Risk Management Tools & Resources

 


Strategies for Reducing Polypharmacy in Senior Care

Polypharmacy is a serious concern among adults, and especially among seniors. Although polypharmacy is preventable, it is a significant contributor to morbidity and mortality.1 Polypharmacy is generally defined as taking multiple medications or more medications than are medically necessary (including over-the-counter drugs and supplements). A 2016 study showed that 36 percent of community-dwelling older adults (ages 62-85 years) were taking five or more prescription medications in 2010 to 2011 — up from 31 percent in 2005 to 2006.2

Because of increased numbers of comorbid conditions, newer medications that effectively treat more medical conditions, and practice guidelines that often recommend multidrug regimens, seniors have a higher rate of polypharmacy.3 Seniors take more medications to control multiple chronic diseases and may have greater difficulty metabolizing them, both of which can produce unfavorable adverse effects.

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Case Study: Patient's Health Deteriorates in the Absence of Proper Pressure Injury Care

The patient in this case study was a male in his mid-eighties who had a history of prostate and bladder cancer leading to bone metastasis. Following a hospital stay, he was transferred to a long-term care/rehabilitation facility. When the patient arrived at the facility, the admissions nurse documented that he had a Stage 4 sacral pressure injury.

The patient subsequently developed several other Stage 2 and Stage 3 pressure injuries on the buttocks. Daily skin assessments were not completed, and facility nurses never documented any wound assessment or patient response to wound treatment. Within 2 weeks, the patient developed a C. difficile infection, and the sacral pressure injury progressed to involve the patient’s bone.

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Case Study: Patient Falls and Dies After Multiple Missteps in Care

Case Study: Multiple Lapses Result in Patient Fall and Injury

The patient was a female in her late sixties who was admitted to a long-term care facility following a craniotomy procedure for craniopharyngioma. The patient had multiple medical issues at the time she was admitted, including postoperative deep vein thrombosis (for which she was receiving anticoagulation therapy) and a ventriculoperitoneal (VP) shunt.

At the time she was admitted to the facility, the patient was exhibiting impulsive behavior and trying to pick at her incision site and tubes. Staff noted that the patient was at high risk of falling and bleeding and placed her in restraints and hand mitts to keep her in bed and prevent her from touching her wound.

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Case Study: Multiple Lapses Result in Patient Fall and Injury

Case Study: Multiple Lapses Result in Patient Fall and Injury

A male in his mid-sixties presented to his local emergency department (ED) with complaints of shortness of breath and chest pain. He had a history of chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD). The patient was admitted to the hospital for exacerbation of COPD symptoms and atypical chest pain.

At various times, the patient was noted to be a fall risk, and he fell twice while in the acute care area of the hospital. After the patient was transferred to the hospital's rehabilitation unit, he was found on the floor and diagnosed with a fractured hip. The patient stated that he tried to contact a nurse for help to the bathroom, but no one responded. The patient's wife alleged that he was overmedicated with acetaminophen/hydrocodone and zolpidem, which increased his risk of falling.

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Reducing Medication Prescribing and Administration Errors: Strategies for Critical Access Hospitals

Laura M. Cascella, MA

Reducing Medication Prescribing and Administration Errors: Strategies for Critical Access Hospitals

Prescribing and administering medications are complex processes, particularly because of the volume of medication orders in hospitals and the increasing number of prescription medications on the market. The Institute of Medicine (IOM) notes that although errors are common throughout the medication process, they are most common at the prescription and administration stages.1

MedPro's malpractice claims data for critical access hospitals (CAHs) confirm these risks. In claims closed between 2006 and 2015, allegations related to medication errors accounted for almost 1 out of 10 claims, and these allegations were associated with prescription and administration issues. Further, 45 percent of medication-related claims for CAHs resulted in outcomes with high clinical severity (i.e., serious patient injury or death).2

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Clinical Judgment: What Is It, and How Does It Contribute to Diagnostic Errors?

Errors in diagnosis are a serious concern in healthcare from a patient safety perspective as well as a medical liability standpoint. MedPro closed claims data show that allegations related to diagnostic errors are prevalent across specialties and healthcare locations. Closed claims data also show that clinical judgment is a major risk factor in diagnosis-related allegations.

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Oversight in Electronic Health Record Causes a Delay in Ovarian Cancer Diagnosis

Electronic health records (EHRs) have transformed the ways in which healthcare providers work and communicate. These systems have been both extolled and criticized over the past decade as their use in hospitals, healthcare practices, and other healthcare facilities has skyrocketed.

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Inadequate Test Tracking Process Leads to Delay in Cancer Diagnosis

Well-designed office systems are critical to the provision of safe, high-quality patient care. This case study from an OB/GYN practice in the Midwest illustrates how system failures can be detrimental to a patient's health.

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