Prevention of Medical Errors

Healthcare providers must work effectively in collaborative teams to improve patient safety

To view the Course Outline and take the exam online, click HERE.

For a printer-friendly version of the exam you can print out, complete and mail to ADVANCE, click HERE.

Learning Scope #924
2 contact hours
Expires June 22, 2014

The goal of this continuing education offering is to provide nurses with current information on the prevention of medical errors. After reading this article, you will be able to:
1. List factors that increase the risk of medical error occurrences.
2. Discuss evidence-based strategies to decrease medical errors.
3. Describe the importance of communication and interdisciplinary healthcare teams in the prevention of errors.

You can earn 2 contact hours of continuing education credit in three ways: 1) Grade and certificate are available immediately after taking the online test. 2) Send the answer sheet (or a photocopy) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.

Merion Matters is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 221-3-O-09), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.

Merion Matters is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).

• The author has completed a disclosure form and reports no relationships relevant to the content of this article.

Editor's note: This article fulfills a continuing education requirement for Florida nurses, who are required to earn contact hours in specific material on medical errors. However, it contains valuable information for all nurses and can be used for contact hours in most states. 

The Institute of Medicine's 1999 report "To Err Is Human" revealed alarming statistics that healthcare errors accounted for an estimated 44,000 to 98,000 inpatient deaths annually, with an estimated cost of approximately $50 billion a year.1 Patient safety became a national healthcare concern.

These findings resulted in the Healthcare Research and Quality Act of 1999 which called for the creation of the Agency for Healthcare Research and Quality (AHQR) with a directive to conduct, support research and build private-public partnerships to reduce healthcare errors.2 Through established collaborative research efforts, AHQR initiatives include seminal publications and the "Web Morbidity and Mortality Rounds" website (http://www.webmm.ahrq.gov/), which serves as an open forum for healthcare professionals to share clinical errors and analysis of available evidence-based practices.

While these examples demonstrate significant strides in the development of improved safety measures, they are only a small representation of the vast number of established organizations and resources dedicated to patient safety. (See Table 1 below.)

Table 1. Patient Safety Agencies/Organizations/Resources

AHRQ

Agency for Healthcare Research and Quality

CDC

Centers for Disease Control and Prevention

IHI

Institute for Healthcare Improvement

IOM

Institute of Medicine

NQF

National Quality Forum

JC

Joint Commission

ISMP

Institute for Safe Medicine Practices

ANA

American Nurses Association

NGC

National Guideline Clearinghouse


Despite the abundance of government and private sector safety initiatives, healthcare errors persist at alarming rates. Adverse events occurred in approximately 33 percent of hospital admissions.3 An estimated 130,000 hospitalized Medicare patients experienced adverse events in a one-month period.4 And in 2010, 168 patients in Florida died and an additional 386 experienced errors, including medication errors, wrong procedures and surgeries on the wrong body part.5

The actual number of medical errors continues to be difficult to track due to underreporting, a lack of a universal reporting system, fear of professional or legal retribution, and a lack of consensus regarding terminology. Reporting of significant adverse events continues to be primarily of a voluntary nature and experts suggest new methods to measure errors and adverse events are needed.

While the majority of data reported relates to hospitals, errors are not limited to inpatient care settings. With an increasing number of patients in outpatient settings, including primary care, ambulatory surgical centers and extended care facilities, the need for more focused research is indicated. Research shows diagnostic errors to be especially problematic in outpatient settings.6

Important Definitions
The Institute of Medicine defines a medical error as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Adverse events are defined as injuries resulting from medical management rather than the underlying disease.1 A near miss is an event or situation that could have resulted in an accident, injury or illness, but did not, either by chance or through timely intervention.1

In 2001, the National Quality Forum (NQF) released a list of errors considered preventable "never events," with an estimated cost of $3.7 billion a year.7 The list includes wrong-site surgery, stage III and IV pressure ulcers, falls, surgical site infection, catheter-related infections and other serious injuries. A more extensive list of "never events" can be found on the National Quality Forum website (http://www.qualityforum.org/). In 2008, The Centers for Medicare and Medicaid Services determined costs associated with never events would not be reimbursed.

