Factors Influencing Medication Administration Outcomes Among New Graduate Nurses Using Bar Code-Assisted Medication Administration.

Paramount to patient safety is the ability for nurses to make clinical decisions free from human error. Yet, the dynamic clinical environment in which nurses work is characterized by uncertainty, urgency, and high consequence, necessitating that nurses make quick and critical decisions. The aim of this study was to examine the influence of human and environmental factors on the decision to administer among new graduate nurses in response to alert generation during bar code-assisted medication administration. The design for this study was a descriptive, longitudinal, observational cohort design using EHR audit log and administrative data. The study was set at a large, urban medical center in the United States and included 132 new graduate nurses who worked on adult, inpatient units. Research variables included human and environmental factors. Data analysis included descriptive and inferential analyses. This study found that participants continued with administration of a medication in 90.75% of alert encounters. When considering the response to an alert, residency cohort, alert category, and previous exposure variables were associated with the decision to proceed with administration. It is important to continue to study factors that influence nurses' decision-making, particularly during the process of medication administration, to improve patient safety and outcomes.

Describing Medication Administration and Alert Patterns Experienced by New Graduate Nurses During the First Year of Practice.

The aim of this study was to describe medication administration and alert patterns among a cohort of new graduate nurses over the first year of practice. Medical errors related to clinical decision-making, including medication administration errors, may occur more frequently among new graduate nurses. To better understand nursing workflow and documentation workload in today's clinical environment, it is important to understand patterns of medication administration and alert generation during barcode-assisted medication administration. Study objectives were addressed through a descriptive, longitudinal, observational cohort design using secondary data analysis. Set in a large, urban medical center in the United States, the study sample included 132 new graduate nurses who worked on adult, inpatient units and administered medication using barcode-assisted medication administration. Data were collected through electronic health record and administration sources. New graduate nurses in the sample experienced a total of 587 879 alert and medication administration encounters, administering 772 unique medications to 17 388 unique patients. Nurses experienced an average medication workload of 28.09 medications per shift, 3.98% of which were associated with alerts, over their first year of practice. In addition to high volume of medication administration, new graduate nurses administer many different types of medications and are exposed to numerous alerts while using barcode-assisted medication administration.

A realist model for home visitation program evaluation.

Increased attention on home visitation as a strategy to reduce child maltreatment and increased funding to support home visitation programs has led to their rapid and widespread adoption in the United States and internationally. The rapid adoption of home visitation programs has occurred without an adequate understanding of the underlying mechanisms of influence on child maltreatment. Consequently, there is a lack of consistency in structures and processes across programs. The variability in structures and processes within and across programs has contributed to the inconsistent findings related to the effectiveness of home visitation as a strategy to constrain child maltreatment. Identifying the underlying mechanisms that are facilitating or constraining program success or failure is essential for informing policy and practice. We propose the use of realist theory to identify the underlying mechanisms of home visitation programs. While realist theory has been used broadly in the social sciences, its uptake in nursing has been slow. Despite its limited use in nursing, realism's primary function, seeking to identify the underlying mechanisms in complex social programs, makes it suitable for investigating many complex phenomena that are of interest to nurse scientists. Here we discuss the theoretical foundations for home visitation programs, the recent evidence for program effectiveness, significant home visitation program components, and we propose a realist model for home visitation program evaluation that may aid in identifying how, for whom, and under what conditions home visitation programs work when these programs are implemented to address child maltreatment.

Development and Testing of the Quality Improvement Self-efficacy Inventory.

Quality improvement is paramount for patient safety. Leading change for quality improvement requires nurses with knowledge and skills beyond the clinical management of patients. In this study, staff nurses working in hospitals throughout Alabama were asked via an online survey to rate their quality improvement knowledge and skills using the new 10-item Quality Improvement Self-Efficacy Inventory (QISEI) and their perceptions of the nursing work environment using the Practice Environment Scale of the Nursing Work Index. Nurses (N = 886) rated the basic quality improvement items higher than the more advanced items. Several nurse characteristics and the nursing work environment were associated with nurses' ratings of their quality improvement knowledge and skills. Educators and administrators in health care organizations can use QISEI to gauge their nurses' knowledge and skills and then develop continuous professional development opportunities aimed at improving quality and safety competencies.

Historic and bioarchaeological evidence supports late onset of post-Columbian epidemics in Native California.

