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Approach to Improving Safety
Search results for "Nurse Managers"
- Nonsurgical Procedural Complications
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Journal Article > Study
Nurses' perceived skills and attitudes about updated safety concepts: impact on medication administration errors and practices.
Armstrong GE, Dietrich M, Norman L, Barnsteiner J, Mion L. J Nurs Care Qual. 2017;32:226-233.
Medication administration errors are common and account for a significant fraction of medication errors. This study sought to assess how bedside nurses' reported attitudes and skills with safety practices affect medication administration errors. Researchers determined that system, local, and individual bedside nurse factors contribute to medication administration errors.
Journal Article > Review
Systematic review of physiologic monitor alarm characteristics and pragmatic interventions to reduce alarm frequency.
- Classic
Paine CW, Goel VV, Ely E, et al. J Hosp Med. 2016;11:136-144.
Alarm safety is now a Joint Commission National Patient Safety Goal. This systematic review analyzed 24 studies on alarm characteristics and 8 studies that evaluated interventions to improve alert fatigue. The vast majority of the time, alarms do not signal problems that require clinician action. The most promising intervention strategies for reducing alarms that have emerged thus far are widening alarm parameters, implementing alarm delays, and frequently changing telemetry electrodes and wires.
Journal Article > Study
The occurrence of adverse events potentially attributable to nursing care in medical units: cross sectional record review.
D'Amour D, Dubois CA, Tchouaket É, Clarke S, Blais R. Int J Nurs Stud. 2014;51:882-891.
Accurately detecting safety events remains challenging, and health care organizations are still struggling to determine the incidence of adverse outcomes associated with nursing care. This study used chart reviews to identify the rates of six adverse events considered to be directly related to nursing care: pressure sores, falls, medication administration errors, pneumonia, urinary infections, and inappropriate use of restraints. One in seven hospitalized adults experienced at least one of these adverse events.
Journal Article > Study
Why don't nurses consistently take patient respiratory rates?
Ansell H, Meyer A, Thompson S. Br J Nurs. 2014;23:414-418.
Basic nursing care, such as measuring and recording vital signs, is often left undone. This qualitative study found that nurses frequently fail to accurately record patients' respiratory rates due to more urgent work tasks, confirming findings from prior studies.
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.
Book/Report
Evaluation of Registered Nurse Competency Processes in Veterans Health Administration Facilities.
Washington, DC: VA Office of Inspector General; April 20, 2012. Report No. 12-00956-159.
This publication presents findings from an investigation, prompted by reports of alarm fatigue, which identified gaps in training and competencies of nurses in 29 Veterans Health Administration facilities.
Journal Article > Commentary
Surveillance: a strategy for improving patient safety in acute and critical care units.
Henneman EA, Gawlinski A, Giuliano KK. Crit Care Nurse. 2012;32:e9-e18.
This commentary describes how surveillance can prevent adverse events and medical errors in critical care.
Journal Article > Study
Patient perceptions of missed nursing care.
Kalisch BJ, McLaughlin M, Dabney BW. Jt Comm J Qual Patient Saf. 2012;38:161-167.
Missed nursing care (failure to perform required patient care elements) is surprisingly common. This qualitative study found that patients were able to reliably identify episodes of missed nursing care and their perceptions correlated with nurses' opinions.
Newspaper/Magazine Article
Promoting patient safety in continence care.
Mangnall J. Nurs Stand. 2012;26:49-56.
This commentary discusses the patient safety ramifications of continence care.
Newspaper/Magazine Article
ALERT: reports of severe harm after intravenous administration of breast milk to infants.
ISMP Canada Safety Bulletin. July 31, 2011;11:1-2.
This announcement reports on mistaken intravenous administration of breast milk and provides recommendations to prevent parenteral administration of enteral nutrition.
Journal Article > Commentary
The perinatal safety nurse: exemplar of transformational leadership.
Raab C, Palmer-Byfield R. MCN Am J Matern Child Nurs. 2011;36:280-287.
This commentary explores the role of the perinatal nurse specialist in providing safe care.
Journal Article > Commentary
Validating patient safety in the endoscopy unit using The Joint Commission standards.
Ragsdale JA. Gastroenterol Nurs. 2011;34:218-223.
This commentary applied Joint Commission patient safety standards to the endoscopy care setting and suggests that audits can improve staff engagement in safety work.
Journal Article > Commentary
Perinatal patient safety and quality.
Simpson KR. J Perinat Neonatal Nurs. 2011;25:103-107.
This commentary describes strategies to improve safety in perinatal care for both mothers and infants.
Cases & Commentaries
Are We Pushing Graduate Nurses Too Fast?
- Web M&M
Nancy Spector, PhD, RN ; March 2011
While caring for a complex patient in the surgical intensive care unit, a nurse incorrectly set up the continuous renal replacement therapy (CRRT) machine, raising questions about how new nurses should be trained in high-risk procedures.
Journal Article > Study
Attitudes toward safety and teamwork in a maternity unit with embedded team training.
Siassakos D, Fox R, Hunt L, et al. Am J Med Qual. 2011;26:132-137.
Nurses on an obstetrics unit with a longstanding teamwork training program reported a generally positive perception of safety culture, but expressed a desire for greater management support of safety efforts.
Journal Article > Study
Skilful anticipation: maternity nurses' perspectives on maintaining safety.
Lyndon A. Qual Saf Health Care. 2010;19:e8.
Obstetric nurses described their approach to ensuring patient safety as being centered around maintaining situational awareness in order to anticipate potential complications.
Journal Article > Study
Supporting structures for team situation awareness and decision making: insights from four delivery suites.
Mackintosh N, Berridge EJ, Freeth D. J Eval Clin Pract. 2009;15:46-54.
This study used direct observation of labor and delivery suites to establish the mechanisms by which teamwork and situational awareness developed among clinicians.
Journal Article > Study
Making patients safer: nurses' responses to patient safety alerts.
Lankshear A, Lowson K, Harden J, Lowson P, Saxby RC. J Adv Nurs. 2008;63:567-575.
This study demonstrated that simply designing "system" safeguards fails to prevent errors in subsequent monitoring and implementation. Investigators used three safety alerts, including latex allergy, as markers of how well these alerts were being adopted in practice by bedside nurses.
Journal Article > Study
Incidence and prevention of iatrogenic urethral injuries.
Kashefi C, Messer K, Barden R, Sexton C, Parsons JK. J Urol. 2008;179:2254-2257; discussion 2257-2258.
Approximately 1 in 300 male patients at this university hospital experienced a urethral injury due to urinary catheter placement. A nursing education program significantly reduced the risk of injury.