Patterns and problems associated with transitions after hip fracture in older adults.

This qualitative, descriptive, longitudinal, multiple case study describes the number and type of care transitions and problems experienced by 21 older urban and rural hip fracture patients in the year following hip fracture repair. Three patterns of transitions emerged: home to hospital to inpatient rehabilitation facility (n = 8); home to hospital to skilled nursing facility (SNF, n = 11); and intermediate nursing home to hospital to SNF (n = 2). Hip fracture patients experienced a median of 4 (range = 4 to 8) transitions in the year following repair. Problems common to all patterns were weight loss, delirium, depression, pressure ulcers, falls, and urinary incontinence. Patients newly admitted to SNFs experienced more problems and order discrepancies than those discharged to an inpatient rehabilitation facility. Families often identified problems first. Strategies to improve transitional care to older hip fracture patients should include improved patient and family involvement at the time of transition, irrespective of initial discharge location.

Keeping patients safe in healthcare organizations: a structuration theory of safety culture.

AIM: This paper presents a discussion of the use of structuration theory to facilitate understanding and improvement of safety culture in healthcare organizations. BACKGROUND: Patient safety in healthcare organizations is an important problem worldwide. Safety culture has been proposed as a means to keep patients safe. However, lack of appropriate theory limits understanding and improvement of safety culture. DATA SOURCES: The proposed structuration theory of safety culture was based on a critique of available English-language literature, resulting in literature published from 1983 to mid-2009. CINAHL, Communication and Mass Media Complete, ABI/Inform and Google Scholar databases were searched using the following terms: nursing, safety, organizational culture and safety culture. DISCUSSION: When viewed through the lens of structuration theory, safety culture is a system involving both individual actions and organizational structures. Healthcare organization members, particularly nurses, share these values through communication and enact them in practice, (re)producing an organizational safety culture system that reciprocally constrains and enables the actions of the members in terms of patient safety. This structurational viewpoint illuminates multiple opportunities for safety culture improvement. IMPLICATIONS FOR NURSING: Nurse leaders should be cognizant of competing value-based culture systems in the organization and attend to nursing agency and all forms of communication when attempting to create or strengthen a safety culture. CONCLUSION: Applying structuration theory to the concept of safety culture reveals a dynamic system of individual action and organizational structure constraining and enabling safety practice. Nurses are central to the (re)production of this safety culture system.

The use of bedside electronic medical record to improve quality of care in nursing facilities: a qualitative analysis.

It appears that the implementation and use of a bedside electronic medical record in nursing homes can be a strategy to improve quality of care. Staff like using the bedside electronic medical record and believe it is beneficial. Information gleaned from this qualitative evaluation of four nursing homes that implemented complete electronic medical records and participated in a larger evaluation of the use of an electronic medical record will be useful to other nursing homes as they consider implementing bedside computing technology. Nursing home owners and administrators must be prepared to undertake a major change requiring many months of planning to successfully implement. Direct care staff will need support as they learn to use the equipment, especially for the first 6 to 12 months after implementation. There should be a careful plan for continuing education opportunities so that staff learn to properly use the software and can benefit from the technology. After 12 to 24 months, almost no one wants to return to the era of paper charting.

Achieving quality improvement in the nursing home: influence of nursing leadership on communication and teamwork.

Leadership, communication, and teamwork are essential elements of organizational capacity and are linked to organizational performance. How those organizations actually achieve improved performance, however, is not clearly understood. In this comparative case study, nursing leadership who facilitated open communication and teamwork achieved improvement while nursing leadership who impeded open communication and teamwork did not.

Medication reconciliation in nursing homes: thematic differences between RN and LPN staff.

The purpose of this qualitative descriptive study was to describe medication reconciliation practices in nursing homes with a specific focus on nursing staff involvement in the process. The study was conducted in eight Midwestern nursing homes and included 46 onsite observations of resident transfers to the nursing home. Informal interviews of nursing staff performing medication reconciliation were conducted during each observation. Findings suggest nursing home nursing staff, including both RN and licensed practical nurse (LPN) staff, were primarily responsible for performing medication reconciliation; however, these staff often varied in how they processed resident transfer information to identify medication order discrepancies. Patterns of differences were found related to their perceptions about medication reconciliation, as well as their actions when performing the process. RN staff were more often focused on resident safety and putting the "big picture" together, whereas LPN staff were more often focused on the administrative assignment and "completing the task."

Detection of patient risk by nurses: a theoretical framework.

