Nursing Standard of Practice Protocol: Iatrogenesis: The Nurse's Role in Preventing Patient Harm

Deborah C. Francis, MSN APRN BC

Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC. These protocols were revised and tested in NICHE hospitals. 

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

Definition

• Iatrogenesis refers to any unintended and untoward consequence of well-intended healthcare interventions.
• Cascade iatrogenesis is a series of adverse events triggered by an initial medical or nursing intervention initiating a cascade of decline.
  • Occurs most frequently among the oldest, most functionally impaired patients and those with a higher severity of illness upon admission.

Overview

• The most common iatrogenic events result from:
  • Adverse reactions to medications
  • Adverse reactions to diagnostic, therapeutic and prophylactic procedures
  • Nosocomial conditions such as hospital-acquired infections, delirium, deconditioning, malnutrition, fecal impaction, incontinence and pressure ulcers
  • Falls or other accidental and environmentally-induced accidents, and
  • Harmful effects to patients related to the values, beliefs, prejudices, fears and attitudes of well intentioned, but ignorant providers

• Iatrogenesis is a very common, often preventable, hazard of hospitalization and is associated with significantly longer hospital stays, increased patient mortality and cost.
• The true extent of the problem of iatrogenesis is not well understood. What we know of the problem may be but the tip of the iceberg.
• In spite of early recognition of the problem and better care and prophylaxis of iatrogenic complications, little progress has been made and the rate of preventable adverse events remains alarmingly high.

Background

• Governmental regulations were initiated in late 1960's after a pandemic of staphylococcal infections in U.S. hospitals and the thalidomide disaster.
• The Institute of Medicine (1999) cites extremely high rates of iatrogenesis in hospitalized patients as a result of medical error and negligence that largely resulted from system failures. The IOM urges immediate, vast and comprehensive system wide changes, including both voluntary and mandatory reporting programs by healthcare organizations.
• In 2000, a Presidential task force identifed a "national problem of epidemic proportions" citing errors made by medical practitioners. The errors caused between 44,000 and 98,000 deaths per year at a cost of up to $29 billion in unnecessary healthcare costs, disability and lost income.
• Major three year study on "Patient Safety in American Hospitals" (released in July 2004) provides compelling evidence that 195,000 Medicare patients die every year in hospitals as a result of medical error at a cost of $2.85 billion annually.
• Medical errors would ranked as the sixth leading cause of death in the United States if it were recognized as a cause of death by the CDC in its Annual Vital Statistics Report.
• Prevalence of Iatrogenesis
  • Hospital admissions: Up to 13%
    • Majority due to adverse drug events
    • 70% are considered preventable
  • Once hospitalized, two to 36% of patients experience iatrogenic complications
    • 50% considered preventable
    • ICU patients have highest rate of iatrogenic complications, with 6.5% associated with permanent disability and 3.7-14% mortality rate.
• Patients 65 years and older suffer twice as many diagnostic complications, two and one half times as many medication reactions, four times as many therapeutic mishaps, and nine times as many falls as those younger patients. Age-related factors that predispose the older patient to iatrogenesis include:
  • Diminished physiologic reserve
  • Impaired compensatory mechanisms
  • Atypical presentation of illness, which complicates accurate diagnosis and treatment. (See Atypical Presentation protocol)
  • More co-morbid, chronic medical conditions, that require more diagnostic procedures and medications
  • Polypharmacy - The prescription, administration or use of more medications than clinically indicated
  • Increased cognitive and functional impairment
  • Other risk factors for iatrogenic complications include:
    • Increased severity of illness and complexity of care
    • Greater numbers of prescribed medications
    • Admission from nursing home or other acute care facility
    • Longer length or stay
    • Lack of attention to functional impairment by physicians upon admission