Errors in healthcare are rarely a result of a single healthcare provider's incompetence. They usually result from complex interactions of multiple individuals and systems. Reason-noted errors occur as a result of active and latent factors.8 Active errors or errors occurring at the sharp end involve personnel and parts of the healthcare system in direct contact with the patient. Their actions tend to be more obvious and may result in errors that have a direct impact on patient safety. Latent errors or errors occurring at the blunt end involve individuals such as managers, administrators and policymakers, and while less obvious, their actions or decisions may lead to a negative impact on patient safety.

Sentinel Event Policy, National Patient Safety Goals
The Joint Commission (JC) developed a Sentinel Event Policy and database in 1996 for self-reported sentinel events. This information is used to analyze errors and provide information to healthcare organizations to deter future occurrences.

The JC defines a sentinel event as an unexpected occurrence involving death or serious physical or psychological injury, which may include loss of limb or function or the risk thereof.9 While a sentinel event is not synonymous with a medical error, it requires the same immediate action and investigation. The number of reported sentinel events only represents a small percentage of overall events, with approximately 60 percent resulting in death. The most frequently reported sentinel events are wrong patient, wrong site, wrong procedure, delay in treatment, unintended retention of a foreign body, intra-operative and post-operative complications, suicide, falls and medication errors.

In 2012, the JC established National Patient Safety Goals for healthcare organizations to address safety concerns. The goals for hospitals include:10
• Use at least two patient identifiers when providing care, treatment and services.
• Eliminate transfusion errors, related to misidentification.
• Report critical results of tests and diagnostic procedures on a timely basis.
• Label all medications, medication containers and other solutions on and off the sterile field in peri-operative and other procedural settings.
• Reduce the likelihood of patient harm associated with the use of anticoagulant therapy.
• Maintain and communicate accurate patient medication information
• Comply with the current Centers for Disease Control and Prevention or World Health Organization hand hygiene guidelines.
• Implement evidence-based practices to prevent healthcare-associated infections due to multi-drug resistant organisms in acute care hospitals.
• Implement evidence-based practices to prevent central line-associated bloodstream infections.
• Implement evidence-based practices for preventing surgical site infections.
• Implement evidence-based practices to prevent indwelling catheter-associated urinary tract infections.
• Identify patients at risk for suicide.
• Conduct a pre-procedure verification process.

Root Cause and Analysis
The JC requires that a root cause and analysis (RCA) be conducted within 45 days of a sentinel event occurrence or from the time the organization becomes aware of the occurrence.9 The RCA involves an in-depth investigation with a focus on systems, processes and human factors to identify the underlying causes associated with an error. Following the identification of causative factors, a detailed action plan is required to identify strategies the organization should implement to prevent future reoccurrence.

The JC requires that RCA be thorough and credible. Individuals in leadership positions as well as those directly involved in the systems and processes being reviewed must be included in the RCA. Identified root causes include:

• Communication failures are one of the most significant contributing factors in medical errors. These include poor communication between healthcare providers with increased risk during transition periods, such as change of shift report, and poor communication between healthcare providers, patients and caregivers. Previous negative interactions (intimidation, threatening behavior) experienced by a nurse negatively impacts their willingness to clarify discrepancies.8-12
• Human factors, including fatigue, distractions, interruptions and care provider workarounds (measures that bypass safety processes), increase errors. The perceived need to resort to a workaround should signal the need for analysis of workflow processes. Healthcare providers who work longer than 12.5 hours have decreased productivity, are three times more likely to commit a patient care error, and suffer higher rates of occupational injury.12,13
• Lack of leadership in the area of safety may limit an organization's effort to identify risk and implement effective preventative strategies. Nursing leadership is essential in creating work flow processes and environments that prevent and mitigate errors.12
• Organizational cultures that do not support nonpunitive approaches to error reporting, investigation and mitigation are associated with an increase in medical errors. The need for proactive nonpunitive approaches to patient safety is imperative to establish and maintain a culture of safety within healthcare organizations.
• Inadequate assessment can lead to a failure to identify and protect individuals at risk for injuries such as falls and suicide.9
• Unsafe physical environment.
• Use of inadequate information management systems. Electronic health records (EHR) and computerized provider order entry (CPOE) have been recommended by many safety agencies as a measure to combat errors. Despite this mandate, only 35 percent of hospitals have adopted an EHR.14  CPOE refers to any system where clinicians directly enter orders such as medications into a computer system, which then transmits the order directly to the pharmacy.15 CPOE systems are generally paired with clinical decision support systems such as allergy or wrong dose alerts. While EHR and CPOE hold promise in decreasing errors through improved communication, the mere presence of information management system does not ensure patient safety. There are still reports of EHR- and CPOE-related errors resulting from complex interplay of systems, failure to follow procedures, workaround of system alerts and human errors.16

