Archive for the ‘patient safety’ Category

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Telling Patients About Staffing Levels: Transparency or Self-Interest?

May 9, 2013

ethicsscreenshotIt’s a very busy Monday. Because of chronic difficulty in recruiting staff, the unit has only three-fourths of its RN positions filled. In addition, Mary Evans, an experienced nurse who always helps less experienced staff with their patients while carrying a full caseload herself, has called in sick.

Linda Smith is 68 years old and two days post-op from hip replacement surgery. As you enter her room, 45 minutes after she first requested pain medication, you can sense her irritation—but worse than that, you can see from the grimace on her face and her guarded movements that she’s in pain. After several days of good nursing care, you’ve let her down, and you consider telling her about the staff shortage. But you wonder: Is it right to disclose today’s short staffing to Ms. Smith?

The situation above is an ethical conundrum because values are in conflict. On one hand, transparency is good and patients have a right to know about administrative factors affecting their care. On the other hand, care should stay focused on a patient’s problems, not the nurse’s.

As the article excerpt above suggests, nurse staffing is a contentious issue having to do with both patient safety and job satisfaction for nurses. We’ve covered this issue many times in the past, most recently in a blog post that got quite a few comments back in January.

But should a nurse ever tell a patient about inadequate staffing? This is the ethical quandary posed by nurse ethicist Doug Olsen in his latest article, in the May issue of AJN (free until the first week of June). Having posed the situation described above, he goes on to pinpoint the ethical principles that come into play when making such a decision, explore the pros and cons of disclosing certain information to patients in various related situations, and emphasize both the need for awareness of the patient’s perspective and the necessity for nurses of engaging in honest self-examination.

As with many such situations, there’s not always a right answer; every situation is different, and gray areas do exist. What’s your take?—Jacob Molyneux, senior editor

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Posted in ethical issues, patient safety | Tagged , , , , , , | 5 Comments »

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Misplacing Our Focus on Quality Improvement

April 24, 2013

Gold_StarBy Maureen Shawn Kennedy, AJN editor-in-chief

I welcome manuscripts written by nurses in clinical practice, especially comprehensive updates on managing a clinical syndrome or a common problem that readers would find informative and interesting. I call these the “meat and potato” papers—the ones that provide substantial content, the need-to-know information that will help nurses provide quality, evidence-based care. The best ones discuss the physiology and pathology underlying clinical symptoms, practice implications for ongoing monitoring and management, and patient and family teaching and concerns.

The other papers I value are those that describe quality improvement initiatives or processes that improve outcomes and, by following the SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines, are sufficiently detailed so that others can replicate them. (For information on what we seek to publish, see a recent blog post.)

Lately, though, I’m seeing more and more submissions that are not so much focused on how to use best practices to improve care, but rather on ways to improve scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The authors typically describe the impetus for the improvement as low scores, get administrative support to set benchmarks for improving scores, and define success as improved scores. Often the changes are clinically insignificant but scores increase, so everyone is happy.

While the HCAHPS is a national measure that has been adopted as a measure of quality, it’s important to keep in mind that it measures the patient’s experience and satisfaction with only a few selected aspects of care, such as, according to the official HCAHPS Web site, “communication with nurses, communication with doctors, responsiveness of hospital staff, pain management, communication about medicines, discharge information, cleanliness of the hospital environment, and quietness of the hospital environment.” And because these measures  are tied to reimbursement, they receive a lot of attention.

There are many more aspects of care—treatment based on evidence, thwarting complications, early mobility to prevent pressure ulcers, adequate patient and caregiver teaching to prevent readmissions, to name a few—that are not measured in such a direct way and that may not be visible to patients and families, but may be more critical to a successful hospital experience.

We need to take a balanced approach to assessing quality and to be sure we’re placing emphasis on the right things. And while patients and their families are—or should be—at the center of what we do, our improvement initiatives shouldn’t be focused on getting a “gold star” for customer service.

