Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information.

Gail Keenan; Elizabeth Yakel; Karen Dunn Lopez; Dana Tschannen; Yvonne B Ford

Study

Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information.

March 13, 2013

Keenan G, Yakel E, Lopez KD, et al. J Am Med Inform Assoc. 2013;20(2):245-51.

View more articles from the same authors.

Direct observation of ward nurses' communication patterns revealed that poor interdisciplinary communication and the lack of a readily accessible care plan overview within the electronic medical record greatly inhibited nurses' situational awareness.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Nurse workarounds in the electronic health record: an integrative review.

August 12, 2020

Effects of individual nurse and hospital characteristics on patient adverse events and quality of care: a multilevel analysis.

October 24, 2018

Safety culture, patient safety, and quality of care outcomes: a literature review.

January 31, 2018

Do staffing levels predict missed nursing care?

June 29, 2011

Targeted communication intervention using nursing crew resource management principles.

March 25, 2015

Effective followership: a standardized algorithm to resolve clinical conflicts and improve teamwork.

August 12, 2015

National estimates of adverse events during nonpsychiatric hospitalizations for persons with schizophrenia.

August 25, 2010

Patient safety events and harms during medical and surgical hospitalizations for persons with serious mental illness.

June 1, 2016

Patient, provider, and system factors contributing to patient safety events during medical and surgical hospitalizations for persons with serious mental illness.

August 9, 2017

Doctors' stress responses and poor communication performance in simulated bad-news consultations.

December 9, 2009

Emotional safety is patient safety.

February 15, 2023

Older veterans and emergency department discharge information.

October 10, 2012

Self-reported patient safety competence among Canadian medical students and postgraduate trainees: a cross-sectional survey.

February 4, 2015

Patient safety: the patient's role.

February 14, 2007

Information distortion in physicians' diagnostic judgments.

July 18, 2012

Surgical site verification: A through Z.

November 22, 2006

Information handoff and outcomes of critically ill patients transferred between hospitals.

November 2, 2016

Surveillance: a strategy for improving patient safety in acute and critical care units.

April 18, 2012

Clinicians' insights on emergency department boarding: an explanatory mixed methods study evaluating patient care and clinician well-being.

August 23, 2023

Patient safety issues continue to plague American hospitals.

August 14, 2019

Speaking up to reduce noise in the OR.

July 22, 2015

Follow-up tips for a safe, efficient practice.

May 31, 2006

Medical errors: should you apologize?

May 3, 2006

Undergraduate baccalaureate nursing students' self-reported confidence in learning about patient safety in the classroom and clinical settings: an annual cross-sectional study (2010–2013).

June 17, 2015

Implementation and spread of a simple and effective way to improve the accuracy of medicines reconciliation on discharge: a hospital-based quality improvement project and success story.

September 11, 2019

Primary care–relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force.

January 19, 2011

Incident learning in radiation oncology: a review.

August 15, 2018

Peer support in anesthesia: turning war stories into wellness.

August 15, 2018

A piece of my mind. Coping with fallibility.

March 6, 2005

Educational strategy to reduce medication errors in a neonatal intensive care unit.

May 13, 2009

Medication errors in a neonatal intensive care unit. Influence of observation on the error rate.

September 3, 2008

An evaluation of a collaborative, safety focused, nurse–pharmacist intervention for improving the accuracy of the medication history.

November 20, 2013

Reforming the Veterans Health Administration—beyond palliation of symptoms.

October 14, 2015

The impact of health system membership on patient safety initiatives.

January 9, 2008

Using care bundles to reduce in-hospital mortality: quantitative survey.

April 14, 2010

Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration.

February 17, 2010

The impact of a computerized physician order entry system on medical errors with antineoplastic drugs 5 years after its implementation.

August 12, 2015

Root causes and preventability of unintentionally retained foreign objects after surgery: a national expert survey from Switzerland.

July 19, 2023

A check-up for safety culture in "my patient care area."

November 14, 2007

Organization and representation of patient safety data: current status and issues around generalizability and scalability.

March 6, 2005

Pharmacy–nursing intervention to improve accuracy and completeness of medication histories.

April 28, 2010

Team training of medical students in the 21st century: would Flexner approve?

February 17, 2010

Hospital responses to the Leapfrog Group in local markets.

February 20, 2008

Follow-up of outpatient test results: a survey of house-staff practices and perceptions.

