Preventing Medical Errors in Speech-Language Pathology

By Susan Mitchell, PhD; Leo Christie, PhD; Gina Ulery, MS

Preventing Medical Errors in Speech-Language PathologyAs a speech-language professional, what’s the first medical error that comes to mind when you think of a critical incident? Most likely, not a hernia operation. The Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services, documented the following case of a routine hernia surgery resulting in a TIA, aspiration and ultimately death:

An elderly man, post hernia surgery, had a transient ischemic attack (TIA) and respiratory difficulties. His speech prior to surgery had been normal but was now slurred. He was also choking on thin liquids. The neurologist examined the patient and recommended a swallowing study. A speech-language pathologist (SLP) evaluated the patient, found him to be at high risk for aspiration, and completed a consultation form recommending NPO status. However, the physician did not see the form, and the patient continued to receive thickened liquids. Two days later, the patient suddenly aspirated, arrested, and died.

Within one hour of the patient’s death, the hospital reviewed the case. The critical incident resulted in changes to the protocol for swallowing evaluations. As part of the updated protocol, the physician “pre-authorizes” an NPO order, and the SLP is authorized to write the NPO order if the bedside swallowing evaluation is suspicious for the risk of aspiration. However, the deadly outcome for this patient had already occurred.

The AHRQ documentation detailed a number of reasons for this tragic error. As in most medical errors, the failure cannot be attributed to a single party. In this case, the critical error had its roots in the failure of both written and verbal communication. First, the SLP did not consider the NPO recommendation important enough to contact the physician immediately, and thus she did not verbally communicate the recommendation to the physician. Second, the hospital protocol resulted in sequestering her consultation form with the NPO recommendation in a special section of the chart, not in the core daily progress notes that all physicians read regularly. Third, the physician did not read the SLP’s consultation form and act upon the recommendation.

The AHRQ commentary further notes, “Medical errors and accidents due to communication mishaps are complex and multifaceted. In this case, liability could be attributed to the physician, the speech therapist, and the nurses caring for the patient. All of them failed to communicate and/or receive critical medical information, and their failure led to the patient’s aspiration. This means that we need to be careful that, after an accident investigation or root-cause analysis, we don’t design protocols that prevent only the specific error from happening again. In this case, an NPO order was the problem, but the root cause analysis revealed general problems with communication. The chance that another patient will die due to lack of a timely NPO order is relatively small.

However, the chance that problems in inter-professional communication will cause other adverse events is high. The institution needs to make sure it does something about the latter, not just the former.”

The Joint Commission Safety Goals include a number of recommended steps to prevent error. Of these, “to improve the effectiveness of caregiver communication” is the one identified by ASHA (2010a) in its website publication, Patient Safety and the SLP (http://www.asha.org/slp/PatientSafety.htm), as the one that affects SLPs and audiologists the most. “This goal requires implementing a process of verifying verbal or telephone orders by having the individual receiving the order read it back.”

Virtually all of the consumers (96%) said hospitals should be required to report medical errors to state health departments. Currently most states (including Florida) do not disclose facility-specific information to the public about mistakes. Yet 82% want each hospital’s medical error record to be available to the public. According to a study in Health Affairs (Classsen et al., 2011), hospital errors are more common than suspected…ten times more common. Medical errors and other adverse events occur in one-third of hospital admissions according to the authors. The more you look for errors, the more you will find.

Preventing Medical Errors in Speech-Language Pathology

2-Hour Online CE Course

Preventing Medical Errors in Speech-Language Pathology is a 2-hour online continuing education (CE/CEU) course that addresses the impact of medical errors on today’s healthcare with a focus on root cause analysis, error reduction and prevention, and patient safety. Multiple scenarios of real and potential errors in the practice of speech-language pathology are included, along with recommended strategies for preventing them. Evidence shows that the most effective error prevention occurs when a partnership exists among care facilities, health care professionals, and the patients they treat. Suggested strategies for preventing errors address all three elements: (1) models for changing the culture in care facilities, (2) lifelong learning for SLPs that is focused on ethical, evidence-based, culturally competent practice and (3) tools for educating and empowering patients. * This course satisfies the medical errors requirement for biennial relicensure of Florida speech-language pathologists and audiologists. Course #20-77 | 2013 | 35 pages | 15 posttest questions

This online course provides instant access to the course materials (PDF download) and CE test. After enrolling, click on My Account and scroll down to My Active Courses. From here you’ll see links to download/print the course materials and take the CE test (you can print the test to mark your answers on it while reading the course document).

Successful completion of the online CE test (80% required to pass, 3 chances to take) and course evaluation are required to earn a certificate of completion. Click here to learn more.

Professional Development Resources is approved by the Continuing Education Board of the American Speech-Language-Hearing Association (ASHA Provider #AAUM) to provide continuing education activities in speech-language pathology and audiology. Professional Development Resources is also approved by the Florida Board of Speech-Language Pathology and Audiology (Provider #50-1635) and the Ohio Board of Speech-Language Pathology and Audiology and is CE Broker compliant (all courses are reported within 1 week of completion).

Preventing Medical Errors in Speech-Language Pathology

Over the past 20 years, medical errors that result in patient injury or even death have become the focus of attention in both popular and professional publications. The Institute of Medicine (IOM) defines a medical error as: “The failure to complete a planned action as intended or the use of a wrong plan to achieve an aim.” Medical errors – which can occur in either the planning stage or the execution stage – are frequently communication errors, which are, unfortunately, very common in health care.

