Archive for the ‘patient safety’ Category


Hospital Shootings: Unacknowledged Job Hazard?

February 3, 2016

Julianna Paradisi, RN, OCN, is an oncology nurse navigator and writes a monthly post for this blog. Illustration by the author.

Active_shooter_post_illustrationRecently, while preparing for work, I received the following text from a coworker already at the hospital:

We’re on lockdown
Armed gunman
Stay home, they announced “active shooter now outside building”

Shocked, barely able to comprehend the message, I texted back:

Are you safe?

She texted back that she and others were in lockdown in the cafeteria. Numbly, I switched on the TV, looking for more information, but found nothing. Not a single report of the event on any station. Turning to the Internet, I found a single tweet referring to an event in progress. Feeling helpless, I texted my husband and daughter and then called my mom, letting them know I was at home, safe, just in case they heard something. Then I waited.

Within an hour, the same coworker texted again:

All clear!

I stared at my phone, not knowing what to do. I went to work.

The resolution of the shooting situation was heartbreaking. However, no patients or hospital staff were harmed. The outcome could have been much worse.

That evening, local media coverage of the crisis remained scant to the point I nearly felt I’d imagined it. It was as though it never happened.

We were lucky. Our shooting occurred outside, on the hospital grounds—as do 41% of hospital shootings, according to a study in the Annals of Internal Medicine. However, 59% occur inside hospitals, endangering patients and staff. Furthermore, the rate of occurrences, inside or out, is increasing.

Hospital staffs have trained for years to handle fire, child abduction, and disasters, man-made or natural. However, the realization that hospitals are soft targets, similar to schools, shopping malls, and movie theaters, dawns more slowly.

Managing a rapidly evolving and unpredictable crisis can be beyond our control. To stay and protect patients may prove impossible. Some coworkers may or may not choose to stay with their patients; you will have to decide whether or not to abandon them too. Ethical choices may come into play—I for one struggle with the concept of abandoning patients. Teachers live with this fear on a daily basis.

According to the 2015 document, Active Shooter Planning and Response in a Healthcare Setting, from the Healthcare and Public Response Sector Coordinating Council, there are a number of ways to prepare a hospital in practical terms for an active shooter situation, and also to understand the kinds of decisions that may become necessary: Read the rest of this entry ?


Health Technology Hazards, 2016: Inadequate Disinfection of Flexible Endoscopes Tops ECRI List

January 14, 2016
hazard/jasleen kaur, via Flickr

hazard/jasleen kaur, via Flickr

The ECRI Institute has released its Top 10 Health Technology Hazards for 2016 report, highlighting health technology hazards for health care facilities and nurses to focus on this year.

Although alarm hazards, which topped the list for the past four years, still pose a significant threat, topping the list at number two, a different repeat offender has claimed the number one spot: inadequate cleaning of flexible endoscopes before disinfection.

Proper reprocessing and cleaning of biologic debris and other foreign material from instruments before sterilization is key, according to the report. And flexible endoscopes, especially duodenoscopes, are difficult to clean because of their long, narrow channels. Failure to clean properly can result in the spread of pathogens. The report points to a series of fatal carbapenem-resistant Enterobacteriaceae infections in the last two years to illustrate this particular threat, and recommends that facilities emphasize to their reprocessing staff that inattention to proper cleaning steps can lead to deadly infections.

Some hazards, such as those arising from health information technology (HIT) issues, insufficient training of clinicians in operating room technologies, and failure to appropriately operate intensive care ventilators, have been touched on in previous years. (See our past posts on ECRI top 10 health technology hazards from 2013, 2014, and 2015.) Here is a brief overview of other hazards that made the cut.

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AJN in December: Inside an Ebola Unit, Acupressure, Early Mobility, EHRs, More

November 30, 2015

AJN1215.Cover.OnlineOn this month’s cover, nurse Elie Kasindi Kabululu cares for a patient at Centre Médical Evangélique in Nyankunde, Beni, Democratic Republic of Congo. Originally, this location served a population of 150,000 and also housed a nursing school; but in 2002, during war in the region, the facility was attacked. About 1,000 people were killed—including patients and staff—and the center was looted and destroyed.

Providing medical assistance in the world’s war-torn and neediest areas is commonplace for health care providers like Kabululu, just as it is for humanitarian organizations such as Médecins Sans Frontières (MSF), which works in 70 countries worldwide—nearly half of these in Africa. Shortly after the recent outbreak of Ebola in West Africa, MSF sent close to 300 international workers to help combat this public health emergency. To read one nurse’s experience traveling to Liberia for MSF to work in a treatment center, see “Inside an Ebola Treatment Unit: A Nurse’s Report.”

Some other articles of note in the December issue:

Original Research: Implementation of an Early Mobility Program in an ICU.” This article, from our Cultivating Quality column, recounts how the effects of an early mobilization program delivered to critically ill patients at a community hospital by an independent ICU mobility team contributed to fewer delirium days and improvements in patient outcomes, sedation levels, and functional status.

