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Redley B, Douglas T, Hoon L, et al. J Adv Nurs. 2022;Epub Jul 7.
Frontline care providers such as nurses play an important role in reducing preventable harm. This study used qualitative methods (direct observation and participatory workshops) to explore nurses’ experiences implementing harm prevention practices when admitting an older adult to the hospital. Researchers identified barriers (e.g., lack of resources, information gaps) and enablers (e.g., teamwork, reminders) to harm prevention during the admission process.
McLeod PL, Cunningham QW, DiazGranados D, et al. Health Care Manag Rev. 2021;46:341-348.
Effective teamwork is critical to ensuring patient safety, particularly in intensive settings such as critical care. This paper describes a “hackathon” – an intensive problem-solving event commonly used in computer science designed to stimulate creative solutions – focused on the challenges encountered by rapid team formation in critical care settings (such as for cardiac resuscitation). Hackathon teams were multidisciplinary, comprised of healthcare professionals and academics with expertise in communications, psychology and organizational sciences. The paper briefly discusses the three solutions proposed, and the impacts of leveraging this approach for solving other problems specific to health care management.
Hendrickson MA, Schempf EN, Furnival RA, et al. Jt Comm J Qual Patient Saf. 2019;45:431-439.
This project report describes a novel procedure for handoffs from the emergency department to the inpatient service. The study team implemented a daily conference call that included nurses, residents, and attending physicians rather than separating physician and nursing handoff workflows. The overall reaction to the interdisciplinary workflow was positive.
Dietz AS, Salas E, Pronovost PJ, et al. Crit Care Med. 2018;46:1898-1905.
This study aimed to validate a behavioral marker as a measure of teamwork, specifically in the intensive care unit setting. Researchers found that it was difficult to establish interrater reliability for teamwork when observing behaviors and conclude that assessment of teamwork remains complex in the context of patient safety research.
Duffy JR, Culp S, Padrutt T. J Nurs Adm. 2018;48:361-367.
Prior research has shown that missed nursing care may in part result from reduced nurse staffing and is associated with adverse outcomes for patients. Using survey data from a sample of nurses at a single community hospital, researchers found that reduced nurse staffing, lower job satisfaction, and decreased satisfaction with teamwork were important factors related to missed nursing care.
BMJ Qual Saf. 2011;22.
Silence and poor communication are known threats to patient safety. Despite efforts to promote teamwork and develop shared tools for communication, there are persistent gaps between nurse and physician practices. This study surveyed nurses and physicians working in labor and delivery units and discovered significant differences in their perceptions of patient harm associated with various clinical scenarios. These differences in patient harm ratings were the greatest predictor of speaking up, suggesting that differences in clinical assessment may serve as a useful target for intervention. The authors discuss the negative impact of environments where mental models are not shared, conflict is poorly managed, and disruptive behaviors stifle open communication. A past AHRQ WebM&M commentary discussed a case of "silence" when members of the operating room team were reluctant to speak up to a senior surgeon.
A young woman with Takayasu's arteritis, a vascular condition that can cause BP differences in each arm, was mistakenly placed on a powerful intravenous vasopressor because of a spurious low BP reading. The medication could have led to serious complications.