensed by the pharmacy before a patient can take any medications they bring from home;
  7. Ask your nurse if the humidity in your room is or can be controlled. It should be kept between 40-60% to help protect against infection. If it isn’t, consider getting a small portable humidifier for your room but first check if it’s use would need to be approved by staff

WHAT ARE YOUR RIGHTS AS A HOSPITAL PATIENT 

Patients have few legal rights with respect to their healthcare. Some are: 

  • To receive a copy of your medical records
  • Privacy of your medical information
  • Informed consent to your treatment (to receive all the information you need to make an informed decision before agreeing to the treatment/procedure).
  • To refuse treatment 
  • To leave the hospital against medical advice and before being discharged, without any loss of insurance coverage for treatment received. This should be avoided and the last resort after you have given your health care team reasonable and sufficient time to address your concerns.  

For further information see Patient Rights

HOSPITAL PERSONNEL: WHO IS WHO AND HOW TO IDENTIFY THEM 

Doctors

Hospitalists

They are Medical Doctors or Doctors of Osteopathy (MD or DO’s) and usually, but not always, wear long white lab coats with an Identification Badge clearly stating their name and profession. Many hospitals employ hospitalists and intensivists specializing in hospital acute care. These groups rotate days and shifts. Ask for your doctor’s name every day and record it. You may not see the same doctor. 

Interns, Residents, Fellows

Many hospitals are affiliated with a university-based medical school. Residents and Fellows are Medical Doctors (MD). They have graduated from medical school and are receiving further training for a specialty practice such as surgery, radiology, emergency, etc. Chief Residents are Residents in their final year of residency who supervise other Residents and usually are among the most knowledgeable physicians in the hospital. Interns have graduated from medical school but do not yet have a full license to practice medicine unsupervised. 

Medical Students

Medical Students have not graduated as medical doctors and wear short white lab coats. They will wear a name badge clearly displaying the affiliated school and the title.  

Attending 

An attending doctor is a physician who has completed residency and practices medicine in a clinic or hospital in the specialty learned during residency. Attending doctors are usually (but not always) in long white lab coats with an Identification Badge clearly stating their name and profession. An attending doctor typically supervises fellows, residents, interns, medical students, and other practitioners. Often the patient does not meet an attending doctor. (Note: because of the risk of transmitting hospital-acquired bacteria, physicians in some institutions no longer wear white coats with long sleeves).

Mid-level

Many doctors employ Physician Assistants (PA) and/or Advanced Nurse Practitioners (ANP) to assist and expand the practice. They may be in short white lab jackets and will have a hospital badge clearly displaying credentials.  

Nurses 

Nurses are usually in one color, like white or navy, chosen by the nursing staff. Nurses wear a name badge with a large RN or LPN clearly displayed on the name badge. Pediatric nurses may be in a different color and will also always wear a name badge with RN or LPN. Many nurses wear hospital-provided scrub clothing in departments such as the operating room and labor and delivery.  A name badge will be prominently displayed with RN or LPN in these instances as well.  

Support Staff

Hospitals have many support staff and volunteers to serve you. Nursing assistants, pharmacy technicians, housekeeping staff, dietary aides as examples of support staff that frequently enter your room. They may be in a color-coded uniform and will wear a name and title badge clearly displaying the department.  

Other Patient Hospital Resources

  • Patient Advocate or Representative
  • Chaplain
  • Administrative Supervisor
  • Social workers

CARE COORDINATION

Due to doctor rotations, the coordination of care for hospital patients is often weak or missing. You may be cared for by multiple physicians and physician groups. You may have an attending doctor along with residents, fellows, and students consulting on your care. You may be assigned to a hospitalist or intensivist group who rotate shifts. Patients and their advocates should know the name, title, and position of everyone treating the patient, and the name and contact information for the nurse in charge, hospitalist or attending doctor, chief resident, and surgeon.

Poorly coordinated care is the cause of many hospital deaths. It is best for the patient to have their primary care doctor, a friend who is a medical professional, or their patient advocate coordinate their care through their nurse by asking the nurse to call a care conference which they can attend. In many cases the hospitalist or attending physician will be responsible for coordinating care, explaining the daily plan of care and answering questions. Ask them if they will be the coordinator. 

HARM, MEDICAL ERRORS AND ADVERSE EVENTS

Not all harm caused by medical treatment is preventable or avoidable, such as harm caused by necessary treatment for which there is a known risk, even when protocols and guidelines are strictly adhered to. 

