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Search results for "Nurses"

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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.

Audiovisual

Empowering Better Nursing Care.

Robert Wood Johnson Foundation.

This photo essay includes interviews with three nurses participating in a nationwide initiative to empower nurses and improve care.

Journal Article > Study

The effect of executive walk rounds on nurse safety climate attitudes: a randomized trial of clinical units.

  • Classic

Thomas EJ, Sexton JB, Neilands TB, Frankel A, Helmreich RL. BMC Health Serv Res. 2005;5:28.

While executive walk rounds (EWRs) vary in application from institution to institution, their use continues to grow as a largely unproven method for improving safety culture. EWRs typically involve a number of executives visiting patient care areas to engage providers and discuss patient safety concerns. This study targeted more than 20 clinical units to determine the impact of EWRs on perceived safety climate using an established survey tool. Results suggested a positive effect on the safety climate attitude of nurses who participated in the rounds. The authors conclude that greater implementation of EWRs may serve as an important tool to improve safety culture and, ultimately, patient safety.

Special or Theme Issue

Human Factors and Technology in the ICU.

Wung SF, ed. Crit Care Nurs Clin North Am. 2018;30:179-310.

Care teams rely on a variety of technologies to support safe practice. This special issue focuses on critical care nursing practice and how human factors affect technology use. Articles cover clinical applications of technology and review the role of technologies in critical thinking, medication delivery, and alarm fatigue.

Journal Article > Study

Making an infusion error: the second victims of infusion therapy-related medication errors.

Treiber LA, Jones JH. J Infus Nurs. 2018;41:156-163.

Providers involved in medical errors may experience emotional distress, referred to as the second victim effect. The authors of this survey study describe nursing graduates' experiences after being involved in medication administration errors. Respondents who self-reported an error frequently blamed themselves.

Journal Article > Review

The association between nurse staffing and omissions in nursing care: a systematic review.

Griffiths P, Recio-Saucedo A, Dall'Ora C, et al; Missed Care Study Group. J Adv Nurs. 2018;74:1474-1487.

Inadequate hospital nurse staffing is linked to increased mortality. This systematic review found that lower nurse staffing is associated with more reports of missed nursing care. Two of the authors summarized the science of missed nursing care in a recent PSNet perspective.

Journal Article > Commentary

Medication errors: the school nurse as second victim.

Stillwater AR. NASN Sch Nurse. 2018;33:163-166.

Second victims can be found in a variety of settings where patient care takes place. This commentary reviews three medication safety incidents involving school nurses and emotional difficulties they experienced as a result. The author outlines a model to help school nurses and educational leadership understand, plan for, and respond after such incidents.

Perspectives on Safety > Perspective

Missed Nursing Care: A Key Measure for Patient Safety

with commentary by Jane Ball, PhD, and Peter Griffiths, PhD, Nursing and Patient Safety, March 2018

This piece explores how missed nursing care may explain the association between low nurse staffing levels and increased mortality in hospital patients.

Journal Article > Commentary

Workarounds are routinely used by nurses—but are they ethical?

Berlinger N. Am J Nurs. 2017;117:53-55.

Workarounds arise as short-term solutions to flaws in process, equipment, or policy. Exploring the ethical implications of nurse workarounds, this commentary spotlights the importance of nurses reporting their use of workarounds to manage the potential for unintended consequences.

Journal Article > Commentary

Incorporating nursing complexity in reimbursement coding systems: the potential impact on missed care.

Sasso L, Bagnasco A, Aleo G, et al. BMJ Qual Saf. 2017;26:929-932.

Multiple factors in the hospital environment influence the incidence of missed nursing care. This commentary describes strategies to address these errors of omission, including changing mental models to recognize the financial benefit of increasing staffing levels to improve patient safety.

Journal Article > Commentary

Recognizing the ordinary as extraordinary: insight into the "way we work" to improve patient safety outcomes.

Henneman EA. Am J Crit Care. 2017;26:272-277.