CE Feature: Incorporating Acupressure into Nursing Practice.” The effects of acupressure can’t always be explained in terms of Western anatomical and physiologic concepts, but this noninvasive practice involves minimal risk, can be easily integrated into nursing practice, and has been shown to be effective in treating nausea as well as low back, neck, labor, and menstrual pain. The author discusses potential clinical indications for the use of acupressure, describes the technique, explains how to evaluate patient outcomes, and suggests how future research into this integrative intervention might be improved.

From our iNurse column: Nurses and the Migration to Electronic Health Records.” In many settings, the clock has been ticking for providers to switch to electronic health records (EHRs). Most U.S. hospitals are now using some form of EHR system, as are a smaller majority of physicians’ offices. This article presents the challenges and benefits of using electronic health records and provides tips for adapting to EHR systems.

There’s much more in our December issue, so click here to browse the table of contents and explore the issue on our Web site.



Recognizing and Managing Late or Long-Term Complications in Adult Allo-HSCT Survivors

November 17, 2015

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

Everybody, myself included, thought he was going to die. Another nurse on another floor had administered his stem cell transplant a few weeks prior, but as his primary nurse I was now in charge of managing its aftereffects.

Ben (not his real name, and some details have been changed) was one of the many young patients I’d cared for who suffered from a violent course of complications following allogeneic hematopoietic stem cell transplant (allo-HSCT). Intractable diarrhea and skin sloughing led to graft-versus-host-disease’s usual sequelae: wounds, drug-resistant infections, looming sepsis. The walls of his bladder, scarred and irritated by the myriad of toxic drugs he’d been given, bled. One day, while I slept at home between night shifts, he lost so much blood that they rushed him to the OR. The treatment—never before performed—stopped the bleeding. But it left him in excruciating, around-the-clock pain.

Between regular doses of Dilaudid and PCA pump pushes, he cried out to me, “I can’t do this. I don’t want this anymore.” I couldn’t blame him—his cancer fight raged on endlessly. Watching his boyishly handsome face grimace with so much pain, I remembered other young allo-HSCT patients’ faces, some of them peaceful only in the postmortem.

As it turned out, Ben survived his ICU stay. I heard about his discharge to the bone marrow transplant unit after I returned from a vacation. I lost touch with him, in the way that most ICU nurses lose touch with their patients (as though the unit is earth and the floors are outer planets, foreign and unknown, impossible to visit). I hope he’s home now, though, and a part of me believes he is—living, joining the growing population of allo-HSCT survivors.

As I read Kara Mosesso’s November CE article in AJN,Adverse Late and Long-Term Treatment Effects in Adult Allogeneic Hematopoietic Stem Cell Transplant Survivors (the first of several articles from Memorial Sloan Kettering Cancer Center about cancer survivorship care), I thought of Ben and was glad to be reminded that people like him do survive. While the current population of allo-HSCT survivors is fairly small, it’s growing, and by 2020 may reach around half a million worldwide.

It seems that all nurses—whether caring for allo-HSCT patients in the acute phase, like me, or in the chronic phase in an outpatient setting, must become familiar with the multifaceted long-term care of this population of patients. The table below, from the article, lists various late and long-term allo-HSCT treatment effects and their risk factors. Visit the article link above for more context, sources, and more.

Late and Long-Term Allo-HSCT Effects

(click to enlarge)

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Check my Conduct: Committing to a Better Way to Act with Colleagues

November 10, 2015

Christina Purpora, PhD, RN, is an assistant professor at the University of San Francisco School of Nursing and Health Professions. She has 30 years of hospital nursing experience.

Kindness quotation. Photo by Steve Robbins/Flickr

by Steve Robbins/Flickr Creative Commons

I wonder whether any of my nurse colleagues can recall having said or done something less than kind to a peer at work. Looking back over 30 years of nursing, I am aware of times that I could have been kinder. Not too long ago, the way that Emily—a less experienced nurse who was new to our unit—conducted herself in response to my reaction to her request for help taught me that I ought to consider a better way to act.

Request for Help
I was walking out of a patient’s room when Emily greeted me by name, then said, “Ms. S has one of the new IV pumps and the alarm keeps going off. I can’t figure out what’s wrong. Can you please help me?”

I felt annoyed at her for making one more demand on my time when I could barely keep up with my current assignment. Rolling my eyes, I curtly replied, “Emily, I think you can handle it. You had the in-service like everybody else.”

Seemingly unrattled by my terse retort, Emily stood her ground. “Yes,” she told me, “I used the troubleshooting tips I learned. But there’s still a problem. I’m concerned about Ms. S. and I’m uncomfortable that I’ve missed something. I think this is a safety issue.”

I recognized Emily’s use of the Agency for Healthcare Research and Quality TeamSTEPPS “CUS” words: Concern, Uncomfortable, and Safety, a tool designed to clearly communicate that a patient is at risk for harm when a first attempt to get a safety threat across to a member of the health care team doesn’t work.

