Archive for the ‘patient safety’ Category

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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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‘Suppose a Client Went Out of His Room’: Study Explores RNs’ Use of Surveillance Technology in Residential Facilities

December 15, 2014

By Sylvia Foley, AJN senior editor

“If people are for instance walking around in the units, well, then they could do all sorts of things . . . ”—study participant

Table 2. Surveillance Devices and Their Use in the Selected Care Facilities

Table 2. Surveillance Devices and Their Use in the Selected Care Facilities

Surveillance technology in residential care facilities for people with dementia or intellectual disabilities has been touted both as a solution to understaffing and as a means to increasing clients’ autonomy. But it’s unclear whether surveillance technology delivers on its promises—and there are fears that its use could attenuate the care relationship. To explore how nurses and support staff actually use this technology, Alexander Niemeijer and colleagues decided to conduct a field study. They report on their findings in this month’s CE–Original Research feature, “The Use of Surveillance Technology in Residential Facilities for People with Dementia or Intellectual Disabilities.” Here’s a brief summary.

Methods: An ethnographic field study was carried out in two residential care facilities: a nursing home for people with dementia and a facility for people with intellectual disabilities. Data were collected through field observations and informal conversations as well as through formal interviews.
Results: Five overarching themes on the use of surveillance technology emerged from the data: continuing to do rounds, alarm fatigue, keeping clients in close proximity, locking the doors, and forgetting to take certain devices off. Despite the presence of surveillance technology, participants still continued their rounds. Alarm fatigue sometimes led participants to turn devices off. Though the technology allowed wandering clients to be tracked more easily, participants often preferred keeping clients nearby, and preferably behind locked doors at night. At times participants forgot to remove less visible devices (such as electronic bracelets) when the original reason for use expired.
Conclusions: A more nuanced view of the benefits and drawbacks of surveillance technology is called for. Study participants tended to incorporate surveillance technology into existing care routines and to do so with some reluctance and reservation. Client safety and physical proximity seemed to be dominant values, suggesting that the fear that surveillance technology will attenuate the care relationship is unfounded. A clear and well-formulated vision for the use of surveillance technology seems imperative to successful implementation.

Read the rest of this entry ?

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Too Tired to Nurse

December 8, 2014

By Shawn Kennedy, AJN editor-in-chief

by patchy patch, via flickr

by patchy patch, via flickr

Just about every nurse I know has been “asked” (or “guilted” or “mandated”) to work an additional shift on top of a grueling one. The worst such experience I ever had was having to work from midnight to 8 am after working a straight week of 4 pm to midnight shifts. I was exhausted, but someone had called in sick, leaving only two RNs and one aide for the 11-bed ED trauma unit.

I was so tired that at one point I found myself falling asleep while I was standing by a patient’s bed charting vital signs. I couldn’t remember the blood pressure reading I had obtained just moments before. It was good luck that I didn’t make an error—and had the good sense to have a colleague double-check medications I was readying (these were the old days, before unit dosing). Read the rest of this entry ?

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A Nurse’s Legal Duty to Discern Potential Harm and Protect Patients

November 7, 2014
Illustration by Janet Hamlin for AJN.

Illustration by Janet Hamlin for AJN.

By Jacob Molyneux, AJN senior editor

The November installment of AJN’s Legal Clinic column by nurse and attorney Edie Brous, “Lessons Learned from Litigation: The Nurse’s Duty to Protect,” describes a case in which nurses were held responsible for not adequately protecting a sedated patient from a sexually predatory physician. The case description begins this way:

NX was a young woman who underwent a laser ablation of genital warts at Cabrini Medical Center in New York City. While still under the effects of general anesthesia, she was transferred to a small, four-bed section of the recovery room. Shortly after her admission to the recovery room, the nurses admitted another patient to a bed two feet away from NX. The curtains were not drawn and there were no patients in the other two beds.

A male surgical resident, Andrea Favara, entered the recovery room wearing Cabrini scrubs and Cabrini identification. Residents were not directly assigned to the recovery room and were seldom called there. The nurses knew all of NX’s physicians but did not know Favara; he wasn’t one of NX’s physicians . . .

The details that follow are disturbing. After describing the case and the failure of nurses to confront this unknown physician or actively monitor his interactions with the patient, Brous sketches the ensuing legal machinations, as well as the ultimate decision of an appeals court. Some of the main take-home points for nurses are as follows: Read the rest of this entry ?

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