Nurse’s Role In Preventing Patient The Nurse’s Role in Preventing Hospital-Induced Harm or Iatrogenesis
Understanding Iatrogenesis
Iatrogenesis, originating from the Greek word “iatro” meaning healer, refers to harm caused unintentionally by a medical professional during patient care, which is not a part of the natural progression of the illness or injury. It is a prevalent and serious risk associated with hospitalization, leading to increased patient morbidity and mortality, extended hospital stays, and eventual placement in nursing homes. This not only impacts patients significantly but also imposes substantial costs on healthcare organizations.
Well-known iatrogenic issues affecting older adults encompass adverse drug events (ADEs), complications arising from diagnostic and therapeutic procedures, hospital-acquired infections (HAIs), pain, and various geriatric syndromes such as falls, delirium, functional decline, and pressure ulcers. Less recognized are the potentially harmful effects of the knowledge, values, beliefs, and attitudes of well-meaning healthcare providers and patients themselves on patient outcomes.
This discussion aims to shed light on common iatrogenic problems affecting older adults and to outline the nurse’s role in preventing such harm. Iatrogenesis is not a novel concept in modern medicine. Back in the 1840s, Ignaz Semmelweis observed that deaths from puerperal sepsis were lower among patients attended by midwives solely working with laboring mothers compared to those treated by medical students who also dissected cadavers and performed surgeries (Hani, 2010). Semmelweis introduced a hand-washing protocol, reducing fatal puerperal fever cases from 12.84% to 2.38%, leading to the development of germ theory and highlighting the crucial role of hand hygiene in infection prevention. In 1981, Steel, Gertman, Crescenzi, and Anderson (2004) raised concerns after reporting that 36% of patients experienced at least one iatrogenic event during hospitalization, even with conservative inclusion criteria.
The Scope of the Problem
The term “iatrogenesis” gained prominence when medical errors causing patient harm made headlines following the release of the landmark Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health System (Kohn, Corrigan, & Donaldson, 1999). This report revealed that errors made by medical practitioners resulted in 44,000 to 98,000 deaths annually, costing up to $29 billion in unnecessary healthcare expenses, disability, and lost income.
The report urgently called for immediate, extensive, system-wide changes, including both voluntary and mandatory reporting programs by healthcare organizations, thus kick-starting the patient safety movement we witness today. In 2004, a national study involving 37 million Medicare patients across 5,000 hospitals found that approximately 195,000 people died each year due to potentially preventable patient safety incidents (Health Grades, Inc., 2004). Despite the call to reduce medical errors by half, iatrogenesis remains a persistent issue.
The Agency for Healthcare Research and Quality (AHRQ) reported to Congress in 2008 that preventable medical injuries were increasing by 19% annually (AHRQ, 2008). Furthermore, in November 2010, the U.S. Department of Health and Human Services’ Office of the Inspector General reported an alarming increase in deaths from adverse events—180,000 patients each year—associated with $4.4 billion in government costs. Additionally, it is estimated that one in seven Medicare beneficiaries (13.5%), equating to about 134,000 patients monthly, experience at least one adverse event, many of which are preventable (Wilson, 2010).
Patients most at risk for experiencing an adverse event during hospitalization are older adults (Rothschild, Bates, & Leape, 2000), critically ill individuals (Garrouste et al., 2008), or those from ethnic or racial minority groups (Johnstone & Kanitsaki, 2006). Up to 70% of these events are considered preventable (Soop, Fryksmark, Köster, & Haglund, 2009; Zegers et al., 2009). Understanding the true extent of the problem is challenging due to several factors.
A lack of standardization in the literature regarding what constitutes iatrogenesis and differing methods of data collection and analysis hinder our knowledge of the issue. Additionally, there is a lack of recognition of the problem and standardized procedures for investigating and reporting adverse events by hospitals and providers, who often disagree on what constitutes a complication and quality of care (Weingart et al., 2006).
Patients themselves, especially older adults, may hesitate to formally identify and report iatrogenic harm, if they even recognize it. Many are too ill or do not comprehend sophisticated medical care enough to recognize an adverse event (Bismark, Brennan, Paterson, Davis, & Studdert, 2006). Consequently, estimating the true human and financial cost of this problem is difficult, and our current understanding of iatrogenesis may only be the tip of the iceberg.
