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Approach to Improving Safety
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Search results for "Health Care Executives and Administrators"

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Meeting/Conference > New Jersey Meeting/Conference

ISMP Medication Safety Intensive.

Institute for Safe Medication Practices. September 21-22, 2017, Maggiano's Little Italy Hackensack, Hackensack, NJ.

This workshop will explore tactics to ensure medication safety, including strategic planning, risk assessment, and Just Culture principles.

Journal Article > Commentary

Implementation of a modified bedside handoff for a postpartum unit.

Wollenhaup CA, Stevenson EL, Thompson J, Gordon HA, Nunn G. J Nurs Adm. 2017;47:320-326.

Ineffective team communication can contribute to sentinel events. This commentary describes how a rural hospital's postpartum unit redesigned its handoff process to create a bedside handoff model and utilized structured educational modalities and nurse champions to drive improvement and acceptance of the approach.

Journal Article > Commentary

AORN Position Statement on Patient Safety.

AORN J. 2017;105:501-502.

This position statement outlines recommendations from the Association of periOperative Registered Nurses on core components of safe perioperative nursing and its role in strengthening patient safety. Elements discussed include error reduction, patient engagement, and appropriate staffing levels.

Journal Article > Study

Cost–benefit analysis of a support program for nursing staff.

Moran D, Wu AW, Connors C, et al. J Patient Saf. 2017 Apr 27; [Epub ahead of print].

Medical errors and adverse events can have a devastating psychological impact on the providers involved, often referred to as second victims. Increasingly, health care institutions are implementing programs designed to provide emotional support to team members who experience emotional distress as a result of adverse events. This study provides an economic cost–benefit evaluation of the Resiliency In Stressful Events (RISE) program at Johns Hopkins Hospital. Investigators estimate a savings of $22,576.05 per nurse who used the RISE program and suggest that the hospital might save as much as $1.81 million annually as a result of RISE. These findings are consistent with a previous study, which demonstrated the positive impact of an emotional support program on work-related outcomes such as turnover intentions and absenteeism. In a past PSNet perspective, Susan Scott discussed the second victim phenomenon and its impact on health care providers.

Journal Article > Study

Does a checklist reduce the number of errors made in nurse-assembled discharge prescriptions?

Byrne C, Sierra H, Tolhurst R. Br J Nurs. 2017;26:464-467.

Checklists can improve patient safety across multiple settings. This pre–post study found that use of a checklist to help nurses dispense medications upon hospital discharge led to a reduction in errors in discharge prescriptions.

Journal Article > Study

Exploring the experience of nurse practitioners who have committed medical errors: a phenomenological approach.

Delacroix R. J Am Assoc Nurse Pract. 2017 Apr 27; [Epub ahead of print].

This qualitative interview study of nurse practitioners who had made errors found that they experience complex reactions, including self-blame, concern for the patient, worries about their professional future, and feelings of failure. These results echo prior work about health care team members as second victims of medical errors.

Journal Article > Study

Safety and efficiency of a new generic package labelling: a before and after study in a simulated setting.

Garcia BH, Elenjord R, Bjornstad C, Halvorsen KH, Hortemo S, Madsen S. BMJ Qual Saf. 2017 Apr 21; [Epub ahead of print].

Look-alike and sound-alike medications can be erroneously substituted for each other, leading to adverse drug events. Use of nonproprietary medication names can prevent look-alike and sound-alike errors. In this simulation study, investigators compared how nurses handle medication packages with a prominent nonproprietary name versus standard medication packages. Participants prepared medications with nonproprietary labeling more quickly, but errors were rare across all packaging types.

Book/Report

Quality and Safety in Nursing: a Competency Approach to Improving Outcomes, Second Edition.

Sherwood G, Barnsteiner J, eds. Hoboken, NJ: Wiley-Blackwell. ISBN: 9781119151678.

The Crossing the Quality Chasm report provided a framework to improve quality and safety in health care. This publication draws on the six aims for quality outlined in the report to review core competencies, knowledge, and attitudes for safe nursing care. Topics covered include nurses as leaders, teamwork, and patient-centered care.

Journal Article > Study

Video analysis of factors associated with response time to physiologic monitor alarms in a children's hospital.

Bonafide CP, Localio AR, Holmes JH, et al. JAMA Pediatr. 2017 Apr 10; [Epub ahead of print].

Bedside monitors alert nurses to clinical deterioration. This prospective observational study examined nurse responses to bedside physiologic monitors. The mean response time was over 10 minutes. Less than 1% of alarms were actionable, underscoring the importance of addressing alarm fatigue.

