Archive for the ‘patient safety’ Category

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May AJN: A-Fib and Epilepsy Updates, an Ethics Collection, Diversity, Resolving Conflict, More

April 24, 2015

AJN0515.Cover.2ndAJN’s May issue is now available on our Web site. And in honor of the upcoming Nurses Week, we are offering free access to the entire issue for the month of May. In addition, because the American Nurses Association has designated this the “Year of Ethics” and the theme of this year’s Nurses Week is “Ethical Practice, Quality Care,” we have also made available a collection of some of our top ethics articles from 1925 to the present. Here’s a selection of what else not to miss in our May issue.

Atrial fibrillation adversely affects the quality of life of millions of people, resulting in significant morbidity and mortality and health care costs. Our CE feature, Atrial Fibrillation: Updated Management Guidelines and Nursing Implications,” reviews the recently updated guideline for the management of atrial fibrillation and stresses how nursing intervention in patient education and transition of care can improve outcomes. This feature offers 3 CE credits to those who take the test that follows the article.

Epilepsy is a serious neurologic disease that affects around 2.2 million people in the U.S. Epilepsy Update, Part 1: Refining Our Understanding of a Complex Disease, the first in a two-part CE series, discusses new research on the causes of epilepsy, new definitions that are changing the ways we evaluate the disease, and the psychosocial challenges faced by people who have it. It offers 2.5 CE credits to those who take the test that follows the article; there’s also a podcast interview with the author (this and other free podcasts are accessible via the Behind the Article podcasts page on our Web site, in our iPad app, or on iTunes).

Improving Outcomes from In-Hospital Cardiac Arrest,” part of our ongoing Critical Analysis, Critical Care series from nurses at the University of Washington, focuses on 2013 evidence-based recommendations from the American Heart Association, which identify five critical areas to focus on to improve cardiac arrest response and patient outcomes. Read the rest of this entry ?

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Never Too Late: One Family Practice’s Shift to EHRs after 50 Years of Paper

April 16, 2015

Editor’s note: We hear a lot about the stress and lack of time for direct patient care that nurses (and physicians) have experienced with the movement to EMRs or EHRs. We’re in a transitional period, and in some instances the use and design of these systems has a long ways to go. But here’s a story with a positive slant, written by someone who might easily have responded very differently, given the circumstances. Change is inevitable; how we react to it throughout our lives, less so. 

By Marilyn Kiesling Howard, ARNP

Niklas Bildhauer/ Wikimedia Commons

Niklas Bildhauer/ Wikimedia Commons

I am a nurse practitioner and my husband of 60 years is a family practitioner. We still work full time in our Gulf Breeze, Florida, practice. About five years ago, we first learned that our paper records were becoming archaic and that Medicare was planning to penalize providers who didn’t switch to the use of electronic health records (EHRs) by a certain date.

It was terrible news—we had 50 years of work in the paper chart genre, and were unsure about how to make the transition. Some who were in our position took the pending requirements as an opportunity to retire, but we weren’t ready for that.

Embracing a predigital innovation. In the 1960s, we started a small family practice in Indiana. As we requested our patients’ records from the files of their most recent physicians, it was not unusual to receive an index card that had the date neatly stamped on the left edge, with a handwritten note on the same line. (Needless to say, we’d already gone upscale, with a folder for each patient and a piece of white note paper.)

We quickly found that the medical record was our link to the prospective health of our patients, so we explored how we might make our records more useful. Joe read about a clinic in Bangor, Maine, where physicians were implementing the problem-oriented medical record (POMR) developed by Dr. Larry Weed, so we flew there to learn about this innovation. Dr. Bjorn and Dr. Cross were still developing their application of the model; their favorite medical secretary was a ‘bored bright housewife,’ and the entire clinic had an aura of excitement and discovery.

When we returned home, we quickly converted our folders to a proper chart with the ‘problem list’ fastened on the left and the progress notes on the right, using the new methodology. As we treated our new patients, we dutifully produced the ‘subjective, objective, assessment, and plan’ (SOAP) model we’d also imported from Maine.

This method sufficed for all the years between the first enlightenment and our leap in May 2011 into the world of pixels. It’s a challenge to get up and running with an EHR system. It was as if we were starting a new office with 2,000 patients to enroll. We had to had to translate and enter all of their old information into the new charting system. Two of our staff did not have computer knowledge and could not type. We went to half production, and our lost revenue was felt for months afterwards. (‘Meaningful use’ rules reimbursed us for about one-half of what the transition cost us.)

