CE: Using Smart IV Infusion Pumps Outside of Patient Rooms.

ABSTRACT: The COVID-19 pandemic has created unique challenges for health care workers, who have demonstrated dedication, collaboration, and innovation in response. In this article, the authors describe an important nursing innovation they employed at Montefiore Medical Center in the Bronx, New York, during the spring 2020 COVID-19 surge: the relocation of smart IV infusion pumps outside of patient rooms. The goals of this innovation were to improve delivery of care, conserve personal protective equipment, limit the spread of the virus, and protect staff from exposure. The authors discuss the initial concerns that arose regarding the safety and efficacy of this practice; the research they conducted with other colleagues in nursing, pharmacy, infection control, and patient safety in the face of scant clinical literature relevant to the difficult circumstances the pandemic created; and the strategies they ultimately employed to ensure that this practice maintained safety and efficacy.

In-Hospital Newborn Falls Associated With a Sleeping Parent: The Case for a New Paradigm.

A newborn fall to the floor from a sleeping parent's arms in the immediate postpartum period may result in a skull fracture, head bleed, and transfer to the NICU for observation. These harmful consequences galvanized frontline clinicians to prevent these tragic accidents, but, a decade later, they continue at a stubbornly low, persistent level. In this article, I suggest that a misunderstanding of sleep science may be a barrier to effective interventions. The science of sleep is presented to inform a new paradigm that would have greater potential of eliminating dangerous newborn falls.

Blame and its consequences for healthcare professionals: response to Tigard.

Tigard (2019) suggests that the medical community would benefit from continuing to promote notions of individual responsibility and blame in healthcare settings. In particular, he contends that blame will promote systematic improvement, both on the individual and institutional levels, by increasing the likelihood that the blameworthy party will 'own up' to his or her mistake and apologise. While we agree that communicating regret and offering a genuine apology are critical steps to take when addressing patient harm, the idea that medical professionals should continue to 'take the blame' for medical errors flies in the face of existing science and threatens to do more harm than good. We contrast Dr Tigard's approach with the current literature on blame to promote an alternative strategy that may help to create lasting change in the face of unfortunate error.

Patients' Perspectives of Engagement as a Safety Strategy.

PURPOSE/OBJECTIVES: To describe patient engagement as a safety strategy from the perspective of hospitalized surgical patients with cancer.
. RESEARCH APPROACH: Qualitative, descriptive approach using grounded theory.
. SETTING: Memorial Sloan Kettering Cancer Center in New York, New York.
. PARTICIPANTS: 13 hospitalized surgical patients with cancer.
. METHODOLOGIC APPROACH: Grounded theory with maximum variation sampling.
. FINDINGS: Participants' perceptions regarding their engagement as a patient safety strategy were expressed through three overarching themes. CONCLUSIONS: Using direct messaging, such as "your safety" as opposed to "patient safety," and teaching patients specific behaviors to maintain their safety appeared to facilitate patient engagement and increase awareness of safety issues. Patients may be willing to accept some responsibility for ensuring their safety by engaging in behaviors that are intuitive or that they are clearly instructed to do; however, they described their involvement in their safety as a right, not an obligation.
. INTERPRETATION: Clear, inviting, multimodal communication appears to have the greatest potential to enhance patients' engagement in their safety. Nurses' ongoing assessment of patients' ability to engage is critical insofar as it provides the opportunity to encourage engagement without placing undue burden on them. By employing communication techniques that consider patients' perspectives, nurses can support patient engagement.

A conceptual framework for patient-centered fertility treatment.

BACKGROUND: Patient-centered care is a pillar of quality health care and is important to patients experiencing infertility. In this study we used empirical, in-depth data on couples' experiences of infertility treatment decision making to inform and revise a conceptual framework for patient-centered fertility treatment that was developed based on health care professionals' conceptualizations of fertility treatment, covering effectiveness, burden, safety, and costs. METHODS: In this prospective, longitudinal mixed methods study, we collected data from both members (separately) of 37 couples who scheduled an initial consult with a reproductive specialist. Data collection occurred 1 week before the initial consultation, 1 week after the initial consultation, and then roughly 2, 4, 8, and 12 months later. Data collection included semi-structured qualitative interviews, self-reported questionnaires, and medical record review. Interviews were recorded, transcribed, and content analyzed in NVivo. A single coder analyzed all transcripts, with > 25% of transcripts coded by a second coder to ensure quality control and consistency. RESULTS: Content analysis of the interview transcripts revealed 6 treatment dimensions: effectiveness, physical and emotional burden, time, cost, potential risks, and genetic parentage. Thus, the revised framework for patient-centered fertility treatment retains much from the original framework, with modification to one dimension (from safety to potential risks) and the addition of two dimensions (time and genetic parentage). For patients and their partners making fertility treatment decisions, tradeoffs are explicitly considered across dimensions as opposed to each dimension being considered on its own. CONCLUSIONS: Patient-centered fertility treatment should account for the dimensions of treatment that patients and their partners weigh when making decisions about how to add a child to their family. Based on the lived experiences of couples seeking specialist medical care for infertility, this revised conceptual framework can be used to inform patient-centered treatment and research on infertility and to develop decision support tools for patients and providers.