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Posted in nursing perspective, patient safety, Shawn Kennedy, AJN editor-in-chief, writing and nursing | Tagged , , , , , | 1 Comment »

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At Denver Nurse Exec Mtg: Sully on Sources of Errors, Chow on Crucial Role of Patients and Families

March 22, 2013

Some quick take-homes from AJN’s editor-in-chief, Shawn Kennedy:

690px-Plane_crash_into_Hudson_Rivercroped

via Wikipedia

I’m in Denver at the annual meeting of the American Association of Nurse Executives (AONE), the organization comprised mostly of hospital nurse executives, administrators, and managers. As you can imagine, the focus is on leadership.

Captain “Sully” Sullenberger, the former US Airways pilot who safely landed a disabled passenger plane on the Hudson River in New York City in 2009, was the featured keynote speaker. He of course talked about the event that launched his second career as a speaker, author, and safety expert, but his message was really about leading in challenging times. Some key messages:

  • His success in landing the plane was the result of teamwork, with everyone executing what they had learned and practiced.
  • Core values must be made real on a daily basis in organizations.
  • Errors and bad outcomes are almost never the result of a single person or event, but a result of a cascading chain of events or failures.
AORN meeting cover image

AORN meeting cover image

Marilyn Chow, who spoke only briefly after accepting the AONE 2013 Lifetime Achievement Award, could as easily have been the keynote speaker at the meeting. Chow, who is vice-president, national patient care services, Kaiser Permanente, spoke with humor and passion about her values and where she thinks nursing’s values should be. She told of her 87-year-old mother’s great joy in helping feed “the old folks” at a senior day care center and identified her as the source for her own belief that “life is a gift and we should spend it doing meaningful things.”

Chow’s core message was that caregivers and families need to be co-leaders in changing health care, that nurses need to start thinking differently about their roles in our changing health care landscape and their potential to play a more prominent role in coordinating care and in meeting the growing need for primary care—and that this needs to happen sooner rather than later.

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Gel and a Poster: A Hand Hygiene Campaign Gets Tested in Two Outpatient Clinics

March 11, 2013

By Sylvia Foley, AJN senior editor

hand.sochacki.98193355_eb8473c967

Hand by sochacki.info, via Flickr

The trouble with hands is that they get into everything, and rapidly move between mouths, noses, eyes, and other people’s hands.

So says David Owen in his recent New Yorker article “Hands Across America,” which describes the development of the first gel sanitizer—and of course it’s nothing nurses and other clinicians don’t already know, just as they know that the practice of hand hygiene is crucial to reducing health care–associated infection rates. Yet adherence to hand hygiene guidelines among health care workers remains low. Interventions to improve hand hygiene have been tested in hospitals with demonstrated success, but have seldom been evaluated in other settings. In this month’s CE–Original Research feature, authors Kate Stenske KuKanich and colleagues describe their evaluation of a hand hygiene campaign in an outpatient oncology clinic and an outpatient gastrointestinal (GI) clinic.

The intervention. At each clinic, the researchers observed health care workers for the frequency of hand hygiene (attempts versus opportunities). After compiling baseline data, they initiated an intervention, which consisted of introducing an alcohol-based gel sanitizer and an informational poster to each clinic. (The gel sanitizer was provided as an alternative to foam sanitizer and soap and water.) One week later, interventional data were collected for five nonconsecutive days. Afterwards the posters and gel sanitizers were removed, and one month later, follow-up data were collected. Lastly, three months after follow-up observations ended, workers at each clinic were surveyed to evaluate their perceptions of the campaign.

Some findings. In both clinics, hand hygiene frequency was poor at baseline, just 11% at the oncology clinic and 21% at the GI clinic. But after the intervention it improved significantly, to 36% at the oncology clinic and 54% at the GI clinic—and the improvements were maintained during the follow-up period. Reported barriers to hand hygiene included skin irritation, forgetfulness, and insufficient time. Although a majority of surveyed workers at both clinics said they preferred soap and water, direct observations showed that once gel sanitizer was available, its use predominated. Indeed, when it was removed following the campaign’s end, many workers began carrying their own.