AIM: This paper is a description of a theoretical framework of how nurses detect and interpret patient risk signals in the context of organizational attitudes and procedures related to patient safety. BACKGROUND: The ability to detect when patients are at increased risk for harm is a challenge faced by nurses worldwide. How nurses are able to discriminate patient risk warning signals from background noise is not well understood. Also, the impact of system-level factors on nurses' signal detection capabilities has not been investigated. DATA SOURCES: Computerized database searches were used to identify nursing, organizational science, and cognitive psychology literature from 1964 to 2009 pertinent to the framework. DISCUSSION: The patient risk detection theory synthesizes concepts of signal detection theory and high reliability theory. Signal detection theory explains the decision-making processes of nurses as they scan for signals of potential patient harm. High reliability theory explains how nurses' signal detection capacities are facilitated when healthcare settings operate as high reliability organizations making patient safety the top priority. CONCLUSION: The patient risk detection theory facilitates understanding of both individual and organizational factors that influence nurses' ability to detect risk in complex healthcare settings. It can be used to guide research on interventions to enhance signal detection by nurses and increase patient safety in today's complex care environments. The theory can also be used to guide design of training programmes that permit nurses to develop practical skills in signal detection.

Influencing leadership perceptions of patient safety through just culture training.

There are differences in perceptions of safety culture between healthcare leaders and staff. Evidence suggests that an organization's actual safety performance is more closely reflected in staff perceptions suggesting that frontline staff may be more aware than the leadership of actual patient safety challenges within their organization. Closing the perception gap between healthcare leaders and staff is critical to aligning the resources and strategies required to create a true culture of safety.

Developing a statewide medication technician pilot program in nursing homes.

In times of fiscal constraints, nursing homes are seeking to maximize use of licensed staff through delegation of low-risk tasks to unlicensed personnel. Between 2004 and 2008, the Arizona State Board of Nursing developed and conducted a pilot program to determine the impact on patient health and safety of licensed nurses delegating medication administration to trained certified nursing assistants. There were no differences in patterns of medication errors before and after the introduction of medication technicians, and structured interviews revealed that participants viewed the role favorably, with reported increased role satisfaction on the part of delegating nurses. Efforts are underway to extend the program statewide.

Using Lean Six Sigma to Improve Pneumococcal Vaccination Rates in a Veterans Affairs Rheumatology Clinic.

Pneumonia is a major cause of morbidity and mortality in the United States. Therefore, prevention of pneumococcal pneumonia by administering effective and well-tolerated vaccines is an important goal, especially in the immunocompromised patients who are at an increased risk of infections. At a large Midwestern Veterans Affairs Rheumatology Clinic, an internal audit revealed a baseline immunization rate of 3%. Through the Lean Six Sigma approach, the investigators sought to increase the rate to 70%. An interprofessional approach incorporating provider education, reinforcement at the point of care, and workflow simplification was sequentially implemented. Lean Six Sigma tools, including process mapping, voice of the customer, and statistical process control charts were utilized. These interventions increased the percentage of eligible patients receiving vaccinations from 3% (n = 19/687) to 23% (n = 11/48) and decreased the vaccine administration time from 15 to 7 minutes. No adverse reactions were reported. This was balanced by an increase in appointment time by 4 minutes in those who received vaccines. The Lean Six Sigma approach was critical to reducing waste and improving value for patients and providers by increasing pneumococcal vaccination rates among the immunocompromised veteran population in a Midwestern Veterans Affairs Rheumatology Clinic.

Medication safety teams' guided implementation of electronic medication administration records in five nursing homes.

BACKGROUND: The 1.6 million nursing home residents in the United States are at high risk for adverse effects from medication errors. In an attempt to decrease medication errors and improve safety practices, from 2003 through 2007 the study investigators partnered with five Midwestern nursing homes in implementing electronic point-of-care medication administration records (eMARs) and focused quality improvement (QI) efforts. METHODS: The eMAR, designed by a vendor as a part of a larger integrated electronic health record, provided a point of information integration for a variety of users, including practitioners, nursing staff, medication administrators, and nursing home leadership. At each nursing home, a medication safety team guided the transition from traditional paper-based systems to the eMAR. RESULTS: The implementation and integration of the eMAR was monitored in more than 300 hours of detailed observation, resulting in nearly 16,000 medication doses across approximately 200 medication administrations (passes) for 3,700 residents. The types of medication errors most receptive to the combined impact of the eMAR and focused QI efforts were late and omitted (or missing) medications. DISCUSSION: Technology provided the structures and processes that improved communication and integrated complex processes. Yet, regardless of how effectively the technology was designed, it was "laid upon" nursing home medication administration systems that were archaic and fragmented. The implementation of technology could not solve chronic structure and process issues in isolation. However, using the technology to streamline processes, support effective decision making, integrate complex tasks, and bring real-time data to a medication safety team provided an effective mechanism to maximize the impact of technology and to minimize the unintended consequences of large-scale change.

