Teamwork, clinical leadership skills and environmental factors that influence missed nursing care - a qualitative study on hospital wards.

Christien Beiboer; Richtsje Andela; Thóra B Hafsteinsdóttir; Saskia Weldam; Tjitske Holtrop; Margreet van der Cingel

Study

Teamwork, clinical leadership skills and environmental factors that influence missed nursing care - a qualitative study on hospital wards.

May 3, 2023

Beiboer C, Andela R, Hafsteinsdóttir TB, et al. Nurse Educ Pract. 2023;68:103603.

View more articles from the same authors.

Myriad factors contribute to missed nursing care including staffing, team and group norms, and teamwork. Nurses in this study described four themes that contributed to missed nursing care: teamwork in nursing wards; informal teaching and communication; influence of formal and informal leaders; and influencing factors in nurses’ work environment. Developing nurses' clinical leadership skills may improve teamwork and reduce missed care.

PubMed citation

Available at

Related Resources From the Same Author(s)

Diagnostic accuracy of emergency nurse practitioners versus physicians related to minor illnesses and injuries.

August 4, 2010

Risky procedures by nurses in hospitals: problems and (contemplated) refusals of orders by physicians, and views of physicians and nurses: a questionnaire survey.

September 28, 2005

Explaining the negative effects of patient participation in patient safety: an exploratory qualitative study in an academic tertiary healthcare centre in the Netherlands.

February 1, 2023

The safety of Australian healthcare: 10 years after QAHCS.

April 15, 2005

If only...: failed, missed and absent error recovery opportunities in medication errors.

March 10, 2010

Design and implementation of an ICU incident registry.

November 1, 2006

Inappropriate prescriptions of direct oral anticoagulants (DOACs) in hospitalized patients: a narrative review.

May 10, 2023

Understanding handling of drug safety alerts: a simulation study.

May 5, 2010

Turning off frequently overridden drug alerts: limited opportunities for doing it safely.

May 21, 2008

Prioritising recommendations following analyses of adverse events in healthcare: a systematic review.

November 4, 2020

Evaluating the medication process in the context of CPOE use: the significance of working around the system.

May 25, 2011

Overriding of drug safety alerts in computerized physician order entry.

January 11, 2006

'Providing good and comfortable care by building a bond of trust': nurses views regarding their role in patients' perception of safety in the intensive care unit.

November 11, 2015

Where are my instruments? Hazards in delivery of surgical instruments.

August 10, 2016

Relating faults in diagnostic reasoning with diagnostic errors and patient harm.

February 8, 2012

Functional safety of health information technology.

April 18, 2012

Impact of a computerized physician order entry system on nurse-physician collaboration in the medication process.

February 4, 2009

Defining near misses: towards a sharpened definition based on empirical data about error handling processes.

June 23, 2010

Organizational culture, team climate and diabetes care in small office-based practices.

October 8, 2008

High-risk medication in home care nursing: a Delphi study.

September 7, 2022

Time-dependent drug–drug interaction alerts in care provider order entry: software may inhibit medication error reductions.

December 2, 2009

The nature and causes of unintended events reported at ten emergency departments.

October 14, 2009

Measuring patient safety culture: an assessment of the clustering of responses at unit level and hospital level.

August 26, 2009

Same system, different outcomes: comparing the transitions from two paper-based systems to the same computerized physician order entry system.

September 24, 2008

Improving clinical handover between intensive care unit and general ward professionals at intensive care unit discharge.

March 18, 2015

Opioids and falls risk in older adults: a narrative review.

May 25, 2022

Accuracy of pediatric trauma field triage: a systematic review.

May 30, 2018

How would final-year medical students perform if their skill-based prescription assessment was real life?

February 22, 2023

Investigating US medical students' motivation to respond to lapses in professionalism.

October 3, 2018

Strategies to reduce the risk of iatrogenic illness in complex older adults.

May 15, 2013

Improving patient safety in the ICU by prospective identification of missing safety barriers using the Bow-Tie prospective risk analysis model.

October 2, 2013

The psychometric properties of the 'Hospital Survey on Patient Safety Culture' in Dutch hospitals.

January 21, 2009

The attributes of medical event reporting systems.

March 27, 2005

How does audit and feedback influence intentions of health professionals to improve practice? A laboratory experiment and field study in cardiac rehabilitation.

April 12, 2017

A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non-routine events, teamwork and patient outcomes.

July 6, 2011

Dedicated teams to optimize quality and safety of surgery: a systematic review.

November 16, 2022

Electromagnetic interference from radio frequency identification inducing potentially hazardous incidents in critical care medical equipment.

July 2, 2008

The next step in learning from sentinel events in healthcare.

