Archive for the ‘patient safety’ Category

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Codeine Overused in Children: Alternatives Exist for Hard-to-Manage Pain

April 23, 2014

By Jacob Molyneux, senior editor

According to a story at MedlinePlus, a study in Pediatrics has found that codeine is still prescribed too often to children during ER visits, though it’s known that a small but significant subset of children metabolize the painkiller far more rapidly than do other children, leading to potentially dangerous results. As AJN‘s February CE article on treating the often severe and stubborn posttonsillectomy pain in children noted, there are other effective and safer options for children in pain, such as hydrocodone in combination with acetaminophen, as well as some non-opioid analgesics. Here’s a brief overview of the article:

Tonsillectomy, used to treat a variety of pediatric disorders, including obstructive sleep apnea, peritonsillar cellulitis or abscesses, and very frequent throat infection, is known to produce nausea, vomiting, and prolonged, moderate-to-severe pain. The authors review the causes of posttonsillectomy pain, current findings on the efficacy of various pharmacologic and nonpharmacologic interventions in pain management, recommendations for patient and family teaching regarding pain management, and best practices for improving medication adherence.

There’s often no perfect answer in pain management, but it helps to know the full range of available strategies, their safety, and how well they work. As with all CE articles, this one is free.

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A Tale of Two Dangerous Products

April 21, 2014
Holding On / D'Arcy Norman, via Flickr

Holding On / D’Arcy Norman, via Flickr

Amanda Anderson, BSN, RN, CCRN, works in critical care in New York City and is enrolled in the Hunter-Bellevue School of Nursing/Baruch College of Public Affairs dual master’s degree program in nursing administration and public administration.

There are two news stories I’ve been chewing on lately. One made it to the front page of my New York Times almost every day for a while, and the other I saw just once in the paper’s international news section several weeks ago.

The blockbuster story involves a single company that covered up a problem with an important part in one of its products. Ten years passed and a number of people died before they finally informed the public about the problem. The products with the flawed part have now been recalled, and the company is embroiled in an investigation and likely to face lawsuits and massive fines.

The far less publicized story is about a growing body of research exposing a problem that results in similar levels of harm. Unlike in the first story, the crucial ‘part’ that affects the product’s safety is human labor—and the detrimental effect of mismanagement of this labor is likewise injury or death. The link between the product flaw and its effects is well established, but there has been no public outcry, product recall, or lawsuit. The story barely made it past the gates of major media, and although the evidence linking this problem to dire results is strong, few industry players are acting on it. Read the rest of this entry ?

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Recent Nurse Blog Posts of Interest, Inhaled Insulin, a Note on Top Blogs Lists

April 4, 2014

By Jacob Molyneux, AJN senior editor/blog editor

Here you will find some links to nursing blog posts, a look at this week’s Affordable Care Act health exchange enrollment numbers, and a couple of items of interest about new treatments or studies, plus a note on blogs that award other blogs badges. A grab bag, so bear with me…

crocus shoots, early spring, I think/ via Wikimedia Commons

crocus shoots, early spring, I think/ via Wikimedia Commons

At the nursing blogs:

RehabRN has a post about a friend who was bullied by a nurse of much higher authority in the same hospital. Such stories, if true, are always upsetting. What can you do but take it when the power differential is so great?

At the INQRI blog (I’m not going to tell you what the initials stand for except that it has something to with quality, research, and nursing), there’s a post about why stroke survivors need a team approach to palliative care.

Megen Duffy (aka Not Nurse Ratched) has a really very good post at a site she sometimes blogs for. I already shared it via a tweet yesterday, but it deserves more. It’s called “Nursing Will Change You.”

At Infusion Nurse Blog, there’s a post addressing IV solution shortages (now happening on top of shortages of some common and necessary drugs due to a variety of reasons). It gives some practical steps clinicians and organizations can take to conserve and is definitely worth a quick look.