An “adverse event” in medicine is an injury caused by medical management rather than by the underlying disease or condition of the patient. A preventable adverse event is an injury that could have been avoided and was caused by an error or system flaw.

It is estimated that up to 50% of the adverse events in hospitals are preventable (World Health Organization). 

HOW TO PROTECT YOURSELF WHILE IN A HOSPITAL 

  1. Have a patient advocate with you;
  2. Know what your condition is and the plan for treatment;
  3. Make sure your identity is checked every time a procedure is done or medication is delivered; 
  4. Make sure everyone washes their hands before touching you and doctors clean their stethoscopes before examining you. Keep a pocket-size hand sanitizer and wipes with you and offer them if necessary. Make sure no doctor’s necktie touches you (many hospitals now discourage wearing neckties because of the risk of transmitting infections). Make sure you always wash your hands when using the restroom and before meals. Make sure your room is cleaned well daily, including all equipment and the floor. Don’t be afraid to speak up. It’s your life that’s at risk; 
  5. Share your health information with all your healthcare providers in the hospital. Do not assume they will know it. Make sure it is correct and complete; 
  6. Share your list of medications with your doctor and nurse; 
  7. Share your wishes with your healthcare providers;
  8. Know and understand everything that’s happening to you, including what tests are being done and what each is for. Ask for the results and what they mean for your health. If you are unsure of anything, ask questions or research online until you understand. You should know what tests and procedures will and will not be helpful for improving your health. Shared decision-making is now the standard of care. You should not be kept in the dark about anything;
  9. Keep a journal to refer to in case of a mix-up or error, including with medication or billing. Over 80 percent of hospital bills contain errors, which increases the chance that your insurance company will reject the claim, potentially costing you thousands of dollars, or you will be seriously overcharged. Record everything that happens to you, everyone who attends to you or consults with you, with names, dates, times, what was said and done, as well as all medications given to you, including IVs, with their names, dosages, and times they are given;
  10. Check all medications before they are given to you, including IVs. Don’t be afraid to ask questions about them. Know why they are being given to you, what each does and the side effects. Inform about any medications you are allergic to. Ask if there are any expected adverse interactions between the medications you are being given. Ask if any medication is being used off-label or has a ‘black box’ warning. Ask about the possible side effects and if a substitute can be given to avoid them. If you do not feel you are being properly medicated, make sure you discuss your concerns with your doctor/nurse or a nurse manager until you are satisfied;
  11. Don’t interrupt the nurse when they are preparing or giving you medication. The more times you distract the nurse the greater the likelihood of error. If they are interrupted for any reason double-check the medication with them;
  12. Ask your doctor if an antibiotic will be given prior to surgery;
  13. Let your doctor and nurse know that you would like to be part of the care team and give input into decisions about you. Make sure you are not just treated as an object. It is your life that is at risk;
  14. Check whether your doctor will be doing your entire procedure and whether they will also be doing your follow-up care. The best results occur when just one doctor is in control at all times;
  15. Ask your nurses to do a bedside shift change;
  16. Be in control and make your own informed decisions. Don’t be intimidated – you are the boss of your body and healthcare. Follow your intuition;
  17. Know the types of medical errors, their causes, how to recognize  and avoid them;
  18. Know the warning signs of a patient in trouble (following);
  19. Be respectful and courteous at all times.

       Above all, ask questions. An informed patient is a safer patient.

10 WARNING SIGNS OF A PATIENT IN TROUBLE

  1. BODY TEMPERATURE is too high (above 100.4° F) or too low (below 96.8° F). 
  2. CHANGES IN HEART RATE (pulse) or RESPIRATORY RATE (breathing). A heart rate that stays less than 60 or greater than 100 beats per minute, or a respiratory rate of less than 15 or greater than 20 breaths per minute, may need to be evaluated.
  3. BLOOD PRESSURE numbers are out of normal. If the systolic (top number in the blood pressure reading) is less than 90 or greater than 180, ask for an assessment.
  4. CHANGES IN MENTAL STATE including confusion, delirium, or an acute change in personality, memory or alertness. 
  5. CHANGES IN URINE OUTPUT OR APPEARANCE. A decrease in the amount of urine (less than 50 ml or 1.7 oz over 4 hours) or urine that appears darker in color 
  6. THE PATIENT SAYS SOMETHING IS WRONG with them. Patients often have a sense that they are experiencing a sudden decline in their health. 
  7. THE PATIENT DOESN’T LOOK RIGHT to the family or advocate. Someone who knows the patient personally is often a better judge of a change in normal appearance or behavior. 
  8. SHORTNESS OF BREATH or having a tight feeling or discomfort in the chest. Shortness of breath can be a sign of heart attack, pulmonary embolism (blood clot), infection or pneumonia. 
  9. ACUTE PAIN, especially in the abdomen. This could be a sign of an infection (including peritonitis), intestinal obstruction, a perforated ulcer, and other potentially life-threatening problems. 
  10. VERY PALE appearance of the skin or breaking out in cold sweats. These symptoms could indicate internal bleeding, shock, infection or heart attack.

