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Search results for "Nurse Managers"

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Journal Article > Commentary

ASPEN Safe Practices for Enteral Nutrition Therapy.

Boullata JI, Carrera AL, Harvey L, et al; ASPEN Safe Practices for Enteral Nutrition Therapy Task Force, American Society for Parenteral and Enteral Nutrition. JPEN J Parenter Enteral Nutr. 2017;41:15-103.

Enteral nutrition is provided to patients in a variety of care settings, and errors in the enteral nutrition–use process may lead to safety hazards. Drawing from current evidence, these consensus guidelines recommend best practices to ensure safety of enteral nutrition, including a six-step standardized approach to administering eternal nutrition that involves independent double-checks and automation with forcing functions.

Journal Article > Review

Prevalence, risk factors, and outcomes of idle intravenous catheters: an integrative review.

Becerra MB, Shirley D, Safdar N. Am J Infect Control. 2016;44:e167-e172.

Prompt removal of intravenous catheters is critical to preventing health care–associated infections. This systematic review found that persistence of idle, or unused, catheters was associated with adverse outcomes. These findings highlight the need to develop and implement practices to reduce the incidence of idle catheters.

Journal Article > Review

Safety risks associated with physical interactions between patients and caregivers during treatment and care delivery in home care settings: a systematic review.

Hignett S, Edmunds Otter M, Keen C. Int J Nurs Stud. 2016;59:1-14.

Adverse events are thought to be common in patients receiving home health care. This systematic review defined home care safety risks for both patients and caregivers, including awkward working positions, social distractions, abuse and violence, and other issues that are relatively unique to this care setting.

Cases & Commentaries

Harm From Alarm Fatigue

  • Spotlight Case
  • CME/CEU
  • Web M&M

Michele M. Pelter, RN, PhD, and Barbara J. Drew, RN, PhD; December 2015

Following a non-ST segment elevation myocardial infarction, a man was admitted to the hospital and placed on a telemetry monitor. As the monitor was constantly sounding with "low voltage" and "asystole" alerts and the patient was well each time clinicians checked, they silenced the alarms. The patient was found dead 4 hours later.

Tools/Toolkit > Multi-use Website

ANA CAUTI Prevention Tool.

Silver Spring, MD: American Nurses Association; 2015.

Nurses play an important role in reducing catheter–associated urinary tract infections (CAUTIs). This toolkit, developed as a Partnership for Patients strategy, focuses on promoting nursing behaviors to prevent CAUTIs including decreasing catheter use and improving catheter maintenance.

Book/Report

Patient Safety in Dialysis Access.

Widmer MK, Malik J, eds. Contrib Nephrol. 2015;184:1-270. ISBN: 9783318027051.

Patients with chronic kidney failure are at high risk for adverse events from treatment errors. This publication raises awareness of safety in end-stage renal disease care, explores factors specific to this setting that contribute to failure, and describes techniques for clinicians to reduce risk of errors.

Journal Article > Study

Do clinicians know which of their patients have central venous catheters?: A multicenter observational study.

Chopra V, Govindan S, Kuhn L, et al. Ann Intern Med. 2014;161:562-567.

Catheter-associated infections are common, and largely preventable, adverse events. Though incidence of these events has declined due to intensive safety efforts, one factor contributing to intravenous catheter infections is the failure to remove unnecessary central venous catheters (CVCs). This study sought to determine whether inpatient physicians know which of their patients have CVCs in place by comparing physician response to direct observation of each patient. Physicians were unaware of CVCs in about 20% of the cases examined. Trainee physicians were more likely to be aware of a CVC than teaching attending physicians or hospitalists, and critical care physicians were more likely to know about a CVC than general medicine physicians. These findings suggest that interventions to reduce CVC-associated infections should address clinician awareness of CVCs. An AHRQ WebM&M commentary discusses best practices for removing CVCs.

Journal Article > Review

Benefits and risks of using smart pumps to reduce medication error rates: a systematic review.

Ohashi K, Dalleur O, Dykes PC, Bates DW. Drug Saf. 2014;37:1011-1020.

Smart infusion pumps, which contain pre-programmed libraries with standardized dosing for commonly used intravenous medications, are considered an integral component of efforts to prevent medication errors. This systematic review found evidence that smart pumps can effectively prevent medication administration errors and clinical adverse drug events. However, the authors uncovered problems associated with smart pump implementation as well, including alert fatigue and failure of clinicians to use the system as intended. In particular, as discussed in a recent qualitative study, nurses frequently employ workarounds that may bypass some safety features of smart pumps. The role of smart pumps in medication safety was discussed in more detail in an AHRQ WebM&M perspective.