We’d decided on a cloud-based system because it was easy to access and the records would be safely stored on a server in Maine, an extra plus due to our propensity for hurricanes in the Florida Panhandle. The program was extremely user friendly. Given our level of expertise, this was a necessity. We took lessons online; the training included a live operator who was willing to stay on the line until the information was understood and applied. The company that runs the system keeps us compliant with meaningful use requirements and lets us know of impending changes.

We have, since we started using it at our clinic, found the EHR so far superior to our handwritten method that it would be impossible for us to return to the scribbled messes, as we see our old charts now. We still refer to them to garner important items such as consults, colonoscopies, surgeries, etc. Those reports are then neatly bar-coded into the EHR. It is no longer necessary to weed, retire, or store the charts. We did not abstract the old charts, simply moved important reports from them. We keep them in our office for quick historical reference. Read the rest of this entry ?

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Interprofessional Collaboration and Education: Making an Ideal a Reality

March 25, 2015
Photo courtesty of Penn Medicine.

Photo courtesty of Penn Medicine.

We hear a lot about interprofessional collaboration, the potentially dynamic and enlightening process of sharing knowledge across disciplines to improve patient care, but what’s being done to make this a reality?

The promotion of interprofessional collaboration is one focus of an ongoing national initiative by the Future of Nursing: Campaign for Action, as described in “Interprofessional Collaboration and Education,” an article in the March issue of AJN.

To close the gap between policy bullet points and the reality of daily work for nurses is neither impossible nor inevitable; it depends on smaller coalitions and the engagement of multiple organizations—but also, one imagines, a willingness to engage in inquiry and to try new and imperfect processes at the local level that may need refinement over time. The article is free, but here are a couple of paragraphs that give an a good overview of why it matters and where we are:

Interprofessional collaboration is based on the premise that when providers and patients communicate and consider each other’s unique perspective, they can better address the multiple factors that influence the health of individuals, families, and communities. No one provider can do all of this alone.

However, shifting the culture of health care away from the “silo” system, in which clinicians operate independently of one another, and toward collaboration has been attempted before without enduring success. For nearly five decades a commitment to interprofessional learning has waxed and waned in health professions training programs. During this time, health care leaders have shown intermittent interest in interprofessional collaboration in the delivery of health care. Strong and convincing outcome data demonstrating the value of team-based care have been lacking, but changes in our health care system now require that we explore how we can make interprofessional collaboration the norm instead of the exception.

Read the rest of this entry ?

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Addressing Alarm Fatigue in Nursing

March 2, 2015
by flattop341/via flickr

by flattop341/via flickr

By Amanda Anderson, a critical care nurse and graduate student in New York City currently doing a graduate placement at AJN.

“Will you please silence that alarm?!” The nurse is on the phone, and can’t reach the screaming cardiac monitor. It’s a normal request, considering that we’re working together in an ICU and the alarm has been ringing for awhile.

But her request for silencing the alarm isn’t issued to me; she’s talking to the unit clerk. Stuck in my patient’s room, I watch as this untrained staff member taps the flashing rectangle on the unit’s central monitor. Without having first been appropriately evaluated, the ringing disappears, along with the words “Multifocal PVCs.”

Later, the same unit clerk absentmindedly turns off a sounding alarm, without encouragement from a nurse. I’m floating today, and although I’ve just met her, I can’t help but ask, “Do you know what that alarm was saying? Was it accurate?”

She is clearly startled by my admonishment, but I persist. “A lot of the alarms around here do seem to be false, but what if this one wasn’t? Do you have the training to know the difference, and to report it?”

If looks could kill, the one that meets my gaze is certainly homicidal, but it’s paired with a grumbled promise to never touch the screen again. So maybe my point has stuck. Read the rest of this entry ?

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A Nursing Conference Focused on Quality and Safety, and a Big ‘What If?’

February 9, 2015

2015ANAQualityConferenceBanner600x100
By Maureen ‘Shawn’ Kennedy, AJN editor-in-chief

“What would quality in hospitals look like if health care institutions were as single-minded about serving clients as the Disney organization?”

Last week I attended the 2015 American Nurses Association Quality Conference in Orlando. The conference, which had its origins in the annual National Database of Nursing Quality Indicators (NDNQI) conference, drew close to 1,000 attendees. Here’s a quick overview of hot topics and the keynote speech by the new Secretary of the Department of Veterans Affairs, plus a note on an issue crucial to health care quality that I wish I’d heard more about during the conference.