• Adverse drug event (ADE) - an untoward reaction to medication(s).Background
  • ADEs are the most common cause of iatrogenesis.
  • ADEs account for approximately 15% of hospital admissions in the patient over 60 years old as compared to 6% for younger patients.
  • 62% of ADEs resulting in hospital admission are potentially preventable and 25% may be life threatening.
  • Majority are due to inadequate drug therapy monitoring therapy or inappropriate dosing.
  • For older people in the hospital, at least one third of ADEs are related to errors and so are considered preventable.
  • Incidence of ADE-related hospital admissions has not decreased in the past 20 years and the absolute numbers may have increased.
  • In the nursing home setting up to two-thirds of the residents suffer an ADE annually.
  • ADEs are associated with significantly longer hospital stays, increased mortality, higher costs of care and occur most often in the geriatric patient.
  • The potential for ADEs is highest among older adults who are the greatest consumers of medications.
  • Polypharmacy increases the risk of drug-drug interactions whose effect on older people is more dramatic.
  • As the number of medications increase, an exponentially greater risk of ADEs occurs.
  • Normal age-related changes tend to exaggerate the effects of drugs leading to more adverse side effects and iatrogenic injury.
  • Common causes include inappropriate drug prescribing, errors in prescription, transcription, administration and complicated medication dosing schedules.

Nursing and Organizational Assessment and Care Strategies of ADEs

• Public and professional education about the problem of polypharmacy and its association with iatrogenesis in the geriatric population needs to be implemented on the national, regional and local levels.
• Healthcare practitioners need to be trained to:
  • Use knowledge of medication pharmacokinetics and pharmacodynamics to alter prescribing and administering practice.
  • Recognize an ADE and be able to differentiate it from a new illness, so that another medication is not inappropriately prescribed to treat a "new" illness or symptom.
  • Regularly review all medications including over-the-counter drugs and those prescribed by multiple providers.
  • Engage in judicious prescribing practices:
    • "Start low and go slow", titrating drug dosages upwards to effect.
    • Discontinue a medication as soon as possible and consider drug holidays in older patients.
  • Chose medications that can treat more than one symptom whenever possible:
    • Calcium channel blockers for patients with both hypertension and angina.
    • Angiotensin-converting enzyme inhibitors can be used to treat both for those with hypertension and congestive heart failure.
  • Avoid drugs that are highly bound to albumin or that are metabolized by the cytochrome p450 system. For the latter, choose drugs that have the most restricted metabolic pathways in order to avoid affecting the blood levels of other medications e.g., bactrim will raise the INR in a patient with coumadin. Also see protocol Medication
  • Aggressively address patient adherence to the extent possible:
    • Minimize the number of drugs.
    • Simplify the regimen.
    • Provide written and effective patient education.
    • Recognize and compensate for mild cognitive deficits, depression, limited educational or developmental level.
    • Utilize written medication schedules, and devices such as a medi-set or simple routines such as daily telephone reminders by family members.
    • Address access issues including cost, transportation, pharmacy's ability to stock a drug (especially narcotic analgesics), inability to open bottles, and cultural beliefs.
• Nurses priorities include:
  • Monitor closely for potential adverse drug events, especially when any new symptom is noted. New onset confusion and sedation are common side effects that have the potential to cause a cascade of iatrogenic problems if not promptly recognized and addressed. (See Delirium and Medication protocols).
  • Collaborate with physicians and pharmacists to review and minimize the use of high risk medications and polypharmacy.
  • Implement nurse-driven non-pharmacologic protocols to address problems such as dementia-related disorders, delirium, anxiety, incontinence and sleep disturbances in order to decrease the current reliance on pharmacologic therapy. (See Dementia protocol)
  • Be a strong patient advocate especially with the most vulnerable at-risk patients who are frail or lack family. As such, nurses need also to be aware of and ensure that baseline cognitive and functional status is communicated to staff throughout the hospital stay in order to recognize subtle changes. (See Function protocol)
• Healthcare organizations priorities:

   

  Adverse Effects of Diagnostic, Therapeutic and Prophylactic Procedures

  Background

  Assessment and Care Strategies: Adverse Effects of Diagnostic, Therapeutic, Prophylactic Procedures

  Nosocomial or Hospital-acquired Complications

  Background

  Definition: Nosocomial Complications: events that are not directly related to the illness or an expected effect of a treatment.