A sweet little post called “Nursing Sisters” is at Adrienne, {Student} Nurse. It’s about how nurses help each other out, starting right from the beginning in nursing school.

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Three Nurses and a Doctor Go Sailing – Some Notes on Communication Style

March 24, 2014

Julianna Paradisi, RN, OCN, writes a monthly post for this blog and works as an infusion nurse in outpatient oncology.

Untitled from the series, Pareidolia. Charcoal and graphite on paper, 12" x 9," by julianna paradisi

Untitled from the series, Pareidolia. Charcoal and graphite on paper,
12″ x 9,” by julianna paradisi

There’s an old joke about the personality differences among nurses of different specialties. It goes like this:

A medical–surgical nurse, an ICU nurse, an ER nurse, and a doctor go sailing. The doctor stands at the bow of the boat and shouts to the nurses, “Trim the sail!”

The med–surg nurse asks, “How do you want it?”

The ICU nurse replies, “I’ll trim, okay. But I’m doing it my way.”

The ER nurse shouts back at the doctor, “Trim the sail yourself!”

ICU style. The joke is a generalization, of course. However, I was a pediatric intensive care nurse once upon a time, and I have to admit that the ICU nurse characterization resonates with my own experience. Like the nurse in the joke, I always have an opinion, and rarely mind sharing it. In the ICU, if another nurse, a physician, a pharmacist, or respiratory therapist didn’t agree, conversation ensued. My colleague, equally opinionated, would state her or his position. Data was consulted, and then, more often than not, consensus occurred.

And I often learned something from sharing information. It made me a better nurse. I learned to dig in on a position only if patient safety or my license was at risk. Everything else was pretty much negotiable, face-to-face. From this perspective, our ICU team was similar to a marriage—it would have been unrealistic to expect there would never be disagreement within our team. In fact, if there was never disagreement, someone probably wasn’t being honest about her or his feelings—an approach that can lead to passive-aggressive behavior.

I don’t know if it’s because I no longer work in ICU, or if nursing culture in general has changed, but lately I’ve noticed some confusion about the difference between open, honest communication and bullying. There’s a difference. Read the rest of this entry ?

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Staffing and Long Shifts – Some Recent Coverage

February 24, 2014

By Shawn Kennedy, AJN editor-in-chief

by patchy patch, via flickr

by patchy patch, via flickr

The March issue will soon be published and be featured on the home page of our Web site, so before the February issue is relegated to the archive section, I want to highlight two articles. Knowing that some readers of this blog may not be regular readers of AJN (I know, hard to believe), I wanted to bring them to your attention.

I don’t usually blog about my own editorials, but the February editorial (“It All Comes Back to Staffing”) has apparently resonated with many readers. I’ve received several letters and a request to reprint it from a state nursing association. (The editorial includes a portion of a poignant letter I received from a reader in response to an editorial I’d written for the December 2013 issue, “Straight Talk About Nursing,” in which I discussed missed care—that is, the nursing care that we don’t get to but is often at the heart of individualizing care.)

The February editorial ties in with a special report, “Can a Nurse Be Worked to Death?”, by Roxanne Nelson, which addresses the recent death of a nurse who was killed in a car accident while driving home after a 12-hour shift. It’s a compelling report and I urge all nurses to read this piece and to think about what it says about long shifts. Read the rest of this entry ?

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Voice of Dissension: When Nurse Teamwork and Patient Safety Diverge

January 29, 2014
ParadisiIllustrationDissension

Dissension (from the series Pareidolia), charcoal & graphite on paper, 12″ x 9,”
2012 by Julianna Paradisi

Julianna Paradisi, RN, OCN, writes a monthly post for this blog and works as an infusion nurse in outpatient oncology. The illustration of this post is by the author.

The term “voice” gets thrown around a lot these days, usually in reference to creative content. Visual artists, writers, musicians, and actors rise to their unique place in the art world on the originality of their voice, not merely for mastery and talent.