While an RCA tends to take a more reactive method, a failure modes and effect analysis is a proactive approach that analyzes a proposed process prior to initiation for possible high-risk points of error and potential consequences. It allows for redesign of the process to minimize or eliminate the chances of error.9

Medication Errors
Medication errors, the most common type of error, occur in acute care settings, long-term care facilities and outpatient settings. The National Coordinating Council for Medication Errors and Reporting and Prevention states a medication error is "any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient or consumer. Such events may be related to professional practice, healthcare products, procedures and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use."17

Most medication errors occur during the prescribing process; however, approximately 50 percent are intercepted prior to reaching the patient. More than 30 percent of errors occur during administration and only 2 percent of these errors are caught prior to reaching the patient.

Particular areas of concern include the administration of identified high-risk drugs (insulin, heparin, warfarin); transition of care points (admission to inpatient from emergency department); and sound-alike, look-alike drugs.10

Strategies to decrease medication errors include:
• Adhere to the eight rights of medication administration: right patient, right drug, right dose, right route, right time, right documentation, right reason and right to refuse.
• Minimize distractions when preparing and administering medications.
• Integrate technology to decrease medication errors at specific steps in the medication administration process. CPOE has been shown to prevent ordering and transcription errors while barcode scanning decreases errors in the dispensing and administration stages. Automated dispensing cabinets do not ensure error reductions and have been cited as causative factors related to restocking functions, returning drugs to the wrong location and human overrides of inherent safety features.15
• Avoid established do not use abbreviations. (See Table 2 below.)
• Develop specific protocols for high-risk drugs, including independent verification and double check procedures.
• Standardize drug packaging and labeling.
• Encourage healthcare providers to document indication for drug use on prescriptions.
• Avoid reliance on memory by standardizing processes and equipment.
• Provide patient-centered care and encourage active participation.

Table 2. Joint Commission Do Not Use Abbreviations10

Abbreviation

Mistaken for

Suggestion

U for Unit

0, 4 or cc

Write Unit

IU for International Unit

IV or 10

Write International Unit

Q.D., QD, qd, or QOD

Each Other

Write Every Day or Every Other Day

Trailing Zero (1.0 mg)

Lack of Leading Zero (.1 mg )

Decimal Point Missed

Write 1 mg

Write 0.1 mg

MS, MSO4, MgSO4

Can Mean Morphine Sulfate or Magnesium Sulfate

Write Out Morphine Sulfate or Magnesium Sulfate

The Elderly
Physiological changes associated with aging, including decreased renal function, visual and auditory decline, and functional limitations, increase the risk of medical errors in the elderly in the acute care setting, extended care facilities and in the home.

Approximately one-third of nursing home residents are taking a minimum of nine medications. This increases the risk of medication-related errors, which have been reported at a rate of 1 per 100 resident months.18

Falls also are more prevalent in the elderly, with one out of three adults aged 65 and older falling each year. Ten percent of fatal falls occur in an inpatient setting. Twenty to 30 percent of those , who fall suffer injuries, including lacerations, head trauma and hip fractures, which increase the risk of early mortality. Even those who do not sustain injuries develop a fear of falling which can limit their activity level and overall physical health. Direct total medical costs associated with falls were an estimated $28.2 billion in 2010.19

Strategies aimed at decreasing falls in the elderly population include:20

• Identification of high-risk factors: history of falls, age 65 or older, medications (sedatives, diuretics, antihypertensives, laxatives, narcotics, hypoglycemic agents, antidepressants), unsteady gait, altered level of consciousness, urinary frequency or urgency, visual impairment. Utilize an established risk tool such as the Morse Fall Scale and a method of identification such as a yellow fall risk identification bracelet.
• Elimination of extrinsic factors, such as room clutter, lack of frequent monitoring, time delay in answering call lights, inadequate lighting.
• Periodic review of high-risk medications.
• Keep the bed in low position with the wheels locked, siderails down (use of siderails has been shown to increase fall incidence), ensure call light and personal items are within reach, and possible use of 24-hour attendant.
• Promote a healthy lifestyle: safety proofing the home, regular weight-bearing exercise, screening and treatment for osteoporosis.

