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Search results for "Health Care Executives and Administrators"

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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 > Commentary

Implementation of the safety huddle.

Kylor C, Napier T, Rephann A, Spence SJ. Crit Care Nurse. 2016;36:80-82.

The safety huddle is becoming common within health care practice as a way to inform clinicians about what is happening during their shift. This commentary describes how huddles can help improve communication and teamwork in the acute care setting.

Journal Article > Study

Inattentional blindness and failures to rescue the deteriorating patient in critical care, emergency and perioperative settings: four case scenarios.

Jones A, Johnstone MJ. Aust Crit Care. 2017;30:219-223.

This qualitative study combined the narratives of various critical care nurses into four representative scenarios demonstrating failure to recognize clinically deteriorating patients. The authors describe inattentional blindness, a concept in which individuals in high-complexity environments can miss an important event because of competing attentional tasks, as a key factor in these failure-to-rescue events.

Journal Article > Study

The impact of interruptions on the duration of nursing interventions: a direct observation study in an academic emergency department.

Cole G, Stefanus D, Gardner H, Levy MJ, Klein EY. BMJ Qual Saf. 2016;25:457-465.

Interruptions are inevitable in the clinical environment, and they have been linked to an increased risk of diagnostic errors by radiologists and medication administration errors by nurses. However, the effects of interruptions are not predictable and many interruptions are essential for proper patient care. Recognizing this, commentators have called for research to analyze the causes and effects of interruptions, rather than attempting to categorically prevent interruptions. This study, conducted in an academic emergency department, contributes to our understanding of how interruptions influence patient care by examining the effect of interruptions on several specific nursing tasks. Interventions that were interrupted took longer than uninterrupted tasks, and interruptions were a significant contributor to overall nursing workload. Patients and families were the most frequent source of interruptions, demonstrating that simply implementing interventions to prevent interruptions could cause unintended consequences. The state of patient safety in the emergency department, including the role of interruptions, is discussed in a past AHRQ WebM&M perspective.

Journal Article > Study

A descriptive study of nurse-reported missed care in neonatal intensive care units.

Tubbs-Cooley HL, Pickler RH, Younger JB, Mark BA. J Adv Nurs. 2015;71:813-824.

This study surveyed nurses in neonatal intensive care units about missed nursing care. As in other care settings, missed nursing care is significant, and reasons include interruptions, urgent patient situations, and increases in patient volume. This finding underscores the need to enhance nursing workflow to prevent errors of omission.

Journal Article > Study

Designing a critical care nurse–led rapid response team using only available resources: 6 years later.

Mitchell A, Schatz M, Francis H. Crit Care Nurse. 2014;34:41-56.

This quality improvement initiative created a nurse-led rapid response team without additional staff costs. According to this study, a lower proportion of cardiac arrests occurred outside the intensive care unit (ICU) following implementation, but the concurrent addition of 26 ICU beds makes the finding difficult to interpret. The literature remains mixed regarding the benefits of rapid response teams.

Journal Article > Study

Changes in end-user satisfaction with computerized provider order entry over time among nurses and providers in intensive care units.

Hoonakker PL, Carayon P, Brown RL, Cartmill RS, Wetterneck TB, Walker JM. J Am Med Inform Assoc. 2013;20:252-259.

This study used serial surveys over a 1-year period to assess changes in physician and nurse satisfaction with a new computerized provider order entry system. Though nurses expressed considerable dissatisfaction initially, their satisfaction improved over time, whereas physicians were only moderately satisfied with the system both initially and after gaining more experience.

Journal Article > Study

Nurses' perceptions of patient safety climate in intensive care units: a cross-sectional study.

Ballangrud R, Hedelin B, Hall-Lord ML. Intensive Crit Care Nurs. 2012;28:344-354.

This survey of nurses in 10 Norwegian intensive care units found that most had a more positive perception of safety culture within their individual unit than for the hospital as a whole. The study used the AHRQ Hospital Survey on Patient Safety Culture.

Journal Article > Commentary

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

Henneman EA, Gawlinski A, Giuliano KK. Crit Care Nurse. 2012;32:e9-e18.

This commentary describes how surveillance can prevent adverse events and medical errors in critical care.