In nursing, voice is important too. Hospitals spend a small fortune in paid staff hours for team-building meetings or retreats for nurses to smooth the rough edges of staff members, reducing friction among unit nurses with the ultimate goals of nurse retention and improved patient care. While these are admirable goals, I’m beginning to wonder if too much emphasis on team building may also diminish a nurse’s unique voice, thereby inadvertently interfering with patient safety? A team is only as strong as its individual members. Read the rest of this entry ?

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Health Technology Hazards: ECRI’s Top 10 for 2014

January 15, 2014
hazard/jasleen kaur, via Flickr

hazard/jasleen kaur, via Flickr

It’s that time of year again—the ECRI Institute has released its Top 10 Health Technology Hazards for 2014 report, and with it come new (and old) hazards to keep in mind.

Alarm hazards still posed the greatest risk, topping the list at number one for the third year running. Other repeat hazards included medication administration errors while using smart pumps (in at number two), inadequate reprocessing of endoscopic devices and surgical instruments (number six), and, at number eight, risks to pediatric patients associated with technologies that may have been designed for use in adults (such as radiology, oxygen concentrators, computerized provider order–entry systems, and electronic medical records). For an overview on these, see our posts from 2012 and 2013.

And here’s a snapshot of new hazards that made the cut, along with some of the report’s suggestions on how to prevent them.

Radiation exposures in pediatric patients (#3)

The risk: Although computed tomography (CT) scans are valuable diagnostic tools, they are not without risk, and children, who are more sensitive to the effects of radiation than adults, are more susceptible to its potential negative effects. According to the report, new empirical studies suggest that “diagnostic imaging at a young age can increase a person’s risk of cancer later in life.”

Some suggestions: The report suggests that health care providers take the following actions: use safer diagnostic options, when possible, such as X-rays, MRIs, or ultrasounds; avoid repeat scanning; and use a dose that is “as low as reasonably achievable.”

Occupational radiation hazards in hybrid ORs (#5)

The risk: Hybrid ORs, which bring advanced imaging capabilities into the surgical environment, are a growing trend. However, with these angiography systems comes exposure to radiation—a risk to both patients and OR staff.

Some suggestions: According to the report, a radiation protection program is a must. The program should include training for staff, who may not have experience with imaging technology; the use of shielding with lead aprons or other lead barriers; and monitoring of radiation levels. Read the rest of this entry ?

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The Not Good Nurse – Some Dark Holiday Reading

January 2, 2014

By Shawn Kennedy, AJN editor-in-chief

GoodNurseHaving some down time over the holidays can be a good chance to catch up on some reading. Because so much of my work entails reading manuscripts submitted to AJN about nursing practice and research, I look for my leisure reading to be something not connected to nursing.

Well, the book I recently read—a quick, engaging read—was about nursing, sort of. The book was Charles Graeber’s The Good Nurse: A True Story of Medicine, Madness and Murder, the story of nurse-turned-serial-killer Charles Cullen. While I find the title to be a bit sensationalist, the book is not. There’s no real answer as to why Cullen did what he did—Cullen apparently had a miserable childhood, was often a target of bullies, had failed marriages and made many suicide attempts to gain sympathy or attention. Graeber doesn’t really seek to answer the why of what Cullen did but instead focuses on his behavior and relationships.

The chilling aspect of the story is how easy it was for Cullen to get away with his killing through the use of essential technology relied on by nurses for the care of hospital patients. The medication and computer systems that he manipulated to cover his tracks also eventually allowed an intrepid nurse colleague to help police prove their case—only a nurse knowledgeable about the day-to-day use of the systems could uncover the wayward patterns.

But the real issue that comes through is how hospitals, fearing litigation, would simply dismiss Cullen when other nurses voiced concerns about his practice, allowing him to find work elsewhere and become someone else’s problem. That’s something I think many nurses might relate to—I certainly can. I worked with a couple of nurses early in my career who, when we reported to the administration that there were consistent errors in the narcotic count or missing medications when they were working, were given a chance to resign or be fired. Neither was ever reported to the board of nursing. Read the rest of this entry ?