Iatrogenesis in Older Adults
The risk of an iatrogenic event is highest among patients aged 65 years and older (Rothschild et al., 2000; Rowell, Nghiem, Jorm, & Jackson, 2010). Evidence suggests it affects between 10.6% and 58.3% of hospitalized older adults (Rowell et al., 2010; Steel et al., 2004; Marengoni et al., 2010; Thornlow, Anderson, & Oddone, 2009). A landmark Harvard Medical Practice Study in 2000 found that older adults suffered twice as many diagnostic complications, two and a half times as many medication reactions, four times as many therapeutic mishaps, and nine times as many falls compared to younger patients (Rothschild & Leape, 2000).
Healthcare Cost and Utilization Project (HCUP) scores found that for 11 of 13 safety indicators, older patients, especially those older than 85 years, were more likely than younger patients to experience higher rates of adverse events (Thornlow, 2009). When combined with chronic renal failure or chronic obstructive pulmonary disease, the risk of adverse event-related in-hospital death significantly increases (Marengoni et al., 2010). Patients admitted from skilled nursing facilities (SNFs) are at a notably higher risk for developing complications in the hospital (Malone & Danto-Nocton, 2004).
Internal Risk Factors for Iatrogenesis
Normal age-related changes and diminished physiological reserve capacity—especially in hepatic, renal, and cognitive functions—along with impaired homeostatic and compensatory mechanisms, impede the older patient’s ability to respond to the physiological and psychological stressors of acute illness, making them more vulnerable to iatrogenesis. Age-associated physiological changes tend to amplify the effects of medications, leading to more adverse side effects, which are often treated with additional medications, compounding the risk of iatrogenic harm.
This risk is heightened by the presence of multiple comorbid conditions and drug-drug and drug-disease interactions resulting from polypharmacy (Robinson & Weitzel, 2008). Aging is associated with an increased risk of infection due to immune senescence. This age-related blunting of the febrile response and decreased physiological ability to mount an immune response or fever can delay diagnosis and treatment, potentially resulting in inappropriate care (McElhaney, 2005).
A diminished thirst sensation dramatically increases the risk of dehydration in older patients who, for functional or cognitive reasons, may also be unable to independently drink adequate amounts of fluids. Older adults with age-associated declines in cardiac reserve receiving continuous intravenous fluids are also at increased risk for iatrogenic congestive heart failure (CHF).
Another important consideration is the atypical presentation of diseases in older adults. Early symptoms of acute medical conditions tend to be vague, insidious, and atypical, often missed or misinterpreted by clinicians, family, caregivers, and patients themselves. This impairs accurate diagnosis and timely treatment, leading to a greater frequency of emergent, higher-risk interventions. For example, acute appendicitis in older adults may present as non-localized abdominal discomfort or may not manifest symptoms until perforation occurs.
An older person experiencing a myocardial infarction may have no pain at all. Older adults with a urinary tract infection (UTI) or pneumonia commonly present with confusion, falls, or functional impairment, rather than the typical symptoms of infection seen in younger individuals. A lack of awareness of atypical presentations can lead to delays in treatment and to patients being inappropriately treated with high-risk medications or labeled as “demented,” rather than assessing for and treating unmet needs such as delirium-related infection or pain.
External Risk Factors for Iatrogenesis
The hospital environment and the complex interrelationships of hospital and provider practice patterns influence patient safety outcomes. Inadequate nurse staffing has consistently been associated with adverse patient outcomes (Frith et al., 2010), and interruptions during clinical care are known to cause more nursing errors (Westbrook, Woods, Rob, Dunsmuir, & Day, 2010). The hospital environment itself can also be hazardous to vulnerable elders with sensory, functional, and cognitive deficits, leading to more falls and fall-related injuries. To further complicate matters, physicians and nurses are typically not adequately trained in geriatric care and are unprepared to manage the complex, chronic care needed by frail older patients (IOM, 2008). Without a solid understanding of the special needs of geriatric patients and the factors within an organization that can increase risk, nurses may inadvertently cause more harm during treatment.
