Defining attributes of patient safety through a concept analysis.

AIM: The aim of this study was to report an analysis of the concept of patient safety. BACKGROUND: Despite recent increase in the number of work being done to clarify the concept and standardize measurement of patient safety, there are still huge variations in how the term is conceptualized and how to measure patient safety data across various healthcare settings and in research. DESIGN: Concept analysis. DATA SOURCES: A literature search was conducted through PubMed and Cumulative Index to Nursing and Allied Health Literature, Plus using the terms 'patient safety' in the title and 'concept analysis,' 'attributes' or 'definition' in the title and or abstract. All English language literature published between 2002-2014 were considered for the review. METHODS: Walker and Avant's method guided this analysis. RESULTS: The defining attributes of patient safety include prevention of medical errors and avoidable adverse events, protection of patients from harm or injury and collaborative efforts by individual healthcare providers and a strong, well-integrated healthcare system. The application of Collaborative Alliance of Nursing Outcomes indicators as empirical referents would facilitate the measurement of patient safety. CONCLUSION: With the knowledge gained from this analysis, nurses may improve patient surveillance efforts that identify potential hazards before they become adverse events and have a stronger voice in health policy decision-making that influence implementation efforts aimed at promoting patient safety, worldwide. Further studies are needed on development of a conceptual model and framework that can aid with collection and measurement of standardized patient safety data.

Pressure ulcer care and public policy: exploring the past to inform the future.

Over the last 25 years, the quality of pressure ulcer (PrU) care has significantly changed because of sweeping public policy changes from the federal government. In fact, how clinicians think about PrU prevention and treatment can be traced back to several landmark changes made by the federal government that affect the continuum of healthcare. Moreover, the types of reimbursements for providers and institutions have dramatically changed in the last 25 years. The purpose of this article is to briefly review some of the major changes in long-term care, acute care, and home healthcare that have been impacted by public policy over the last 25 years.

Racial disparities in the frequency of patient safety events: results from the National Medicare Patient Safety Monitoring System.

BACKGROUND: Although there is extensive evidence of racial disparities in processes and outcomes of medical care, there has been limited investigation of disparities in patient safety. OBJECTIVE: To determine whether there are racial disparities in the frequency of adverse events studied in the Medicare Patient Safety Monitoring System. DESIGN AND SUBJECTS: Abstraction of 102,623 randomly selected charts from hospital discharges of non-Hispanic white and black Medicare patients between January 1, 2004 and December 31, 2007 to assess frequency of patient safety events in 4 domains: general (pressure ulcers and falls), selected nosocomial infections, selected procedure-related adverse events, and adverse drug events due to anticoagulants and hypoglycemic agents. MEASURES: Racial disparities in risk of patient safety events, and differences in adverse event rates among hospital groups stratified by percentage of black patients. RESULTS: Blacks had higher adjusted risk than whites of suffering one of the measured nosocomial infections (1.34; 95% confidence interval, 1.17-1.55; P < 0.001) and one of the measured adverse drug events (1.29; 95% confidence interval, 1.19-1.40; P < 0.001). After adjustment for patient and hospital factors, patients in hospitals with the highest percentages of black patients were at increased risk of experiencing one of the measured nosocomial infections (1.9% vs. 1.5%; P < 0.001) and adverse drug events (8.7% vs. 7.8%; P < 0.01). CONCLUSIONS: Hospitalized blacks are at higher risk than whites of experiencing certain patient safety events. In addition, hospitals serving high percentages of black patients have higher risk-adjusted rates of selected patient safety events.

Nursing research and participant recruitment: organizational challenges and strategies.

Hospitals as research environments are crucial in advancing evidence-based practice and translational research. The authors discuss issues related to hospital-based nursing research such as institutional review board approval, the HIPAA, structure, unit characteristics, and nurse staffing as well as research-related issues such as study purpose and design, participant recruitment, and research personnel. Strategies and suggestions for nurse executives to assist researchers in overcoming recruitment challenges are presented.

Annual checkup: the CMS pressure ulcer present-on-admission indicator.

PURPOSE: To provide the wound care practitioner with information about the Centers for Medicare and Medicaid Services (CMS) pressure ulcer present-on-admission (POA) indicators. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After reading this article and taking this test, the reader should be able to: 1. Describe the history and rationale for the CMS financial incentives for pressure ulcer (PrU) prevention. 2. Identify the CMS Pressure Ulcer POA indicators and 2009 ICD-9 coding for PrU staging. 3. Discuss the implications of the new CMS reimbursement for PrUs on healthcare organization practices with examples of successful interventions for PrU reduction.