Catastrophic decline of Indigenous populations in the Americas following European contact is one of the most severe demographic events in the history of humanity, but uncertainty persists about the timing and scale of the collapse, which has implications for not only Indigenous history but also the understanding of historical ecology. A long-standing hypothesis that a continent-wide pandemic broke out immediately upon the arrival of Spanish seafarers has been challenged in recent years by a model of regional epidemics erupting asynchronously, causing different rates of population decline in different areas. Some researchers have suggested that, in California, significant depopulation occurred during the first two centuries of the post-Columbus era, which led to a "rebound" in native flora and fauna by the time of sustained European contact after 1769. Here, we combine a comprehensive prehistoric osteological dataset (n = 10,256 individuals) with historic mission mortuary records (n = 23,459 individuals) that together span from 3050 cal BC to AD 1870 to systematically evaluate changes in mortality over time by constructing life tables and conducting survival analysis of age-at-death records. Results show that a dramatic shift in the shape of mortality risk consistent with a plague-like population structure began only after sustained contact with European invaders, when permanent Spanish settlements and missions were established ca. AD 1770. These declines reflect the syndemic effects of newly introduced diseases and the severe cultural disruption of Indigenous lifeways by the Spanish colonial system.

Nurse Cognition, Decision Support, and Barcode Medication Administration: A Conceptual Framework for Research, Practice, and Education.

This article synthesizes theoretical perspectives related to nurse cognition. We present a conceptual model that can be used by multiple stakeholders to study and contemplate how nurses use clinical decision support systems, and specifically, Barcode-Assisted Medication Administration, to make decisions during the delivery of care. Theoretical perspectives integrated into the model include dual process theory, the Cognitive Continuum Theory, human factors engineering, and the Recognition-Primed Decision model. The resulting framework illustrates the process of nurse cognition during Barcode-Assisted Medication Administration. Additionally, the model includes individual or human and environmental factors that may influence nurse cognition and decision making. It is important to consider the influence of individual, human, and environmental factors on the process of nurse cognition and decision making. Specifically, it is necessary to explore the impact of heuristics and biases on clinician decision making, particularly related to the development of alarm and alert fatigue. Aided by the proposed framework, stakeholders may begin to identify heuristics and cognitive biases that influence the decision of clinicians to accept or override a clinical decision support system alert and whether heuristics and biases are associated with inappropriate alert override.

Alert Types and Frequencies During Bar Code-Assisted Medication Administration: A Systematic Review.

BACKGROUND: Existing literature explores the effectiveness of bar code-assisted medication administration (BCMA) on the reduction of medication administration error as well as on nurse workarounds during BCMA. However, there is no review that comprehensively explores types and frequencies of alerts generated by nurses during BCMA. PURPOSE: The purpose was to describe alert generation type and frequency during BCMA. METHODS: A systematic review of the literature using PRISMA guidelines was conducted using CINAHL, PubMed, EMBASE, and Ovid Medline databases. RESULTS: After screening for inclusion and exclusion criteria, a total of 8 articles were identified and included in the review. Alert types included patient mismatch, wrong medication, and wrong dose, though other alert types were also reported. The frequency of alert generation varied across studies, from 0.18% to 42%, and not all alerts were clinically meaningful. CONCLUSIONS: This systematic review synthesized literature related to alert type and frequency during BCMA. However, further studies are needed to better describe alert generation patterns as well as factors that influence alert generation.

Clinical Information Needs: A Concept Analysis.

Health care organizations have invested resources to implement and upgrade information systems capable of collecting large quantities of data. Recent technology developments have created a renewed interest in studying clinician information needs. However, a common definition and analysis of the concept clinical information needs have not been provided. Walker and Avant's method was used to perform a concept analysis. Following a review of relevant literature, a clinical information need was defined as a conscious expression, which can be verbal or nonverbal, of a desire for knowledge to answer clinical questions in the course of decision making to deliver patient care.

Variation in academic preparation and progression of nurses across the continuum of care.

BACKGROUND: Changing health care needs are driving new models of care that emphasize care coordination, health promotion, and disease management by registered nurses (RNs). A skill-mix favoring professional (baccalaureate or above) over technical (less than baccalaureate) education is promoted by national initiatives. PURPOSE: To examine the academic preparation and progression of general practice RNs in practice settings across the care continuum. METHOD: Secondary analyses of data from the Texas Board of Nurses RN Licensure databases in 2008 and 2014. FINDINGS: Overall the professional skill-mix for general practice RNs improved from 47.1% to 50.2%. Disparities were identified in home health (31.6%), long-term care (27.8%) and nonmetropolitan areas (31.7%). Role change was the strongest correlate of academic progression. DISCUSSION: Non-hospital and rural practice settings may be vulnerable to the effects of an undereducated RN workforce. More effective reimbursement policies and employer incentives are needed to drive academic progression and address disparities across practice settings.

Can proactive rapid response team rounding improve surveillance and reduce unplanned escalations in care? A controlled before and after study.