The researchers concluded that “introducing a gel sanitizer and providing informational posters can yield modest short-term improvements in overall hand hygiene performance in outpatient clinics.” They recommend that administrators and influential health care workers

  • collaborate in fostering an environment conducive to adherence.
  • provide a variety of hand hygiene products, including gel sanitizer.
  • encourage workers to participate in creating motivational posters.

For full details, please read the article—it’s free online. We’ve also got an exclusive podcast with the lead author. And as always, please consider sharing your thoughts and experiences with us in the comments.

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Posted in continuing education, infection control, nursing research, patient safety | Tagged , , , , | 1 Comment »

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AJN’s February Issue: COPD, Fungal Meningitis Outbreak, SIDs, Nursing Leadership

February 1, 2013

AJN0213 Cover OnlineAJN’s February issue is now available on our Web site. Here’s a selection of what not to miss.

Last month, we published findings from a quantitative study exploring antiparkinson medication–withholding times during hospitalization and symptom management. This month you can catch part two of this series, which reports on findings from a qualitative study on the perioperative hospitaliza­tion experiences of patients with Parkinson’s disease. Participants’ comments in this study made it clear that the actions of nurses could affect the perioperative experience for better or worse. The article is open access and can earn you 2.1 continuing education (CE) credits.

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the U.S. Our CE feature “COPD Exacerbations” outlines current guidelines and evidence-based recommendations for identifying, assessing, and managing COPD exacerbations. The article is open access and can earn you 2.6 CE credits.

This month we introduce our new series, Perspectives on Leadership, which is coordinated by the American Organization of Nurse Executives. This first article, “Partnering for Change,” describes how one hospital’s nurse leaders and staff worked together to change the way nurses conduct shift report.

Matthews_BillboardEach year in the U.S., more than 4,500 infants die suddenly and unexpectedly. February’s In Our Community article, “Babies Are Still Dying of SIDS,” describes how a nurse’s advocacy and activism resulted in safe-sleep legislation. A podcast with the authors of the article is also available.

Want to learn how hospitals, clinics, and the public health system responded to the recent fungal meningitis outbreak? Read this month’s Emerging Infections article for more.

There is plenty more in this issue, including a report on the recovery of health care facilities following Hurricane Sandy, so stop by and have a look. Feel free to tell us what you think on Facebook, or here on our blog.

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What’s So Hard to Understand: Patient Safety, Quality Care Linked to Nurse Staffing

January 29, 2013

By Maureen Shawn Kennedy, AJN editor-in-chief

shawnkennedyThe data linking nurse staffing as well as shift length with patient outcomes and satisfaction with care continue to roll in. The latest report on nurse staffing, published in the January 13 issue of Medical Care by McHugh and MA, links higher nurse–patient ratios and good work environments to reduced 30-day readmission rates. Read the abstract here.

Most nurses seem to support better nurse–patient ratios, but there’s continuing ambivalence about reducing shift length, as seen in the comments we received on a recent blog post asking whether it’s time to retire the 12-hour nursing shift.

In August, researchers reported a link between nurse staffing and hospital-acquired infections.  Publishing in the American Journal of Infection Control, the authors noted a “significant association” between nurse–patient staffing ratios and both urinary tract infections and surgical site infections. Further, they noted that reducing nurse burnout was associated with fewer infections. (Read our news report on the study here.)

Health Affairs published a report in November called “The Longer the Shifts for Hospital Nurses, The Higher the Levels of Burnout and Patient Dissatisfaction.” The findings were there, loud and clear—researchers Stimpfel, Sloane, and Aiken found that “extended shifts undermine nurses’ well-being, may result in expensive turnover and can negatively affect patient care.”

And in December, we published a CE article (“Staffing Matters—Every Shift”) that looked at data suggesting that not just nurse–patient ratios, but the skill mix and relative experience levels among nurses in a unit, affected patient outcomes. (Here’s the blog post we ran describing the article’s main points.)

But all this shouldn’t be news. In 2004, Health Affairs carried a report by Ann Rogers and colleagues noting the link between long working hours and the risk of error. And in 2002, researchers led by Jack Needleman and Peter Buerhaus reported study findings in the New England Journal of Medicine: in brief, data from 799 hospitals in 11 states showed that more care by RNs (as opposed to LPNs or nurse aides) led to better patient outcomes. Read the rest of this entry ?