As the number of elderly continues to increase substantially, a disproportionately high incidence of bacteremia (in particular, healthcare-associated) has been reported. Urinary tract infections are the most common source of bacteremia impacting adults older than age 65, especially in females. Bacteremia is associated with a decline in functional status and increased mortality. Specific challenges associated with care of the elderly in regard to bacteremia include:

• An increase number of co-morbidities and contact with healthcare system/procedures.
• Atypical presentation as compared to younger adults which make diagnosis more difficult. Altered mental status is a more common presentation in elderly. Fever and elevated white blood cell count are not always present in the elderly with bacteremia.
• Antibiotics therapy may be complicated by physiologic changes, including a decrease in glomerular filtration rate, total body water and lean body mass.

Preventative measures, such as avoidance of urinary catheters, early recognition and vigilant monitoring, are critical to decrease the incidence and complications of bacteremia in the elderly.21

Pediatrics
The pediatric population has increased vulnerability for medical errors due to unique physiological characteristics, developmental issues and dependence on others. Healthcare settings and many current safety measures are focused on meeting the needs of adults rather than the specific needs of children. Medication-related errors are of particular concern with rates reported up to three times higher in children as compared to adults.22

For instance, in September 2006 three neonates died as a result of an accidental Heparin overdose in a Midwestern hospital. An RCA revealed a pharmacy technician inadvertently filled the automated dispensing cabinet with 1 ml vials of Heparin containing 10,000 units per ml instead of the intended 10 units per ml vials. Several nurses did not notice the discrepancy and the erroneous dose was administered on multiple occasions.23

UPS Medmarx® 2006-2007 database reveals the most common types of harmful pediatric medication errors were: improper dosing, omissions, wrong drug, prescribing, administration technique, wrong time, wrong dosage form and wrong route. Identified causes of pediatric medication errors include: performance deficit, knowledge deficit, violation of established protocols, miscommunication, calculation error, computer entry error, failure to monitor, improper use of pumps and documentation errors.24

Specific pediatric interventions include:
• Develop pediatric-specific error reporting systems.
• Enhance family-centered care by increasing both verbal and written communication with caregivers.
• Adhere to established pediatric best practice guidelines when developing policies and in the delivery of care.
• Use of preprinted medication order forms and weight-based dosage calculation tools.
• Increased use of pharmacists with pediatric expertise.
• Specialty training for all healthcare practitioners involved in the care of children.
• Consistent monitoring for potential adverse medication events.

Language Barriers
According to the 2010 U.S. Census, 24.5 million Americans self-report limited English proficiency.25 Language barriers present a challenge to healthcare providers and contribute to errors. Research shows the use of professional translators to reduce the incidence of medical errors as compared to no interpreter or use of an ad hoc translator such as a family member.26 As the U.S. population continues to become more diverse, the need for properly trained professional translators will likely increase.

Second and Third Victims of Medical Errors
The first victim of a medical error is the patient and family, the healthcare providers are the second victims, and the organization as a whole is the third victim.27 While over the last decade progress has been made in shifting from a culture of blame and punitive action to one of transparency, the caregiver involved in the incident often fails to receive the needed support to address the physical and psychological consequences.

Caregivers involved in serious medical errors may suffer from immediate and prolonged physical and psychological disorders, including anxiety, depression, shame, sleep disturbances and post-traumatic stress disorder. According to a report by the Institute for Safe Medication Practices, in 2011 a veteran nurse committed suicide seven months following a fatal pediatric medication error with subsequent state licensing disciplinary actions and employment termination.27 While the exact motivation for this nurse's suicide may never be revealed, feelings of abandonment felt by second victims only serve to isolate and punish.

In an effort to address the burdens faced by the second victim, Charles Denham proposes five rights using the acronym TRUST:
• Treatment that is just
• Respect
• Understanding and compassion
• Supportive care
• Transparency and opportunity to contribute to learning.