  Specific Nosocomial Complications Nosocomial complications include the following:

  Nosocomial Infection

  • Implement computerized order entry systems to minimize the risk of prescription and transcription errors, and to provide practitioners with readily accessible information about high risk drugs to avoid in the elderly and common drug-drug and drug-nutrient interactions.
  • Recruit pharmacists and physicians with expertise in geriatrics to ensure that high risk drugs are not included on pre-printed order sets and to educate their peers in the principles of geriatric prescribing.
  • Diagnostic tests and procedures involve some degree of risk based on whether or not they are invasive and whether they administer a pharmacologically inert agent such as contrast dye or radiation therapy.
    • Contrast dye, used in CT scans and myelography, can produce both allergic and non-allergic reactions including urticaria, angioedema or anaphylaxis.
      • Radiocontrast infusion in patients with renal impairment can cause acute renal failure or an exacerbation of congestive heart failure.
      • Intrathecal use of contrast media in myelography is known to produce vasovagal syncope, nausea, postural headache, hearing loss, aseptic meningitis and encephalopathy.
    • Medical procedures are linked to significantly more preventable adverse effects.
      • Thoracentesis is linked to cardiac arrhythmias, bleeding, infection and pneumothorax in the older adult.
      • Colonic perforations occur due to endoscopy.
      • Urinary tract infections result from the use of an indwelling bladder catheter
      • Over administration of intravenous fluids in an older patient with age-related reduced cardiac reserve can cause congestive heart failure.
  • Surgical complications in patients over 65 years occur at a rate twice that of younger patients and both the rates of postoperative complications and death tends to increase with age.
    • Atypical presentation of disease accounts for a high number of emergent and therefore far more risky surgeries in the older patient. (See Atypical Presentation Topic)
    • Geriatric patients account for half of all surgical emergencies and three-fourths of all operative deaths, so timely diagnosis and optimal perioperative care is critical for survival.
  • Prevention/Management
    • Ensure that the older patient clearly understands the risks and benefits of any and all invasive procedures and is truly making an "informed" consent.
    • Determine risk versus benefit proactively. Potentially harmful diagnostic and therapeutic procedures may well be contraindicated if the potential benefit does not clearly increase the potential for improving patient outcomes.
    • Maintain a heightened awareness and assessment of the situation while reviewing risks and benefits, and err on the side of caution with the older patient.
  • Occur in the hospitalized older patient with far greater frequency due to a variety of patient (age-related changes, multiple chronic conditions and complexity of illness), provider (lack of awareness and education) and organizational (structure and process) factors.
  • The most common preventable and potentially life threatening iatrogenic complications in the hospitalized elder include nosocomial infections, delirium, functional decline, deconditioning, malnutrition, pressure ulcers, depression, incontinence and fecal impaction.
  • Nosocomial Infection
  • Delirium
  • Deconditioning and functional decline
  • Malnutrition and dehydration
  • Pressure ulcers
  • Urinary Incontinence
  • Fecal impaction and fecal incontinence
  • Environmentally-induced complications
• Prevalence and Significance

   

  Nursing Care Strategies/Management of Nosocomial Infections

   

  • Affects approximately three million American patients every year causing 60,000 deaths at a cost exceeding 4 billion in direct healthcare costs.
  • Occur in 6-17% of hospitalized older patients and an equal number of nursing home residents.
  • Highest risk patients include:
    • Geriatric patients who, once infected, are more likely to experience adverse outcomes.
    • Critically ill patients tend to be the sickest and most immune compromised patients. They also undergo more invasive procedures and intravascular devices which significantly increase the risk of secondary infection.
  • Approximately one-third of nosocomial infections are considered preventable by effective infection control programs.
  • The most common nosocomial infections are those of the urinary and respiratory tracts.
    • Pneumonia is one of the most common infections in both hospitalized and skilled nursing facility patients.
    • Pulmonary aspiration is a complication frequently seen in neurologically impaired and post-operative patients.
    • Urinary tract infections are most often related to indwelling catheter use and the risk increases by approximately 5% per hospital day.
    • Other infections that commonly affect hospitalized older patients include those affecting the:
      • Skin - such as methicillin resistant streptococcal aureus (MRSA)
      • Gastrointestinal tract - especially clostridium difficile colitis
      • Oropharyngeal cavity - such as candida infections
    • Surgical-site infections, which occur in approximately 2.7% of surgical procedures, are one of the most common types of nosocomial infection, although data on incidence is limited and demonstrates a lower risk after age 65 years.
  • Hand washing remains the single most effective strategy to eliminate nosocomial infection.
  • Initial and ongoing staff and patient/family education regarding the significant risk of infection to hospitalized patients.
  • Visible reminders of the importance of infection control.
  • Active, continuous infection control surveillance, rather than passive voluntary reporting programs need to be encouraged as they are far more effective in decreasing hospital infection rates.
• Delirium or acute confusional state: (See Delirium protocol)