BACKGROUND: Unplanned escalations manifest as a breakdown of hospital care attributable to clinician error through missed or delayed identification of physiological instability, ineffective treatment, or iatrogenic harm. OBJECTIVES: To examine the impact of an Early Warning Score-based proactive rapid response team model on the frequency of unplanned intra-hospital escalations in care compared with a rapid response team model based on staff nurse identification of vital sign derangements. DESIGN: Pre- and post Early Warning Score-guided proactive rapid response team model intervention. SETTING: 237-bed community hospital in the southeastern United States. PARTICIPANTS: All hospitalized adults (n = 12,148) during a pre- and post-intervention period. METHODS: Logistic regressions used to examine the relationship between unplanned ICU transfers and rapid response team models (rapid response team vs. Early Warning Score-guided proactive rapid response team). RESULTS: Unplanned ICU transfers were 1.4 times more likely to occur during the rapid response team baseline period (OR = 1.392, 95% CI [1.017-1.905]) compared with the Early Warning Score-guided proactive rapid response team intervention period. CONCLUSIONS: This study reports a difference in the frequency of unplanned escalations using different rapid response models, with fewer unplanned ICU transfers occurring during the use of Early Warning Score-guided proactive rapid response team model while accounting for differences in admission volumes, age, gender and comorbidities. Implementation of this model has implications for patient outcomes, hospital operations and costs.

Monthly variation of unfinished nursing care at the US Army Burn Center.

OBJECTIVE: To describe the monthly variation in the prevalence and patterns of unfinished nursing care and to determine the relationships between the system of nursing care and unfinished nursing care at the US Army Burn Center. METHODS: This was a repeated measures, descriptive study. For one week per month for six months, all nurses providing direct patient care on two inpatient burn units (intensive care and progressive care) were asked to complete an anonymous paper survey, which contained the Perceived Implicit Rationing of Nursing Care instrument, to estimate the prevalence of unfinished nursing care on their unit. Unit administrative data also were collected from the unit nursing leaders each month. Descriptive statistics and multilevel modeling were used in the analysis. RESULTS: Most (80.5%) eligible nurses participated at least once; 46.6% participated three or more times. A high proportion (85.7-100%) of nurses left at least one element of care unfinished; the mean number of activities left unfinished over each 7 shift period per nurse was 16.2. Only nursing care hours provided by float staff significantly predicted nurse estimates of unfinished nursing care, ß=.008, SE=.001, p<.05. CONCLUSIONS: The prevalence of unfinished nursing care at the US Army Burn Center was high and generally consistent with other studies of unfinished nursing care in non-burn settings. The inability to meet the demand for nursing care, as evidenced by the presence of unfinished nursing care, may be the result of a limited surge capacity. Implications for research, policy, and practice were discussed.

Seamless Transitions: Achieving Patient Safety Through Communication and Collaboration.

BACKGROUND: Although more than a decade has passed since the imperative to reduce fragmentation of care, high rehospitalization rates among Medicare patients with chronic diseases persist; at least 25% of these are considered preventable. Transitional care models that emphasize coordination among providers have demonstrated significant reductions in hospitalization rates. However, achieving effective collaboration among providers across disciplines and/or facilities through implementation of transitional care models can be challenging. OBJECTIVES: The aims of this article are to (1) describe a collaborative transitional care program implemented by a 7-hospital health care system and a postacute senior care service provider organization to pilot a transitional care program (Transitions Across Care Settings [TRACS]) for improving coordination of care for their mutual patients and (2) share results and lessons learned from this quality initiative. METHODS: The goal of the TRACS program, which used the Coleman Care Transitions Intervention model, was to reduce 30-day readmissions to lower than the national averages for an initial target population of inpatients with pneumonia, congestive heart failure, and acute myocardial infarction diagnoses. RESULTS: The overall readmission rate for 104 patients in the pilot TRACS program was 4.8%. Readmission rates were 0% for acute myocardial infarction, 7.1% for congestive heart failure, and 4.4% for pneumonia. CONCLUSIONS: A culture of patient safety was facilitated by a registered nurse transitions coach through consistent communication and flow of patient information during patient hand offs across the care continuum. More than 1000 patients are already admitted to the next iteration of the TRACS program, resulting in a sustainable enterprise.

Mitogenomics supports an unexpected taxonomic relationship for the extinct diving duck Chendytes lawi and definitively places the extinct Labrador Duck.