Reprinted by Permission. Adapted from Warning Signs of a Rapidly Declining Patient. Empowered Patient®. Copyright 2011 Julia A. Hallisy and Helen W. Haskell. Please note that the above warning signs are intended to be used as a guideline only and are not a substitute for the medical opinion of your care provider. 

TYPES OF MEDICAL ERRORS, THEIR CAUSES, HOW TO RECOGNIZE AND AVOID THEM

The following is a summary of medical errors that occur at hospitals, including soft errors (such as communication errors) that don’t directly cause harm but can cause hard errors that result in harm (see Table of Medical Errors). This summary includes practical information about what a patient can do to help them avoid being harmed by a medical error, and how a patient can recognize if an error has occurred or is likely to occur.

Communication Errors                                   

Communication failure is the leading cause of medical errors. The TeamStepps program is used at many hospitals for communication and teamwork to avoid errors. Ask if it is being used at yours.

Patient – Staff 

Patient – staff communication errors occur when your doctor, nurse or support staff are distracted, overworked or stressed, have frequent interruptions, have language barriers or poor communication skills, don’t take the time to read your medical record carefully or don’t report critical information about you. 

How to recognize: 

  • You are given incorrect information 
  • Staff doesn’t seem to be informed about your condition or diagnosis 
  • Staff can’t provide enough information for you to be able to give an informed consent 
  • Staff doesn’t know your name
  • Staff gives a poor response to a complaint.
  • Staff fails to escalate concerns. 

What you can do: 

  • Nurse or support staff communication problem: tell the charge nurse why you think there is a problem (see above) and ask if the nurse or support staff can pay more careful attention to you
  • You or your advocate should be present for any discussions or communications about you. This is one reason you should assign an advocate: so someone can be present in case you can’t be or you are not awake or alert. 

Patient and Team Transfer 

Hand-off Errors

Many errors occur during a patient hand-off such as a change of shift, or a change of team in the operating room during surgery, or when moving from one area to another, such as from the Emergency Room to a cath lab. Errors with medication and the omission of critical clinical data in the handoff can also happen during the transition. 

  1. Change of shiftNurses should conduct a change of shift and report in your presence (and/or your advocate), instead of at the nurses’ station. You and/or your advocate should be included.

           What you can do:

    • During the session correct any mistakes or omissions
    • Speak Up! if you are not included in the change of shift and report! Let the nurse-in-charge know that you have not been included. 

       2. Transfer/change of patient care area or departmentA report should be made in your presence (and/or your advocate) during a transfer. 

            What you can do:

    • Confirm your name as the patient being transferred. Listen and participate in the conversation about your condition and your clinical data  
    • Speak Up! if you are not included in the hand-off report, if you do not agree with or understand something or if you cannot verify any information that is passed along about you. 

Identification Errors

These errors occur when the nurse or support staff has failed to identify you at all or identified you incorrectly. Make sure that the nurse or support staff has:   

         1. Positively identified you – The nurse or support staff must check your name band and confirm your name and birthdate with you.

             What you can do:   

    • Speak Up! if the nurse or support staff has not confirmed with you that the name and birthdate on your ID wristband are correct!
    • Do not let anyone perform any activity, procedure, or test until you have been positively identified.  

          2. Asked about your allergiesThe nurse or support staff must verify the allergies on your allergy band and confirm them with you.

               What you can do: 

    •  Speak Up! if the nurse or support staff has not verified with you that the allergies on your allergy wristband are correct!

           3. Verified all labels on lab work – All labels, such as for blood or urine samples, must have your name on them.

                What you can do: 

    •  Speak Up! if the nurse or support staff has not offered for you to verify all labels on your blood and urine samples!

Patient Discharge Errors

These errors include failure to communicate information or inadequate communication of information at the time of discharge or after discharge, including lack of follow-up and unreported test results.