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When There’s a Disconnect Between Good Nursing Practice and Reality

December 6, 2013

Recently I spoke with other nurses about our personal experiences with hospitalization and those of family members, and the conversation turned to disappointment with nursing practice and nursing care. In fact, whenever I’ve asked, every colleague has disclosed a similar experience. Some say that they’d never leave a family member alone in a hospital.

We need to acknowledge that there is a disconnect between what we know to be good practice and what is often the reality—even in facilities with Magnet accreditation. There are far too many instances in which nursing practice is substandard.

shawnkennedyThis is a heads-up about Shawn Kennedy’s editorial in this month’s issue of AJN, excerpted above. You should read it. The article, “Straight Talk About Nursing,” is free. There are no easy answers to the issues it raises. That’s all the more reason to discuss them openly.

In AJN, we often focus on examples of best practices and insightful, compassionate, engaged care. And we get that there are many institutional obstacles that undermine nurses in their attempts to provide quality care to patients. But even so, we’d be remiss to pretend we don’t hear about, and sometimes personally experience, care that simply falls short. This is scary, at least to me. Patients depend on nurses in so many ways. So have a look at the article and let us know your thoughts, as a nurse or as a patient.—Jacob Molyneux, senior editor

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Scrubs on the Street: Big Concern?

November 20, 2013
This colorized 2005 scanning electron micrograph (SEM) depicted numerous clumps of methicillin-resistant Staphylococcus aureus bacteria, commonly referred to by the acronym, MRSA; Magnified 2390x. CDC/via Wikimedia Commons

This colorized 2005 scanning electron micrograph (SEM) depicted numerous clumps of methicillin-resistant Staphylococcus aureus bacteria, commonly referred to by the acronym, MRSA; Magnified 2390x. CDC/via Wikimedia Commons

By Shawn Kennedy, AJN editor-in-chief

Last week I came across this article on the Reporting on Health blog from the Annenberg School of Communications and Journalism at the University of Southern California. It discusses one woman’s campaign to get hospital health care providers to stop wearing scrubs outside of the hospital. She wants people to photograph the ‘offenders’ and send the photos to hospital administrators. She’s concerned that the clothing will pick up infection-causing bacteria in the community and spread infection to weak, immunocompromised patients.

Wearing uniforms outside of the clinical setting has been debated on and off for years. Here’s an excerpt from an editorial comment that appeared in the March 1906 issue of AJN (you can read the full article for free as a subscriber):

AJNArchiveExcerptNursesonStreet

So again, the concern was about bringing bacteria into the environment of sick people. Recently, though, the concerns have evolved to include as well the reverse scenario: bringing resistant hospital bacteria home. (See a nurse’s follow-up post at Reporting on Health for a good summary of some current issues.)

As one person quoted in the initial post about this idea of “outing” people in scrubs outside the hospital points out, evidence remains inconclusive on whether bacteria on clothing is at play in causing infections. (One of its links includes a 2007 evidence review that notes the following: “The hypothesis that uniforms/clothing could be a vehicle for the transmission of infections is not supported by existing evidence.”) Aside from our pretty universal agreement as to the need for the strict compliance observed in the OR, how concerned should we be about hospital personnel wearing uniforms from home to hospital and home again, perhaps doing errands along the way?

I asked AJN’s infection control consultant, Betsy Todd, MPH, RN, CIC, about any recommended standards around this. She replied, “There’s just the AORN standards for OR wear. We long ago stopped worrying about leaving our work shoes in our lockers; and I think, despite the periodic microbiologic surveys of ties, coat sleeves, etc., the general idea still is that no links have been shown between organisms on clothing and the spread of infection.”

However, she further notes the following: “I always tell nurses that the first thing they should do when they get home is get out of their uniforms before hugging kids or the dog. I suspect the risk is bigger in this direction—more superbugs likely to be riding home with us than riding into the hospital with us.”

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