Most sessions presented quality improvement (QI) projects and many were well done. There were some topics I hadn’t seen covered all that much, such as reducing the discomfort of needlesticks, enhancing postop bowel recovery, and promoting sleep. But projects aimed at preventing central line infections, catheter-associated urinary tract infections (CAUTIs), and pressure ulcers ruled the sessions. These of course are among the hospital-associated conditions that might cause a hospital to be financially penalized by the Centers for Medicare and Medicaid Services (CMS). The ANA also had a couple of sessions on preventing CAUTIs by means of a tool it developed in the Partnership for Patients initiative of the CMS to reduce health care–associated infections.

The keynote by Robert McDonald, the fairly new Secretary of the Department of Veterans Affairs, touted the services and resources available for the 9 million veterans who access care through the VA system. He surprised me and—if the murmuring I heard around me was any indication—a lot of others when he reported that patients in the VA system rated their care higher than did patients at general hospitals. The comment from an attendee: “Well, I guess it’s good once you get an appointment.”

He said the VA was “using the crisis of last year to move forward” and acknowledged that improving access was a priority, noting that the VA has hired 1,578 nurses since last year.

What if? It seemed appropriate that a meeting focused on quality took place at a venue known for its high quality customer focus. What would quality in hospitals look like if health care institutions were as single-minded about serving clients as the Disney organization? I’m not talking about the superficial attempts some hospitals implement, like valet parking or blazer-wearing patient service representatives. Read the rest of this entry ?

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System Barriers to RN Activation of Rapid Response Teams: New Evidence

February 6, 2015

By Sylvia Foley, AJN senior editor

Rapid response teams (RRTs) in acute care facilities are there to decrease mortality from preventable complications. But there is evidence that RRT systems “aren’t working as designed, particularly with regard to problems in the activation stage,” according to nurse researcher Jane Saucedo Braaten.

Figure 1. Five Domains of Cognitive Work Analysis and Corresponding Study Questions

Figure 1. Five Domains of Cognitive Work Analysis and Corresponding Study Questions (click image to enlarge)

Interested in how hospital system factors influence RNs’ activation behavior, Braaten decided to investigate further. She reports on her findings in this month’s CE–Original Research feature, “Hospital System Barriers to Rapid Response Team Activation: A Cognitive Work Analysis.” Here’s a summary.

Purpose: To use cognitive work analysis to describe factors within the hospital system that shape medical–surgical nurses’ RRT activation behavior.
Methods:
Cognitive work analysis offers a framework for the study of complex sociotechnical systems and was used as the organizing element of the study. Data were obtained from interviews with 12 medical–surgical nurses and document review.
Results: Many system factors affected participants’ activation decisions. Systemic constraints, especially in cases of subtle or gradual clinical changes, included a lack of adequate information, the availability of multiple strategies, the need to justify RRT activation, a scarcity of human resources, and informal hierarchical norms in the hospital culture. The most profound constraint was the need to justify the call. Justification was based on the objective or subjective nature of clinical changes, whether the nurse expected to be able to “handle” these changes, the presence or absence of a physician, and whether there was an expectation of support from the RRT team. The need for justification led to delays in RRT activation.
Conclusions: Although it’s generally thought that RRTs are activated without hesitation, this study found the opposite was true. All of the aforementioned constraints increase the cognitive processing load on the nurse. The value of the RRT could be increased by modifying these constraints—in particular, by lifting the need to justify calls, improving protocols, and broadening the range of culturally acceptable triggers—and by involving the RRT earlier in patient cases through discussion, consultation, and collaboration.

Read the rest of this entry ?

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Health Technology Hazards, 2015: Alarm Issues Still Lead ECRI Top 10

January 12, 2015
hazard/jasleen kaur, via Flickr

hazard/jasleen kaur, via Flickr

It’s a new year, and the ECRI Institute has released its Top 10 Health Technology Hazards for 2015 report, highlighting new health technology hazards (and some older, persistent ones) for health care facilities and nurses to keep in mind.

Alarm hazards still posed the greatest risk, topping the list at number one for the fourth year running. But this year, the report focused on different solutions. Often, according to the report, strategies for reducing alarm hazards focus on alarm fatigue—a hazard nurses have long battled. Now, the report recommends that health care facilities examine alarm configuration policies and practices for completeness and clinical relevance. These practices include:

  • determining which alarms should be enabled.
  • selecting alarm limits to use.
  • establishing the default alarm priority level.
  • setting alarm volumes.

Repeat hazards that made the list included inadequate reprocessing of endoscopes and surgical instruments (#4), robotic surgery complications due to insufficient training (#8), and, in at #2, data integrity issues such as incorrect or missing data in electronic health records and other health IT systems. For an overview of these hazards, see our posts on ECRI top 10 health technology hazards from 2013 and 2014.

And here’s an overview of new hazards that made the cut, along with some of the report’s suggestions on how to prevent them. Read the rest of this entry ?

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