Hospitalized older adults are at particularly high risk for cascade iatrogenesis, which occurs when an initial medical or nursing intervention triggers a series of complications, initiating a cascade of decline that is often irreversible (Robinson & Weitzel, 2008). For example, a cognitively impaired surgical patient who is inappropriately treated for pain may develop delirium, be medicated for agitated behaviors, become lethargic from over-sedation, and subsequently develop aspiration pneumonia.
Deconditioning caused by prolonged bed rest increases fall risk and could lead to a fractured hip when the patient falls while trying to get to the bathroom. This prolongs the hospital stay, increasing the risk of further complications and adverse outcomes. Iatrogenic cascades have been found to occur most frequently among the oldest, most functionally impaired patients, and those with a higher severity of illness upon admission (Robinson & Weitzel, 2008).
Adverse Drug Events
Adverse effects of medications are the most common type of iatrogenesis in hospitalized older adults. These include any adverse outcomes that occur during the course of routine, appropriate medication use, as well as those caused by inappropriate prescribing, administration errors, and suboptimal adherence by the patient. It is estimated that 35% of older persons experience an ADE every year, almost half of which are preventable (Safran et al., 2005). On average, patients with ADEs experience longer hospital stays and have greater in-hospital and 30-day mortality rates.
Approximately 10% to 20% of older adults are prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) despite known gastrointestinal side effects, including ulcerations and bleeding, and an increased risk of impaired renal function, resulting in an estimated 3,300 excess deaths and 41,000 excess hospitalizations annually (Arnstein, 2010). Still, many nurses and other healthcare practitioners are not aware of the risks, with some hospital protocols continuing to use NSAIDs as a first-line agent to treat pain in older adults, contrary to the 2009 guidelines from the American Geriatrics Society (2009).
Polypharmacy, prevalent among older patients, increases the risk of drug interactions, whose effects on this population are more dramatic. It has been shown to be a significant predictor of hospitalization, nursing home placement, death, hypoglycemia, fractures, impaired mobility, pneumonia, and malnutrition (Frazier, 2005). A 2004 national study estimated that 888,000 ADEs occurred in hospitalized Medicare patients from high-risk medications alone, including warfarin, hypoglycemic agents, digoxin, and antibiotics (Classen, Jaser, & Budnitz, 2010).
Nurses need to closely monitor patients for adverse side effects of medications and be aware of the need for age-adjusted doses, especially with high-risk medications. Anticoagulation dosing based on creatinine clearance and weight is critical to avoid further harm to the patient (Jaffer & Brotman, 2006). Medication reconciliation upon admission, transfer, and discharge is another key strategy needed to maintain geriatric patient safety.
Adverse Effects of Medical Procedures
Acutely ill older patients are at the greatest risk for iatrogenic harm, partly due to the need for more diagnostic, prophylactic, and therapeutic medical, surgical, or nursing procedures and interventions. Diagnostic procedures involve some degree of risk based on whether they are invasive or administer a pharmacological or radiological agent, such as contrast material.
Contrast dye, commonly used in CT scans and myelography, can produce both allergic and non-allergic reactions ranging from urticaria and angioedema to anaphylaxis. Radiocontrast infusion in patients with renal impairment can cause acute renal failure (ARF) or exacerbate CHF. Gadolinium, used as a contrast agent for magnetic resonance imaging (MRI), has been associated with nephrogenic systemic sclerosis in patients with impaired renal function. Additionally, patients with preexisting renal impairment exposed to nephrotoxins such as aminoglycosides or a radiocontrast agent, and patients with CHF given NSAIDs, are at significantly greater risk for ARF (Cheung, Ponnusamy, & Anderton, 2008).
Exposure to iodinated radiocontrast material should be avoided or minimized in patients with renal insufficiency, and nursing staff must closely monitor the patient’s hydration status before and after the use of contrast dye in diagnostic studies. Particular attention needs to be paid to the patient’s orthostatic blood pressure, urine output, and jugular venous pressure (Cheung et al., 2008). Administering age-adjusted, appropriate medications to premedicate prior to procedures is critical, as is the nurse’s ability to question what may be a high-risk drug or dose for the older adult. For example, the anticholinergic antihistamine diphenhydramine, routinely prescribed before a blood transfusion to prevent minor transfusion reactions, can precipitate delirium in older patients.