   

  Deconditioning and Functional Decline

   

  Malnutrition and Dehydration

  (See Nutrition and Hydration)

  Pressure Ulcers (See Pressure Ulcer)

  Urinary Incontinence

  (See Urinary Incontinence)

   

  Depression

  (See Depression)

   

  Fecal Impaction and Incontinence

  It is critical that nurses recognize their important role in preventing these nosocomial complications which far too often can and do trigger a cascade of inevitable decline that could have been prevented if the initial iatrogenic event had not occurred. For specific care strategies and management follow link to corresponding topic.

   

  Environmentally-induced Accidental Complications

  (See Falls)

  Background

   

  Provider Values, Beliefs and Attitudes

   

  Nursing Interventions

  It is important that nurses examine their belief systems and not unwittingly contribute to the patient's suffering and despair because of biases against older patients that can compromise objectivity.

  • Delirium is one of the most common iatrogenic complications in hospitalized elders affecting 50% or more post-operative hip fracture and thoracic surgery patients over age 65.
  • Between 25 and 60% of hospitalized elders risk a loss of physical function during the course of hospitalization.
  • Prolongs hospital stay and increases risk of nursing home placement and death.
  • Contributing factors include:
    • Lack of education and awareness by nursing, medical and hospital staff to the importance of functional impairment to patient outcomes and quality of life.
    • Organizational structures and processes of care that can impede the staff from knowing the patient's baseline functioning.
  • Nursing must recognize the older adult at greatest risk of deconditioning, and implement aggressive progressive mobilization and self care protocols and promote restraint-free care.
  • Malnutrition is the single strongest predictor of long term mortality in the geriatric patient, even if the patient receives nutritional interventions in the hospital.
  • Malnutrition is associated with longer lengths of stay, and increased hospital and home health costs.
  • The prevalence of malnutrition, or risk thereof in hospitalized patients, ranges from 40-62% with up to 78% of patient's nutritional status noted to deteriorate during hospital stay.
  • Dehydration can be a medical emergency in the older patient and present as delirium or Falls (See Delirium and Falls Topics).
  • Age-related diminished thirst sensation and inability to concentrate urine, medications, altered level of consciousness, and cognitive or functional impairment can contribute to dehydration and malnutrition.
  • Nurses must closely monitor intake and output or laboratory values, question or prevent prolonged NPO status, and avoid delays due to scheduling of diagnostic tests.
  • Affects 33% of patients in acute care and 50-80% in skilled nursing facilities.
  • Functional incontinence, in which patients are unable to meet their own elimination needs, is very common in acute care setting.
  • One of the most common causes of nursing home placement.
  • Contributes to development of pressure ulcers, social isolation and depression.
  • Nurses need to recognize transient incontinence and collaborate with physician to assist the patient to regain continence.
  • Affects one third of hospitalized elders with higher rates seen in patients in long term care and those with chronic disabling conditions.
  • Common comorbid condition in patients with dementia and CVA.
  • Cognitive impairment may be a either a presenting symptom or result of depression.
  • Depression in older adults commonly presents atypically with increased complaints of physical and somatic complaints.
  • May coexist with anxiety.
  • Associated with increased morbidity and mortality with highest suicide rates noted among older men.
  • It is critical that nurses screen older patients for depressive symptoms, especially vague somatic complaints, and work with physicians to aggressively manage late life depression.
  • Fecal incontinence is common in the elderly affecting up to 50% of patients in skilled nursing facilities.
  • Fecal impaction is one of the primary causes of fecal incontinence and very common among patients in acute and long term care settings.
  • Primary risk factors for fecal impaction include polypharmacy, especially with constipating medications (e.g. narcotic analgesics, calcium channel blockers, iron) and chronic use of laxatives, immobility, reduced fluid intake, malnutrition, weakness, delirium, dementia, and depression.
  • Prevention of fecal impaction and assisting patients to manage constipation is critical to avoid unnecessary surgery and resultant pain and suffering.
  • Physical features of hospital environments can contribute to iatrogenic events, most notably injuries or deaths related to falls, restraints and equipment defects.
  • Falls are a major public health problem among older adults and the consequences can be devastating.
    • Falls occur at a rate of 1.5 per hospital bed per year at a cost of approximately $1000 per bed. As such, a 250 bed hospital can anticipate an average of 375 falls per year totaling $250,000. Skilled nursing facility incidence is even higher.
    • Older adults tend to be at greatest risk of falling in the hospital due to a variety of intrinsic and extrinsic factors.
      • Try This Issue 8 - Fall Risk Assessment
  • Environmental hazards that need to be eliminated:
    • Slickly waxed floors are a serious hazard to any patient, however the age-related changes in vision and conditions such as neuropathy significantly increase this risk.
    • Inappropriate foot wear which can contribute to falls.
    • Unnecessary clutter and equipment at the bedside, therapeutic lines and devices that tether the patient.
    • Defective or improperly used equipment.
  • Restraints, including full hospital bed siderails, increase the risk of harmful and potentially fatal injuries. (See Physical Restraint protocol)
    • Hospital beds with full side rails have caused injuries and deaths in higher risk patients due to both bed entrapment and falls over the side rails.
    • Older adults at risk for falls, delirium, with dementia or dementia-related behaviors are at greatest risk of being restrained (See Dementia and Delirium protocols)