Priorities for family building among patients and partners seeking treatment for infertility.

BACKGROUND: Infertility treatment decisions require people to balance multiple priorities. Within couples, partners must also negotiate priorities with one another. In this study, we assessed the family-building priorities of couples prior to their first consultations with a reproductive specialist. METHODS: Participants were couples who had upcoming first consultations with a reproductive specialist (N = 59 couples (59 women; 59 men)). Prior to the consultation, couples separately completed the Family-Building Priorities Tool, which tasked them with ranking from least to most important 10 factors associated with family building. We describe the highest (top three) and lowest (bottom three) priorities, the alignment of priorities within couples, and test for differences in prioritization between men and women within couples (Wilcoxon signed rank test). RESULTS: Maintaining a close and satisfying relationship with one's partner was ranked as a high priority by majorities of men and women, and in 25% of couples, both partners ranked this factor as their most important priority for family building. Majorities of men and women also ranked building a family in a way that does not make infertility obvious to others as a low priority, and in 27% of couples, both partners ranked this factor as the least important priority for family building. There were also differences within couples that involved either men or women ranking a particular goal more highly than their partners. More women ranked two factors higher than did their partners: 1) that I become a parent one way or another (p = 0.015) and 2) that I have a child in the next year or two (p < 0.001), whereas more men ranked 4 factors higher than their partners: 1) that our child has [woman's] genes (p = 0.025), 2) that our child has [man's] genes (p < 0.001), 3) that I maintain a close relationship with my partner (p = 0.034), and 4) that I avoid side effects from treatment (p < 0.001). CONCLUSIONS: Clinicians who support patients in assessing available family-building paths should be aware that: (1) patients balance multiple priorities as a part of, or beside, becoming a parent; and (2) patients and their partners may not be aligned in their prioritization of achieving parenthood. For infertility patients who are in relationships, clinicians should encourage the active participation of both partners as well as frank discussions about each partner's priorities for building their family.

Recognizing and managing errors of cognitive underspecification.

OBJECTIVES: James Reason describes cognitive underspecification as incomplete communication that creates a knowledge gap. Errors occur when an information mismatch occurs in bridging that gap with a resulting lack of shared mental models during the communication process. There is a paucity of studies in health care examining this cognitive error and the role it plays in patient harm. The goal of the following case analyses is to facilitate accurate recognition, identify how it contributes to patient harm, and suggest appropriate management strategies. METHODS: Reason's human error theory is applied in case analyses of errors of cognitive underspecification. Sidney Dekker's theory of human incident investigation is applied to event investigation to facilitate identification of this little recognized error. RESULTS: Contributory factors leading to errors of cognitive underspecification include workload demands, interruptions, inexperienced practitioners, and lack of a shared mental model. Detecting errors of cognitive underspecification relies on blame-free listening and timely incident investigation. Strategies for interception include two-way interactive communication, standardization of communication processes, and technological support to ensure timely access to documented clinical information. Although errors of cognitive underspecification arise at the sharp end with the care provider, effective management is dependent upon system redesign that mitigates the latent contributory factors. CONCLUSIONS: Cognitive underspecification is ubiquitous whenever communication occurs. Accurate identification is essential if effective system redesign is to occur.

A one-to-one mentoring support service for breast cancer survivors.

PURPOSE: ABCD: After Breast Cancer Diagnosis (ABCD) is a Wisconsin-based mentoring service that pairs breast cancer survivors with women recently diagnosed with breast cancer. Since 1999, ABCD has trained volunteers to provide personalized information and emotional support. This review describes participants' perceptions of this survivorship program and its utility for breast cancer patients. METHODS: ABCD conducted 3 "program effectiveness" surveys between 2002 and 2006. Surveys were conducted over the telephone and used a 5-point Likert scale to elicit evaluations of the organization, mentors, resources, and other program dimensions. RESULTS: Survey results indicate that this model is a successful resource that could be replicated for breast cancer survivors nationally. Respondents were especially satisfied with the helpfulness of the program for them and their families, mentor confidentiality, and emotional support. Areas for improvement focused on mentee familiarity with the ABCD website and helpline and improvement in mentor knowledge. Approximately 60% of respondents would consider becoming mentors. CONCLUSION: ABCD is a positive and successful program with consistent participant satisfaction. The program has expanded nationally to address the needs of survivors. This model could be further replicated to provide support to survivors, family, and friends at no cost.

