Evidence That Nurses Need to Participate in Diagnosis: Lessons From Malpractice Claims.

OBJECTIVES: There is a pressing need for nurses to contribute as equals to the diagnostic process. The purpose of this article is twofold: (a) to describe the contributing factors in diagnosis-related and failure-to-monitor malpractice claims in which nurses are named the primary responsible party and (b) to describe actions healthcare leaders can take to enhance the role of nurses in diagnosis. METHODS: We conducted a review of the Controlled Risk Insurance Company Strategies' repository of malpractice claims, which contain approximately 30% of United States claims. We analyzed the malpractice claims related to diagnosis (n = 139) and physiologic monitoring (n = 647) naming nurses as the primary responsible party from 2007 to 2016. We used logistic regression to determine the association of contributing factors to likelihood of death, indemnity, and expenses incurred. RESULTS: Diagnosis-related cases listing communication among providers as a contributing factor were associated with a significantly higher likelihood of death (odds ratio [OR] = 3.01, 95% confidence interval [CI] = 1.50-6.03). Physiologic monitoring cases listing communication among providers as a contributing factor were associated with significantly higher likelihood of death (OR = 2.21, 95% CI = 1.49-3.27), higher indemnity incurred (U.S. $86,781, 95% CI = $18,058-$175,505), and higher expenses incurred (U.S. $20,575, 95% CI = $3685-$37,465). CONCLUSIONS: Nurses are held legally accountable for their role in diagnosis. Raising system-wide awareness of the critical role and responsibility of nurses in the diagnostic process and enhancing nurses' knowledge and skill to fulfill those responsibilities are essential to improving diagnosis.

Using human factors engineering to improve patient safety in the cardiovascular operating room.

Despite significant medical advances, cardiac surgery remains a high risk procedure. Sub-optimal work system design characteristics can contribute to the risks associated with cardiac surgery. However, hazards due to work system characteristics have not been identified in the cardiovascular operating room (CVOR) in sufficient detail to guide improvement efforts. The purpose of this study was to identify and categorize hazards (anything that has the potential to cause a preventable adverse patient safety event) in the CVOR. An interdisciplinary research team used prospective hazard identification methods including direct observations, contextual inquiry, and photographing to collect data in 5 hospitals for a total 22 cardiac surgeries. We performed thematic analysis of the qualitative data guided by a work system model. 60 categories of hazards such as practice variations, high workload, non-compliance with evidence-based guidelines, not including clinicians' in medical device purchasing decisions were found. Results indicated that hazards are common in cardiac surgery and should be eliminated or mitigated to improve patient safety. To improve patient safety in the CVOR, efforts should focus on creating a culture of safety, increasing compliance with evidence based infection control practices, improving communication and teamwork, and designing better tools and technologies through partnership among all stakeholders.

Mandatory public reporting: build it and who will come?

Rates of healthcare-associated infections (HAI) are being reported on an increasing number of public information websites in response to legislative mandates driven by consumer advocacy. This represents a new strategy to advance patient safety and quality of care by informing a broad audience about the relative performance of individual healthcare facilities. Unlike typical consumer health informatics products, the target audience and targeted health behaviors are less easily defined; further, the impact on providers to improve care is unknown relative to other incentives to improve. To address critical knowledge gaps facing all state agencies embarking on this new frontier, we found it essential and straightforward to recruit the assistance of university research faculty from a variety of disciplines. That interdisciplinary group was quickly able to define a 5-year applied evaluation research agenda spanning a progressive set of crucial questions.