Implementation of evidence-based practices in the context of a redevelopment project in a Canadian healthcare organization.

PURPOSE: The recent introduction of a project management office (PMO) in a major healthcare center, led by a nurse, provides a unique opportunity to understand how a PMO facilitates successful implementation of evidence-based practices in care delivery. DESIGN: A case study with embedded units (individuals, projects, and organization). In this study, the case is operationally defined as the PMO deployed in a Canadian healthcare center. METHODS: The sources of evidence used in this study were diverse. They consisted of 38 individual interviews, internal documents, and administrative data. The data were collected from March 2009 to November 2011. Content analysis was used to analyze the qualitative data. FINDINGS: PMO experts help improve practices, and the patients thus receive safer and better quality care. Several participants point out that they could not make the changes without the PMO's support. They mention that they succeeded in changing their practices based on the evidence and acquired knowledge of change management with the PMO members that can be transferred to their practice. CONCLUSIONS: With the leadership of the nurse director of the PMO, members provide a range of expertise and fields in evidence-based change management, project management, and evaluation. CLINICAL RELEVANCE: PMO facilitates the implementation of clinical and organizational practices based on evidence to improve the quality and safety of care provided to patients.

Role of performance measurement in a major redevelopment project: the case of the McGill University Health Centre Transition Support Office.

Healthcare is currently in the midst of a construction boom. An increasing number of hospitals are being constructed using the principles of evidence-based design to improve the quality and safety of patient care while at the same maximizing efficiency. As the McGill University Health Centre embarks on a redevelopment journey, performance measurement has been deemed to be a key requirement for monitoring progress toward established objectives. This article discusses the role played by performance measurement in supporting the redevelopment project. Specifically, the importance given to performance measurement, the need for a performance evaluation framework, a description of the framework and the measurement process are presented.

Characteristics of work interruptions during medication administration.

OBJECTIVE: To document characteristics of nurses' work interruptions (WIs) during medication administration. DESIGN: A descriptive observational study design was used along with a sample of 102 medication administration rounds. Data were collected on a single medical unit using a unit dose distribution system during fall 2007. METHOD: Data collection on WIs relied on direct structured observation. The following WI characteristics were recorded: source, secondary task, location, management strategies, and duration. RESULTS: 374 WIs were observed over 59 hours 2 minutes of medication administration time (6.3 WI/hr). During the preparation phase, nurse colleagues (n= 36; 29.3%) followed by system failures such as missing medication or equipment (n= 28; 22.8%) were the most frequent source of WIs. Nurses were interrupted during the preparation phase mostly to solve system failures (n= 33; 26.8%) or for care coordination (n= 30; 24.4%). During the administration phase, the most frequent sources of WIs were self-initiation (n= 41; 16.9%) and patients (n= 39; 16.0%). The most frequent secondary task undertaken during the administration phase was direct patient care (n= 105; 43.9%). WIs lasted 1 min 32 s on average, and were mostly handled immediately (n= 357; 98.3%). CONCLUSIONS: The process of medication administration is not protected against WIs, which poses significant risks. CLINICAL RELEVANCE: Interventions to reduce WIs during the medication administration process should target nurses and system failures to maximize medication administration safety.

Work interruptions and their contribution to medication administration errors: an evidence review.

BACKGROUND: In many surveys, nurses cite work interruptions as a significant contributor to medication administration errors. OBJECTIVES: To review the evidence on (1) nurses' interruption rates, (2) characteristics of such work interruptions, and (3) contribution of work interruptions to medication administration errors. SEARCH STRATEGY: CINHAL (1982-2008), MEDLINE (1980-2008), EMBASE (1980-2008), and PSYCINFO (1980-2008) were searched using a combination of keywords and reference lists. SELECTION CRITERIA: Original studies published in English using nurses as participants and for which work interruption frequencies are reported. DATA COLLECTION AND ANALYSIS: Studies were identified and selected by two reviewers. Once selected, a single reviewer extracted data and assessed quality based on established criteria. Data on nurses' work interruption rates were synthesized to produce a pooled estimate. RESULTS: Twenty-three studies were considered for analysis. A rate of 6.7 work interruptions per hour was obtained, based on 14 studies that reported both an observation time and work interruption frequency. Work interruptions are mostly initiated by nurses themselves through face-to-face interactions and are of short duration. A lower proportion of interruptions resulted from work system failures such as missing medication. One nonexperimental study documented the contribution of work interruptions to medication administration errors with evidence of a significant association (p = 0.01) when errors related to time of administration are excluded from the analysis. Conceptual shortcomings were noted in a majority of reviewed studies, which included the absence of theoretical underpinnings and a diversity of definitions of work interruptions. CONCLUSIONS: Future studies should demonstrate improved methodological rigor through a precise definition of work interruptions and reliability reporting to document work interruption characteristics and their potential contribution to medication administration errors, considering the limited evidence found. Meanwhile, efforts should be made to reduce the number of work interruptions experienced by nurses.

Requesting wrist radiographs in emergency department triage: developing a training program and diagnostic algorithm.

Crowding is extremely problematic in Canada, as the emergency department (ED) utilization is considerably higher than in any other country. Consequently, an increase has been noted in waiting times for patients who present with injuries of lesser acuity such as wrist injuries. Wrist fractures are the most common broken bone in patients younger than 65 years. Many nurses employed within EDs are requesting wrist radiographs for patients who present with wrist complaints as a norm within their working practice. Significant potential advantages can ensue if EDs adopt a triage nurse-requested radiographic protocol; patients can benefit from a significant time-saving of 36% in ED length of stay (M. Lindley-Jones & B. J Finlayson, 2000)­ when nurses initiated radiographs in triage. In addition, the literature suggests that increased rates of patient and staff satisfaction may be achieved, without compromising quality of radiographic request or quality of service (W. Parris,S. McCarthy, A. M. Kelly, & S. Richardson, 1997). Studies have shown that nurses are capable of requesting appropriate radiographs on the basis of a preset protocol. As there are no standardized set of rules for assessing patients, presenting with suspected wrist fractures, a training program as well as a diagnostic algorithm was developed to prepare emergency nurses to appropriately request wrist radiographs. The triage nurse-specific training program includes the following topics: wrist anatomy and physiology, commonly occurring wrist injuries, mechanisms of injury, physical assessment techniques, and types of radiographic images required. The triage nurse algorithm includes the clinical decision-making process. Providing triage nurses with up-to-date evidence-based educational material not only allowed triage nurses to independently assess and request wrist radiographs for patients with potential wrist fractures but also strengthening the link between competent nursing care and better patient outcomes. A review of the literature also found that such initiatives increase patient and staff satisfaction as well as promoting efficient use of right staff at the right time.

A conceptual framework contributing to nursing administration and research.

The health care system has undergone major changes in the last decade. With greater acuity and complexity of illness, the adoption of innovative technologies and the shortage of health care personnel, the coordination and integration of health care services has become increasingly demanding for administrators. Growing dissatisfaction and concerns about safety issues are being expressed by the users of care who need to navigate through an increasingly complex system and by health care personnel who feel less efficient within the organization. Nursing administrators have a responsibility to address these issues but there is little scientific evidence to guide their actions. There are also few comprehensive models highlighting the main components of nursing administration - models that could guide nursing administration research. This paper presents a conceptual framework for nursing administration and research that links patient health care needs, nursing resources and the nursing care processes to the context of the health care system, and the social, political and cultural environments of care. A selected review of the oncology and cancer care literature is presented to demonstrate how this framework can organize existing knowledge about these concepts in the context of cancer care.