How to recognize:

  • Rushed discharge
  • Discharge plan documentation is not adequate or available for anyone to discuss with you

What you can do:

  • Ensure that you have the following to take with you at discharge:
    • Who to reach for help or questions, with contact information  
    • A list of medications and instructions
    • Instructions for follow-up care, including an appointment with your doctor and what to do at home (if applicable)
    • Results of all tests and imaging (x-rays, MRI, CT scan)
  • Ask to have your discharge instructions recorded and available to you online or in your patient portal. Get login information
  • If, within 2 days of discharge, you have not received any test or imaging results that were unavailable when you were discharged, contact the charge nurse to request them (refer to your discharge papers).

TABLE OF MEDICAL ERRORS  

Sources: The National Quality Forum, the National Patient Safety Agency, Hospital Health and Improvement Network, US Dept of Health and Human Services, The Hospitalist. 

Introduction

All medical errors are considered serious. The following medical errors are preventable and can cause serious illness, injury or death. Harm can be prevented in many cases if an error is caught early and corrected quickly. For more information, including “inappropriate procedures”  see APRA Patient Safety Toolkit

Harm of any kind should always be reported (see What to Do If You Have Been Harmed or Think An Error Has Occurred). If significant disability or death has occurred the patient or their advocate should report the matter to the state health department whether or not it is clear that an error was the cause, as hospitals do not report most errors (see How to Report a Medical Error, Patient Harm or Dangerous Conditions). 

* Never Events – Preventable errors that can result in permanent injury or death and should never happen.

MEDICATION*

Cause

Wrong:

  • Patient
  • Medicine
  • Dose
  • Time
  • Route
  • Rate
  • Preparation.

How to Recognize

  • Nausea, constipation or diarrhea
  • Difficulty breathing
  • Breathing too slowly
  • Increased or decreased heart rate
  • Increased or decreased blood pressure
  • Swelling of lips or face
  • Confusion
  • Falling asleep 
  • Itching, rash or hives
  • Severe pain, headache or stomach ache
  • Seizure
  • Dizziness
  • Loss of muscle control
  • Vision loss
  • Death or serious injury. 

How to Avoid

  • Have the nurse tell you the name of the medicine, the dosage, how often it is given, and what it is for. Take notes. When someone from your medical team comes to give you your medication make sure it’s the right medicine, time, and dose.
  • DO NOT INTERRUPT the nurse while they are administering medication.

MEDICAL DIAGNOSIS

Cause

  • Delay in or failure to diagnose and treat appropriately
  • Failure to employ indicated tests
  • Use of outmoded tests or therapy
  • Failure to act on the results of monitoring or testing
  • Error in reading the image 
  • Laboratory or pathology error
  • Test results lost, misplaced or disregarded.

How to Recognize

N/A

How to Avoid

  • Be sure the doctor has explained your condition to your satisfaction. If you don’t understand something, ask for clarification
  • Have the nurse or a family member present every time a doctor speaks with you
  • Keep a journal in your room for every discussion with a doctor
  • If you are not improving request a consultation with a specialist that manages your problem or ask for a second opinion 
  • Learn more.

HOSPITAL ACQUIRED INFECTION

Common types include: catheter-associated urinary tract infections, surgical site infections, bloodstream infections, pneumonia. Source: CDC. 

Cause

Unclean conditions, materials, equipment or instruments resulting in infection or sepsis (a life-threatening condition caused by infection) and septic shock that can lead to death.

How to Recognize

    • Fever or chills
    • Severe pain
    • Redness, swelling or pus
    • Change in blood pressure, heart rate, or breathing
    • Unusual sweating
    • Dizziness or confusion
    • Rash or hives
    • The patient may feel like they are dying (common with septic patients)
    • The patient does not look right!

Sepsis Emergency (must have all of the following conditions)

  • Fever 
  • Hypotension (low blood pressure)
  • Tachycardia (rapid heart rate) 

How to Avoid

  • Do not let any healthcare person touch you unless they wash their hands and sanitize their equipment when entering your room. No exceptions! Even and especially doctors, ties, and stethoscopes!
  • Wash your hands when using the restroom and always before eating 
  • Report if your room has not been cleaned or you do not feel it was cleaned to your satisfaction  
  • Make sure central intravenous lines are removed as soon as possible 
  • Request any foley catheter to be removed as soon as possible
  • See Warning Signs of a Patient in Trouble.

Life Threatening? (see Is It An Emergency)

PNEUMONIA

Cause

  • Ventilator-Associated Pneumonia (VAP) is a type of lung infection developed while on a ventilator (breathing machine)
  • Healthcare-Associated Pneumonia (HAP) is pneumonia that develops while in the hospital when you are not on a ventilator
  • VAP and HAP are most often bacterial infections and less commonly caused by viruses or fungi.