The initial irritation I’d felt turned to embarrassment, and I answered Emily’s explanation with, “Okay, let’s go see Ms. S.” I followed Emily to her patient’s room where, together, we figured out the problem. Ms. S. was unharmed. Outside of the patient’s room, Emily thanked me and asked what she could do for me in exchange for the time I’d spent helping her. When nothing came to mind, she reiterated, “Please let me know if something comes up, because I’d happy to help you.”

My embarrassment grew in the presence of Emily’s team approach. With the potential safety threat averted, we carried on with our respective patient care responsibilities.

Reflect and Amend
For the rest of the shift, I couldn’t stop thinking about my outburst, which stood in glaring contrast to Emily’s professionalism. When I realized that a patient could have been harmed while I was resisting my peer’s call for help, I was horrified. I wanted to apologize to Emily. Read the rest of this entry ?


Preventing Newborn Falls

November 4, 2015
Photo by Joseph Sacchetti.

Photo by Joseph Sacchetti.

An acquaintance of mine once admitted to dropping her newborn baby while feeding her in the middle of the night. At the time I inwardly scoffed—how can someone be that tired, I thought judgmentally. Fast-forward to a few years later when I can now speak as a new mother—and to being that tired.

Sleep deprivation is no joke. And it doesn’t necessarily begin when the baby is born. The last few months of pregnancy and the discomfort that comes with it make for difficult sleep preceding the birth.

Many maternity units now promote “rooming in,” where a newborn baby stays in the mother’s room rather than with the nurses in the nursery. This makes newborn fall prevention an important issue. Take poor sleep in the last months of pregnancy and the physical and mental exhaustion of labor and add pain and limited mobility from the birth itself, especially a C-section birth; large rails on hospital beds making the transfer of one’s baby from bassinet to the mother’s bed difficult; and possible pain meds for mom, and the recipe could spell disaster.

In my case, with an emergency C-section and limited mobility, I found it very hard to pick my baby up from his bassinet and bring him into my hospital bed for a feeding. Luckily my husband stayed in the hospital room overnight and the nurses checked in around the clock, but not all mothers may be as fortunate.

In the November Safety Monitor column, “Preventing Newborn Falls While Supporting Family Bonding,” the Pennsylvania Patient Safety Reporting System highlights examples of such falls, pointing out that most occur “between midnight and 7 AM.” The article also highlights what hospitals—and nurses—can do to prevent these occurrences. Newborn fall prevention programs might include: Read the rest of this entry ?


AJN in November: New Cancer Survivorship Series, Holistic Nursing, Safe Opioid Use, More

October 30, 2015

AJN1115.Cover.2nd.inddOn this month’s cover, a nurse provides care to a patient at Clearview Cancer Institute in Huntsville, Alabama. The photo was chosen as the third-place winner of AJN’s 2015 Faces of Caring: Nurses at Work contest. Photographer Kim Swift shot the photo while shadowing her sister, a nurse, for a day. Swift sought to capture what she calls “the trust factor” between patients and nurses. She found a prime example of that relationship when she noticed the way one patient looked at her nurse as he explained an aspect of her cancer treatment.

To read the first in a series of AJN articles on cancer survivorship from the Memorial Sloan Kettering Cancer Center, see “Adverse Late and Long-Term Treatment Effects in Adult Allogeneic Hematopoietic Stem Cell Transplant Survivors.” This article—the first of several on cancer survivorship—summarizes the identification, evaluation, and management of potential treatment-related effects in adult survivors of hematopoietic stem cell transplants, with special focus on cardiovascular disease risk factors.

Some other articles of note in the November issue:

CE Feature:Imagery for Self-Healing and Integrative Nursing Practice.” Research suggests that that the use of imagery can help reduce patients’ pain and anxiety and improve their quality of life and outlook on their illness. The second article in a five-part series on holistic nursing describes how imagery can be used to encourage patients’ healing process and presents an imagery technique and a sample script to use in practice.

Clinical Feature: Prescription Opioid Analgesics: Promoting Patient Safety with Better Patient Education.” Inappropriate use of prescription opioids has increased sharply in the past two decades in the United States. Patients and caregivers must have an adequate understanding of safe use, storage, and disposal of opioids to prevent adverse drug events in patients and others. Using a case study, the author of this article examines the risks of nonmedical opioid use in postoperative patients and highlights the nurse’s role in patient education to avoid adverse outcomes.

From our Safety Monitor column: Preventing Newborn Falls While Supporting Family Bonding.” Recent studies and reports suggest that newborn injuries, such as falls, may be an unintended consequence of leaving newborns with fatigued parents in the first hours and days of life. This article addresses the circumstances behind newborn falls in hospitals when infants are in the care of family members, and reports on steps hospitals—and nurses—can take to effectively prevent these accidents. Read the rest of this entry ?


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