Dilemmas in measuring and using pressure ulcer prevalence and incidence: an international consensus.

Pressure ulcer prevalence and incidence data are increasingly being used as indicators of quality of care and the efficacy of pressure ulcer prevention protocols. In some health care systems, the occurrence of pressure ulcers is also being linked to reimbursement. The wider use of these epidemiological analyses necessitates that all those involved in pressure ulcer care and prevention have a clear understanding of the definitions and implications of prevalence and incidence rates. In addition, an appreciation of the potential difficulties in conducting prevalence and incidence studies and the possible explanations for differences between studies are important. An international group of experts has worked to produce a consensus document that aims to delineate and discuss the important issues involved, and to provide guidance on approaches to conducting and interpreting pressure ulcer prevalence and incidence studies. The group's main findings are summarised in this paper.

Assessing risk and preventing pressure ulcers in patients with cancer.

OBJECTIVE: To identify risk factors for pressure ulcers that may place the patient with cancer at higher risk. The role of nursing to provide pressure ulcer preventive measures will be discussed. DATA SOURCES: Current research and published literature CONCLUSION: Research suggests that comprehensive prevention programs are effective in reducing pressure ulcer incidence rates and can be cost-effective. Comprehensive pressure ulcer prevention guidelines include risk assessment, skin care, offloading, and nutrition. Immobility places patients with cancer at greater risk. IMPLICATIONS FOR NURSING PRACTICE: Nurses are at the forefront of predicting patients at risk for pressure ulcers and working with the multidisciplinary team to implement a pressure ulcer preventive program. There remains a dearth of research related to pressure ulcers and cancer. Research in this area is strongly suggested.

Pressure ulcer prevention and care: implementing the revised guidance to surveyors for long-term care facilities.

The revised guidelines for long-term care surveyors by the Centers for Medicare and Medicaid Services link the existing pressure ulcer prevention and treatment evidence base with federal guidelines. The guidance document is detailed and attempts to ensure that residents receive optimal care to help prevent and manage these wounds. Implementation of the guidance document recommendations requires a complete review, and possibly revision, of existing policies and procedures. Understanding the background, rationale, and methods to implement these recommendations will help administrators and clinicians develop protocols of care that are effective, cost efficient, and comply with the new guidelines.

Quality improvement for pressure ulcer care in the nursing home setting: the Northeast Pressure Ulcer Project.

OBJECTIVES: The objectives of this study were to evaluate the impact of a collaborative model of quality improvement in nursing homes on processes of care for the prevention and treatment of pressure ulcers. STUDY DESIGN: The study design was experimental. SETTING: We studied 29 nursing homes in New Jersey, Pennsylvania, and Rhode Island. PARTICIPANTS: Participants consisted of pressure ulcer quality improvement teams in 29 nursing homes. INTERVENTION: Quality improvement teams attended a series of workshops to review clinical guidelines and quality improvement principles and to share best practices, and worked one-on-one with mentors to implement quality improvement techniques and to collect data independently. MEASUREMENTS: We calculated process measures based on the Agency for Healthcare Research and Quality (AHRQ) guidelines. Process measures addressed each facility's processes of care for the prevention and treatment of pressure ulcers at baseline and after 12 months of intervention. Prevention measures focused on recent admissions and high-risk residents; treatment measures focused on patients newly diagnosed with pressure ulcers and all patients with pressure ulcers. RESULTS: Overall, 6 of 8 prevention process measures improved significantly, with percent difference between baseline and follow up ranging from 11.6% to 24.5%. Three of 4 treatment process measures improved significantly, with 5.0%, 8.9%, and 25.9% difference between baseline and follow up. For each process measure, between 5 and 12 facilities demonstrated significant improvement between baseline and follow up, and only 2 or fewer declined for each process measure. CONCLUSION: Improvement in processes of care after the use of a structured collaborative quality improvement approach is possible in the nursing home setting.

Pressure ulcer prevention and management.

