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Search results for "Nurse Managers"

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Journal Article > Study

Prevalence of medication administration errors in two medical units with automated prescription and dispensing.

Rodriguez-Gonzalez CG, Herranz-Alonso A, Martin-Barbero ML, et al. J Am Med Inform Assoc. 2012;19:72-78.

Technological solutions such as computerized provider order entry (CPOE) hold promise for reducing medication errors at the prescribing and dispensing stage, but patients may still be harmed by incorrect administration of medications, which have been shown to be disturbingly common in prior studies. Conducted at an academic hospital in Spain that had an established CPOE system, this study found an overall administration error rate of 22%, consistent with prior studies. The hospital in question did not have a barcoding medication administration system. Combining barcoding with CPOE in a closed-loop system has been shown to significantly reduce the overall medication error rate.

Journal Article > Commentary

Perinatal patient safety from the perspective of nurse executives: a round table discussion.

Thorman KE, Capitulo KL, Dubow J, Hanold K, Noonan M, Wehmeyer J.  J Obstet Gynecol Neonatal Nurs. 2006;35:409-416.

The authors summarize a discussion between six nurse executives in issues related to perinatal patient safety, such as communication gaps and regulatory pressures. The discussants share stories of initiatives implemented at their institutions to help reduce medical errors.

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 > 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

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 > Study

Data-driven implementation of alarm reduction interventions in a cardiovascular surgical ICU.

Allan SH, Doyle PA, Sapirstein A, Cvach M. Jt Comm J Qual Patient Saf. 2017;43:62-70.

Reducing the number of alarms can help alleviate alarm fatigue and the associated patient safety hazards. In this study, researchers successfully implemented a number of interventions which led to a 61% decrease in average alarms per monitored bed in a cardiovascular surgical intensive care unit and a reduction in cardiorespiratory events.

Journal Article > Study

Certified registered nurse anesthetist perceptions of factors impacting patient safety.

McMullan SP, Thomas-Hawkins C, Shirey MR. Nurs Adm Q. 2017;41:56-69.

Certified registered nurse anesthetists provide anesthesia to a large fraction of patients. This survey study explored the relationships between work environment, workload, experience, perceptions of safety culture, and adverse event reporting by certified registered nurse anesthetists.

Journal Article > Commentary

Promoting civility in the OR: an ethical imperative.

Clark CM, Kenski D. AORN J. 2017;105:60-66.

The operating room is a complex environment that can affect clinicians' communication and teamwork behaviors. Describing a disrespectful encounter in the operating room, this commentary illustrates how such interactions can influence the safety of care delivery and highlights ways nurses can mitigate the situation, such as by raising concerns about disruptive conduct.

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 > Commentary

Instrument count sheets and set reviews as patient safety tools.

Spear J. AORN J. 2016;104:588-592.

Inaccurate information can contribute to error, delays, and stress in the operating room. This commentary discusses how incomplete instrument count sheets affect the surgical process. The author offers recommendations for developing effective count sheets and performing instrument set reviews to enhance reliability in the operating room.

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 > Review

Factors influencing patient safety during postoperative handover.

Rose M, Newman SD. AANA J. 2016;84:329-338.

Patient handoffs between care teams are vulnerable to error. This scoping review explored the literature to identify factors that affect the safety of handoffs from anesthesia providers to the postanesthesia care unit. Individual communication styles, team dynamics, and policy were described as elements that influence information transfers. A past PSNet perspective discussed the importance of safe inpatient handovers.

Journal Article > Commentary

How communication among members of the health care team affects maternal morbidity and mortality.

Brennan RA, Keohane CA. J Obstet Gynecol Neonatal Nurs. 2016;45:878-884.

Communication failures in obstetric care can increase risk of harm for the mother and the infant. This commentary highlights how nurses can incorporate teamwork principles and structured communication to reduce risks of maternal injury.

Journal Article > Commentary

Use of a surgical safety checklist to improve team communication.

Cabral RA, Eggenberger T, Keller K, Gallison BS, Newman D. AORN J. 2016;104:206-216.

Surgical team communication is an important element of safe care. This project report describes how one hospital implemented a checklist program that utilized time outs and debriefings to support transparency and improve surgical teamwork behaviors.

Journal Article > Commentary

Using standardized OR checklists and creating extended time-out checklists.

Hey LA, Turner TC. AORN J. 2016;104:248-253.

Checklist use in the surgical environment has received attention worldwide. This commentary discusses the development of an extended time-out checklist for operating rooms, implementation barriers to consider, how checklists can augment teamwork, and the role of nurses as leaders on improvement projects.

Journal Article > Study

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.

van Galen LS, Struik PW, Driesen BEJM, et al. PLoS One. 2016;11:e0161393.

Unplanned transfers of hospitalized patients to the intensive care unit are often considered a safety issue. This root cause analysis of consecutive unplanned intensive care unit admissions found that the most frequent cause was insufficient patient monitoring by nurses. In many cases, vital signs were not monitored as specified by treating physicians.

Journal Article > Study

A 'busy day' effect on perinatal complications of delivery on weekends: a retrospective cohort study.

Snowden JM, Kozhimannil KB, Muoto I, Caughey AB, McConnell KJ. BMJ Qual Saf. 2017;26:e1.

This study found that perinatal complications of childbirth, including low Apgar scores, neonatal seizures, and postpartum hemorrhage, were more prevalent during the weekend, echoing the weekend effect in other health settings. Higher patient volume was also associated with worse outcomes, consistent with prior studies of nurse staffing ratios. These results argue for staffing changes to ensure safety at busy times and outside usual business hours.

Journal Article > Study

Relationship between operating room teamwork, contextual factors, and safety checklist performance.

Singer SJ, Molina G, Li Z, et al. J Am Coll Surg. 2016;223:568-580.e2.

Although checklists have been shown to improve safety and surgical mortality, they can be difficult to implement, which limits their effectiveness in clinical practice. This study examined whether perceptions of teamwork predicted checklist performance. Trained observers used standardized tools to rate the extent of checklist completion and quality of teamwork. They found that checklists were implemented as intended in only 3% of cases. Surgical teams with better surgeon buy-in to checklists, clinical leadership, communication, and overall teamwork completed more checklist components. Clinical factors, including older patient age and longer duration of surgery, were also associated with performing more of the checklist. The authors suggest that teamwork is critical to checklist implementation. A PSNet interview discussed the challenges of implementing checklists in health care.

Newspaper/Magazine Article

Mean girls of the ER: the alarming nurse culture of bullying and hazing.

Robbins A. Good Housekeeping. May 20, 2016.

Disruptive behaviors are receiving increased attention as a cultural factor that contributes to medical error. Although much of the focus has been on physicians, the presence of bullying among nurses is also a concern. This magazine article explores nurse behaviors such as withholding information, intimidation, and name calling that negatively affect patient safety and nurse retention.

Journal Article > Study

Tune-in and time-out: toward surgeon-led prevention of "never" events.

Jones N. J Patient Saf. 2016 Jan 11; [Epub ahead of print].

This study surveyed surgical nurses at an Australian hospital regarding their perceptions of surgeon adherence to the World Health Organization surgical safety checklist. Though nurses felt surgeon-led time outs are valuable and lead to fewer adverse events, 94% of them reported experiencing hostility from surgeons, such as a "condescending, sarcastic attitude" related to the time out process.

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