May 24, 2006

Improving hospital safety culture for falls prevention through interdisciplinary health education.

December 23, 2020

"Saying sorry": some strategies for effective apology within the workplace.

January 23, 2019

The preventive surgical site infection bundle in colorectal surgery: an effective approach to surgical site infection reduction and health care cost savings.

September 10, 2014

Recognizing our biases, understanding the evidence, and responding equitably: application of the socioecological model to reduce racial disparities in the NICU.

March 8, 2023

Integration of a formalized handoff system into the surgical curriculum: resident perspectives and early results.

January 26, 2011

Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system.

January 16, 2013

Managed care penetration and other factors affecting computerized physician order entry in the ambulatory setting.

March 7, 2007

The heart of darkness: the impact of perceived mistakes on physicians.

March 6, 2005

What are we doing when we double check?

April 1, 2020

Patient safety threats in information management using health information technology in ambulatory cancer care: an exploratory, prospective study.

June 10, 2020

Medication double-checking procedures in clinical practice: a cross-sectional survey of oncology nurses' experiences.

September 7, 2016

Factors influencing a nurse's decision to question medication administration in a neonatal clinical care unit.

June 29, 2016

Oncology nurses' beliefs and attitudes towards the double-check of chemotherapy medications: a cross-sectional survey study.

March 21, 2018

Motivational antecedents of incident reporting: evidence from a survey of nurses and physicians.

November 27, 2013

Healthcare failure mode and effect analysis in the chemotherapy preparation process.

November 17, 2021

Data as a catalyst for change: stories from the frontlines.

February 11, 2015

Examining medical office owners and clinicians perceptions on patient safety climate.

November 7, 2018

How differences between manager and clinician perceptions of safety culture impact hospital processes of care.

February 14, 2018

Examination of the relationship between management and clinician perception of patient safety climate and patient satisfaction.

June 7, 2017

Case study: getting boards on board at Allen Memorial Hospital, Iowa Health System.

April 2, 2008

Driving improvement in patient care: lessons from Toyota.

March 6, 2005

Incomplete EHR adoption: late uptake of patient safety and cost control functions.

September 19, 2007

Iatrogenic delirium and coma: a "near miss."

May 21, 2008

Medical record review of deaths, unexpected intensive care unit admissions and clinician referrals: detection of adverse events and insight into the system.

November 9, 2005

Protocolization of analgesia and sedation through smart technology in intensive care: improving patient safety.

September 6, 2023

Pharmacist-led intervention on the reduction of inappropriate medication use in patients with heart failure: a systematic review of randomized trials and non-randomized intervention studies.

August 18, 2021

Promoting patient safety using an early warning scoring system.

August 27, 2008

The relationship between the nursing work environment and the occurrence of reported paediatric medication administration errors: a pan Canadian study.

October 2, 2013

Chemotherapy in home care: one team's performance improvement journey toward reducing medication errors.

October 12, 2011

The relationship between nursing experience and education and the occurrence of reported pediatric medication administration errors.

April 27, 2016

Simulation, mastery learning and healthcare.

March 1, 2017

Investigating patient safety culture across a health system: multilevel modelling of differences associated with service types and staff demographics.

July 25, 2012

Practising open disclosure: clinical incident communication and systems improvement.

January 7, 2009

Computerized physician order entry in the cardiac intensive care unit: effects on prescription errors and workflow conditions.

April 30, 2014

Adverse drug events in U.S. adult ambulatory medical care.

May 25, 2011

Reducing falls and fall-related injuries in mental health: a 1-year multihospital falls collaborative.

November 13, 2013

Effect of electronic health records in ambulatory care: retrospective, serial, cross sectional study.

April 15, 2005

Safety strategies in an academic radiation oncology department and recommendations for action.

January 30, 2005

Measuring hospital-acquired complications associated with low-value care.

March 6, 2019

Patient self-medication--a change in hospital practice.

August 23, 2006

Quality in cancer diagnosis.

May 26, 2010

Factors contributing to preventing operating room "never events": a machine learning analysis.

May 10, 2023

Transitioning between electronic health records: effects on ambulatory prescribing safety.

May 4, 2011

Signal and noise: applying a laboratory trigger tool to identify adverse drug events among primary care patients.

August 1, 2012

How do black-serving hospitals perform on patient safety indicators?: Implications for national public reporting and pay-for-performance.

