The Association of the Nurse Work Environment and Patient Safety in Pediatric Acute Care.

OBJECTIVES: Eighteen years ago, the Institute of Medicine estimated that medical errors in hospital were a major cause of mortality. Since that time, reducing patient harm and improving the culture of patient safety have been national health care priorities. The study objectives were to describe the current state of patient safety in pediatric acute care settings and to assess whether modifiable features of organizations are associated with better safety culture. METHODS: An observational cross-sectional study used 2015-2016 survey data on 177 hospitals in four U.S. states, including pediatric care in general hospitals and freestanding children's hospitals. Pediatric registered nurses providing direct patient care assessed hospital safety and the clinical work environment. Safety was measured by items from the Agency for Healthcare Research and Quality's Culture of Patient Safety survey. Hospital clinical work environment was measured by the National Quality Forum-endorsed Practice Environment Scale. RESULTS: A total of 1875 pediatric nurses provided an assessment of safety in their hospitals. Sixty percent of pediatric nurses gave their hospitals less than an excellent grade on patient safety; significant variation across hospitals was observed. In the average hospital, 46% of nurses report that mistakes are held against them and 28% do not feel safe questioning authority regarding unsafe practices. Hospitals with better clinical work environments received better patient safety grades. CONCLUSIONS: The culture of patient safety varies across U.S. hospital pediatric settings. In better clinical work environments, nurses report more positive safety culture and higher safety grades.

Safety and Quality of Pediatric Care in Freestanding Children's and General Hospitals.

OBJECTIVES: The purpose of this study was to evaluate quality and safety of care in acute pediatric settings from the perspectives of nurses working at the bedside and to investigate hospital-level factors associated with more favorable quality and safety. METHODS: Using data from a large survey of registered nurses in 330 acute care hospitals, we described nurses' assessments of safety and quality of care in inpatient pediatric settings, including freestanding children's hospitals (FCHs) (n = 21) and general hospitals with pediatric units (n = 309). Multivariate logistic regression models were used to estimate the effects of being a FCH on favorable reports on safety and quality before and after adjusting for hospital-level and nurse characteristics and Magnet status. RESULTS: Nurses in FCHs were more likely to report favorably on quality and safety after we accounted for hospital-level and individual nurse characteristics; however, adjusting for a hospital's Magnet status rendered associations between FCHs and quality and safety insignificant. Nurses in Magnet hospitals were more likely to report favorably on quality and safety. CONCLUSIONS: Quality and safety of pediatric care remain uneven; however, the organizational attributes of Magnet hospitals explain, in large part, more favorable quality and safety in FCHs compared with pediatric units in general acute care hospitals. Modifiable features of the nurse work environment common to Magnet hospitals hold promise for improving quality and safety of care. Transforming nurse work environments to keep patients safe, as recommended by the National Academy of Medicine 20 years ago, remains an unfinished agenda in pediatric inpatient settings.

Missed Nursing Care in Pediatrics.

OBJECTIVES: A growing literature suggests that missed nursing care is common in hospitals and may contribute to poor patient outcomes. There has been scant empirical evidence in pediatric populations. Our objectives were to describe the frequency and patterns of missed nursing care in inpatient pediatric settings and to determine whether missed nursing care is associated with unfavorable work environments and high nurse workloads. METHODS: A cross-sectional study using registered nurse survey data from 2006 to 2008 was conducted. Data from 2187 NICU, PICU, and general pediatric nurses in 223 hospitals in 4 US states were analyzed. For 12 nursing activities, nurses reported about necessary activities that were not done on their last shift because of time constraints. Nurses reported their patient assignment and rated their work environment. RESULTS: More than half of pediatric nurses had missed care on their previous shift. On average, pediatric nurses missed 1.5 necessary care activities. Missed care was more common in poor versus better work environments (1.9 vs 1.2; P < .01). For 9 of 12 nursing activities, the prevalence of missed care was significantly higher in the poor environments (P < .05). In regression models that controlled for nurse, nursing unit, and hospital characteristics, the odds that a nurse missed care were 40% lower in better environments and increased by 70% for each additional patient. CONCLUSIONS: Nurses in inpatient pediatric care settings that care for fewer patients each and practice in a professionally supportive work environment miss care less often, increasing quality of patient care.