      Management:

• Proactive approach to patient safety needs to be a priority including: (See Falls protocol)
  • Every effort must be made to implement restraint free management programs and to closely monitor the high risk restrained patient.
  • Patients need to be encouraged to wear sturdy shoes or slippers with rubber soles whenever they get out of bed.
  • Routinely check hospital slippers to ensure the skid surface on sole of foot remains when patient ambulates.
• Equipment acquisition and hospital design and remodel must consider the age-related sensory and functional changes of the burgeoning older population.
• Properly placed handrails and contrasting colors to clearly identify doorways and toilet seats can assist the visually-impaired patient to more safely function within the environment.
• Seating needs to be of the appropriate height with arm rests that will facilitate safe transfers.
• Finally, hospitals must promote a culture of safety that includes:
  • Removal from service of any malfunctioning equipment
  • Enforce good safety behaviors at both the unit and organizational level
  • Prompt and blame-free reporting
  • Healthcare provider's values, beliefs, fears, prejudices and attitudes can be equally detrimental to patients.
    • A nurse's perception of older adults as chronically ill and frail may foster increasing dependence and functional decline when the patient is not provided the opportunity or assistance to routinely ambulate or engage in self-care skills.
    • A diagnosis of dementia may lead a prejudiced or uneducated clinician to expect less of a patient and to subsequently offer fewer treatment options. The assumption that the quality of life of the demented person is "poor" may contribute to the physician assuming that palliation or institutionalization is the most appropriate goal of care.
    • Most physicians are poorly trained in geriatric healthcare, unaware of the importance of the core concepts of geriatric medicine that promote function, and an interdisciplinary approach with emphasis on early discharge planning.
    • The present system of hospital care not only perpetuates dependency and iatrogenesis among geriatric patients, but tends to "erode their self-esteem, identity and individuality."
  • Older patients are more vulnerable to the values, beliefs, attitudes of the healthcare provider because they tend to:
    • Underreport or deny symptoms.
    • Be less assertive with the physician or less aggressive in seeking second opinions due to generational differences.
  • Increasing awareness to the dangers of diagnostic and therapeutic interventions and implementing proactive interventions at the national, regional and local levels such as:
    • JCAHO 2009 National Patient Safety Goals
    • Patient and public safety awareness campaign
    • Mandate increased geriatric education in the profession and allied health schools
• Healthcare Organizational priorities
  

