Missed or incomplete nursing care can adversely affect care quality and safety. Based on survey responses from 295 frontline nurses in the Philippines, this study explored factors contributing to missed nursing care during the COVID-19 pandemic. Findings suggest that nurses most frequently missed tasks such as patient surveillance, comforting patients, skin care, ambulation, and oral hygiene. The authors suggest that increasing nurse staffing, adequate use of personal protective equipment, and improved safety culture may reduce instances of missed care.
Li Q, Hu P, Kang H, et al. J Nutr Health Aging. 2020;25:492-500.
Missed and delayed diagnosis are a known cause of preventable adverse events. In this cohort of 107 patients with severe or critical COVID-19 in Wuhan, China, 45% developed acute kidney injury (AKI). However, nearly half of those patients (46%) were not diagnosed during their stay in the hospital. Patients with undiagnosed AKI experienced greater hospital mortality than those without AKI or diagnosed AKI. Involvement of intensive care kidney specialists is recommended to increase diagnostic awareness.
Ning H-C, Lin C-N, Chiu DT-Y, et al. PLoS One. 2016;11:e0160821.
Correct identification of patient specimens is crucial to timely and accurate diagnosis. This pre–post study demonstrated substantial improvements in already low rates of patient specimen identification errors following each of three successive strategies: discarding improperly labeled specimens, using barcodes, and automating specimen labeling.
Lin Y-K, Lin C-J, Chan H-M, et al. Injury. 2014;45:83-7.
Full-time trauma surgeons had a lower incidence of diagnostic errors (defined as the incidence of missed injuries in severely injured patients) compared with surgeons who primarily practiced in other specialties, according to this retrospective analysis of patients admitted to a Taiwanese surgical intensive care unit.
Berkenstadt H, Haviv Y, Tuval A, et al. Chest. 2008;134:158-62.
Simulation training is being widely implemented in health care, in settings ranging from the emergency department to the operating room. Acting in response to an incident of preventable hypoglycemia, this Israeli hospital conducted a simulation training exercise focusing on teamwork training for nurses, with the goal of improving patient handoffs. The intervention resulted in improvement in nurses' communication of critical information during handoffs.
Youk JH, Kim E-K, Kim MJ, et al. Radiographics. 2007;27:79-94.
The investigators reviewed evidence on ultrasonographic guidance for breast biopsy and provide suggestions on how to minimize sampling error and other problems associated with this diagnostic procedure.
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