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Approach to Improving Safety
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Search results for "Nurse Managers"

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Journal Article > Study

Examining the relationship among ambulatory surgical settings work environment, nurses' characteristics, and medication errors reporting.

Farag AA, Anthony MK. J Perianesth Nurs. 2015;30:492-503.

This survey study of nurses across four ambulatory surgical wards in Ohio found that nursing managers' leadership styles and some aspects of the safety climate (such as teamwork and organizational learning) were associated with how willing nurses are to report medication errors.

Journal Article > Study

Nurses' perspectives regarding the disclosure of errors to patients: a qualitative study.

McLennan SR, Diebold M, Rich LE, Elger BS. Int J Nurs Stud. 2016;54:16-22.

In this qualitative interview study, most nurses believed that errors should be disclosed to patients, but few of them reported actually disclosing errors. Barriers to error disclosure included insufficient training, lack of organizational support, and personal fears. These findings are consistent with prior studies of physicians and underscore the difficulty in making error disclosure the standard of care.

Journal Article > Study

Surgical programs in the Veterans Health Administration maintain briefing and debriefing following medical team training.

West P, Neily J, Warner L, et al. Jt Comm J Qual Patient Saf. 2014;40:235-239.

This study surveyed nurse managers to evaluate the implementation of pre-surgical briefings and post-surgical debriefings recommended by the World Health Organization's Safe Surgery program. Researchers found that practices were variably sustained and team training appeared to augment implementation.

Book/Report

Work Design Drivers of Organizational Learning about Operational Failures: A Laboratory Experiment on Medication Administration.

Tucker AL. Cambridge, MA: Harvard Business School; November 19, 2012. (Revised September 2013). HBS Working Paper No. 13-044.

This paper investigates techniques for engaging frontline employees in proactive organizational improvement instead of creating individual workarounds.

Audiovisual

Making health care safer: stopping C. difficile infections.

CDC Vital Signs. March 2012:1-4.

This newsletter article and accompanying set of infographics describes strategies to help patients and health care providers prevent health care–associated infections.

Journal Article > Commentary

Strategies for improving patient safety: linking task type to error type.

Mattox EA. Crit Care Nurse. 2012;32:52-78.

This commentary discusses types of errors associated with specific nursing tasks to illustrate how cognitive factors can affect safety.

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.

Web Resource > Multi-use Website

Simulation Training for Rapid Assessment & Improved Teamwork (STRAIT) Project.

Center for Perioperative Research in Quality, Vanderbilt University.

This AHRQ-funded project supports interprofessional communications training for post-anesthesia care unit teams and targets nurse handoff improvements.

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.

Cases & Commentaries

Workaround Error

  • Web M&M

Tess Pape, PhD, RN, CNOR; February 2006

Bypassing the safeguards of an automated dispensing machine in a skilled nursing facility, a nurse administers medications from a portable medication cart. A non-diabetic patient receives insulin by mistake, which requires his admission to intensive care and delays his chemotherapy for cancer.

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 > 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 > 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

Understanding interrater reliability and validity of risk assessment tools used to predict adverse clinical events.

Siedlecki SL, Albert NM. Clin Nurse Spec. 2017;31:23-29.

The ability to proactively identify and mitigate risk is key to safety improvement. This commentary describes several risk assessment tools available to develop estimates of potential adverse events and discusses how to ensure those assessments are valid and reliable.

Journal Article > Review

A concept analysis of systems thinking.

Stalter AM, Phillips JM, Ruggiero JS, et al. Nurs Forum. 2016 Dec 21; [Epub ahead of print].

Systems thinking focuses on enabling an organization to learn from experience to address complex problems. This review highlights four primary components of a systems approach to provide context for interprofessional efforts to improve quality and safety.

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