April 15, 2020

The role of patient safety culture in the causation of unintended events in hospitals.

February 20, 2013

Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with computer simulation.

June 9, 2021

Integration of prospective and retrospective methods for risk analysis in hospitals.

November 11, 2009

To what extent are adverse events found in patient records reported by patients and healthcare professionals via complaints, claims and incident reports?

January 30, 2005

Common contributing factors of diagnostic error: a retrospective analysis of 109 serious adverse event reports from Dutch hospitals.

August 23, 2023

Risk factors for clinically relevant deviations in patients' medication lists reported by patients in personal health records: a prospective cohort study in a hospital setting.

March 2, 2022

About politeness, face, and feedback: exploring resident and faculty perceptions of how institutional feedback culture influences feedback practices.

September 26, 2018

Clinical reasoning in the context of active decision support during medication prescribing.

April 5, 2017

Variation in the rates of adverse events between hospitals and hospital departments.

February 9, 2011

Design of a retrospective patient record study on the occurrence of adverse events among patients in Dutch hospitals.

March 14, 2007

Multiprofessional team simulation training, based on an obstetric model, can improve teamwork in other areas of health care.

April 9, 2014

Prospective risk analysis of health care processes: a systematic evaluation of the use of HFMEA in Dutch health care.

July 15, 2009

Patient record review of the incidence, consequences, and causes of diagnostic adverse events.

July 7, 2010

Can a structured checklist prevent problems with laparoscopic equipment?

July 23, 2008

Patient safety in primary allied health care: what can we learn from incidents in a Dutch exploratory cohort study?

November 16, 2011

Crew resource management in the intensive care unit: a prospective 3-year cohort study.

July 1, 2015

Understanding how the design and implementation of online consultations affect primary care quality: systematic review of evidence with recommendations for designers, providers, and researchers.

November 30, 2022

Specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident reports.

June 10, 2009

Do patients' disruptive behaviours influence the accuracy of a doctor's diagnosis? A randomised experiment.

March 23, 2016

Strengths and weaknesses in the diagnostic process of endometriosis from the patients' perspective: a focus group study.

September 15, 2021

Exploring the causes of adverse events in hospitals and potential prevention strategies.

February 24, 2010

Classification of medication incidents associated with information technology.

October 9, 2013

Performance variability in perioperative sentinel events: report on a nationwide data set.

April 20, 2022

Potentially inappropriate medications and their effect on falls during hospital admission.

March 23, 2022

Prevalence of medication transfer errors in nephrology patients and potential risk factors.

November 6, 2019

Overall performance of a drug-drug interaction clinical decision support system: quantitative evaluation and end-user survey.

April 13, 2022

Drug–drug interactions that should be non-interruptive in order to reduce alert fatigue in electronic health records.

October 31, 2012

Delayed recognition of deterioration of patients in general wards is mostly caused by human related monitoring failures: a root cause analysis of unplanned ICU admissions.

September 7, 2016

Prognosis of undiagnosed chest pain: linked electronic health record cohort study.

April 19, 2017

Mortality review as a tool to assess the contribution of healthcare-associated infections to death: results of a multicentre validity and reproducibility study, 11 European Union countries, 2017 to 2018.

August 4, 2021

The effect of structured medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients - a multicenter interrupted time series study.

August 10, 2022

Information technology cannot guarantee patient safety.

May 2, 2007

February 26, 2020

Evaluation of a predevelopment service delivery intervention: an application to improve clinical handovers.

October 17, 2012

Building safer systems by ecological design: using restoration science to develop a medication safety intervention.

April 12, 2006

Experiences with Lean Six Sigma as improvement strategy to reduce parenteral medication administration errors and associated potential risk of harm.

July 26, 2017

Important factors for effective patient safety governance auditing: a questionnaire survey.

January 30, 2019

Gender biases and diagnostic delay in inflammatory bowel disease: multicenter observational study.

February 15, 2023

Standardization in patient safety: the WHO High 5s project.

June 4, 2014

Clinical diagnoses vs. autopsy findings in early deceased septic patients in the intensive care: a retrospective cohort study.

July 28, 2021

Association between workarounds and medication administration errors in bar-code-assisted medication administration in hospitals.

April 25, 2018

Barriers and success factors to the implementation of a multi-site prospective adverse event surveillance system.

July 23, 2014

A multi-facetted patient safety resource--a qualitative interview study on hospital managers' perception of the nurse-led Rapid Response Team.

August 23, 2023

February 13, 2008

Implementation and evaluation of a laboratory safety process improvement toolkit.

May 22, 2019

Impact of interactions between drugs and laboratory test results on diagnostic test interpretation—a systematic review.

November 21, 2018

Diagnostic error as a result of drug-laboratory test interactions.