Journal Article > Study

Nursing interruptions in a trauma intensive care unit: a prospective observational study.

Craker NC, Myers RA, Eid J, et al. J Nurs Adm. 2017;47:205-211.

Interruptions are a known patient safety hazard. This direct observation study demonstrated that intensive care unit nurses were interrupted about every 20 minutes. Interruptions by physicians were of longer duration and were more likely to result in the nurse moving to another activity. The authors conclude that further study is needed to determine the clinical significance of interruptions in the intensive care unit setting.

Journal Article > Study

Organizational perspectives of nurse executives in 15 hospitals on the impact and effectiveness of rapid response teams.

Smith PL, McSweeney J. Jt Comm J Qual Patient Saf. 2017;43:289–298.

According to this survey of nursing leaders, they perceived that rapid response teams improve patient outcomes and safety culture. Evaluations of rapid response were usually informal and often did not capture standardized data. The authors advocate for future research to examine what different types of hospitals perceive as valuable in rapid response teams.

Journal Article > Study

Operational failures detected by frontline acute care nurses.

Stevens KR, Engh EP, Tubbs-Cooley H, et al. Res Nurs Health. 2017;40:197-205.

This prospective reporting study asked frontline nurse participants to record operational failures, or breakdowns in usual care processes, in the course of their usual work. Nurses recorded about six such failures per shift, suggesting that systems failures are common in acute care settings.

Journal Article > Study

Common predictors of nurse-reported quality of care and patient safety.

Stimpfel AW, Djukic M, Brewer CS, Kovner CT. Health Care Manage Rev. 2017 Mar 3; [Epub ahead of print].

Researchers analyzed survey data from 731 nurses to understand predictors of nurse-reported quality of care and patient safety. They found that both job satisfaction and organizational constraints were significant predictors of quality and safety.

Journal Article > Review

New graduate registered nurses' knowledge of patient safety and practice: a literature review.

Murray M, Sundin D, Cope V. J Clin Nurs. 2017 Mar 2; [Epub ahead of print].

This review spotlights the importance of closing the theory–practice gap for nurses just entering independent practice and discusses methods employed to address the potential for error during this transformative period.

Journal Article > Review

Evaluating situation awareness: an integrative review.

Orique SB, Despins L. West J Nurs Res. 2017 Mar 1; [Epub ahead of print].

Situation awareness in teams contributes to their reliability. Examining tools to monitor situation awareness among nurses, this review determined that measures to track this safety behavior are lacking. A WebM&M commentary discussed situation awareness and patient safety.

Journal Article > Commentary

Learning and mindfulness: improving perioperative patient safety.

Graling PR, Sanchez JA. AORN J. 2017;105:317-321.

The surgical environment is complex, and strategies to address human error and learn from mistakes are important to improve safety in this setting. This commentary discusses how organizational learning and mindfulness can help perioperative staff manage and prevent missteps in the operating room.

Journal Article > Commentary

Using simulation to prepare nursing staff for the move to a new building.

Knippa S, Senecal PA. J Nurses Prof Dev. 2017;33:E1-E5.

Simulation provides opportunities to test skills in a variety of situations to improve safety and efficiency. This commentary describes the application of a simulation strategy to prepare nursing staff for a new environment to reduce risks.

Journal Article > Study

Effectiveness of a 'Do not interrupt' bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study.

Westbrook JI, Li L, Hooper TD, Raban MZ, Middleton S, Lehnbom EC. BMJ Qual Saf. 2017 Feb 23; [Epub ahead of print].

This randomized controlled trial had nurses on four hospital wards wear "do not interrupt" vests during medication administration. The rate of interruptions the intervention nurses experienced was compared to the rate in four control wards that did not have nurses wear vests. Although the intervention reduced non–medication-related interruptions, nurses reported that the vests were time consuming and uncomfortable; less than half would support continuing the intervention. This study demonstrates the need to design and test sustainable interventions to improve patient safety.

Journal Article > Commentary

Opioids for pain management in older adults: strategies for safe prescribing.

Davies PS. Nurse Pract. 2017;42:20-26.

Use of opioids for pain management in older adults can contribute to various problems, including fall-related injury and delirium. This commentary discusses the role of nurse practitioners as prescribers of opioids and offers practice recommendations to reduce risks.

Journal Article > Commentary

Medication governance: preventing errors and promoting patient safety.

Kavanagh C. Br J Nurs. 2017;26:159-165.

Medication errors are a significant challenge to patient safety. Discussing various factors that weaken the medication administration process, this commentary highlights collaboration, safety culture, and curriculum development as tactics to enhance the role of nurses and nurse educators in improving medication safety.

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