A 2011 Consumer Reports Poll on Hospital Safety interviewed 1,026 adults ages 18+ using a nationally representative probability sample. The results:

  • 77% expressed high or moderate concern re: harm by hospital infection during hospital stay
  • 71% expressed high or moderate concern re: harm by a medication error
  • 65% were similarly concerned about surgical errors

 

Preventing Medical Errors in Speech-Language PathologyIn the State of Florida, speech-language pathologists and other health professionals are required to complete a course on the prevention of medical errors each time they renew their license. Preventing Medical Errors in Speech-Language Pathology is designed to help SLPs be vigilant to the kinds of medical errors that can occur in their practice and take proactive steps to prevent them. This course addresses the impact of medical errors on today’s healthcare with a focus on root cause analysis, error reduction and prevention, and patient safety. Multiple scenarios of real and potential errors in the practice of speech-language pathology are included, along with recommended strategies for preventing them. Evidence shows that the most effective error prevention occurs when a partnership exists among care facilities, health care professionals, and the patients they treat. Suggested strategies for preventing errors address all three elements: (1) models for changing the culture in care facilities, (2) lifelong learning for SLPs that is focused on ethical, evidence-based, culturally competent practice and (3) tools for educating and empowering patients. * This course satisfies the medical errors requirement for biennial relicensure of Florida speech-language pathologists and audiologists. Course #20-77 | 2013 | 35 pages | 21 posttest questions | ASHA credit expires 4/20/2016.

One the most common medical procedures in which speech-language pathologists have a primary role is the evaluation and treatment of swallowing and feeding disorders. Because of the nature of swallowing disorders, treatment is frequently complex, and a number of dysphagia management issues have become very contentious. In addition, the potential for error, adverse outcomes and litigation is significant.

“This newly revised course teaches everyday strategies for preventing errors that can occur in the practice of speech-language pathology,” says Leo Christie, President and CEO of Professional Development Resources. “Rather than targeting individuals when a medical error happens, efforts today are focused upon those elements in the work environment like fatigue or distraction that can lead medical errors. This approach of focusing on system error over human error has proved to be useful in reducing the risk of patient injury.”

Preventing Medical Errors in Speech-Language Pathology also includes a section on race and ethnicity. The authors point out that there is an increasing need for bilingual health professionals to serve the rapidly growing ethic segments of our population. According to the U.S. Census Bureau (2012), minorities comprise 37% of the U.S population. When professionals are not familiar with the cultural norms, customs, and languages of their patients, miscommunications can arise and cause serious diagnostic and treatment errors.

The course describes in detail a number of patient safety goals and concludes with a series of recommendations for improving interpersonal communication in order to prevent medical errors. Recommended strategies include the following:

  1. Slow down, speak slowly and spend a small amount of additional time with each patient
  2. Use plain, nonmedical language. Explain things as you would to your own grandmother.
  3. Show or draw pictures to help your patient understand and remember.
  4. Limit the amount of information provided, and repeat it.
  5. Use the “teach-back” technique to confirm that the patient understands.
  6. Create a shame-free environment by encouraging questions.
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Preventing Medical Errors in Behavioral Health – 2013 Update

Preventing Medical Errors in Behavioral Health

By: Leo Christie, PhD; Catherine Christie, PhD; Susan Mitchell, PhD

CE Credit: 2 Hours

Target Audience: Florida-licensed Psychologists, Counselors, Social Workers & MFTs

Learning Level: Intermediate

Course Type: Online
Preventing Medical Errors in Behavioral HealthThis course is intended to increase clinicians’ awareness of the types of errors that can occur within mental health practice, how such errors damage clients, and numerous ways they can be prevented. Its emphasis is on areas within mental health practice that carry the potential for “medical” errors. Examples include improper diagnosis, breach of confidentiality, failure to maintain accurate clinical records, failure to comply with mandatory abuse reporting laws, inadequate assessment of potential for violence, and the failure to detect medical conditions presenting as psychiatric disorders (or vice-versa). It includes detailed plans for error reduction and prevention like root cause analysis, habitual attention to patient safety, and ethical and legal guidelines. The course includes numerous case illustrations to help demonstrate common and not-so-common behavioral health errors and specific practices that can help clinicians become proactive in preventing them. There is a new section on preventing medical errors in the use of technology. *This course satisfies the medical errors requirement for license renewal of Florida mental health professionals. Course #20-70 | 2013 | 31 pages | 15 posttest questions
Professional Development Resources is approved as a provider of continuing education by the Association of Social Work Boards (ASWB #1046); the National Board of Certified Counselors (NBCC#5590); the American Psychological Association (APA); the National Association of Alcoholism & Drug Abuse Counselors (NAADAC #000279); the Commission on Dietetic Registration (CDR #PR001); the Continuing Education Board of the American Speech-Language-Hearing Association (ASHA #AAUM); the American Occupational Therapy Association (AOTA #3159); and various state licensing boards.
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Preventing Medical Errors in Speech-Language Pathology

Preventing Medical Errors in Speech-Language Pathology

Click on image to view course details

2-hour course required for license renewal of Florida SLPs and Audiologists on December 31, 2011.

This course addresses the impact of medical errors on today’s healthcare with a focus on root cause analysis, error reduction and prevention, and patient safety. Multiple scenarios of real and potential errors in the practice of speech-language pathology are included, along with recommended strategies for preventing them. Evidence shows that the most effective error prevention occurs when a partnership exists among care facilities, health care professionals, and the patients they treat. Suggested strategies for preventing errors address all three elements: (1) models for changing the culture in care facilities, (2) lifelong learning for SLPs that is focused on ethical, evidence-based, culturally competent practice, and (3) tools for educating and empowering patients. 2010 | 33 pages | 16 posttest questions | Course #20-10S

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