March 6, 2019

Separate medication preparation rooms reduce interruptions and medication errors in the hospital setting: a prospective observational study.

February 15, 2017

International comparability of patient safety indicators in 15 OECD member countries: a methodological approach of adjustment by secondary diagnoses.

January 30, 2005

A World Health Organization field trial assessing a proposed ICD-11 framework for classifying patient safety events.

November 15, 2017

Recommendations to improve the usability of drug–drug interaction clinical decision support alerts.

November 25, 2015

Detection of postoperative respiratory failure: how predictive is the Agency for Healthcare Research and Quality's Patient Safety Indicator?

September 29, 2010

Opportunities and challenges for quality and safety applications in ICD-11: an international survey of users of coded health data.

February 17, 2016

Using social and behavioural science to support COVID-19 pandemic response.

June 3, 2020

Effect of a pharmacy-based centralized intravenous admixture service on the prevalence of medication errors: a before-and-after study.

August 10, 2022

Interventions to improve team effectiveness: a systematic review.

November 18, 2009

Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents.

October 6, 2010

Why do doctors make mistakes? A study of the role of salient distracting clinical features.

December 11, 2013

January 19, 2011

Medication reconciliation performed by pharmacy technicians at the time of preoperative screening.

July 29, 2009

Systematic literature review on the effectiveness and safety of paediatric hospital-at-home care as a substitute for hospital care.

May 17, 2023

Effect of automated unit dose dispensing with barcode scanning on medication administration errors: an uncontrolled before-and-after study.

December 1, 2021

Related Resources

Intensive care unit critical incident analysis as an objective tool to select content for a simulation curriculum.

September 13, 2023

Dangers and deaths around black pregnancies seen as a ‘completely preventable’ health crisis.

September 6, 2023

Interview

In Conversation with Kathleen Sanford and Sue Schuelke about Virtual Nursing

August 30, 2023

Perspectives on Safety

Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges

August 30, 2023

Identifying failure modes in telemedicine: an instructional needs assessment.

August 9, 2023

The impact of safety culture, quality of care, missed care and nurse staffing on patient falls: a multisource association study.

June 28, 2023

Context matters: toward a multilevel perspective on context in clinical reasoning and error.

June 21, 2023

Clinical Investigation Booking Systems Failures: Written Communications in Community Languages.

May 31, 2023

Nurse staffing and inpatient mortality in the English National Health Service: a retrospective longitudinal study.

May 3, 2023

Ensuring competency and safety when onboarding newly hired professional staff.

May 3, 2023

Floating to intensive care units: nurses' messages for instant action to promote patient safety.

May 3, 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

In situ simulation-based team training and its significance for transfer of learning to clinical practice--a qualitative focus group interview study of anaesthesia personnel.

April 19, 2023

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

April 12, 2023

Reducing risks in complex care transitions in rural areas: a grounded theory.

March 22, 2023

WebM&M Cases

Agitated Delirium Contributes to Missed Testing and Delayed Diagnosis of Gastric Perforation

March 15, 2023

Gender biases and diagnostic delay in inflammatory bowel disease: multicenter observational study.

February 15, 2023

Work environment and operational failures associated with nurse outcomes, patient safety, and patient satisfaction.

January 25, 2023

How to induce an error management climate: experimental evidence from newly formed teams.

November 2, 2022

Exploring care left undone in pediatric nursing.

September 28, 2022

Analyzing and discussing human factors affecting surgical patient safety using innovative technology: creating a safer operating culture.

August 31, 2022

Nurses' harm prevention practices during admission of an older person to the hospital: a multi-method qualitative study.

August 10, 2022

Speaking up or remaining silent about patient safety concerns in rehabilitation: a cross-sectional survey to assess staff experiences and perceptions.

July 6, 2022

Missed nursing care in the critical care unit, before and during the COVID-19 pandemic: a comparative cross-sectional study.

June 22, 2022

Psychological intervention to improve communication and patient safety in obstetrics: examination of the health action process approach.

April 13, 2022

WebM&M Cases

A Case of Mistaken Capacity: Why A Thorough Psychosocial History Can Improve Care.

March 31, 2022

TeamSTEPPS® for Diagnosis Improvement.

March 23, 2022

Analysis of the interprofessional clinical learning environment for quality improvement and patient safety from perspectives of interprofessional teams.

March 16, 2022

See More About The Topic

Hospitals

Quality and Safety Professionals

Nursing

Missed Care

Latent Errors

Teamwork, clinical leadership skills and environmental factors that influence missed nursing care - a qualitative study on hospital wards.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Teamwork, clinical leadership skills and environmental factors that influence missed nursing care - a qualitative study on hospital wards.

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