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Search results for "Nurse Managers"

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Journal Article > Commentary

Standardized handoff report form in clinical nursing education: an educational tool for patient safety and quality of care.

Lim F, Pajarillo EJY. Nurse Educ Today. 2016;37:3-7.

Due to variability in handoff practices across teams, units, and organizations, the process is vulnerable to error. This commentary describes a standardized change-of-shift form designed to help improve nursing students' communication skills and clinical reasoning.

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.

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.

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 > 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 > 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 > Commentary

Using Kotter's change model for implementing bedside handoff: a quality improvement project.

Small A, Gist D, Souza D, Dalton J, Magny-Normilus C, David D. J Nurs Care Qual. 2016;31:304-309.

Change management has been described as a critical strategy to ensure safety improvements are sustained. This commentary discusses how one hospital applied a well-known change model to implement a new bedside handoff process and reports positive reactions from nurses and patients one month after the intervention.

Journal Article > Study

Changes in efficiency and safety culture after integration of an I-PASS-supported handoff process.

Sheth S, McCarthy E, Kipps AK, et al. Pediatrics. 2016;137:1-9.

The I-PASS signout tool has become a widely used method of patient handoffs when transferring care from the primary clinician to a covering clinician. This study used the I-PASS framework to develop and implement a standardized signout process for transferring patients from the pediatric cardiac intensive care unit to the general ward. The new process significantly improved clinician workflow and perceived safety culture relating to handoffs.

Journal Article > Study

Why do we still page each other? Examining the frequency, types and senders of pages in academic medical services.

Carlile N, Rhatigan JJ, Bates DW. BMJ Qual Saf. 2017;26:24-29.

Despite the ubiquity of smartphones, the vast majority of physicians still rely on one-way pagers for communication. This study analyzed the frequency and content of pages on an internal medicine service at a teaching hospital and compared the data to a similar study performed in 1988. Physicians received an average of 22 pages per day, of which 76% were deemed clinically relevant by independent reviewers and 82% required a response. This represented a nearly 50% increase in the volume of pages compared to 1988. Doctors on regionalized services (where patients were admitted to a common unit) received significantly fewer pages than those caring for patients on nonregionalized services, implying that regionalized services may aid face-to-face communication. As interruptions have been shown to negatively affect patient safety, the authors advocate for developing secure two-way methods of communication (such as secure text messaging) for nurses and physicians in order to improve the efficiency of communication around clinical issues.

Cases & Commentaries

A Room Without Orders

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

Amy Vogelsmeier, PhD, RN, and Laurel Despins, PhD, RN; January 2016

Admitted to the hospital for chemotherapy, a man with leukemia and diabetes arrived on the medical unit on a busy afternoon and waited until his room was ready. The nurse who checked him in assumed that his admitting orders were completed on the previous shift. That night, the patient took his own insulin from home without a meal and experienced a preventable episode of hypoglycemia.

Newspaper/Magazine Article

The most crucial half-hour at a hospital: the shift change.

Landro L. Wall Street Journal. October. 26, 2015.

Information exchange can be challenging when nurses hand off care responsibilities at the end of their shifts. This news article discusses bedside shift reports as a strategy to improve communication among nursing staff and engage patients in their care.

Journal Article > Study

Nurse staffing levels and patient-reported missed nursing care.

Dabney BW, Kalisch BJ. J Nurs Care Qual. 2015;30:306-312.

Missed nursing care may explain part of the link between nurse staffing and patient outcomes. In this study, researchers interviewed 729 inpatients from 2 hospitals to measure missed nursing care and found that nurse staffing hours and skill mix were associated with timeliness of nursing care.

Journal Article > Review

Bedside shift-to-shift handoffs: a systematic review of the literature.

Mardis T, Mardis M, Davis J, et al. J Nurs Care Qual. 2016;31:54-60.

Incomplete handoffs and poor communication regarding key clinical information may lead to adverse events. According to this systematic review, current research on bedside nursing handoffs suggests this method (conducting handoffs at the patient's bedside, instead of in a conference room or nurses' station) can improve patient and staff satisfaction, but evidence regarding its effect on patient safety is largely lacking.

Journal Article > Study

Failures in communication through documents and documentation across the perioperative pathway.

Braaf S, Riley R, Manias E. J Clin Nurs. 2015;24:1874-1884.

This qualitative study of communication among providers in perioperative care revealed a reliance on written documentation, which was often difficult to find or missing key information, rather than verbal signout. This finding underscores the importance of structured, verbal handoffs to ensure adequate provider communication.

Journal Article > Study

Nursing handovers as resilient points of care: linking handover strategies to treatment errors in the patient care in the following shift.

Drach-Zahavy A, Hadid N. J Adv Nurs. 2015;71:1135-1145.

This prospective study examined 200 hospital nurse handovers. Documentation was missing in nearly half of patients' files, and dosage discrepancies were identified in 23% of cases. Use of strategies that emphasized the input and interaction of the incoming team—such as face-to-face verbal updates with questions—were associated with fewer treatment errors.

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 > Review

Bedside shift reports: what does the evidence say?

Gregory S, Tan D, Tilrico M, Edwardson N, Gamm L. J Nurs Adm. 2014;44:541-545.

Bedside shift reports may decrease risk of errors and augment teamwork, but this strategy has not been widely integrated into nursing practice. This review examines the evidence for bedside shift reports and their impact on individual skill development, communication, and patient satisfaction.

Journal Article > Study

A step toward high reliability: implementation of a daily safety brief in a children's hospital.

Saysana M, McCaskey M, Cox E, Thompson R, Tuttle LK, Haut PR. J Patient Saf. 2014 Aug 12; [Epub ahead of print].

This study describes the implementation of a daily safety brief at a children's hospital. The daily brief uncovered many unexpected outcomes and generally took less than 15 minutes each day. Participants felt this meeting improved awareness of daily events and communication between departments.

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