Medical procedures such as thoracentesis and cardiac catheterization have also been linked to significantly more preventable adverse effects in older adults, such as cardiac arrhythmias, bleeding, infection, and pneumothorax (Dumont, Keeling, Bourguignon, Sarembock, & Turner, 2006). The literature is full of case reports of iatrogenic injuries and deaths due to medical or nursing procedures such as venous embolism caused by the injection of CT contrast (Imai, Tamada, Gyoten, Yamashita, & Kajihara, 2004); aspiration deaths caused by barium, emollient laxatives, and contrast medium (Hunsaker & Hunsaker, 2002); colonic perforations caused by endoscopy or enema (Bobba & Arsura, 2004); and complications associated with percutaneous endoscopic gastrostomy tubes (Ghevariya, Paleti, Momeni, Krishnaiah, & Anand, 2009).
The risk for injurious falls is higher in older adults with devices or lines that tether them to the bed. As such, proactive assessment of when to discontinue tethering devices and ongoing evaluation of potential safety hazards is important. Restraints, including full hospital bed rails, once a cornerstone of fall prevention programs, have increasingly been recognized as harmful and potentially fatal to patients.
It is the older adult who is at the greatest risk for being restrained in an effort to prevent a fall or to manage agitated behaviors associated with delirium. Therefore, every effort must be made to implement nonpharmacological, restraint-free behavior management and fall prevention interventions as noted in clinical protocols. Restraining the patient with physical devices or medication often exacerbates agitated behavior and may contribute to falls, aspiration, skin breakdown, deconditioning, and other complications, especially when applied without addressing pain, elimination, or other care needs.
Medical and nursing interventions, even those considered relatively risk-free, such as the administration of intravenous therapy, can be dangerous in older patients. Excessive venipuncture—for example, from daily laboratory tests in stable patients—places the vulnerable older patient at increased risk not only for infection but also for phlebitis, venous thrombotic embolism (VTE), and unnecessary suffering.
Given the age-related reduced cardiac reserve, intravenous fluids can lead to preventable CHF or electrolyte abnormalities. Sherman (2005) identifies three forms of geriatric iatrogenesis, referred to as the “hypos of hospitalization,” that can delay discharge, increase costs, and lead to adverse patient outcomes.
Iatrogenic-induced hypokalemia occurs when intravenous fluids are given without potassium, while orthostatic hypotension can be induced when an antihypertensive medication is given based exclusively on supine blood pressures. Transient decreases in oral intake in patients receiving oral hypoglycemic agents or standing insulin orders can cause preventable hypoglycemia.
Bed rest, in and of itself, can have serious negative effects on older patients, including functional decline, VTE, pressure ulcers, delirium, orthostatic hypotension, falls, anorexia, constipation, and fecal impaction, among other adverse outcomes. Older adults are at the greatest risk for VTE, which is both preventable and common in hospitalized older adults, partly due to underuse of prophylactic anticoagulation (Jacobs, 2003). Aggressive pharmacological thromboprophylaxis is necessary unless there is a contraindication such as active bleeding, in which case mechanical prophylaxis with sequential compression devices is warranted (Jaffer & Brotman, 2006).
Perioperative complications in older patients can be as high as twice that of younger patients, and mortality can be three to seven times higher (Saver, 2010). Bentrem, Cohen, Hynes, Ko, and Bilimoria (2009) found that older adults were more likely to experience surgical complications including cardiac (acute myocardial infarction and cardiac arrest), pulmonary (pneumonia, pulmonary embolism, and respiratory failure), and urological issues (UTI and renal failure). On a positive note, the authors found that surgical site infections (SSIs), postoperative bleeding events, VTE, and rates of return to the operating room were not significantly different from those of younger adults.
Nurses are called upon to take a more active role in identifying older patients at higher risk of surgical complications, given the evidence that only a small percentage of surgeons and anesthetists recognize these age-associated risks and routinely order appropriate postoperative monitoring (Pirret, 2003). A simple preoperative nursing assessment tool used in more than 7,000 patients over a two-year period identified higher-risk patients needing improved postoperative monitoring, reducing acute admissions to the ICU from 40% to 19% (Pirret, 2003).