How to Recognize

  • Cough,
  • Fever
  • Chills
  • Trouble breathing.

How to Avoid

Prevention techniques that limit exposure to bacteria include:

  • Ensure everyone who touches you washes their hands and sanitizes their equipment. Wash your hands when necessary and always before eating 
  • The head of your bed should be elevated by 30 degrees
  • The doctor should wean you off a ventilator as fast as possible 
  • If you are on a ventilator the amount of sedation should be limited.

TREATMENT

Cause

  • Error in the performance of an operation, procedure, or test
  • Error in administering the treatment
  • Inappropriate (not indicated) care
  • Inadequate monitoring or follow-up of treatment.

How to Recognize

  • No improvement in the condition of the patient or the patient gets worse 
  • An adverse event as a result of the error such as allergic response, shock, injury.

How to Avoid

Ensure:

  • Your identity is confirmed
  • Allergies are verified
  • Your advocate (or a nurse) is present when a doctor speaks with you.

UNNECESSARY SURGERY 

Cause

  • The doctor is not trained or up to date in new or alternative techniques
  • The doctor is not informed about conservative non-invasive approaches such as physical therapy and exercise
  • The doctor is influenced by incentives to perform a particular procedure i.e. notoriety, financial.

Higher risk for unnecessary surgery: 

  • The doctor is not Board Certified or a Diplomate in the specialty
  • The surgery is performed at a small hospital in a rural or underserved area.

How to Recognize

N/A

How to Avoid

  • Get a second opinion for any surgery
  • Research your condition and all treatments recommended 
  • Do not have surgery until you are completely satisfied with the reason for and risk of the procedure  
  • Ask to go over the consent form with your doctor prior to your surgery 
  • Take your time reading and signing the consent for surgery
  • Verify your name, the procedure and the risks before signing the consent for surgery.

BLOOD, PATHOLOGY OR IMAGING TESTS

Cause

Procedure mistakes, mix-ups, and unreported results.

How to Recognize

N/A

How to Avoid

  • Be sure the nurse has told you the name of the test or procedure
  • Ask who ordered the test or procedure
  • Ask your nurse for the results and what they mean
  • Verify the label has your name on it or label it yourself with the technician. 

PATIENT FALLS*

Note: Any patient fall should be reported immediately.

Cause

  • Chaotic room environment with slipping and tripping hazards
  • The bed is left in the high position
  • Walking unaccompanied
  • Walking after receiving pain medication.

How to Recognize

      Patient falls.

How to Avoid

  • Follow the directions of the nurse. Call don’t fall.
  • If you are at risk for falling ensure you are wearing an armband that reads High Risk for Falls
  • Always walk with someone. Ask for assistance especially after medications for pain
  • Sit for a brief time before standing to avoid becoming dizzy
  • Always walk with someone if you are identified as high risk for falling by your nurse. If your care team agrees, then stay mobile and walk multiple times per day while in the hospital.
  • Learn more

WRONG SURGICAL OR OTHER INVASIVE PROCEDURE*

Cause

  • Failure to use the proper pre-procedure checklist
  • Failure to properly verify identity
  • Failure of the doctor to order the correct procedure
  • Failure to enter the correct procedure in the medical record.

How to Recognize

  • No improvement in the clinical condition of the patient or it gets worse 
  • An adverse event such as allergic response, shock, injury
  • If you suspect that you have undergone the wrong procedure or surgery on the wrong side or body part, clarify this with your care team.

How to Avoid

Ensure: 

  • Your identity is confirmed
  • Your allergies are verified
  • Your advocate (or a nurse) is present when a doctor speaks with you.

ADMINISTRATION OF INCOMPATIBLE BLOOD OR BLOOD PRODUCTS* 

Cause

  • Mislabeled blood
  • Incorrectly completed forms
  • Failure to check donated blood before a transfusion. 

How to Recognize

  • Fever,
  • flank pain
  • blood in the urine
  • hypotension.

How to Avoid

Ensure that your identity has been verified before receiving blood and that it matches the blood bag.

SURGICAL INSTRUMENTS OR SPONGES LEFT IN THE BODY AFTER SURGERY* 

Note: Report any symptoms of pain, fever, or any other symptoms to the nurse immediately after your surgical procedure.

Cause

Wrong instrument and sponge count.

How to Recognize

  • Pain
  • Fever

How to Avoid

N/A

BEDSORES / PRESSURE ULCERS*

Cause

Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility.