Posted in continuing education, nursing perspective, nursing research, patient safety | Tagged , , , , , , | 20 Comments »

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Health Technology Hazards: ECRI’s Top 10 for 2013

January 4, 2013
hazard/jasleen kaur, via Flickr

hazard/jasleen kaur, via Flickr

It’s a new year and with it comes new health care technology hazards to keep in mind, as listed in the most recent ECRI Institute report, 2013 Top 10 Heath Technology Hazards. While some risks from last year’s list made a repeat appearance, a few new topics made the cut for 2013.

Alarm hazards still posed the greatest risk, topping the list at number one. Other repeat hazards included medication administration errors while using smart pumps, unnecessary radiation exposure, and surgical fires. For an overview on these, see our post from last year.

Several new opportunities for harm seemed to involve new information technology (IT) that is making its way into health care facilities, such as smartphones and mobile devices. Here’s a snapshot of several of these, and some suggestions the report gives on how to prevent them.

Patient/data mismatches in electronic health records (EHRs) and other health IT systems

The risk: One patient’s records ending up in another patient’s file may not be a new phenomenon—it happened in traditional paper-based systems as well. But newer, more powerful health IT systems have the capability to transmit mistaken data to a variety of devices and systems, multiplying the adverse effects that could result from these errors.

Some suggestions: The report suggests that when purchasing health IT systems, facilities should consider how all the connected technologies facilitate placing the right patient data into the right record. It also states that a “patient-centric” approach is preferable to a “location-centric” one. All patient flow and device movement should be kept in mind, as well as planning for all types of transfers (not just routine ones). And during implementation of any project or software upgrade, appropriate testing should be carried out to avoid surprises.

Interoperability failures with medical devices and health IT systems

The risk: Establishing interfaces among medical devices and IT systems has the potential to reduce errors associated with manual documentation, but achieving the appropriate exchange of data can be difficult, and can lead to patient harm. (For example, interfaces between medical devices may not work properly, systems can be incompatible, and one device can have unintended effects on another.)

Some suggestions: Although there are challenges to integrating medical devices and systems, the report stresses that health care facilities should be actively engaged in the process—albeit cautiously. An inventory of interfaced devices and systems, including software versions, should be kept. Hospitals should follow best practices as described in the International Electrotechnical Commissioner’s standards (available on the International Organization for Standardization’s Web site). When making changes to interfaced equipment, all stakeholders should be involved (and this includes nurses). Finally, before any broad system modifications are implemented, testing should be carried out to ensure everything works as expected.

Caregiver distractions from smartphones and other mobile devices

The risk: While much has been said about the security considerations associated with the use of smartphones, tablet computers, and other handheld devices, another topic that is starting to get attention is the potential for substandard patient care or even physical harm to patients if caregivers are distracted by their devices. Making mistakes or missing information as a result of distraction isn’t the only problem. Caregivers who are distracted by their devices may miss clues about the patient’s condition or cause patients to question the quality of their care.

Some suggestions: According to the report, staff should be educated about the risks associated with the use of smartphones and mobile devices, especially the potential for digital distractions that affect patient care. Hospitals should come up with a “mobile device management strategy” that includes appropriate use of the devices, including specific measures users must take to ensure safety and security. Hospitals may also want to consider restricting personal use of these devices during patient care activities.

Other hazards that topped the list for 2013 include the following:

  • air embolism hazards
  • inattention to the needs of pediatric patients when using technologies that may have been  designed for use in adults (such as radiology, oxygen concentrators, computerized provider order-entry systems, and electronic medical records)
  • inadequate reprocessing of endoscopic devices and surgical instruments

Click here to request a copy of the full report.—Amy M. Collins, editor

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AJN’s January Issue: Men in Nursing, Perioperative Medication Withholding in Patients with PD, Book of the Year Awards, More

December 28, 2012

AJN0113.Cover.Online

AJN’s January issue is now available on our Web site. Here’s a selection of what not to miss, including two continuing education (CE) articles, which you can access for free.

