ECRI’s Top 10 Patient Safety Concerns for 2014

safety Photo © One Way Stock.

For the past few years, we’ve highlighted the ECRI Institute’s annual Top 10 Health Technology Hazards report, which provides an overview of new and old technology hazards for health care facilities to keep in mind (read this year’s post here).

Now ECRI has released a new report entitled “Top 10 Patient Safety Concerns for Healthcare Organizations.” The goal of the list, according to ECRI, is to “give healthcare organizations a gauge to check their track record in patient safety.” The list, which will be published on an annual basis, draws upon more than 300,000 patient safety events, custom research requests, and root-cause analyses submitted to the institute’s federally designated patient safety organization (PSO) for assessment. A selection from the top 10 can be found below.

Poor care coordination with a patient’s next level of care

The concern: Gaps in communication about patient care—for example, between hospital and provider, among providers, and between long-term care settings and hospitals—have been reported to ECRI’s PSO. And while it is best practice for hospitals to send a patient’s discharge information to all of a patient’s providers, this doesn’t always happen.

Some suggestions: On reason information doesn’t get passed on, according to the report, is that staff aren’t always able […]

2016-11-21T13:04:28-05:00June 20th, 2014|Nursing|1 Comment
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Still a Nurse: A Shift in Professional Identity

Illustration by Jennifer Rodgers. All rights reserved. Illustration by Jennifer Rodgers. All rights reserved.

The June Reflections, “Making It Fit,” is a frank exploration of the ways health care professionals form separate cultures within each institution. It’s told by a newly minted advanced practice nurse whose previous job had been as a staff nurse in an ED. Now she’s taken a job as a psychiatric NP and finds herself on uncertain ground:

When I walked onto the unit my first day, expecting to be embraced by the nurses, I was dumbfounded and hurt that my own profession didn’t accept me with open arms. The inpatient unit is a melting pot of professions, and I found that I didn’t necessarily fit with the doctors, the social workers, or the staff nurses.

The author finds herself alone, neither nurse nor physician but instead something in between. As she describes her process of finding a new kind of nursing identity, she is very clear that this is not a case of nurses “eating their young.” Rather, it’s about finding a new normal. The short essay is an honest, smart look at career advancement and the associated challenges we hear less about, and is well worth a read.—Jacob Molyneux, AJN senior editor

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2016-11-21T13:04:29-05:00June 19th, 2014|career, nursing perspective|0 Comments
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The Ethics of No-Smokers Hiring Policies: Examining the Assumptions

Army nurses light up in 1947. Photo courtesy of Everett Collection / Newscom. Army nurses light up in 1947. Photo courtesy of Everett Collection / Newscom.

By Jacob Molyneux, senior editor

The Ethical Issues column in the June issue is called “The Ethics of Denying Smokers Employment in Health Care” (free until July 16). As in his previous columns, nurse–ethicist Doug Olsen models the thinking process of an ethicist, illuminating the fundamentals of ethical reasoning even as he tackles a specific ethical question.

Most positions we take on tough questions depend on a number of assumptions, both conscious and otherwise. In this article, Olsen does a great job identifying and then testing the assumptions that underlie such no-smokers hiring policies. Here are the main ones, as Olsen describes them:

2016-11-21T13:04:29-05:00June 16th, 2014|career, Ethics, nursing perspective|10 Comments
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When Metrics and Testing Replace Listening and Physical Assessment

By Gail M. Pfeifer, MA, RN, AJN news director

Emergency x 2 by Ian Muttoo, via Flickr. by Ian Muttoo/via Flickr

I was appalled as I read the Narrative Matters column by physician Charlotte Yeh in the June issue of Health Affairs, for two reasons. Aside from the compassion I felt for her suffering at being hit by a car on a rainy Washington, D.C., evening in 2011, I was dismayed that most of her story took place in an ED, one of the settings in which I used to work. While there, she met with a series of omissions that included not just medical care omissions but also—though she never explicitly connects the dots—basic and serious nursing care omissions.

It saddens me to think that one of the things I fought so hard to implement on our unit more than 20 years ago—transforming the staff’s automatic labeling of arriving patients (an MI, an MVA, a gunshot wound) into a unique picture of who that patient really was under those traumatic circumstances—has still not come to pass. Yet that change of vision is so important to completing the picture and arriving at an accurate diagnosis. Noting that her care demanded a better balance of necessary test-based […]

2016-11-21T13:04:30-05:00June 13th, 2014|career, nursing perspective|3 Comments
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Life Drawing

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

by julianna paradisi - all rights reserved by julianna paradisi – all rights reserved

With one double-gloved hand I pull the unblemished skin of her buttock laterally. Holding a syringe in the other, I pierce the large muscle with a needle, injecting acid-yellow methotrexate deep inside. Its purpose is to deplete the tiny, nonviable embryo inside her of folic acid, preventing its growth, a rupture, and potential harm to the woman.

Usually I administer chemotherapy to stop the life cycle of tumors, not the rapidly dividing cells of an embryo that missed its mark, mistakenly lodged in a fallopian tube instead of finding its way into her uterus where both of them could have been safe. Ectopic, it sacrificed viability, and threatens the life of its host.

Prone on the stretcher after the twin injections, she cries quietly. I hand her a box of tissues. She blows her nose. I try to think of something comforting to say, something that lets her know this is sad for me too. Resources are limited, so the powers that be decided that the safety provided by a chemotherapy-certified nurse outweighs the education, skill, and emotional support provided by an obstetrics nurse. Most likely they’re right, but […]

2016-11-21T13:04:31-05:00June 11th, 2014|career, nursing perspective|4 Comments
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Views expressed on the blog are solely those of the authors or persons quoted. They do not necessarily reflect AJN’s views or those of Wolters Kluwer Health/Lippincott Williams and Wilkins.
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