Saver (2010) recommends a multipronged approach to reduce surgical complications in older adults, including tracking clinical indicators, performing thorough assessments, protecting patients intraoperatively, and providing patient education. The assessment should review six preoperative markers linked to six-month mortality in older adults: impaired cognition, recent falls, low serum albumin, anemia, functional dependence, and multiple comorbidities.
Functional dependence in activities of daily living (ADLs) is the most significant predictor of mortality, and having four or more of the preoperative markers predicted mortality with high sensitivity and specificity. Assessment findings can be used to target postoperative interventions including prevention of delirium, falls, and functional decline. Nurses can also collaborate with nutrition services to enhance postoperative monitoring and management (Barbosa-Silva & Barros, 2005).
Postoperative nursing care that focuses on preventing infection, reducing tension at the surgical site, and optimizing nutritional status effectively prevents surgical wound dehiscence, a serious complication with up to 50% mortality (Hahler, 2006). The older adult’s oral intake needs to be carefully monitored and reported, and insulin adjusted to prevent hypoglycemia and optimize glycemic control (Sherman, 2005). It is also important to monitor geriatric patients for atrial fibrillation, a potentially preventable condition occurring in about one-third of patients after coronary artery bypass surgery and associated with other complications, including cognitive changes, renal impairment, infection (Mathew et al., 2004), and stroke (Lip & Edwards, 2006).
Safe nursing processes must be adopted and well integrated into hospital and nursing cultures. Westbrook et al. (2010) demonstrated that interruption of a nurse during medication administration resulted in a 12.1% increase in failure to follow standard procedures and a 12.7% increase in clinical errors. Hospital initiatives now include efforts to ensure nurses administering medications are not disturbed and to involve patients more in care decisions and treatment planning to mitigate this risk.
Given the substantial evidence that communication and systemic problems cause iatrogenic patient harm, The Joint Commission mandates greater involvement of patients in their care and formal time-outs and verification procedures at high-risk times to prevent wrong-site surgeries and other errors. Prior to any invasive procedure, nurses must ensure the patient clearly understands the inherent risks and benefits before giving informed consent.
Although healthcare professionals are trained to weigh the risks and benefits, it is critical to heighten assessment of the situation and to err on the side of caution in geriatric patients. Potentially harmful diagnostic and therapeutic procedures may well be contraindicated if the potential benefit does not clearly enhance patient outcomes. This is particularly important given strong evidence that the older population tends to have lower rates of understanding the risks and benefits of procedures for which they provide consent (Mahon, 2010). Given the age-associated increase in sensory deficits, it is crucial to identify and address any visual or hearing impairments that may impede patient understanding. Multiple discussions over time may be warranted to ensure the patient comprehends the situation. If a professional disagreement occurs, nurses are encouraged to escalate significant issues of potential harm up the chain of command.
Hospital-Acquired Infections
Hospital-acquired infections (HAIs), first defined in 1970 by the Centers for Disease Control and Prevention (CDC) as infections developing in a patient after hospital admission, pose a serious risk to any patient. Like other iatrogenic harm, the risk and potential for poor outcomes related to HAIs rise dramatically with age (Duffy, 2002). HAIs are among the leading causes of morbidity and mortality in hospitalized patients (World Health Organization, 2002). It is estimated that HAIs affect more than 2 million patients in the United States annually and cause at least 90,000 deaths (Leape & Berwick, 2005), at a cost exceeding $4.5 billion (Hollenbeak et al., 2006).
Although the true incidence is difficult to determine, evidence suggests that 5% to 10% of patients develop HAIs, which increase morbidity, mortality, length of stay, and cost of care (Gordts, Vrijens, Hulstaert, Devriese, & Van de Sande, 2010; Lanini et al., 2009). Additionally, a disturbing increase in risk has been noted in recent decades (Burke, 2003). The rate of HAIs is highest among older (Rothschild et al., 2000) and critically ill patients, who tend to be the most immunocompromised, undergo more invasive procedures, and receive more intravascular devices, significantly increasing the risk of secondary infection.