The need for a coordinated planned compassionate response for all victims of a medical error is crucial. Immediate attention must be provided to the patient and family following a medical error, followed by measures to allow frontline caregivers to participate in the RCA process and mitigation activities for future prevention.28

Public Education and Involvement
Patients and families are often considered the last line of defense in the effort to prevent medical errors.28 The AHRQ recommends healthcare consumers should be advised to:
• Make sure that all healthcare providers know every medicine you take, including prescription and over-the-counter medicines and dietary supplements, such as vitamins and herbs.
• Bring all medicines and supplements to doctor visits. "Brown bag" your medicines.
• Make sure the doctor knows about any allergies and adverse reactions you have had to medicines.
• When your doctor writes a prescription for you, make sure you can read it.
• Ask for information about your medicines in terms you can understand:
    -What is the medicine for?
    -How am I supposed to take it and for how long?
    -What side effects are likely? And what do I do if they occur?
    -Is this medicine safe to take with other medicines or dietary supplements I am taking?
    -What food, drink or activities should I avoid while taking this medicine?
• Verify your prescription when you pick up your medicine from the pharmacy.
• Ask if you have any questions about the directions on your medicine labels.
• Ask for written information about the side effects your medicine could cause.
• Ask all healthcare workers who will touch you whether they have washed their hands.
• When discharged from the hospital, ask your doctor to explain the treatment plan you will follow at home.
• If you are having surgery, make sure that you, your doctor and your surgeon all agree on exactly what will be done. Surgeons are expected to sign their initials directly on the site to be operated on before the surgery.
• Speak up if you have questions or concerns. You have a right to question anyone involved with your care.
• Make sure that all doctors have your important health information. Do not assume that everyone has all the information they need.
• Ask a family member or friend to go to appointments with you. Even if you do not need help now, you might need it later.
• Follow up on test results. Do not assume "no news is good news."
• Learn about your condition and treatments by asking your doctor and nurse and by using other reliable sources. For example, treatment options based on the latest scientific evidence are available from the Effective Healthcare website (www.effectivehealthcare.ahrq.gov/options). Ask your doctor if your treatment is based on the latest evidence.

Additional Strategies
Communication has been cited as major root cause of medical errors. The use of standardized tools can improve the accuracy of communication:
• SBAR (Situation, Background, Assessment and Recommendation) provides a framework for reporting and documenting during periods of transition or handoff.12
• Teamwork and collaboration have been stressed by the JC. Interprofessional collaboration can be achieved through the use of multidisciplinary care approach. Training members of teams to work effectively is crucial to improve patient safety. The AHRQ developed TeamSTEPPS™, an evidence-based teamwork approach used to improve communication and team skills. A lack of effective teamwork has been associated with increased negative outcomes and mortality.12
• The use of evidence to support and guide clinical decision making.
• Leadership is needed at all levels of a healthcare organization to assess and promote a culture of safety. AHRQ notes a culture of safety includes the attitudes and behaviors that are related to patient safety and that are expected and appropriate to promote patient safety. When an error occurs, leaders must respond through actions that promote a nonpunitive investigation, development of an action plan and evaluation.12

Medical errors remain at unacceptable levels despite efforts by numerous safety organizations. Healthcare providers must work effectively in collaborative teams in a culture of safety where they are provided with opportunities to question inconsistencies, report errors and participate in RCA and safety improvement strategies.

Mary Mckay is an assistant clinical professor teaching in the undergraduate nursing program at the University of Miami School of Nursing and Health Studies.

References
1. Kohn, L.T., Corrigan, J.M., & Donaldson, M.S. (Eds.). (2000). To err is human: Building a safer health system. Washington, DC: National Academy Press.

2. Agency for Healthcare Research and Quality. (2009). Advancing patient safety: A decade of evidence, design, and implementation. AHRQ Publication No. 09(10)-0084, Rockville, MD. Accessed at http://www.ahrq.gov/qual/advptsafety.htm

3. Classen, D., Resar, R., Grifin, F., et al. (2011). Global trigger tool shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs, 30(4), 581-588.

4. Pear, R. (2012). Report finds most errors at hospitals go unreported. Accessed at http://www.nytimes.com/2012/01/06/health/study-of-medicare-patients-finds-most-hospital-errors-unreported.html?_r=1&ref=healthandhumanservicesdepartment

5. Kestin, S., & LaMendola, B. (2011). Little or no progress on medical mistakes in Florida. Sun Sentinel. Accessed at http://articles.sun-sentinel.com/2011-07-29/health/fl-hk-medical-mistakes-overview-20110710_1_wrong-site-surgeries-medical-mistakes-wrong-body-part

6. Bishop, T., Ryan, A., & Casalino, L. (2011). Paid malpractice claims for adverse events in inpatient and outpatient settings. Journal of the American Medical Association, 305(23), 2427-2431.