Technology implementation and workarounds in the nursing home.

OBJECTIVE: This study sought to explore the relationship of workarounds related to the implementation of an electronic medication administration record and medication safety practices in five Midwestern nursing homes. DESIGN: As a part of a larger study, this qualitative evaluation was conducted to identify workarounds associated with the implementation of an electronic medication administration record. Data were collected using multimethods including direct observation, process mapping, key informant interviews, and review of field notes from medication safety team meetings. MEASUREMENTS: Open and axial coding techniques were used to identify and categorize types of workarounds in relation to work flow blocks. RESULTS: Workarounds presented in two distinct patterns, those related to work flow blocks introduced by technology and those related to organizational processes not reengineered to effectively integrate with the technology. Workarounds such as safety alert overrides and shortcuts to documentation resulted from first-order problem solving of immediate blocks. Nursing home staff as individuals frequently used first-order problem solving instead of the more sophisticated second-order problem solving approach used by the medication safety team. CONCLUSION: This study provides important practical examples of how nursing home staff work around work flow blocks encountered during the implementation of technology. Understanding these workarounds as a means of first-order problem solving is an important consideration to understanding risk to medication safety.

Measuring organizational attributes of primary care practices: development of a new instrument.

OBJECTIVE: To develop an instrument to measure organizational attributes relevant for family practices using the perspectives of clinicians, nurses, and staff. DATA SOURCES/STUDY SETTING: Clinicians, nurses, and office staff (n=640) from 51 community family medicine practices. DESIGN: A survey, designed to measure a practices' internal resources for change, for use in family medicine practices was created by a multidisciplinary panel of experts in primary care research and health care organizational performance. This survey was administered in a cross-sectional study to a sample of diverse practices participating in an intervention trial. A factor analysis identified groups of questions relating to latent constructs of practices' internal resources for capacity to change. ANOVA methods were used to confirm that the factors differentiated practices. DATA COLLECTION: The survey was administered to all staff from 51 practices. PRINCIPAL FINDINGS: The factor analysis resulted in four stable and internally consistent factors. Three of these factors, "communication,""decision-making," and "stress/chaos," describe resources for change in primary care practices. One factor, labeled "history of change," may be useful in assessing the success of interventions. CONCLUSIONS: A 21-item questionnaire can reliably measure four important organizational attributes relevant to family practices. These attributes can be used both as outcome measures as well as important features for targeting system interventions.

Nursing home error and level of staff credentials.

Providing safe nursing home care is both a clinical and fiscal challenge in many countries. The fiscal realities result in the addition of other workers, such as medication technicians or aides (CMT/A), to the health care team. The purpose of this study was to determine the impact of various levels of credentialing among nursing home staff who deliver medications (RN, LPN, or CMT/A) on medication error. In addition, the impact of distractions and interruptions was explored. Using naïve observation, 39 medication administrators representing various levels of credentialing were unobtrusively observed to determine the number of medication errors, distractions, and interruptions in five nursing homes. There were no differences in medication error rates by level of credential. However, RNs had more interruptions during their medication administration, and these increased interruptions were associated with increased medication error rates when wrong time errors were excluded (p = .0348).

Barriers to safe medication administration in the nursing home--exploring staff perceptions and concerns about the medication use process.

The purpose of this study was to explore staff perceptions and concerns about the medication use process in the nursing home setting. A total of 76 staff members from 5 nursing homes in 3 Midwestern states participated in key informant interviews and focus groups. Common themes included issues related to communication, competing demands, and the challenges of a paper-based medication administration record. Concerns frequently were associated with the timeliness and accuracy of the medication administration process. Recognition of staff concerns are an important first step in improving the nursing home medication use process. Staff insight provided clarification related to impediments to safe medication practices. This study provides insight into how technology can improve the nursing home medication use process.

Maximizing Team Performance: The Critical Role of the Nurse Leader.

Facilitating team development is challenging, yet critical for ongoing improvement across healthcare settings. The purpose of this exemplary case study is to examine the role of nurse leaders in facilitating the development of a high-performing Change Team in implementing a patient safety initiative (TeamSTEPPs) using the Tuckman Model of Group Development as a guiding framework. The case study is the synthesis of 2.5 years of critical access hospital key informant interviews (n = 50). Critical juncture points related to team development and key nurse leader actions are analyzed, suggesting that nurse leaders are essential to maximize clinical teams' performance.