How to Recognize

  • Stage 1) A reddened or pale area over a bone
  • Stage 2) The skin has become a sore
  • Stage 3) The sore has become deeper and a small crater has appeared 
  • Stage 4) Serious skin and tissue damage with no pain. Infection may have or is about to set in.

How to Avoid

Bedrest is not a good thing.  

  • Be sure you are moving and out of bed as much as possible and as soon as possible  
  • Ensure all of your body is checked routinely
  • Ensure your nurse is conducting at least a daily skin assessment.

SURGERY OR OTHER INVASIVE PROCEDURE ON THE WRONG PERSON, SITE OR SIDE OF BODY*

Cause

Failure to use proper pre-surgery checks for identity and surgery site.

How to Recognize

Usually discovered by medical personnel at the next check or handoff.

How to Avoid

  • Before surgery be sure the nurse has confirmed with you the surgery that you will be having   
  • Do not have surgery until the surgical site has been identified and marked to your satisfaction. Only allow the surgeon performing your surgery to mark and identify the surgical site.
  • Ask to remain awake while the surgeon does a pre-surgery check.

BLOOD CLOTS OR DVT (deep vein thrombosis) IN A LEG

Cause

  • Prolonged bed rest, such as after surgery or an accident
  • Surgery on the legs.

How to Recognize

  • Pain and/or swelling, tenderness in the calf or leg 
  • Leg cramps often starting in the calf
  • May have no symptoms.

How to Avoid

  • Ensure you have a DVT assessment
  • Use compression stockings
  • The doctor may order a device called an Intermittent Pneumatic Compression Device
  • If you are at bedrest you should receive a blood thinner like subcutaneous Heparin.

MEDICAL DEVICE FAILURES* 

Medical devices such as IV pumps, suction, oxygen, blood pressure cuffs, etc.

Cause

The device is used or functions other than as intended.

How to Recognize

  • Device is alarming inappropriately, constantly or not at all
  • Results or data does not make sense
  • The patient’s condition gets worse
  • The patient’s condition does not improve.

How to Avoid

Notify your nurse if you feel anything is wrong even if it seems insignificant. For example: alarms keep going off and you are having the same symptoms as before the device was applied. See Warning Signs of a Patient in Trouble

Life Threatening? (see Is It An Emergency) 

HOSPITAL ACQUIRED ACUTE KIDNEY FAILURE (Acute Renal Failure)

Cause

  • Decreased blood flow to the kidney due to shock
  • Toxic substance introduced to the kidney
  • Urinary tract obstruction.

How to Recognize

  • Little or no urine output
  • Elevated kidney function lab results (BUN, Creatinine).

How to Avoid

See Warning Signs of a Patient in Trouble

Life Threatening?  (see Is It An Emergency)

AIRWAY SAFETY FAILURE

Cause

Complications related to airway safety events for high-risk patients: 

  • Airway blocked or partially blocked
  • Wrong tube placement 
  • Poor airway maintenance.

How to Recognize

  • The patient turns ashen or blue
  • Breathing is labored
  • Choking
  • Airway devices are not in place or loose.

How to Avoid

Airway management procedures must be in place for critically ill patients in the ICU who are at risk for difficult intubations.

MISPLACEMENT OF A NASAL OR GASTRIC TUBE THAT IS NOT DETECTED PRIOR TO USE*

Cause

The tube was not checked properly for correct positioning or the tube slipped out.

How to Recognize

  • Coughing
  • Choking
  • Difficulty breathing.

How to Avoid

Notify your nurse immediately if you feel anything is wrong. Any choking, coughing or difficulty breathing needs to be reported.

INTRAVENOUS ADMINISTRATION OF MIS-SELECTED CONCENTRATED POTASSIUM CHLORIDE*

Cause

  • Wrong preparation
  • Wrong medication.

How to Recognize

Death

How to Avoid

N/A

CHILDBIRTH RELATED

Cause

  • Complication associated with labor-inducing drugs
  • Complication associated with epidural or other local anesthesia
  • Complication of episiotomy
  • Injury to mother associated with forceps delivery
  • Infection in mother following childbirth or Caesarean section
  • Retained placenta
  • Severe bleeding during labor or delivery, or following birth.
  • Severe bleeding after Cesarean section.

How to Recognize

  • Deep vein thrombosis (DVT) or other blood clots requiring treatment. Pain and/or swelling, tenderness in the calf or leg. Leg cramps often start in the calf. May have no symptoms.
  • Postpartum depression or psychosis (depression or severe mental changes following birth)
  • Death of mother.