This chapter reviews 218 published and unpublished research reports of pressure ulcer prevention and management by nurse researchers and researchers from other disciplines. The electronic databases MEDLINE (1966-July 2001), CINAHL (1982-June 2001), AMED (1985-July 2001), and EI Compedex Plus (1980-June 2001) were selected for the searches because of their focus on health and applied research. Moreover, evaluations of previous review articles and seminal studies that were published before 1966 are also included. Research conducted worldwide and published in English between 1930 and 2001 was included for review. Studies using descriptive, correlational, longitudinal, and randomized control trials were included. This review found that numerous gaps remain in our understanding of effective pressure ulcer prevention and management. Moreover, the majority of pressure ulcer care is derived from expert opinion rather than empirical evidence. Thus, additional research is needed to investigate pressure ulcer risk factors of ethnic minorities. Further studies are needed that examine the impact of specific preventive interventions (e.g., turning intervals based on risk stratification) and the cost-effectiveness of comprehensive prevention programs to prevent pressure ulcers. Finally, an evaluation is needed of various aspects of pressure ulcer management (e.g., use of support surfaces, use of adjunctive therapies) and healing of pressure ulcers.

A comprehensive program to prevent pressure ulcers in long-term care: exploring costs and outcomes.

With scrutiny from survey agencies (Centers for Medicare and Medicaid Services and state agencies) and potential litigation increasing, long-term care facilities must implement aggressive pressure ulcer prevention programs. However, cost-effective pressure ulcer prevention continues to be a challenge for most long-term care facilities, in part because limited research is available to guide their efforts. Two long-term care facilities (Facility A with 150 beds and Facility B with 110 beds) participated in a quasi-experimental study using retrospective and prospective study data to evaluate the effect of implementing a protocol of care to address the incidence of pressure ulcers. Retrospective study results showed a combined, cumulative, 5-month pressure ulcer incidence of 43% in Facilities A and B. Implementation of the comprehensive prevention program resulted in an 87% decrease in pressure ulcer incidence in Facility A (from 13.2% to 1.7% per month, P = 0.02) and a 76% decrease in Facility B (from 15% to 3.5% per month, P = 0.02). The average monthly cost of prevention for a high-risk resident was $519.73 (plus a one time cost of $277 for mattress and chair overlays). More than half ($277.15) of the monthly costs relates to labor; the most expensive item cost is for support surfaces. This study demonstrated that this comprehensive program resulted in a significant decrease in the incidence of pressure ulcers in two long-term care facilities. Because labor and support surface costs remain high, long-term care facilities are encouraged to use prevention intervention strategies based on risk stratification.

Hospital-acquired pressure ulcers: results from the national Medicare Patient Safety Monitoring System study.

OBJECTIVES: To determine the national and state incidence levels of newly hospital-acquired pressure ulcers (PUs) in Medicare beneficiaries and to describe the clinical and demographic characteristics and outcomes of these individuals. DESIGN: Retrospective secondary analysis of the national Medicare Patient Safety Monitoring System (MPSMS) database. SETTING: Medicare-eligible hospitals across the United States and select territories. PARTICIPANTS: Fifty-one thousand eight hundred forty-two randomly selected hospitalized fee-for-service Medicare beneficiaries discharged from the hospital between January 1, 2006, and December 31, 2007. MEASUREMENTS: Data were abstracted from the MPSMS, which collects information on multiple hospital adverse events. RESULTS: Of the 51,842 individuals in the MPSMS 2006/07 sample, 2,313 (4.5%) developed at least one new PU during their hospitalization. The mortality risk-adjusted odds ratios were 2.81 (95% confidence interval (CI) = 2.44-3.23) for in-hospital mortality, 1.69 (95% CI=1.61-1.77) for mortality within 30 days after discharge, and 1.33 (95% CI = 1.23-1.45) for readmission within 30 days. The hospital risk-adjusted main length of stay was 4.8 days (95% CI = 4.7-5.0 days) for individuals who did not develop PUs and 11.2 days (95% CI = 10.19-11.4) for those with hospital-acquired PUs (P < .001). The Northeast region and Missouri had the highest incidence rates (4.6% and 5.9%, respectively). CONCLUSION: Individuals who developed PUs were more likely to die during the hospital stay, have generally longer hospital lengths of stay, and be readmitted within 30 days after discharge.

Family and friends to the rescue: experiences of rural older adults with heart failure.

The purpose of this study was to describe the experiences of rural community-dwelling older adults with heart failure who required assistance with activities of daily living (ADLs) and instrumental ADLs (IADLs). The context of the study was a rural area in a southern U.S. state. Twenty older adults with ADL/IADL needs living in the rural area were recruited during hospitalization and interviewed in their homes after discharge. The semi-structured interview focused on ADLs/IADLs and community resources. This qualitative descriptive study used hermeneutic methods for analysis. Four themes were identified: Accepting Limitations, Disappointments and Unmet Expectations, Figure It Out, and Complex Connections. The findings indicate that despite the older adults' medical conditions, they were able to set up complex arrangements, which allowed them to remain in their homes. Understanding the help older adults require after discharge will assist nurses in developing programs that are available, accessible, and acceptable to older adults who live in rural areas.