Nurses are increasingly recognized as key contributors to safe patient care. This commentary describes how a surveillance program can help gain insights about nursing work and identify opportunities for improvement and research.

Journal Article > Commentary

AORN Position Statement on Patient Safety.

AORN J. 2017;105:501-502.

This position statement outlines recommendations from the Association of periOperative Registered Nurses on core components of safe perioperative nursing and its role in strengthening patient safety. Elements discussed include error reduction, patient engagement, and appropriate staffing levels.

Journal Article > Study

Safety and efficiency of a new generic package labelling: a before and after study in a simulated setting.

Garcia BH, Elenjord R, Bjornstad C, Halvorsen KH, Hortemo S, Madsen S. BMJ Qual Saf. 2017;26:817-823.

Look-alike and sound-alike medications can be erroneously substituted for each other, leading to adverse drug events. Use of nonproprietary medication names can prevent look-alike and sound-alike errors. In this simulation study, investigators compared how nurses handle medication packages with a prominent nonproprietary name versus standard medication packages. Participants prepared medications with nonproprietary labeling more quickly, but errors were rare across all packaging types.

Book/Report

Quality and Safety in Nursing: a Competency Approach to Improving Outcomes, Second Edition.

Sherwood G, Barnsteiner J, eds. Hoboken, NJ: Wiley-Blackwell; 2017. ISBN: 9781119151678.

The Crossing the Quality Chasm report provided a framework to improve quality and safety in health care. This publication draws on the six aims for quality outlined in the report to review core competencies, knowledge, and attitudes for safe nursing care. Topics covered include nurses as leaders, teamwork, and patient-centered care.

Journal Article > Study

Identifying hospitalized patients at risk for harm: a comparison of nurse perceptions vs. electronic risk assessment tool scores.

Stafos A, Stark S, Barbay K, et al. Am J Nurs. 2017;117:26-31.

This study compared nurses' identification of patients at risk for harm to an electronic predictive model and found that nurses more commonly identified psychological or social risks as relevant to harm. The nurses did not identify some patients whom the predictive model deemed high risk in cases where the risk had been incorporated into the plan of care. The authors suggest that nurse perceptions could inform more accurate predictive models, though neither approach was tested against an actual safety outcome.

Journal Article > Study

Effectiveness of a 'Do not interrupt' bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study.

  • Classic

Westbrook JI, Li L, Hooper TD, Raban MZ, Middleton S, Lehnbom EC. BMJ Qual Saf. 2017;26:734-742.

This randomized controlled trial had nurses on four hospital wards wear "do not interrupt" vests during medication administration. The rate of interruptions the intervention nurses experienced was compared to the rate in four control wards that did not have nurses wear vests. Although the intervention reduced non–medication-related interruptions, nurses reported that the vests were time consuming and uncomfortable; less than half would support continuing the intervention. This study demonstrates the need to design and test sustainable interventions to improve patient safety.

Journal Article > Study

Separate medication preparation rooms reduce interruptions and medication errors in the hospital setting: a prospective observational study.

Huckels-Baumgart S, Baumgart A, Buschmann U, Schüpfer G, Manser T. J Patient Saf. 2016 Dec 21; [Epub ahead of print].

Interruptions are known to contribute to medication administration errors. This pre–post study found that nurses experienced fewer interruptions and made fewer medication errors following the introduction of a separate medication room. These results demonstrate how changing the work environment can promote safety.

Journal Article > Commentary

2016 Updated American Society of Clinical Oncology/Oncology Nursing Society Chemotherapy Administration Safety Standards, including standards for pediatric oncology.

Neuss MN, Gilmore TR, Belderson KM, et al. J Oncol Pract. 2016;12:1262-1271.

Administration errors involving chemotherapeutic agents can result in patient harm. This set of standards provides guidance to help ensure reliable use of these high-alert medications for both adult and pediatric patients. Components of the revised standards are expanded to include two-person verification, vinca alkaloid mini-bag administration, and labeling enhancements for home-based chemotherapy.

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

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.

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