Urinary tract infections (UTIs) are the most common HAIs, accounting for 30% to 40% of all nosocomial infections (Brosnahan, Jull, & Tracy, 2004). The risk is directly related to the use and duration of indwelling urethral catheters, accounting for approximately 80% of hospital-acquired UTIs. In one series, 99% of older patients who received an indwelling catheter developed a UTI during the acute hospital stay; 50% of catheters used were determined not to be clinically justified (Hazelett, Tsai, Gareri, & Allen, 2006).
A systematic review of the effects of indwelling catheter duration on patient outcomes revealed both a significant increase in UTIs when the catheter was left in for more than 48 hours and a reduction in hospital length of stay when it was removed within 48 hours (Fernandez & Griffiths, 2006). Even without a catheter, older patients are at increased risk for UTIs due to age-related physiological changes, functional abnormalities (such as prostate enlargement), the use of medications that promote urinary retention, and chronic diseases that increase infection risk or impair bladder function.
Hospital-acquired pneumonia (HAP) is the second most common type of nosocomial infection after UTIs, with an estimated mortality rate of 20% to 46% (Arozullah, Khuri, Henderson, Paley, & Daley, 2001), and is the third most common postoperative complication after urinary tract and wound infections. Patients receiving continuous mechanical ventilation have a six- to twenty-one-fold increased risk of developing bacterial HAP (CDC, 2003). Pulmonary aspiration of secretions from the oropharyngeal or gastrointestinal tract is the most common cause of HAP and is considered preventable in the majority of cases (Weitzel, Robinson, & Holmes, 2006).
Hospital-acquired bloodstream infections are common, serious, and costly infections that are a leading cause of death in this country (Wenzel & Edmond, 2001). These infections are most often related to the use of invasive devices, and more than 50% occur in critically ill patients. Catheter-associated bloodstream infections (CABSIs) are serious infections in ICU patients, occurring in 3% to 7% of all patients with central venous catheters (Warren, Zack, Cox, Cohen, & Fraser, 2003), associated with increased mortality and cost (Shannon et al., 2006).
Surgical site infections (SSIs) are the most common type of nosocomial infection in patients undergoing surgery and are associated with prolonged and more costly hospitalizations (Malone, Genuit, Tracy, Gannon, & Napolitano, 2002). Patients with SSIs are also twice as likely to die, 60% more likely to be admitted to the ICU, and five times more likely to be hospitalized than patients who do not develop SSIs (Kirkland, Briggs, Trivette, Wilkinson, & Sexton, 1999). Gram-positive organisms account for the majority of bacterial infections (Malone et al., 2002). Although the risk of SSIs varies according to the type of surgery and patient-specific factors, evidence demonstrates that factors related to the hospital itself, such as practice patterns and the environment of care, significantly increase the risk of patient harm (Hollenbeak et al., 2006).
Other infections commonly affecting hospitalized older patients include those impacting the gastrointestinal tract, such as Clostridium difficile (C. difficile) colitis, and the skin, such as methicillin-resistant Staphylococcus aureus (MRSA). C. difficile infections are affecting significant numbers of hospitalized older patients. It is estimated that 20% to 40% of hospitalized patients are colonized with the C. difficile toxin compared to 2% to 3% of healthy adults (Bartlett, 2006). Fifteen percent to 25% of patients with antibiotic-associated diarrhea, and more than 95% with pseudomembranous colitis, carry the C. difficile toxin, which is becoming more refractory to treatment and more prone to relapse (Freeman et al., 2010; Dubberke et al., 2010).
The alarming increase in antimicrobial-resistant organisms, such as MRSA and vancomycin-resistant enterococcus (VRE), is of great concern. Patients older than 80 years are at significantly greater risk for being carriers of MRSA (Eveillard, Mortier, et al., 2006). MRSA increased in prevalence from 2% of S. aureus infections in 1974 to 63% in 2004, while VRE has steadily increased from less than 1% in 1990 to 28.5% of enterococcal isolates in 2003 (CDC, 2006). On a positive note, a more recent review from nine U.S. hospitals suggests that MRSA decreased by 9.4% per year from 2005 to 2008 (Kallen et al., 2010). Vancomycin resistance has been shown to be an independent risk factor for death and is associated with poor patient outcomes, including longer lengths of stay, increased mortality, and higher costs of care (Salgado & Farr, 2003). More recently, the increase in multidrug-resistant organisms has been associated with significantly longer hospital stays, increased costs, and higher mortality.