Priming Patient Safety Through Nursing Handoff Communication: A Simulation Pilot Study.

Understanding how safety culture mechanisms affect nursing safety-oriented behavior and thus patient outcomes is critical to developing hospital safety programs. Safety priming refers to communicating safety values intended to activate patient safety goals. Safety priming through nursing handoff communication was tested as a means by which cultural safety values may affect nursing practice. The mixed-methods pilot study setting was an academic medical center's high-fidelity simulation lab. Twenty nurses were randomized into intervention and control groups. The intervention group received a safety priming intervention; all participants were observed for completing appropriate actions in response to patient safety risks embedded in a scenario. Stimulated recall interviews were conducted following simulation completion. Nurses receiving the safety priming intervention performed slightly but non-significantly more safety actions than nurses who did not (60.5% vs. 57.9% of 43 actions). Implications for both research and practice are discussed for interventions targeting routine versus safety goal-directed nursing actions.

An exploration of nursing home organizational processes.

The purpose of this study is to explore the relationship between nursing home staffs' perceptions of organizational processes (communication, teamwork, and leadership) with characteristics (turnover, tenure, and educational preparation) of the nursing home administrator (NHA) and director of nursing (DON). NHAs and DONs rate communication, teamwork, and leadership significantly higher than direct care staff do (registered nurses, licensed practical nurses, certified nurse aides [CNAs]). CNAs have the lowest ratings of communication and teamwork. Turnover of the NHA and DON is significantly and negatively associated with communication and teamwork. Two thirds of DONs surveyed hold less than a baccalaureate degree; this does not influence staffs' ratings of communication, teamwork, and leadership. Findings from this study highlight the need to explore differences in perceptions between administrative and direct care staff and how these may or may not influence staff development and quality improvement activities in nursing homes.

Entrepreneurial program of research and service to improve nursing home care.

This is a methodological article intended to demonstrate the integration of multiple goals, multiple projects with diverse foci, and multiple funding sources to develop an entrepreneurial program of research and service to directly affect and improve the quality of care of older adults, particularly nursing home residents. Examples that illustrate how clinical ideas build on one another and how the research ideas and results build on one another are provided. Results from one study are applied to the next and are also applied to the development of service delivery initiatives to test results in the real world. Descriptions of the Quality Improvement Program for Missouri and the Aging in Place Project are detailed to illustrate real-world application of research to practice.

Nursing home safety: a review of the literature.

The number of older persons in the United States is rapidly growing and, based on this growth projection, the number of consumers needing nursing home (NH) care will likely triple in the next 10 years. Although NHs have been bombarded and scrutinized about the care that they provide, the concept of safety (specifically, error prevention) remains at the margin of most quality improvement efforts. The purpose of this review is to explore what has recently been written (2000-2005) about the evolution of the NH as an organization focused on safety and the most critical clinical processes that must be closely monitored for a safe NH environment to occur. After a thorough review of both organizational and clinical NH literature, 30 organizational studies and 39 clinically based studies were reviewed. The review revealed that, organizationally, teamwork, communication, and leadership all were critical in resident and staff outcomes and clinically, assessment was an important missing process at critical points in the residents' care for prevention and timely treatment of potentially dangerous conditions. The value of the registered nurse (RN) in this setting was clear in the many assessment issues noted and the lack of RN guidance for adherence to recognized practice guidelines. To explicate the role of the RN, first, better outcome measures must be developed that are nurse sensitive. A second clear agenda for NH research is the explication of the role of leadership, particularly nursing leadership, to create an environment where open and accurate communication can be accomplished among all of the diverse NH roles. This will help all members of the team to identify care improvement opportunities. Finally, a new frontier for the NH setting is the use of technology and the need to harness the information that has set in the NH system for years. Information mastery for staff and leadership is a necessary aspect of the organization that must be developed to provide sound information for strategic and focused change to occur.

Moving from a culture of blame to a culture of safety in the nursing home setting.

TOPIC: A culture of safety. PURPOSE: To explore the current culture of blame and what organizational elements must be impacted to move toward a culture of safety in the nursing home setting. METHODS: A mixed-method approach incorporating a case study and staff member survey results were used to explicate the organizational elements impacting the current nursing home culture. CONCLUSION: Nurse leaders can create an environment in which every member of the team feels a responsibility and an ability to insure that residents are safe by improving communication and participation in decision making.