Chendytes lawi, an extinct flightless diving anseriform from coastal California, was traditionally classified as a sea duck, tribe Mergini, based on similarities in osteological characters. We recover and analyze mitochondrial genomes of C. lawi and five additional Mergini species, including the extinct Labrador Duck, Camptorhynchus labradorius. Despite its diving morphology, C. lawi is reconstructed as an ancient relictual lineage basal to the dabbling ducks (tribe Anatini), revealing an additional example of convergent evolution of characters related to feeding behavior among ducks. The Labrador Duck is sister to Steller's Eider which may provide insights into the evolution and ecology of this poorly known extinct species. Our results demonstrate that inclusion of full length mitogenomes, from taxonomically distributed ancient and modern sources can improve phylogeny reconstruction of groups previously assessed with shorter single-gene mitochondrial sequences.

Patient Turnover: A Concept Analysis.

Patient turnover influences the quality and safety of patient care. However, variations in the conceptual underpinnings of patient turnover limit the understanding of the phenomenon. A concept analysis was completed to clarify the role of patient turnover in relation to outcomes in the acute care hospital setting. The defining attributes, antecedents, consequences, and empirical referents of patient turnover were proposed. Nursing leaders should account for patient turnover in workload and staffing calculations. Further research is needed to clarify the influence of patient turnover on the quality and safety of nursing care using a unified understanding of the phenomenon.

Outcome Measurement in Nursing: Imperatives, Ideals, History, and Challenges

Nurses have a social responsibility to evaluate the effect of nursing practice on patient outcomes in the areas of health promotion; injury and illness prevention; and alleviation of suffering. Quality assessment initiatives are hindered by the paucity of available data related to nursing processes and patient outcomes across these three domains of practice. Direct care nurses are integral to self-regulation for the discipline as they are the best source of information about nursing practice and patient outcomes. Evidence supports the assumption that nurses do contribute to prevention of adverse events but there is insufficient evidence to explain how nurses contribute to these and/or other patient outcomes. The purposes of this article are to examine the imperatives, ideal conditions, history, and challenges related to effective outcome measurement in nursing. The article concludes with recommendations for action to move quality assessment forward, such as substantial investment to support adequate documentation of nursing practice and patient outcomes.

Resource scarcity drives lethal aggression among prehistoric hunter-gatherers in central California.

The origin of human violence and warfare is controversial, and some scholars contend that intergroup conflict was rare until the emergence of sedentary foraging and complex sociopolitical organization, whereas others assert that violence was common and of considerable antiquity among small-scale societies. Here we consider two alternative explanations for the evolution of human violence: (i) individuals resort to violence when benefits outweigh potential costs, which is likely in resource poor environments, or (ii) participation in violence increases when there is coercion from leaders in complex societies leading to group level benefits. To test these hypotheses, we evaluate the relative importance of resource scarcity vs. sociopolitical complexity by evaluating spatial variation in three macro datasets from central California: (i) an extensive bioarchaeological record dating from 1,530 to 230 cal BP recording rates of blunt and sharp force skeletal trauma on thousands of burials, (ii) quantitative scores of sociopolitical complexity recorded ethnographically, and (iii) mean net primary productivity (NPP) from a remotely sensed global dataset. Results reveal that sharp force trauma, the most common form of violence in the record, is better predicted by resource scarcity than relative sociopolitical complexity. Blunt force cranial trauma shows no correlation with NPP or political complexity and may reflect a different form of close contact violence. This study provides no support for the position that violence originated with the development of more complex hunter-gatherer adaptations in the fairly recent past. Instead, findings show that individuals are prone to violence in times and places of resource scarcity.

What Nurses Do During Time Scarcity-and Why.

Time scarcity is a common occurrence in the nurse work environment that stimulates a decision-making process, known as clinical prioritization or implicit rationing. In implicit rationing, nurses must decide what care they will complete and what they will leave unfinished. Five mechanisms that influence this process are supported in the literature. The effects of these influential mechanisms leave patients vulnerable to unmet educational, psychological, care coordination and discharge planning needs. Potential areas for intervention by nurse leaders include redesigning care delivery models to reduce time scarcity, adding balancing measures to performance monitoring systems to promote patient-centered care, and creating work cultures that support the values of nursing.

Unfinished nursing care: An important performance measure for nursing care systems.

Performance measurement is a core administrative function and an essential component of organizational quality programs. The prevalence of performance measurement initiatives increased significantly after the release of the Institute of Medicine series on quality. Nursing performance measures are limited in their scope, resulting in an underrepresentation of process measures. Development of performance indicators that reflect how effectively organizational units actually transform nursing resources into nursing services should be a high priority. Unfinished nursing care is a nursing process performance measure that reflects the complexity of the nursing care environment and can be useful in comparing process performance across systems and organizations. Unfinished nursing care is congruent with many of the National Quality Forum requirements for endorsement and warrants further refinement as an important nurse-sensitive performance measure.