   

  Expected Outcomes

  Patient

  Healthcare provider

  Institution

  Follow-up Monitoring

  • Implement appropriate initial and ongoing training to all staff:
    • Provide geriatric training to all medical, nursing and ancillary healthcare professionals and care providers well integrated into hospital orientation, unit-precepting and annual mandatory training programs.
    • Hospital staff needs to understand the increased vulnerability of the geriatric patient, to readily identify those at higher risk, and to proactively intervene to prevent patient harm.
    • Emphasis on teamwork needs to be an integral component of all training programs.
  • Standardize and simplify structure and processes of care and work routine:
    • Computerized patient records to minimize the number of medication errors due to illegible handwriting.
    • Pre-programmed medication alerts to prevent adverse drug-drug interactions.
    • Decision support tools such as standardized evidence-based guidelines and protocols or simple paper-based can reduce unnecessary variation in care and promote best practice and positive patient outcomes.
    • Hospital leadership need to promote a geriatric approach to frail older patients with greater emphasis placed on interdisciplinary care, early rehabilitation and proactive discharge planning.
    • Ensure the use of hearing amplifiers, glasses, walkers and other assistive devices at the bedside to maximize patient functioning and promote patient safety.
    • Teamwork is essential and ongoing efforts must be made to teach and ensure that staff works effectively in teams.
  • Improve access to pertinent healthcare information, and proactively intervene in high-risk patients:
    • Examine current information processes, particularly verbal and written documentation, to ensure that pertinent functional, cognitive and personal information is shared with the nursing team.
    • Recognize those populations most at risk of iatrogenesis.
    • Involve family and caregivers as much as possible and provide patient safety education and training and refer to community resources.
    • Recognize the value of functional and cognitive assessment in identifying those patients most at risk of poor outcomes and to target geriatrically-sound interventions to those most at risk.
      • For example, knowledge of the concept of diminishing physiologic reserve capacity with aging should prompt the nurse to understand the need to balance diagnostic and therapeutic interventions with the need for rest and sleep.
      • Closely monitor sleep patterns in order to prevent sleep deprivation.
      • Schedule tests and therapy only after the patient has adequate rest is critical to prevent delirium and promote healing.
      • Manage pain with around the clock analgesics and ensure pain medication is provided prior to mobilization to maximize the patient's ability to participate in rehabilitative therapy.
      • Automatic stop orders for bedrest and bladder catheters, close monitoring of food and fluid intake, and regular opportunities for out of bed activity, mobilization and socialization are important.
  • Involve the patient in mutual goal setting and promote a more collaborative relationship between the nurse and the patient to attain those goals and to foster more patient control, self-care and autonomy.
  • Collaborate closely with discharge coordinator to ensure referral to community resources to aide discharge "at-risk" patients in a timely manner.
  • Implement effective quality monitoring
    • Promote a culture of safety in which everyone is aware of the significance of iatrogenic events and effective systems to prevent, identify and report all possible complications.
    • Ensure a blame-free system that recognizes that most iatrogenic harm is due to systems rather than individual failure, mandates reporting of near misses and treats them just as seriously as actual events.
    • Nurses with gerontological expertise need to join hospital environmental safety rounds and offer evidence-based recommendations for color schemes and architectural design to hospital design planners.
  • Patient safety will be free from preventable iatrogenic complications.
  • Iatrogenic complications will be identified and treated with minimal or no adverse outcomes.
  • Patients at risk for iatrogenic complications will be identified and preventive strategies instituted.
  • Healthcare providers will receive on-going education surrounding iatrogenesis in the elderly.
  • Iatrogenic events will be recognized at treated early to prevent further complications.
  • The number of preventable iatrogenic complications will decrease.
  • Continuing education on iatrogenesis will be provided annually to all care providers.
  • Continuous Quality Improvement (CQI) programs will be instituted to monitor and address iatrogenesis.
    • Tracking of iatrogenic events and the underlying etiology will be on-going and used as a tool for improvement.
    • Educate caregivers and continue assessment processes.
• Tracking of iatrogenic events and the underlying etiology will be on-going and used as a tool for improvement.
• Educate caregivers and continue assessment processes