How to Avoid

  • Keep your legs elevated or moving as much as possible while in the hospital
  • Report any pain or tenderness in your calf or leg.  
  • Report any severe pain at the site of your incision or your vaginal area  
  • Report any excessive bleeding immediately.

FAILURE TO RESCUE

Cause

  • Delay in or failure to provide treatment to a patient who was getting worse 
  • In-hospital strokes that are not immediately diagnosed and treated
  • Failure to recognize clinical deterioration
  • Failure to physically assess the patient. 

How to Recognize

  • Condition gets worse
  • No improvement in condition.

How to Avoid

See Warnings Signs of a Patient in Trouble 

Life Threatening? (see Is It An Emergency) 

DELIRIUM: HOSPITAL-ACQUIRED OR FROM FEVER, INTOXICATION, OR OTHER MEDICAL CAUSE 

Cause

  • Usually due to multiple causes 
  • Noisy, chaotic environments for many days with no defined day or night time hours
  • A combination of medications that create a delirium state of mind (administration of benzodiazepine, Librium, Valium, Lorazepam).

How to Recognize

  • Easily distracted
  • Restlessness
  • Illusions
  • Incoherent.

How to Avoid

You and your advocate should be aware of how to recognize the condition. Discuss with your nurse or doctor if you are at high risk due to any of the following conditions or categories:

  • age
  • metabolic imbalance
  • dementia
  • high blood pressure
  • alcohol abuse 
  • severity of illness
  • coma.

Optimize medications

  • Ask for a review of all medications to avoid medications that make delirium worse
  • Do not avoid pain medications as pain can trigger or make delirium worse
  • Ask if the Confusion Assessment Method (CAM) is being applied routinely. If not, ask for it to be conducted.
  • Avoid sleep deprivation, turn down the lights, keep noise to a minimum
  • Re-orient to time and place frequently.

OMISSION

Cause

  • Delay in diagnosis 
  • Inadequate dose of medication
  • Failure to provide indicated treatment
  • Failure to order an evidence-based test or scan
  • Avoidable delay in treatment or in responding to an abnormal test*
  • Failure to respond to an urgent situation
  • Missed care
  • Failure to provide prophylactic (preventative)  treatment
  • Failure to follow guidelines.

How to Recognize

N/A

How to Avoid

  • Know your treatment plan
  • Take notes on the plan the doctor discusses with you.

NEVER EVENTS

*Source: The National Quality Forum List of Serious Reportable Events, 2016. Adapted for patients by APRA.

Never Events are preventable medical errors that can result in serious disability or death and should be reported to the state department of health. They are called Never Events because they should never happen. It is recommended that hospitals tell the patient about the event and apologize, report it, and not require the patient to pay for anything related to the event, however, this rarely happens. Some states require reporting but hospitals often do not do this so patients (or their families or advocates) should always report events they think might be Never Events to the state department of health.

Some Never Events are found in the Table of Medical Errors. The rest are listed here:

Surgical events

  1. Death of an ASA Class 1 (healthy) person during or immediately following an operation or procedure.

Product or device events

  1. Death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility
  2. Death or serious injury associated with an intravascular air embolism that occurs while being cared for in a healthcare setting.

Patient protection events

  1. Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person
  2. Death or serious disability associated with patient disappearance
  3. Patient suicide, attempted suicide, or self-harm resulting in serious disability, while being cared for in a healthcare facility.

Care management events

  1. Death or serious injury associated with unsafe administration of blood products
  2. Death or serious injury to the mother associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare setting
  3. Death or serious injury to a newborn child associated with labor or delivery in a low-risk pregnancy 
  4. Artificial insemination with the wrong donor sperm or egg
  5. Death or serious disability resulting from the irretrievable loss of an irreplaceable biological specimen
  6. Death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results.

Environmental events

  1. Death or serious disability associated with an electric shock in the course of a patient care process in a healthcare setting
  2. Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or is contaminated by toxic substances
  3. Death or serious injury associated with a burn incurred from any source in the course of a patient care process in a healthcare setting
  4. Death or serious injury associated with the use of restraints or bed rails while being cared for in a healthcare setting.

Radiologic events

  1. Death or serious injury associated with introduction of a metallic object into the MRI area.

Criminal events

  1. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider
  2. Abduction of a patient/resident of any age
  3. Sexual abuse/assault within or on the grounds of a healthcare setting
  4. Death or significant injury resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare setting.

IS IT AN EMERGENCY OR DO YOU THINK IT MAY BE LIFE-THREATENING? 