A new era of pressure ulcer accountability in acute care.

PURPOSE: To familiarize wound care practitioners with the 5 Million Lives Campaign's pressure ulcer prevention intervention. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in wound care. OBJECTIVES: After reading this article and taking this test, the reader should be able to: 1. List organizational and national initiatives that address pressure ulcer prevention. 2. Identify characteristics of pressure ulcers. 3. Identify 6 strategies that help prevent pressure ulcers.

Use of high-resolution, high-frequency diagnostic ultrasound to investigate the pathogenesis of pressure ulcer development.

OBJECTIVES: To investigate the pathogenesis of pressure ulcers utilizing high-resolution ultrasound and to explore the utility of this technology for the detection of incipient pressure ulcers prior to visual clinical signs. DESIGN: An observational prospective study comparing high-resolution ultrasound images obtained from 119 long-term-care facility residents determined to be at risk for pressure ulcer development (Braden Scale score of 18 or less) with images obtained from 15 healthy volunteers (medical students and medical residents). Common pressure ulcer sites were scanned, including the heels, sacrum, and ischial tuberosity. SETTING: A medical center and a long-term-care facility. INTERVENTION: Anatomic sites universally accepted as at risk for pressure ulcer development were scanned using high-resolution ultrasound; the sites did not have visual evidence of skin breakdown. The images obtained from the long-term-care facility residents were compared with images considered normal that were obtained from healthy volunteers. In addition, documentation of the clinical assessment finding for erythema was reviewed, recorded, and compared with the high-resolution ultrasound finding for each specific site. MEASUREMENTS: The images obtained were classified as not readable, normal, or abnormal. The images classified as abnormal were further classified by depth of abnormal finding: pattern 1 (deep) or pattern 2 (superficial). The images classified with the abnormal finding pattern 1 (deep) were further classified and subdivided by anatomic location of abnormal finding(s): subgroup 1, abnormal findings in the subdermal area only; subgroup 2, subdermal and dermal abnormal findings; and subgroup 3, subdermal, dermal, and subepidermal edema. Pattern 2 (superficial) included images with abnormal findings limited to the dermal/epidermal junction. RESULTS: 630 (55.3%) of the images obtained from the long-term-care residents were different from the images obtained from the healthy volunteers. The healthy volunteers' images classified as normal had the expected ultrasound findings for homogeneous pattern of ultrasound reflections, allowing for visualization of various skin layers (epidermis, superficial papillary dermis, deep reticular dermis, and hypodermis) and subcutaneous tissue (subdermal). However, many images (55.3%) obtained from the residents at risk for pressure ulcer development had patterns where areas within the various skin layers were not visible, interrupted by areas indicative of fluid or edema. Moreover, most images (79.7%) with abnormal ultrasound patterns did not have documentation of erythema. CONCLUSION: High-resolution ultrasound is an effective tool for the investigation of skin and soft tissue changes consistent with the documented pathogenesis of pressure ulcers. A progressive process for pressure ulcer development from deep subdermal layers to superficial dermal then epidermal layers can be inferred. Dermal edema was only present with subdermal edema. In other words, there was never evidence of dermal edema in the absence of subdermal edema. A better understanding of the pathogenesis of pressure ulcers through the use of high-resolution ultrasound to detect soft tissue damage and edema before visible clinical signs could lead to earlier and more focused pressure ulcer prevention programs, resulting in reduced pain and suffering for improved patient quality of life and wound care cost savings.

Acknowledged funding sources in pressure ulcer literature: a systematic review.

OBJECTIVE: To identify pressure ulcer research funding sources. DESIGN: A systematic review of the acknowledgment sections of pressure ulcer literature published between 2000 and 2002. RESULTS: Sixty-four papers were identified that acknowledged funding sources. Governmental funding sources were acknowledged in 53% (n = 34) of these papers, followed by manufacturers (30%, n = 19), consumer/professional organizations (17%, n = 11), provider organizations (11%, n = 7), philanthropic organizations (11%, n = 7), and academic institutions (9%, n = 6). CONCLUSION: Although various governmental organizations fund most pressure ulcer-related projects, this systematic review found that many other sources of funding are available. Researchers are encouraged to explore multiple sources for funding clinical research.