Journal Article > Study

Intensive care unit nurses' information needs and recommendations for integrated displays to improve nurses' situation awareness.

Koch SH, Weir C, Haar M, et al. J Am Med Inform Assoc. 2012;19:583-590.

The commonly used expression "missing the forest for the trees" is a shorthand summary of the concept of situational awareness—the degree to which a clinician's perception matches reality. Situational awareness requires that clinicians can perceive the information they need, comprehend the importance of this information, and forecast the implications of this information (i.e., adverse consequences that might happen). Nurses' role in patient safety is largely dependent on maintaining situational awareness, and this study used direct observation of intensive care unit (ICU) nurses in three hospitals to assess the degree to which monitoring devices and other information displays supported each phase of situational awareness. The authors found that the design of bedside information displays often impaired nurses' ability to gather critical patient data, particularly around medications, resulting in the potential to harm situational awareness. The authors make recommendations, based on human factors engineering principles, to improve the quality of information displays in the ICU.

Journal Article > Commentary

Is the drug shortage affecting patient care in your critical care unit?

Alspach JG. Crit Care Nurse. 2012;32:8-13.

This commentary discusses how drug shortages influence critical care and invites readers to share their experiences via a survey link.

Journal Article > Commentary

A clinical nurse specialist intervention to facilitate safe transfer from ICU.

St-Louis L, Brault D. Clin Nurse Spec. 2011;25:321-326.

This commentary describes a formal assessment, consultation, and follow-up initiative led by a clinical nurse specialist to improve patient transfer from the intensive care unit (ICU) to medical wards.

Journal Article > Study

Moral distress, compassion fatigue, and perceptions about medication errors in certified critical care nurses.

Maiden J, Georges JM, Connelly CD. Dimens Crit Care Nurs. 2011;30:339-345.

This survey of intensive care unit nurses revealed many barriers to reporting medication errors, and nurses reporting higher levels of burnout had more strongly negative opinions of the utility of error reporting.

Journal Article > Commentary

Failure to rescue in neonatal care.

Gephart SM, McGrath JM, Effken JA. J Perinat Neonatal Nurs. 2011;25:275-282.

This commentary suggests numerous strategies to reduce the incidence of failure to rescue in the neonatal intensive care unit.

Journal Article > Study

Nurses' behaviors and visual scanning patterns may reduce patient identification errors.

Marquard JL, Henneman PL, He Z, Jo J, Fisher DL, Henneman EA. J Exp Psychol Appl. 2011;17:247-256.

Medication administration errors are a common problem and have been linked to interruptions during nursing workflow. This study used behavioral psychology techniques to analyze how nurses' bedside behaviors influenced their ability to prevent medication administration errors.

Journal Article > Commentary

Development of a modified early warning score using the electronic medical record.

Albert BL, Huesman L. Dimens Crit Care Nurs. 2011;30:283-292.

This commentary describes how one hospital developed an early warning score system to improve rapid response team deployment.

Journal Article > Study

Nurses' perceptions of simulation-based interprofessional training program for rapid response and code blue events.

Wehbe-Janek H, Lenzmeier CR, Ogden PE, et al. J Nurs Care Qual. 2012;27:43-50.

This study found that nurses supported the use of simulation-based training to foster improved communication and teamwork.

Newspaper/Magazine Article

Too many abandon the "second victims" of medical errors.

ISMP Medication Safety Alert! Acute Care Edition. July 14, 2011;16:1-3.

This piece discusses second victims and describes how five factors can help clinicians involved in adverse events.

Journal Article > Study

Team situation awareness and the anticipation of patient progress during ICU rounds.

Reader TW, Flin R, Mearns K, Cuthbertson BH. BMJ Qual Saf. 2011;20:1035-1042.

Situational awareness refers to the degree to which perception matches reality. This study assessed situational awareness of intensive care unit teams through direct observation of team rounds and assessment of the degree to which team members were able to anticipate clinical deterioration.

Journal Article > Study

ICU nurses' acceptance of electronic health records.

Carayon P, Cartmill R, Blosky MA, et al. J Am Med Inform Assoc. 2011;18:812-819.

This study found that ICU nurses were more accepting of electronic health records (EHR) at 12 months after implementation compared to 3, and this acceptance was predicted by EHR usability and computerized provider order entry usefulness.

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