Journal Article > Study

Organizational, cultural, and psychological determinants of smart infusion pump work arounds: a study of 3 U.S. health systems.

Dunford BB, Perrigino M, Tucker SJ, et al. J Patient Saf. 2014 Aug 12; [Epub ahead of print].

Smart infusion pumps, which provide alerts and decision support for high-risk medications, have a proven record of preventing adverse drug events. However, like with all technology users may engage in workarounds that (intentionally or inadvertently) bypass the safety features of the equipment. This qualitative study among nurses at three health systems identified several reasons why nurses used workarounds despite having an overall strong positive perception of smart pumps. While the technology itself necessitated workarounds at times (for example, if the drug to be infused was not in the pump's programmed library), workarounds were more commonly attributed to nontechnical factors such as production pressures or inadequate training. In order to improve adherence to smart pump's safety features, organizations will need to address both technical factors and issues related to nurses' work environment.

Newspaper/Magazine Article

Multifaceted initiative to reduce "alarm fatigue" on cardiac unit reduces alarms and increases nurse and patient satisfaction.

Agency for Healthcare Research and Quality. Health Care Innovations Exchange. June 18, 2014.

Clinical alarms have been described as a serious patient safety issue. This article relates how one hospital implemented a series of actions reduce nuisance alarms in a cardiac unit and reports a substantial decrease in audible alerts with no subsequent adverse effects. Interventions included expanding limits for triggering heart rate alarms and collaboration between two nurses to design customized alarm parameters for individual patients.

Journal Article > Study

Avoiding potential harm by improving appropriateness of urinary catheter use in 18 emergency departments.

Fakih MG, Heavens M, Grotemeyer J, Szpunar SM, Groves C, Hendrich A. Ann Emerg Med. 2014;63:761-768.

This pre-post study found that implementation of institutional guidelines for urinary catheter placement led by a clinician champion in emergency departments decreased inappropriate catheter use. The authors recommend establishing guidelines for placement, engaging clinician champions, conducting audits, and providing feedback to improve safety related to catheters.

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.

Book/Report

Eliminating Catheter-Associated Urinary Tract Infections.

Chicago, IL: Health Research & Educational Trust; July 2013.

This toolkit reveals how to apply strategies from the Comprehensive Unit-based Safety Program to drive reductions in catheter–associated urinary tract infections.

Cases & Commentaries

The Unfamiliar Catheter

  • Web M&M

Sonia C. Swayze, RN, MA, and Angela James, RN, BSN; March 2013

While drawing labs on a woman admitted after a lung transplant, a nurse failed to clamp the patient's large-bore central line, allowing air to enter the catheter. The patient suffered a cerebral air embolism and was transferred to the ICU for several days.

Cases & Commentaries

CVC Placement: Speak Now or Do Not Use the Line

  • Web M&M

Mark Ault, MD, and Bradley Rosen, MD, MBA; February 2013

A woman found unresponsive at home presented to the ED via ambulance. The cardiology team used the central line placed during resuscitation to deliver medications and fluids during pacemaker insertion. Hours later, a chest radiograph showed whiteout of the right lung, and clinicians realized that the tip of the line was actually within the lung.

Cases & Commentaries

Preventing PICC Complications: Whose Line Is It?

  • Web M&M

Nancy Moureau, BSN, RN, CRNI, CPUI, VA-BC; December 2012

A woman undergoing treatment for myasthenia gravis via PICC developed extensive catheter-related thrombosis, bacteremia, and sepsis, and ultimately died. Although the PICC line was placed at one facility, the patient was receiving treatment at another, raising questions about who had responsibility for the line.

Web Resource > Multi-use Website

Tubing and Luer Misconnections: Preventing Dangerous Medical Errors.

US Food and Drug Administration.

This Web site provides information about tubing misconnections and how to prevent them.

Journal Article > Commentary

Implementing AORN recommended practices for laser safety.

Castelluccio D. AORN J. 2012;95:612-627.

This commentary recommends strategies, such as checklists and standardized equipment carts, to help nurses ensure laser safety in perioperative care.

Book/Report

Preventing Central Line–Associated Bloodstream Infections: a Global Challenge, a Global Perspective.

The Joint Commission. Oakbrook Terrace, IL: Joint Commission Resources; May 2012.

This monograph provides guidance, tools, and techniques for hospitals to help decrease central line–associated bloodstream infections.

Newspaper/Magazine Article

Smart pump custom concentrations without hard "low concentration" alerts.

ISMP Medication Safety Alert! Acute Care Edition. February 23, 2012;17:1,3-4.

This newsletter piece reviews smart infusion pump errors and makes recommendations to prevent them.

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