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Search results for "Nurse Managers"

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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

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

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 > 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

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

'Providing good and comfortable care by building a bond of trust': nurses views regarding their role in patients' perception of safety in the intensive care unit.

Wassenaar A, van den Boogaard M, van der Hooft T, Pickkers P, Schoonhoven L. J Clin Nurs. 2015;24:3233-3244.

This qualitative study explored the means by which intensive care unit nurses enhance their patients' perception of safety. Nurses emphasized the importance of communicating with patients and families, ensuring patients' physical safety, and building trust with families so that patients feel safe.

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

Higher quality of care and patient safety associated with better NICU work environments.

Lake ET, Hallowell SG, Kutney-Lee A, et al. J Nurs Care Qual. 2016;31:24-32.

This survey of nurses found that those who rated their work environment as poor were more likely to report quality and safety problems, underscoring the well-described link between nurses' working conditions and patient safety. Improving nurse working conditions is a patient safety strategy.

Special or Theme Issue

Quality and Safety.

Albarran J, Scholes J, eds. Nurs Crit Care. 2015;20:167-220.

Nurses have a key role in patient safety and advocacy in critical care settings. Articles in this special issue explore the impact of interruptions on nursing care, ward rounds as an opportunity for checklist use, and the importance of integrating safety concepts into nursing education.

Journal Article > Study

Improving medication administration safety: using naïve observation to assess practice and guide improvements in process and outcomes.

Donaldson N, Aydin C, Fridman M, Foley M. J Healthc Qual. 2014;36:58-68.

This cross-sectional study presents data collected from the Collaborative Alliance for Nursing Outcomes benchmarking registry. In this convenience sample, nurses deviated from medication administration safe practices approximately 11% per encounter, and administration errors occurred 0.32% per encounter. Distractions or interruptions accounted for nearly one-fourth of the safe practice deviations.

Journal Article > Study

The effect of an electronic SBAR communication tool on documentation of acute events in the pediatric intensive care unit.

Panesar RS, Albert B, Messina C, Parker M. Am J Med Qual. 2016;31:64-68.

Use of a structured communication tool within an electronic medical record resulted in increased high-quality communication between nurses and physicians around critical patient events.

Journal Article > Study

Parents' perspective on safety in neonatal intensive care: a mixed-methods study.

Lyndon A, Jacobson CH, Fagan KM, Wisner K, Franck LS. BMJ Qual Saf. 2014; 23:902-909.

This interview, observation, and survey study found that parents of infants in neonatal intensive care units identified three core aspects of safety: physical safety relating to immediate treatment, the effect of care on future development, and emotional safety for infants and family, such as having confidence in caregivers. These results argue for enhancing patient and family engagement in safety in this setting.

Journal Article > Review

A systematic review of teamwork in the intensive care unit: what do we know about teamwork, team tasks, and improvement strategies?

Dietz AS, Pronovost PJ, Mendez-Tellez PA, et al. J Crit Care. 2014;29:908-914.

Improving teamwork and communication is a continued focus in the hospital setting. This systematic review revealed that although studies of teamwork in the intensive care unit abound, the field lacks common definitions and constructs. Teamwork usually entailed joint strategy and shared goals, and quality improvement approaches to enhance teamwork typically involve team training and development of structured protocols. Many interventions target rounds, during which interdisciplinary providers discuss each patient, or handoffs between clinicians. The authors suggest that communication is the most prominent aspect of teamwork and propose further study in conceptualizing teamwork to design effective interventions. The heterogeneity in defining and measuring teamwork may account for mixed results in improving safety outcomes. An AHRQ WebM&M perspective describes the Veterans Health Administration's medical team training program.

Journal Article > Study

Successful implementation of a unit-based quality nurse to reduce central line–associated bloodstream infections.

Thom KA, Li S, Custer M, et al. Am J Infect Control. 2014;42:139-143.

Central line–associated bloodstream infections (CLABSIs) cause substantial morbidity and mortality. Efforts to combat these complications include implementation of checklists and—perhaps more importantly—the enhancement of safety culture. Despite the widespread success of these interventions, some institutions continue to experience CLABSI rates that are above national benchmarks. This study describes the introduction of a unit-based quality nurse dedicated to preventing CLABSIs within a surgical intensive care unit (ICU) at an academic medical center. The quality nurse helped to educate staff about health care–associated infections and prevention strategies. The nurse also provided immediate, direct feedback to staff regarding their compliance with best practices. The average CLABSI rate decreased significantly, even after adjusting for multiple factors including reduction in CLABSI rates in other adult ICUs. A unit-based quality nurse may prove to be a powerful adjunct to the current available tools for reducing these costly infections.

Journal Article > Study

Developing a medical emergency team running sheet to improve clinical handoff and documentation.

Mardegan K, Heland M, Whitelock T, Millar R, Jones D. Jt Comm J Qual Patient Saf. 2013;39:570-575.

This study group created a standardized running sheet for documenting medical emergency team (MET) events at their medical center. About half of ward nurses felt that this tool improved patient handoffs to the arriving METs.

Journal Article > Review

Interprofessional care in intensive care settings and the factors that impact it: results from a scoping review of ethnographic studies.

Paradis E, Leslie M, Gropper MA, Aboumatar HJ, Kitto S, Reeves S. J Crit Care. 2013;28:1062-1067.

This review found that little is still understood about the processes, relationships, and organizational factors that influence interprofessional teamwork in intensive care units.

Journal Article > Study

Improving adverse drug event detection in critically ill patients through screening intensive care unit transfer summaries.

Anthes AM, Harinstein LM, Smithburger PL, Seybert AL, Kane-Gill SL. Pharmacoepidemiol Drug Saf. 2013;22:510-516.

Medication errors are common when patients are transferred from the intensive care unit (ICU) to regular wards. This study used screening of ICU transfer summaries to detect these errors.

Perspectives on Safety > Perspective

Quality and Safety Challenges in Critical Care: Preventing and Treating Delirium in the Intensive Care Unit

with commentary by Eduard E. Vasilevskis, MD; E. Wesley Ely, MD, MPH; Robert S. Dittus, MD, MPH, Delirium as a Safety Target, December 2012

This piece details a number of evidenced-based practices to help detect, prevent, and treat delirium, which is now seen as a patient safety hazard.

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.

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