December 1, 2010

Using inpatient hospital discharge data to monitor patient safety events.

May 8, 2013

Nurses' perceived skills and attitudes about updated safety concepts: impact on medication administration errors and practices.

June 28, 2017

Rolling out the rapid response team.

June 1, 2011

Is there a benefit to multidisciplinary rounds in an open trauma intensive care unit regarding ventilator-associated pneumonia?

February 3, 2010

The many faces of error disclosure: a common set of elements and a definition.

April 4, 2007

Diagnosis is a team sport—partnering with allied health professionals to reduce diagnostic errors: a case study on the role of a vestibular therapist in diagnosing dizziness.

July 27, 2016

A piece of my mind. Mentorship malpractice.

April 20, 2016

Experience with family activation of rapid response teams.

October 6, 2010

Medical emergency team implementation: experiences of a mentor hospital.

December 17, 2008

Using the NAM diagnostic process framework to teach clinical reasoning in computerized case presentations to 251 medical students.

September 9, 2020

The contribution of nurses to incident disclosure: a narrative review.

August 28, 2013

Related Resources

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Patient Safety Innovations

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

May 31, 2023

Danger in discharge summaries: abbreviations create confusion for both author and recipient.

May 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Interview

In Conversation with Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

April 26, 2023

Perspective

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

April 26, 2023

Measuring team hierarchy during high-stakes clinical decision making: development and validation of a new behavioral observation method.

April 12, 2023

Journal Article

Study

Demonstrating the value of a standardized cognitive assessment tool through the use of interprofessional rapid safety rounds.

March 29, 2023

Safety risks and workflow implications associated with nursing-related free-text communication orders.

March 15, 2023

Factors differentiating nursing homes with strong resident safety climate: a qualitative study of leadership and staff perspectives.

February 15, 2023

Communication during interhospital transfers of emergency general surgery patients: a qualitative study of challenges and opportunities.

October 26, 2022

WebM&M Cases

Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan.

September 28, 2022

WebM&M Cases

Preventable Transfer to the Hospital

July 8, 2022

Associations between safety outcomes and communication practices among pediatric nurses in the United States.

January 19, 2022

Examining the meaning of the language used to communicate the nursing hand-off.

November 24, 2021

It's like sending a message in a bottle: a qualitative study of the consequences of one-way communication technologies in hospitals.

October 13, 2021

Facilitators and barriers of care transitions - comparing the perspectives of hospital and community healthcare staff.

June 16, 2021

Patient Safety Innovations

Project BOOST Increases Patient Understanding of Treatment and Follow-up Care

May 26, 2021

Strategies to prevent missed nursing care: an international qualitative study based upon a positive deviance approach.

May 12, 2021

Has the COVID pandemic strengthened or weakened health care teams? A field guide to healthy workforce best practices.

March 31, 2021

Understanding the peer, manager, and system influence on patient safety.

February 10, 2021

WebM&M Cases

Code Status vs. Care Status

December 23, 2020

Factors influencing physician responsiveness to nurse-initiated communication: a qualitative study.

December 2, 2020

Lost in translation--silent reporting and electronic patient records in nursing handovers: an ethnographic study.

November 18, 2020

Do falls and other safety issues occur more often during handovers when nurses are away from patients? Findings from a retrospective study design.

November 11, 2020

Communication through the electronic health record: frequency and implications of free text orders.

July 29, 2020

Is one-pen, one-patient achievable in the hospital? A quality improvement project to reduce risks of inadvertent insulin pen sharing at a large academic medical center.

January 29, 2020

The contribution of staffing to medication administration errors: a text mining analysis of incident report data.

December 18, 2019

Peer support for nurses as second victims: resilience, burnout, and job satisfaction.

November 20, 2019

Secure text messaging in healthcare: latent threats and opportunities to improve patient safety.

October 30, 2019

See More About The Topic

Hospitals

Nurse Managers

Quality and Safety Professionals

Information Professionals

Nursing

Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

Demonstrating the value of a standardized cognitive assessment tool through the use of interprofessional rapid safety rounds.

Project BOOST Increases Patient Understanding of Treatment and Follow-up Care

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information.

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

Demonstrating the value of a standardized cognitive assessment tool through the use of interprofessional rapid safety rounds.

Project BOOST Increases Patient Understanding of Treatment and Follow-up Care

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site