Patient-provider communication about gestational weight gain among nulliparous women: a qualitative study of the views of obstetricians and first-time pregnant women.

BACKGROUND: In 2009 the Institute of Medicine updated its guidelines for weight gain during pregnancy, in part because women of childbearing age now weigh more pre-pregnancy and tend to gain more weight during pregnancy than women did when the previous set of guidelines were released in 1990. Women who begin pregnancy overweight or obese and women who gain weight outside IOM recommendations are at risk for poor maternal and fetal health outcomes. With these concerns in mind, we examined what obstetricians communicate about gestational weight gain to their pregnant patients and how nulliparous patients perceive weight-related counseling from their obstetricians. METHODS: We conducted one-on-one, semi-structured interviews with 19 nulliparous women and 7 obstetricians recruited from a single clinic at a large academic medical center in the United States. Interviews were transcribed verbatim and analyzed inductively using thematic analysis. RESULTS: We identified 4 major themes: 1) Discussions about the amount and pace of gestational weight gain: obstetricians reported variation in the frequency and timing of weight-related discussions with patients while most patients said that weight was not emphasized by their obstetricians; 2) The content of communication about nutrition and physical activity: obstetricians said they discuss nutrition and activity with all patients while most patients reported that their obstetrician either discussed these topics in general terms or not at all; 3) Communication about postpartum weight loss: obstetricians said that they do not typically address postpartum weight loss with patients during prenatal visits while patients had concerns about postpartum weight; and 4) Patient feelings about obstetrician advice: most patients said that their obstetrician does not tend to offer "unsolicited advice", instead offering information in response to patient questions or concerns. Women were divided about whether they desired more advice from their obstetrician on weight gain, nutrition, and activity. CONCLUSIONS: Our analysis revealed discrepancies between obstetricians' and patients' perceptions of their weight-related clinical interactions. Our findings suggest that there is a missed opportunity to use prenatal visits as opportunities to discuss healthy eating and exercise during pregnancy, the postpartum period, and beyond. Additional research on the design, implementation, and testing of interventions to address prenatal nutrition and physical activity is warranted.

Positioning medical students for the geriatric imperative: using geriatrics to effectively teach medicine.

Medical schools must consider innovative ways to ensure that graduates are prepared to care for the aging population. One way is to offer a geriatrics clerkship as an option for the fulfillment of a medical school's internal medicine rotation requirement. The authors' purpose was to evaluate the geriatrics clerkship's impact on internal medicine knowledge and medical student attitudes toward older adults. Mean National Board of Medical Examiners (NBME) internal medicine subject exam scores from geriatrics and internal medicine students who matriculated from 2005 to 2011 were compared using student's t-tests. Academic performance was controlled for using the United States Medical Licensing Exam Step 1 exam scores. Focus groups were conducted to explore student attitudes. Geriatrics students performed just as well on the NBME exam as their internal medicine colleagues, but reported greater comfort with elder care. Geriatrics students also reported more positive attitudes toward older adults. Completing an internal medicine requirement using a geriatrics clerkship is an innovation for medical school curriculum structure.

Application of human error theory in case analysis of wrong procedures.

OBJECTIVES: The goal of this study was to contribute to the emerging body of literature about the role of human behaviors and cognitive processes in the commission of wrong procedures. METHODS: Case analysis of 5 wrong procedures in operative and nonoperative settings using James Reason's human error theory was performed. RESULTS: The case analysis showed that cognitive underspecification, cognitive flips, automode processing, and skill-based errors were contributory to wrong procedures. Wrong-site procedures accounted for the preponderance of the cases. Front-line supervisory staff used corrective actions that focused on the performance of the individual without taking into account cognitive factors. CONCLUSIONS: System fixes using human cognition concepts have a greater chance of achieving sustainable safety outcomes than those that are based on the traditional approach of counseling, education, and disciplinary action for staff.

Unrecognized hypoglycemia due to maltodextrin interference with bedside glucometry.

INTRODUCTION: Glucometry is widely used to confirm or exclude hypoglycemia in patients with suggestive clinical findings. Nonglucose sugars may be detected by certain types of glucometers, causing false elevation of the glucometer analysis of the blood sugar. Since these other sugars are not functionally glucose and may even induce excess insulin release, clinical hypoglycemia may be missed. CASE REPORT: We report a 79-year-old man on enteral feeds containing maltodextrin, a glucose polymer, who had persistently high glucometer-measured blood glucose despite normal blood glucose measured by formal laboratory analysis. DISCUSSION: Excess insulin administration, based on the erroneous glucometer reading, may have caused unrecognized fatal clinical hypoglycemia. This has been reported following intravenous administration of related nonglucose sugars but not with enteral maltodextrin. Further study is required to confirm the effects of maltodextrin on glucometry. CONCLUSION: False elevation of blood glucose measured on certain point-of-care glucometers can occur following the oral administration of maltodextrin.