There are 3 things that you or your advocate can do:

  • Use the emergency call button or cord to get help right away
  • Call the hospital operator and ask for the Rapid Response Team 
  • As a last resort when all else has failed call 911. 

Not an emergency?

Notify your nurse right away. Use your call button or cord to call them. Explain the problem in as much detail as possible. 

WHAT TO DO IF YOU HAVE BEEN HARMED, THINK AN ERROR HAS OCCURRED OR THERE IS A PROBLEM 

If you know or think that harm was caused by your treatment or lack of treatment, or another possibly life-threatening matter that needs urgent attention, you have a right to question the person(s) who is responsible, to speak to the people in charge and to report the matter to the authorities if you aren’t satisfied. In fact, to protect yourself and others, you MUST do these things. It’s not about blame and shame, it’s about changing the game. Patients must be part of the change to improve healthcare.

Ask to review your medical records and how the error or harm, and the events following, were recorded. According to federal law, patients have a legal right to receive a copy of their medical records, however, states also have laws regarding this and there is a procedure to follow when filing a request. If the hospital refuses to provide access to your medical records discuss your state’s law with the hospital representative.

WHERE TO GO FOR FURTHER HELP

  • Speak to the nurse-in-charge. They may call or notify your physician on duty to evaluate your condition. Ask the nurse-in-charge and the physician for a full explanation of any error or harm and how it occurred.
  • There is always a hospitalist or physician on-call to tend to your needs.
  • If you still have questions or concerns:
    • call the hospital operator and ask for the Administrative Supervisor or Nurse Manager. The hospital has a nurse in an administrative position 24/7.  The Administrative Supervisor or Nurse Manager may notify the Chief Medical Officer and/ or the Chief Nursing Officer.
    • ask your nurse to contact the hospital’s patient representative or advocate who can assist you with other hospital officials, with other resources you may need and to problem-solve any issues that arise. Every hospital also has a Risk Management Department. The purpose of this department and staff is to manage risk to the hospital.
  • If you are not still not satisfied, consider contacting your State Department of Health and/or the U.S. Department of Health and Human Services to file a complaint.

HOW TO REPORT A MEDICAL ERROR, PATIENT HARM OR DANGEROUS CONDITIONS 

If you do not receive satisfaction from the hospital, report the event or issue to the appropriate authorities who can take action: your State Department of Health. To file a complaint about a doctor contact your State Medical Board.

SUBMIT A REVIEW ABOUT YOUR HOSPITAL EXPERIENCE 

APRA accepts and posts hospital reviews from patients. Please submit a review so that others have the opportunity to learn from your experience.

ABOUT THE AUTHORS AND APRA

Marlene McAllister, MSN, RN, NEA, BC, CNO (Ret.) has been a senior healthcare administrator for over 20 years, including Chief Nurse Executive at St. John Medical Center in Tulsa Oklahoma and most recently Chief Nursing Officer at Medical Center Health System in Odessa, Texas. She has served as a Vice President with ORBIS International, a New York based agency dedicated to fighting blindness worldwide, and is a 2011 Johnson & Johnson/Wharton Nurse Executive Fellow and a graduate of the University of Colorado graduate program in nursing. McAllister has served on the Board of Directors of Planned Parenthood of West Texas, and the Advisory Board of the Laura Bush Institute for Women’s Health and currently serves on the Board of Directors of the American Patient Rights Association. 

Ronald Liss is a mechanical engineer and serial entrepreneur. Liss is the Founder and CEO of the American Patient Rights Association. 

American Patient Rights Association (APRA) is an independent, nonprofit, consumer organization of people for fair, safe, affordable healthcare. Membership is free and confidential. Receive valuable benefits by registering today. Further information is available here.

SPECIAL THANKS TO:

Dr. Doug Salvador, MD, MPH  – Chief Medical Officer, Baystate Medical Center, Springfield, Massachusetts 

Dr. Frederick S. Southwick, MD, FACP, CPPS  – Director of Patient Care Quality and Safety, Division of Hospitalist Medicine, University of Florida

Dr. John T. James, Ph.D. – former chief toxicologist for NASA, author of “A Sea of Broken Hearts: Patient Rights in a Dangerous, Profit-Driven Health Care System”, and founder of Patient Safety America. 

DONATE TO SAVE LIVES

APRA can only continue to develop and offer programs like this that can save lives and reduce the cost of healthcare with the generous support of people like you. Please give a gift today. Any amount will do. Thank you for your support.  

Copyright © American Patient Rights Association, Inc., 2021.  All rights reserved.

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