7. National Quality Forum. Accessed at www.qualityforum.org/Topics/SREs/List_of_SREs.aspx

8. Reason, J.T. (1990). Human error. New York, NY: Cambridge University.

9. Joint Commission Sentinel Event Policy. Accessed at www.jointcommission.org/assets/1/18/Sentinel_Event_Policy_3_2011.pdf

10. Joint Commission National Patient Safety Goals. Accessed at www.jointcommission.org/standards_information/npsgs.aspx

11. Hennerman, E., Gawlinski, A., Blank, F., et al. (2010). Strategies used by critical care nurses to identify, interrupt and correct medical errors. American Journal of Critical Care Nurses, 19(6), 500-509.

12. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. AHRQ Publication No. 08-0043, April 2008. Agency for Healthcare Research and Quality, Rockville, MD. Accessed at www.ahrq.gov/qual/nurseshdbk

13. Joint Commission. (2011). Sentinel Event Alert Issue 48: Healthcare worker fatigue and patient safety. Accessed at www.jointcommission.org/sea_issue_48

14. Charles, D., Furukawa, M. and Hufstader, M. (2012) Electronic health record systems and intent to attest to meaningful use among non-federal acute care hospitals in the United States: 2008-2011. The Office of the National Coordinator for Health Information Technology.

15. Koppel, R. (2009). EMR entry error: Not so benign. Agency for Healthcare Research and Quality Web M&M Rounds. Accessed at www.webmm.ahrq.gov/case.aspx?caseID=199

16. Agency for Healthcare Research and Quality. (2011). Patient Safety Network. Patient Safety Primer. Computerized provider order entry. Accessed at http://psnet.ahrq.gov/primer.aspx?primerID=6

17. The National Coordinating Council for Medication Errors and Reporting and Prevention. Accessed at http://www.nccmerp.org/

18. Desai, R., Williams, C., Greene, S., et al. (2011). Medication errors during patient transitions into nursing homes: Characteristics and association with harm. The American Journal of Geriatric Pharmacotherapy, 9(6), 413-422.

19. Centers for Disease Control and Prevention. (2012). Falls among older adults: An overview. Accessed at www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html

20. Kulik, C. (2011). Components of a comprehensive fall-risk assessment. American Nurse Today. Accessed at www.americannursetoday.com/article.aspx?id=7634&fid=7364

21. Bader, M. & Loeb, M. (2009). Bacteremia in the elderly. Aging Health, 5(6), 743-751.

22. Steering Committee on Quality Improvement and Management and Committee on Hospital Care. (2011). Principles of Pediatric Patient Safety: Reducing harm due to medical care. Pediatrics, 127(6), 1199-1212.

23. Joint Commission. (2008). Sentinel Event Alert: Preventing pediatric medication errors. Accessed at www.jointcommission.org/assets/1/18/SEA_39.PDF

24. ISMP Medication Safety Alert: Infant Heparin Flush Overdose. Accessed at http://search.ismp.org/?index=517791&query=heparin+overdose+in+neonates&search=Search

25. U.S. Census Bureau. Language spoken at home: 2010 American Community Survey. Accessed at http://www.census.gov/hhes/socdemo/language/data/acs/index.html

26. Flores, G., Milagros, A., Barone, C., et al. (2012). Errors of medical interpretation and their potential clinical consequences: A comparison of professional versus ad hoc versus no interpreters. Annals of Emergency Medicine. Mar 14.

27. Smetzer, J. (2012). Don't abandon the "second victims" of medical errors. Nursing 2012, 42(2), 54-58.

28. Conway, J., Federico, F., Stewart, K., Campbell, M.J. (2011). Respectful Management of Serious Clinical Adverse Events (Second Edition). IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement.

29. Agency for Healthcare Research and Quality. (2011). 20 Tips to Help Prevent Medical Errors. Patient fact sheet. AHRQ Publication No. 11-0089 Accessed at http://www.ahrq.gov/consumer/20tips.htm.




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