Even though more men are starting to become nurses, they still make up less than 7% of all RNs.  In “Men in Nursing,” the authors discuss the challenges of recruiting and retaining men in the nursing profession. This article is open access and can earn you 2.1 CE credits.

 In this month’s original research article, the authors report on findings from a quantitative study exploring antiparkinson medication withholding times during hospitalization and symptom management. Part one of a two-part series, this article is open access and can earn you 2.5 CE credits. Look for part two in our next issue, which reports on findings from a qualitative study on the perioperative hospitaliza­tion experiences of patients with PD.

After sustaining a needlestick injury during a research study, nurse Lynn Petrik created a new safety device for a commonly used glucose sensor. “From Putty to Prototype” takes readers through the steps of her invention, from the prototype to the provisional patent.

 Looking for a good read? The votes are in, and the winners of AJN’s annual Book of the Year Awards are listed in this issue. A supplemental online only companion to the article gives the judges reviews for each book.  

 And finally, read “The Clinical Nurse Leader and the Case Manager: Are Both Roles Needed?” for an exploration of these two roles, how they complement each other, and why each is necessary.

 There is plenty more in this issue, so stop by and have a look. Feel free to tell us what you think on Facebook or our blog. And have a happy and healthy New Year!


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Nurse Staffing Matters at the Shift Level—Evidence-Based Scenarios Illustrate How to Apply What We Know

December 10, 2012

We know that staffing matters. Studies have shown that hospitals with lower proportions of RNs have higher rates of death overall, death following compli­cations (that is, failure to rescue), and other adverse events. But how do such data on staffing translate into what the average hospital nurse experiences on a shift?

That’s the question posed by Gordon West and colleagues, the authors of this month’s CE, “Staffing Matters—Every Shift.” To address it, they reviewed findings from the Military Nursing Outcomes Database (MilNOD). MilNOD, a quality improve­ment and research project conducted in four phases between 1996 and 2009, encompassed data from 111,500 shifts on 56 inpatient units in 13 U.S. military hospitals. The project explored “the effects of staffing levels and skill mix on the probability of patient falls, medication errors, and needlestick injuries to nursing staff.”

As the authors explain, the MilNOD data showed that the number, mix, and experience of nurses on a shift—not just on a unit—were associated with adverse events for patients and needlestick injuries to nurses. West and colleagues offer several realistic, descriptive scenarios to illustrate the potential effects of staffing changes and to show how such knowledge can be applied to daily decision making.

To learn more, read the article, which is free online.—Sylvia Foley, AJN senior editor


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Posted in continuing education, nurses, nursing research, patient safety | Tagged , | 2 Comments »

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A Crucial Distinction: Missing Incidents vs. Wandering in People With Dementia

December 3, 2012

At every stage of dementia, people with the condition are at risk for both missing incidents, in which they are unattended and unable to navigate a safe return to their caregiver, and “wandering,” a term often used to describe repetitive locomotion with patterns such as lapping or pacing. By understanding the differences between these two phenomena, nurses can teach caregivers how to anticipate and prevent missing incidents, which are not necessarily related to wandering. The authors differentiate missing incidents from wandering, describe personal characteristics that may influence the outcomes in missing incidents, and suggest strategies for preventing and responding to missing incidents.

When someone’s behavior is consistently outside the norm, our tendency is to stop paying close attention to observable differences in that behavior. This may be particularly true when we are responsible for the care and safety of a person with dementia. As described by the overview above, one of the CE articles in the December issue of AJN, “Missing Incidents in Community-Dwelling People with Dementia,” focuses on a crucial distinction between two types of behavior in people with dementia, one that is expected and manageable and even at time beneficial (for exercise, self-calming, etc.), and one that can be far more dangerous. Here’s a useful table that spells out some of the key differences to keep in mind between missing incidents and wandering. But for a more detailed look at the topic, please click the link above and read the entire article.—Jacob Molyneux, senior editor

Missing IncidentsAnedWandering 

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